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Health Protection in Scotland - A Consultation Paper

Chapter 3: Major Issues for Health Protection in Scotland

51. "Our National Health, a plan for action, a plan for change" recognised three clinical priorities: coronary heart disease, cancer and mental health. This chapter illustrates some of the other major issues for health protection in Scotland which have been identified on the basis of, for example, the current burden of ill health from exposure to hazards, likely trends in their future occurrence and areas of public concern.

Injuries in children and young people

52. Accidental injury is the main cause of death of children and young people. Accidents in the home cause most deaths within the 0-4 age range, while motor vehicle and pedestrian accidents cause most deaths among school-age children. Injuries from accidents at school account for 20-30% of all accidental injuries to school-age children, but the reporting of accidents varies widely between schools (Scottish Needs Assessment Programme, 1994). These injuries occur mainly in the playground in primary schools and during sports in secondary schools. Accidental injury is also the main single cause of death among young men aged 15-34 years, accounting for 25% of male deaths. These injuries and deaths are mainly among car and motorcycle users.
53. Deaths from injuries in early life make a substantial contribution to lowering overall life expectancy rates. The prevention and control of injuries in childhood and early adulthood is therefore a key health protection challenge.

Healthcare associated infections (HAI) and anti-microbial resistance

54. A marker of the extent of HAI is the number of bloodstream infections due to Methicillin Resistant Staphylococcus aureus (MRSA). Since the late 1990s, reports have been increasing at a rate of 15% per year. This has led to prominent public concern. HAI, however, is not a new phenomenon. In the 19^th century, infection in hospital was a recognised and common hazard of care. Its resurgence has been for a range of reasons. More invasive treatments, more complex ways of delivering care for patients (at times in inadequate environments) and increasing numbers of older people and others more susceptible to infections, have been partly to blame. But lack of commitment to reducing the risk of HAI in healthcare settings and to maintaining good standards of hygiene, has also been a key factor.
55. Anti-microbial resistance arises when bacteria and other organisms find ways of surviving treatments such as antibiotics and disinfection. The best-known example is S.aureus which has developed resistance to many conventional antibiotics. MRSA, in its most virulent forms, is a serious hazard in health care. The recent Antimicrobial Resistance Strategy and Scottish Action Plan (2002) provide a template for further action.

Infections of childhood

56. Infectious diseases are the most common reason for a child to attend a general practitioner. They result in up to one-half of hospital admissions in this age group, most commonly with respiratory or abdominal complaints. Breast-feeding is vital to help the young child build up its resistance to disease. Childhood immunisation programmes have been successful in eradicating some diseases, and safe and effective vaccines promise further successes . Existing and planned screening programmes will help to detect and prevent the spread of infections, such as HIV, from mother to baby.
57. Recent concerns surrounding MMR vaccination have shown that parents remain anxious about interventions in healthy children and associated risks and benefits. The E. coli O157 Task Force highlighted the need for children to be educated effectively about good hygiene and for them to be cared for in settings with adequate wash-hand basins and other hygiene facilities. Parents participating in the Task Force expressed concerns about some doctors’ ability to recognise the onset of symptoms indicative of severe infections. This highlights the on-going need for effective high quality training of healthcare professionals dealing with infection in childhood.

Infections associated with injecting drug use

58. HIV infection, hepatitis B and hepatitis C (HCV) infection are the main diseases spread by injecting drug misuse. HCV infection is now widespread among injecting drug users. A report on HCV, published by the Scottish Needs Assessment Programme in 2000, highlighted the need to control this illness as one of the key public health challenges of the new millennium. By the late 1990s, it was estimated that 62% of those injecting had been infected. Harm reduction measures have helped reduce, but not control, the spread. Of concern is evidence pointing towards needle sharing becoming more frequent. A significant number of those infected will need liver transplants in the coming decades.
59. Preventing and controlling drug misuse is a major challenge for society in which the NHS plays a major role. Health protection services are key players in this. The recent outbreak of Clostridium novyi has shown that contamination of drugs, an on-going problem, can result in outbreaks.

Sexually transmitted infections

60. Since 1995, there has been a gradual and sustained increase across the UK in diagnoses of sexually transmitted infections such as chlamydia, gonorrhoea, syphilis and genital warts. In general, the increase has been greatest among teenage males and females but there is evidence from the investigation of clusters of cases of gonorrhoea, syphilis and HIV that there is increasing unsafe sexual behaviour among young heterosexual adults and men who have sex with men. A major complication of chlamydia and gonorrhoea is pelvic inflammatory disease which can lead to ectopic pregnancies and infertility.
61. The Executive has funded the £3 million Healthy Respect project in Lothian to help guide future action in this area. It aims radically to transform teenage attitudes to sexual health and sexual relationships, reduce the level of teenage pregnancies, and prevent the spread of sexually transmitted infections amongst young people. A sexual health strategy for Scotland is also being developed.

Respiratory illnesses associated with exposure to airborne hazards

62. The UK has the highest rates in Europe of young adults reporting asthma symptoms and probably the highest incidence of childhood asthma in the world. There has been an increase of about 50% in the prevalence of childhood asthma over the last 30 years, part of a general increase in atopic diseases over the same time period. An estimated 21% of UK children aged 12-14 year olds reported having been diagnosed as asthmatic at least once in their life. There is some evidence that rates are higher in Scotland than in other UK countries. Admissions to hospital because of asthma have greatly increased over the last 10 years.
63. Recent major studies have concluded that air pollution with chemical hazards such as smoke or traffic plays a minimal role in causing asthma or in aggravating its symptoms when compared to biological hazards such as infections or allergens. In 1994, a severe thunderstorm in the UK was associated with the largest outbreak of asthma ever recorded. It is thought that the release of small aerosilised particles of grass was the main causative factor. Smoking also plays a role especially in adults. Most evidence points to the illness being caused by a number of interrelating factors which makes risk reduction difficult. However there is need for more concerted action in this area.
64. Studies of the relationship between ill health and air pollution have established that the main hazard is probably airborne particles that are small enough to get into the deeper areas of the lungs (rather than polluting gases and vapours). The concentration of particles is much higher in urban than in rural areas, due mainly to road traffic. There is now clear evidence that exposure to high concentrations of airborne particles causes short-term exacerbation of respiratory and cardio-vascular diseases, and that long-term exposure increases the incidence particularly of the latter.

Intestinal infections caused by organisms of animal origin

65. E.coli O157, campylobacter, salmonella, and cryptosporidium are the most significant causes of severe infectious intestinal disease in Scotland. The main reservoir of these micro-organisms is the gut of farm animals, especially cattle, sheep, and poultry. They can be transmitted from animals to humans through a variety of routes e.g. food, water, contact with animal faeces. Reducing the risk to health from these therefore requires an integrated approach involving those concerned with animal health, farming, the rural environment, water, food, waste, education and human health.
66. The incidence of salmonellosis has been falling in recent years with most commentators agreeing that this is due to risk reduction measures targeted at the poultry flock. In Scotland, most of the recommendations made by Professor Pennington in the wake of the E. coli O157 outbreak in central Scotland have been put in place. Most evidence points to a fall in the number of outbreaks associated with the consumption of meat and meat products although they still do occur. The E. coli O157 Task Force report provides a template for further action in this field and the implementation of its recommendations will go a long way to protecting us not only from that micro-organism but the others described above. One challenge will be the increasing global trade in food with products coming from an ever-increasing number of countries.

Falls in older people

67. Each year a third of the population aged over 65 years has a fall, and half of these fall at least twice. Mortality associated with falls is high. A common consequence, especially in women, is a fracture of the femur with a 33% mortality rate in one year. Those aged over 75 years old who are admitted after an accident (most often a fall) occupy a bed for, on average, 18 days. Falls are a major cause of disability and handicap in older people. Even the fear of falling limits activity and increases the risk of admission to care.
68. A recent SEHD Report by the Expert Group on Healthcare of Older People made a number of recommendations on the NHS’s role in assessing individuals’ risk of falling and offering interventions to reduce their risk. Most falls are multi-factorial in origin, and there is now a clear understanding of the risk factors involved. Successful interventions are those which address multiple risk factors and there is now substantial evidence from randomised controlled trials that these interventions are effective. The report recommended the establishment of NHS assessment services. Commentators have recommended that this approach be accompanied by one which seeks to improve environmental safety measures especially through joint working with housing agencies.

Cancers linked with exposures to radiation

69. Radon is a natural radioactive gas which emanates from the ground and accumulates in buildings. The gas decays into other radioactive species and, for most of the UK population, inhalation of these is clearly the largest source of exposure to radiation. The National Radiological Protection Board estimates that radon causes some 3000 excess cases of cancer in the UK population annually and is therefore the UK’s second biggest cause of lung cancer after smoking.
70. A principal cause of all skin cancers is exposure to ultraviolet radiation from the sun and white skinned Scots are particularly susceptible. According to figures provided by the Scottish Information and Statistics Division, the last quarter of the 20^th century saw the annual incidence of non-melanoma skin cancers rise from just under 2000 (in 1975) to just under 6000 (in 1998). Over the same period, the annual incidence of (the more serious) melanoma showed a similar rate of increase from less than 200 to over 500 cases. These represent the most rapid rates of increase for any common form of cancer in Scotland.

Emerging and "re-emerging" infections

71. As society evolves, so do micro-organisms. Through this process of change, new ecological niches arise which facilitate the spread of harmful organisms (some new, some old) and so give rise to epidemics. Since the early 1970s, at least 30 previously unknown infectious diseases for which there is no fully effective treatment, have become prominent. The collapse of the Soviet Union has been associated with the rise of a "re-emerging" infection, diphtheria. Tuberculosis rates are increasing throughout the world, including London. The 1990s saw a major epidemic of drug resistant TB in New York.
72. The incidence of variant Creutzfeldt-Jacob disease (vCJD) (still a uniformly fatal disease) continues to increase at a rate of 21% per year. It is still too early to forecast longer-term trends with any certainty. If in 4 or 5 years the trend has flattened out, it would rule out the extreme scenarios of the spread of the epidemic unless there was a secondary epidemic. However, there remain many uncertainties, not least about the extent to which the disease can be spread by medical treatments. Because of these, we must maintain vigilance and act with prudence in preventing transmission.
73. The key to combating these new threats is strong awareness of the possibility of them occurring, effective diagnostic and surveillance systems and good international co-operation. These were recently put to the test in Scotland with the outbreak of Clostridium novyi in injecting drug users in the West of Scotland. A key conclusion of the Sheriff Principal in the subsequent Fatal Accident Inquiry was that, on the whole, public health systems had worked effectively. But there remains a need to strengthen these to cope with the unforeseen.

Incidents and outbreaks caused by the deliberate release of biological, chemical or radiological agents

74. In 1995, for the first time, a terrorist group in Japan deliberately used the chemical warfare agent sarin against a civilian population. Since September 11^th 2001, awareness has grown of the threat from an individual or group deliberately releasing a biological or chemical hazard.
75. A large-scale deliberate release of a chemical or biological agent has never happened in the United Kingdom. However, the risk cannot be ignored. Hoaxes can occur. Therefore, the NHS and its partners need contingency plans to deal with this possibility. Effective health protection services are essential players in countering the threat from this source.

Climate Change

76. Climate change is considered the most serious environmental threat to our planet. Climate change impacts are expected to touch on many aspects of our lives, including our health. The Department of Health (in England) has studied the potential impact of climate change on public health and made a number of conclusions, including:

• far too little is known of the likely effects of climate change on health;
• winter deaths are likely to decline, while heat-related deaths in summer are likely to increase;
• food poisoning cases linked to warm weather are likely to increase;
• increasing severe storms will enhance the risk of injury or death, and flooding can lead to immense anguish.

77. Specifically in Scotland, the primary negative impact of our climate arises from pervasive dampness, increasing the incidence of respiratory diseases. Key to reducing these impacts will be an improvement in the quality of housing against damp and a reduction in the incidence of fuel poverty. These issues are being addressed by the Executive's climate change and social policies.

Conclusion

78. Exposure to hazards continues to be a significant cause of ill health in Scotland. Reducing the risk of this occurring will make a major contribution to improving Scotland’s health.

Key Questions

• Do consultees agree that the health problems detailed in this section, are major issues for health protection in Scotland?
• Could consultees indicate any other health problems, which they consider to be major issues for health protection and give the reasons why.

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