Managing major public health crises

The recent terrorist attacks in New York have shown how all societies need rescue, health, and public health services to respond immediately to major disasters. Subsequent covert releases of anthrax (and scares and hoaxes) have been straining public health and reference laboratory services.¹ The epidemic of foot and mouth disease in the United Kingdom has not directly threatened human health, but its control has required huge efforts and resources. Control measures have affected health services: primary care has had to deal with the stress experienced by affected communities; public health services have responded to disposing of over four million animals with concomitant zoonoses like bovine spongiform encephalopathy, Escherichia coli O157, and the specialist microbiological reference laboratories were needed to exclude cases of human infection.²

What lessons can be learnt from these events? This question is timely in Britain, because the arrangements for health protection in the new NHS are yet to be finalised, though we know that regional directors of public health will oversee this function (see box B1).³,⁴

Box 1.

: Components of health protection³

• Monitoring of and protection against communicable disease
• Protection against non-communicable environmental hazards
• Planning for and response to emergencies

Events in the United States emphasise the need to be able to deliver surge capacity for health protection. It must be possible to rapidly deliver support when local services look like being overwhelmed.¹,³ An immediate lesson from the foot and mouth epidemic is that the potential impact on human health of any major activity outside the health sector must be speedily considered. Those responsible for controlling the epidemic found public veterinary services had been slimmed down; they had to recruit veterinarians from the private sector, abroad, and out of retirement. The capacity of veterinary laboratories was sorely taxed. Despite the recommendations of the Phillips report, which derived lessons from the epidemic of bovine spongiform encephalopathy, local public health and veterinary networks did not assume executive roles or provide emergency liaison.⁵ These events in the United States and the United Kingdom indicate the need for clear direction at the executive level to establish rapidly effective collaboration between national bodies and between appropriate local and national agencies.

How would the United Kingdom respond to likely threats to human health (see box B2)?³ Will there be sufficient surge capacity among personnel and laboratories to make them work? Are there identifiable health services, and managers to take on quickly executive responsibility?

Box 2.

: Some events to which health protection services have to respond

• Major outbreaks of infectious diseases (gastrointestinal disease, legionnaires' disease, meningococcal disease)
• Outbreaks of disease of presumed, but unknown, infectious cause
• Urgent needs to reduce incidence of specific infection (tuberculosis, genital chlamydia)
• Fire or explosion in a plastics factory releasing toxic substances
• Previously unrecognised pathogen in the national blood supply
• Uncontrolled serious infection contracted in hospitals (for example, methicillin resistant Staphylococcus aureus)
• Chemical or biological contamination of water supplies
• Vaccine scare, or the need to immunise rapidly a section of the population
• Surgeon found to be infected with an infectious bloodborne virus who has practised in many areas
• A serious infection affecting several hospitals (for example, a viral haemorrhagic fever)
• The next influenza pandemic
• Major epidemic in animals that has implications for human health
• Act of terrorism, such as a bomb blast or deliberate release of a chemical or biological agents

A need for greater surge capacity was recently identified by politicians and should feature in the forthcoming communicable disease strategy.⁶,⁷ Currently available human resources are deficient. The number of consultants in communicable disease control was set after the 1988 Acheson report at roughly one per health authority.⁸ Since then antimicrobial resistance, hospital associated infections, sexually transmitted infections, emergency planning, and non-communicable environmental hazards have been added to health protection services. This is in addition to continuing programmes such as immunisation and tuberculosis control. Even in 1997 a survey of local teams by the Communicable Disease Surveillance Centre for the NHS executive found major deficiencies in human resources. The numbers of consultants need to increase, but growth in non-medical and nursing staff also needs to be greater.⁹,¹⁰ Staff for reference laboratories are a priority and all the non medical personnel need career structures.

Although health protection is integral to public health services, other staff contribute a lot during crises.^3–10 Annual influenza vaccination campaigns rely on primary care trusts, and outbreaks of tuberculosis have required staff from outside affected districts. In the new NHS these people will be employed in many separate trusts.⁴ We need in place mechanisms for immediate release of staff needed for health protection. Public health staff should probably be in managed public health networks.¹¹ But below the regional level who will manage these and ensure rapid responses to emergencies? It must be clear which bodies bear local responsibility for the control of communicable disease: all primary care trusts, one lead trust, a public health network, or the local authority?

Training programmes provide enhanced surge capacity. If well supported, trainees contribute to and gain immensely from crises. Within 36 hours of the attack on New York the US Centers for Disease Control and Prevention had assigned 35 trainees to support local public health departments. For a major emergency in the United Kingdom some help could come from continental Europe. Many threats cross national boundaries, and the European Union's programme for intervention epidemiology training provides trainees used to moving rapidly between countries.¹² International threats require multinational planning.¹ However the United Kingdom must provide health protection through its own staff who know their locality and have the confidence of the people. Here the United Kingdom is vulnerable as the numbers of public health trainees are declining. Planning of the public health workforce was promised in a white paper.¹⁰ This must include health protection.

Some of these issues may be tackled by the chief medical officer's communicable disease strategy or emerge from his project to strengthen public health services.⁹,¹⁰ Initially the strategy was required to operate within pre-existing financial constraints. NHS funding has been increased, but mostly against specific targets. Recent events make a powerful case for also increasing investment in health protection.