Memorandum by the Public Health Laboratory
1. The PHLS welcomes this inquiry and the opportunity
for a critical look at this important area of PHLS core business.
2. Many of the problems with the surveillance of
infectious diseases were well described in the recent strategy
from CMO England. Some additional areas are highlighted in this
3. Areas where surveillance needs to modernise include
the targeted selection of subjects and samples from settings typical
of where infection is found, the use of new testing technologies,
the intelligent use of information technology, the linking of
laboratory reports with clinical data and outcomes, and real engagement
with those at the front line.
4. Some of the threats and current obstacles to improved
surveillance are described. The PHLS has reservations over the
hasty organisational changes proposed in Getting Ahead of the
Curve, and is unclear how these will assist progress in surveillance.
It is difficult to see the changes will manage to be resource-neutral.
Other key points in this evidence are summarised on the final
5. Infectious diseases are an ever-present threat.
Staff from the current PHLS will need to continue with their important
personal contribution, whatever their individual employing organisation
from April 2003.
1. The Public Health Laboratory Service (PHLS) operates
across England and Wales and provides some services under contract
in Scotland and Northern Ireland. For over 50 years it has provided
a range of expert laboratory-based microbiological services and
also epidemiological work related to infectious diseases. The
remit of this Inquiry falls within the core business of the PHLS.
2. The PHLS welcomes this inquiry and the opportunity
to contribute to the evidence before the committee. With the proposed
organisational changes in England and in Wales this year and next,
it is timely to look again at the systems for the surveillance
of infectious disease. The recent strategy from the CMO England
for combating infectious disease, Getting Ahead of the Curve,
provides the overall context within England. Whilst the PHLS Board
has made clear its concern with the proposals in that strategy
for the over-hasty dispersal of current PHLS resources1, it has
also indicated the PHLS is prepared to cooperate fully with a
Ministerial determination on the issue2. That being so, the evidence
that follows here attempts to look forward critically but constructively
to help improve the nation's ability to Fight Infection".
What are the main problems facing the surveillance,
treatment and prevention of human infectious disease in the UK?
3. Although there are many definitions of surveillance,
the shortest and most telling is that surveillance is the delivery
of information for action". This not only has the merit of
brevity, but also emphasises that surveillance should not be merely
the process of amassing large volumes of data. Surveillance also
entails the analysis and interpretation of data so as to create
meaningful information. The information that is so created must
be of a form that can inform purposeful action, which in the case
of communicable disease control often needs to be of a rapid and
reactive nature, though it will also include action taken as part
of a longer-term policy implementation. Finally, surveillance
must deliver information to those who are required to take the
action, be that a direct clinical or public health intervention,
setting of a strategy or the further development of a policy.
In the absence of timely, valid and accessible information on
communicable disease epidemiology, control of the spread of disease
within the population, and development of policy for communicable
disease control and prevention would be no more effective than
would the development and practice of economic policy and financial
business without suitable economic data.
4. Enormous advances in communicable disease control
were achieved in the 19th and 20th centuries through improvements
in sanitation, hygiene and nutrition, and latterly through the
use of vaccines and antimicrobial agents, although resistance
to these is an ever present and increasing threat. The development
of new vaccines probably represents the greatest potential for
future control and prevention of communicable disease, but for
many infections of public health importance it is unlikely that
effective vaccines will be developed in the next 10-20 years.
For example, no vaccines exist for HIV, hepatitis C and malaria,
and better ones are needed for tuberculosis. In the meantime,
control continues to depend on the identification and control
of threats in food, water and the environment, the promotion of
disease avoidance and early identification and treatment of human
5. The new challenges for communicable disease surveillance
and control include the need to be able to identify and respond
to new or re-emerging infections, particularly those resulting
from increasing international travel, the effects of modern health
care and animal husbandry (not least on the emergence of antimicrobial
resistance), the every present risk of transfer of infection from
other species (such as avian influenza), and the threat of bio-terrorism.
In addition, there is now a growing recognition that infectious
diseases can give rise to chronic disease sequelae, such as cancers
(eg hepatitis B and human papillomavirius), peptic ulceration
(helicobacter pylori) and infertility (eg genital chlamydial infection).
Any cost-benefit analysis for intervention strategies is incomplete
without considering the chronic effects of acute infection. Thus
even within the confines of communicable disease, surveillance
has evolved from primarily being used for collation of reported
outbreaks and simple description of trends, (once mostly of gastrointestinal
and respiratory conditions), to a broader portfolio of activities.
In the 21st century communicable disease surveillance encompasses
the analysis of data on sexual and other behaviours, uptake of
vaccines, cancers, and a widening range of demographic and clinical
descriptors. This will inform public health and clinical policy
and practice on conditions and issues that include chronic infection,
vaccine safety, screening, performance monitoring, healthcare
associated infection, travel health, antimicrobial resistance
and deliberate release.
6. Additional challenges for surveillance are posed
by changes in clinical practice and the infrastructure of the
health services within which it is delivered. With the increasing
delegation of policy implementation and responsibility for delivery
of clinical and public health services to the local level (Primary
Care Trusts and Hospital Trusts), many surveillance systems will
need to be retooled to provide information that can inform action
at this local level. Furthermore, the growing awareness of inequalities
between socio-economic groups in the burden of communicable disease
morbidity, and the development of government policies on reducing
such inequalities, requires that surveillance systems can deliver
information on socio-economic variations in communicable disease
incidence. These changes are unlikely to be resource-neutral.
7. Surveillance must respond to the expectations
of professionals and the public, raised by advances in technology,
particularly information technology and the pressures to continuously
improve standards of healthcare delivery ie clinical governance.
It should meet the need to link human disease data with data from
outside the health service, and achieve this within constraints
imposed by new legislation and interpretation of older legislation
on confidentiality, data protection and human rights. It is timely
to review the evidence base for how and why surveillance is now
being undertaken, with a view to making its inputs and outputs
most relevant to clinical practice and public health performance.
This kind of development requires greater collaboration and more
shared ownership of surveillance systems by clinicians and public
health practitioners than has hitherto been the case as well as
greater awareness of the importance and use of surveillance data
by decision-makers and the public. For this it will be necessary
to address current concerns over the uses of patient data within
the health service and also to harness advances in information
technology to facilitate the capture, analysis and dissemination
of the large volumes of data that will sometimes be necessary.
A major function of surveillance has always been to detect the
unexpected, but since the events of 11 September 2001 and the
bio-terrorist attacks that followed, it is clear that effective
health protection should include surveillance to detect what might
previously have been unthinkable to most people in the NHS. This
poses significant challenges, with the need to extend surveillance
beyond the realms of clinical certainty and even beyond the current
reach of the health service.
8. Most recently, Getting Ahead of the Curve has
made explicit calls for the development of more integrated surveillance
systems that draw on human, environmental and veterinary data.
Current surveillance systems for acute gastrointestinal infection
in England and Wales have achieved many notable public health
successes in recent years, such as the early detection of national
and international outbreaks and the recognition of emerging problems
such as Escherichia coli O157, through the close integration of
local regional and national microbiological and epidemiological
expertise. The broadening of these systems through the integration
of surveillance data from environmental and veterinary sources
should add to their strengths. It will be important, however,
that a set of principles for the sharing and analysis of combined
data sets be agreed between the relevant agencies, to ensure that
data are not over-interpreted and that the current strengths and
partnerships in surveillance are built upon. It should also be
recognised that not all gastrointestinal infections are foodborne
and that surveillance is key in defining transmission routes for
different pathogens. Surveillance of gastrointestinal infection
is funded through the Department of Health, although the results
of foodborne disease surveillance are of greater direct benefit
to the Food Standards Agency since the formation of the latter.
Demands for surveillance information from the Food Standards Agency,
which has a legitimate interest in and need for the data, are
unlikely to be matched with increased funding from the Department
of Health to meet those increasing demands.
9. The increased ease of access to data has required
new data protection legislation and led to both public and professional
concerns about the possible abuse of personal data. These concerns
have been particularly focussed on uses of patient data for purposes
other than direct clinical care, suggesting that a distinction
needs to be made between population-based surveillance and data
management for the purposes of action directed at the individual.
Whether the placement of CsCDC outside the NHS will also give
rise to concerns about the exchange of information between clinicians
working in the NHS and CsCDC working in the HPA has yet to be
determined. It may be some time before the HPA is as closely integrated
with the NHS as was the PHLS, both in professional and public
perception and in reality.
10. An issue for further debate relates to the local
structures for identification and management of infectious disease.
Investment here is uneven3 and responsibilities unclear. In the
new system, partnerships will be needed between the health protection
specialists (health protection units and laboratories of the HPA),
the public health generalists (PCTs in public health networks),
clinicians and microbiology generalists (in PCTs and acute trusts)
and local authorities. Whilst service level agreements (SLAs)
and memoranda of understanding (MOU) will help define those relationships,
there is no substitute for genuine partnership based on mutual
respect and understanding. With new management structures this
will take time to develop and could be inhibited by tensions relating
to accountability or funding. At present, for example, the source
of funding is unclear for the identification and typing of pathogens
for public health rather than clinical purposes, other than for
specialised work done by the HPA through its own laboratories
or by commissioning.
11. Increased and sustained investment for surveillance
of infections within primary care and community settings will
be needed. There is a particular need to combine clinical and
demographic data with laboratory results. Such surveillance is
able to reveal the epidemiological pattern of infection at a population
12. Among the many issues raised in Getting Ahead
of the Curve was the urgent need to update infectious disease
legislation. For example, in spite of the increasing problem of
tuberculosis, it is illegal to require treatment for those with
active disease, unlike in the United States.
13. A further area of concern is the high rates of
exposure to and ease of transmission of infections in special
groups, such as men having sex with men, and in special settings,
including prisons and detention centres. The reform needed to
reduce transmission rates may need to be fundamental, eg around
attitudes to casual sex in the young, or potentially counterproductive
to other government policies, eg around the handling and dispersal
of asylum seekers.
14. One of the priority areas for action outlined
within Getting Ahead of the Curve is antimicrobial resistance.
Around half of the bacteria currently tested for resistance are
from hospital patients yet most antibiotic prescribing is in the
community. This means the vast majority of community infections
deemed (rightly or wrongly) to require antibiotic have no antibiotic
susceptibility done. Those that do have such tests done, recorded
and included in passive surveillance are likely to have recalcitrant
infections, maybe recalcitrant owing to resistance, or are from
patients with complex problems. These form a biased sample. Similar
problems of bias apply to most other areas of passive surveillance.
15. By international standards, laboratory testing
might also be sub-optimal. For antibiotic resistance testing,
for example, isolates are often not identified to species level,
except from bacteraemias; isolates are tested with too few antibiotics;
and those antibiotics they are tested with are not consistent
in different places, making it difficult to pool data. There is
also a need for surveillance of the molecular basis of resistance,
requiring detailed investigation by a reference, specialist or
16. The right way to keep abreast of antibiotic resistance
would be sentinel surveys of resistance in community pathogens
with all patients presenting with a particular set of symptoms
being sampled, not the present eclectic sub-set. For isolates
passing through diagnostic laboratories, there would need to be
identification of species and the routine testing with a wider
range of antibiotics, including core sets in all laboratories.
Were such data collected for surveillance purposes, computer expert
systems could be used to identify anomalous resistance patterns,
so identifying isolates that required reference laboratory and
molecular investigation. It is unclear how such systems could
develop and be funded under the HPA, though it is noted antimicrobial
resistance is a priority area in Getting Ahead of the Curve.
17. Although this PHLS evidence has concentrated
on the diagnosis and surveillance of infectious disease, this
is not to downplay issues relating to treatment and vaccination
policy. In some areas, there are significant weaknesses in the
evidence base to support clinical decision-making related to infections,
especially in primary care. The difficulties in promulgating guidelines
and changing practice even when evidence is available also need
to be recognised.
Will these problems be adequately addressed by
the Government's recent infectious disease strategy, Getting Ahead
of the Curve?
18. The PHLS and its Board has welcomed this strategy
and the prominence it has given to the need for a concerted effort
to deal with infectious disease. In the months since the strategy
was announced, most effort has been focussed on the establishment
of the Health Protection Agency (HPA) and the transfer of many
of the current PHLS laboratories to the NHS. The PHLS has expressed
concern about the implementation processes1, 2, but has no issue
with the remaining policies within Getting Ahead of the Curve,
even though some, like the creation of a Microbiology Inspector
remain inadequately defined. The overall implementation project
plan for Getting Ahead of the Curve has not been shared
with the PHLS, but the PHLS stands ready to give what expert assistance
it can, for example to contribute to plans to improve surveillance,
including exploring new ways of encouraging and facilitating reporting,
such as direct from general practice and the public.
19. Whilst welcoming the strategy, the PHLS would
have wished to have been more closely involved in its generation.
The PHLS believes that had recommended practices in policy-making
been followed4, we could have avoided some of the difficulties
currently being experienced in the smooth introduction of the
changes desired by Government. With PHLS assistance, a more coherent
policy might have been generated.
20. Issues of concern from the PHLS include the pace
of change, especially the disruption of the integrated PHLS network
for microbiology and epidemiology before alternatives are ready.
Risks to business continuity over the change period are being
identified and mitigating action put in hand, but time and internal
capacity may prove too tight. There are staff retention issues
during this period, especially in already short supply areas,
eg staff handling food, water and environmental (FWE) samples,
and those at risk of redundancy like group managers. This is in
spite of the short-term guarantees within the change management
protocol agreed with the Trade Unions. Also, there are risks from
disillusionment of PHLS staff who feel their public health role
has been undervalued or unrecognised in the decision to transfer
them to individual NHS trusts. This is a serious threat to morale
and to their future commitment to deliver the public health activities
that are required.
21. Concerns over the future for surveillance were
considered by the PHLS Research and Scientific Strategy Committee5
to be top of the league" in terms of risks of the proposed
changes. Whilst some believe routine laboratorybased surveillance
might be little affected, especially that which already comes
from NHS hospitals, others believe the lack of explicit funding
for public health work will mean this could well fall off. There
is real and general concern about the capacity to deliver enhanced
surveillance or to mount an acute response.
22. It appears the laboratory support for public
health in the Regions will be dependent on the HPA regional labs,
the former PHLs following transfer to NHS management, and the
rest of the NHS labs which will be expected to recognise their
PH responsibilities. There will need to be the cooperation of
host" Trusts in which HPA regional labs will be located,
but this has been compromised by three statements6: that early
consideration should be given to handing management of clinical
microbiology back to the Trust; that part of their laboratory
funding will be completely removed and redistributed to PCTs as
part of general allocations in 2004; and that their funding for
public health work will be guaranteed at its present level only
until March 2005. The cooperation of host" Trusts in which
former PHLs are located has also been compromised by the last
two of these DH statements. There appear to be no plans as yet
for providing any material incentive for NHS laboratories to rise
to the public health challenge, and a fear that in local tussles
about funding, money will be diverted from public health purposes.
23. Whilst Getting Ahead of the Curve recognised
the important synergy between routine diagnostic and public health
microbiology, the current proposals appear to introduce and increase
the separation. This is a retrograde step. National level public
health work, whether microbiological or epidemiological, benefits
from personal knowledge and experience of activity at the routine
diagnostic of field sharp-end, and reflection with practitioners
on a daily basis. R&D activity likewise is more likely to
reflect the important issues that affect practice and recognise
the potential biases in data if done side by side with routine
work. The PHLS has had a wide spectrum of activity related to
communicable diseases within one organisation: it remains to be
seen how the very real potential for silos to be created will
be counteracted in the new structures.
24. The need for national co-ordination of certain
outbreak investigations must not be forgotten in the implementation
of the Health Protection Agency. This and the need to bring national
expert support to bear on some local outbreaks were two of the
reasons for the creation of CDSC. For example, the nationwide
distribution of food means that national level investigations
are needed and the investigation of legionella outbreaks often
require specialist input. Relationships between Divisions in the
Health Protection Agency and across regions of the NHS will require
recognition of national jurisdiction on occasion.
25. The PHLS is especially well placed to contribute
to the public health response to communicable disease in countries
with more limited resources as a result of its expertise in communicable
disease surveillance, epidemiology and microbiology. A wide range
of collaborative projects is currently carried out with other
countries by the staff within the PHLS. These are largely conducted
on an ad hoc basis, often carried out by staff in their
own time or grant funded. The potential contribution, however,
is greater than this and, in particular, could include the ability
to respond to communicable disease emergencies around the world
at the request of the WHO as well as the opportunity to train
health professionals from other countries in the UK. The inability
of the PHLS to respond to requests of this sort, other than exceptionally,
is the result of a lack of surge capacity and the opportunity
costs to the PHLS resulting from the deployment of experienced
staff, which would impair the ability of the PHLS to fulfil its
26. The WHO has made clear its wish to be able to
call on the expertise of the PHLS. Following a presentation by
WHO to the PHLS Board in 2001, the development of international
work within the PHLS was supported with the rider that this had
to be balanced against already stretched resources. While the
potential benefit to other countries has rightly been emphasised,
the benefit to the UK of the involvement of the PHLS in such work
should also be stressed. Such work provides staff with experience
of exotic infections in the field or laboratory, infections which
could be at risk of importation. While the former benefit is potentially
of interest to DfID, the latter is of more direct interest to
the DH. Joint support from these two Departments, based on agreement
at an appropriately high level, is needed to unlock the potential
for a more substantial and responsive PHLS/HPA contribution in
27. The areas in which the PHLS could make a significant
To make people available to provide emergency
assistance in response to outbreaks.
To support capacity-strengthening in specific
countries by seconding PHLS staff on a temporary basis.
To enable people with expertise in specific
aspects of microbiology and/or epidemiology to provide support
to specific countries on a consultancy basis.
To use our expertise and facilities in this
country to train people from other countries.
To target our support efforts to specific
countries and specific infections (eg lassa fever) where the UK
need to strengthen its capacity coincides with that of the target
28. A large number of other concerns have been raised
within the PHLS. The proposals for stripping out and repackaging
R&D funding appear to have little merit, but do have the potential
to disrupt current good work, including that on peer reviewed
grants for external agencies. Efficiencies in bulk purchasing
may be lost together with the PHLS network, adding to the disbelief
that the changes can be resource neutral. There are many important
synergies between the regional and national parts of the PHLS
which many fear are being jeopardised as the constituent parts
are placed in different organisations. Reference and specialist
microbiology needs to link in with routine public health microbiology,
and both with routine clinical diagnostic work. The advantages
may be being lost from the handling in the same laboratory of
human specimens and food, water and environmental samples, maybe
relating to the same outbreak. In the PHLS there has been collaboration
between epidemiology and public health microbiology at all levels,
and it is unclear how this will be maintained.
29. Having a skilled and well-motivated workforce
will be key to delivering the aspirations of Getting Ahead
of the Curve. It is feared the central role of the PHLS in
supporting training and high standards may be lost to those joining
the NHS. As CsCDC change into local health protection consultants,
fewer of them may have a background in medical microbiology. All
this means extra effort will be needed to ensure that there is
mutual understanding across the public health and microbiology
disciplines, with common training modules for both doctors and
scientists/non-medical specialists. With time and the right enthusiasm,
there might even be merging of elements of the public health microbiology"
and health protection specialist" career paths. To achieve
this, the HPA might be expected to need a creative and forward-looking
training programme for its staff. However, it seems all the current
PHLS medical microbiology training posts are proposed for transfer
to numerous bodies in the NHS, with damage to the maintenance
of expertise and succession planning specially need by the PHLS/HPA.
Currently, the expected role of the HPA in managing training in
other disciplines is unclear.
30. The medical microbiologist and clinical epidemiologist
could also benefit from increased joint training and understanding
with veterinary colleagues, and with infectious disease physicians.
As increased investment elsewhere in the NHS increases demands
for clinicians, it will be especially important to look critically
at skill mix in health protection. This means a joint HPA-NHS
plan to exploit to the full the abilities of all the players in
the multidisciplinary team, removing any artificial barriers to
personal career progress.
31. In spite of many reservations, PHLS staff at
all levels are striving to introduce the changes required by Government,
whilst seeking to mitigate the risks. The PHLS is now committed
to working with DH on delivering the changes, in the light of
the Secretary of State having determined the more limited role
for the PHLS in future.
Is the UK benefiting from advances in surveillance
and diagnostic technologies: if not, what are the obstacles to
its doing so?
32. Advances in information technology in recent
years have offered new opportunities but have also raised the
expectations of those who provide as well as those who process
and receive information. It is now possible to collate, analyse
and disseminate data in much larger volumes and at far greater
speed than ever before. These same developments in information
technology have also provided the opportunity of bringing together
large volumes of data from disparate sources for analysis and
record linkage, with the prospect of gaining greater insight into
disease patterns and associations. An example is the examination
of suggested associations between MMR vaccination and a series
of clinical syndromes. The electronic patient record and electronic
health record projects have the potential of making it possible
to access a greater breadth and depth of patient data for surveillance
purposes. For these benefits to be realised it is vital that Public
Health organisations, such as the PHLS or HPA, that lie outside
the immediate jurisdiction of the NHS Information Authority, are
given ample opportunity to contribute to discussions on the development
and implementation of initiatives such as the Electronic Health
33. With these advances, however, comes the expectation
that the effort required to provide, manipulate or access those
data should be less. Within the PHLS there has been significant
investment and advances made in the capture and manipulation of
data derived from newer diagnostic technologies based on the analysis
of the nucleic acid (the genes) of micro-organisms, particularly
in reference laboratories such as CPHL at Colindale (see later
reference to Bioinformatics). Similarly, investment in IT systems
procurement and in-house development of statistical programmes
have realised significant advances in the PHLS ability to analyse
and disseminate data from the national surveillance database (labBase2).
However, the implementation of electronic data capture of routinely
generated microbiology investigation results from PHLS and NHS
laboratories has proved a more difficult nut to crack. Although
the PHLS has developed software that has been successfully implemented
in a range of laboratories in England and Wales, the full implementation
of this mechanism of electronic data capture continues to be difficult
to achieve, because of the lack of IT system and data coding standards
within laboratories and the seeming lack of IT resources available
to the NHS, particularly for the implementation of systems that
are not directly supporting clinical care.
34. Advances in information technology have also
led to increased expectations of users as to the volume of information
that may be accessed, and of the ease and speed with which it
may be accessed. In particular, the Internet and its associated
technologies have provided unprecedented access to information
for professionals and public alike. World wide web technologies
for the dissemination of information have been exploited by the
PHLS and others for the delivery of communicable disease surveillance
information. These technologies have also been used for the capture
of surveillance data.
35. Reference laboratory developments in molecular
typing and subtyping of organisms had added greatly to the power
of surveillance systems in detecting outbreaks and significant
trends, and led to greater understanding of disease epidemiology
and sources of infection. For example the recent development of
typing system for cryptosporidium has shown that while some organisms
are found in both humans and other animals there are others that
only appear to infect humans.
36. Diagnostic technologies have now advanced to
the point of being able to identify the actual genetic code of
organisms found to be causing illness in humans. This opens up
new possibilities in respect of patient management and surveillance.
It may soon be possible to tell within hours, or even minutes,
whether a patient with tuberculosis has an antimicrobial resistant
strain, whereas this can take weeks using existing culture-based
methods. The potential uses of these new technologies for surveillance
and epidemiological studies are as, if not more, exciting, with
the possibility of fingerprinting organisms. The processing of
the large and complex sets of data that these diagnostic techniques
generate has given rise to a new scientific discipline, known
as Bioinformatics, which has been identified as a priority for
development within the PHLS, in view of the potential benefits
that it offers for microbial epidemiology, surveillance, outbreak
management, and patient diagnosis and management.
37. The impact of near patient testing is as yet
unknown. The main drive for the use of such tests may well, in
the short term at least, come from the pharmaceutical industry,
with the promotion of over-the-counter tests for infections for
which over-the-counter medication is available. Such testing has
the potential to undermine existing laboratory reporting but also
has the potential to provide an important platform for greatly
improved clinical reporting, particularly if linked to the electronic
health record project, and if the electronic health record project
is linked to public health requirements. These issues are discussed
in a BMJ article7.
38. The PHLS has nationally and internationally recognised
expertise in the development and application of mathematical modelling
and statistical techniques to surveillance. Example of advances
in Mathematical/statistical technique analysis by the PHLS include:
Automated outbreak detection systems that
have been developed and deployed by CDSC, have been since adopted
and adapted by RIVM in the Netherlands.
Modelling to predict future trends and to
assess likely impact of interventions (particularly powerful when
combined with economic data and modelling), has contributed significantly
to understanding and policy development on HIV/AIDS and vaccine
Geographical information system (GIS) developmentsrelatively
underdeveloped as yet, and mainly used for outbreak investigation,
but a potential powerful tool for detection of outbreaks and identification
of exposures eg in combination with water supply, food distribution
or veterinary data.
39. As well as technological advances, there have
been significant advances in the range of data sources used for
communicable disease surveillance in recent years. The most important
of these is probably NHS Direct, with which CDSC has developed
reporting algorithms and surveillance systems for the most common
infectious disease syndromes, and also for alert conditions that
might indicate the deliberate release of the most likely agents
to be used in a bio-terrorist attack. This system has recently
attracted interest from the USA, where similar systems are being
proposed as part of the development of national preparedness for
Should the UK make greater use of vaccines to
combat infection and what problems exist for developing new, more
effective or safer vaccines?
40. The PHLS has an excellent record of working with
the Joint Committee on Vaccination and Immunisation (JCVI) and
others, for example in the much praised4 introduction of meningococcal
C vaccine in 1999. Using its network of laboratories, the PHLS
has been involved in field studies, undertaking surveillance related
to vaccine trials and programmes, and monitoring potential adverse
effects. Albeit the very many technical challenges, there are
still many other infections that remain potentially vaccine preventable.
Many of the practical barriers to making good progress are described
in another submission to this Inquiry8, together with personal
views on the strategic approach needed in the future. This submission
from a PHLS expert team reinforces concerns expressed in this
document over how national surveillance will continue and flourish
under the new arrangements.
Which infectious diseases pose the biggest threats
in the foreseeable future?
41. In recent years the PHLS has produced overviews
of communicable diseases, with a ranking of infections judged
to be of the greatest significance. The last exercise was in 1999.
The methodology to produce the tables shown involved asking CsCDC
and GUM physicians as well as PHLS staff9, with a separate exercise
for those with a primary care perspective10. There was no formal
weighting according to the actual and recorded burden of disease,
and assessment of the potential for health gain (arguably the
most important criterion to influence investment) was subjective.
Communicable diseases of highest public health priority 19999
|Ranking of infectious disease by burden in primary care 199910
| 1 upper respiratory tract
| 2 Meningococcal|| 2 tonsilitis/pharyngitis
| 3 Chlamydia trachomatis|| 3 otitis media/externa
| 4 Influenza|| 4 urinary tract infections
| 5 Tuberculosis|| 5 acute cough
| 6 MRSA|| 6 diarrhoea
| 7 E Coli 0157|| 7 dyspepsia/helicobacter
| 8 Salmonellosis|| 8 viral rashes
| 9 Campylobactor|| 9 vaginal discharge
|10 Helicobacter pylori||10 leg ulcers
|11 TSE||11 sinusitis|
|12 Hepatitis C||12 headlice/scabies
|13 Pneumococcal disease||13 bacterial skin infections
|14 Hepatitis B||14 fungal skin infections
|15 Clostridium difficile||15 cellulites
|16 Malaria||16 genital chalmydia
|17 Staphylococcus aureus||17 chronic fatigue/ME
|18 Gonorrhoea||18 chicken pox
|19 RSV||19 penumonia|
|20 cryptosporidium||20 antibiotic resistance surveillance
42. Threats could include those to mortality (head count or years
of life lost), morbidity, economic impact or political risk. Whichever
way infectious threats are assessed, however, an influenza pandemic
ought to come at the top of the list. The view in Getting Ahead
of the Curve was that it is not a matter of if but when there
is another flu pandemic. Although global and national influenza
surveillance is in place, the ease of international and domestic
travel and the changed structure of society could well lead to
an international mortality in tens of millions, as in the 1918-19
pandemic. Limitation in supply of vaccine to a new strain, with
the inevitable delay in manufacture, could produce real difficulties
for health and social care economies in the UK. These are already
operating with high utilisation rates and little spare capacity,
and yet would be expected to cope with a major surge in demand
over a several week period.
43. While pandemic influenza presents a major and unpredictable
threat, the annual (albeit variable) influenza epidemics in the
UK, along with infections due to other common respiratory viruses,
account for greater morbidity and mortality than infrequent influenza
pandemics, though not necessarily greater years of life lost.
The opportunity to intervene effectively against influenza has
been increasing substantially in recent years and is likely to
continue to increase. Increased vaccination uptake has been successfully
promoted and more effective influenza vaccines are on the horizon.
Effective anti-influenza drugs, with little in the way of troublesome
side effects, are now coming on to the market. Near patient tests
offer the promise of more rapid individual clinical diagnosis
(and treatment) as well as novel methods for influenza surveillance.
Vaccines against some of the other respiratory viruses are also
being developed. In the light of these developments, enhanced
surveillance and assessment of disease burden, continuing development
of microbiological methods, and research are essential both for
epidemic and pandemic influenza.
44. HIV/AIDS headed the 1999 priority list and the prevalence
of HIV is rising steadily. The UK made an excellent start in the
fight against HIV as it undertook early mass behavioural interventions
against AIDS and HIV from circa 1986 before infection had had
much of a chance to penetrate. However the infection is now proving
difficult to contain with unacceptable levels of transmission
among gay men and steadily rising numbers of heterosexually acquired
infections. While the majority of these are acquired abroad, increasing
numbers are now acquired in the UK. The numbers of people living
with HIV in the UK is forecast to rise from 27,000 in 2002 to
36,000 in 2004. There is also a growing international spectre
of anti-viral resistance which requires careful monitoring.
45. Genital chlamydia is of importance because its association
with infertility. Recent trials with which the PHLS has been associated
have shown the potential for health gain through opportunistic
screening in primary care.
46. Tuberculosis now poses a substantial public health problem
in some areas of England and Wales and in some population subgroups.
Difficulties with the control of the disease are compounded by
high rates of new disease in people recently arrived from high
prevalence parts of the world, the HIV epidemic, homelessness
and drug resistance. The PHLS (HPA) has a central role to play
in the development and implementation of the national action plan
announced in Getting Ahead of the Curve. Microbiological
diagnosis, drug sensitivity testing and epidemiological typing
are key elements in the control strategy along with the development
of better methods in all these areas. Strengthened epidemiological
surveillance is also essential for determining the success of
control activities and shaping future control policy.
47. Gastrointestinal infections were given little attention in
Getting Ahead of the Curve, in spite of them being common
experience of all members of the population, with one in five
affected by infectious intestinal disease each year. The annual
cost to the nation is in the region of three-quarters of a billion
48. Norwalk-like viruses (NLV) account for the major burden of
recognised gastrointestinal infection, the greatest impact of
outbreaks being in hospitals.12 NLV have been prominent in the
media headlines this summer with large outbreaks in hospitals
leading to ward closures. These, in turn, lead to disruption of
services, including operationswith adverse consequences
for the Government's Waiting List initiative. The epidemiology
of campylobacter infection, the major bacterial pathogen causing
gastrointestinal infection, is still poorly understood, though
recent studies are helping shed light on potential inter-species
differences in disease transmission.13 Whilst fortunately uncommon,
Verotoxin producing E.coli (0157) can result in severe chronic
sequelae, including renal disease. The most recent major outbreak
in the UK took place in Scotland in 1997, and the subsequent inquiry14
commented unfavourably on some aspects of the laboratory arrangements
there. This could be a warning for England when the PHLS network
49. Helicobacter pylori is a problematic but common infection,
generating large prescribing costs in primary care15. Hepatitis
B and C are similarly diseases where the costs of treatment are
mounting in the light of technical advances and a better appreciation
of the possible long-term consequences.
50. There are lessons from the handling of the Foot and Mouth
Disease (FMD) epidemic16 for the investigation of animal diseases
generally, some of which, unlike FMD, might be a zoonotic risk
to humans. Work on human and animal health continues to need to
be better integrated with joint work programmes and some joint
budgets for use at regional and local levels for surveillance
What policy interventions would have the greatest impact on
preventing outbreaks of and damage caused by infectious disease
in the UK?
51. Various suggestions have been made in the above paragraphs
for how systems could be improved, but in order to answer this
question adequately there needs to be a secure evidence base.
This may well be present for the introduction of a new vaccine,
or the introduction of new screening, but rarely is it otherwise
the case. Such evidence would need to benefit from health economic
and behavioural science input, with the potential for health gain
as the driving factor. Whilst there are many areas of infectious
disease prevention and control which do not lend themselves to
randomised control studies, there are some new methods being developed
for assessing the evidence base for prevention and control interventions.
52. A weakness of Getting Ahead of the Curve is its lack
of analysis of the strengths and deficiencies of current infectious
disease surveillance, control and prevention arrangements. In
this respect, it would be of interest for the evidence base to
be shared that justified the organisational changes proposed in
Getting Ahead of the Curve and how this policy could be
delivered whilst remaining resource neutral. One route to securing
such evidence is to evaluate changes post hoc. Whilst others might
well learn from experience in the implementation of Getting
Ahead of the Curve in England, were this formally evaluated,
the English might be able to learn from evaluation of the proposed
Welsh health protection model, and from that of the implementation
of Scottish plans for health protection, yet to be announced.
53. Some policy interventions can be sparing of resources, and
these have the potential for the greatest impact for the smallest
pain. For example, carefully drafted central guidance and clear
advice can have impact far beyond the minimal cost of generating
the guidance, although the implementation may well prove expensive.
Updated advice to local health and social care economies on how
best to cope were there another flu pandemic is overdue from DH,
in spite of this being a WHO requirement17. Were the GMC to reinforce
with all doctors the need to recognise their population/public
health as well as clinical responsibilities, we might see improved
reporting of outbreaks. There are some areas left to doctors which
could benefit from opening up to other suitably trained health
care professionals, which could save money as well as improve
results: giving TB health visitors limited power to prescribe
would be one such example. The recording of and learning from
outbreaks, adverse incidents and near misses ought to be resource-releasing
too, especially if the trend towards increasing litigation continues.
The same applies to the continued effort to reduce health care
associated infection, including relatively simple measures like
hand hygiene practices, and programmes on the insertion and maintenance
of intravenous and urinary catheters.
54. Other areas need additional resources, with the amounts being
well justified by the health gain generated. For example, surveillance
is threatened without adequate support from the public, and the
DH and CMO are well placed to ensure that support is forthcoming.
Surveillance would benefit most from policy interventions that
encourage or otherwise facilitate the flows of data and information
that are necessary for informing timely and effective interventions.
Priorities in this respect include:
Promulgating public information and professional guidance
on the uses of patient information for public health purposes.
Greater promotion of the development and adoption of common
standards for information systems within the health service, particularly
with respect to coding schema and data interchange formats.
Ensuring that key developments, such as the electronic
patient record and the electronic health record projects, meet
public health requirements as well as clinical care requirements.
Consideration of how best to ensure reporting by laboratories
(particularly if current generally good levels of reporting are
compromised by restructuring of laboratory services as a result
of either implementation of Getting Ahead of the Curve or
Ensuring that appropriate priority is given to resourcing
of information system developments that support surveillance.
Making available R&D funds for development of information
systems that will support surveillance, particularly in respect
of surveillance within primary care and the capture of results
from near patient testing.
55. Beyond the health service, there is a need for policy that
will promote a more systematic approach to testing of animals,
food and water for pathogens that represent a public health threat
to man. At present, for example, many important zoonoses are only
tested for on an infrequent and sporadic basis by veterinary agencies
because the organisms have little health or economic impact on
the animals from which humans can acquire infection.
56. For now, much PHLS effort is being spent on how best to retain
the current strengths of the PHLS whilst moving to the new structures.
The Board has already put on record that taking more time to introduce
the changes would increase the likelihood that current good work
is not lost in the upheaval. In the absence of any evidence to
justify the proposed speed, this is put forward as the one policy
intervention above all which would have the greatest impact. Where
transfers prove not straightforward, delaying the changes for
a year would increase the chance of the transition being concluded
safely. It should be noted this would not mean that progress could
not be made on many other fronts, or in other locations.
57. The PHLS network has played a major part in controlling infection
and communicable diseases in the past. Following the infectious
disease strategy from the CMO, England, the staff as a whole and
the constituent parts are now looking to working within new structures.
Whether based within local NHS Trusts, within the HPA or in the
National Public Health ServiceWales, staff of the current
PHLS hope and expect to be able to continue contributing their
expertise to the fight against infection. This submission has
outlined some issues that need to be addressed to help that fight.
The most important of these are outlined in the box.
Key Points in Evidence from the PHLS
Take time to achieve change, resource it adequately, identify
and deal with risks to business continuity, carry those affected
through the change process, and evaluate change carefully. From
the PHLS perspective, the process of generating and implementing
the strategy Getting Ahead of the Curve has fallen below
the high standards normally expected.
Resources, whether human or financial, have to match expectations.
It is hard to see how this is the case, if the implementation
of Getting Ahead of the Curve is to be resource neutral.
Ensure shared ownership of surveillance by those who generate
the data, whether clinicians, microbiologists or epidemiologists.
Improved feedback to those working at a local level may improve
cooperation, but financial and other practical barriers may need
to be identified and removed too, eg funding for public health
work, including reporting to CDSC.
Harness new technology, particularly information technology,
to improve recognition and reporting of infections. Substantial
additional investment will be required.
Move away from passive surveillance to techniques involving
less biased selection of samples.
There is productive synergy between routine work for the
NHS (clinical diagnostic or field investigation), R&D, and
enhanced public health activities. It will be important not to
lose these benefits in the new structures either from separation
at a local level or from separation of local activities from work
needed at a national level.
Surveillance and communicable disease control would be
assisted by an acceptance of population and public health responsibilities
by all clinicians.
Enhance the evidence base for dealing with infections,
recognising the importance of development as an integral part
of the specialised laboratory work needed for surveillance in
a changing world.
Update the law relating to infectious diseases to recognise
new problems, new structures and modern attitudes to human rights.
Inform and educate the public about infections and how
the responsible use of data can help protect them and their families
1. PHLS formal responses to the consultation document on creating
the Health Protection Agency and to the Discussion paper on the
future contribution of microbiology services in the public health
regions. On www.phls.co.uk/hpa info/index.htm
2. Letter from the chair of the PHLS to the Secretary of State
23 September 2002. On www.phls.co.uk/hpa info/index.htm
3. Infection Control in the Community study June 2002 on www.phls.co.uk/publications/pdf/ICICreport.pdf
4. Modern policy-making: ensuring policies deliver value for money.
Report by the Comptroller and Auditor General. HC 289 November
5. PHLS Research and Scientific Strategy Committee: report on
the implementation of the theme recommendations from the PHLS
review. September 2002
6. Letter from CMO and the DH Permanent Secretary September 2002
on the future arrangements for microbiology laboratory services
7. Borriello S P. Near patient Microbiological tests; BMJ 1999;
8. Zambon MC, Brown DWG, Miller E. Submission to this inquiry
9. Horby P, Rushdy A, Graham C, O'Mahony M on behalf of the PHLS
overview of communicable diseases committee. PHLS overview of
Communicable Diseases 1999. Communicable Disease and Public
Health 2001; 4:8-17
10. McNulty CAM, Smith GE, Graham C on behalf of the PHLS primary
care coordinators. PHLS primary care consultationinfectious
disease and primary care research and service development priorities.
Communicable Disease and Public Health 2001; 4 18-26
11. Food Standards Agency. A report of the Study of Infectious
Intestinal Disease in England. 2000 London: The Stationery Office.
12. Meakins SM, Adak GK, Lopman BA, O'Brien SJ. General outbreaks
of Infectious Intestinal Disease (IID) in Hospitals, England and
Wales, 1992-2000. J Hosp Infect (in press).
13. Gillespie IA, O'Brien SJ, Frost JA, Adak GK, Horby P, Swan
AV, Painter MJ, Neal KR and the Campylobacter Sentinel Surveillance
Scheme Collaborators. A case-case comparison of Campylobacter
coli and Campylobacter jejuni infection: A tool for
generating hypotheses. Emerging Infect Dis 2002; 8: 937-42.
14. The Pennington Group. Report of the circumstances leading
the 1996 outbreak of infection with E Coli 0157 in Central Scotland,
the implications for food safety and the lessons to be learnt.
Edinburgh. SO. 1997
15. See submission to this Inquiry from the Helicobacter Working
16. Anderson I. Foot and Mouth Disease 2001: Lessons to be Learned
Inquiry. HC 888. The Stationery Office. July 2002 ISBN 0-10-297624-4
17. Influenza Pandemic preparedness Plan. The role of WHO and
Guidelines for national and regional planning. Geneva, Switzerland.
April 1999. On www.who.int/emc