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.
MEDICAL RESEARCH COUNCIL BUDGET 2001-04 £
| 2000-01|| 2001-02
|| 2002-03|| 2003-04
|Real terms increase (%)||
|Total extra funding||9.7
|core programmes and PhD stipends||
(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
Tuberculosis (often in relation to HIV).
Deliberate release of biological agents (eg into
food or water supply, aerosol, smallpox etc).
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.
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
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.