Memorandum by the Infection Control Nurses
This evidence is submitted on behalf of the
Infection Control Nurses Association of the UK and Eire. The Association
has 1,600 members, mainly nurses. The membership is representative
of many areas in which health and social care is delivered in
primary and secondary care settings as well as private healthcare
providers. The evidence has been prepared from written comments
as well as from a debate on the subject of surveillance that took
place at our recent annual conference.
1. What are the main problems facing
the surveillance, treatment and prevention of human infectious
disease in the United Kingdom?
1.1 Current surveillance systems are not all
standardised and therefore there is a variety of surveillance
data that is collected. Collection of accurate data can be difficult
and time consuming, which may lead to information being incomplete.
Feedback of surveillance data in a timely manner is vital in order
for actions to be agreed and taken but turn around of information
is often slow indicating a need to improve feed back systems.
1.2 Mechanisms do not always exist to ensure
that data collected in primary care informs policies and strategies
in secondary care and vice-versa. For example data on tuberculosis
infection in the community should inform decisions made within
acute hospitals as to how many isolation rooms are needed including
those that are negative pressure for multi-drug resistant disease.
Although systems exist for surveillance in acute hospitals and
the notification of infectious diseases system operates in the
community these do not necessarily embrace other areas where care
is delivered such as nursing and residential homes or special
schools. The existing notification of infectious disease does
not at present give the in depth information that is needed to
develop health promotion and infection prevention strategies.
In addition this system identifies only those who have attended
a health care professional for treatment and therefore not all
cases will be identified and the true incidence of disease is
not always known.
1.3 In order to address the difficulties
of accurate data collection across care settings lateral and innovative
ways of collecting the data need to be developed, for example,
using the expertise of organisations that work with high risk
groups such as substance misuse teams and homeless workers. It
will be necessary to develop partnerships for data collection,
whether this is through surgeons in the acute setting or School
Nurses in community areas. Without the engagement of these clinicians
and care workers there is a danger that the data and the actions
taken in response to the data will not have local ownership and
changes will not take place. However, where data is collected
locally there is a need for validation to improve accuracy. Whilst
it is acknowledged that collecting a minimum amount of data could
give accurate and valuable information, more in-depth data, for
example on risk factors may be needed to inform future prevention
and treatment strategies.
1.4 There are enormous disparities in infection
and infectious disease prevention services across the country.
The Public Health Laboratory Service study into Infection Control
in the Community (published June 2002) found that the ratio of
Community Infection Control Nurses (CICNs) to population ranged
from 0-4.5 whole time equivalent (wte) CICNs per 500,000 population
with a median range of 1.7 wte. This report also identified serious
gaps in tuberculosis contact tracing with many CICNs fulfilling
multiple roles that involve contact tracing and infection prevention
1.5 Public perception of risk impacts on
the ability of CICNs to perform their role within the limited
resources available to them. CICNs report that much of their time
is spent on addressing and mitigating against risks that have
low likelihood of causing a problem, which spreads their resources
inappropriately and does not allow them to focus on in depth work
with real risks. There is a need for the public to receive a cohesive
message that there will always be risks with infectious disease,
together with a realistic approach to what "science"
can offer in terms of infectious diseases.
1.6 With regards to education on infection
prevention there is a need to address this across all healthcare
providers, particularly in the community setting. The PHLS study
into Infection Control in the Community found that 58 per cent
of districts had no training programme for dental practices. Although
National Vocational Qualification programmes of learning are in
progress in relation to infection control there are specific issues
in community settings where frequently there is poor access to
CICNs for mentorship and where assessors have little or no background
understanding of specific infectious diseases and infection prevention
1.7 Treatments for infectious diseases can
have undesirable side effects and may need to be taken for prolonged
periods of time (for example treatments for HIV and tuberculosis),
which can lead to lack of compliance and risk of drug resistance
2. Will these problems be adequately addressed
by the Government's recent infectious disease strategy, Getting
Ahead of the Curve?
2.1 Getting Ahead of the Curve offers immense
potential to make a difference. Implementing the strategies for
Hepatitis C, Tuberculosis and sexual health will require good,
targeted surveillance data and interventions based on principles
of collaborative working. Implementing these strategies will require
expert and organised leadership.
2.2 Getting Ahead of the Curve will only
impact on the prevention and treatment of infectious disease if
new ways of working are embraced. There is a need to challenge
assumptions and to ensure that everyone recognises their role
and responsibilities in infection prevention. The involvement
of all stakeholders, including patients, relatives, domestic staff
etc, in the development of infection prevention strategies is
vital in order to promote ownership and to focus on what is achievable.
2.3 There is a need to consider how the
primary and secondary care settings will interact in implanting
the targeted action plans and actions required within Getting
Ahead of the Curve. Strategic Health Authorities may play a role
in supporting the development of collaborative strategies and
programmes for infectious disease prevention.
3. Is the United Kingdom benefiting from
advances in surveillance and diagnostic technologies; if not,
what are the obstacles to its doing so?
3.1 Although infection prevention and control
staff have access to computer hardware there is still a need to
improve this and to work towards using portable methods of data
collection more effectively. Resources for this remain an issue
with many infection prevention and control teams in both primary
and secondary care settings having no or limited access to funds
to enable upgrading of equipment on a regular basis.
3.2 Compatibility between different computer
systems used within laboratories and primary and secondary care
settings makes timely linking and use of data difficult. There
may be a need to develop standard systems that uses automatic
data capture and interfaces with patient administration data systems
within Trusts. The opportunity to integrate surveillance information
into the electronic patient record must not be missed.
4. Should the United Kingdom make greater
use of vaccines to combat infection and what problems exist for
developing new, more effective or safer vaccines?
4.1 The UK could make more use of vaccination,
particularly for illnesses that result in economic and social
disruption such as the flu. Within the Wessex area GPs are not
being encouraged to vaccinate `at risk' groups under 65 years,
because they will not be paid for it. Wide coverage of the population
could result in fewer emergency admissions, outbreaks in hospitals
and care homes, time off work and school.
4.2 The immunisation programme needs to
be considered in view of recent public concerns over safety of
vaccines. It is important that the public receive the message
that no vaccine is 100 per cent safe or 100 per cent effective.
Current scepticism over vaccine safety will impact on the introduction
of new vaccine programmes and cautious promotion of new programmes
will be required otherwise there is a danger that there will be
a decrease in the numbers of children protected.
4.3 The impact of higher levels of immigrants
may need to be taken in to consideration when determining vaccination
strategies. Whereas the resident UK population will have been
exposed to infectious diseases such as chickenpox as children,
thus giving immunity, as these diseases are not common in other
countries there is the potential for the proportion of adults
that are susceptible to these infections to be increased. This
can in turn lead to outbreaks of these infections and the risk
of long term complications, for example, damage to the foetus
during pregnancy leading to ongoing health problems when the child
5. Which infectious diseases pose the biggest
threats in the foreseeable future?
5.1 The impact of multi-resistant organisms
is not confined to acute care settings. As increasing numbers
of patients, who would traditionally have been cared for in hospital
settings, are being cared for in the community there is the risk
that these organisms will become more prevalent in the wider community.
An increasingly elderly population as well as health care developments
improving survival of serious and chronic disease leads to a rise
in the susceptibility of the general population to infection with
these organisms. Poor standards of infection control in some community
settings can contribute to the spread of these organisms and there
is a need to address this within the standards set by the National
Care Standards Commission, which are at present very basic and
limited in terms of infection control.
5.2 Tuberculosis continues to pose a threat
due to a number of reasons. As previously noted compliance with
treatment may be poor. Increasing levels of immigrants from areas
with high levels of drug resistant disease may increase drug resistant
levels in the UK. As rates of tuberculosis have declined in the
20th century health care professionals may not have a high index
of suspicion for the disease when patients present with symptoms,
therefore diagnosis can often be made late.
5.3 Sexually transmitted infections including
Hepatitis B and C and HIV. Despite education campaigns there is
evidence that sexually transmitted infections are not declining.
Although the national strategies for combating these infections
have much to offer there is a need for good quality targeted surveillance
to ensure effective use of resources and effective targeting of
prevention in the community.
5.4 Food related illness continues to be
a large problem in terms of both individual notified cases and
outbreaks. The impact of these economically in terms of loss of
earnings and working/school days lost is immense. There is a need
for much more lateral and collaborative thinking for strategies
to prevent these infections. The role of school nurses and health
visitors in the promotion of hygiene should be explored, with
nationally supported campaigns linking to the national curriculum.
Opportunities to promote food hygiene on the back of other campaigns,
for example the `five a day fruit/vegetable' campaign should be
5.5 Changing patterns of existing diseases
cannot necessarily be predicted but must be considered. This is
demonstrated well by the numerous and ongoing outbreaks of gastro-enteritis
due to Norwalk-like viruses that have occurred throughout 2002.
These outbreaks have not been restricted to healthcare settings
but have been present in schools and hotels and have had considerable
impact economically due to outbreak control requirements.
6. What policy interventions would have the
greatest impact on preventing outbreaks of and damage caused by
infectious disease in the United Kingdom?
6.1 Policy interventions need to focus firstly
on prevention of infection and infectious disease. There is a
need to ensure infection prevention education is given priority,
which suggests this should be a mandatory requirement in all areas
where care is delivered.
6.2 There is a need to ensure that infection
prevention and control is an integral part of all new health initiatives
and National Service Frameworks. Controls Assurance Standards
for infection control have led to infection prevention becoming
part of the organisational structure in Primary Care and Acute
Trusts. This approach is needed in the wider community.
6.3 The development of standards for infection
control in all care settings should be encouraged. This should
be followed by monitoring and possibly by an accreditation scheme.
Monitoring should include not only the existence of policies,
but also the implementation of them.
6.4 There is a need for Local Authorities
and District Councils to work more closely with the Health Protection
Agency and in turn for these to work with secondary care providers
to incorporate infection prevention and control into all initiatives.
6.5 Outbreak management must include the
development of teams that work across boundaries of health and
social care provision.
24 November 2002