Memorandum by The Royal College of Pathologists
Q1: A recent report on Communicable Diseases
by the UK Department of Health stated that "post-war optimism
that their conquest was near has proved dramatically unfounded".
What is your assessment of the overall position? More specifically,
is it simply that not enough progress is being made in reducing
the spread of such diseases? Or is the global situation actually
deteriorating? Would it be an exaggeration to talk of a crisis?
A: The situation varies in different countries.
Some diseases are much less common where the benefits of public
health (water, sewerage, nutrition, housing, environment), vaccination
and antibiotics have been realised. Poverty often equates with
lack of public health benefit, and is a major influence on infectious
disease.
Substantial progress has been made in some areas,
such as the eradication of Small pox. Some of the others like
Malaria and TB have proven to be far more difficult to eradicate
than previously thought. In many cases evidence about how to reduce
the burden is available but there is lack of action e.g. poor
diagnosis and treatment of Malaria.
There are increased risks from: new diseases
e.g. SARS; travel, lifestyle, war, breakdown of infrastructure;
medical advances can create new ecological niches e.g. immunosuppression,
polypharmacy; antimicrobial resistance. Lack of infrastructure
also means that when the developing world is faced with new challenges
it is less able to cope (HIV, drug resistant TB).
Q2: What reliable data exist regarding the
numbers of people infected globally with the four diseases[12]
on which the Committee is focusing particular attention? What
trends are discernible in both the numbers infected and the patterns
of infection? And what are the main underlying causes of infection
and of any changes in its incidence and pattern?
A:WHO and HPA will have figures. Surveillance
mechanisms could be improved in rural areas in developing countries,
but confirmation of diagnosis will also depend on laboratory diagnostic
facilities being available.
Malaria will continue to be a problem but hopefully
the use of ACT, insecticide impregnated nets and spraying of insecticides
will reduce cases.
Despite development of drug resistance and increase
of TB in HIV/AIDS patients, improvement in detection of smear
positive TB cases and DOTS will hopefully result in reduced transmission
of infection.
Similarly the availability of relatively low
cost ART to increasing numbers of HIV patients, especially in
Africa provides some hope given the size of the population. However
diagnostic facilities to support the use of ARTs and follow disease
progression are generally lacking. The HIV epidemic in India continues
to pose a major threat. Recent reliable surveillance data suggests
that this epidemic is declining slowly through the sustained commitment
of the national government and inter-governmental organisations
like WHO and charitable organisations.
Avian influenza H5N1 currently does not appear
to transmit very readily either to or between humans.
Changes in incidence and pattern are affected
by population growth, shifts from rural to urban living without
adequate infrastructure, and cultural issues.
Q3: What intergovernmental surveillance systems
exist to give early warning of outbreaks of infectious diseases?
Are these systems adequate? And what improvements might be made?
A: WHO and demographic health surveys internationally.
HPA will be able to give information on UK and European surveillance
systems. It is impossible to say if they are adequate for all
situations e.g. detection of cases in rural areas poorly served
by healthcare facilities; for some diseases spread is likely to
be more rapid in urban areas with high person-to-person contact.
Providing accurate data about public health in developing countries
continues to be a major challenge.
Q4: Given the continuance of current or planned
intergovernmental programmes to prevent or control the four diseases,
what predictions can be made of their likely spread and pattern
over the next 10 years?.
A: Political stability and conflict are
major factors that affect spread of diseases, and undermine progress
made. They need to be included in any model (not underestimating
the difficulty). Travel, migration, drug resistance, and success
of control programmes will influence spread and pattern.
Q5: What do you consider to be the principal
blockages to achieving progress in the prevention or control of
the four diseases? And how might these blockages be removed by
more, or better-targeted or better-coordinated intergovernmental
action?
A: The four diseases are most prevalent in the
developing world. The major blockages are: poverty; poor public
health; insufficient diagnostic facilities and ineffective use
of laboratory services; political instability; poor governance;
educational and cultural issues.
BETTER MANAGEMENT
SYSTEMS AND
SUPERVISION TO
ENSURE POLICIES
ARE IMPLEMENTED
PROPERLY
Better diagnostics—the UK has enormous
expertise in this area, but there is little support for "time
out" for doctors or scientists to spend time abroad—either
those in training or established in their careers (despite the
recommendations in the Crisp report).
BETTER CO-ORDINATION
BETWEEN INTERESTED
PARTIES AND
IMPROVED LIAISON
Outside the political solutions to these underlying
problems the availability of medication, education and research
should improve the situation.
Most government health services now recognise
that TB control must go beyond DOTS, but the broader Stop TB strategy
is not yet fully operational in most countries. Although the funds
available for TB control have increased enormously since 2002,
reaching US$ 2 billion in 2007, interventions on the scale required
by the Global Plan to stop TB would cost an extra US$ 1.1 billion
in 2007.
IN HIV there are many people involved with no
clear strategy/plan given the complexity of the disease. Strong
vertical programmes, like HIV, risk diverting resources away from
other priority areas like TB and Malaria.
Q6: What role does your organisation play
in combating the four diseases? Do you believe that it is correctly
configured and adequately resourced to do the job? With which
other organisations do you collaborate? How would you assess the
degree of synergy?
A: The Royal College of Pathologists promotes
excellence in the practice of pathology and is responsible for
maintaining standards of practice through training, assessments,
examinations and professional development.
Members of the College, both medical and scientists,
are experts in the diagnosis and management of disease, including
infectious disease. They provide a spectrum of laboratory and
clinical services which varies from specialty to specialty. Many
laboratory services, microbiology, virology, haematology, chemical
pathology for example are critically important in the diagnosis,
treatment and control of many communicable diseases including
Malaria, TB, HIV, and Avian Influenza.
The RCPath has an international committee co-chaired
by a Vice President of the College. This committee aims to further
the aims of the College in other parts of the world in a context
sensitive manner, and members of this committee have contributed
to this paper. Many international members of the College are frequently
leaders in medical microbiology and virology in their countries
and have considerable influence in the detection and control of
the four communicable diseases.
We believe the Academy of Medical Royal Colleges
could enhance its co-ordinating role for College International
activities. Also we believe that UK quality assurance in diagnostics
(such as through CPA (UK) Ltd) could be helpful in relevant context
specific ways.
Members of the RCPath are frequently the first
to detect infections with the four diseases and alert other clinicians
and public authorities in the UK, contributing to surveillance
via HPA and others.
RCPath liaises with Department of Health, academic
institutions, professional and scientific organisations in the
UK, CPA (UK) Ltd, and other Royal Colleges.
Q7: What are the main non-health causes (e.g.
global warming, poverty, changes in land use, international travel,
lifestyle, population) of the spread of the four diseases? To
what extent can intergovernmental action in non-health fields
contribute to alleviation of their spread? What action is taking
place or planned in these areas? And what more needs to be done?
Do you consider that there is sufficient "joined-up"
thinking in approaching the problem?
A: Poverty and weak management systems are
very important. Lifestyle—HIV; global warming and population
movement—Malaria; international travel—all 4. No,
there is not sufficient joined up thinking (viz. Crisp report
and lack of NHS support for overseas placements)—but this
also needs to be complemented by joined up activities in overseas
governments (e.g. between ministries of health, education, finance,
agriculture, water, etc.).
The lack of laboratory diagnostic facilities
to enable accurate diagnosis is important—they underpin
effective treatment, control and surveillance. There needs to
be better support for simple good quality diagnostics.
Q8: Cases of Tuberculosis fell progressively
in the UK until the mid-1980s but started to rise again in the
early 1990s. Around 6,500 cases are now reported each year, an
increase of about a quarter since the early 1990s. What are the
main factors of the revival of Tuberculosis infections in Britain?
And how could intergovernmental action help to reverse the trend?
A: The rise in TB in the UK is largely due
to migration from countries of high prevalence, and drug resistance
is also a threat.
Intergovernmental action should: make efforts
to reduce TB in the countries from where the migrants originate;
address underlying reasons for migration be it political, economic
or social or AIDS/HIV related; work to reduce stigma, thereby
promoting better care-seeking.
Q9: Tuberculosis is potentially curable by
long-term antimicrobial therapies. Yet the numbers of reported
cases worldwide seem to be rising. Are the necessary medicines
not getting through to patients? What are the barriers to effective
long-term therapy? Are we now seeing infections which stem from
other conditions—e.g. HIV/AIDS? Or are there other reasons
why a treatable disease should be spreading? How might intergovernmental
action help to deal with this situation?
A: See earlier comments. However HIV is
driving the TB epidemic in Africa. MDR TB is the main challenge
in Russia and Western Europe; XDR TB in Africa and in high HIV
settings is another emerging threat. There is failure to detect
smear-negative cases (especially in HIV and paediatric cases)
and improvements in laboratory diagnosis are required.
Q10: To what extent do you believe that the
2004 Stockholm Convention limiting the use of DDT against Malaria-carrying
mosquitoes has been a factor of increases in the spread of the
disease? Has any risk analysis been carried out comparing the
relative dangers to human health posed by DDT and Malaria?
A: There is some evidence that reduction
in use of DDT has resulted in increase in Malaria. There is also
now more interest in vector control (see Gates investment for
work based at Liverpool School of Tropical Medicine).
Q11: What intergovernmental action is planned
or in hand for early detection of the transmission of Avian Flu
from birds to humans and of human-to-human transmission in potential
source countries? Is this proving sufficiently effective to prevent
an Influenza pandemic? What more could be done?.
A: WHO is the main organisation for human
(globally), HPA major role UK. Will however depend on infrastructure
and arrangements in various countries.
Q12: To what extent do you consider that the
rise in infections in the four diseases is attributable to increased
microbial resistance to antibiotics? What intergovernmental action
is taking place in this area?.
A: The rise in Falciparum Malaria and the
associated morbidity and mortality has been attributed to increasing
drug resistance to antimalarials and the resistance of mosquitoes
to insecticides. This is being addressed with aggressive ACT combination
therapy together with the use of long lasting insecticide impregnated
nets and DDT spraying. There is however evidence that ACTs are
not being used effectively; also use of ACT has not been linked
to the need for a confirmed diagnosis of Malaria. National policies
in malarious areas are in a state of flux—leadership from
WHO is ambiguous on some topics e.g. Malaria and anaemia diagnosis.
The increase in MDR TB has contributed to increasing
TB in certain parts of the world, though overall the majority
of the strains remain sensitive to standard ATT.
Primary resistance to ART is not thought to
have contributed significantly to the HIV epidemic but lack of
laboratory support to detect resistance is lacking, so problem
may be under-estimated.
Q13: In a number of countries, including the
UK, there is a problem with hospital-acquired infections. What
intergovernmental sharing of knowledge is taking place to help
bring this problem under control?
A: There is very little formal intergovernmental
sharing of knowledge of HCAI. The scale of HCAI both in terms
of morbidity and mortality is not known in many countries, plus
definitions will differ making comparisons difficult. HCAI is
influenced by many factors including configuration of services
and staffing levels. With increasing international travel and
health tourism, there are many opportunities for spread of HCAI.
Many developing countries either do not have (or only have) rudimentary
surveillance systems.
Q14: Are there any difficulties with regard
to patents or intellectual property which are impeding the flow
of medicines or other control methods to those infected? Is intergovernmental
action needed to improve the situation?
A: The issue of intellectual property rights
is a sensitive issue in the area of AI—regarding the development
of a vaccine as well as for newer drugs. An intergovernmental
body bas been created to discuss this, the last meeting was held
in Singapore last year. Also issues around patients on medicines
for Malaria and HIV.
Q15: What interchange exists between States
in regard to knowledge of and training in the diagnosis and treatment
of the four diseases or regarding preparations for dealing with
outbreaks? What improvements might be made through intergovernmental
action?
A: WHO has extensive Guidelines on all four
diseases, though for some the evidence base is not robust. The
challenge at country level is translating paper into action. That
is where the difficulty arises in developing countries whose resources
and capabilities are already overstretched and/or weak.
16: The International Health Regulations 2005
are intended to provide a global framework for the rapid identification
and containment of public health emergencies. How effective do
you consider this response system to be? Do improvements need
to be made?
A: It is better than previous arrangements
and will be the mechanism of response to a Pandemic in the future.
There will be improvements to be made.
Q17: What intergovernmental planning has been
undertaken to cope with the impact of an outbreak of infectious
disease caused by deliberate release of micro-organisms into the
environment? Is there adequate liaison between the various agencies
involved, including intelligence, law enforcement and health care
professionals? How could action by intergovernmental bodies help
further?
A: HPA has worked on this and liaised with
NHS and others.
Q18: Though our remit is focused specifically
on known infectious diseases, we would be interested to know how
you view the global threat from new or previously unrecognised
ones and from the transmission of infections from animals to humans.
A: Many of the issues mentioned in Question
1 are relevant.
There is a lack of appreciation of relationships
between diagnostics, clinical management of infected patients
(including use of antimicrobials), healthcare associated infection,
health protection and health promotion—all services currently
provided by UK Medical Microbiology Departments working with others.
The current UK preoccupation with "tests" being done
as cheaply as possible threatens this valuable integration of
knowledge. UK could provide expertise in providing evidence about
cost effectiveness and clinical effectiveness.
Q19: What resources (subscriptions, staff,
training, medicines etc) does the UK Government commit to intergovernmental
bodies to help in the fight against the four diseases listed?
A: Global fund with direct government support
through SWAPs disease. Specific international research programmes.
Q20: Do you wish to provide any other relevant
information in addition to what you have said in answer to the
above?
A:No.
February 2008
12 HIV/AIDS, Tuberculosis, Malaria and Avian Influenza. Back
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