Select Committee on Science and Technology Minutes of Evidence

Memorandum by Dr Jeremy Hawker, Regional Epidemiologist CDSC (West Midlands)

I am aware that you will already have received evidence from the Public Health Laboratory Service (my employer) and the Faculty of Public Health Medicine and do not intend to repeat what has already been said. Rather, I will add my own personal views based on my experience as a Regional Epidemiologist and a former district Consultant in Communicable Disease Control.

Effectiveness of Current Surveillance Systems and Opportunities for Improvement  

1. One of the most welcome aspects of Getting Ahead of the Curve was the proposal to place a duty of care on all microbiology laboratories to report for public health surveillance purposes. It is important that this is taken forward with clear standards that have to be met in terms of timeliness and data completeness and that the relevant performance management agencies (now Strategic Health Authorities (StHAs)) are encouraged to ensure that they are adequately implemented in all Trusts. The proposal for Standard Operating Procedures will also be of value in ensuring that laboratories test specimens appropriately. It is also important that other potential sources of data are given a clear responsibility by the Government and the profession to report data of public health significance. Whereas some functions of surveillance can be met despite a certain level of under ascertainment (eg some trend analyses), an important role of surveillance at the local level is to identify individuals who may require public health interventions, eg to protect contacts of cases of tuberculosis (TB), meningococcal meningitis or hepatitis B. In such cases, even one non-reported case should be viewed as an adverse event.

2. One definition of surveillance is that it is information for action". In the process of setting up of the Health Protection Agency (an initiative that I strongly support), it would be easy to forget that many of the services required to control communicable disease will continue to be the responsibility of Primary Care Trusts (PCTs) to provide or commission. These services include Genitourinary Medicine clinics, TB services and childhood immunisation services. Therefore, it is important that information on the burden and trends in communicable diseases is available by PCT. However, most surveillance systems do not do this: for example, statutory notifications are by local authority and information on sexually transmitted infections (KC60) is by provider clinic. In order to allow such feedback, data providers need to report the PCT that the patient is registered with or to provide a geographical marker (such as postcode of residence) that would allow allocation to a PCT (at least to its' geographical area). The postcode option would be preferable because the recent history of the NHS would suggest that boundaries will change (surveillance requires baseline setting and monitoring trends) and also because postcode allows allocation to other geographical boundaries, for example cases of Cryptosporidium infection can be analysed against water supply areas. There are some CDSC initiatives planned that could address some of these gaps but, as there will inevitably be concerns relating to patient confidentiality issues, political support will be needed to systematically address this issue.

3. The Government has, quite rightly, prioritised reducing the inequalities in health that affect the UK population. However, there has been little consideration of the contribution of infectious diseases to the burden of inequalities in published documents. Large social and ethnic inequalities can be demonstrated for serious infections, such as HIV, meningitis and TB, and for common respiratory, gastrointestinal and sexually transmitted infections. I have previously summarised these inequalities in a chapter written for the PHLS Review of Communicable Diseases 1999-2000 ( review/Ch10.pdf). In many of these cases the relative risks are far in excess of anything seen for non-infectious diseases. In addition, many of the interventions that might be planned to reduce the burden of these diseases (such as immunisation, sex education, promotion of breast feeding, smoking cessation) are themselves often taken up less by disadvantaged groups. In order to successfully address these inequalities we need to be able to set a baseline and monitor trends: this requires being able to allocate cases to a social group with a known denominator (most easily by using postcode of residence to allocate to a census Enumeration District) and to an ethnic group (healthcare providers are already required to collect these data for other purposes). Again, there will be the same concerns about patient confidentiality as in the previous paragraph.

4. To some extent, the issues in the previous three paragraphs could be addressed in any review of the law relating to infectious disease control. Such a review was recommended by the Committee of Inquiry into the future development of the Public Health function, chaired by Sir Donald Acheson (the then Chief Medical Officer) that reported in 1988. A consultation document was issued a couple of years after that but parliamentary time was never found for the legislation itself. This is an important issue because the current laws define the list of diseases that are statutorily notifiable by clinicians and for which certain legal control measures are available. That the Public Health Act and Regulations are out of date can be illustrated by the fact that Legionnaires' Disease is certainly not notifiable and E. coli O157 contracted from a farm visitor centre or a nursery is probably not notifiable either (there are similar concerns relating to the control measures available in the legislation). It was gratifying therefore to see that Getting Ahead of the Curve proposed modernising public health law: it is to be hoped that this Chief Medical Officer receives more political support than his predecessor.

5. Most other European countries have clear case definitions for what infections are notifiable or reportable. We do not have such definitions and this is a weakness in our system. Getting Ahead of the Curve proposes the development of such definitions. These should be included in any review of the law although, as this will inevitably take time, good practice case-definitions could be developed fairly quickly by relevant professional groups based on existing models (in the Communicable Disease Control Handbook we based our definitions on European Union definitions).

6. The two most promising areas for development of existing surveillance systems are routine use of molecular epidemiology for some diseases and the use of more powerful geographical analyses. Molecular epidemiology essentially allows improved detection of linked cases of infection by better discriminatory testing of the infecting organisms (eg by DNA fingerprinting"). We certainly miss outbreaks of common organisms, such as Campylobacter and Salmonella enteritidis PT4, because they are lost in the high background level: better discriminatory testing would allow us to identify many of these. Studies in the UK and other countries have also identified the potential of molecular testing of isolates from TB cases to identify previously unnoticed clusters and to shed light on transmission patterns: it is easy to foresee a situation where similar results could be obtained for sexually transmitted infections. Introduction of such tests into routine surveillance would however need extra resources: perhaps this should be first call on the money that used to go through PHLS to subsidise" local Public Health Laboratories, rather than the current plan of adding it to the general NHS pot for allocation to PCTs?

7. Detection of outbreaks has always required timely reporting of cases and this need has now been intensified by the requirement to be able to detect a covert deliberate release of a biological or chemical hazard. Such data should be as near to real time as possible and we cannot rely on routine laboratory testing to detect such threats. A related issue is the need to detect novel or emerging pathogens. As we cannot routinely test for pathogens that we are not yet aware of and as we do not yet know what syndrome they will cause (AIDS, vCJD and Clostridium noyvi in drug users were all syndromes that were not previously predicted as caused by infectious agents) we need to have systems in place that could monitor a change in any clinical syndrome. Dr Gillian Smith and other CDSC staff based in my unit have developed a system with NHS Direct that allocates callers to specific clinical syndromes and analyses changes in their incidence each day so that analysed data are available the day after the call was made. As primary and secondary care become more computerised, it would not be impossible to imagine a system (perhaps in five to 10 years time) where similar automated data collection and analyses could be available for the pattern of illnesses being seen in GP surgeries, A+E departments, medical admission wards and ITUs. Such IT systems will also have related information of relevance to health protection, eg antimicrobial prescribing. The ability to deliver such a system is obviously primarily with the NHS and would require the commitment of the NHS Information Authority and others. However, there would also be great benefit to the NHS, for example in managing their annual winter bed pressures (it should be remembered that winter pressures relate better to the incidence of the clinical syndromes influenza-like illness" and acute respiratory infection" rather than to laboratory isolates of influenza virus).

8. The ability to make best use of surveillance data for policy development purposes would increase with access to appropriate experts in systematic literature review, mathematical modelling, health economics and behavioural psychology.

Other Aspects of Getting Ahead of the Curve  

9. The creation of a specialist Health Protection Agency (HPA) is a major opportunity to improve prevention and control of human infectious disease in the United Kingdom. In particular, the opportunities for specialisation, teamworking and peer support at local level are to be welcomed, as are the integration of local, regional and national staff into the same organisation.

10. It needs to be recognised however, that local health protection activity is currently underfunded and that, irrespective of whether the creation of the HPA is itself cost-neutral, this would need to be rectified in order to make the system safe. The 1997 Survey of the Communicable Disease Control function undertaken for the NHS Executive found significant under-resourcing in many districts and showed that this was linked to underperformance. Since then, not only have many districts not adequately responded to the survey, but the complexity of the health protection agenda has increased and the implementation of Shifting the Balance of Power has disrupted many existing support networks.

11. It is important that PCTs (and the Strategic Health Authorities that performance manage them) are made aware of their remaining responsibilities to provide and commission the many services that underpin health protection. As an example, the recent Response on behalf of the specialty societies for Genitourinary Medicine to the Parliamentary Health Select Committee reported on the loss of immediate open access services (for diagnosis and treatment of sexually transmitted infections) and the development of a waiting list of an estimated 40,000 individuals. It is difficult to view this as anything other than a serious system failure requiring immediate action by PCTs and StHAs to rectify it.

12. The Regional Director of Public Health (RDPH) is given an important role in Getting Ahead of the Curve in ensuring that health protection is undertaken adequately and this is to be welcomed. However the RDsPH might wonder where their clear and unambiguous powers are to balance their clear and unambiguous responsibility"?

13. There is a significant training need for both the new specialists in health protection and the general" public health professionals who will work in PCTs and other organisations. This will cover both knowledge and skills and affect those in training and those already in substantive posts. This need highlights the existing shortfall in academic health protection. The Acheson Inquiry into the future development of the Public Health function in 1988 was set up in response to the mismanagement of two large outbreaks of infectious disease. One of its' main recommendations was the establishment of Institutes of Public Health to provide an academic focus for training and research in public health. Whereas such institutes were established in (I believe) all regions, most did not include any resource to improve communicable disease control training or research. This remains an important weakness.

14. Neither the Acheson Inquiry or Getting Ahead of the Curve addresses the adequacy of Local Authorities' contribution to health protection. Infectious disease legislation gives the responsibility and powers for control of notifiable infections to local authorities rather than the NHS (although an NHS employee is usually made available to the local authority to act as their proper officer" under the legislation). It appears to me that some local authorities take their responsibilities far more seriously than others. It is also fair to say that some smaller local authorities lack the necessary expertise to replicate the level of service that some larger authorities can provide.


15. Other witnesses will be better placed to address this issue in detail. I would however like to point out a link to a previous area of interest of this Committee, namely concern over the development of antimicrobial resistance. For example, there is currently concern over the development of resistance to penicillin and other antibiotics of the pneumococcus (a serious cause of pneumonia, septicaemia, meningitis and other diseases), but there is also a vaccine available which gives protection against all the common antibiotic resistant strains. There is even more concern over the development of multi-drug resistance by the TB bacillus, whilst at the same time a debate as to whether routine BCG immunisation is warranted in the UK: although it is true to say that BCG is less than perfect, it is of some use and is equally effective against multi-drug resistant strains. There is at present no vaccine available against Staphylococcus aureus (and, I gather, some technical barriers towards producing one), but should such a vaccine be developed there would be no reason to assume that it would not be effective against MRSA: perhaps we will some day be immunising certain groups of patients to protect them before admission to hospital? A Staphylococcus aureus vaccine would also be of use during the next influenza pandemic.

16. The role of influenza vaccine in preventing hospital admissions and deaths during winters with significant influenza virus activity is now well accepted. However, as the winter bed pressures and excess winter deaths occur every year, not just when influenza virus is circulating, the role of immunisation against other pathogens, particularly RSV, needs to be considered.

Dr Jeremy Hawker

Regional Epidemiologist, CDSC (West Midlands)

2 December 2002

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