. . . the searchers of the town, suspecting that we both were in a house where the infectious pestilence did reign, sealed up the doors, and would not let us forth . . .
- Romeo and Juliet Act V Scene II
Infectious disease treatment has improved since Shakespeare penned these lines. Then, plague and pestilence meant almost certain death. And yet, despite a lack of scientific knowledge, the town authorities knew that confining those infected would help to stop the spread of infection.
Powers of medical detention still exist under state legislation. Section 38 of the 1947 Health Act states that a chief medical officer, with the agreement of a second medical practitioner, may order the detention of a person who is a probable source of infection in a hospital or other place. It could only be used in the case of acute polio, cholera, diphtheria, plague, small pox, tuberculosis, typhoid, typhus and viral haemorrhagic disease. Of these diseases, only tuberculosis remains an ongoing problem. While in theory a refusal to accept TB treatment could trigger a person's detention, in practice patients are more than happy to accept treatment with modern therapies.
Communicable disease monitoring and reporting is an important element in protecting the population from the spread of infectious disease. Now, there are moves to overhaul the entire system, in recognition of the dated nature of regulations and the advances which have been made in both the investigation and treatment of human infection.
The present regulations require a medical practitioner "as soon as he becomes aware or suspects that a person on whom he is in professional attendance is suffering from or is a carrier of an infectious disease" to send a written notification to the medical officer of health (see accompanying table for list of diseases).
In practice, the notification process does not function well. Under-reporting has been well documented, with one study in the former Eastern Health Board showing 89 per cent of GPs did not notify a single case in 1995. Of all the notifications that year, 15 per cent came from a single locum agency.
Why is this? Dr Declan Bedford, the Chairman of the Irish Medical Organisation's Public Health Doctors Committee, thinks that GPs need to see better feedback for the system to work. He also cites the paltry £2 notification fee paid to doctors which, in his opinion, needs to be increased to encourage better reporting of communicable diseases.
Dr Bedford makes an important point when he says that GPs are particularly good at notifying cases of measles, meningitis and TB. These illnesses are relatively rare, potentially fatal and the benefits of prompt reporting are obvious. For less serious and more common conditions, such as gastroenteritis, the benefits of surveillance may be less clear.
"Say you eat some suspect food tonight. It takes 48 hours for you to become sick and you might decide to suffer in silence for another one or two days. You eventually go to your GP, who starts treatment to see if the gastroenteritis will settle. If you are no better two days later, a stool sample will be sent to the laboratory. Results will be available a total of 10 days after you ate the contaminated food."
But, Dr Bedford argues, early notification can make a difference. "If a GP or hospital doctor were to notify the health board `on suspicion' (as they are entitled to do) then the 10-day wait drops to four days. This makes a huge difference in terms of taking a food history, for example, in which the public health specialist needs to record in detail what you ate in the seventy two hours before the diarrhoea and vomiting started".
From a GP's perspective, it can be frustrating that, in the event of an outbreak of infectious disease at weekends there is no public health doctor available from Friday evening to Monday morning. Dr Bedford agrees and points to a study carried out by himself and Dr Fenton Howell in the North Eastern Health Board. Out of Hours Public Health Needed for Meningococcal Disease was published last December in the Journal of Communicable Disease & Public Health. The study showed that 25 per cent of cases of meningococcal disease occurred at weekends when no formal arrangements were in place through which public health doctors could be contacted.
The National Disease Surveillance Centre is currently considering a discussion document on the disease notification process. It proposes to broaden the scope of notification to include laboratories as well as medical practitioners. Broadening the categories of notifiers will also allow for a smaller and more focused list of diseases to be notified by each. For example, GPs would be required to notify all vaccine-preventable diseases as well as gastroenteritis, sexually transmitted diseases, meningitis and chicken pox, while hospital doctors and infectious control nurses would focus on TB, legionnaires' disease and congenital infections among others. There would also be some overlap between categories.
Dr Darina O'Flanagan, director of the National Disease Surveillance Centre (NDSC), says "we hope to improve the level of reporting through a number of initiatives. By getting laboratories throughout the State on line and reporting directly to public health departments and on to the NDSC, both the accuracy and the speed of infectious disease reporting will improve. At a primary care level, as general practices become computerised and can report on line, the level of clinical reporting should improve also. The NDSC and our colleagues in regional public health departments will in turn feed back trends to general practitioners on an ongoing basis via web site reports and bulletins."
Dr O'Flanagan says their ultimate aim will be to merge the laboratory and clinical feedback into a single comprehensive system. "We have made a submission under the National Development Plan to obtain funding for a system called Computerised Infectious Disease Reporting (CIDR) which we believe will bring about the improvements needed." The Irish College of General Practitioners has undertaken a major initiative in the area of infectious disease surveillance. Working in co operation with the NDSC and with significant funding from the Department of Health, it has set up a network of practices to monitor infectious disease throughout the Republic.
The project director, Dr Dermot Nolan, explains: "We have 20 practices currently reporting cases of influenza, shingles and chickenpox. The system is working incredibly well, with the survey results being e-mailed to the college before onward transmission to the NDSC".
Underlining the views of Dr O'Flanagan, he says that the European Influenza Surveillance Scheme has recently looked at the Irish model and concluded that electronic data transmission is the way forward for infectious disease reporting.
The practical benefits are considerable. "Experience in the UK has shown that a rise in influenza cases presenting to general practice occurs seven to 10 days before hospitals are hit with increasing numbers of patients," says Dr Nolan. "It allows hospitals to cancel elective work and to bring in extra staff to cope with the surge in demand."
From a patient's point of view, there is a need for further education and information on what to expect following disease notification. And, following the recent calls by Department of Justice officials for the compulsory screening of immigrants, an enhanced communicable disease reporting system would go a long way towards combating any drive towards any unethical and undemocratic medical treatment of refugees.