Memorandum by the Association of Port
Health Authorities
INTRODUCTION
The Association of Port Health Authorities represents
the overwhelming majority of local and port health authorities
having international trade or passenger flows at sea and airports
within their areas. Legislation currently in force in the UK to
control the spread of communicable diseases, both within the UK
and potentially entering from abroad, places enforcement responsibilities
on our member authorities, which therefore provide the necessary
services to discharge those duties both adequately and effectively.
Our member authorities are in the front line
in protecting the UK from imported communicable diseases. We are
therefore pleased and grateful to be invited to submit evidence
to the Ad Hoc Committee's inquiry.
We have addressed our evidence to the inquiry
by responding to those numbered issues in the invitation only
where we believe that we have the competencies to do so. However,
we would firstly like to make a general point regarding the scope
of the enquiry.
The inquiry is focussed on four particular diseases
(HIV/AIDS, Avian Influenza, Malaria and Tuberculosis) as well
as generally. Indeed 11 of the 20 issues in the call for evidence
relate solely to one or more of the four specified diseases. We
do not believe that the focus should be so constrained to those
diseases. Previous UK and international legislation on the control
of communicable diseases has been prescriptive about the diseases
covered and the necessary controls to combat their spread. This
approach has been proved to be entirely inadequate in relation
to emerging diseases and the Association believes that international
and UK controls to combat the spread of communicable diseases
must focus on modes and pathways of transmission rather than on
specific diseases. Only by adopting this approach can we respond
to, and deal with, existing and emerging disease threats.
The Association has participated actively in
the World Health Organisation (WHO) review of the International
Health Regulations, leading to the passing of the International
Health Regulations 2005. We continue to be contributing actively
to the associated guidance currently being developed by WHO.
As the control and enforcement authorities,
we are also contributing to the review of UK legislation currently
in progress though Parliament in the Health and Social Care Bill.
There are a number of Port Health Authorities
constituted in legislation covering seaports. There are no Port
Health Authorities constituted for airports. For both airports
and seaports where there is no constituted port health authority,
it is the local authority in whose area the port is that is given
responsibilities under port health legislation. In our submission
of evidence we will refer to all of these as port health authorities.
Turning to our more specific evidence, we refer
now to the issues and to the numbering of those issues in the
call for evidence.
Issue 1
We agree with the conclusion in the UK Department
of Health report on communicable diseases that the post-war optimism
of the conquest of infectious diseases has proved dramatically
unfounded. Our experience is that, with few exceptions, existing
diseases have not been controlled nor eradicated and further that
other newly emerging diseases over the latter half of the 20th
century demonstrate that controls are more than ever necessary.
In our view the recent revision of the International Health Regulations
go a long way towards providing those controls.
We believe that it is the increased international
mobility of increasing numbers of people over the last 30 or 40
years, through ever cheaper air transport, that presents the risk
of existing and new diseases being rapidly spread across the globe.
We therefore conclude that the global situation
is certainly changing, but we would not consider it to be a crisis,
provided that international controls have sufficient flexibility
to deal with both existing and newly emerging threats.
Issue 3
Port health authorities, in conjunction with
the Health Protection Agency, provide port health services at
sea and airports to control the potential import of communicable
diseases. In undertaking these statutory duties we must rely on
intergovernmental surveillance systems to provide us with the
necessary information on the current disease situation throughout
the world.
The WHO provides such information to port health
authorities, either through the Department of Health as specific
communications, or through information on their website. There
are also other information systems on disease surveillance available
to port health authorities that port health authorities can refer
to.
However, the Association would welcome the establishment
of a single reference point containing all the available information
that port health authorities need in order to fulfil their statutory
duties and to enforce legislation.
Issue 6
We have outlined our role in the control of
the spread of Malaria under issue 7 below. We also have a role
in controlling the spread of both Avian Influenza and Tuberculosis.
In regard to Avian Influenza Port Health and
Local Authorities are responsible for the control of all products
of animal origin entering the EU through the UK's sea and airports.
When controls are put on products from a third country due to
the presence of Avian Influenza it is our members who must put
those controls in place. In undertaking these controls we work
closely with both UK and EU competent authorities as well as colleagues
throughout the EU. In our view, this is an area where the intergovernmental
collaboration works well.
In regard to Tuberculosis entering the UK through
sea and airports it is Port Health and Local Authorities that
enforce the relevant legislation. The medical into these controls
are provided by the Health Protection Agency, whose doctors are
appointed as authorised officers of the local or port health authority.
Indeed at the major airports the local authority will run the
TB screening, including X-rays, where this is generally funded
through the HPA.
The Association believes that a Chest X-ray
is a must for all new entrants as Pulmonary TB is the only form
that is easily transmissible to others. It not only helps to diagnose
active illness but also latent TB. It is well known that a large
number of recent immigrants develop the illness after being in
the country for some months to few years. It is mainly due to
activation of Latent TB.
Currently chest X-rays and pre-entry screening
are advocated for new entrants before offering a visa for entry
to the UK in certain countries. Experience at Heathrow is that
a significant number of new entrants are coming with abnormal
chest X-rays and marked sputum for TB negative, while it is well
known this test depends on the quality of the specimen supplied,
on the person who performs the test and it take 2—3 months
the organism grows in the culture. Then treatment is for 6—9
months with standard regimen. But new entrants are allowed to
come with these abnormal certificates. Heathrow also has evidence
of abuse of Visa medical system with an element of corrupt practices.
Recent statistics for TB monitoring at Heathrow
Airport are given it the following table:
|
| Year | Number of New Entrants seen
| Number of Chest X-rays (CXR) done
| Probable TB referred for further management with abnormal CXR
| Active TB Confirmed among abnormal CXR by Consultant Radiologist
| Active TB Diagnosed among the Results received from community
|
|
| 2003/04 | 175,039
| 70,805 | 848
| 205 | 80
|
| 2004/05 | 189,623
| 74,382 | 1,599
| 294 | 224
|
| 2005/06 | 190,685
| 74,060 | 1,521
| 587 | Received only 4% results
|
|
2006/07 stats not ready 184,217 new entrants were screened,
66,812 chest x-rays were carried out
58% of these referred during the last 18 months are on TB
treatment or on Chemoprophylaxis as for Latent TB.
Issue 7
Non—health causes of the spread of communicable diseases
are well documented and no doubt others will give evidence of
these. However, the Association has concerns and can give evidence
on some of these.
Cases of "airport malaria" in Europe are well documented
and Port Health Authorities in the UK are at the forefront in
preventing infected mosquitoes entering through our international
airports by advising on and enforcing the disinsection of aircraft.
The UK does not have the species of mosquito that could transmit
malaria, but it has done in the past. With climate warming generally
accepted as happening now and into the foreseeable future, the
risk of malaria becoming indigenous in the UK is increasing.
There are other insect vector-borne communicable diseases
already becoming a concern internationally and the increasing
mobility of people and goods via air and sea raises the risk of
those vectors and diseases entering the UK.
This increase in mobility, fuelled by both the increase in
affluence of a large part of the population and by the reducing
cost of travel in real terms, also means that more and more people
are travelling further and further afield, and to places where
they would not have gone, even a generation ago. This lifestyle
change results in people travelling to areas with a greater risk
of contracting communicable diseases.
With the ever more diverse nature of the population there
is also an increase in the numbers of people travelling to visit
the countries of their origin where some communicable diseases
are endemic and retuning to the UK infected themselves.
Issue 16
The Association has been closely involved with WHO on the
development of the International Health Regulations 2005 and we
believe they provided a considerably improved framework for the
international control of communicable diseases. In particular
they provide a flexible response to be made to particular diseases
that can cope with new diseases as they emerge.
Turning the Regulations into the practicalities of comprehensive
and effective control at points of entry is the key to the effectiveness
of the Regulations. If countries get that right then our view
is that the Regulations will provide effective global controls.
We therefore contribute to the review of legislation undertaken
by the Department of Health and with the WHO in drawing up guidance
documents.
Issue 17
Port health and local authorities are Category 1 responders
under the Civil Contingencies Act 2004, and therefore must have
plans in place for dealing with emergencies.
We believe, however, that a closer link between the Civil
Contingencies Act and the control of infectious disease at points
of entry should be established to build upon much good progress
that has been made in recent years. This would also enable local
authorities with Ports within their area to hold proper practice
exercises as regards control infectious disease to complement
work already done concerning terrorism and natural disasters.
Issue 19
The Association is mainly funded by subscriptions from member
authorities. One of the functions of the Association is to provide
training for authorities and their officers.
Member authorities do provide, at their own expense, members
and officers to attend and contribute to meetings of the Association.
Local authorities receive government general financial support
through the RSG. This funding is based on a needs assessment and
for those authorities that have ports we are given to understand
that includes an element for port health services. However, Authorities
are often unable to determine the amount of any resource included
in the overall support. Whilst we feel that local authorities
are best placed to determine locally what services to provide
and how to provide them and financial support should not be ring-fenced,
we feel that a greater clarity on exactly what element of the
general support relates to the sea or airport would better enable
our members to judge whether that element was adequate.
Some port health services at airports are funded by the Department
of Health by direct reimbursement of costs, and the provision
of Medical expertise is provided by the Health Protection Agency
at no cost to authorities.
February 2008
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