Memorandum by the Royal College of Physicians
and Surgeons of Glasgow
RESPONSE TO
THE PRINCIPAL
ISSUES ON
WHICH THE
COMMITTEE WELCOMES
VIEWS:
1. There will always be new infections,
new problems with older infections, and new challenges. A crisis
may not only be medical but may also be economic. For example,
vCJD has not been mentioned in the pre-amble, yet this was an
infection caused by a class of organisms which had not hitherto
been known to exist and which has had enormous economic impact
as well as medical impact. We may concentrate on four key diseases,
but the principles applied and control systems developed by the
UK should be robust enough to cope with those unexpected challenges
which come along from time to time, as SARS did "out of the
blue" in 2003, leading to disaster. Adequate resources in
terms of finance, manpower and expertise have to be made available
if such crises are to be averted.
2. Health Protection Scotland (HPS) and
the Health Protection Agency (HPA) in England are, in effect,
part of a world-wide network of epidemiological services. However,
rather like military and diplomatic services require adequate
intelligence so as to be able to function optimally, public health
and clinical medicine also require the same sort of service in
terms of data collection regarding what is going on and expert
analysis of that data. HPS and HPA are the epidemiological eyes
and ears of healthcare, and allow for appropriate planning for
the future, including appropriate apportioning of resources.
3. Open and honest sharing of information
across international borders is vital if outbreaks are to be controlled
or, better still, prevented. An example of this would be the 2003
case of the existence of SARS being known within mainland China
prior to its wider recognition throughout the world only after
the virus had entered Hong Kong. To become optimally effective,
international groups like WHO have to be in a position to access
data from wherever and whenever they need it, and achieving this
sort of state of affairs will require a high-quality level of
international diplomacy to be brought to bear. Other ways of spotting
the emergence of infection problems with potential wider consequences
must be sought out by the international scientific community.
HPS and HPA would have an important role to play in this process.
4. There is always the potential for problems,
or even for disaster, if considerable attention is not paid towards
controlling the four key diseases. For example, AIDS/HIV has been
known about for a quarter of a century, and the modes of its transmission
between human beings have been abundantly clear for a very long
time, and yet the disease continues to spread in many parts of
the world. The extent to which social (including gender), morality
and political issues, as well as medical and economic issues,
are responsible for this continuing spread need to be the subject
of high-quality investigation, as a vaccine (even if one comes
along in the near future) may not be the whole answer, as has
been the case in the past with many other diseases, such as TB.
Fostering and development of cooperation within and between countries—"joined
up thinking"—with respect to prevention initiatives,
travel health, the work of major British agencies such as the
Royal Colleges and accreditation schemes such as Trent etc. is
likely to prove fruitful. Medical tourism may become an important
factor with respect to the spread of antimicrobial resistance
around the world, and the UK is involved in this.
5. Economic and social deprivation are certainly
key factors in our inability to eradicate these diseases. International
cooperation of the sort which is being sought to control global
warming would seem to be appropriate. Resources devoted towards
development of vaccines, including improved vaccines for TB and
commercially viable vaccines which currently don't exist such
as malaria, hepatitis C, dengue and HIV might be fruitful, as
this would assist with control.
6. The Royal College of Physicians &
Surgeons of Glasgow is a charitable organisation. The College
collaborates with the NHS, with other Royal Colleges and Faculties,
with specialist societies, with universities (including medical
schools), and through such collaboration seeks to create the optimal
environment to tackle the four diseases, on all the relevant fronts
including clinical, research and teaching/education. Within its
membership are specialists from various fields of infection, including
infectious diseases, tropical medicine, travel medicine (including
the Faculty of Travel Medicine), microbiology and virology. It
also has surgeons and dentists among the membership.
The College is outward-looking, and fosters
links overseas. It has a substantial number of members and fellows
based overseas, and an active International Committee. The College
hosts the MRCP(UK) and MRCS(UK) exams overseas, giving it substantial
links and contacts in a wide variety of countries in all of the
continents. The College supports and promotes research in infectious
diseases and works to improve teaching and training of infection
specialists.
7. "Health tourism" is an issue,
which may be stimulated in part through poverty and lack of access
to adequate treatment and clinical care. This can only be remedied
through a world-wide initiative to improve people's standards
of living and to help provide with access to adequate non-judgemental
healthcare in their countries of domicile.
Despite years of public education, greater openness
about and rational discussion of sexual issues and the problems
associated with unsafe practices could still be achieved. HIV
remains a sexually transmitted disease of great potency.
Better promotion in the UK of the speciality
of Travel Medicine would be of assistance.
In many Far Eastern airports (eg Hong Kong,
Singapore), the body temperate of arriving visitors is checked
electronically as an initiative to help pick out patients potentially
suffering from dangerous infections, such as influenza or SARS.
8. It is partly a function of greater international
movement of human beings for whatever reason. While it is probably
not a great contributor to case numbers at the moment, immigrant
healthcare workers (including doctors) are sometimes found to
have tuberculosis or HIV, and it would seem prudent to deal with
this issue prospectively rather than wait till problems occur.
The lack of an effective vaccine (BCG is a poor one) is an impediment.
9. Apart from prevention, diagnosis is the
main factor. However, unless the condition is actively considered
by the infected patient's doctor, it will usually not be diagnosed,
as special tests have to conducted to make a definitive diagnosis.
This is an issue requiring improved training and education. It
may be worth considered checking for TB among healthcare workers,
including immigrants. Again the lack of an effective vaccine is
a problem.
10. The control of mosquitoes and other
biting arthropods does not only control malaria but also controls
other important infectious diseases, such as dengue, elephantiasis,
yellow fever, and numerous arboviruses (such as West Nile fever,
which afflicted the USA very badly within the last few years).
Whether or not the various international conventions are of value
or not, the issue of vector control will require constant consideration
and revisiting for the foreseeable future.
11. Influenza is important, but too narrow
a focus may miss the problem. For example, H5N1 influenza may
not turn out to be the main problem. Better vaccines, and ways
of delivering vaccines, as well as new drugs for influenza to
help combat the drug resistance problems which will inevitably
develop, all merit attention. Robust international systems to
spot trends in influenza and other relevant respiratory infections
(SARS is an example) will remain important for the foreseeable
future. It would be helpful to foster the strongest possible political
and medical links with China and its associated territories (Hong
Kong, Macau, Taiwan etc) as part of this process, as China is
key in the influenza story (Royal College activities and UK sourced
hospital accreditation may be able to help with this).
12. Resistance to antimicrobials (not just
antibiotics but also antivirals, antimalarials and antifungals)
is a growing phenomenon worldwide. As well as being driven by
inadequate practice and different legislative approaches to healthcare
around the world (eg "over the counter" sales of antimicrobials
are the case in some parts of the world), such resistant organisms
can be transferred around the world in or on the bodies of human
beings. This phenomenon needs constant epidemiological surveillance.
Continuing research into the development of new antimicrobial
agents is vital. Vaccine development can help with this, as the
use of vaccines effective against organisms with a tendency to
manifest antimicrobial resistance can help prevent people acquiring
the problem in the first place. An effective vaccine against Staphylococcus
aureus (including MRSA) and Clostridium difficile may yield dividends.
13. Not enough. There is free passage of
TB and HIV around the world, with very little testing for these
conditions among people crossing international borders. The issue
would benefit from serious, honest and open debate. Also, hospital
acquired organisms can be transferred around the world in or on
the bodies of human beings, for example during repatriation of
patients from overseas. This issue again merits consideration.
14. We live in a market economy, and have
to recognise that industry needs to make a profit and to reward
its shareholders. Government investment in this area is valuable
however, and greater centrally-led encouragement of UK hospitals
and trusts to become more involved in research (not just concentrating
on university departments) would open up enormous resources of
expertise, manpower and patient numbers. Clinically-led research
within NHS hospitals is currently not as common and productive
as it should be.
15. This could be facilitated both through
governmental cooperation, as well as through NGO cooperation (eg
Royal Colleges, hospital accreditation groups). The Royal Colleges
such as the RCPSGlasgow are major organisations in the educational
field and possess world-wide high profiles. Also, the commercial
sector can be of value here too, for example through the development
of international consultancy in the field of healthcare utilising
the special skills and knowledge of healthcare and related staff
to educate and train overseas. The NHS could share more of its
expertise with the rest of the world through this mechanism.
16. Public education, and the co-opting
of the public as a rational partner in the control of infection,
is key. Intelligent cooperation with the mass media, and rational
use of the internet, will be of ever-increasing importance. The
NHS and other relevant groups such as the Royal Colleges may benefit
from greater training in the use of the mass media.
17. Humanity faces a global threat from
this. Adequate training of healthcare and other relevant professionals
(including police and military) to be able to spot episodes of
potential deliberate release of infectious diseases into the UK
is mandatory. The maintenance and development of appropriately
located and adequately funded physical set-ups (eg isolation units,
specialised ambulances, trained staff etc) to cope with such events
is mandatory.
18. Attention to high quality surveillance
systems, the training of adequate numbers of high-quality staff
to operate such systems and to analyse and interpret the data
generated, and better international cooperation would be valuable.
Enhanced and effective cooperation between medical and veterinary,
agricultural, pharmaceutical and other commercial organisations,
and other relevant data collection bodies would be valuable.
19. Joined-up thinking with respect to the
training of doctors and other healthcare workers, and the international
dimensions, is key. The UK government would be wise to look at
the extent to which the UK currently interacts with the training
and professional development of healthcare colleagues domiciled
in overseas countries, and look at how this potentially valuable
resource could be optimised (eg Royal Colleges, hospital accreditation
groups). The RCPSGlasgow has considerable overseas links in place
and a strong track record in education and training.
20. Great Britain could take a lead of education
and training, such as facilitating the dissemination of Royal
College influence and thus spreading good practice, and good governance,
around the world.
Research is important, but so is the education
and training of staff.
An encouragement of the international movement
of doctors would be valuable, for example allowing doctors domiciled
outside the European Union to enter the UK for a period of time
to allow them to acquire specialist training prior to returning
home to take up their senior postings—this would allow greater
exchange of information and insight between the different national
medical groups working around the world and would facilitate networking
between the UK and key groups elsewhere which would last for a
long time. Such a state of affairs would be advantageous to efforts
to control the international spread of infection and antimicrobial
resistance. The British Postgraduate examinations, such as MRCP(UK)
and MRCS(UK), have high international standing but are possibly
becoming less popular outside of the European Union as doctors
who are successful in these prestigious exams nevertheless have
relatively small chances of being able to achieve postgraduate
training in the UK to better equip them for a career in their
own country. On the other hand, the USA encourages this type of
activity, and welcomes overseas doctors into their country to
train.
Also, the UK may find it helpful to look at
the model of the Joint Commission in the USA, which is a private
non-profit company which works both nationally and internationally
to spread good practice in hospitals, including with respect to
infection control. Accreditation helps to ensure quality and adequate
standards within hospitals and healthcare provider organisations,
and ensure their maintenance. The UK's NHS is well equipped to
play this game, especially in countries with socialised medical
systems, and is used to working in such a way that available resources
are used most rationally—the Trent Accreditation Scheme,
an experienced international accreditation scheme based within
the UK NHS, is well-equipped to develop a similar international
role to that of the Joint Commission.
Initiatives such as the Faculty of Travel Medicine
and the International Committees of the various Royal Colleges
also have a role to play in effective international infection
control.
A rational look at the growing phenomenon of
medical tourism is warranted, as this is growing in the UK and
represents one means by which infection can spread around the
world.
Tourism companies selling holidays overseas
currently appear to have no clear duty (for example in their promotional
literature) to warn their clients that they may be at risk of
acquiring infectious diseases such as malaria—this may be
worth consideration.
January 2008
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