Memorandum by the Association of Clinical
1. Surveillance depends on timely collection
of data to indicate any increases in infectious disease activity
from baseline. Often this will involve an element of screening
normal populations. Problems therefore arise when data is either
not submitted or is not analysed efficiently. It may also be incomplete
eg when a screening programme has insufficient coverage. Prevention
of infection relies on targeting intervention measures effectively
and this has to take into account the epidemiology of that infection.
Therefore surveillance underpins effective prevention. Treatment
of infection is usually based on a positive diagnostic result
combined with clinical evidence. It will also take into account
information on possible drug resistance. Diagnostic laboratories
must therefore provide a rapid service so that treatment can be
provided effectively. New technologies offer opportunities to
reduce testing time and, although initially costly, should be
utilised. Research and development in all these fields needs to
be adequately funded. Finally there must be educational initiatives
aimed at increasing public awareness of the problems of infectious
diseases and how to avoid them.
2. The new strategy Getting Ahead of
the Curve does, in theory, address these issues. The quality
of reporting within the current system has been criticised although
it does at least provide a basis for improvement. There is concern
that the commitment to surveillance may be lost with the introduction
of the new agency and that the situation will deteriorate. In
particular the time-scale for the implementation of change is
a major cause for concern since surveillance mechanisms may not
be in place before the demise of the PHLS, ie April 2003. There
also needs to be commitment to the continued development of diagnostic
services since this is not a static field.
3. Continuing development and the introduction
of new technologies for both diagnosis and surveillance have been
crucial elements in a fast-moving field. It is essential that
this continues and that the role, often historically fulfilled
by PHLS, is recognised. Dedicated funding is needed which distinguishes
between pure research and the development of microbiology services.
4. Obviously where effective vaccines are
available they should be used to protect those at risk. Again,
the use of epidemiology to identify these groups is essential
and continuous monitoring is essential to determine uptake. Vaccine
development is costly so that future candidates for investment
should be assessed to be ultimately vaccine preventable, ie that
efficient and effective use of the vaccine can be achieved. Unfortunately
the public faith in vaccination has been damaged recently and
this will require some effort to restore confidence.
5. In addition to the areas already mentioned,
ie sexually transmitted infection, antimicrobial resistance, particularly
multi-drug resistant TB and vancomycin resistant MRSA and hospital
acquired infections, threats exist from re-emerging infectious
problems, eg TB.
Other areas for consideration should be:
(i) "New" agents which arise, eg
the recognition of several major viral infections such as Human
Immunodeficiency virus and Hepatitis C in the last 20 years. There
are numerous other less global but equally severe infections,
eg Hepatitis E virus, some of which may be zoonoses and these
need to be investigated.
(ii) The continuing evolution of microbial
agents which confers not only antimicrobial resistance but may
alter host range.
(iii) The rapid spread of infection worldwide
which is possible as a result of increased travel, eg influenza
(iv) Bioterrorism organisms: anthrax, plague
and tularaemia, clostridium botulinum, Q-fever and any bacterium
engineered for virulence and transmissibility.
(v) vCJD. We have not seen all the implications
of this yet as the total number of individuals infected is currently
unknown and difficult to predict.
(vi) Endogenous retroviruses transmitted
from animals (eg pigs) to humans. This is a theoretical possibility
if xenotransplantation is approved. The global impact of the transmission
of a retrovirus from chimpanzees to man, ie HIV, has been clearly
6. Statutory reporting may help to achieve
this but needs to be enforced and is difficult to achieve. In
addition suitable IT systems are required. As mentioned previously,
developments in testing which provide early and quick diagnosis
also need support to enable effective surveillance. Increased
screening for certain infections, eg HCV, would provide better
baseline epidemiological data and subsequently better targeted