Select Committee on Science and Technology Minutes of Evidence

Memorandum submitted by Professor S P Borriello

1.   What are the main problems facing surveillance treatment and prevention of human infectious disease?

  1.1  The main problems in preventing infections are not new and include the following:

    —  Human behaviour (non-sexual)—Best practice has been identified for eg, food production and handling/preparation, and hospital infection control. This is all too often not implemented or followed eg, hand-washing. More work needs to be done on identifying how to influence human behaviour.

    —  Human behaviour (sexual)—Casual sex and rejection of barrier contraception contribute to the increases in sexually transmitted infections (STIs), as does human trafficking and enforced prostitution. For the former, more work is needed on use of professional communicators (eg advertisers) to ensure effective messaging to target groups.

    —  Population perception of risk—Risk communication is poor. This compromises introductions of new vaccine programmes and continuation of existing ones. A more pro-active approach of risk communication may reduce the impact of publicity perceived adverse events. Risk communication is also essential to influence sexual behaviour and reduce STIs.

  1.2  The main problems facing surveillance are:

    —  Capture of diagnosis/test result as testing becomes increasingly "near patient" and community based.

    —  The increasing primacy of individual privacy and confidentiality.

2.   Will these problems be adequately addressed by the Government's recent infectious disease strategy, Getting Ahead of the Curve?

  Only partly. There is a strong case for the HPA to have a separate Vaccine Division.

3.   Is the UK benefiting from advances in surveillance and diagnostic technologies?

  No. Overall, analysis of data provided to surveillance centres is rudimentary and lacks the application of sophisticated analytical techniques for trend analysis, pattern recognition and cause-effect linkage that is routinely applied in other disciplines eg, financial analysis, meteorological analysis.

  The huge potential of new diagnostic technologies is poorly realised in the UK due to conservatism as a nation characteristic, under investment in adoption of current new technology, insufficient evidence based guidance to advise on investment, delays in modernisation/rationalisation of pathology.

4.   Should the UK make a greater use of vaccines?

  Yes. However, problems do exist in development and utilisation of new, more effective/safer vaccines. The drive is towards better characterised and standardised vaccines ie, away from whole cell attenuated (with risk of adverse reactions or reversion to wild type) and towards sub-unit vaccines. Problems exist primarily in lack of GMP facilities causing bottlenecks in early safety trials, absence of good animal models for early safety and efficacy studies, the huge costs of clinical trials, and risks of litigation.

  The underlying science of basic immunology related to induced protective immunity needs to be further developed, as does our understanding of adjuvents and other methods of immunomodulation.

  Studies on the genetic basis of adverse reactions need to be encouraged, with the prospect of pre-screening to prevent exposure of such individuals to particular vaccines or vaccination regimes.

5.   Which infectious diseases pose the biggest threats in the foreseeable future?

  Most predictions are based on what is currently a problem and expected to increase, and as such are well-known eg, TB, HIV-AIDS. The key point is that HIV was not predicted, and its next equivalent is unknown. The next flu pandemic is predicted only in so far as that there will be one. The purposeful or inadvertent release of a genetically engineered microorganism has also enjoyed much debate and publicity.

  Key areas that have not received adequate consideration and which may contribute to emergence of a significant future threat are:

    —  Increasing exposure to new environments. Most consideration has been given to encroachment by people. However, unregulated/illegal export of wildlife and derived products poses a real risk of bringing a new pathogen into an environment (the UK) where population density and practices favour transmission. In other words, the "jump" is made easier. An example of risk here is the illegal importation and sale of bush meat with questionable provenance.

    —  Development of engineered vaccines for veterinary use, or engineered microbes to control plant pests could lead to an unforeseen and unpredictable change to host range (to include man) or creation of virulence for man where none previously existed.

6.   What policy interventions would have the greatest impact on preventing outbreaks and damage?

  Most of the practices needed to attend to this issue are already well known (see response to point 1 above). The main problem is one of ensuring maintenance of best practice and introduction and adoption of policy. The policy interventions that will have the biggest impact are those that help guarantee safe food and clean water.

  There also needs to be greater understanding of where and how outbreaks are detected to facilitate earlier intervention, so minimising damage caused. There has been an over emphasis on surveillance in the belief that surveillance detects outbreaks. In the vast majority of cases, the situation is that outbreaks are reported to those who are given responsibility for surveillance eg, the two most recent ones in the UK being legionella (Barrow-in-Furness; Sandwell, W Midlands) and Salmonella (National). Good epidemological investigation helps to identify the source, which then enables key interventions. It follows therefore that supporting early detection of outbreaks (improved diagnostics, improved training and awareness of frontline staff) and improved and earlier reporting of outbreaks with good epidemiological response is paramount.

  We had the pre-surveillance era, and are now at the end of the first quarter century of the structured national surveillance era. There is need to move into the "post-surveillance" era, where more resource is shifted to targeted specific question led surveillance and to interventions.

Professor SP Borriello

January 2003

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