Abstract
Health protection is a key function of Public Health England, encompassing emergency preparedness, resilience and response, environmental health, and communicable disease control. The aim of this article is to discuss the role of health protection, its structure in England, and how GPs are integral to the reporting, surveillance and actions to protect public health. Case studies are included. Finally, the article will highlight knowledge that GPs will find useful when considering notifiable infectious diseases and the role of GP and health protection in the NHS Long Term Plan.
Introduction to health protection within public health
Health protection is a key function of public health, with the World Health Organisation adhering to the definition of Sir Donald Acheson who defined public health as ‘the art and science of preventing disease, prolonging life and promoting health through the organized efforts of society’ (Acheson, 1988).
Health protection is frequently at the forefront of the news, with a wide range of high-profile events, including a recent rise in cases of measles (BBC News, 2019) through to the Novichok poisoning incident in Salisbury (Public Health England (PHE), 2018).
A working definition of health protection as proposed by Ghebrehewet et al. (2016) is: The protection of individuals, groups and populations through the expert advice and effective collaboration to identify, prevent and mitigate the impacts of infectious disease, and environmental, chemical and radiological threats.
Table 1 highlights the three domains of health protection and their actions. It should be noted that practically, at a local level much of the functions of these domains overlap.
Domains and functions of health protection.
Source: Faculty of Public Health (2014) and Ghebrehewet et al. (2016).
Health protection organisation within PHE
The United Kingdom Faculty of Public health has divided the specialism of public health practice into three functions as illustrated in Fig. 1, where the subsequent functions of health protection are shown.
Structure of PHE and its health protection function.
PHE was established in 2013 and is an executive agency of the Department for Health and Social Care (North East and North Central London health protection team (NENCL HPT), 2019). England is divided into four regions North, South, Midlands and East, and London. London is an integrated centre and region with three local health protection teams (PHE, 2019). Emergency preparedness, resilience and response (EPPR) is mandated by the Civil Contingencies Act 2004 and requires NHS England and its organisations to provide contingencies and plan for emergencies or incidents (NHS England, 2019). The other stated aims of PHE are:
Protecting and improving global health Supporting the NHS Supporting and developing the public health system Improving health and wellbeing Reducing inequalities
The health protection role of PHE is implemented locally by a health protection team (HPT); geographical leads work with boroughs, with expert leads providing disease-specific advice and information for strategy and policy, both locally and nationally (NENCL HPT, 2019).
The broad function of health protection is reflected in the wide range of professions involved, and requires close and co-ordinated working with multiple organisations. Institutions involved include schools, universities, workplaces, health care institutions such as care homes, hospitals and their infection control teams. Examples of other PHE bodies include Centre for Radiation, Chemical and Environmental Hazards (CRCE), Field Epidemiological Services, and National Infection Service (NIS) (NENCL HPT, 2019).
The specialists within the local HPT include consultants in health protection and consultants in communicable disease control, specialist nurses, health protection practitioners, public health registrars, information officers and administrators (NENCL HPT, 2019).
This team may liaise with microbiologists and virologists; both locally and nationally, national experts and laboratories at the NIS, PHE colleagues at CRCE, and EPRR leads, public health consultants and environmental officers at local authorities, GPs and hospital doctors.
Investigation and response
A HPT provides a 24-hour service, during which time they respond to daily notifications of infectious diseases, environmental hazards and emergencies. They then not only investigate and advise on outbreaks, but also assist on application of national guidance to local cases and incidents.
The legal framework for local authorities to act is mandated through the Health Protection (Local Authority Powers) Regulations 2010 and enables them to request or require action to be taken to prevent, protect against, or control a significant risk to human health (NENCL HPT, 2019).
For example, they can:
Require that a child with a disease is kept away from school Require a head teacher to provide a list of contact details of pupils attending their school Disinfect/decontaminate premises or articles on request Request (but not require) individuals or groups to co-operate for health protection purposes Restrict contact with, or relocate, a dead body for health protection purposes
Teams are notified by medical professionals if the disease in question is clinically suspected or if organisms are isolated by medical laboratories. The first step is to confirm that the information or report is correct and confirms it to be a case of the infectious disease about which there is concern. Basic information is collected, including clinical and demographic details with the timeline of presentation. It should be established whether there is an epidemiological link. Such a link is defined as a case affecting an individual with the disease who has had exposure to a confirmed case of the disease (Ghebrehewet et al., 2016). A case can be defined as possible, probable or confirmed. A subsequent risk assessment is carried out by identifying and detailing the exposure and who else is at risk. Often a disease-specific Standard Operating Procedure aide-memoire aids identification. Details are entered into a dedicated program ‘HPZone’ enabling case and incident management.
Once this investigation has been carried out, the response can include advice and reassurance, proactive case finding, immediate control measures (such as exclusion advice), information to others and immediate further clinical investigations. In cases where there are environmental hazards, further environmental investigations may be advised.
Case studies: Examples of control of communicable diseases
A wide variety of diseases are notified to HPTs. Below are case studies providing examples of how diseases are managed and the role of GPs. These include management of a local outbreak and a suspected case.
Measles
This is a vaccine preventable disease that is on the increase due to decreasing uptake of Measles, Mumps and Rubella vaccine (MMR) (BBC News, 2019). This is a Morbillivirus RNA measles virus and is highly contagious, with 90% of susceptible close contacts developing measles following exposure. It has an incubation period of 7–14 days (average 10–12 days) and infectious period 4 days before and after the onset of rash (Ghebrehewet et al., 2016).
Case study 1.
A 3-year-old girl is reported by her GP to have a measles-type rash with prodrome. She has received only one MMR vaccination.
Establish any epidemiological links: ○ The girl is a member of a nursery and a community in which measles is circulating • Close contacts information including vaccination status and whether vulnerable: ○ Within the household there are no pregnant or immunocompromised contacts, but there is a 3-month-old sibling ○ Within healthcare she spent time not isolated in the GP practice waiting room but has not attended an acute hospital ○ Other contacts: A nursery during the infective period
Organise human normal immunoglobulin (HNIG) for vulnerable (under 6 months old) contact (sibling) Provide the mother with information and a fact sheet on measles Contact GP practice and send information to risk assess the GP premises with help from the HPT Provide the nursery with information, a measles fact sheet and letters to circulate to parents detailing actions for children exposed, including post-exposure MMR Add context/details to enable identification nationally of any further cases linked to this case via the nursery, etc. Create a separate situation on HPZone to track any further cases of measles from the same nursery
Whooping cough
Whooping cough is caused by gram negative coccobacilli, Bordetella pertussis and Bordetella parapertussis, and is transmitted via droplet spread. It should be suspected in those with a cough lasting 14 days or more associated with post-tussive vomiting, paroxysms of coughing and an inspiratory whoop. It is communicable until 48 hours of therapy or 21 days without treatment.
Case study 2.
A 5-month-old baby attends A&E with severe cough and breathing difficulties
Doctors clinically suspect whooping cough Epidemiological link: None established Contact assessment: ○ Mother unclear about pertussis vaccination status ○ Household contacts include parents, but there are no siblings or other contacts. Neither parents are healthcare workers ○ Patient isolated almost immediately upon arrival in A&E
Isolate case in hospital with droplet precautions for 48 hours on appropriate antibiotics Take nasophayrngeal swabs to confirm the case No chemoprophylaxis needed for the parents, as they are neither vulnerable nor at risk of transmitting to other vulnerable contacts Risk assessment of contacts in waiting room to be completed by the hospital infection control team
The role of a GP and primary care in health protection
General practice is a key partner in health protection. Some traditional strengths of general practice, including coverage of population and co-ordination of care (Watt, 2018), enable and complement health protection measures. General practice facilitates case finding, rapid vaccination programmes, identification and treatment of cases and contacts. This has been confirmed in a scoping review of the interaction between general practice and public health. This review noted that the protection and surveillance function of public health was completed in general practice by the identification and early treatment of disease (Levesque et al., 2013). The review suggests that the investigation and clinical advice, although a public health function, overlaps with general practice.
Within the domain of health protection, the role of the GP is mainly concerned with the control of infectious diseases. GPs will have very little involvement in environmental hazards. However, for EPRR surveillance data collected in primary care may be used in contingency planning and so GPs may be involved if business continuity plans are implemented, for example, during a flu pandemic.
Health protection ‘tools’ experienced in general practice
Ghebrehewet et al. (2016) describe the ‘tools’ on which health protection relies, including some (incident and outbreak management; immunisation and surveillance) encountered and facilitated by GPs.
Identification and notification of infectious diseases
Incident and outbreak management applies to all three domains, but again, GPs will often be involved with control of communicable diseases (CCD), mainly in the identification and notification of cases. There are currently 32 notifiable infectious diseases in England and 60 notifiable organisms (causative agents) according to the Health Protection (Notification) Regulations of 2010 (PHE, 2010). The time frame for notifications corresponds to a colour. Those designated as red are urgent and mandate verbal notification within 24 hours, and written notification within 7 days. Non-urgent cases can be notified in writing within 7 days (paper, secure fax or electronic e.g. CoSurv, secure online reporting, secure e-mail) (NENCL HPT, 2019; PHE, 2010).
Vaccination promotion and implementation
Immunisations are one of the most effective public health interventions in history, affecting both the morbidity and mortality of diseases. General practice plays an important role in ensuring appropriate immunisation of the population. This includes call and recall, checking immunisation status of new patients and recording of immunisations. Several immunisation programmes are delivered within the school setting by school immunisation providers (contracted by NHS England) including influenza, meningitis, human papilloma virus, and diphtheria, polio, tetanus immunisations.
Given the increase in scepticism about immunisation and the ‘anti-vax’ movement, GPs have an important role in promoting vaccinations and encouraging uptake. Knowledge of the schedule and common side effects can be found in the Green Book and on the PHE website.
Surveillance systems and use of data
Surveillance systems implemented for health protection enable teams to follow health trends over time, prioritise healthcare issues, detect and respond to epidemics and enhance knowledge on behaviour of diseases (Ghebrehewet et al., 2016). GPs may be involved in all three health protection domains. GPs may report respiratory conditions that may be related to air pollution or gastrointestinal conditions due to a contaminated food source. For CCD and EPRR, GPs will report cases. The GP clinical codes are utilised in analysis of case trends.
What is useful for a GP to know before contacting the HPT?
Information GPs may collect.
High-risk groups for GI transmission.
What does the HPT ask of general practice?
If a disease is notified by the GP, or the GP provided the sample from which the disease was identified, the reporting clinician or practice manager will be contacted and information about the patient, household and other contacts will be requested, if not already provided. If the patient about which there is concern has attended the GP’s premises during the infective period (for example, in a case of measles), the practice will be required to undertake a risk assessment and identify any at-risk contacts.
Once completed, chemoprophylaxis or vaccinations are often suggested. It is at this point that PHE requires the assistance of GPs. PHE does not have prescription rights or the ability to administer medications. The local HPT may ask the GPs to prescribe medication or administer vaccine to contacts. In some circumstances (for example, HNIG administration as in the case study) the HPT will order and organise delivery of medication to the practice and ask the GP or practice nurse to liaise with the patient and administer the supplied medication.
This has been a contentious issue, particularly surrounding the contractual obligations between GPs and PHE (Mahase, 2018). Local systems for reimbursement of ordering and administration exist for vaccinations outside the immunisation schedule or for ‘off label’ administration. Point 13 of the National Health Service (Charges for Drugs and Appliances) Regulations 2015 refers to the exemption of charges for public health services.
If there are concerns, or trainees are interested in local agreements, then discussion with practice partners or the local Clinical Commissioning Group is suggested.
Future challenges and opportunities for GPs in health protection
This article has highlighted the function and structure of health protection in England and the way in which GPs enable and facilitate its delivery. In the NHS Long Term Plan published in 2018, improvement of population health and recognition of the role of public health is an integral component of the report (NHS, 2018).
As public health challenges evolve, and as the range of communicable diseases and methods of transmission evolve with globalisation, GPs must be alert to how this affects their population. With the rise of anti-vaccination propaganda and reduced uptake of vaccination we may see re-emergence of some diseases.
How GP trainees can engage with public health and health protection
GP trainees on public health attachments usually spend 2 weeks with the local HPT during their rotation. If not, it is possible to organise a familiarisation attachment directly using study or annual leave through your local HPT. Subsequently, it may be possible to attend 1 day a month to maintain contact and develop skills.
Useful resources for GPs
PHE website for individual vaccines and diseases. Includes information for health professionals and disease guidance An excellent resource for school exclusion advice is found on the Gov.uk website ‘Health protection in schools and other childcare facilities.’ Chapter 9 provides a specific exclusion table The Green Book: Up-to-date resource for immunisation schedules, vaccination advice and current evidence. This includes information on catch-up vaccinations and use if patients are exposed to disease Nationally developed Patient Group Directions for the use of vaccines in primary care can be found on the NHS England and National Institute for Health and Clinical Excellence websites Email bulletins are sent from PHE on vaccinations and health protection updates
KEY POINTS
Public health is integral to the NHS Long Term Plan Health protection is a key function of public health GPs must respond to the changing presentation of diseases and population needs to continue to facilitate health protection Health protection can be divided into three main functions: CCD, EPRR and environmental hazards In England, health protection is implemented locally through HPTs; these teams liaise with GPs, multiple stakeholders and national bodies GPs are key partners in the role of health protection and are involved at multiple levels including identification and notification of cases, investigation of cases, immunisation and contribution of data to surveillance programmes
Footnotes
Acknowledgement
We thank to Melissa Wyatt of the London RCGP Library for her assistance in sourcing research material for this article.