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Infections—a new awakening?
Journal of Infection (I985)
II,
I-3
Editorial I n f e c t i o n s - - a n e w awakening?
Regular readers of this Journal hardly need reminding that infections present a continuing threat to our species. This reality contrasts with the rosy expectations of those who were misled by the near-disappearance from advanced countries of several major infectious diseases and the marked decline of others during the I95OS and I96Os. It has recently become obvious, however, that the classical infections of the past, except for smallpox, have not disappeared from the world. Indeed some of them, e.g. malaria, schistosomiasis, poliomyelitis, are even increasing in many developing countries with which we are in more and more regular contact. Even in the most advanced countries the two major anatomical portals--respiratory and alimentary--continue to provide for the continued high incidence of respiratory infections and for the rapidly increasing n u m b e r of food-borne infections. Innumerable infectious agents exploit with versatility the new opportunities opened up by changes in our lifestyle and diet, and by high-technological advances in industry and in medicine. Previously unfamiliar microbes such as campylobacters, keep emerging as important causes of serious disease and we continue to unmask others--legionellas and rotaviruses for instance--which were previously unknown. Even ' n e w ' infections still appear. These include pandemic acute haemorrhagic conjunctivitis due to enterovirus type 70 and the acquired i m m u n e deficiency s y n d r o m e ( A I D S ) caused by a retrovirus which has lately invaded our population. All this is familiar to those engaged in infectious disease practice and has been reviewed in recent publications?, ~ It was not so obvious to others, however, until the bursts of publicity about hepatitis, legionnaires' disease, genital herpes and A I D S. Reduced fear and lowered awareness of the problem of infection led to complacency and lessened enthusiasm to maintain control measures and to utilise fully such available preventive measures as vaccines. T h e rational principles of good hygiene and sanitation which did so m u c h to reduce the incidence of many communicable diseases in the past have become less popular than more fashionable, well-advertised but ineffectual measures such as the use of disinfectants t o ' kill all known germs '. However, the addition of A I D S to the growing list of diseases which can be spread by intimate and sexual contact, even from mother to u n b o r n or newborn child, by transfusion of blood and by blood products as well as potentially by organ transplantation has stimulated a spectacular, semi-irrational over-reaction to an unfamiliar threat. N o t only has this been displayed by the public at large but even by some professionals who have lost touch with the classical principles of managing infection. By contrast, the calm competence of the infection specialist has m u c h to offer in such troubled times? We have seen similar t h o u g h even less justifiable over-reactions to Lassa fever. No doubt more novel plagues that generate alarm and despondency are yet to come. T h e s e reactions, however, may be u s e f u l if they signal the start of an awakening to grim reality and promote a realisation that infections and o163-44.53/S5/o4oooi + 03 $02.oo/0 I
I985 The British Society for the Study of Infection JIN II
2
Editorial
infectious diseases have not been conquered, that they will never disappear and that they will continue to provide unpleasant surprises and problems which require properly organised arrangements for their recognition and management. Since this is only natural, forseeable and forseen, 4 why is it not obvious to the health administrations of the many countries which have allowed their infectious diseases services to decline ? In a world of increasing competition for scarce resources it is easy to take a paranoid view of the low priority given to infection compared with more popular and influential medical specialties. Even if there is some truth in this as an explanation it is unhelpfully simplistic. T h e report of the Royal College of Physicians 5 suggests that realism may yet prevail, t h o u g h it would be dangerous to seek the answer in relation to the clinical aspect alone. Laboratories play an important part in the surveillance and control of infection. T h e threatened demise of the U . K . Public Health Laboratory Service, even in part, should be vigorously opposed. 6 Perhaps more weight should be placed on the formative influences which conditioned those who are now the senior planners and policy makers and the consultants in other specialties. They, after all, matured during the era when infections were apparently reeling back under the combined influence of improved hygiene and sanitation, better nutrition and housing, vaccines and antimicrobial wonder-drugs. Unless they are engaged in the detailed action against infections or are unusually aware of the ecological realities of our changing environment and lifestyle, they might hardly realise that this trend was neither inevitable nor p e r m a n e n t and that new biological balances would be struck by the natural selection and adaptation of infectious agents to the changing m o d e m world. Even more important may have been the poor quality of health data available to governments in the form of routine morbidity and mortality statistics. Understandably, these were first introduced for those infections and other definable diseases which were perceived as major threats at the turn of the century. Predominantly they mirrored the decline of those same classical infections which responded most dramatically to improved conditions and to prophylactic measures of control. Although amended from time to time, the system has been unable to reflect infections not included in the classification or undetectable by the surveillance methods in use. Many important infections are unidentifiable, hidden or scattered among the various categories of the International Classification of Disease on which m u c h reliance has been placed. 2 Misled by an outdated emphasis on epidemics and mortality rather than on disability and the costs of curing sickness, health administrations have thus been largely 'flying blind'. Without adequate information they may have been t e m p t e d to regard as self-interested propaganda the warnings of those who as epidemiologists, microbiologists or clinicians dealing with infection in h u m a n beings or animals were better placed to recognise what was happening, especially through participation in the collaborative surveillance networks developed by the Public Health Laboratory Service with its Communicable Disease Surveillance Centre, as well as the Communicable Diseases (Scotland) Unit and the World Health Organisation (WHO). As part of the response by W H O to this challenge the first of a projected series of advanced training courses on the epidemiology and surveillance of
Editorial
3
c o m m u n i c a b l e diseases was held in Glasgow in 1983. A critical analysis of the situation in E u r o p e has been published by the Regional Office for E u r o p e of W H O . 2 T h e Royal College of Physicians has reported. 5 Is this the dawn of a new awakening ? Will new t h o u g h t s be converted into action ? W e m u s t hope so and, as warriors in the continuing battle against infection and infectious diseases, reinforce our collaborative efforts to gather and make k n o w n the facts of life to the decision-makers. N. R. Grist References
I. Tyrrell DAJ. The abolition of infection. Hope or illusion? Rock Carling Fellowship Lecture. London: Nuffield Provincial Hospitals Trust. i982. 2. Velimirovic B, Greco D, Grist N, Mollaret H, Piergentili P, Zampieri A. Infectious diseases • in Europe. A fresh look. Copenhagen: WHO Regional Office for Europe. 1984. 3. Gillis O. Panic. London: The Sunday Times, 24 February 1985. I7-I8. 4. Dubos R. Man adapting. New Haven: Yale University Press, 7th edn. I98I. 5. Future Consultant Staffing in Communicable and Tropical Diseases. A report of the Royal College of Physicians. J Roy Coll Physns Lond I985 ; I9: 7-9. 6. Howie J. Threat to the PHLS. Br M e d J 1985; 29o: 579-580.
II,
I-3
Editorial I n f e c t i o n s - - a n e w awakening?
Regular readers of this Journal hardly need reminding that infections present a continuing threat to our species. This reality contrasts with the rosy expectations of those who were misled by the near-disappearance from advanced countries of several major infectious diseases and the marked decline of others during the I95OS and I96Os. It has recently become obvious, however, that the classical infections of the past, except for smallpox, have not disappeared from the world. Indeed some of them, e.g. malaria, schistosomiasis, poliomyelitis, are even increasing in many developing countries with which we are in more and more regular contact. Even in the most advanced countries the two major anatomical portals--respiratory and alimentary--continue to provide for the continued high incidence of respiratory infections and for the rapidly increasing n u m b e r of food-borne infections. Innumerable infectious agents exploit with versatility the new opportunities opened up by changes in our lifestyle and diet, and by high-technological advances in industry and in medicine. Previously unfamiliar microbes such as campylobacters, keep emerging as important causes of serious disease and we continue to unmask others--legionellas and rotaviruses for instance--which were previously unknown. Even ' n e w ' infections still appear. These include pandemic acute haemorrhagic conjunctivitis due to enterovirus type 70 and the acquired i m m u n e deficiency s y n d r o m e ( A I D S ) caused by a retrovirus which has lately invaded our population. All this is familiar to those engaged in infectious disease practice and has been reviewed in recent publications?, ~ It was not so obvious to others, however, until the bursts of publicity about hepatitis, legionnaires' disease, genital herpes and A I D S. Reduced fear and lowered awareness of the problem of infection led to complacency and lessened enthusiasm to maintain control measures and to utilise fully such available preventive measures as vaccines. T h e rational principles of good hygiene and sanitation which did so m u c h to reduce the incidence of many communicable diseases in the past have become less popular than more fashionable, well-advertised but ineffectual measures such as the use of disinfectants t o ' kill all known germs '. However, the addition of A I D S to the growing list of diseases which can be spread by intimate and sexual contact, even from mother to u n b o r n or newborn child, by transfusion of blood and by blood products as well as potentially by organ transplantation has stimulated a spectacular, semi-irrational over-reaction to an unfamiliar threat. N o t only has this been displayed by the public at large but even by some professionals who have lost touch with the classical principles of managing infection. By contrast, the calm competence of the infection specialist has m u c h to offer in such troubled times? We have seen similar t h o u g h even less justifiable over-reactions to Lassa fever. No doubt more novel plagues that generate alarm and despondency are yet to come. T h e s e reactions, however, may be u s e f u l if they signal the start of an awakening to grim reality and promote a realisation that infections and o163-44.53/S5/o4oooi + 03 $02.oo/0 I
I985 The British Society for the Study of Infection JIN II
2
Editorial
infectious diseases have not been conquered, that they will never disappear and that they will continue to provide unpleasant surprises and problems which require properly organised arrangements for their recognition and management. Since this is only natural, forseeable and forseen, 4 why is it not obvious to the health administrations of the many countries which have allowed their infectious diseases services to decline ? In a world of increasing competition for scarce resources it is easy to take a paranoid view of the low priority given to infection compared with more popular and influential medical specialties. Even if there is some truth in this as an explanation it is unhelpfully simplistic. T h e report of the Royal College of Physicians 5 suggests that realism may yet prevail, t h o u g h it would be dangerous to seek the answer in relation to the clinical aspect alone. Laboratories play an important part in the surveillance and control of infection. T h e threatened demise of the U . K . Public Health Laboratory Service, even in part, should be vigorously opposed. 6 Perhaps more weight should be placed on the formative influences which conditioned those who are now the senior planners and policy makers and the consultants in other specialties. They, after all, matured during the era when infections were apparently reeling back under the combined influence of improved hygiene and sanitation, better nutrition and housing, vaccines and antimicrobial wonder-drugs. Unless they are engaged in the detailed action against infections or are unusually aware of the ecological realities of our changing environment and lifestyle, they might hardly realise that this trend was neither inevitable nor p e r m a n e n t and that new biological balances would be struck by the natural selection and adaptation of infectious agents to the changing m o d e m world. Even more important may have been the poor quality of health data available to governments in the form of routine morbidity and mortality statistics. Understandably, these were first introduced for those infections and other definable diseases which were perceived as major threats at the turn of the century. Predominantly they mirrored the decline of those same classical infections which responded most dramatically to improved conditions and to prophylactic measures of control. Although amended from time to time, the system has been unable to reflect infections not included in the classification or undetectable by the surveillance methods in use. Many important infections are unidentifiable, hidden or scattered among the various categories of the International Classification of Disease on which m u c h reliance has been placed. 2 Misled by an outdated emphasis on epidemics and mortality rather than on disability and the costs of curing sickness, health administrations have thus been largely 'flying blind'. Without adequate information they may have been t e m p t e d to regard as self-interested propaganda the warnings of those who as epidemiologists, microbiologists or clinicians dealing with infection in h u m a n beings or animals were better placed to recognise what was happening, especially through participation in the collaborative surveillance networks developed by the Public Health Laboratory Service with its Communicable Disease Surveillance Centre, as well as the Communicable Diseases (Scotland) Unit and the World Health Organisation (WHO). As part of the response by W H O to this challenge the first of a projected series of advanced training courses on the epidemiology and surveillance of
Editorial
3
c o m m u n i c a b l e diseases was held in Glasgow in 1983. A critical analysis of the situation in E u r o p e has been published by the Regional Office for E u r o p e of W H O . 2 T h e Royal College of Physicians has reported. 5 Is this the dawn of a new awakening ? Will new t h o u g h t s be converted into action ? W e m u s t hope so and, as warriors in the continuing battle against infection and infectious diseases, reinforce our collaborative efforts to gather and make k n o w n the facts of life to the decision-makers. N. R. Grist References
I. Tyrrell DAJ. The abolition of infection. Hope or illusion? Rock Carling Fellowship Lecture. London: Nuffield Provincial Hospitals Trust. i982. 2. Velimirovic B, Greco D, Grist N, Mollaret H, Piergentili P, Zampieri A. Infectious diseases • in Europe. A fresh look. Copenhagen: WHO Regional Office for Europe. 1984. 3. Gillis O. Panic. London: The Sunday Times, 24 February 1985. I7-I8. 4. Dubos R. Man adapting. New Haven: Yale University Press, 7th edn. I98I. 5. Future Consultant Staffing in Communicable and Tropical Diseases. A report of the Royal College of Physicians. J Roy Coll Physns Lond I985 ; I9: 7-9. 6. Howie J. Threat to the PHLS. Br M e d J 1985; 29o: 579-580.