Derby GP Specialty Training Programme

24th March 2010

Mike SandysActing Director of Public Health

Areas to be covered: Infectious Diseases

Role of Public Health Specialist

Epidemics and Pandemics

NHS Screening Programmes

Public Health is “The science and art of preventing disease,

prolonging life and promoting health through the organized efforts and informed choices of society”

History of Public Health Specialist Chadwick - 1843

Duncan of Liverpool

Snow – 1854

Pre-74: Medical Officer for Health (going back to the days of Duncan)

1972: Faculty of Public Health set up

Routes to accreditation

• Faculty Training Scheme/MPH/Part A/ Part B

• Generalist defined register

• Specialist defined register

10 competencies Surveillance and assessment of the population’s health and well

being

Promoting and protecting the population’s health and wellbeing

Developing quality and risk management within an evaluative culture

Collaborative working for health and well being

10 competencies Developing health programmes and services and reducing

inequalities

Policy and strategy implementation

Working with, and for, communities to improve health and well being

Strategic leadership for health and well being

Research and development to improve health and well being

Ethically managing self and others

Role of Public Health Specialist Promote

Prevent

Protect

Promote Health Improvement

Needs Assessment

Partnership Working

Determinants of Health

Prevent IFR

Service Development

Clinical Effectiveness

Screening Programmes

Protect Vaccination and Immunisation

Emergency Planning

Health Protection

Infectious Disease: an historical perspective Bubonic plague. Killed one third of the population

(1.3million deaths) between 1346 and 1350 Britain.

Late 1830’s – small pox epidemic killed 42,000 in Britain

Major sanitary reforms brought the traditional scourges of population health (diphtheria, cholera, TB) under control

Burden of infectious disease 40% of people consult their GP each year because

of an infection

Infections account for 70,000 deaths a year

Infections put 150,000 into hospital each year

Notification of Infectious Diseases The statutory requirement for the notification of certain infectious

diseases came into being towards the end of the 19th century

Diseases such as cholera, diphtheria, smallpox, and typhoid had to be reported in London from 1891, and in the rest of England and Wales from 1899

Originally the head of the family or landlord had the responsibility of reporting the disease to the local 'Proper Officer' but now this is restricted to the attending medical practitioner, either in the patient's home or at a surgery or hospital.

Notification of Infectious Diseases The prime purpose of the notifications system is speed in detecting possible

outbreaks and epidemics. Accuracy of diagnosis is secondary, and since 1968 clinical suspicion of a notifiable infection is all that is required. If a diagnosis later proves incorrect it can always be changed or cancelled

Statstics were collected nationally at the Registrar General's Office, who already collected data on births, marriages and deaths. The Office was later known as the Office of Population Censuses and Surveys (OPCS) and now as the Office for National Statistics (ONS), but in 1997 the responsibility for administering the NOIDs system transferred to the Communicable Disease Surveillance Centre (CDSC), now the Health Protection Agency (HPA) Centre for Infections (CfI).

Reporting Procedures The Proper Officers are required every week to inform the HPA Centre for

Infections (CfI) details of each case of each disease that has been notified.

The Information Management & Technology Department within the CfI has responsibility for collating these weekly returns and publishing analyses of local and national trends.

The attending Registered Medical Practitioner, should fill out an official Formal Notification certificate (from a pad supplied locally) immediately on diagnosis of a suspected notifiable disease and return it to where the pad was obtained (this could be the Local Authority (LA), Primary Care Trust (PCT) or Health Protection Unit (HPU)).

List of Notifiable Diseases

Diseases notifiable (to Local Authority Proper Officers) under the Public Health (Infectious Diseases) Regulations 1988:Acute encephalitis Acute poliomyelitis Anthrax Cholera Diphtheria Dysentery Food poisoning Leptospirosis Malaria Measles Meningitis

Meningococcal septicaemia (without meningitis) Mumps Ophthalmia neonatorum Paratyphoid fever Plague RabiesRelapsing fever Rubella Scarlet fever

Smallpox Tetanus Tuberculosis Typhoid fever Typhus fever Viral haemorrhagic fever Viral hepatitisHepatitis AHepatitis BHepatitis Cother Whooping cough Yellow fever

Local contacts:Local HPA office:

Health Protection AgencyEast Midlands North TeamCity HospitalHucknall RoadNottinghamNG5 1PBTel: 0844 225 4524 Fax: 0115 9693523

Health Protection Agency Created in 2002/03 to ‘act as a source of national

expertise and to provide key services at national regional and local level

At a local level this maximised the use of scarce CCDC resources at a time when PCTs (303 of the in those days) were coming into being

Polonium, Swine flu

What the HPA/On call does: Investigation

Contact Tracing

Epidemiology/Mapping

What to refer Environmental Health Hazards (individual)

NOIDS/Epidemics

Environmental Health Hazards (neighbourhood)

Public Health Law Public Health (Control of diseases) Act 1984

Statutory responsibilities lie with the local authority not the health service

Section 35 – go to a JP to order a person to be medically examined if a person is suffering from a notifiable disease, in the interests of that person, or in the public interest to do so

Section 36 – same but groups of people

Section 37 – removal for treatment.

Although normally talk about section 47/9 of the Mental Health Act 1983

Public Health Law Public Health (Infectious Diseases) Regulations

1988 – provide immunisation services but not for mandatory immunisation

Public Health (Aircraft) Regulations 1979

Not updated since Human Rights Act passed, being re-written but progress slow.

Further information and resources regarding Notifiable Diseases can be found at:

www.hpa.org.uk

Communicable Disease Handbook – Hawker & Begg

Epidemics and Pandemics

Pandemics in 1918/19, 1957, 1968, 2009

Swine Flu 2009 Early days

Wave 1

NPFS

Wave 2

Swine Flu 2009 – Early Days Initial cases rung through to HPA for swabbing,

tamiflu and contact tracing (F3000)

Sets a new requirement on the HPA to ‘contain’ an emerging disease

Issues around contact tracing capacity, call centre capacity

Swine Flu 2009 – Phase 1 Pre National Pandemic Flu Service (NPFS)

Local system in place (DHU/Adastra)

PSD paperwork faxed through to DHU/PCT

Worked for us, not sure if worked for GPs

Swine Flu 2009 – Phase 2 National Pandemic Flu Service (NPFS) set up late

July

GPs left dealing with young children

Took pressure off primary care but risks around inappropriate prescribing, missing other important illnesses

Swine Flu 2009 Gold, Silver, Bronze levels of command

Gold (Strategic Level)

The level of management which comprises senior strategic decision makers from the key organisations involved. It directs the overall multi-agency response, authorises expenditure, and ensures long-term resourcing and expertise. Gold Command is in overall command and has responsibility and accountability (with regard to the individual agencies) for the incident or event.

Silver (Tactical Level)

The level of management comprising senior representatives from the key organisations involved. Silver Command manages the implementation of the policy established at the strategic level. It determines priorities in obtaining and allocating resources and plans and co-ordinates the reporting point for operational activities.

Bronze (Operational Level) The management of the immedicat ‘hands on’ work undertaken at the site(s) of the emergency or other affected areas. Bronze (Tactical) Commanders will be deployed to take charge of specific operational tasks or areas of responsibility within their service.

Health in Derby

Joint Strategic Needs Assessment Expected increase in ages 75+ and 85+ population

1 in 5 children are living in poverty

One quarter of people are estimated to smoke

Ranked 34th worse nationally of 354 LAs for alcohol-harm related hospital admissions

NHS Derby City has the highest elective crude admission rate to Trauma & Orthopaedic speciality in the EMSHA region

Approximate 10 year inequalities gap in male and female life expectancy

On the plus side …. Derby is least deprived of the three major cities in the

East Midlands region

In 2008, had a lower overall unemployment rate compared to East Midlands and National averages

Estimated 27% of people eating their 5-a-day, higher than seen in the East Midlands and England

1 in 5 people achieving 30+ minutes moderate intensity exercise or active recreation 3 times per week

On the plus side …. One of the best uptake rates of the HPV vaccine (to

protect young girls from cervical cancer) in the UK

95% of children were immunised from Diphtheria, Tetanus and Polio by their 5th birthday

76% of the population were vaccinated against seasonal flu during 2008/09

Cancer Screening Programmes Breast

Cervical

Bowel

Prostate

Chlamydia

Breast Screening Programme The NHS Breast Screening Programme provides free breast screening

every three years for all women in the UK aged 50 and over. Around one-and-a-half million women are screened in the UK each year. Because the programme is a rolling one which invites women from GP practices in turn, not every woman will receive an invitation as soon as she is 50. But she will receive her first invitation before her 53rd birthday.

There are around 80 breast screening units across the UK, each inviting a defined population of eligible women (aged 50 to 70) through their GP practices. Women are invited to a specialised screening unit, which can be hospital based, mobile, or permanently based in another convenient location such as a shopping centre.

Breast Screening Programme Women under 50 are not currently offered routine screening. This is because film

mammograms are not as effective in pre-menopausal women. as the density of the breast tissue makes it more difficult to detect problems, and also because the incidence of breast cancer is lower in this age group. The average age of the menopause in the UK is 50.

The programme in the UK has screened more than 19 million women and has detected around 117,000 cancers.

The World Health Organisation's International Agency for Research on Cancer (IARC) concluded that mammography screening for breast cancer reduces mortality. The IARC working group, comprising 24 experts from 11 countries, evaluated all the available evidence on breast screening and determined that there is a 35 per cent reduction in mortality from breast cancer among screened women aged 50 - 69 years old. This means that out of every 500 women screened, one life will be saved.

Cervical Screening Cervical screening is not a test for cancer. It is a method of preventing

cancer by detecting and treating early abnormalities which, if left untreated, could lead to cancer in a woman's cervix (the neck of the womb). The first stage in cervical screening is taking a sample using Liquid based Cytology (LBC).

All women between the ages of 25 and 64 are eligible for a free cervical screening test every three to five years. In the light of evidence published in 2003 the NHS Cervical Screening Programme now offers screening at different intervals depending on age.

Cervical Screening The new intervals are:Age group (years) Frequency of screening 25 First invitation 25 – 49 3 yearly 50 – 64 5 yearly 65+ Only screen those who have not been screened

since age 50 or have had recent abnormal tests

The NHS call and recall system invites women who are registered with a GP. It also keeps track of any follow-up investigation, and, if all is well, recalls the woman for screening in three or five years time. It is therefore important that all women ensure their GP has their correct name and address details and inform them if these change.

Cervical Screening Women who have not had a recent test may be offered one when they

attend their GP or family planning clinic on another matter. Women should receive their first invitation for routine screening at 25.

This is because changes in the young cervix are normal. If they were thought to be abnormal this could lead to unnecessary treatment which could have consequences for women's childbearing. Any abnormal changes can be easily picked up and treated from the age of 25. Rarely, younger women experience symptoms such as unexpected bleeding or bleeding after intercourse. In this case they should see their GP for advice.

In June 2009 the Advisory Committee on Cervical Screening  reviewed the policy of starting screening at age 25 and agreed unanimously there should be no change in the current policy.

Bowel Cancer Screening Third most common cancer in the UK, and the second leading cause of

cancer deaths, with over 16,000 people dying from it each year.

Regular bowel cancer screening has been shown to reduce the risk of dying from bowel cancer by 16 per cent.

Bowel cancer screening aims to detect bowel cancer at an early stage (in people with no symptoms), when treatment is more likely to be effective.

Programme hubs operate a national call and recall system to send out faecal occult blood (FOB) test kits, analyse samples and despatch results. Each hub is responsible for coordinating the programme in their area and works with up to 20 local screening centres.

Bowel Cancer Screening The NHS Bowel Cancer Screening Programme offers screening every two

years to all men and women aged 60 to 69. People over 70 can request a screening kit by calling a free phone helpline when the programme reaches their area.

GPs are not directly involved in the delivery of the NHS Bowel Cancer Screening Programme but they will be notified when invitations for bowel cancer screening are being sent out in their area. They will also receive a copy of the results letters sent to their patients.

Men and women eligible for screening will receive an invitation letter explaining the programme and an information leaflet. About a week later, an FOB test kit will be sent out along with step-by-step instructions for completing the test at home and sending the samples to the hub laboratory.

Prostate Cancer All screening programmes cause some harm. This could include false

alarms, inducing anxiety, and the treatment of early disease which would not otherwise have become a problem.

When considering population screening programmes the benefits and harms must be carefully assessed, and the benefits should always outweigh the harms.

Until there is clear evidence to show that a national screening programme will bring more benefit than harm, the NHS will not be inviting men who have no symptoms for prostate cancer screening.

Principals of Screening Programme In 1968, Wilson and Jungner of the World Health Organisation developed

ten principles which should govern a national screening programme. These are:

The condition is an important health problem Its natural history is well understood It is recognisable at an early stage Treatment is better at an early stage A suitable test exists An acceptable test exists Adequate facilities exist to cope with abnormalities detected Screening is done at repeated intervals when the onset is insidious The chance of harm is less than the chance of benefit The cost is balanced against benefit

Chlamydia

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Resources and further reading:

www.cancerscreening.nhs.uk

‘Screening – Evidence & Practice’Angela Rattle & Muir Gray