Memorandum by the Society for General
1. CURRENT EFFECTIVENESS
Infectious disease surveillance in the UK looks
at a wide range of infectious agents from a variety of viewpoints.
It is aimed, in part, at achieving improved protection of public
health by an increased understanding of the epidemiology of infectious
agents and the early recognition of significant trends and new
events of public health significance. It also monitors progress
and effectiveness in control and prevention strategies. Ideally
surveillance should be targeted at high priority public health
issues and should provide information of direct relevance to policy
development. It should be sufficiently flexible to move on rapidly
in the face of new challenges; those involved in surveillance
need to be acutely aware of the necessity to remain alert for
the novel and unexpected.
Influenza is an example of surveillance in a
field of continuing and major public health importance, in which
the UK has had an internationally leading role. We have an outstandingly
good national surveillance programme, centred on the PHLS, but
also make important contributions to the global surveillance of
influenza through our international reference centres at the National
Institute for Medical Research (MRC), PHLS and National Institute
for Biological Standards and Control (NIBSC). Collaborating closely
with WHO, these centres have a key role in the early identification
of new influenza virus variants of epidemic and pandemic potential
and in ensuring that up-to-date influenza vaccines effective against
these variants will be available. It is worthy of mention that
the WHO influenza surveillance network, one of the most effective
and practical aspects of WHO activities, was established in 1948
on the advice of a British virologist, Sir Christopher Andrewes,
and has enjoyed substantial input from UK scientists for the last
Surveillance of poliovirus and poliomyelitis
in relation to the global programme on polio eradication has received
major attention in the UK as has measles, rubella and mumps surveillance
in relation to our public health immunisation programme. A further
good example of UK surveillance is in the field of meningitis
including studies relevant to the effectiveness of vaccination.
The introduction of Hib and more recently meningococcal C vaccine
in the UK were examples of public health intervention where surveillance
played, and still plays, a critical role in the design and effectiveness
monitoring of the vaccination programme. The above examples of
surveillance have all depended for their success on strong academic
science inputs, and rely on advanced technologies and innovation.
There are many other examples, including the
important field of food microbiology, for example the surveillance
of Salmonella strains in relation to food safety and food-related
outbreaks of disease.
Surveillance in the UK will increasingly need
to focus on the arrival of exotic agents such as West Nile virus,
dengue, ebola and others, and will need to include alertness for
agents introduced through bioterrorism.
It is important that surveillance is not restricted
to humans and human agents. Surveillance of wild and domestic
animals is critically important. Many of the new infectious agents
of man were of animal origin, eg the influenza/chicken/Hong Kong/97
virus, vCJD, HIV. We neglect the study of animal sources of new
infections at our peril.
The UK needs to be well prepared for the unexpected.
The capacity and flexibility to introduce rapidly and effectively
new areas of surveillance in relation to new diseases remains
critically important to UK public health, as for example in the
case of BSE and vCJD. New diseases will require scientific imagination
and innovation for their study.
In the view of SGM, surveillance should not
involve merely "stamp collecting", but should be well
targeted at issues of major public health concern and include
the analysis of outcome measurements. Innovation, including the
implementation into surveillance activities of new tools such
as PCR-based methods for microbial detection, genetic profiling
and molecular biological methods, which all have an increasingly
important role, will be essential to state-of-the-art surveillance.
Surveillance needs to be underpinned by a strong R & D effort,
which is integrated and cohesive rather than "add-on".
Effective surveillance depends upon close collaboration
between laboratory microbiologists, scientists, medical and clinical
professionals and public health experts. It will require increasing
amounts of investment in IT and biometrics facilities and must
maintain good and effective communication with government.
We believe that there are clear advantages in
having a strong central steer (eg the Health Protection Agency)
rather than completely devolved responsibility. At present in
the UK surveillance is undertaken in England, Scotland, Wales
and Northern Ireland without the existence of an overarching UK
strategy. We believe that a unified UK surveillance system would
serve us better. It is also important that the UK surveillance
activities should strengthen their links with international and
major national bodies such as WHO, the European Commission and
The proposed organisational changes in relation
to setting up the Health Protection Agency offer opportunities
for new thinking on integrated UK-wide surveillance. However,
it could also involve risks to the future of existing, high quality,
surveillance activities such as those conducted by PHLS. If changes
are made too rapidly and without sufficient consultation, systems
that have been developed over many years and are of proven success
and value may be at risk.
For the future, the excellence of infectious
disease surveillance in the UK will depend heavily on the continued
availability of well-trained and experienced microbiologists in
stable career positions. Currently there is a serious shortage
of microbiologists in some areas of medical and clinical science.
Also there is a drift away from science subjects at school level.
Remedial actions are required to encourage the recruitment, retention
and training of microbiologists.
The SGM, recognising the importance of microbiological
education, has developed a successful education programme aimed
at fostering and advising on microbiology teaching in schools
and colleges. The programme provides resources for lessons and
experimental work as part of the National Curriculum, and training
support for teachers, technicians and students. It operates at
both primary and secondary levels.
2. LINKS BETWEEN
The introduction of effective interventions,
such as vaccines, anti-microbials and antiviral therapies, needs
to be informed by effective surveillance, which, in turn, monitors
their effectiveness. The interventions of the future may well
be driven by an improved knowledge of the genetic and molecular
as well as pathological features of the infectious agents. Drugs
could potentially, in the future, be tailored to the genetic and
other characteristics of individual patients and the incident
Surveillance often needs to take account of
behavioural modification, as in the case of sexually transmitted
diseases, or dietary habits and customs in relation to food safety
Prevention of infection and disease by the use
of safe and effective vaccines has been one of the great successes
of medicine. The UK has made major contributions to this field
over many years and has a national vaccination programme of very
high quality, much admired by other countries. However, there
are no grounds for complacency; there is an important need for
new vaccines against diseases for which there are none available
at present, and for vaccines of improved effectiveness, safety
and cost-benefit. Research and development work is a major and
continuing need in this field. It needs to involve academic scientists,
public health and clinical experts and vaccine manufacturers.
Characteristically, scientific concepts for new vaccine design
arose from basic biomedical research in academia, and further
development work is undertaken in biotechnology companies and
by the large, multinational vaccine manufacturers. There are some
eight of these in the world, which together produce a high proportion
of the vaccines needed by many countries.
The Society for General Microbiology believes
that continued funding of academic microbiological research will
be important in relation to vaccination. There is a need for a
clearer mechanism for prioritisation of targets for vaccine development
and related R&D activities. The public sector will continue
to have a key role in independent clinical evaluation of new vaccines
to establish safety and efficacy and will need to establish close
collaboration with industry. High quality surveillance programmes
will be needed, in association with development of new vaccines
and assessment of their effects.
There are many infectious diseases for which
new or improved vaccines are urgently needed. These clearly include
the big three agents, HIV/AIDS, malaria and TB. But there are
many other vaccine targets which receive less recognition. They
include vaccines against meningococcus type B, respiratory syncytial
virus, rotavirus, herpes viruses (including CMV), papilloma virus
and Helicobacter, as well as against potential "bioterrorism"
agents for which no vaccines are currently available.
SGM believes that the programme of accelerated
vaccine development and greater use of existing vaccines, as indicated
in the Getting Beyond the Curve strategy, should be given
a very high priority by the new Health Protection Agency. Again,
progress will depend upon increased funding of research and development,
and a strong government commitment to the task.
The HPA will have a critically important role
in providing a platform for the effective interaction of the several
agencies in the UK involved in vaccine science, the delivery of
vaccination programmes, and the prioritisation of projects. It
will also need to be a powerful and articulate advocate of increased
funding for this vitally important aspect of fighting infection.
4. PUBLIC CONCERNS
Recent events in relation to MMR vaccine safety
has clearly indicated the public's attitude and depth of distrust
of government assurances on vaccine safety. There is a strong
and vociferous anti-vaccine lobby. It is very important that as
professionals we get better at communicating to the public the
advantages and risks of vaccination. This is part of the bigger
issue of the public's general lack of confidence in scientists
and scientific advice. Progress in fighting infection will be
greater if the public are on the same side as the scientific community.
The new HPA will need to take this challenge on board among its
5. SUMMARY AND
The establishment of the new Health Protection
Agency provides an important and unique opportunity for the UK
to strengthen its programmes and strategy on fighting infection,
particularly in relation to effective surveillance and preventative
measures including vaccination.
Success in these objectives depends strongly
upon a commitment to research and development. In addition, microbiology
is clearly an essential tool and there is a need for increased
levels of education and training in microbiology.
A high priority for the HPA will be the effective
management of change and reorganisation without risking damage
to the systems which currently serve us well. In particular, the
partial dissolution of the PHLS, as proposed, needs to be approached
with great care and considerable consultation if the quality of
surveillance of infectious disease is not to suffer.