Memorandum by the Royal College of Physicians
1. The Royal College of Physicians (RCP)
plays a leading role in the delivery of high quality patient care
by setting standards of medical practice and promoting clinical
excellence. We provide physicians in the United Kingdom and overseas
with education, training and support throughout their careers.
As an independent body representing over 20,000 Fellows and Members
worldwide, we advise and work with government, the public, patients
and other professions to improve health and healthcare.
2. The RCP has a number of specialties with
an interest in this issue, and our evidence reflects their views.
The following responses are based on opinion among a number of
key specialties with an interest in this issue, including from
our Joint Specialty Committee (JSC) on Genito-urinary Medicine,
and our JSC on Infection and Tropical Medicine.
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?
3. Global population increases and the vastly
increased movement of populations, such as through the increase
in travel globally, increasing numbers of refugees and economic
migrants, can all impact on the spread of disease. Although the
world-wide level of infectious diseases has remained similar,
there are some specific increases/decreases in certain disease
areas, and with increased drug resistance and new emerging infections.
In the context of tuberculosis, plans to increase the number of
patients who are successfully diagnosed with tuberculosis have
had only minor success. It is the opinion of some of our colleagues
working in this area that the burden of tuberculosis is approximately
stable, but the problems associated with drug resistant disease
are increasing and provide an increased threat to the UK. The
burden of disease could be considered a crisis. Other new infectious
diseases continue to emerge and assessing their relative impact
in advance is difficult.
SEXUAL HEALTH
4. It is a pertinent and useful example
therefore to consider sexually transmitted infections including
HIV in the UK. In 2005 the Health Select Committee described the
"sexual health crisis", and the government swiftly responded
within the White Paper "Choosing Health" to highlight
sexual health as a priority. This was backed with the announcement
by the Secretary of State for health that there would be "targeted"
funding to achieve improvements in services to improve access,
to shorten the time to diagnosis and treatment, and to prime innovative
outreach services to increase the diagnosis of HIV and other infections.
5. This approach was extremely well received
by specialists and at the time the RCP convened a working party
on sexual health, with a multidisciplinary group with representatives
from different colleges, the BMA and the HPA. At the time that
Choosing Health was launched, particularly around the funding
announcement, our working party felt its work in making the case
had been achieved, and agreed to disband itself. This was, however,
alongside the warning from the working party that as the money
earmarked by government to achieve public health improvement was
not ring-fenced, there needed to be close scrutiny of how that
money was effectively delivered to provider services.
6. Assurances were given by the Department
of Health that this would be achieved by performance management
through strategic health authorities, for example for PCTs achieving
reductions in access time to genitourinary medicine services and
implementation of the national Chlamydia screening programme.
RCP and speciality associations (such as BASHH) continued to monitor
this, and along with the independent advisory group on sexual
health have since sadly documented the failure of the mechanism
for delivering funding targeted at public health through primary
care trusts. The financial problems in the NHS in 2006-07 have
resulted in numerous examples of where money targeted by government
to improve sexual health of the population was used to make up
the deficits. Multiple examples of PCTs failing to implement Chlamydia
screening have also been documented. Indeed, when this issue was
raised with the Department of Health, specialty societies were
advised to "keep up the pressure on PCTs'.
7. These concerns about the lack of delivery
were so strongly felt at the highest level that a national support
team for sexual health was created to try to assist PCTs with
their plans and implementation.
8. There are a number of lessons that can
be learnt from this with regards to other aspects of the public
health control of communicable diseases. Certainly it is clear
that the PCTs, even when given targets which are included in the
NHS top 6 targets, cannot be automatically relied upon to deliver
those resources to enable services to meet public health targets
because of the priority given to dealing with the short term financial
problems within the NHS. Whether this scenario would also apply
to pandemic flu or MDRTB is conjecture, but this does illustrate
the great dilemma for public health improvements which may require
investment for a longer period and in the main are not supporting
acute services.
9. Despite the limitations on resources,
specialists across all disciplines in sexual health services have
achieved improvements in access targets by modernisation. However,
the sustainability of this is now threatened by the implementation
of Payment by Results (PbR) and other new systems of funding without
appropriate communication. Furthermore, if the management of HIV
and other services are to be funded through such a PbR route then
there must be a reality check regarding the importance of public
health in commissioning bodies. In the experience of some of our
colleagues, this has been lacking and there appear to be great
concerns regarding the impact of privatisation on public health.
Q2. What reliable data exist regarding the
numbers of people infected globally with the four diseases[13]
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?
10. Factual data regarding numbers of people
infected globally should be provided from this consultation by
the WHO. There is recent published data on HIV infection and the
burden of HIV disease worldwide has been adjusted downwards, but
this still leaves very large numbers of people involved with no
room for complacency. Figures for tuberculosis suggest the disease
is constant since tuberculosis is essentially a disease of man.
More robust data on patterns of transmission, duration of infection
and better isolation procedures could be used to decrease disease.
In terms of tuberculosis, approximately one third of the world's
population (1.6 billion people) is estimated to be infected with
the organism and therefore it is unlikely that there will be a
major decrease in disease numbers in the medium term. However,
tuberculosis reactivation is associated with poverty and it is
clear that the major decline in this disease in the UK was associated
with improved social and economic conditions rather than with
drug discovery or vaccination. This concept is pivotal in the
understanding of tuberculosis. Multi- and now extensively-drug
resistant (MDR/XDR-TB) have emerged and are on the increase.
11. Reliable data in the UK come from CDSC
(part of the HPA), particularly with HIV and TB. The WHO has reasonable
data on TB and malaria and UNAIDS produces data on the global
HIV problem. In addition, EuroSurveillance provides information
on a variety of communicable diseases of public health import.
One of the most important issues is the link between HIV and TB;
a lot of the new cases of TB in the UK are linked to HIV infection.
These are often related to immigrants and many can be related
to the terrible situation in Zimbabwe, forcing people to flee
that country.
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?
12. UK surveillance of communicable diseases
is considered to be very good, among the best globally. The current
systems are good but threats to the HPA budget may impact on this.
However, if there is an increasing trend to use private suppliers
of diagnostics, some of the established notification systems may
be threatened.
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?.
13. Those who are involved in such programmes
may predict decreases in incidence but to date success had been
limited and it is hard to be optimistic about the future. In particular,
the worldwide incidence of tuberculosis and malaria are unlikely
to change. In terms of pandemic flu, a need for an extremely rapid
response at the country of origin in the face of the emergence
of a new strain requires prior agreement from a great number of
countries to divert significant resources to a resource poor nation,
and there is no good evidence that this is likely to occur.
14. If the conflicts around the world continue,
particularly in Africa, there will be increasing numbers of HIV
and TB-infected people. Perhaps more important numerically in
the next 10 years is the epidemic of HIV in Asia, particularly
in India and China. If HIV increases, so will TB. Malaria is likely
to increase as a problem because of global warming so that some
regions previously free of malaria may become endemic again. It
is also possible that some transmission may occur in southern
Europe.
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?
15. The principle blockade to achieving
progress in the prevention of control tuberculosis, malaria and
HIV is economic and social deprivation. In the short term, in
tuberculosis there is a major issue with a very prolonged duration
of drug therapy required, which is for a minimum of 6 months,
and could be tackled by new drug regimens. Better diagnostics
for tuberculosis are also urgently required.
16. Another block to progress on these important
4 diseases is the relative lack of infection specialists in the
UK compared to Europe and the USA. Reducing risk to travellers
needs better education of the public and infection specialists
can raise awareness. Communicable diseases presenting to UK hospitals
may be missed if there are inadequate numbers of physicians with
expertise in infectious diseases. Better education of clinical
staff will help. Intergovernmental involvement in the promotion
of training and education in infection can help, as can continued
provision of funding for research. New vaccines will be required,
as will new antimicrobials.
SEXUAL HEALTH
17. From the perspective of our colleagues
working in GUM, it is clear that the major block to improvement
in STI rates in the UK was not government, which provided leadership
and strategy at the highest level, nor clinicians and managers
in provider services, but was in commissioning bodies where competing
priorities meant that public health investment, even when targeted,
lost out to addressing the financial deficits, which necessitated
making savings.
18. Our JSC on Genito-urinary Medicine calls
for the reintroduction of ring-fenced money to ensure that primary
care trusts are not able to divert funding away from national
strategic health priorities.
19. This issue is particularly pertinent
as only a few weeks ago the European Union has taken forward a
call for action to increase the uptake of HIV testing to reduce
late presentation of individuals with AIDS. To implement greater
testing in the UK requires investment by primary care trusts but
will then, if successful, lead to increased numbers of individuals
diagnosed with HIV who will require antiretroviral treatment.
In the absence of a national tariff for the management of outpatients,
it would be up to commissioners in different areas to find different
solutions for a problem that must be nationally equitable and
accessible to achieve the expected economic and public health
benefits of improved management and fewer transmissions of HIV.
This equally applies to problems associated with this infection
such as MDRTB and co-infection with hepatitis. We trust that in
preparing changes in the way in which these services are funded
that the Department of Health will ensure that clinical priorities
and public health are paramount and guides the mechanism of funding
rather than the converse.
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?
20. The RCP interacts with specialist societies
such as the British Infection Society and the Royal Society of
Tropical Medicine & Hygiene which are involved in disseminating
research findings, developing local guidelines and international
protocols for the management of influenza, tuberculosis and malaria.
However, these organisations do not have a front line role in
dealing with diseases that are largely based internationally.
21. The RCP is closely involved with infectious
diseases training and professional standards through its Medical
Specialties committees and through joint working with the RCPath,
and Medical Microbiology in particular. It is also allied closely
with the Medical Research Council and the Wellcome Trust, both
of which fund important research in this area.
Q7. What are the main non-health causes (eg
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?
22. Tuberculosis, as discussed previously,
is closely linked to poverty and social crowding. Influenza is
affected by lifestyle, social crowding, sharing space with animal
reservoirs and international travel. Malaria is predominantly
related to lifestyle and changes in land use, and HIV is related
to lifestyle and poverty.
23. Global warming is also important for
communicable diseases in 2 main ways. Firstly, there is a higher
risk of increasing the breeding sites for vectors of disease,
such as mosquitos, so that disease transmission is facilitated.
Secondly, because of increased flooding and increased regions
of drought, there will be a rise in the number of waterborne diseases
such as cholera.
24. Increased travel by UK residents increased
their risk of acquiring infections abroad (including HIV) and
bringing these diseases back to the UK. They potentially increase
the reservoir of infection in the UK. More importantly, the unrest
in the world will increase the pressure on the UK from refugees
and economic migrants who may bring infections with them. Providing
proper health care, and research into the health needs of migrants,
is one way that intergovernmental agencies can help. Things are
not as "joined up" as they should be—for example,
the work of the Home Office in moving asylum seekers around the
country disrupts their health care in detrimental ways, interrupting
treatment regimens for serious conditions like TB and HIV.
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?
25. Action to alleviate poverty would have
a major effect on all these diseases but cannot be undertaken
by a single government alone and requires commitment at levels
far greater than are currently considered. The main factors driving
the rise in tuberculosis in the UK are migration and poverty with
relatively little contribution from HIV. The restriction of access
of migrants, refugees and asylum seekers to health services both
the primary and secondary care which is currently ongoing is conducive
to 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; 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.
26. The increase in TB cases is largely
related to increases in immigration from countries with high TB
prevalences but is also linked to the increased numbers of people
with HIV in the UK. At the same time, the expertise to diagnose
and manage TB is limited with too few specialists in infection
so that often patients are managed by those with less knowledge
and experience. Laboratories need to be strengthened so that they
have the resources to use new methods of rapid diagnostics and
rapid assessment of drug resistance in TB isolates. Intergovernmental
cooperation in providing better screening for TB in asylum seekers
and new immigrants will help, as will raising the awareness in
general practice about the presenting features of TB. Although
the dispersion of asylum seekers in the UK may make sense from
a Home Office perspective, this should not be pursued for those
in the middle of treatment programmes for TB. Having to move home
or city during a treatment course will lead to poor adherence
to the treatment programme, will lead to risk of disease relapse
and possibly increase the risk of drug resistance evolving.
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—eg HIV/AIDS? Or are there other reasons
why a treatable disease should be spreading? How might intergovernmental
action help to deal with this situation?
27. There are many reasons why tuberculosis
appears to be on the increase. Firstly, approximately 50% of patients
with the disease are not diagnosed. The gold standard for worldwide
diagnosis is microscopy, which has 50% of the sensitivity of culture
which is the standard used in more affluent countries despite
that the fact that there are tests available which are both cheap
and culture based. (N. Engl. J. Med. 2006; 355:1539-50). Secondly,
the crowding of people together in poor urban centres increases
transmission of tuberculosis generally. Thirdly, 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.
28. Intergovernmental action could be used
to support the development of appropriate diagnostics and new
short course regiments for treatment. It could provide funds for
such diagnostics and for laboratories in resource poor environments
to be properly equipped such as to protect the workers from the
diseases in which they encounter. In addition there could be action
to improve healthcare facility design reduce nosocomial transmission
of disease in outpatient and inpatient settings which would have
a broad range of benefits. Reducing disease transmission is also
a priority in prisons which tend to be run by governments.
29. Most of the failure of TB treatment
is due to the fact that the resources are not available in many
countries to provide the supervision of therapy that is needed.
Directly observed anti-TB therapy is the ideal but is rarely realised,
even in developed countries. Treatment courses take at least 6
months and this can be difficult for the patient without encouragement
and support. There can also be problems in maintaining adequate
supplies of TB medication for patients in some settings.
30. In addition, HIV affects the way that
TB presents and may lead to delayed diagnosis so that the infected
individual may have longer to infect others before receiving treatment.
Many countries do not have the resources to culture specimens
for TB so both under- and over-treatment occur. Very few places
do adequate surveillance of drug resistance. Resistant TB is an
increasingly recognised issue. In addition to risks to the individual
patient in not being cured, the risk of infecting others increases
with inadequate therapy. Also, second line treatment for resistant
TB is considerably more expensive than standard treatments. Intergovernmental
efforts to improve diagnostics in high prevalence areas would
help, as would research in to better diagnostics. There should
also be encouragement to produce better drugs for TB that act
more quickly and could, therefore, shorten treatment times.
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?
31. Although the DDT ban will have had some
effect, there are more fundamental issues to do with resources
that governments use to combat mosquitoes and other insect vectors
of diseases.
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?.
32. There is certainly a (probably realistic)
assumption that intergovernmental efforts to prevent spread of
flu at source are unlikely to work since a great deal of effort
is being put into pandemic flu planning, such as the DH Expert
Panel and HPA. It is vitally important that universal sharing
of data, which has been a problem in certain areas (see section
16) and reciprocal agreements for highly effective treatment campaigns
at sites of emergence for pandemic should be supported at an intergovernmental
level.
33. The preparation for and response to
avian "flu has been very good, particularly in the UK. The
problem is that vigilance will have to be maintained over long
time periods.
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?.
34. Antimicrobial resistance is a particular
problem in TB, but less so in HIV. The adopting of ACT (artemisinin
combination therapy) for malaria by the WHO should help to reduce
the threats from drug-resistant malaria. However, good surveillance
of drug resistance in all of these diseases needs to be maintained.
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?
35. There is wide recognition of the problem
of healthcare-associated infections (HCAI) and there is now increased
public awareness about it. Unfortunately, the reduction in hospital
beds in the UK, plus failure to manage many patients outside hospital,
increases pressures so that bed occupancy is far too high. This
increases the risk of HCAI, as does the increasing number of frail,
elderly people in hospital who do not have sufficient defences
against infection. Surveillance is improving but there needs to
be more work with hospitals, community trusts and the HPA to help
to reduce the problem. The RCP has a HCAI committee chaired by
Professor Jonathan Friedland.
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?
36. There are considerable issues in the
area of diagnostics in which many new 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
pattern 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 providing similar equipment at reduced prices for poorer
countries (see also section 16).
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?
37. Education of the public is essential
and this needs to be in the context of health programmes which
can provide necessary diagnosis and treatment. In some areas of
the world there are conflicts between religious messages (ie superstition)
and the knowledge base which need to be addressed. Worldwide provision
of internet-based learning opportunities for those in healthcare
are required. Support for education would benefit from intergovernmental
co-operation.
38. Interchange between the United States
and the UK is largely via academic links, with many UK specialists
attending international meetings in the United States and elsewhere.
Most of these meetings are research based but some are knowledge
based and related to clinical issues. The changes in training
of UK doctors (through MMC) has made it difficult for exchange
of clinical trainees to occur. This was very useful and many UK
specialists had time training in the US in the past. In addition,
the restrictions placed on foreign doctors coming to the UK also
affects US trainees who may want to experience NHS practice. Dealing
with outbreaks is probably done fairly well with international
epidemiological links.
Q16. 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?
39. There are limitations to the IHR which
depend on the will of international governments to implement the
agreed actions. This was recently clearly demonstrated in the
sharing of flu specimens from Indonesia, where there were concerns
that these would be used in vaccines which would only be available
for rich countries, and the citizens of the country supplying
specimens would not benefit. One issue is that IHR does not explicitly
cover biological specimens. If IHR is to work so there is need
for high quality infrastructure, communication systems and labs.
There also should be complementary legislation on animal diseases
since this is from where new pathogens may emerge.
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?
40. Each region has an infectious diseases
physician designated as a smallpox diagnostic expert and to whom
authorities would turn in the event of a deliberate release of
a pathogen. The HPA also has plans in place.
41. However, it is the feeling of some colleagues
that vast amounts of money have been spent on bioterrorism quite
out of proportion on the likely damage that this can cause. Any
terrorist is likely to find it easier to use radioactive or chemical
weapons than biological ones and this should not therefore be
a priority area.
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.
42. It is inevitable there will be continued
emergence of new infectious diseases and in transmission of diseases
from the animal population to the human population for the foreseeable
future and therefore surveillance needs to be generic and not
too disease specific for the recognition of new outbreaks.
43. The threat of emerging infections, such
as SARS, is ever-present and the government needs to maintain
readiness. There needs to be a network of good diagnostic laboratories
able to respond rapidly to new diseases and the surveillance system
needs to be in place. The weakness is in the number of clinicians
trained in clinical infection so there is a risk that new infections
or odd presentations of known infections may be recognised late.
In addition, the pace of NHS work and the reduction in beds may
mean that some people are discharged with new infections so rapidly
that the new problem is not diagnosed. There is also a paucity
of isolation beds in the UK and very few isolation facilities
in Emergency Departments in NHS hospitals.
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?
44. The UK needs to strengthen clinical
infection services in the NHS; currently infectious diseases physicians
are rarely employed outside of teaching hospitals. There should
be an increase in emphasis on training on infectious diseases
in the UK medical school curricula and in postgraduate medical
training. There should also be more emphasis on providing help
to developing countries where these four diseases are highly prevalent
so that appropriate research, clinical trials and clinical management
can be pioneered. Funding for basic science and applied clinical
science in these areas needs to be a priority.
Q20. Do you wish to provide any other relevant
information in addition to what you have said in answer to the
above?
45. The UK is at the forefront on 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.
The UK has very few ID doctors per head of population (compared
to the US, Scandinavia etc) and expansion of training and an increase
in consultant numbers is urgently required.
18 January 2008
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