5.1     As noted above, both prudent use of antimicrobials and infection control are informed by surveillance. Surveillance provides the information on which to base policies, and by which to assess their effectiveness. Surveillance is not cost-free; it costs money to gather and transmit information, and it costs money to collect and analyse it. Witnesses have proposed various ways to improve surveillance in the United Kingdom, of disease in general and resistance in particular, both by getting new information, and by adding value to information already available.

Duty to report

  5.2     At present, in the United Kingdom, certain clinical conditions are notifiable under the Public Health (Control of Disease) Act 1984 and the Public Health (Infectious Diseases) Regulations 1988. Our witnesses point to various shortcomings of this regime.

  5.3     First, there is no requirement to report resistance as such; all current reporting is voluntary. Dr Mayon-White observes that voluntary informal reporting "strains slightly the rules of medical confidentiality" (Q 177). The PHLS would like mandatory reporting, not of every resistance—"That would be far too broad and you would be overwhelmed with data" (Q 91)—but of certain key resistances either known elsewhere but not in the United Kingdom, or unknown but anticipated (Q 92). They offered a list of eight resistances; Dr Mayon-White proposed a list of just four (Q 195). See Box 8.

Box 8

MANDATORY REPORTING

Notifiable diseases under the Public Health (Control of Disease) Act 1984, s.10

*  Cholera

*  Plague

Relapsing fever

*  Smallpox

Typhus

Also required to be notified under the 1984 Act, s.11

Food poisoning

Required to be notified under the Public Health (Infectious Diseases) Regulations 1988 (S.I.1988 No. 1546)

Acute encephalitis

Acute poliomyelitis

Anthrax

Diphtheria

Dysentery (amoebic or bacillary)

*  Leprosy

Leptospirosis

*  Malaria

Measles

Meningitis

Meningococcal septicaemia (without meningitis)

Mumps

Ophthalmia neonatorum

Paratyphoid fever

*  Rabies

Rubella

Scarlet fever

Tetanua

Tuberculosis

Typhoid fever

*  Viral haemorrhagic fever

(including Dengue fever,

Ebola virus and Lassa fever)

Viral hepatitis

Whooping cough

*  Yellow feverProcedure for notification

Notification under the Act and Regulations is to be made by a doctor to the "proper officer of the local authority" (normally the CCDC), and by him to the District Health Authority. The proper officer must report cases of the diseases marked *, and "any serious outbreak of any disease", to the Chief Medical Officer immediately; and must make weekly and quarterly returns of all notifiable diseases (except leprosy) to the Registrar General.

Resistances proposed to be notifiable

PHLS list (Q 92)

Organism

Staphylococcus aureus

Neisseria meningitidis

Enterobacteriaceae (not Proteus)

Acinetobacter

Streptococcus pyogenes

Streptococcus pneumoniae

Mycobacterium tuberculosis

Antimicrobial

Vancomycin (i.e. VRSA)

Penicillin

Carbapenems

All â-lactams

Vancomycin

Penicillin

Isoniazid and rifampicin -

(i.e. MDR-TB)

Dr Mayon-White's list (Q 195)

MRSA

MDR-TB

VRE

Resistant pneumococci

  5.4     Secondly (AMM p 4), notifiable diseases are required to be reported to the "proper officer" appointed by the local authority; in practice this is usually the CCDC of the health authority. There is no requirement to report to PHLS. Thirdly, the regulations refer to diseases according to a very antiquated classification. In Dr Mayon-White's view, they ought to be brought in line with modern microbiology, and refer to diseases by their causative organism (Q 177). Finally, one of the notifiable diseases is "food-poisoning". As Dr Mayon-White explained, "The food poisoning statistics are a ragbag of conditions", embracing everything from E. coli to indigestion (Q 183).

  5.5     The Department of Health informed us, "The Government is currently reviewing the provisions of the Public Health (Control of Disease) Act 1984 (and the regulations made under it) with the intention of bringing forward new legislation when Parliamentary time allows. Proposals for the new legislation will be set out in a discussion document which the Government expects to publish in the Spring. One of the provisions expected to feature in the new legislation is a requirement on laboratories to notify certain specified test results. This would be in recognition of the role laboratory testing now plays in the diagnosis of disease. It would also complement the existing system of notification of actual or suspected cases of certain diseases undertaken by registered medical practitioners. The definitive list of results to be reported would be determined in consultation with experts once the legislation has completed its passage through Parliament, but the Department will consider the inclusion of test results which can indicate some causes of hospital-acquired infection or resistance to (certain forms of) antibiotics. These are likely to include, for instance, test results indicating MRSA infection..." (letter 14.1.98, cp Q 777).

  5.6     Dr Christopher Bartlett of PHLS, Director of the Communicable Disease Surveillance Centre, recommended that mandatory reporting of certain resistances be backed up by "an untoward event reporting system, in which any unusual or unexpected resistance marker in any micro-organism is reported. The advantage of this is that you can identify new antimicrobial resistance events at an early stage and implement investigations to try and sort out the determinants. Untoward event reporting has been shown to be very effective in disease surveillance" (Q 95).

Scotland and Northern Ireland

  5.7     The PHLS is an agency of the Department of Health, and operates only in England and Wales. Scotland has microbiological laboratories, which report on a voluntary basis to the Scottish Centre for Infection and Environmental Health (SCIEH) of the NHS in Scotland; the SCIEH is "broadly analogous" to the PHLS Communicable Disease Surveillance Centre. PHLS-type services in Northern Ireland are provided by the Northern Ireland Public Health Laboratory in Belfast. Surveillance of TB and HIV/AIDS is integrated across the United Kingdom.

  5.8     Dr Alasdair MacGowan, Chairman of the Working Party on Antimicrobial Resistance Surveillance of the British Society for Antimicrobial Chemotherapy (BSAC), told us, "There is a problem, in terms of integration of the various national parts of the United Kingdom, as to what we should be doing" (Q 97). Professor Brian Duerden, Deputy Director of PHLS, agreed: "We do need to improve the links with Scotland and Northern Ireland to get the national picture".

  5.9     The Chief Medical Officer for England and Wales considers liaison to be good, but sees scope for improvement, e.g. in compatibility of definitions and data-collection (Q 818). The Scottish Office say, "There is evidence that reporting may be more comprehensive in Scotland" than in England and Wales[59]; a system for electronic laboratory reporting, "fully compatible" with the PHLS system, is being established in Scotland as recommended in the Pennington Report; and a recent review has recommended retaining separate Scottish reference laboratories for Salmonella, Campylobacter, E. coli 0157, MRSA and meningococci, rather than merging these functions with PHLS, on ground of both clinical and cost effectiveness (p 565). The Chief Medical Officer for Northern Ireland tells us that DHSS (NI) are currently working on setting up a Regional Communicable Disease Epidemiology Unit, with a view inter alia to "strengthening links with PHLS" (p 546).

Information technology

  5.10     Surveillance is a prime target for applications of information technology, for both analysis and transmission of data; and many of our witnesses call for investment in this area (e.g. AMM Q 47, Mayon-White Q 177). The Chief Medical Officer agreed; he noted the importance of confidentiality of patient-specific data (Q 777).

Linking and feedback: the ICARE model

  5.11     Value can be added to surveillance data by using information technology to link them with other data. Resistance data can be linked with records of antimicrobial usage; with clinical data from doctors submitting specimens for analysis (AMM p 5); and with clinical outcome data, to test the correlation between in vitro and in vivo (WHO Q 138; Davey p 156, Q 276). SmithKline Beecham are enthusiastic about the capacity of information from this "triangle" (usage, clinical outcome and resistance) to effect "the transformation of antibiotic use" (p 106).

Box 9

LINKING AND FEEDBACK IN THE USA

National Nosocomial Infection Surveillance (NNIS)

NNIS began in 1970, as a voluntary system to collect demographic and resistance data from certain wards in participating hospitals. It now involves 250 hospitals, all of 100 beds or more; it is still expanding, and becoming more representative of the generality of US hospitals. NNIS is confidential; CDC returns to each hospital its own results, in relation to the overall distribution.

Project ICARE

ICARE takes NNIS data and adds information about antibiotic usage. It currently involves 40 hospitals, each of which receives a nominal $3-4000 to support data collection; it covers 13 "bug-drug" combinations, chosen for their clinical importance. Like NNIS, ICARE is confidential; CDC returns to each hospital its own results, in relation to the overall distribution. In feeding back results to each hospital, the ICARE team at CDC try to identify interventions which can bring down rates of resistance. "One size doesn't fit all": two hospitals may have equally high levels of MRSA; in one case the cause may turn out to be overuse of cephalosporins, in the other proximity to a nursing home with poor infection control. Dr John McGowan, Professor of Infectious Diseases at Emory University, commented that, as a means of tackling resistance, ICARE has the advantage, over general guidelines, of being highly specific and taking full account of local circumstances, including constraints on resources. One limiting factor for ICARE, admitted by CDC, is the usage data; if pharmacy information exists at all, it is often set up to inform billing rather than to analyse usage. Another, pointed out by Dr McGowan, is the absence of community surveillance, which for some bug-drug combinations would be crucial.

  5.12     Value can also be added by feeding surveillance data, with analysis and comparisons, back to those who provided it. According to the BSAC, "The PHLS at present does not regularly return analysis of the sensitivity data it collects on a routine basis to those who provide it" (p 79). The Minister for Public Health said that the PHLS is committed "in principle" to improving the situation (Q 776).

  5.13     At CDC in the USA we learned about the US National Nosocomial Infection Surveillance (NNIS) system, and about Project ICARE (Intensive Care Antibiotic Resistance Epidemiology): see Box 9. We were most impressed by ICARE, and wondered how the concept might be transplanted to the United Kingdom. One way forward might be for a group of United Kingdom hospitals to ask to participate in ICARE itself; alternatively, a free-standing United Kingdom project might be supported from the NHS R&D Budget. Dr Mary Cooke, for the Department of Health (Q 786), pointed out that UK NINSS (see above, paragraph 4.28) is less developed than US NNIS, but said that incorporating prescribing information would make it more useful.

Resources for the PHLS

  5.14     The PHLS is roughly half funded by payments from the NHS and other "customers", with the balance of its budget provided by the Department of Health. The departmental contribution has been falling, and is projected to fall further:

1995-96	£52.1m (actual)
1996-97	£51.8m (actual)
1997-98	£51.9m (forecast)
1998-99	£50.9m (estimate)
1999-2000
2000-2001

The Minister for Public Health acknowledged that the PHLS is "an indispensable resource in protecting the public", and that the NHS must be "competent and adequately resourced" to deal with the problems of resistance; and she acknowledged the need for improved surveillance. However, she gave no indication that the Department will find more money for the PHLS (QQ 768, 779).

Crisis in clinical academic microbiology

  5.15     In microbiology as in other medical specialties, clinical research is led by the clinical academic staff who combine a medical school appointment with an NHS contract. However, clinical academic posts in microbiology are currently being lost: we have heard that chairs are vacant at St Thomas' Hospital, the Royal London Hospital and King's College Hospital in London, and in Sheffield and Liverpool. The Chief Medical Officer acknowledged this problem, and is anxious to resolve it (Q 814); he pointed to the paradox that this shortage of specialists has arisen at a time of great scientific excitement for the discipline. Glaxo Wellcome identify a decline in the capacity of UK universities to conduct research and produce well-trained graduates in microbiology; this, they say, is why most of their antibacterial research is done in Italy (p 408). SmithKline Beecham likewise identify a "technology gap" and a "lack of trained people" (p 485).

  5.16     SmithKline Beecham blame underfunding of the discipline "for many years". The AMM blame the Research Assessment Exercise (RAE), "which has laid greater value on the more fundamental aspects of research than those of a more practical and immediately applicable nature" (AMM p 376; cp Amyes p 544). They point out that, if funds are forthcoming for the applied research into the epidemiology and control of resistant organisms which many of our witnesses say is needed, they will be of limited use without "the very staff with the capability to lead such research and who have the credibility to ensure the implementation of any changes in practice".

  5.17     We ourselves expressed concern about the state of clinical academic medicine generally, in our report Medical Research and the NHS Reforms in 1995 (3rd Report 1994-95, HL Paper 12). The Committee of Vice-Chancellors and Principals (CVCP) responded by setting up an independent Task Force, chaired by Sir Rex Richards, whose report Clinical Academic Careers was published in July 1997. We met Sir Rex to discuss his report in December 1997, as recorded in our 3rd Report of this Session (HL Paper 47). The Task Force found that medicine generally came poorly out of the RAE; they blamed the conflicting demands of teaching, research administration and clinical service, coupled with disparity of reward between clinical academics and NHS staff (3rd Report 1997-98, QQ 5-6). The CVCP has not yet responded to the Richards Report; but the NHS Executive and the Higher Education Funding Council for England (HEFCE) have already taken steps to improve liaison in connection with the RAE. In particular, as announced in June 1997 in a letter to Vice-Chancellors and others (3rd Report 1997-98, para. 8), they have set up a task group on how the RAE should treat health services research, and another on the implications for the RAE of the links between teaching, research and patient care.

A national strategy for surveillance

  5.18     Professor Finch says, "At present there is no national systematic monitoring arrangement prospectively studying trends in resistance, that might provide robust data on which to make firm judgements [e.g. of the impact of OTC antibiotics]. Current data is selective in terms of sampling and is rarely denominator controlled" (p 189). The ICNA say, "There is currently no standardised national data collection system in operation in the United Kingdom which allows for comparison over time and between centres" (p 126). The AMM swell the chorus of disapproval: "The PHLS network of 48 laboratories and some NHS and university-run laboratories do collect bacterial strains of interest on a voluntary basis to send to central PHLS reference facilities or report to CDSC. Overall this has been a rather haphazard process and needs to be done systematically" (p 5, cp Q 5).[60] They go on, "Systematic collection of epidemiological data on resistance should be initiated immediately...The costs to the NHS are likely to be modest compared with many other actions" (p 14).

  5.19     Cost is an issue. The AMM told us, "Most United Kingdom laboratories are not resourced to perform surveillance". According to the BSAC, "Much of the data published in medical journals derives from pharmaceutically sponsored studies [see ABPI p 177, and Box 11 below]...Although the pharmaceutical industry in conjunction with private companies, NHS and university laboratories has put considerable effort into producing good quality surveillance data so far, this has not resulted in an ongoing surveillance programme. The Government, the NHS R&D Programme and charities have not funded large-scale surveillance schemes" (p 79).

  5.20     The Royal College of Pathologists define the need in terms of institutions (p 456). "We commend the apparently outmoded concept of well-found diagnostic laboratories alongside appropriate clinical facilities; these should be strategically sited in selected hospitals, adequately staffed...and funded...able to carry out appropriate surveillance...with results nationally and internationally co-ordinated...ready to define problems when and where they arise; and able to make persuasive applications for appropriate research funding..."

  5.21     The PHLS are not defensive of the status quo. Dr Bartlett would like to see "support for the development of surveillance systems within an overall national surveillance strategy. At least there needs to be developed a consensus beyond the PHLS, working with colleagues in the NHS and academia, including clinicians and public health colleagues also" (Q 107).

  5.22     Work on a strategy for resistance surveillance is in fact in hand. "The BSAC has recently set up a Working Party on Resistance Surveillance. It has proposed a multi-level approach to surveillance in the United Kingdom. Discussions have started with the PHLS as to how surveillance in the United Kingdom can be improved by a collaborative arrangement. In addition the BSAC is actively seeking partnerships with the pharmaceutical industry[61] and the Wellcome Trust, and has a proactive approach to implementing its concepts of surveillance during 1998 and beyond" (BSAC p 76). Details of the BSAC's proposals are given in their written evidence (p 80). The ABPI support them, and call on the Government to resource them (p 178). The Minister for Public Health said, "We support a strategic approach to this", but was unable to make any commitment as to resources (Q 778).

60   Cp also Amyes and Young, pp 374 and 376. Back

61   Including Zeneca and SmithKline Beecham. Back