The Royal Society of Edinburgh (RSE) is pleased to respond to the House of Lords Science and Technology Select Committee Inquiry into Fighting Infection. The RSE is Scotland’s premier Learned Society, comprising Fellows elected on the basis of their distinction, from the full range of academic disciplines, and from industry, commerce and the professions. This response has been compiled by the General Secretary with the assistance of Research Officer, Dr Marc Rands, and a number of Fellows with substantial experience in medicine and health.
The specific issues identified in the call for evidence are addressed below:
What are the main problems facing the surveillance, treatment and prevention of human infectious disease in the United Kingdom?
In order to have a satisfactory national surveillance system it is important to have comprehensive, timely and reliable data. Not all infections need to be reported and not all of those that do will receive the same degree of urgency. Among the Notifiable Diseases there is often a lack of uniformity in reporting and it is likely that there is a considerable under-reporting of patients with conditions such as food poisoning. This, of course, is often due to the fact that, unless the patient is badly affected, there will not be any involvement with the medical community and even then notification to the public health authorities will not necessarily always follow.
Among other problems with the present surveillance system are:
Although good surveillance of the communicable diseases is generally considered to be the most powerful and effective control technique it is still often under-rated despite its value being well demonstrated in the eradication of smallpox from the world in the 1960s
Because of the new advances in medicine there are increasing numbers of subjects being taught in medical schools and there is often not enough time for medical students to be given information about the value of surveillance. Thus, after qualification there is usually not the required priority given to carrying out the necessary procedures.
There are now fewer medically qualified persons in public health departments and microbiological laboratories - especially those with infectious disease experience - than in former years. Therefore there is perhaps less awareness in this area of work of the importance and urgency of their findings.
Because the infection process involves not only the virulence of the microbe but also the susceptibility of the host and the state of the environment in which the host lives, successful surveillance entails the interaction of several disciplines whether in the health centre, the hospital, the laboratory or within environmental agencies. Also, several infections can be transmitted from animals so that the involvement with the veterinary authorities cannot be ignored. This extended chain of communication can have the potential for creating problems.
Problems can also arise if there is not the closest possible interaction between those treating infection and those preventing it.
Will these problems be adequately addressed by the Government’s recent infectious disease strategy, Getting Ahead of the Curve?
Getting Ahead of the Curve certainly addresses many of the problems associated with the control of infection. There are, however, areas that still need to be dealt with. For example, the responsibility of medical faculties of universities to ensure that students are made more aware of the value and methodology of surveillance techniques and the enhancement of arrangements (e.g. the formation of "spotter" general practitioners) to give an early warning of hazards.
It is also important to recognise that the strategy "Getting Ahead of the Curve" refers to the situation in England. In Scotland there are differences in the surveillance system in several respects. For example, another area where perhaps more emphasis could have been given is in the multidisciplinary working of those involved with infection and environmental problems. This already happens in the Scottish Centre for Infection and Environmental Health where there are medical, veterinary, nursing and environmental personnel working in the same building and under the same administrative structure.
Is the United Kingdom benefiting from advances in surveillance and diagnostic technologies; if not, what are the obstacles to its doing so?
The surveillance agencies, diagnostic laboratories and departments of infectious diseases in the United Kingdom are still admired elsewhere in the world but there seems to be an increasing tendency for blunting, to some extent, the expertise of those working in this area by their responsibilities becoming more general. For example, unlike the USA where infectious disease physicians usually concentrate solely on infectious problems, in the UK many of these doctors are general physicians with an interest in infection and therefore do not have the same opportunity to go into the subject as deeply as their American counterparts.
Should the United Kingdom make greater use of vaccines to combat infection and what problems exist for developing new, more effective or safer vaccines?
Undoubtedly immunisation, despite some concerns, has been an extremely effective weapon to combat infection. Because of the success of polio and measles vaccines it is likely that these diseases will be as successfully dealt with as has happened to smallpox. There are of course several other diseases of high morbidity which could lend themselves to effective immunisation – especially, in this country, certain respiratory infections of childhood e.g. Respiratory Syncytial Virus infection. Although there appears to be many difficulties associated with the development of a vaccine against the Acquired Immune Deficiency Syndrome (AIDS) such is the impact of this disease that every effort should be made to bring immunisation to a successful conclusion.
What infectious diseases pose the biggest threats in the foreseeable future?
Creutzfeldt – Jakob disease of the brain obtained by eating meat from cattle infected with Bovine Spongiform Encephalopathy and the tragic rise in the number cases of AIDS have been timely reminders that alarming and fatal hazards can appear in the population quite unexpectedly. For the moment these probably pose the biggest threat but history has shown that new problems can come along with surprising rapidity and are frequently difficult to predict.
What policy interventions would have the greatest impact on preventing outbreaks of and damage caused by infectious disease in the United Kingdom?
Greater emphasis on the education of professionals (medical, nursing, environmental and veterinary) at both undergraduate and postgraduate level in the treatment and control of infection.
The adoption of an even greater integrated approach between those involved in the clinical, epidemiological and laboratory aspects of infection.
Surveillance operations should be re-assessed to ensure that they are not encumbered with obsolete, over-elaborate and redundant procedures and that they can incorporate new methods as rapidly as possible.
Further enhancement of health education efforts to ensure that all sections of society accept that they have the knowledge and a responsibility to try and deal with infection as effectively as possible.
In responding to this inquiry the Society would like to draw attention to the following Royal Society of Edinburgh responses which are of relevance to this subject: Healthcare in 2020 (September 2000) and the RSE Inquiry into Foot and Mouth Disease in Scotland (July 2002).
Professor Andrew Miller CBE
Royal Society of Edinburgh
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Edinburgh EH2 2PQ
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Fax: +44 (0)131 240 5024