Memorandum by the British Infection Society
1. This statement is largely correct. The
idea that new antimicrobial agents and improved disease control
strategies would largely eradicate infections was unfounded. Although
there has been great success in reducing the burden of certain
conditions (such as smallpox and leprosy), attempts to eradicate
other conditions such as malaria have not proved nearly so successful.
Unforeseen problems have arisen, with the emergence of new infections
and the development of antimicrobial resistance in already established
diseases. Lack of interest in antimicrobial discovery/development
by some major drug manufacturers has delayed, and continues to
delay, progress. Research into new antimicrobial drugs is essential,
and this is an area where intergovernmental action could be useful.
Future progress in reducing the burden of disease
depends largely on the amount of resource and effort applied.
This is illustrated by WHO predictions on mortality from HIV/AIDS,
where the likely trends vary enormously depending on the intervention
measures that are taken. However, even with the most optimistic
modelling the burden of HIV/AIDS is likely to continue to increase
over the next 20 years. For many other infectious diseases the
global burden is likely to fall very slowly, assuming that there
is continued investment in disease control and treatment programmes.
However, it is impossible to allow for the effect of new and emerging
diseases, or for dramatic changes in antimicrobial resistance.
Similarly an unexpected interruption or failure of an established
disease control programme (for example due to civil or political
upheaval, or withdrawal of funding) could have a dramatic effect
on the burden of infectious disease. Conversely, giving greater
international priority to control programmes could speed the reduction
or eradication of certain infectious diseases. Modelling of some
of these factors can be found in the WHO report on the projections
of global mortality.
2. Extensive data exist on HIV /AIDS,
tuberculosis, and malaria. The best available statistics are compiled
by the WHO, although at best these are (by the nature of the diseases,
and the countries in which they are common) estimates (http://www.who.int/whosis/en/).
Both HIV and tuberculosis can cause a wide range of clinical syndromes
from asymptomatic infection to serious disease, and while the
latter is relatively easy to recognise asymptomatic infection
can often not be detected without specific screening (which is
not available in much of the world). These overall figures also
fail to take account of vital information such as the prevalence
of drug resistant tuberculosis or HIV.
Avian influenza is currently a very rare cause
of human disease. The main concern is that there may be a change
in the behaviour of the virus such that it becomes more transmissible
from person to person: The likelihood of this happening, and the
impact that it would have, is difficult to predict. It should
also be borne in mind that the next influenza pandemic could be
another strain entirely, with little avian connection.
3. There are examples in specific countries or areas
of relatively successful programmes to control malaria and tuberculosis.
However on a global basis success to date has been limited and
it is hard to be optimistic about the future. At best it seems
likely that continuing current levels of funding may prevent a
significant increase in the incidence and prevalence of these
diseases. Most estimates suggest that for HIV, even an optimistic
view of the next 10 years will still see a significant increase
in prevalence. It is possible that there will be some minor changes
in the pattern of disease, but the biggest burden is still likely
to fall the developing countries of Africa and Asia. Pandemic
influenza is rather different, in that an emergency response rather
than an ongoing control programme will be needed. If a potential
outbreak is to be controlled there will need to be an extremely
rapid response at the country of origin in the face of the emergence
of a new strain of influenza. This would require not only an adequate
surveillance system but also prior agreement for a great number
of countries to divert significant resources to a resource poor
nation. This is clearly an area where intergovernmental cooperation
would be essential.
4. Published WHO data and modelling probably
provides the best estimates of these.
5. Many technical problems limit progress
in the prevention and control of infections. However the biggest
factor is economic and social deprivation. With more money, and
better social conditions, many of these diseases would disappear.
This is illustrated by changes in the western world in previous
centuries, when malaria and TB were largely eradicated without
any major medical breakthroughs. Instead the diseases gradually
disappeared as a result of better living conditions and improvements
in general public health.
6. The British Infection Society is a charitable
organisation which brings together specialists in various fields
of infection prevention, control, diagnosis, and treatment. It
supports and promotes research in infectious diseases (including
the important international diseases), and works to improve teaching
and training of infection specialists. However, it does not have
a front line role in dealing with diseases that are largely based
internationally.
7. In global terms poverty is the most important
factor allowing the continuing spread of these four infections.
Other factors that could be listed, for example overcrowding,
sharing living space with animal reservoirs, poor hygiene, etc.
can all be traced back to poverty. Concerted international action
on global poverty could have a huge impact on mortality from infectious
diseases, but this would need to be on a far greater scale than
anything that is currently being considered. Lifestyle and increased
global mobility may play a small part in introducing diseases
such as tuberculosis, malaria, and HIV to this country, but this
is not of great significance overall.
The situation for pandemic influenza is rather
different, in that the speed and frequency of international travel
could play an important role in disseminating an outbreak worldwide.
In the past it has taken many weeks for pandemics to become global,
but experience with SARS has shown that in the age of mass travel
airborne infections can spread around the world within a matter
of days. We need to have the flexibility to be able to cope with
such situations.
8. The main factors driving the rise in
tuberculosis in the UK are migration and poverty with relatively
little contribution from HIV. Restriction of access of migrants,
refugees and asylum seekers to health services both in primary
and secondary care encourages the spread of tuberculosis in the
community. This approach is not ethical and significant financial
savings to the NHS cannot be made by preventing refugees and asylum
seekers accessing healthcare but the health detriment is significant.
This trend could and should be reversed if there is a serious
intention to combat the rise of TB in the UK; such people should
be encouraged to have health checks independently from immigration
procedures. The prospect of financing this by appropriate charging
of outpatient and primary care use by those who should pay (eg
US visitors & others with whom there is no reciprocal health
care arrangement) needs investigation. This requires governmental
rather than intergovernmental action.
9. There are many reasons why tuberculosis
appears to be on the increase. Approximately 50% of patients with
the disease are not diagnosed. The standard test used for diagnosis
world wide is microscopy, which has only 50% of the sensitivity
of culture (the standard used in more affluent countries). This
is despite the fact that there are tests available which are both
cheap and culture based. The crowding of people together in poor
urban centres increases transmission of tuberculosis generally.
There is a major interplay between tuberculosis and HIV. HIV increases
the rate of reactivation of tuberculosis and conversely tuberculosis
drives the HIV genome to replicate.
Intergovernmental action could be used to support
the development of TB control programmes, encompassing appropriate
diagnostics, and new short course regiments for treatment, with
drugs quality controlled and free to patients. Other essential
requirements which could be promoted by such action include: laboratories
in resource poor environments which are equipped adequately to
protect the workers from the diseases in which they encounter,
improved healthcare facilities designed to reduce nosocomial transmission
of disease in outpatient and inpatient settings, and ending the
black market in antimicrobial drugs which threatens TB control
programmes in many developing countries. Action is also needed
(whether on a governmental or intergovernmental level) to reduce
disease transmission in prisons, which are acting as an amplifier
for drug resistant infections.
10. In certain situations the benefit of
DDT for controlling malarial vector mosquitoes outweighs the danger
of the compound for human health. This assumes that DDT is used
in strict compliance to guidance, and that alternative agents
are used whenever appropriate. The relative risks and benefits
of using DDT are summarised in the WHO DDT position paper. This
document takes account of the 2005 Stockholm Convention, and we
are not sure that it is helpful to consider the Stockholm Convention
as an obstruction to the control of malaria.
11. The Committee should talk about pandemic
influenza rather than specifically about avian influenza. Although
there has been considerable focus on the H5N1 form of the virus,
it is entirely possible that a different strain will cause the
next pandemic, and may not be associated with birds at all. Any
control mechanisms must take this contingency into account. The
International Health Regulations (see para 16) are intended to
form an important part of the identification and control process
for infections such as pandemic influenza. In principal the IHR
framework is a good one, and potentially very important for global
security against pandemic influenza. However, the IHR depends
on the will of international governments to implement the agreed
actions, and this is one area where better intergovernmental cooperation
could be very important. There needs to be better sharing of information,
and also of resources. Some countries, notably in South East Asia,
have made great effort to develop their own pandemic preparedness
plans. However the fact that many developed countries (including
the UK) are putting a great deal of effort into plans to protect
their own populations from pandemic flu suggests that there is
a (probably realistic) assumption that intergovernmental efforts
to prevent the spread of influenza are unlikely to be effective.
12. Resistance to available antimicrobial
treatment is a well-recognised problem in malaria, tuberculosis,
and HIV. It may also be an issue with antiviral drugs for the
treatment of influenza, although this is less well documented
at present. In terms of HIV and tuberculosis, the greatest problem
remains providing even basic treatment for the majority of infected
people in developing countries. Although the emergence of drug
resistance is worrying, and may become a bigger problem in the
future, the main priority is to ensure adequate treatment for
standard disease. The picture with malaria is rather different,
and there is an important role for intergovernmental cooperation
in establishing the best drug regimens for treating drug resistant
malaria and minimising the emergence of new resistance. (For example,
there have been insufficient efforts to regulate the inappropriate
promotion of monotherapy of malaria using artemesenin related
compounds in much of Africa.) An intergovernmental approach could
also help to improve and standardise the quality of `legitimate'
drugs, and reduce the trade in black market medications.
13. In the last few years British Departments
of Health have paid rather more attention to healthcare associated
infections (HCAIs), with some improvement in outcome. More could
be done, mainly in terms of improving buildings and facilities,
and promoting research. This is largely a governmental rather
than an intergovernmental issue. Some countries (including the
UK) were slow to learn lessons from other areas with both very
high and very low levels of HCAIs, and there is a role for improved
intergovernmental sharing of knowledge to plan future changes.
There is a little evidence that the British Department of Health
is collaborating with other governments in order to learn lessons
for the future.
14. Many new diagnostic tests are based
on patented molecular approaches which will almost certainly be
too expensive for the parts of the world where they are most needed.
A shareware approach should be encouraged. Intergovernmental action
to suspend patent issues for resource-poor countries (possibly
compensating companies) should be considered. Support for the
purchasing of equipment by affluent country health systems could
be directly linked to providing similar equipment at reduced prices
for poorer countries.
15. Education of the public is essential in the context
of health programmes which can provide necessary diagnosis and
treatment. In some areas of the world there are conflicts between
local beliefs (religious, political, or superstitious), and the
actual facts. Worldwide provision of internet based learning opportunities
for those in healthcare are required. Support for education would
benefit from intergovernmental co-operation
16. The International Health Regulations
are discussed in para 11. As IHR 2005 only came into place in
June 2007 it is too early to assess how effective it will be.
A lengthy review process was completed before the current implementation
phase and it would not be appropriate to make any changes until
the regulations have been placed for a while and properly assessed.
17. It would be wrong to focus specifically
on bioterrorism, and we do not think that this should be a priority
area for the committee. However, many of the responses would be
the same for either deliberate or "natural" release
of a highly contagious virus (such as pandemic influenza or SARS).
Experience with planning exercises for bioterrorist release have
not suggested that the UK is particularly well prepared to deal
with a serious contagious disease threat, and further work is
needed. This is largely a governmental rather than an intergovernmental
issue, and requires considerable local and regional effort in
order to maintain a viable response. This implies continued central
Departmental encouragement and the provision of adequate resources
if local multidisciplinary and intersectoral teams are to undergo
the necessary cycles of exercises and review. The development
of "top down" plans for outbreak control, including
central and international cooperation is required, but provides
a false sense of national security unless regional and local teams
are genuinely educated, involved and supported so that such plans
can actually be implemented.
18. There will inevitably be new infectious
agents emerging, both as a result of evolution of current pathogens
(as with influenza), and due to the appearance of genuinely new
and unknown diseases (often zoonotic in origin). However, it is
likely that any such infections will be transmitted through the
same routes as our current major infectious diseases (eg airborne,
blood-borne, sexually transmitted, or vector spread). If we have
robust mechanisms in place to limit the spread of currently known
infections it is likely that these have would provide a good foundation
for dealing with a new threat. Similarly good surveillance systems
could be easily modified in the face of a new or emerging infection.
20. The UK is at the forefront of international
health and infectious disease (ID) research internationally and
this research base needs to be protected. Increased numbers of
academic ID and epidemiology physicians and scientists are required.
We also have a strong tradition of training doctors and scientists
in international health and tropical medicine, and this should
be supported and expanded. There are a number of specialist ID
centres in teaching hospitals in Britain. Which are centres of
excellence in managing infectious disease. They also play a key
role in setting standards for antimicrobial stewardship and infection
control, which are essential elements in preventing the emergence
of antimicrobial resistance. While this may appear to be a domestic
problem, global mobility means that resistant organisms will rapidly
spread around the world, and maintaining high standards is an
international as well as a national priority. Existing ID centres
should be supported and expanded, and there should be a drive
to introduce more infection specialists into district general
hospitals as well as in large teaching centres. This would require
an increase in posts in all infection specialties, encompassing
physicians, researchers, and microbiologists. The UK has very
few ID doctors per head of population (compared to the US, Scandinavia
etc) and expansion of training and consultant numbers is urgently
required.
February 2008
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