Select Committee on Science and Technology Written Evidence

Memorandum by The British Infection Society

  We welcome this opportunity to contribute to the evidence to be considered by the House of Lords relating to human infectious disease. We are a body with over 600 members that includes a broad spectrum of those interested in infection, including infectious disease physicians, adult and paediatric, clinical microbiologists, and virologists, public health physicians, genito-urinary physicians, and basic scientists.

  In response to the numbered questions listed in the call for evidence:

(1.a)  Surveillance of Infectious Disease

    The key difficulty in this area is that presently surveillance for infectious diseases is mostly a passive exercise. A case must, at present, be identified, suitable samples sent, the causative microorganism identified, and a report issued to the responsible clinician and surveillance network. This "reactive" system will always underrepresent the true incidence of an infectious disease outbreak, and will necessarily provide data that are lagging behind the evolution of the infection. Surveillance data is crucial in identifying and controlling infectious disease. It will be provided particularly by those who are "infection specialists"—infectious diseases physicians (adult and paediatric), microbiologists/virologists and public health physicians. Reporting of less serious but common infections will involve others such as in primary care.

    The success of the HPA will depend on the reliability and accuracy of information delivered in a timely fashion; a structured "infection service" supported by a robust IT service would provide the infrastructure for this to happen, as well as providing a consistent quality of clinical infection service.

    In addition to the "passive" surveillance, it would be beneficial to carry out some more active surveillance involving population sampling. This is performed, for example, from time to time to quantify the incidence of influenza in patients presenting with fever and sore throat. This form of surveillance could be extended both to community acquired and hospital based infections, and would provide a more accurate estimate of the threats posed by particular infectious diseases.

(b)  Treatment of Infectious Diseases

  A major problem is the lack of defined national structure to deliver infection services at local level, encompassing the key elements of those whose training is specifically focussed on infection: specialists in clinical infectious diseases (adult and paediatric), microbiology/virology and public health. Although there are centres within the UK that do provide such a service, they are geographically unevenly distributed; for example, the South West does not have an Infectious Disease Unit, and most DGHs do not have input from those trained in infectious diseases. We believe that all should be entitled to the same quality of care regardless of where they live. The infection team requires skills from each of the above disciplines and the profession has recognised this and introduced a new joint training programme of Infectious Diseases and Microbiology/Virology two years ago. Doctors trained under this scheme will be in an excellent position to strengthen the infection service (whether appointed to teaching or district general hospitals) and builds on the common areas of interest between the disciplines. Joint training is currently being discussed between paediatric ID and microbiology/virology and also between public health (infection) and ID. The proposed service structure for infection has received support from the Royal College of Physicians, Royal College of Pathologists, Royal College of Paediatrics and Child Health and the Faculty of Public Health Medicine (copy of discussion document can be provided).

  Effective treatment of Infectious Diseases is continually hampered by the development of resistance to antibiotics in microorganisms, as investigated by a previous House of Lords committee. We would like to stress the need for increased support into research into Infectious Diseases, both at a basic level and also in the directed search for novel anti-infectives. The UK has a productive scientific community that is in danger of a serious decline due to the continuing reduction in funding for scientific research. This is particularly important in the field of infection, where we face new challenges with new pathogens and antibiotic resistance. We also have new opportunities, with the advent of new technologies producing for example the complete DNA sequence of many human pathogens. Although funding of the Medical Research Council is increasing in real terms, this is only by a very small percentage (see table). The income of UK charities that support research is currently considerably diminished because of poor stock market performance. If we are to improve the treatment of Infectious Diseases within the UK, more funding for Infectious Disease Research is essential.

2000-01 2001-02 2002-03 2003-04 Three year
Total339.9349.6 371.9387.2
Real terms increase (%) 6.2
Total extra funding9.7 32.047.389.1
and e-science1.0
core programmes and PhD stipends 16.1

(c)  Prevention of Infectious Diseases

  This requires integration of surveillance, laboratory based diagnosis, epidemiology and effective treatment. There should be sufficient manpower attached to units such as in Infectious Diseases managing chronic infections such as hepatitis C and hepatitis B and HIV to ensure patients receive consistent and repeated information about reducing risk of infection. There must be sufficient support to sustain immunisation strategies.

  2.  The Society broadly welcomes the Government's Infectious Disease strategy. We feel there are a number of areas that do not address some of the problems identified above. How will the skills of the regional epidemiologist best be used? It seems unsatisfactory for them to be dislocated from their association with local microbiology laboratories. There is a strong argument to have responsibilities that include closer and active links with groups of HPA public health consultants at subregional level, since most outbreaks are limited to local or subregional areas. The principle of having an epidemiologist as an active part of that team will strengthen and develop the local structures, enhance recruitment, training and research. There is a concern that if the regional epidemiologists are strongly bound to the central HPA structure, this will detract from their ability to work on a regular basis as part of the local team. This will weaken the response to an Infectious Disease outbreak.

  In addition, although "Getting Ahead of the Curve" addresses many of the issues around surveillance of infectious diseases and laboratory structures essential for diagnosis, it does not address the fundamental issue of service delivery. As identified above, a surveillance system is only as good as the data being fed in. Ensuring a uniform national "infection" structure with networking between infection "centres" (larger centres with an Infectious Diseases Unit where most training, education, research etc. will occur) and infection "units" (smaller departments where the similar skills are represented but in lesser quantity (eg at DGH) each supported by robust IT structures (with two way flow of information) is fundamental to a successful infectious diseases strategy.

  3.  We do not feel that the UK is benefiting from the advances in diagnostic and surveillance technologies. There is an ever increasing number of rapid molecular methods of diagnosis of infectious diseases (eg based on the polymerase chain reaction). Investment in these technologies is not currently sufficient to ensure their widespread use.

  There is a real shortfall in dissemination of surveillance information to clinicians. This requires a considerable improvement of Information Technology provided to physicians treating infection. As a principle, we feel that there will be a greater quality and commitment to accurate and timely data input if there is free flow of information in both directions ie those entering data are able to very easily obtain information back from the central database providing a sense of common "ownership".

  4.  The UK vaccination programme is presently highly effective. There is a danger that the introduction of new vaccines with potential side-effects might lead to a decrease in uptake of all vaccines. The majority of childhood illnesses are effectively covered. However, there is a safe and effective vaccine for chickenpox available which is in use in the USA. This could potentially be introduced.

  5.  The biggest threats posed by infectious diseases are:

    —  Bacteria resistant to antibiotics, both in hospital and community.

    —  Travel-acquired infections.

    —  Tuberculosis (often in relation to HIV).

    —  Deliberate release of biological agents (eg into food or water supply, aerosol, smallpox etc).

    —  Influenza epidemics.

  6.  We have considered what interventions would have the greatest impact on securing early diagnosis and treatment of infection and provide optimum information aimed at preventing outbreaks of and damage caused by infectious disease in our responses above. To summarize:

    —  National structure of infection services (ID, micro/virology, public health)

      —  Network structure of multidisiplinary teams to provide optimum identification and management of infection and facilitate active epidemiological response. Ensure delivery of optimum service and also facilitate manned rotas, subspecialisation, recruitment, training, education, and research which will be essential to sustain infection services long term.

    —  Improved IT structures to maximise data from passive surveillance.

      —  IT is fundamental to the success of timely flow of information.

    —  Implementing programmes of active surveillance.

      —  More detailed targeted information for specific diseases or specific populations.

    —  Increasing the use of molecular diagnostic techniques.

      —  More rapid diagnosis will lead to more rapid action to control infection.

    —  Improving the support to basic and applied research into infectious diseases.

October 2002

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