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The global impact of HIV infection and disease

A Nicoll, ON Gill

Summary: Patterns of HIV infection and disease are changing. HIV will soon Key words:
enter the top five causes of death worldwide and is now believed to cause more acquired
deaths than malaria. Commonwealth countries account for around 60% of prevalent immunodeficiency
HIV infections worldwide. Around half of all global HIV transmissions are to people
disease transmission
under 25 years of age. HIV is lowering life expectancy and reversing gains in
child survival in east and central Africa. The incidence and prevalence of HIV epidemiology
infection have increased enormously in southern Africa recently. A more generalised HIV infections
pattern of heterosexual HIV transmission is emerging in parts of South and South international
East Asia. Injecting drug use and related HIV transmission is increasing in cooperation

resource-poor countries. Countries where HIV prevalence is low but rising and population surveillance
there are high levels of other STIs offer particular opportunities for early preventive health
intervention, as it is easier to intervene against HIV when it is entering a country
than when it has become established. In countries with weak family and social
networks there is inadequate care for the increasing numbers of parentless children.
HIV is prejudicing tuberculosis control programme in most African countries and
will do the same in Asia. AIDS mortality has fallen in industrialised countries
but the prevalence of HIV infection and treatment costs are increasing. Countries
that have used multisectoral approaches at an early stage and have had political
support for HIV prevention early in their epidemics have been able to limit
transmission. Others, intervening later, have been able to reduce transmission.
Surveillance methods need to adapt to changing patterns of infection and disease.

Commun Dis Public Health 1999; 2: 85-95.

Introduction and data sources from many sources, but draws particularly on those
In the two decades since the first cases of AIDS presented at regional and global Monitoring of the
appeared in the United States (US) and Africa over 47 AIDS Pandemic (MAP) seminars in Abidjan, Lima,
million people are estimated to have been infected Manila, and Veyrier, at the 12th international
with HIV, nearly 14 million of whom have already died conference on AIDS, and in global reports from the
(table 1). The spread of HIV has been uneven and the joint United Nations Programme on AIDS
epidemiology of HIV has changed substantially in the (UNAIDS)1,2. It updates an earlier paper 3, placing
past three years. These points must be understood in emphasis on recent changes in the pandemic and pays
order to determine priorities, and to target, evaluate, particular attention to the developing world, and
and adjust interventions. The epidemiology of HIV countries of special relevance to the United Kingdom
infection is incompletely understood, but it is better (UK). Unless stated otherwise all prevalence and
known than the epidemiology of many other incidence statements refer to best estimates of the
infections. This paper is based on data and analyses global position at the end of 1998 4 with country
specific estimates for the end of 1997 2.
Data from serological surveys 5,6 have been
A Nicoll, ON Gill
HIV and STD Division combined with natural history studies and modelling
PHLS Communicable Disease Surveillance Centre techniques to estimate the incidence of infection,
disease (AIDS), and deaths due to HIV infection7, 8.
Address for correspondence:
Dr Angus Nicoll Field surveys in developing countries have confirmed
HIV and STD Divison the validity of this approach, showing that the
PHLS Communicable Disease Surveillance Centre incidence of infection and premature mortality are
61 Colindale Avenue comparable with predictions 9,10. Such approaches
London NW9 5EQ
provide more reliable data in resource-poor countries
tel: 0181 200 6868, ext 4695
fax: 0181 200 7868 than clinical AIDS case reporting, which is subject to
email: incompleteness of presentation, recognition, and



BOX Definitions

Adults – here defined as people aged 15-49 years

Children – <15 years of age
Core Groups – groups of people experiencing or responsible for more HIV transmission than their numbers would suggest.
Pandemic – an epidemic that affects the whole world.
Prevalence of HIV – the level of HIV infection - comprises pre-existing infections, including those recently acquired, but not those
among people who have died. Prevalence includes people whose infection has advanced to AIDS and represents the current burden
of infection on the community and the current and future burdens of disease and death it will experience. It can be expressed both
as the numbers of people living with HIV (prevalent infections) and the percentage of the adult population currently living with
infection. For example, Uganda has an estimated 930 000 prevalent HIV infections among adults and children, and the prevalence is
9.5% among adults.
Prevention programmes – programmes intended to reduce HIV transmission, or to prevent transmission rates from rising, often
through modifying behaviours associated with transmission.
Sentinel surveillance – measuring levels of infection in particular groups (such as pregnant women) so as to inform changes in levels
of infection in the wider population.
Transmission or incidence of HIV – the number or rate of new HIV infections in the community.
Young people – adolescents and young adults (adults < 25 years of age).

reporting (though AIDS reporting is a useful indicator 10% of global gross national products.
of important trends11). A number of countries remain, Commonwealth countries are disproportionately
however – notably in North Africa, the Middle and affected and contain around 60% of prevalent HIV
Far East – where knowledge of the prevalence of HIV infections worldwide 2. Probably about nine out of ten
infection is particularly sketchy (figure 1). people living with HIV are unaware of their infection.
Transmission has recently increased in countries
Global epidemiology of infection and where levels of infection were low previously (see
transmission Definitions Box).
HIV infection continued to spread in the late 1990s so As epidemics of HIV infection fuelled largely by
that the entire world was affected by the end of 1998, heterosexual transmission have developed in
with about 33 million people living with HIV infection resource-poor countries the age at which transmission
or AIDS, and about 16 000 new infections each day occurs has fallen: half of all global transmission is now
(table 1). Around 90% of new infections arise in poorly believed to be to people under the age of 25 years12.
resourced countries, which together account for only The predominant mode of adult transmission continues

TABLE 1 Global estimates of the HIV/ AIDS epidemic – end of 1998

People newly infected with HIV in 1998 Total 5.8 million

Adults 5.2 million
Women 2.1 million
Children < 15 years 590 000

Number of people living with HIV/AIDS Total 33.4 million

Adults 32.2 million
Women 13.8 million
Children < 15 years 1.2 million

AIDS deaths in 1998 Total 2.5 million

Adults 2.0 million
Women 900 000
Children < 15 years 510 000

Total number of AIDS deaths since the pandemic began Total 13.9 million
Adults 10.7 million
Women 4.7 million
Children < 15 years 3.2 million

Total number of HIV infections since the pandemic began Total 47.3 million
Adults 42.9 million
Women 18.5 million
Children < 15 years 4.4 million

Total number of AIDS orphans* since the pandemic began 8.2 million (end 1997)

* Defined as children whose mother or both parents died as a result of AIDS when they were under 15 years of age
Source: References 2 and 3


TABLE 2 Recent change in prevalence of HIV infection in adults aged 15 to 49 years in countries receiving aid
from the UK
Prevalent infections among adults (%)
Percentage increase
Country at end 199432 at end 1997 2 in prevalent infections

Bangladesh 15 000 (0.03) 21 000 (0.03) 28

Bolivia 2000 (0.06) 2600 (0.07) 30
Botswana 125 000 (18) 190 000 (25) 60
Brazil 550 000 (0.65) 570 000 (0.63) 4
Cambodia 90 000 (1.9) 120 000 (2.4) 33
China 10 000 (0.0015) 400 000 (0.06) >100
Ghana 172 000 (2.3) 200 000 (2.4) 16
India 1 750 000 (0.38) 4 100 000 (0.82) >100
Kazakstan 500 (0.006) 2 500 (0.03) >100
Kenya 1 000 000 (8.3) 1 600 000 11) 60
Malawi 650 000 (13.6) 670 000 (15) 3
Nepal 5000 (0.051) 25 000 (2.4) >100
Nigeria 1 050 000 (2.2)* 2 200 000 (4.1) <100*
Pakistan 40 000 (0.063) 62 000 (0.09) 55
Peru 30 000 (0.25)* 71 000 (0.56) <100*
Russia 3 000 (0.004) 40 000 (0.05) >100
South Africa 650 000 (3.2) 2 800 000 (13) >100
Tanzania 840 000 (6.4) 1 400 000 (9.4) 43
Uganda 1 300 000 (14) 870 000 (9.5) -30†
Zambia 700 000 (17) 730 000 (19) 4
Zimbabwe 900 000 (17) 1 400 000 (26) 55

* Despite these published figures it is now considered that the 1994 estimates were an underestimate and therefore that the true increase in prevalence
over the period was probably less than 100% for these countries
† The reduction in Uganda is likely to be real, reflecting both reduced transmission and the effects of HIV related mortality (see Impact page 93 onwards)

to be unprotected, penetrative heterosexual intercourse drug users are of greater importance (figure 1).
(that is, without effective use of a barrier contraceptive). Most HIV infected children acquire infection from
The presence of other sexually transmitted infections (STIs) their mothers, and in resource-poor countries
– especially those causing ulcers, which are common in substantial numbers of adults and children continue
most developing countries – facilitates heterosexual to acquire infection through infected blood products,
transmission13. In countries where infection is concentrated mainly transfused blood that has not been screened
among certain vulnerable groups, however, transmission for antibodies to HIV 2,14.
through unprotected anal intercourse between men and These generalisations hide substantial complexities
sharing of injecting equipment between injecting both within and between countries. National prevalences

FIGURE 1 Current patterns of HIV transmission by country, 1997/8

Transmission mostly confined
to behaviourally or economically
vulnerable groups
(homosexual men, injecting drug
users, commercial sex workers,
and heterosexual transmission
in some deprived groups)
Transmission widespread
in the heterosexual population
as well as vulnerable groups

Within the same country both
patterns existing in different regions

Low prevalence at present, unclear
if moving to generalised transmission

Source: PHLS AIDS and STD Centre, Communicable Disease Surveillance Centre


TABLE 3 Impact of HIV – by country (more than 500 000 HIV infections, an adult (15 to 49 years) HIV prevalence of

more than 1%, or where HIV prevalence more than doubled between 1994 and 1997) 2

Prevalence of HIV infection

Countries with more than 500 000 infections Incidence
or adult (15 - 49 years) prevalence of more Prevalence doubled
than 1% 1 (k = thousand, m = million) between 1994 and 1997

sub-Saharan Africa

West Africa Benin (2%), Burkina Faso (7.1%), Cote d’Ivoire (670k, 10.1%),
Gambia (2.2%), Ghana (2.4%), Guinea (2.1%), Guinea-Bissau (2.25%),
Liberia (3.6%), Mali (1.7%), Niger (1.5%), Nigeria (2.2m, 4.1%),
Senegal (1.8%), Sierra Leone (3.2%), Togo (8.5%) no countries

East Africa Burundi (8.3%), Eritrea (3.1%), Ethiopia (2.5m, 9.3%),

Kenya (1.6m, 11.6%), Malawi (670k, 14.9%), Mozambique (1.2m, 14%),
Rwanda (12.8%), Tanzania (1.4m, 9.5%), Uganda (930k, 9.5%),
Zambia (730k, 19%), Zimbabwe (1.4m, 25%) no countries

Central Africa Angola (2.1%), Cameroon (4.9%), CAR (10.1%), Chad (2.8%),
Congo (7.8%), Democratic Republic Congo (990k, 4.3%), Gabon (4.2%) Angola

Southern Africa Botswana (25%), Lesotho (8.3%), Namibia (20%), S Africa (2.9m, 13%) South Africa

South and south east Asia

South Asia India (4.1m, 0.82%) India, Nepal

South east Asia Cambodia (2.4%), Mynamar (1.8%), Thailand (2.2%) Cambodia, Mynamar, Vietnam

Rest of Asia and the Pacific

Central Asia no countries Kazakstan

East Asia no countries China, Indonesia, Philippines

The Pacific no countries no countries

Australasia no countries no countries

The Americas

North America USA (810k, 0.8%) no countries

The Caribbean Dominican Republic (1.9%), Haiti (5.2%),

Jamaica (1%) Trinidad (1%) Dominican Republic

Latin America Brazil (580k, 0.63%), Honduras (1.5%) Honduras, Venezuela

Europe and central Asia

Northern, southern, and

western Europe no countries no countries

Eastern Europe and no countries Belarus, Estonia, Russia,

central Asia Ukraine

North Africa and the

Middle East (western Asia) no countries Turkey

* excludes countries with less than a million population

of HIV infection (as a percentage of the adult population) to be concentrated where the infection is endemic but
vary many hundred-fold and even within sub-Saharan occurs mostly among vulnerable groups such as men
African countries prevalences differ by a factor of 20 (table who have sex with men (through unprotected anal
2)2. Countries that are heavily affected, where either more intercourse) and injecting drug users (IDUs; through
than 500 000 infected people live or where the prevalence sharing injecting equipment). Examples would be the
exceeds 1%, or is rising swiftly, are listed in table 3. countries of western Europe, North America,
Another important difference between countries is Australasia, and most parts of Latin America. In a few
the occurrence of ‘concentrated’ and ‘generalised’ of these counties, deprived and/or marginalised
patterns of transmission(figure 1). Transmission is said populations (homosexual men, IDUs, commercial sex


FIGURE 2 Proportional increase in country HIV prevalence rates between 1994 and 1997


Proportional increase
over 100% (27)
10% to 100% (45)
0.01% to 10% (33)
no increase (31)
no 1997 data (36)

Source: Adapted from UN AIDS/WHO report on the global HIV/AIDS epidemic - June 1998

workers) are experiencing substantial amounts of transmission have often passed through a phase of
heterosexual transmission - for example, some black concentrated transmission, usually attributed to
populations in the US1. The prevalence may be high heterosexual transmission among core groups (see
(over 5%) or very high (over 50%) in affected groups but Definitions), such as commercial sex workers,
because they form a minority in the population the businessmen, and truck drivers.
overall adult prevalence is generally under 1% 2 . High levels of blood transfusions in developing
Transmission is said to be in generalised in countries or countries also make a potent contribution. It is believed
areas within countries where the infection is spread that nearly a quarter of the estimated 2.5 million blood
broadly through the adult population and heterosexual transfusions given in Africa in 1995 had not been
transmission predominates - such as in countries of east screened for HIV antibodies. Many studies have shown
and central Africa, where HIV infection has been that a large proportion of the transfusions were
endemic for over 15 years and where the prevalence in unnecessary14. Generalised transmission is now reaching
adults is well over 1%2. Countries with generalised broader populations in parts of India and Brazil; both
FIGURE 3 HIV and injecting drug use, 1997

IDU with reported

HIV (96 countries)

IDU without
reported HIV (20)

no 1997 data (36)

Source: WHO Programme on Substance Abuse (published in UN AIDS/WHO report on the global HIV/AIDS epidemic - June 1998)



countries have areas of concentrated and of generalised routine antenatal HIV testing followed by a short
transmission (figure 1). Countries such as Russia and course of antiretroviral therapy for mother and infant,
the Newly Independent States (NIS) of the former USSR delivery by caesarean section, and the avoidance of
may experience the same transition because of their high breastfeeding 17. Antenatal HIV screening has not
incidence of other STIs15. Finally there are more than 30 become routine in the UK, even in high prevalence
countries with low levels of infection and where it is areas, and efforts are underway to increase testing18.
unclear whether transmission will become concentrated Trials in Thailand have shown that shorter courses of
or generalised (figure 1), including the large populations antiretroviral therapy reduce the risk of vertical
in China, Pakistan, and Bangladesh. transmission19, but the practicalities, cost, and possible
adverse effects of short antiretroviral regimens pose
Countries where the prevalence of HIV infection special difficulties for resource-poor countries 20.
is rising
The prevalence of HIV infection has remained low for Regional summaries
several years in some countries, while in others Sub-Saharan Africa21
transmission has begun recently to rise or reach high levels, Six in every ten HIV infected men, eight in ten infected
(particularly those in the third column of table 3, and shown women and nine in ten infected children in the world
in dark in figure 2)2. Highly populated countries with a live in sub-Saharan Africa, which still accounts for
low prevalence but rapidly increasing HIV transmission nearly half of all the new infections worldwide, mostly
are China, India, and Russia and the NIS. associated with generalised transmission (figure 1).
Heterosexual transmission predominates, but
Drug injecting and HIV transfusion-related transmission is a significant and
HIV transmission caused by sharing injecting equipment readily preventable source of infection. Africa is not
and spread of HIV to and among sexual partners of IDUs universally affected by HIV and a mosaic of epidemics
have been major risk factors for infection in many is progressing at varying rates in different areas. In
industrialised countries. Injecting drug use is also of southern Africa, transmission in Botswana, South
growing importance in resource-poor countries (figure Africa, and Zimbabwe has intensified considerably in
3)2. Early intervention in such situations to reduce the mid to late 1990s, where the prevalence of the
needle sharing among IDUs may prevent explosive infection among pregnant women in some areas has
epidemics. In European cities the prevalences of HIV reached the highest levels ever recorded: 43% in
infection among IDUs have usually remained under Francistown, Botswana in 1997; 59% in Beit Bridge,
20% 1 . In North American cities, however, once Zimbabwe in 1996, and 27% in Kwa Zulu Natal, South
prevalence among IDUs has risen above 10%, it has Africa in 1997 (figure 4) 2. These countries have been
almost invariably risen to levels of 40% or more1,2,16. especially vulnerable because of the phenomenon of
oscillatory migration: men leave their families for
Children and HIV transmission work for prolonged periods, during which they live
Between one and two thousand infants are infected in hostels, often having sex with commercial sex
daily through mother to child transmission, equivalent workers. Similarly, the employment of women as sex
to around 590 000 infections a year (table 1). These workers in neighbouring or distant countries has been
occur largely where adult transmission is generalised, a potent mechanism for spreading HIV between
so that 90% are in resource-poor countries. Infections countries 1. In contrast, prevalences in west Africa
can occur before birth but most take place during birth countries have been lower and stable in the past three
or as a result of breastfeeding. Several industrialised years (figure 2). The highest prevalence, 10%, is in
countries, notably the US and France, have reduced Cote d’Ivoire and the lowest, 1.8%, is in Senegal, where
mother to child transmission substantially through HIV prevention has been particularly successful
FIGURE 4 HIV prevalence among pregnant women: FIGURE 5 HIV prevalence among pregnant women:
selected provinces of South Africa, 1990-1997 Dakar, Senegal, 1989-1996
30 10
KwaZulu Natal HIV 1
25 Free State HIV 2
HIV prevalence (%)
HIV prevalence (%)

Eastern Cape


0 0
1990 91 92 93 94 95 96 97 1989 90 91 92 93 94 95 96
Year Year
Source: National AIDS Programme, Senegal (published in UN AIDS/WHO report
Source: Department of Health, South Africa
on the global HIV/AIDS epidemic - June 1998)
(published in UN AIDS/WHO report on the global HIV/AIDS epidemic - June 1998)


(figure 5)2. The situation in Nigeria, the most populous

injecting. For example, southern areas of Vietnam are
country in Africa, remains unclear. more highly affected than the north and there is
Turning to east African countries, the prevalence evidence of a recent resurgence of infection through
of HIV infection in women under 25 years of age injecting in Thailand 25,26.
attending urban antenatal centres in Uganda has been In India infection levels and transmission are
falling since 1994 11,22, indicating that transmission has known to have risen sharply in a few states recently.
declined substantially from far higher rates in the One third (10/31) of the states accounted for 96% of
1980s. In some other countries – for example, Zambia the AIDS cases and the major impact has been on
– some signs of lessening impact are being seen in new Maharashtra in the west, Tamil Nadu and Pondichery
generations of young women 23. The declines in urban in the south, and Manipur in the north east 2,3. In
Uganda have followed changes in behaviour; the Manipur most transmission is associated with sharing
deferment of first sexual intercourse and greater use drug injecting equipment, but elsewhere heterosexual
of condoms in casual relationships24. These trends sex accounts for most transmission. HIV was
remain exceptional, however, and elsewhere in east concentrated previously among sex workers and
and central Africa the picture is less optimistic. people attending clinics for STIs but in some areas
The overall prevalence increased in Tanzania and infection is now moving towards a generalised
Kenya between 1994 and 1997 (table 2), while in pattern. In 1996 and 1997 HIV began appearing at
Malawi the prevalence of infection in rural areas has increasing levels in pregnant women: in Maharashtra,
risen, to approach the high levels seen in urban areas5. Chinnai, and Manipur (where very few women inject
Even where prevention has had some effect, situations drugs) a prevalence of 1% to 2% was observed2,3.
where 6% of girls are already HIV infected by the age Trends in HIV transmission remain unclear in
of 16 years (in Zambia 23) or 10% by the age of 20 (in China, although extensive public health surveillance
urban Uganda 22) indicate appreciable transmission. has begun1. Transmission associated with injecting
drug use is common in Yunnan and, although there
South, south east, and east Asia, and the Pacific25,26 are also unconfirmed reports of more generalised
This part of the world illustrates the need for extensive transmission (Liao SS and Detels R, personal
cooperation between countries to prevent HIV communication June 1998), reported levels of risky
transmission 2. The extensive network of social and sexual behaviour are lower than those reported
economic links across the larger ‘golden triangle’ (from elsewhere28,29.
Eastern Mynamar (Burma) to Yunnan (China) and The economic downturn of 1997/8 in South East
including Manipur (India) and the Mekong Delta Asia may exacerbate the situation, perhaps by driving
(Cambodia and Vietnam) makes it more meaningful more young women into the sex industry 1.
to consider the area as a whole than to look at
transmission country by country. Another set of foci Latin America and the Caribbean 30
is the large metropolitan areas in western and southern Sex between men is a far more important route of
India (Mumbai (the former Bombay) and Chinnai). infection in Latin America than in Africa or Asia. HIV
The pattern of infection in this region has been of transmission has stayed more concentrated than
concentrated transmission, but some countries are now generalised, and most new infections are occurring
also experiencing generalised transmission. Large among people who live on the social and economic
epidemics of infection associated with sharing injecting margins of society. The prevalence of HIV infection in
equipment sharing are continuing in Vietnam, Malaysia, pregnant women is low overall, but there have been
Myanmar, and parts of India and China. Extensive some recent isolated increases - for example, in
transmission through heterosexual sex, either on its own Honduras (to 1%) and Porto Alegre, Brazil (to 3%-4%)1,2,5.
or in association with drug injecting has taken place in Brazil is something of an exception as generalised spread
Thailand and Cambodia, parts of India, and perhaps also is taking place in some areas and prevalences in pregnant
China. There are indications that heterosexual women in sum urban areas have risen to over 1%2. In
transmission in Thailand and Cambodia is beginning to 1996 nearly 60% of AIDS cases were attributed to
predominate over transmission associated with injecting heterosexual transmission of HIV, which seems to be
drug use25-27. Use of commercial sex workers by young moving into younger age groups and into small towns
and older men has been a tradition in South East Asia. and rural areas. Only 708 Brazilian municipalities
Sex workers and their regular clients have acted as potent reported AIDS cases in 1987, compared with 2585 in
core groups, with high levels of STIs, which has greatly 1997. In the Andean sub-region (Bolivia, Columbia,
amplified HIV transmission. Peru, and Venezuela) and the ‘southern cone’ (Argentina
This has been the case especially in Cambodia and and Chile) sex between men remains the main mode of
Thailand where ‘high intensity’ sex workers (women transmission1. Heterosexual transmission is common
who have many partners each day) have compounded throughout the Caribbean and there are signs that some
the problem25. The prevalence of HIV infection has islands could be approaching generalised transmission.
remained lower in Indonesia and the Philippines, even This is already the case in Haiti, where the prevalence is
among female sex workers, possibly because their pace remarkably high (8% in pregnant women)5. In Jamaica
of work is less intense. Variation and change is also and Trinidad the overall prevalence in adults is
seen in HIV transmission associated with drug approaching 1%2.


Russia, the Newly Independent States, central

differences exist between racial groups, with prevalences

Asia, and eastern Europe ten or 20 times higher among blacks than whites in some
Intensive screening of populations at low and high risk urban areas. In the same poor inner city areas HIV
in these countries found very small numbers of HIV transmission has become generalised, with prevalence
infections until 199531. Since 1995, however, HIV has rising above 1% among pregnant women1.
spread swiftly among IDUs in cities in the Ukraine, HIV transmission in Canada recently increased
Belarus, Moldova, and the Russian Federation. HIV is from 2500 to 3000 new infections per year from 1989 to
now emerging in the Caucasus, the Baltic States, and 1994 to around 4200 in 1996, an annual rate of 26 per
Kazakstan. Estimates of numbers of HIV infections in 100 000 adults (compared with 8/100 000 in England and
Russia and the NIS have risen from less than 3000 in Wales in the late 1990s)34,35. The rise in Canada has been
1994 to over 190 000 in 19972,31,32. There is considerable attributed to epidemics among IDUs34 . In Europe
potential for further increases as there are large groups transmission through sex between men has on the whole
of impoverished IDUs – for example, in the Moscow area predominated in northern countries while in south
– to which HIV has yet to spread, and job-related western Europe (Portugal, Spain, and Italy) most
migration may make such spread inevitable (V infections have been associated with drug injecting1,35a.
Pokrovsky, personal communication, June 1998). Drug The incidence of AIDS and HIV related mortality
use practices are extremely risky. Equipment used to has fallen in North America, western Europe, and
manufacture opiates is often contaminated with HIV or Australasia since the introduction of highly active
other bloodborne viruses (hepatitis B and C), human antiretroviral therapy (HAART)4. The improvement
blood is added to drug solutions as a cleansing agent, in survival is increasing the prevalence of HIV
and ready-made drugs are sold in used syringes. infection, especially that of people receiving treatment.
Transmission through sex between men is also occurring HAART is expensive, so the total costs of HIV care in
but is underreported because of official intolerance of these countries have increased enormously and will
homosexuality. Little is known about the numbers of probably continue to do so34,36,37.
sex workers and the levels of HIV infection among them,
but the numbers of women involved may have increased
New variants of HIV
due to economic insecurity (V Pokrovsky, personal
Three new groups of recombinant HIV-1 viruses have
communication, June 1998)1. Women from this region
emerged recently in parts of Russia, China, and
have migrated as sex workers to western Europe and
Nigeria38. These are apparently sudden reassortments
the Middle East, and even to China and India1. There is
of previously recognised subtypes, rather than a
concern that concomitant epidemics of syphilis among
gradual evolution of HIV-1. The biological and public
populations at risk will lead to extensive heterosexual
health significance of these recombinants is yet to be
transmission15. So far there is no clear evidence that
assessed, but their emergence and spread requires
transmission is becoming generalised, as the prevalence
close monitoring.
in blood donors and pregnant women is low, and any
increases seen can be explained by infections in IDUs of
both sexes. Effective HIV prevention and prevention
HIV transmission appeared among IDUs in Poland opportunities
and Yugoslavia in the late 1980s. Unlike the NIS there Several countries have been successful in either
has been little evidence in these countries that averting substantial HIV transmission (such as
transmission has intensified in the 1990s and the Senegal, the UK, the Netherlands, and the Nordic
incidence of AIDS remains low. The prevalence of HIV countries) or of reducing previously substantial HIV
infection in IDUs has stayed low in Slovenia, Slovakia, transmission (such as Switzerland, Thailand, and to
and the Czech Republic, but rates of around 10% have some extent Uganda). The common factor linking these
been reported in Poland6. There is only limited evidence countries is centrally supported, multisectoral HIV
of westward spread of the Russian syphilis epidemic15, prevention programmes, with political support39,40. Per
but cases of syphilis associated with transmission in capita spending on HIV prevention has been lower in
Russia have presented in the UK33. the US and Canada than in the UK and Switzerland,
which are having greater success at containing HIV 41.
North America, western Europe, and Australasia Following sustained publicity and much public
Transmission is almost exclusively a concentrated awareness of HIV, however, the US has recently seen
phenomenon in these regions: most HIV infections are improvements in sexual behaviour in its youth42. As the
acquired through sex between men or in association costs of treatment rise the cost-benefit ratio of primary
with injecting drug use (figure 1). In a few countries prevention in well-resourced countries becomes more
(for example, the UK and Belgium) many infections are attractive, making effective sexual health promotion
among immigrant populations, mostly acquired abroad and needle exchanges an even better investment than
in countries where the prevalence is higher. Between before.
400 000 and 650 000 people in the US are HIV infected, It is considered far easier and more cost-effective
of whom probably two thirds are aware of the fact1. to intervene against HIV epidemics at their start before
Similar proportions have been suggested for Canada and transmission becomes intense or generalised 43 .
western European countries 1,34 . In the US great Evidence for this has come from STI intervention trials


FIGURE 6 Projected changes in life expectancy: selected

Thailand and Uganda, although successful in
African countries with high HIV prevalence, 1955-2000 reducing transmission, are left with a massive legacy
of prevalent infections that will burden their care
Average life-expectancy at birth, in years

Botswana services for many years11,27,47.
60 Zimbabwe

Current and future impact
Malawi Mortality
50 Nearly 14 million people are thought to have died
from HIV infection since the pandemic began in the
late 1970s and it is estimated that in 1998 about 2.5
40 million people died because of HIV infection (table 1).
In 1997 HIV was one of the top ten causes of deaths
worldwide and it is likely soon to become one of the
0 top five. In 1998, for the first time, deaths from HIV
1955 60 65 70 75 80 85 90 95 2000
Year exceeded those from malaria2. The extensive early
Source: United Nations Population Division, 1996 spread of HIV in east and central Africa means that
(published in UN AIDS/WHO report on the global HIV/AIDS epidemic - June 1998)
the experience there can be taken to show what will
happen in other resource-poor countries if infection
in east Africa, which have been effective where the reaches high levels (5% to 10% or more). Population
prevalence of HIV infection is rising, but less so where based surveys have shown that death rates among
infection is already widespread in the population 44,45. adults aged 15 to 60 years have doubled in Malawi,
Theoretical work has also suggested that early Tanzania, Uganda, Zambia, and Zimbabwe (figure
interventions should be more successful at preventing 6)10. This will progressively reduce life expectancy in
HIV transmission than if the same resource is applied subSaharan Africa (figure 7). HIV is also increasing
later to reduce an already high HIV incidence 43 . child mortality, undoing improvements in child
Several countries where the prevalence of HIV survival seen in the past 20 years.
infection is currently low but rapidly rising and where One study in Uganda found that HIV was reducing
the incidence of other STIs is high – including average life expectancy by 16 years 48. These effects
Bangladesh, China, India, Nepal, Pakistan, and Russia will next be seen in the next 10 years in southern
– therefore present particular opportunities for Africa. The effect on national and regional
prevention 46. There are other countries where the development will be especially potent because age
prevalence of HIV is already moderate or high but specific mortality rates associated with HIV are
where infection is still spreading into new populations highest among adults at ages when they are at their
and where preventive measures would be a most productive and when they are responsible for
particularly good investment. These include the greatest numbers of elderly and child dependants1,2.
Botswana, Brazil, Cambodia, Kenya, South Africa, and South, South East, and East Asia; the Pacific;
Zimbabwe (table 3). eastern Europe; and Central Asia are only starting to
HIV prevention targeted at new cohorts of young feel the impact of HIV disease and mortality. Even
people remains a good investment in any country before the economic downturn of 1997, secondary
where HIV transmission is substantial. Even in care facilities in Thailand where extensive spread had
countries that have reduced HIV transmission still face arrived earliest were beginning to find it difficult to
substantial problems caring for existing patients. cope with HIV associated morbidity 49. Cambodia
presents a more typical Asian picture, where in late
FIGURE 7 Increase in mortality in men aged 15-60 years,
based on household reports (sibling histories): selected 1997 there were an estimated 120 000 prevalent HIV
African countries, 1986 to 1997 infections but a cumulative AIDS total of less than 10
000. Irrespective of current and future HIV prevention
Probability of dying from all causes (%)

70 1995/96
this picture will change dramatically in the next
60 decade as HIV associated mortality and morbidity
1993 inevitably increase50.

40 1995
1989 1990/91 Orphans
30 1986
The greatest impact of HIV related mortality is among
1990 young adults, often soon after they have become
20 1988
parents. By December 1997 around 8 million children,
10 more than 90% of them in sub-Saharan Africa, had
already lost their mothers prematurely because of HIV
0 (table 1)1. The ability of societies to support orphans
Zimbabwe Tanzania Malawi Uganda Zambia
varies. In the advanced epidemics of east Africa many
Source: Timaeus I, London School of Hygiene and Tropical Medicine, from
Demographic and Health Survey data (published in UN AIDS/WHO report on the communities retain family networks that can sustain
global HIV/AIDS epidemic - June 1998) many children. Such support is less the common in



urban societies or societies with traditions of migrant behaviours, and to monitor key associated diseases
labour. (notably tuberculosis) and mortality among young
It is predicted that where nuclear families are the adults 52 . WHO and UNAIDS have to update
norm (for example, in Thailand), or where prolonged previously published surveillance guides53,54. The
wars have prejudiced family networks (for example, objectives of HIV surveillance need clarifying: there
in Cambodia and Angola), societies will be less able is as yet no systematic global surveillance for HIV
to care for their orphans1. subtypes. Much development work remains to be
done at international, regional, and national levels.
HIV and tuberculosis
Fifty per cent of young adults are already infected with References
Mycobacterium tuberculosis and an estimated 15.3 1. Monitoring the AIDS Pandemic (MAP). The status and trends
million people were infected both with HIV and M. of the HIV/AIDS epidemics in the world. Geneva: MAP, June
tuberculosis by the end of 1997 (nearly 80% of them in 1998.
2. Joint United Nations Programme on AIDS (UNAIDS) and
sub-Saharan Africa) 1. Most HIV negative people the World Health Organization (WHO). Report on the global
infected with M. tuberculosis will not develop disease. HIV/AIDS epidemic June 1998. Geneva: UNAIDS & WHO,
HIV infection is the strongest risk factor for 1998.
progression to active tuberculosis: in areas with a high 3. HIV and STD Division, PHLS Communicable Disease
prevalence of HIV infection, the incidence of Surveillance Centre. Health and population occasional paper:
sexual health and health Care: HIV, AIDS and sexually transmitted
tuberculosis is also rising 1. People dually infected also infections, global epidemiology, impact and prevention. London:
have tuberculosis recurrence rates after treatment that Overseas Development Administration, 1996.
are far higher than for people without HIV infection. 4. UNAIDS and WHO. Report on the global HIV/AIDS epidemic
When the prevalence of HIV infection rises above 10% – update December 1998. Geneva: UNAIDS & WHO, 1998.
in the adult population numbers of tuberculosis cases 5. United States Bureau of the Census. HIV/AIDS surveillance
database, July 1998 release. Washington DC: US Bureau of the
double over what was previously expected. Census, 1998.
Tuberculosis control programmes in some African 6. European Centre for the Epidemiological Monitoring of
countries are close to being overwhelmed. The clinical AIDS. European HIV prevalence database (December 1997
presentation of tuberculosis is less straightforward in update). St Maurice: CESES, December 1998.
people with HIV infection, challenging tuberculosis 7. Mulder DW, Nunn AJ, Kamali A, Nakiyingi, Wagner H-V,
Kengeya-Keyondo J. Two year HIV-1 associated mortality
control programmes with difficulties in diagnosis as in a Uganda rural population. Lancet 1994; 343: 1021-3.
well as by increasing case numbers 51. In 1996 an 8. Chin J, Lwanga SK. Estimation and projection of adult AIDS
estimated 7.4 million people developed tuberculosis, cases: a simple epidemiological model. Bull World Health
more than 80% of whom were in 22 countries, with Organ 1991; 69: 399-406.
India and China together contributing 43%. Clearly 9. Wawer MJ, Serwadda D, Gray RH, Sewankambo N, Li N,
Nalugada F, et al. Trends in HIV-1 prevalence may not reflect
if HIV transmission becomes generalised in Asia there trends in incidence in mature epidemics: data from the Rakai
will be a major impact on tuberculosis incidence. population-based cohort, Uganda. AIDS 1997; 11: 1023-30.
10. Timaeus IM. Impact of the HIV epidemic on mortality in sub-
Future surveillance (‘second generation Saharan Africa: evidence from national surveys and censuses.
In: Carael M, Schwartlander B (editors.) Demographic impact
HIV surveillance’) of AIDS. AIDS 1997; 12 (suppl 1): S15-27.
Numbers of AIDS cases in many resource-poor 11. Stoneburner R, Low-Beer D, Tembo G, Mertens T, Asiimus-
countries are swamping reporting systems while the Okiror G. Human immunodeficiency virus dynamics in East
value of AIDS case reporting in industrialised Africa deduced from surveillance data. Am J Epidemiol 1996;
countries is diminishing because of the effects of the 144: 682-95.
12. UNAIDS and WHO. Report on the global HIV/AIDS epidemic.
use of potent antiretrovirals. In response a number of Geneva: UNAIDS & WHO, December 1997.
counties are developing or enhancing methods for HIV 13. Cohen MS. Sexually transmitted diseases enhance HIV
surveillance – collecting data on the distribution of transmission: no longer a hypothesis. Lancet 1998; 351 (suppl
HIV infection in the population, describing the III): S5-7.
characteristics of those who probably became infected 14. World Health Organization. Preventing HIV transmission in
health facilities. Geneva: WHO, 1995.
recently, and studying the behaviour and 15. Tichonova L, Borisenko K, Ward H, Meheus A, Gromyko A,
sociobiological factors associated with current HIV Renton A. Epidemics of syphilis in the Russian Federation:
transmission. This requires substantial improvement trends, origins and priorities for control. Lancet 1997; 350:
in existing national and international surveillance 210-3.
systems. 16. Des Jarlais DC, Friedman SR. HIV epidemiology among
injecting drug users. Int J STD AIDS 1997; 7 (suppl 2): 57-61.
Industrialised countries are adopting the reporting 17. Madelbrot L, Le Chenadec J, Berrebi A, Bongain A, Benifla J,
of diagnosed HIV infections, if this is not already in Del Fraissy K-L, et al. Perinatal HIV-1 transmission: interaction
place, and relying less on AIDS case reporting alone. between zlodovudine prophylaxsis and made of delivery in
For developing countries UNAIDS and WHO are the French perinatal cohort. JAMA 1998; 280: 55-60.
taking a lead in developing ‘second generation HIV 18. Nicoll A. Antenatal screening for HIV in the UK: what is to
be done? J Med Screen 1998; 5: 170-1.
surveillance’. They are being encouraged to develop 19. Mojenson L. Short-course zidovudine for prevention of
or strengthen unlinked sentinel surveillance of HIV perinatal infection. Lancet 1999; 353: 766-7.
infection, to adopt methods for surveillance of risky 20. WHO. Recommendations on the safe and effective use of



short-course ZDV for prevention of mother-to-child Darlinghurst, Australia: National Centre in HIV
transmission of HIV. Wkly Epidemiol Rec 1998; 73: 313-20. Epidemiology, 1998.
21. MAP. The status and trends of the HIV/AIDS epidemics in sub- 37. Department of Health. HIV/AIDS strategy (report of a
Saharan Africa. Abidjan, Cote d’Ivoire: MAP Network conference). London: DH, 1998.
Workshop, 3-4 December 1997. 38. Goudschmidt J. The significance of virus sub-types for
22. Tarantola D, Schwartlander B. HIV/AIDS epidemics in sub- epidemiology and pathogenesis. 12th World AIDS
Saharan Africa: dynamism, diversity and discrete declines? conference; Geneva, June-July 1998 (presentation No. 486).
AIDS 1997; 11 (suppl B): S5-21. 39. Malcolm A, Dowseth G (editors). Partners in prevention:
23. Fylkesnes K, Musonda RM, Kasumba K, Ndhlovu Z, international case studies of effective health promotion practice
Mluanda F, Kaetano L, et al. The HIV epidemic in Zambia: in HIV/AIDS. Geneva: UNAIDS, 1998.
socio-demographic prevalence patters and indications of 40. Tarantola A, et al. Amounts, patterns and trends of national
trends among childbearing women. AIDS 1997; 11: 339-45. and international financing of the response to HIV/AIDS
24. Musinguzi J, Asiimwe-Okiror G, Opio AA. Sexual behaviour in developing countries. 12th world AIDS conference;
change due to HIV/AIDS results of population based KABP Geneva, June - July 1998 (abs 44232).
surveys conducted in five districts in Uganda. Working 41. Albert T, Williams G. The economic burden of HIV/AIDS in
paper for UNAIDS Best Practice Workshop, Nairobi, Canada (CPRN Study No. H02). Toronto: Canadian Policy
February 1997. Research Networks Inc, 1998.
25. Dore GJ, Brown T, Tarantola D, Kaldor JM. HIV and AIDS 42. CDC. Trends in sexual risk behaviours among high school
in the Asia-Pacific region: an epidemiological overview. students – United States, 1991-7. MMWR Morb Mortal Wkly
AIDS 1998; 12 (suppl B): S1-10. Rep 1998; 47: 749-52.
26. Mills S, Ungchusak K, Srinivasan V, Utomo B, Bennett A. 43. Robinson NJ, Mulder DW, Auvert B, Hayes RJ, Grosskurth
Assessing trends in HIV risk behaviours in Asia. AIDS 1998; H. Modelling the impact of alternative HIV intervention
12 (suppl B): S79-86. strategies in rural Uganda. AIDS 1995; 9: 1263-70.
27. Siriwasin W, Shaffer N, Roongpisuthipong A, Bhiraleus P, 44. Grosskurth H, Mosha F, Todd J, Mwijarubi E, Klokke A,
Chinayon P, Wasi C, et al. HIV prevalence, risk and partner Senkoro K, et al. Impact of improved treatment of sexually
serodiscordance among pregnant women in Bangkok. JAMA transmitted diseases on infection in rural Tanzania:
1998; 280: 49-54. randomised controlled trial. Lancet 1995; 346: 530-6.
28. Liu H, Xie J, Yu W, Song W, Gao Z, May Z, et al. A study of 45. Wawer MJ, Sewankambo NK, Serwadda, Quinn TC, Paxton
sexual behaviour among rural residents of China. J Acquir LA, Kiwanuka N, et al. Control of sexually transmitted
Immune Defic Syndr 1998; 19: 80-8. diseases for AIDS prevention in Uganda: a randomised
29. Cleland J, Ferry B (editors). Sexual behaviour and AIDS in the community trial. Lancet 1999; 252: 525-35.
developing world. London: WHO and Taylor & Francis, 1995. 46. Gerbase A, Rowley J. Heymann D. Global STD estimates.
30. MAP. The status and trends of the HIV/AID/STD epidemics in Sex Transm Dis 1998; 74 (suppl): S12-4.
Latin America and the Caribbean. Rio de Janeiro: MAP 47. Anon. The HIV/AIDS collaboration annual report 1997/8.
Network, 1997. Nonothaburi, Thailand: The HIV/AIDS Collaboration,
31. Gromyko A. Epidemiological trends of HIV/AIDS and other Thailand, 1998.
sexually transmitted diseases in eastern Europe. Copenhagen: 48. Boerma JT, Nunn AJ, Whitworth JAG. Mortality impact of
WHO Europe, 1997. the AIDS epidemic: evidence from community studies in
32. WHO.Working estimates of adult HIV seroprevalence as of less developed countries. In Carael M, Schwartlander B
end 1994. Wkly Epidemiol Rec 1995; 70: 356-7. (editors.) Demographic impact of AIDS. AIDS 1997; 12
33. Ratcliffe L, Nicoll A, Carrington D, Wong H, Eggleston SI, (suppl 1): S3-14.
Lightfoot NF, et al. Reference laboratory surveillance of 49. Surasiengsunk S, Kiranandana S, Wongboonsin K.
syphilis in England and Wales 1994, to 1996. Commun Dis Demographic impact of the HIV epidemic in Thailand. AIDS
Public Health 1998; 1: 14-21. 1998; 12: 775-84.
34. Anon. Estimates of HIV prevalence and incidence in Canada. 50. WHO. STD/HIV/AIDS surveillance report. No 10. Manila:
Ottawa: Bureau of HIV/AIDS and STD, Laboratory Centre Western Pacific Region, October 1997.
for Disease Control, November 1998. 51. Chintu C, Muringa A. An African perspective on the threat
35. Report of a Working Group (Chairman: Professor NE Day) of tuberculosis and HIV/AIDS – can despair be turned to
convened by the Director of the Public Health Laboratory hope? Lancet 1999; 353: 997.
Service on behalf of the Chief Medical Officers. The 52. Schwartlander B. Broadening the tools for public health
incidence and prevalence of AIDS and the prevalence of surveillance 12th world AIDS conference; Geneva, June -
other severe HIV disease in England and Wales for 1995 to July 1998 (presentation No. 193).
1999: projections using data to the end of 1994. Commun Dis 53. World Health Organization Global Programme on AIDS.
Rep CDR Rev 1996: 6: R1-24. Unlinked anonymous screening for the public health surveillance
35a.Hamers FF, Downs AM, Infuso A, Brunet JB. Diversity of of HIV infection. Proposed international guidelines. Geneva:
the HIV/AIDS epidemic in Europe. AIDS 1998; 12 (suppl WHO, 1989.
A): S63-70. 54. Chin J. Public health surveillance of AIDS and HIV
36. Anon. National Centre in HIV Epidemiology annual report. infections. Bull World Health Organ 1990; 68: 529-36.

Weekly Returns Service of the Royal College of

General Practitioners
DM Fleming

Summary: General practitioners in 69 practices in England and Wales monitor Key words:
the spread of epidemic diseases in the community through the Weekly Returns Service communicable diseases
(WRS) of the Royal College of General Practitioners, which has existed for over 30 episode of care
years. Participating general practitioners summarise diagnoses and consultation/ family practice
episode type (new episodes/ongoing consultations) for a defined population morbidity
(currently about 570 000) and data are extracted to provide the ‘weekly return’,
sentinel surveillance
which includes age specific weekly incidence of new episodes of selected illnesses.
The service has been used extensively to measure the burden of influenza and
total acute respiratory illness in the community and the impact of enteric infections.
It also provides information about illnesses for which there are no other major data
sources – for example, chickenpox, scabies, and (historically) mumps.
The entire network is electronically linked. Direct links with microbiological
laboratories are being forged in order to integrate clinical and microbiological data
in defined populations.

Commun Dis Public Health 1999; 2: 96-100.

Introduction over the years and describes how the data are used and
Common infectious illnesses usually have a limited where they can be found.
impact on individuals but because many people contract
them their impact on the population is considerable. On History of the Weekly Returns Service
average less than 1% of the population consult their The WRS evolved from the Epidemic Observation Unit
general practitioners for flu-like illnesses in winter of the College of General Practitioners that was set up in
influenza epidemic periods1, but seroconversion rates 1953 7 . This unit provided a forum for general
in populations suggest that over 10% of the population practitioners interested in the epidemiology of common
may be infected2. Almost everyone suffers influenza at infectious diseases to share experiences about the spread
some time but people do not equate the experience with and impact of conditions diagnosed and treated in their
a risk of death, even though about 25 000 excess deaths practices. The Records Unit of the college (now the
in England and Wales in the winters of 1989/903 and Birmingham Research Unit) set up consistent methods
1996/97 were attributable to influenza4. About 25 deaths of recording and of data capture in order to monitor and
are attributed to chickenpox each year5, yet very few study disease7. At that time, the data were collected
children escape infection before the age of 10 years6. using diagnostic indexes8 and relevant details were
This report describes the Weekly Returns Service extracted each week to provide the ‘weekly return’.
(WRS) of the Royal College of General Practitioners About 20 diagnoses (classified in the College
(RCGP) and discusses its contribution (actual and Classification of Disease, a truncated version of the
potential) to monitoring common illnesses. The service International Classification of Disease (7th Revision))
was set up to serve a sentinel function and to warn were covered. The data were sent by post and
particularly of the emergence of epidemic illnesses. The aggregated at the college’s Birmingham unit.
report shows how recording methods have improved In 1976 additional diseases and health problems were
included in response to specific requests – for example,
DM Fleming, Birmingham Research Unit asthma, duodenal ulcer, and acute myocardial infarction
Royal College of General Practitioners were added either because of their seasonality or because
associations with infection were considered likely. The
Address for correspondence: incidence of new episodes of duodenal ulcer has declined
Douglas Fleming
Royal College of General Practitioners
(figure 1) since Helicobacter pylori has been identified as
Birmingham Research Unit a causal factor and has been treated specifically.
Lordswood House Since the mid 1980s the Birmingham unit responsible
54 Lordswood Road for the WRS has published an annual report of weekly
Harborne incidence data. Previously, reports had been made for
B17 9DB
the Council of the RCGP and for the Department of
tel: 0121 426 1125 Health but these had not included summaries of the data.


FIGURE 1 Duodenal ulcer – mean weekly incidence (per

From 1976 to 1996 selected weekly data were published
routinely in the OPCS Monitor, and the data have been 100 000, all ages) in males and females: 1976 to 1997
used in reviews of specific diseases published by the
PHLS. Weekly data are not currently published 5
routinely, but data that relate to influenza and the
interpretation of epidemic conditions are published by 4

the PHLS Communicable Disease Surveillance Centre.

Since 1994 a quarterly newsletter has been sent to 3

participating practices, which helps them to avoid

recording problems, draws attention to topical issues, 2

and clarifies the use of diagnostic rubrics.


How the WRS works

Reports from the WRS are based on new episodes of 1976 78 80 82 84 86 88 90 92 94 96 98
illness, including ‘first ever diagnoses’. A new episode Year
occurs when a patient presents with what is clearly a
new diagnosis or for advice and treatment for an 450 000 patients is usually available by noon on
exacerbation of pre-existing illness, but not when a Wednesday. Data are thus reported in the week after
patient consults simply for management to be reviewed the patient first consulted, and allocated to diagnoses
or to obtain a repeat prescription. The identification of based on initial clinical impressions. The intention is to
individual episodes is particularly important for provide information at the earliest possible opportunity.
conditions such as asthma, which are influenced by Notifications from other sources are often delayed until
seasonal and environmental factors. diagnoses are confirmed by laboratories and by clerical
Computerisation in general practice in the late 1980s procedures in clinical settings and departments of public
enabled data to be collected about a wider range of health, postal delays, and time taken to check and
illnesses. The discipline of data entry increased as analyse the data.
practices began to record assessment diagnoses and the
types of consultation/episode from every consultation. The need for information from primary care
In 1991, several of the WRS practices contributed to the Many illnesses, including several of importance to public
Fourth National Morbidity Survey in General Practice 9, health, are treated almost exclusively in primary care -
but not all had appropriate computer software. Some for example, common childhood infections, enteric
practices recruited for the survey joined the WRS. The infections, asthma, and epidemic respiratory diseases.
network currently includes 69 practices that care for Information about disease incidence in the community
570 000 people, and some growth is expected as more is therefore vital. Microbiological investigation is
practices become able to communicate electronically. undertaken rarely for most disorders; thus diagnosis in
Data extracts are taken from the practice each primary care is essentially clinical. Statutory
Tuesday night/Wednesday morning and procedures notifications of some clinical diagnoses places the onus
exist to follow up missing data. Practice computerised to notify on the attending physician. Rates of conditions
information systems provide tabular data on numbers treated in primary care ascertained through the WRS are
of patients consulting with diagnostic Read codes and generally higher than those ascertained through
information about the practice population, by age groups statutory notifications. The difference is particularly
and sex. Read codes are mapped to the International noticeable for enteric infections, for which the estimated
Classification of Disease (9th revision) for analysis. A incidence based on the WRS population greatly exceeds
preliminary analysis of data covering the seven days that based on microbiological reports, which in turn
ending on the previous Sunday for a population of exceeds notifications of food poisoning10, defined as ‘any

FIGURE 2 Mumps – mean weekly incidence (per 100 000, all ages) in four week periods: 1967 to 1997

40 MMR vaccine
35 introduced


1967 69 71 73 75 77 79 81 83 85 87 89 91 93 95 97


FIGURE 3 Chickenpox – mean weekly incidence (per 100 000, all ages) in four week periods: 1970 to 1997







1967 69 71 73 75 77 79 81 83 85 87 89 91 93 95 97

disease of an infectious or toxic nature caused by or cycle of mumps activity and patient records were
thought to be caused by consumption of food or water’11. examined to evaluate complications15. The database has
Notifications based exclusively on microbiological since been used to monitor the impact of vaccination16
investigation underestimate the problem because (figure 2). Each bar of the histogram represents the mean
organisms are not necessarily recoverable from stool weekly incidence (all ages) of mumps reported in a four
specimens examined and because many patients consult week period. The combined measles, mumps, and
and provide specimens relatively late in the course of rubella vaccine was introduced in 1988 at a trough in
the illness, or indeed provide no specimen, or do not the natural cycle of incidence of mumps, yet the impact
consult. For the purpose of statutory notification doctors of the vaccination programme was evident within six
are required to notify on suspicion of diagnosis12, but months.
notification is often delayed until a microbiological For chickenpox the WRS also provides important
diagnosis has been made. data17 on which to judge both the need for a vaccination
The timeliness of accurate information is particularly programme and to monitor its impact should it be
important in the surveillance of influenza. Influenza introduced. Incidence varies year by year, usually
activity increases every winter and clinical surveillance peaking in late spring or early summer (figure 3). About
aims to identify its onset and monitor its impact. a fifth of cases are aged 15 years and over.
Virological surveillance complements clinical Monitoring illness in the community identifies
surveillance by identifying and characterising the unrecognised or potentially important health problems
causative organism, and in this we have collaborated that have not been adequately explained. The incidence
with the PHLS Central Public Health Laboratory 13. of acute bronchitis in children aged 0 to 4 years during
Isolates identified in this collaborative project are often the four winters 1993/94 to 1996/97 varied in magnitude
the first to be typed and characterised for antigenic but peaked consistently in week 51 (figure 4), matching
profile. During the winter season of 1996/97, the first the pattern of isolations of respiratory syncytial virus
viruses were identified by sentinel surveillance schemes reported to the PHLS. Acute bronchitis is also a problem
in seven out of the eight European countries in which in elderly people, however, in whom the incidence peaks
they operate, as opposed to other sources14. consistently around the first week of the New Year (figure
Sentinel practice data can be used to evaluate the 5), when the death rate (from all causes) commonly,
need for a vaccine and to monitor its effects. Analysis of though not invariably, reaches its highest level regardless
WRS data for mumps in 1976 revealed a three yearly of ambient temperature18. The causes of acute bronchitis

FIGURE 4 Acute bronchitis – incidence (per 100 000 children aged 0 to 4 years) by week and year compared with
reports of respiratory syncytial virus infection: weeks 45-08 1993 to 1997

1600 1993/94 1994/95 1995/96 1996/97

1400 Isolates






45 48 51 2 5 8 45 48 51 2 5 8 45 48 51 2 5 8 45 48 51 2 5 8


FIGURE 5 Acute bronchitis – incidence (per 100 000, age ≥ 65 years) by week and year compared with total deaths (all

ages): weeks 45-08 1993 to 1997

Incidence Deaths
900 1993/94 1994/95 1995/96 1996/97 25000
800 Deaths
700 Incidence 20000

200 5000
0 0
45 48 51 2 5 8 45 48 51 2 5 8 45 48 51 2 5 8 45 48 51 2 5 8

in elderly people at this time of year are not known. phenomenon. Of additional interest are the actual
Finally there are illnesses for which there are unlikely numbers of peaks and troughs throughout the year and
to be any other sources of data – for example, hand, foot the marked difference in the relative sizes of the peaks
and mouth disease19 and scabies20. in September (weeks 35-39).
The validity of diagnosis in the surveillance
Diagnostic validity population can also be demonstrated using data from
The validity of diagnosis is important in the supplementary investigations in a sample of the
interpretation of morbidity data from whatever source. practices, as illustrated for influenza in figure 7. This
Common illnesses are diagnosed in general practice comparison is particularly telling because of the
within the confines of a consultation of five to ten difficulty of distinguishing influenza clinically from
minutes during an illness that may last only a week. other common viral infections. The link between
Many diagnoses are made without supportive evidence epidemics of flu-like illness and virologically confirmed
from laboratory investigations because the additional influenza has been identified in several European
benefits yielded by a diagnostic test in individual cases surveillance networks21.
often cannot justify the inconvenience for a patient, the Validation usually relies on the existence of a
time involved in taking a specimen and reporting the diagnostic gold standard and these rarely exist. In the
result back to the patient, and the laboratory costs. early days of combined clinical and virological
Within a sentinel network, the concern is more for surveillance for influenza we were content to achieve a
the validity of diagnosis at a population rather than an virus positivity rate of 10% to 15% in specimens
individual level. One approach to validation involves submitted during epidemic periods. Positivity rates
comparing data from differing sources. Figure 6 exceeding 30% are now common and when investigation
contrasts the variation in incidence of new episodes of by polymerase chain reaction is included even higher
asthma reported in the sentinel network in the past ten rates have been achieved. Improvements in the process
years in children aged 5 to 14 years with hospital of investigation (better specimens, sealed tubes, efficient
admissions for the period 1990 to 1994. It shows delivery, improved laboratory techniques) bring as much
synchronous timing in the peaks and troughs, indicating to explaining the clinical syndromes as does greater care
that the two data sources are recognising the same in clinical assessment. Isolating virus in swabs from
FIGURE 6 Asthma in children aged 5 to 14 years – FIGURE 7 Influenza-like illness – incidence (per 100 000,
(percentage variation from average incidence) – new all ages) and virus isolates of influenza in the WRS: winter
episodes reported by the WRS and hospital episodes for of 1996/97
England: 1990 to 1994

120 250 30
wrs Flu A
hes Flu B 25
80 200
% difference

Virus isolates

40 150
0 10
-60 0 0
1 4 8 12 16 20 24 28 32 36 40 44 48 52 38 40 42 44 46 48 50 52 2 4 6 8 10 12 14 16 18 20
Week Week



elderly people is more difficult than in swabs from results through the internet and through PHLS
children, yet influenza vaccination policy is justified publications. WRS data already appear in quarterly
largely by the excess deaths among elderly people during summaries of infectious diseases published as CDR
influenza epidemics that are presumed to be due to Supplements. Direct interaction with our practices to
influenza virus infection3,4. Delayed consultation by obtain additional information will help us to respond to
elderly people may account for the difficulty of isolating specific requests for information.
this virus but, whatever the explanation, it highlights
the difficulty of defining a gold standard for diagnosis. Acknowledgements
Seroconversion might be considered a more secure Many thanks to the practices that participate in the WRS
standard but this implies exposure to an organism rather for their enormous contribution, and to Dr AM Ross for
than illness caused by it. comments on this manuscript. The project is supported
Some sentinel practice networks stipulate criteria for by the Department of Health, which has given
diagnosis, but the WRS has not adopted a rigid position. permission to publish.
If criteria are to be useful they need to be specific, based
on objective evidence rather than reported symptoms, References
and applicable to patients of all ages and at all stages of 1. Fleming DM, Zambon M, Bartelds A, de Jong JC. Duration
and magnitude of influenza epidemics. Eur J Epidemiol (in press).
the disease. Some European surveillance networks use
2. Monto AS, Sullivan KM. Acute respiratory illness in the
a raised temperature as a criterion for diagnosing community. Frequency of illness and the agents involved.
influenza. At the very least this implies that a doctor Epidemiol Infect 1993; 110: 145-60.
cannot diagnose influenza without measuring the 3. Curwen M, Dunnell K, Ashley J. Hidden influenza deaths. BMJ
patient’s temperature, and that the diagnosis cannot be 1990; 300: 896.
4. Dedman DJ, Joseph CA, Zambon M, Fleming DM, Watson JM.
made in a patient once fever has abated. We have
Influenza surveillance in England and Wales: October 1996 to
recently confirmed the diagnosis of pertussis in 49 out June 1997. Commun Dis Rep CDR Rev 1997; 7: R212-9.
of 150 patients with protracted cough, on the basis of 5. Mortality statistics: cause, Series DH2 (1979-1996). London: Office
seroconversion (E Miller, personal communication). The for National Statistics, 1979-1996.
clinical features usually associated with an attack of 6. Preblud SR, Orenstein WA, Bart KJ. Varicella: clinical
manifestations, epidemiology and impact in children. Pediatr
whooping cough, if rigidly applied, would not have
Infect Dis 1984; 3: 505-9.
enabled us to identify these cases. The children with 7. College of General Practitioners Annual Report 1954. (available
pertussis tended to have a milder illness than was seen from the Royal College of General Practitioners, London)
before immunisation was widespread. The elderly 8. Research Unit of the Royal College of General Practitioners.
people diagnosed would not have been recognised at Diagnostic Index. J Roy Coll Gen Pract 1971; 21: 609.
9. McCormick A, Fleming DM, Charlton J (editors). Morbidity
all. The diagnoses were made because we did not use
statistics from general practice; fourth national study 1991-92. Series
strict criteria and because of improvements in the MB5 no.3. London: HMSO 1995.
microbiological tests available. 10. McCormick A. The notification of infectious diseases in England
and Wales. Commun Dis Rep CDR Rev 1993; 3: R19-25.
Quality assurance 11. Djuretic T, Ryan MJ, Fleming DM, Wall PG. Infectious
intestinal disease in elderly people. Commun Dis Rep CDR Rev
Some degree of quality assurance is provided by 1996; 6: R107-12.
comparing information derived from differing sources, 12. Chief Medical Officer. Definition of food poisoning. London:
as was shown above for asthma and influenza. In 1992 Department of Health, 1992 (PL/CMO(92)4).
a regional comparison of the incidence of allergic rhinitis 13. Fleming DM, Chakraverty P, Sadler C, Litton P. Combined
during the pollen season (hay fever) demonstrated internal clinical and virological surveillance of influenza in winters of
1992 and 1993-4. BMJ 1995; 311: 290-1.
consistency 22. We have seen that the annual reporting rate 14. Zambon M. Sentinel surveillance of influenza in Europe, 1997/
for herpes zoster is remarkably consistent. Timely reporting 1998. Eurosurveillance 1998; 3: 29-31.
is an essential ingredient of an effective sentinel network 15. Research Unit of the Royal College of General Practitioners.
and this itself is a measure of quality. It is also relevant The incidence and complications of mumps. J Roy Coll Gen
that even at critical times of the year (for example at Pract 1974; 24: 545-51.
16. Jones AGH, White JM, Begg NT. The impact of MMR vaccine
Christmas and New Year) the weekly report has been on mumps infection in England and Wales. Commun Dis Rep
based on a patient population of 500 000 despite staff CDR Rev 1991; 1: R93-6.
leave and conflicting priorities at such times. 17. Joseph CA, Noah ND. Epidemiology of chickenpox in England
and Wales, 1967-85. BMJ 1988; 296: 673-6.
Latest and future developments 18. Fleming DM, Cross KW, Crombie DL, Lancashire RJ.
During 1998, the data collection system in practices was Respiratory illness and mortality in England and Wales. Eur J
completely automated and we began to gather Epidemiol 1993; 9: 571-6.
19. Bendig JWA, Fleming DM. Epidemiological, virological, and
information from all consultations and not just new clinical features of an epidemic of hand, foot, and mouth disease
episodes. This allows us to report on consultation in England and Wales. Commun Dis Rep CDR Rev 1996; 6: R81-6.
frequencies and opens opportunities to report prevalence 20. Barrett NJ, Morse DL. The resurgence of scabies. Commun Dis
rates based on patients consulting in a year. Methods of Rep CDR Rev 1993; 3: R32-3.
linking routine microbiological data from practices with 21. Fleming DM, Cohen J-M. Experience of European
collaboration in influenza surveillance in the winter of 1993-
clinical incidence material are being developed in 1994. J Public Health Med 1996; 18: 133-42.
collaboration with Professor T Elliott of the University 22. Ross AM, Fleming DM. Incidence of allergic rhinitis in general
Hospital in Birmingham. We plan to disseminate the practice 1982-92. BMJ 1994; 8: 161-76.