Volume 70 December 1977
885
Section of Epidemiology & Community Medicine President A M Adelstein MD
Meeting 10 March 1977
Communicable Disease Control breaks of cholera were to supervene before the Royal Commission of 1869 led to changes in local government introduced by the legislation of 1871 and 1872. This paved the way for the consolidating Public Health Act of 1875, which placed responsibilities for the control of the environment and of Control of Communicable Disease infection firmly with the local authorities. at District Level One of the recommendations of the Royal Control of communicable disease is a function of Commission was that full-time medical officers of the local authority. It is interesting to trace how health should be appointed. Already, in 1847, this came about following the events of the In- Liverpool had appointed Duncan as their medical dustrial Revolution. Towards the end of the eight- officer of health by Private Act of Parliament, and eenth century and during the early part of the in 1848 John Simon was likewise appointed in nineteenth, dramatic social changes occurred, re- London. By 1873 there were approximately 1600 sulting in the migration of large numbers of a district authorities and three-quarters of them had predominantly country-dwelling population into medical officers of health; but they were partthe new towns and embryonic cities. With them timers, since the legislation had not followed the they brought their rural modes of sanitation and Commission's recommendation. It was not until environmental hygiene, which had been relatively 1909 that a statutory requirement to appoint fulladequate in the more sparsely populated country- time medical officers of health was laid upon side. There was no adequate administrative or counties. The Public Health Act of 1936 gave very conlegislative framework to contend with such a situation. Sir John Simon (1897) vividly describes siderable powers to local authorities to control the the problems: land drains were doubling up in- spread of infection by controlling the activities of effectively as foul sewers, domestic cesspools were those suffering from notifiable infectious diseases often constructed in the basements of houses and and by disinfecting premises and fomites which there was no system of refuse disposal -'the might also act as sources. There were also powers householder stored his filth as he liked, or got rid of to enforce improved standards of environmental it as he could'. hygiene. Subsequent Acts have reinforced these It was not surprising that, with overcrowding, powers and, together with the various regulations malnutrition, and long hours of work super- under the Acts, make up the armamentarium of imposed on such circumstances, infections of all control. The medical officer of health was both kinds became rampant (Brockington 1956). expert adviser and executive officer of the local Cholera was introduced into the country in 1832, health authority, and over the years built up with disastrous results. The disease became wide- considerable expertise in the measures needed to spread and mortality was immense. Although it control outbreaks of infection. cannot be adequately quantified because returns Adequate control is dependent upon rapid rewere by no means complete, Simon reports that cognition of infection, the understanding of modes certain named places in Great Britain with fewer of transmission, levels of infectivity and susceptithan five and a quarter millions of aggregate bility, and the ability to weigh the pros and cons of population suffered 31 376 deaths, and in Ireland a variety of potential courses of action. The the deaths were 21 171. Three further major out- identification and control of the disseminator of Dr A J Rowland (Bristol Health District (T), 10 Marlborough Street, Bristol BSJ 3NP)
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Proc. roy. Soc. Med. Volume 70 December 1977
infection, and the protection, surveillance and, if necessary, control of those who have been put at risk, is a vital part of the task. The work involves visits to homes, places of work and hospitals, interviews with and, if necessary, medical examination of individuals. Appropriate advice must be given, and specimens may need to be collected for bacteriological, virological, or serological examination. The results of pathological tests must be considered and interpreted, and appropriate further action taken. In outbreaks which engender public interest, information must be given to the press in a balanced way. It was rarely possible, or indeed necessary, for the medical officer of health to do all this himself. He delegated much of it to senior medical staff in his department, and much of the domiciliary and other visiting was carried out by public health inspectors and health visitors on his staff. The recent reorganization of the National Health Service resulted in the abolition of the medical officer of health and his department. Responsibility for the control of communicable disease remained with the local authority, but now the chief adviser and executive officer to the health authority is the chief environmental health officer (CEHO), who has an extensive technical and legal training, but is not medically qualified. Medical advice is provided by the area health authority who appoint a medical officer to advise the local authority. In this role he is known as the medical officer for environmental health (MOEH). The Department of Health and Social Security were, however, quite explicit in stating that this was not to be viewed as a full-time occupation (Circular HRC (74) 1974) and in the majority of cases a district community physician (DCP), primarily appointed to undertake health service management and planning as a member of a district management team, devotes part of his time to acting as MOEH for one or more district councils. The only exception to this generality is the appointment of full-time medical specialists in environmental health for single district areas, often in association with metropolitan counties. Thus, in effect, we are back to the concept of a part-time medical officer which existed in the late nineteenth century. As a consequence, a new approach to the organization of control of infection in the community at local authority district level has had to emerge. A major prerequisite of any organization is an effective communications system. In a battle, a successful outcome will depend heavily on a knowledge of the disposition and tactics of the enemy, combined with as good an understanding as possible of the ways in which he is inclined to act. When attempting to keep infection in the community under control, the MOEH is as reliant upon an understanding of his 'enemy' (the agent)
and an effective communications and intelligence network as is the general on a battlefield. Prior to 1974, the medical officer of health was able to devote a large part of his time, or that of a senior medical member of his staff, to environmental work, including the control of infection. The inspectors who usually carried out investigational visits were on his staff, and often were based in the same building. Communications with other medical officers and their staff were not difficult, the public health department being seen as the identifiable centre of operations. Reorganization of the health service and local government has changed the situation; now the MOEH can devote only part of his time to environmental matters if he is to carry out conscientiously his parallel duties as district community physician. He is less often in his office, much more likely to be taking part in a management or planning team meeting, or chairing a working party, and there is no deputy in his office in his absence. He has no infrastructure of staff as had his predecessor; the environmental health officers lead a separate existence and are likely to be geographically separate as well. Medical advice is thus difficult to come by at short notice; the MOEH may seem to be elusive and difficult to pin down. Conversely he finds that his work in the NHS is subject to interruption, often by rather petty but none the less potentially important day-to-day problems that arise. Such difficulties can be particularly troublesome in large urban nonmetropolitan districts, and they are not conducive to effective communications. Control of communicable disease in a district should be seen as a team effort between the chief environmental health officer (CEHO), the MOEH, and the director of the public health laboratory (PHL). Like the MOEH, the CEHO is involved in frequent meetings and may be difficult to contact at short notice, but he has his staff of environmental health officers (EHO) who frequently undertake domiciliary visits and investigations, and who are less difficult to locate. The director of the PHL is usually easily acessible, and usually has other staff who may well be able to help when problems require solution or queries arise. But these are only a very few of those who may be involved in a communicable disease situation, with whom the MOEH may need to be in touch. Fig 1 demonstrates just a few of the intercommunications which may occur. It is important for information contained in one part of the system to be rapidly available to other parts, particularly to those immediately concerned with taking effective control action. In the situation illustrated in Fig l it is difficult for this to occur. Besides needing to be well informed in that way, the MOEH will receive notifications of infectious disease by post and, often more important, by telephone. Such
Section of Epidemiology & Community Medicine
887
MOEH. He will be in day-to-day contact with GPs or their staff, with control of infection officers and nurses in hospitals, with consultants or their junior staff, with health visitors, the PHL, teachers, and with members of the public - some of whom may be anxious or truculent and uncooperative. He must have guaranteed access at all times to the MOEH, but must be able to recognize when it is appropriate to interrupt, say, a management team meeting, and when it is appropriate to wait. He thus needs to be intelligent, experienced, and good at personal relationships, especially over the teleEHOs phone. He must be able to keep a cool head under pressure and keep clear and effective records. Fig 1 Some of the intercommunications concerned with Depending on the volume of work generated by the control of infection in a district. Information passing the district, he may devote all or part of his time to along any one channel ideally should be shared with all communicable disease control work, but there other channels must be no doubt where his primary responsibilities lie, and he must always be available information must be recorded and acted upon to receive and relay messages and provide inforpromptly, as necessary. Domiciliary investigations mation to bona fide enquirers during working must be organized; good communications with hours. Outside normal working hours alternative visiting staff are essential. Householders and mem- arrangements must be made. I regard this clerk as the lynch-pin of the whole bers of the public in general may need information organization, the centre of the communications or advice. Reports may be received from head teachers which will require evaluation and action network, the keeper of the information or records library, and the basic point of reference for all. as necessary. The PHL must be kept informed of the day-to-day situation and the epidemiological This is a function which the MOEH can never background of specimens. Laboratory reports effectively fulfil himself because of his various daily must be received (the more important ones by committments in his management role. The sectelephone) and recorded. Results must be reviewed retary to the DCP/MOEH can serve in this capand appropriate decisions and action must follow. acity, but it will often be better to separate the two Statistical information must be prepared weekly roles to avoid overloading the secretary, especially for the Office of Population Censuses and Surveys. since the clerk, who may be called the 'control of During unusual or potentially serious incidents, infection clerk', can more effectively relate to other GPs, hospital doctors, hospital control of infection workers in the control of infection field and from officers and nurses, other MOEH and, if necessary, experience can build up an expertise in the role. Control of communicable disease in the district the Department of Health and Social Security, must be kept informed. Unless the com- can then be carried out on a day-to-day basis by munications networks can be rationalized, the inspectors or nurses relating directly to the clerk, situation can become difficult to handle efficiently, who maintains their central records for them, and particularly in larger urban areas and when there from whom they receive each morning information may be port or airport health responsibilities as on the visits and investigations which need to be carried out. Reference will be made to the MOEH well. A way of solving the problem is to create a for guidance as necessary. It has been traditional for domiciliary incentral agency which can act both as a focus of communications and as an information centre- a vestigations concerning communicable disease central point, manned by a responsible person, control to be undertaken by environmental health known to everyone likely to produce or need officers (formerly public health inspectors). In information about the occurrence of communic- some centres, however, state registered or state able disease in the district. A clerk, easily available enrolled nurses, often working part-time, are used. by telephone, and with the right personal qualities, They are more suited to the role since they are is very satisfactory; it is not necessary for a doctor medically trained, and it is often more acceptable to fulfil this function. The clerk can be based in the for a nurse to discuss personal health matters and health office or the environmental office, employed to request the provision of specimens of feces or by the health service or the local authority, depend- urine. Nurses may undertake certain procedures, ing upon local circumstances and agreements. But such as the collection of nose or throat or pernasal he has to be something of a paragon, and re- swabs, and may be trained to take venous blood cognized by all as directly responsible to the for serological investigations and blood culture. CEHO
PHL
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Proc. roy. Soc. Med. Volume 70 December 1977
They are better able to undertake health education in relation to control of infection in the home, and can discuss cases with GPs. In short, they can act as control of infection nurses in the community setting. The control of infection clerk and two or more part-time control of infection nurses thus comprise the focal control of infection unit, working under the daily control of the MOEH. All communications are made initially to this unit, and from it all information flows (Fig 2). The environmental health officers will be involved when, for instance, questions of food-borne disease or food hygiene arise, and may then make visits in their own right. Or they may act, in lieu of the nurses, as control of infection officers. They also form a valuable reserve when, for instance, an outbreak occurs which requires more domiciliary visiting than the basic staffing of the control of infection unit can handle. When nurses are employed, it is better to have two working part-time than one full-time, since this introduces a useful degree of flexibility. Bristol was fortunate in having, prior to the appointed day, an epidemiology department in the public health department which held the potential nucleus of a control of infection unit. Such a unit was therefore created at the outset. So far the area health authority has provided five clinical medical officer sessions a week to cover the clinical guidance of the unit during the mornings, when the day-to-day decisions have to be made and when most of the problems and queries arise. The unit deals with some two thousand notifications of infectious disease a year, together with cases and outbreaks which come to notice through other channels. Every four weeks it produces a brief bulletin of infectious disease trends in Bristol City which is distributed through the family practitioner committee to all GPs in the city; it also MOEH
DHSS
GPs \ PATIENTS PATIENTS
/
CONTROL OFO INFECTION _ UNIT
(
PUBLIC
HOSPITAL ~~~DOCTORS
OTHER MOEH
PHL
HTs EHOs
CEHO
Fig 2 A central control unit can act as an information and communications centre, should know of all important information passing around the system, and is always accessible
Table 1 Control of infection unit (CIU): functions of staff
Clerk (full time) Receives notifications, laboratory reports, messages Answers bona fide enquiries Calls on MO/MOEH as required Raises record cards Maintains records Maintains statistics Renders returns to OPCS and DHSS Undertakes liaison with chest clinic (TB), public health laboratory, hospital laboratories, hospital control of infection staff Sends out circulars to GPs and others under direction of MO Medical officer (mornings only) Daily scrutiny of new notifications, active records Directs domiciliary investigations Initiates specific control action (e.g. Schedule 5 Infectious Diseases Regulations 1968) Keeps MOEH informed Undertakes special investigations under advice from MOEH Liaises with GPs, HTs and others as required Meets weekly (jointly) with director of PH laboratory, and consultant (infectious diseases) Nurses or inspectors (part time) Report each morning to CIU Collect new information
Undertake domiciliary investigations Arrange for provision of specimens Undertake other visits and consultations (GPs, schools, nurseries &c) as required Serve notices, &c Give general advice and health education
goes to surrounding MOsEH, the environmental health officers, the Director of the PHL and other interested persons. The detailed functions of those working in the unit are shown in Table 1. During the first three years of its existence the unit has handled a total of 7466 notifications. In the very early days a very large food poisoning outbreak, with ramifications all over the west country, provided a severe test of its effectiveness; as a result it was possible to identify some defects. T-he worst of these was due to the dissemination of information about contacts in other districts by both the unit and the CEHO's department, so that there was some duplication. An important lesson which emerged from this episode was that in such cases there should be a meeting, at an early stage, between the MOEH, the CEHO and the director of the PHL. Since this experience, other episodes have been handled without difficulty. A controlled comparison of the effectiveness of the unit with that of other methods of operation has not been carried out. To make such a comparison, the questions which would have to be asked would relate to speed of making initial contact for purposes of notification or advice, both in and out of working hours; the effectiveness of the unit in dissemination of important information; the rapidity and the completeness with which contacts are traced; the frequency of requests made to, the unit for advice, and the usefulness and effectiveness of that advice; and,
Section of Epidemiology & Community Medicine
perhaps most important, the proportions of general practitioners, hospital doctors and community doctors who are aware that the unit is a centre for all communications relating to infectious diseases and their control. REFERENCES Brockington C F (1956) A Short History of Public Health. J & A Churchill, London; p 8 Circular HRC (74) (1974) Reorganization of Local Government: Reorganization of National Health Service: Transitional Arrangements and Organization and Development of Services: Environmental Health. HRC (74) 13, February Simon J (1897) English Sanitary Institutions, 2nd edn. John Murray, London; p 167
Dr N S Galbraith (Communicable Disease Surveillance Centre, Public Health Laboratory Service, Colindale, London NW9 5EQ) A National Centre for the Surveillance and Control of Communicable Disease
889
typhoid outbreak in 1897 (Borough of Maidstone 1898) was caused by contamination of the local reservoir at Barming by sewage-polluted water from the nearby catchment area at East Farleigh. However, the spread of communicable -disease began to change from local to national and then international by the turn of the century, and particularly after World War I, as a result of the widespread national and international distribution of foodstuffs and other materials and the greatly increased movement of population. The foodborne outbreak of typhoid fever in Aberdeen in 1964 (Aberdeen Typhoid Outbreak 1964) was caused by the contamination of canned corned beef in South America, where sewage-polluted river water had been used in the cooling process of the cans; it was one of a series of such episodes which had been taking place since at least as early as 1929 (Anderson & Hobbs 1973). A National Laboratory Service Recognition that a local public health service alone was inadequate for the control of nationally and internationally distributed disease came about because of the risk of epidemics in World War II.
This risk, together with the threat of bacteriological warfare and the then inadequate laboratory facilities, particularly in the south of England, led The purpose of this paper is to describe the main to the creation of the Emergency Public Health events leading up to the establishment of the Laboratory Service in England and Wales in 1939 Communicable Disease Surveillance Centre and to (Wilson 1951). Similar considerations in the consider its functions and how these might de- United States of America resulted in the invelop. auguration of the Communicable Disease Center in 1946 (Andrews 1946). Although there were no Introduction large wartime epidemics, the Emergency Public Public health in Britain effectually began with the Health Laboratory Service proved to be of great publication of the famous report of the Poor Law value in the investigation and control of national Commissioners, 'on an inquiry into the sanitary disease - for example, salmonellosis due to imporcondition of the Labouring Population of Great ted dried egg (Medical Research Council 1947) Britain' in 1842, the principal author of which was and became a permanent part of the health service Edwin Chadwick. He suggested 'that for the under the National Health Service Act 1946, promotion of the means necessary to prevent dropping the word 'Emergency' from its title. The disease it would be good economy to appoint a most important function of this national labdistrict medical officer,...' (Poor Law Commis- oratory service was to provide an epidemiological sioners 1842), a suggestion which was taken up first intelligence network covering the whole country by the City of Liverpool with the appointment of (Thomson 1943) supporting the local public health Dr Andrew Duncan as Officer of Health in 1847; in service. Together, these two services were well able 1848 Dr John Simon was appointed the Medical to investigate and control communicable disease, Officer of Health of the City of London. These and nationally as well as locally, until the 1970s. all the subsequent appointments of medical officers of health were district or local appointments, a The Needfor a National Epidemiological Centre most appropriate base because the diseases they Although the need for national coordination of were appointed to prevent were local diseases. The epidemiological services has been expressed precholera outbreak in Soho, London, investigated by viously (Galbraith 1967, 1968), three principal Dr John Snow in 1854, was caused by con- events led to the establishment of the Communitaminated water from the local Broad Street pump cable Disease Surveillance Centre (CDSC) in 1977. First, in March and April 1973 the infection of a (Snow 1855), and even at the end of the nineteenth century communicable disease still remained pre- laboratory technician with smallpox in London led dominantly local; for example, the Maidstone to the deaths of two persons who visited the
885
Section of Epidemiology & Community Medicine President A M Adelstein MD
Meeting 10 March 1977
Communicable Disease Control breaks of cholera were to supervene before the Royal Commission of 1869 led to changes in local government introduced by the legislation of 1871 and 1872. This paved the way for the consolidating Public Health Act of 1875, which placed responsibilities for the control of the environment and of Control of Communicable Disease infection firmly with the local authorities. at District Level One of the recommendations of the Royal Control of communicable disease is a function of Commission was that full-time medical officers of the local authority. It is interesting to trace how health should be appointed. Already, in 1847, this came about following the events of the In- Liverpool had appointed Duncan as their medical dustrial Revolution. Towards the end of the eight- officer of health by Private Act of Parliament, and eenth century and during the early part of the in 1848 John Simon was likewise appointed in nineteenth, dramatic social changes occurred, re- London. By 1873 there were approximately 1600 sulting in the migration of large numbers of a district authorities and three-quarters of them had predominantly country-dwelling population into medical officers of health; but they were partthe new towns and embryonic cities. With them timers, since the legislation had not followed the they brought their rural modes of sanitation and Commission's recommendation. It was not until environmental hygiene, which had been relatively 1909 that a statutory requirement to appoint fulladequate in the more sparsely populated country- time medical officers of health was laid upon side. There was no adequate administrative or counties. The Public Health Act of 1936 gave very conlegislative framework to contend with such a situation. Sir John Simon (1897) vividly describes siderable powers to local authorities to control the the problems: land drains were doubling up in- spread of infection by controlling the activities of effectively as foul sewers, domestic cesspools were those suffering from notifiable infectious diseases often constructed in the basements of houses and and by disinfecting premises and fomites which there was no system of refuse disposal -'the might also act as sources. There were also powers householder stored his filth as he liked, or got rid of to enforce improved standards of environmental it as he could'. hygiene. Subsequent Acts have reinforced these It was not surprising that, with overcrowding, powers and, together with the various regulations malnutrition, and long hours of work super- under the Acts, make up the armamentarium of imposed on such circumstances, infections of all control. The medical officer of health was both kinds became rampant (Brockington 1956). expert adviser and executive officer of the local Cholera was introduced into the country in 1832, health authority, and over the years built up with disastrous results. The disease became wide- considerable expertise in the measures needed to spread and mortality was immense. Although it control outbreaks of infection. cannot be adequately quantified because returns Adequate control is dependent upon rapid rewere by no means complete, Simon reports that cognition of infection, the understanding of modes certain named places in Great Britain with fewer of transmission, levels of infectivity and susceptithan five and a quarter millions of aggregate bility, and the ability to weigh the pros and cons of population suffered 31 376 deaths, and in Ireland a variety of potential courses of action. The the deaths were 21 171. Three further major out- identification and control of the disseminator of Dr A J Rowland (Bristol Health District (T), 10 Marlborough Street, Bristol BSJ 3NP)
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Proc. roy. Soc. Med. Volume 70 December 1977
infection, and the protection, surveillance and, if necessary, control of those who have been put at risk, is a vital part of the task. The work involves visits to homes, places of work and hospitals, interviews with and, if necessary, medical examination of individuals. Appropriate advice must be given, and specimens may need to be collected for bacteriological, virological, or serological examination. The results of pathological tests must be considered and interpreted, and appropriate further action taken. In outbreaks which engender public interest, information must be given to the press in a balanced way. It was rarely possible, or indeed necessary, for the medical officer of health to do all this himself. He delegated much of it to senior medical staff in his department, and much of the domiciliary and other visiting was carried out by public health inspectors and health visitors on his staff. The recent reorganization of the National Health Service resulted in the abolition of the medical officer of health and his department. Responsibility for the control of communicable disease remained with the local authority, but now the chief adviser and executive officer to the health authority is the chief environmental health officer (CEHO), who has an extensive technical and legal training, but is not medically qualified. Medical advice is provided by the area health authority who appoint a medical officer to advise the local authority. In this role he is known as the medical officer for environmental health (MOEH). The Department of Health and Social Security were, however, quite explicit in stating that this was not to be viewed as a full-time occupation (Circular HRC (74) 1974) and in the majority of cases a district community physician (DCP), primarily appointed to undertake health service management and planning as a member of a district management team, devotes part of his time to acting as MOEH for one or more district councils. The only exception to this generality is the appointment of full-time medical specialists in environmental health for single district areas, often in association with metropolitan counties. Thus, in effect, we are back to the concept of a part-time medical officer which existed in the late nineteenth century. As a consequence, a new approach to the organization of control of infection in the community at local authority district level has had to emerge. A major prerequisite of any organization is an effective communications system. In a battle, a successful outcome will depend heavily on a knowledge of the disposition and tactics of the enemy, combined with as good an understanding as possible of the ways in which he is inclined to act. When attempting to keep infection in the community under control, the MOEH is as reliant upon an understanding of his 'enemy' (the agent)
and an effective communications and intelligence network as is the general on a battlefield. Prior to 1974, the medical officer of health was able to devote a large part of his time, or that of a senior medical member of his staff, to environmental work, including the control of infection. The inspectors who usually carried out investigational visits were on his staff, and often were based in the same building. Communications with other medical officers and their staff were not difficult, the public health department being seen as the identifiable centre of operations. Reorganization of the health service and local government has changed the situation; now the MOEH can devote only part of his time to environmental matters if he is to carry out conscientiously his parallel duties as district community physician. He is less often in his office, much more likely to be taking part in a management or planning team meeting, or chairing a working party, and there is no deputy in his office in his absence. He has no infrastructure of staff as had his predecessor; the environmental health officers lead a separate existence and are likely to be geographically separate as well. Medical advice is thus difficult to come by at short notice; the MOEH may seem to be elusive and difficult to pin down. Conversely he finds that his work in the NHS is subject to interruption, often by rather petty but none the less potentially important day-to-day problems that arise. Such difficulties can be particularly troublesome in large urban nonmetropolitan districts, and they are not conducive to effective communications. Control of communicable disease in a district should be seen as a team effort between the chief environmental health officer (CEHO), the MOEH, and the director of the public health laboratory (PHL). Like the MOEH, the CEHO is involved in frequent meetings and may be difficult to contact at short notice, but he has his staff of environmental health officers (EHO) who frequently undertake domiciliary visits and investigations, and who are less difficult to locate. The director of the PHL is usually easily acessible, and usually has other staff who may well be able to help when problems require solution or queries arise. But these are only a very few of those who may be involved in a communicable disease situation, with whom the MOEH may need to be in touch. Fig 1 demonstrates just a few of the intercommunications which may occur. It is important for information contained in one part of the system to be rapidly available to other parts, particularly to those immediately concerned with taking effective control action. In the situation illustrated in Fig l it is difficult for this to occur. Besides needing to be well informed in that way, the MOEH will receive notifications of infectious disease by post and, often more important, by telephone. Such
Section of Epidemiology & Community Medicine
887
MOEH. He will be in day-to-day contact with GPs or their staff, with control of infection officers and nurses in hospitals, with consultants or their junior staff, with health visitors, the PHL, teachers, and with members of the public - some of whom may be anxious or truculent and uncooperative. He must have guaranteed access at all times to the MOEH, but must be able to recognize when it is appropriate to interrupt, say, a management team meeting, and when it is appropriate to wait. He thus needs to be intelligent, experienced, and good at personal relationships, especially over the teleEHOs phone. He must be able to keep a cool head under pressure and keep clear and effective records. Fig 1 Some of the intercommunications concerned with Depending on the volume of work generated by the control of infection in a district. Information passing the district, he may devote all or part of his time to along any one channel ideally should be shared with all communicable disease control work, but there other channels must be no doubt where his primary responsibilities lie, and he must always be available information must be recorded and acted upon to receive and relay messages and provide inforpromptly, as necessary. Domiciliary investigations mation to bona fide enquirers during working must be organized; good communications with hours. Outside normal working hours alternative visiting staff are essential. Householders and mem- arrangements must be made. I regard this clerk as the lynch-pin of the whole bers of the public in general may need information organization, the centre of the communications or advice. Reports may be received from head teachers which will require evaluation and action network, the keeper of the information or records library, and the basic point of reference for all. as necessary. The PHL must be kept informed of the day-to-day situation and the epidemiological This is a function which the MOEH can never background of specimens. Laboratory reports effectively fulfil himself because of his various daily must be received (the more important ones by committments in his management role. The sectelephone) and recorded. Results must be reviewed retary to the DCP/MOEH can serve in this capand appropriate decisions and action must follow. acity, but it will often be better to separate the two Statistical information must be prepared weekly roles to avoid overloading the secretary, especially for the Office of Population Censuses and Surveys. since the clerk, who may be called the 'control of During unusual or potentially serious incidents, infection clerk', can more effectively relate to other GPs, hospital doctors, hospital control of infection workers in the control of infection field and from officers and nurses, other MOEH and, if necessary, experience can build up an expertise in the role. Control of communicable disease in the district the Department of Health and Social Security, must be kept informed. Unless the com- can then be carried out on a day-to-day basis by munications networks can be rationalized, the inspectors or nurses relating directly to the clerk, situation can become difficult to handle efficiently, who maintains their central records for them, and particularly in larger urban areas and when there from whom they receive each morning information may be port or airport health responsibilities as on the visits and investigations which need to be carried out. Reference will be made to the MOEH well. A way of solving the problem is to create a for guidance as necessary. It has been traditional for domiciliary incentral agency which can act both as a focus of communications and as an information centre- a vestigations concerning communicable disease central point, manned by a responsible person, control to be undertaken by environmental health known to everyone likely to produce or need officers (formerly public health inspectors). In information about the occurrence of communic- some centres, however, state registered or state able disease in the district. A clerk, easily available enrolled nurses, often working part-time, are used. by telephone, and with the right personal qualities, They are more suited to the role since they are is very satisfactory; it is not necessary for a doctor medically trained, and it is often more acceptable to fulfil this function. The clerk can be based in the for a nurse to discuss personal health matters and health office or the environmental office, employed to request the provision of specimens of feces or by the health service or the local authority, depend- urine. Nurses may undertake certain procedures, ing upon local circumstances and agreements. But such as the collection of nose or throat or pernasal he has to be something of a paragon, and re- swabs, and may be trained to take venous blood cognized by all as directly responsible to the for serological investigations and blood culture. CEHO
PHL
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Proc. roy. Soc. Med. Volume 70 December 1977
They are better able to undertake health education in relation to control of infection in the home, and can discuss cases with GPs. In short, they can act as control of infection nurses in the community setting. The control of infection clerk and two or more part-time control of infection nurses thus comprise the focal control of infection unit, working under the daily control of the MOEH. All communications are made initially to this unit, and from it all information flows (Fig 2). The environmental health officers will be involved when, for instance, questions of food-borne disease or food hygiene arise, and may then make visits in their own right. Or they may act, in lieu of the nurses, as control of infection officers. They also form a valuable reserve when, for instance, an outbreak occurs which requires more domiciliary visiting than the basic staffing of the control of infection unit can handle. When nurses are employed, it is better to have two working part-time than one full-time, since this introduces a useful degree of flexibility. Bristol was fortunate in having, prior to the appointed day, an epidemiology department in the public health department which held the potential nucleus of a control of infection unit. Such a unit was therefore created at the outset. So far the area health authority has provided five clinical medical officer sessions a week to cover the clinical guidance of the unit during the mornings, when the day-to-day decisions have to be made and when most of the problems and queries arise. The unit deals with some two thousand notifications of infectious disease a year, together with cases and outbreaks which come to notice through other channels. Every four weeks it produces a brief bulletin of infectious disease trends in Bristol City which is distributed through the family practitioner committee to all GPs in the city; it also MOEH
DHSS
GPs \ PATIENTS PATIENTS
/
CONTROL OFO INFECTION _ UNIT
(
PUBLIC
HOSPITAL ~~~DOCTORS
OTHER MOEH
PHL
HTs EHOs
CEHO
Fig 2 A central control unit can act as an information and communications centre, should know of all important information passing around the system, and is always accessible
Table 1 Control of infection unit (CIU): functions of staff
Clerk (full time) Receives notifications, laboratory reports, messages Answers bona fide enquiries Calls on MO/MOEH as required Raises record cards Maintains records Maintains statistics Renders returns to OPCS and DHSS Undertakes liaison with chest clinic (TB), public health laboratory, hospital laboratories, hospital control of infection staff Sends out circulars to GPs and others under direction of MO Medical officer (mornings only) Daily scrutiny of new notifications, active records Directs domiciliary investigations Initiates specific control action (e.g. Schedule 5 Infectious Diseases Regulations 1968) Keeps MOEH informed Undertakes special investigations under advice from MOEH Liaises with GPs, HTs and others as required Meets weekly (jointly) with director of PH laboratory, and consultant (infectious diseases) Nurses or inspectors (part time) Report each morning to CIU Collect new information
Undertake domiciliary investigations Arrange for provision of specimens Undertake other visits and consultations (GPs, schools, nurseries &c) as required Serve notices, &c Give general advice and health education
goes to surrounding MOsEH, the environmental health officers, the Director of the PHL and other interested persons. The detailed functions of those working in the unit are shown in Table 1. During the first three years of its existence the unit has handled a total of 7466 notifications. In the very early days a very large food poisoning outbreak, with ramifications all over the west country, provided a severe test of its effectiveness; as a result it was possible to identify some defects. T-he worst of these was due to the dissemination of information about contacts in other districts by both the unit and the CEHO's department, so that there was some duplication. An important lesson which emerged from this episode was that in such cases there should be a meeting, at an early stage, between the MOEH, the CEHO and the director of the PHL. Since this experience, other episodes have been handled without difficulty. A controlled comparison of the effectiveness of the unit with that of other methods of operation has not been carried out. To make such a comparison, the questions which would have to be asked would relate to speed of making initial contact for purposes of notification or advice, both in and out of working hours; the effectiveness of the unit in dissemination of important information; the rapidity and the completeness with which contacts are traced; the frequency of requests made to, the unit for advice, and the usefulness and effectiveness of that advice; and,
Section of Epidemiology & Community Medicine
perhaps most important, the proportions of general practitioners, hospital doctors and community doctors who are aware that the unit is a centre for all communications relating to infectious diseases and their control. REFERENCES Brockington C F (1956) A Short History of Public Health. J & A Churchill, London; p 8 Circular HRC (74) (1974) Reorganization of Local Government: Reorganization of National Health Service: Transitional Arrangements and Organization and Development of Services: Environmental Health. HRC (74) 13, February Simon J (1897) English Sanitary Institutions, 2nd edn. John Murray, London; p 167
Dr N S Galbraith (Communicable Disease Surveillance Centre, Public Health Laboratory Service, Colindale, London NW9 5EQ) A National Centre for the Surveillance and Control of Communicable Disease
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typhoid outbreak in 1897 (Borough of Maidstone 1898) was caused by contamination of the local reservoir at Barming by sewage-polluted water from the nearby catchment area at East Farleigh. However, the spread of communicable -disease began to change from local to national and then international by the turn of the century, and particularly after World War I, as a result of the widespread national and international distribution of foodstuffs and other materials and the greatly increased movement of population. The foodborne outbreak of typhoid fever in Aberdeen in 1964 (Aberdeen Typhoid Outbreak 1964) was caused by the contamination of canned corned beef in South America, where sewage-polluted river water had been used in the cooling process of the cans; it was one of a series of such episodes which had been taking place since at least as early as 1929 (Anderson & Hobbs 1973). A National Laboratory Service Recognition that a local public health service alone was inadequate for the control of nationally and internationally distributed disease came about because of the risk of epidemics in World War II.
This risk, together with the threat of bacteriological warfare and the then inadequate laboratory facilities, particularly in the south of England, led The purpose of this paper is to describe the main to the creation of the Emergency Public Health events leading up to the establishment of the Laboratory Service in England and Wales in 1939 Communicable Disease Surveillance Centre and to (Wilson 1951). Similar considerations in the consider its functions and how these might de- United States of America resulted in the invelop. auguration of the Communicable Disease Center in 1946 (Andrews 1946). Although there were no Introduction large wartime epidemics, the Emergency Public Public health in Britain effectually began with the Health Laboratory Service proved to be of great publication of the famous report of the Poor Law value in the investigation and control of national Commissioners, 'on an inquiry into the sanitary disease - for example, salmonellosis due to imporcondition of the Labouring Population of Great ted dried egg (Medical Research Council 1947) Britain' in 1842, the principal author of which was and became a permanent part of the health service Edwin Chadwick. He suggested 'that for the under the National Health Service Act 1946, promotion of the means necessary to prevent dropping the word 'Emergency' from its title. The disease it would be good economy to appoint a most important function of this national labdistrict medical officer,...' (Poor Law Commis- oratory service was to provide an epidemiological sioners 1842), a suggestion which was taken up first intelligence network covering the whole country by the City of Liverpool with the appointment of (Thomson 1943) supporting the local public health Dr Andrew Duncan as Officer of Health in 1847; in service. Together, these two services were well able 1848 Dr John Simon was appointed the Medical to investigate and control communicable disease, Officer of Health of the City of London. These and nationally as well as locally, until the 1970s. all the subsequent appointments of medical officers of health were district or local appointments, a The Needfor a National Epidemiological Centre most appropriate base because the diseases they Although the need for national coordination of were appointed to prevent were local diseases. The epidemiological services has been expressed precholera outbreak in Soho, London, investigated by viously (Galbraith 1967, 1968), three principal Dr John Snow in 1854, was caused by con- events led to the establishment of the Communitaminated water from the local Broad Street pump cable Disease Surveillance Centre (CDSC) in 1977. First, in March and April 1973 the infection of a (Snow 1855), and even at the end of the nineteenth century communicable disease still remained pre- laboratory technician with smallpox in London led dominantly local; for example, the Maidstone to the deaths of two persons who visited the
