Select Committee on Science and Technology Written Evidence

Memorandum by Dr Elizabeth Haworth, CDSC South East

  On behalf of both CDSC South East and myself as an individual working in the field of infection control/health protection, I offer the following short submission in answer to the particular questions posed for the consultation.

  1.  Current infection surveillance systems are incomplete and not adequately representative of infection risks to the whole population. The laboratory reporting system in place through the PHLS CDR reporting scheme is used responsibly by most clinical microbiologists, though may miss infections dealt with in the private sector. However, too many laboratories have inadequate pathology systems and IT support to allow efficient routine, automatic electronic reporting of infection. Laboratory reporting will not include near patient testing which is likely to increase rapidly when tests are reliable. Capture of this data will be necessary from Primary Health Care. Though an unusual infection of public health importance is quite likely to be reported to CDSC Colindale, the Regional Epidemiologist or the local CCDC, this requires special action by microbiologist or infectious disease physician (or GP) rather than automatic extraction from the existing record. Thus there is the risk of non-reporting/failure to alert because of human omission (due to over commitment). Without some standardisation of pathology systems or establishing specific standardised microbiology/infection modules of them and investment in IT support to ensure effective electronic reporting throughout all health care settings, the problem of under-reporting will persist.

  To allow for the problem of emerging/new infections and the continuing frequent changes in the organisation of health services in the UK, an individual patient based syndromic reporting system needs to be set up nationally. It may be that this could be developed along side a change in routine reporting of known pathogens to a sentinel site system. However, such a change, which would release resources for new surveillance developments, would need thorough investigation and validation.

  Links between infectious agents and treatment of the infections caused is poor. Where it exists it is due to the enthusiasm of individuals. However record linkage at the individual patient level is possible and essential to register the use of antibiotics and sensitivity/resistance patterns. This needs the universal use of an electronic patient record and IT development and support to make the health care linkages. Such information is essential to target research needed to inform the development of effective antimicrobials against new and resistant organisms.

  There is a continuing challenge to get surveillance and control of infection taken more seriously. Better use of surveillance, particularly targeted for risk groups, eg travellers abroad, asylum seekers, prisoners, the immunosuppressed, children, the elderly, to establish and monitor successful public health programmes for the prevention and control infection would make the case. There is much scope to learn from international approaches to the surveillance control and prevention of infectious diseases. I am currently exploring approaches to the surveillance and control of hospital associated infection (HCAI) and antimicrobial resistance (AR) in Hong Kong and Australia. I am impressed by the progress made in Hong Kong to reduce the burden of HCAI and AR. This is done largely by detailed surveillance of individual infections, regular point prevalence surveys in hospital and for AR, rapid feedback of antibiotic appropriateness to the prescriber and the control of prescribing by senior consultants in clinical infectious diseases/microbiology. The ratio of infection control nurses to hospital beds is at least 50 per cent greater than in the UK to allow this to happen.

  2.  Some of the above problems have been discussed in the Government's recent health protection strategy, Getting Ahead of the Curve (GAC). This has stressed the importance of implementation being resource neutral. While, in the long term, with improved prevention of infectious and non-infectious environmental disease, this may be possible, in the short term successful implementation will need considerable investment in IT, education and more specialist health professionals. Health economic/cost benefit studies should be used to help develop a national framework for GAC implementation together with the authority and specific funding necessary.

  3.  The UK is not benefiting yet from advances in surveillance and diagnostic technologies because of the failure to establish a programmed approach to the surveillance and control of infection and to make this an exciting health care development. GAC seeks to establish such an approach, but will need investment to make this happen.

  4.  There is no doubt great potential for the effective use of vaccines to prevent and control infection (in human and other animals). However, with recent and continuing biotechnical advances and current regulatory standards it is no longer possible or appropriate for Health Departments to produce vaccines. More work is needed to create an international coalition between WHO and Government Health Departments/Public Health Authorities to produce a joint business and investment plan for the world-wide production of a range of vaccines and promotion of vaccine development to agreed specifications. An adequate profit margin must be allowed to attract biotechnical interest, fund high quality manufacturing costs and allow for necessary research and development. This means that such a coalition will need to subsidise the cost of immunisation programmes, especially in developing countries. In addition, more and better targeted education for the public and health professionals will be necessary to appraise immunisation evidence and assess and manage risk and communicate these through better use of the media.

  5.  It is difficult to predict which infectious diseases pose the biggest threats to the UK population in the foreseeable future. Tuberculosis is a growing threat in vulnerable individuals, including asylum seekers and the homeless, particularly where the TB control infrastructure is weak, and against an increasing number and proportion of immunosuppressed people in the UK. Immunosuppression is a risk factor for a range of infectious diseases, including new and emerging viral infections. AR in the absence of effective new antibiotics is also a threat until AR is controlled. My guess is that the greatest threat will be an as yet unknown viral infection such as a new strain of influenza, perhaps due to antigenic shift in zoonotic flu which causes a flu pandemic. However, other threats include infections which emerge because of global environmental/climatic change, bioterrorism and the as yet unclear risk of prion disease in humans.

  6.  The policy interventions which would have greatest impact on the prevention of outbreaks and the complications of infection include:

    —  Better education of consumers, in collaboration with food producers and suppliers.

    —  More visible preventive measures delivered through co-ordinated multiagency pro-active health protection.

    —  Co-ordinated development of and access to the infection evidence base by appraisal and categorisation of current evidence, a co-ordinated, if possible, international research programme to fill the gaps in knowledge/credible evidence and making this readily available by improving access to and accelerating development of Cochrane reviews, the National Electronic Library for Health and its Communicable Disease Branch.

October 2002

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