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Disease: a warning from history

Improved public health, medical advances and greater public awareness should have consigned many diseases to the past. But now illnesses such as rickets and syphilis have staged a comeback. Ingrid Torjesen looks at the latest efforts to combat them

By the late 20th century, many infectious and deficiency diseases that were once commonplace seemed to have been consigned to the history books. The public health feat was achieved by a combination of clean water and proper sewerage systems, better nutrition and medical advances such as vaccination, antibiotics and widespread availability of barrier contraceptives, combined with greater knowledge and awareness of illnesses. In 1980, one disease - smallpox - was declared eradicated by the World Health Assembly.

However, in recent years, some diseases thought to have largely died out have seen a resurgence. We take a look at the reasons why.

Measles

2007 saw the biggest rise in occurrence in cases of measles since the Health Protection Agency started collecting data 1995. There were 971 cases in England and Wales - an increase of 30 per cent on 2006. Of these, nearly four fifths were in children under 15 and linked to small outbreaks in nurseries and schools.

Measles, which is highly infectious and can be transmitted between people breathing the same air, used to be endemic in the UK. But after the introduction of a vaccine in the 1960s, cases fell massively. In the early 1990s, the World Health Organisation set a target to eradicate measles by 2000. The strategy relied on protecting 95 per cent of the susceptible population using the combined measles, mumps and rubella vaccine.

However, in 1998 a team of researchers including Andrew Wakefield published a controversial paper in The Lancet describing a novel inflammatory bowel condition in 12 autistic children. It said behavioural problems had begun in eight of the 12 children shortly after receiving the MMR vaccination.

Uptake of the MMR vaccine plunged. While in 1996-97 92 per cent of two-year-old children in England received both doses, by 2003-2004 it was 80 per cent. Although levels of the vaccination uptake have begun to improve, there are still pockets of very low uptake, particularly in London.

"The plan was to clear polio and then measles. We were well on the way to doing that in this country. It is disgraceful that chance should be gone," says Eithne MacMahon, consultant virologist and honorary senior lecturer in infection and immunology at Guy's and St Thomas' foundation trust.

"In order to ensure that you do not get spread, the target we are aiming for is 95 per cent uptake with two doses of vaccine and it is quite hard to realise. You don't need that kind of coverage with a lot of other infections," adds Dr MacMahon.

She thinks the tide is beginning to turn because measles has returned and the alleged autism link has been discredited by further studies.

"Autism was a fear [parents] felt threatened with. Because there was no measles around, no one was afraid of measles. Once people start to see that this is a very serious and potentially fatal illness that is best avoided, that helps the pendulum swing back in the other direction."

Many children do not get both doses of the MMR vaccine. Only 90 per cent become immune to measles after the first dose, so the second is vital. In 2004 and 2005 an MMR catch-up campaign was attempted in London to reach such children, but with limited success.

"The campaign took place near the peak of the MMR scare and there was not very much measles around. I think the stimulus for parents would be greater now to have it done," says David Elliman, consultant in community child health at Islington primary care trust and Great Ormond Street Hospital for Children trust.

For parents who choose not to give their children the MMR vaccination, sending repeat appointments is a waste of time, adds Dr Elliman. "They need much more information, so that means sitting down with a health professional."

Reluctant parents often say they have read a lot of research into MMR, but this turns out to be newspapers and the internet and not the original article, he says. When they are shown that and told no country has an official policy of single vaccines, parents frequently change their minds.

Tuberculosis

Tuberculosis vaccine BCG used to be given to all children through the schools programme, but this ended two years ago, and it is offered only to babies in high-incidence TB areas or with parents or grandparents from high-incidence countries.

Tina Harrison, awareness officer for charity TB Alert, says this is because the vaccine is only 75-80 per cent effective for around 15 years.

"If BCG was brought out today, it would not get through medical trials. Most other vaccines are 95 per cent-plus effective. We've been experiencing an increase for 20 years while offering it to everyone for 18 of those years. There is a misconception that TB was eradicated in the UK, but it never was. Although we got down to around 5,500 cases in 1987 since then there has been an increase just about every year."

In 2007 there were 8,496 cases of TB recorded, actually a 0.7 per cent decrease on the 8,555 cases recorded in 2006. Forty per cent of all reported cases occur in London.

Great Ormond Street infectious disease consultant Delane Shingadia says that while the UK as a whole has seen only slight increases, rates have almost quadrupled in the capital in the past 10 years.

"The WHO cut-off for a high-prevalence country is a rate of 40 cases per 100,000 population and London has now exceeded that at about 43 per 100,000."

Around 70 per cent of TB cases in the UK occur in non-UK-born people. The disease can infect any part of the body, but only lung or throat TB is infectious and even these require very close sustained household contact.

Although a TB screening programme is in place for migrants entering the UK from countries with a high incidence of the disease, Health Protection Agency consultant epidemiologist Ibrahim Abubakar says this is not the solution.

"In 80 per cent of cases, the disease develops at least two years after arrival and often in other parts of their body than their lungs, so a chest x-ray would not pick it up anyway."

Dr Abubakar says TB's resurgence is caused by the breakdown of infrastructure in former Soviet states and sub-Saharan Africa's HIV epidemic.

"Our data does not suggest that the epidemic has in any way affected the indigenous population. If you look at the absolute number of UK-born white individuals, the numbers getting TB are actually dropping."

The WHO estimates around a third of the world's population has latent TB. Ms Harrison says small studies have suggested it is more likely to activate here in some communities than in their home countries because of vitamin D deficiency caused by poor diet. "Vitamin D plays a huge part in keeping the immune system fighting infections," she says.

In 2004 the Department of Health published a national plan outlining strategies for dealing with TB and in 2007 a toolkit for commissioners to help them plan services in their areas.

Dr Abubakar argues TB services are running as well in the UK as other developed countries. "Early diagnosis and prompt effective treatment are the key to TB control. Identify all your cases as soon as they become symptomatic, treat them and make sure they complete their treatment."

But Ms Harrison says many PCTs outside high incidence areas such as London, Luton and Birmingham are not taking TB seriously or following the toolkit's recommendations, which hinge mostly on raising awareness of symptoms among at-risk groups, health professionals and the general public to improve detection.

Dr Shingadia says the toolkit is not mandatory, so commissioners do not have to adhere to it.

"Unlike other commissioning processes such as for HIV, where there are clearly defined financial resources, I don't think TB has the same degree of commitment from PCTs," he says.

Rickets

The bowed legs characteristic of rickets were frequently seen on children living in urban slums on a poor diet after the industrial revolution. The disease is linked to a deficiency in vitamin D, which is needed for strong bones and is found in certain foods, but is also made by the body if the skin is exposed to sunlight of the right wavelength.

But in the winter in the UK there is not enough sunlight of the right wavelength in areas north of Birmingham to enable the body to do this, so residents who do not go out in the sun, who cover up or have darker skin are at particular risk of vitamin D deficiency.

When rickets reappeared in the 1970s among children across the UK, a public health campaign to reduce it involving issuing vitamin D drops to everyone at risk was launched. But as time went on, the focus moved on, the NHS stopped providing the vitamins and children stopped taking them.

The Department of Health now estimates rickets could affect one in 100 children in Asian, Afro-Caribbean and Middle Eastern communities. All pregnant and breastfeeding women and all children under four are advised to take vitamin D supplements, with those on benefits or low incomes able to get these free through the Healthy Start initiative.

The National Institute for Health and Clinical Excellence is concerned that clinicians are not doing enough to emphasise the importance of vitamin D and is likely to address this in its next guidance on maternal and child nutrition.

In 2005 paediatricians told the then Bradford and City teaching PCT they were seeing around 60 children, predominantly from the South Asian community, with vitamin D deficiency every year and that a third of these had rickets.

"We felt that in 2005 we shouldn't be seeing any children with that kind of problem," says Shirley Brierley, consultant in public health at the now Bradford and Airedale teaching PCT.

The PCT decided to fund vitamin D supplements for all children under two and anyone in at-risk groups: those of South Asian, African, African Caribbean or Middle Eastern descent. It is also encouraging all pregnant and breast-feeding women to take them.

Eighteen months ago, Blackburn with Darwen PCT also realised it was seeing around one case of rickets a week in the south Asian community, and spent£160,000 on vitamin D supplements. These are available to anyone, although they are targeted at pregnant women, young mothers, children under five and adolescent girls in the local south Asian community.

Children from the community often do not get much sunlight until they go to school because they stay at home with their mothers and adolescent girls are at risk when they start wearing the hijab.

"We recognised the people we have identified have been from a particular part of our community, but we want to make sure that we provide the best service across the community by making the supplements available more widely. We don't want this to be seen as an ethnic-specific issue," says director of development and engagement Craig Oates.

As part of its health and well-being strategy, the PCT is also working with the local community to set up accompanied walks for Asian women.

"Asian ladies will have a guide who will take them around a local park so they are out with their community with ladies they are friends with, but they have someone accompanying them so they feel safe and comfortable. They are getting sunlight and they are getting exercise, so it is not just a quick fix."

Syphilis

Once associated with sailors with a girl in every port, syphilis began resurging in the 1990s in former Eastern bloc countries when health systems collapsed.

Cases in the UK have increased tenfold, from 301 in 1997 to 3,702 in 2006. Initially the spread was confined to urban areas and men who have sex with men, but in 2005 the infection began to be seen in an increasing proportion of heterosexual men and women.

A quarter of those with syphilis also have HIV and oral sex is implicated in the spread of syphilis in 39 per cent of gay men, says the Health Protection Agency.

When the disease first started to re-emerge, Mark Bellis, director of the Centre for Public Health in Liverpool, studied affected men in Manchester and found it was occurring predominantly in a gay subpopulation that was having a lot of unprotected sex with anonymous partners, often while using drugs such as GHB.

"They wanted to go out and enjoy themselves in a particular way and despite the fact that they knew the risks around that, to feel comfortable with having unprotected sex and not worrying about it, they were using drugs as well.

"It is very difficult to get messages across to people when they are sober which they are then expected to implement when they are taking drugs or alcohol. We have to think about disease and socialising the same way that individuals do; that alcohol, drugs and sex are not necessarily separate issues for many people but are all part and parcel of the same night out," he says.

The globalised party scene is also contributing to the problem with cheap flights taking over from sailing ships as the conduits of the infection, says Dr Bellis.

"It is just as easy and may be quicker for people in Manchester using a cheap flight to go to a party in Berlin as anywhere else, so you are exposed not just to the profile of infection within your own country but the profile within another country as well."

Dr Patrick French, consultant in genitourinary medicine at a Camden PCT sexual health clinic, says syphilis was fairly common in the late 1970s and early 1980s among gay men, until the emergence of HIV, when people started to use condoms. "A huge seismic change happened in sexual behaviour and it was essentially eradicated as an infection in Britain."

He is alarmed that it is increasing again in this same population. "Syphilis is extremely easy to test for and extremely easy to cure. Part of sexually transmitted infection control, particularly for bacterial STIs like syphilis, is making sure there is good access to testing and treatment - particularly for gay men in terms of syphilis. There is a concern that there may be people presenting to services with symptoms and signs of syphilis who are not being tested."

Dr French adds that many clinicians are unaware of what to look out for with the condition. "There is a whole generation of doctors and nurses who have grown up trained in an era when there was very little syphilis around. It is really only doctors and nurses who qualified before 1985 that have seen much syphilis, so there is a real need for increased awareness."

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