The global impact of HIV infection and disease

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

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

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

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

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

Mixed
Within the same country both
patterns existing in different regions

Uncertain
Low prevalence at present, unclear
if moving to generalised transmission

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

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 TABLE 3 Impact of HIV – by country (more than 500 000 HIV infections, an adult (15 to 49 years) HIV prevalence of
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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)
vary many hundred-fold and even within sub-Saharan
African countries prevalences differ by a factor of 20 (table
2)2. Countries that are heavily affected, where either more
than 500 000 infected people live or where the prevalence
exceeds 1%, or is rising swiftly, are listed in table 3.
Another important difference between countries is
the occurrence of ‘concentrated’ and ‘generalised’
patterns of transmission(figure 1). Transmission is said
to be concentrated where the infection is endemic but
occurs mostly among vulnerable groups such as men
who have sex with men (through unprotected anal
intercourse) and injecting drug users (IDUs; through
sharing injecting equipment). Examples would be the
countries of western Europe, North America,
Australasia, and most parts of Latin America. In a few
of these counties, deprived and/or marginalised
populations (homosexual men, IDUs, commercial sex

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

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.

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

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)

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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
8
Gauteng
HIV prevalence (%)
HIV prevalence (%)

Eastern Cape
20
6

15
4
10
2
5

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)

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(figure 5)2. The situation in Nigeria, the most populous
country in Africa, remains unclear.
Turning to east African countries, the prevalence
of HIV infection in women under 25 years of age
attending urban antenatal centres in Uganda has been
falling since 1994 11,22, indicating that transmission has
declined substantially from far higher rates in the
1980s. In some other countries – for example, Zambia
– some signs of lessening impact are being seen in new
generations of young women 23. The declines in urban
Uganda have followed changes in behaviour; the
deferment of first sexual intercourse and greater use
of condoms in casual relationships24. These trends
remain exceptional, however, and elsewhere in east
and central Africa the picture is less optimistic.
The overall prevalence increased in Tanzania and
Kenya between 1994 and 1997 (table 2), while in
Malawi the prevalence of infection in rural areas has
risen, to approach the high levels seen in urban areas5.
Even where prevention has had some effect, situations
where 6% of girls are already HIV infected by the age
of 16 years (in Zambia 23) or 10% by the age of 20 (in
urban Uganda 22) indicate appreciable transmission.
South, south east, and east Asia, and the Pacific25,26
This part of the world illustrates the need for extensive
cooperation between countries to prevent HIV
transmission 2. The extensive network of social and
economic links across the larger ‘golden triangle’ (from
Eastern Mynamar (Burma) to Yunnan (China) and
including Manipur (India) and the Mekong Delta
(Cambodia and Vietnam) makes it more meaningful
to consider the area as a whole than to look at
transmission country by country. Another set of foci
is the large metropolitan areas in western and southern
India (Mumbai (the former Bombay) and Chinnai).
The pattern of infection in this region has been of
concentrated transmission, but some countries are now
also experiencing generalised transmission. Large
epidemics of infection associated with sharing injecting
equipment sharing are continuing in Vietnam, Malaysia,
Myanmar, and parts of India and China. Extensive
transmission through heterosexual sex, either on its own
or in association with drug injecting has taken place in
Thailand and Cambodia, parts of India, and perhaps also
China. There are indications that heterosexual
transmission in Thailand and Cambodia is beginning to
predominate over transmission associated with injecting
drug use25-27. Use of commercial sex workers by young
and older men has been a tradition in South East Asia.
Sex workers and their regular clients have acted as potent
core groups, with high levels of STIs, which has greatly
amplified HIV transmission.
This has been the case especially in Cambodia and
Thailand where ‘high intensity’ sex workers (women
who have many partners each day) have compounded
the problem25. The prevalence of HIV infection has
remained lower in Indonesia and the Philippines, even
among female sex workers, possibly because their pace
of work is less intense. Variation and change is also
seen in HIV transmission associated with drug
COMMUNICABLE DISEASE AND PUBLIC HEALTH
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injecting. For example, southern areas of Vietnam are
more highly affected than the north and there is
evidence of a recent resurgence of infection through
injecting in Thailand 25,26.
In India infection levels and transmission are
known to have risen sharply in a few states recently.
One third (10/31) of the states accounted for 96% of
the AIDS cases and the major impact has been on
Maharashtra in the west, Tamil Nadu and Pondichery
in the south, and Manipur in the north east 2,3. In
Manipur most transmission is associated with sharing
drug injecting equipment, but elsewhere heterosexual
sex accounts for most transmission. HIV was
concentrated previously among sex workers and
people attending clinics for STIs but in some areas
infection is now moving towards a generalised
pattern. In 1996 and 1997 HIV began appearing at
increasing levels in pregnant women: in Maharashtra,
Chinnai, and Manipur (where very few women inject
drugs) a prevalence of 1% to 2% was observed2,3.
Trends in HIV transmission remain unclear in
China, although extensive public health surveillance
has begun1. Transmission associated with injecting
drug use is common in Yunnan and, although there
are also unconfirmed reports of more generalised
transmission (Liao SS and Detels R, personal
communication June 1998), reported levels of risky
sexual behaviour are lower than those reported
elsewhere28,29.
The economic downturn of 1997/8 in South East
Asia may exacerbate the situation, perhaps by driving
more young women into the sex industry 1.
Latin America and the Caribbean 30
Sex between men is a far more important route of
infection in Latin America than in Africa or Asia. HIV
transmission has stayed more concentrated than
generalised, and most new infections are occurring
among people who live on the social and economic
margins of society. The prevalence of HIV infection in
pregnant women is low overall, but there have been
some recent isolated increases - for example, in
Honduras (to 1%) and Porto Alegre, Brazil (to 3%-4%)1,2,5.
Brazil is something of an exception as generalised spread
is taking place in some areas and prevalences in pregnant
women in sum urban areas have risen to over 1%2. In
1996 nearly 60% of AIDS cases were attributed to
heterosexual transmission of HIV, which seems to be
moving into younger age groups and into small towns
and rural areas. Only 708 Brazilian municipalities
reported AIDS cases in 1987, compared with 2585 in
1997. In the Andean sub-region (Bolivia, Columbia,
Peru, and Venezuela) and the ‘southern cone’ (Argentina
and Chile) sex between men remains the main mode of
transmission1. Heterosexual transmission is common
throughout the Caribbean and there are signs that some
islands could be approaching generalised transmission.
This is already the case in Haiti, where the prevalence is
remarkably high (8% in pregnant women)5. In Jamaica
and Trinidad the overall prevalence in adults is
approaching 1%2.
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 Russia, the Newly Independent States, central
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Asia, and eastern Europe
Intensive screening of populations at low and high risk
in these countries found very small numbers of HIV
infections until 199531. Since 1995, however, HIV has
spread swiftly among IDUs in cities in the Ukraine,
Belarus, Moldova, and the Russian Federation. HIV is
now emerging in the Caucasus, the Baltic States, and
Kazakstan. Estimates of numbers of HIV infections in
Russia and the NIS have risen from less than 3000 in
1994 to over 190 000 in 19972,31,32. There is considerable
potential for further increases as there are large groups
of impoverished IDUs – for example, in the Moscow area
– to which HIV has yet to spread, and job-related
migration may make such spread inevitable (V
Pokrovsky, personal communication, June 1998). Drug
use practices are extremely risky. Equipment used to
manufacture opiates is often contaminated with HIV or
other bloodborne viruses (hepatitis B and C), human
blood is added to drug solutions as a cleansing agent,
and ready-made drugs are sold in used syringes.
Transmission through sex between men is also occurring
but is underreported because of official intolerance of
homosexuality. Little is known about the numbers of
sex workers and the levels of HIV infection among them,
but the numbers of women involved may have increased
due to economic insecurity (V Pokrovsky, personal
communication, June 1998)1. Women from this region
have migrated as sex workers to western Europe and
the Middle East, and even to China and India1. There is
concern that concomitant epidemics of syphilis among
populations at risk will lead to extensive heterosexual
transmission15. So far there is no clear evidence that
transmission is becoming generalised, as the prevalence
in blood donors and pregnant women is low, and any
increases seen can be explained by infections in IDUs of
both sexes.
HIV transmission appeared among IDUs in Poland
and Yugoslavia in the late 1980s. Unlike the NIS there
has been little evidence in these countries that
transmission has intensified in the 1990s and the
incidence of AIDS remains low. The prevalence of HIV
infection in IDUs has stayed low in Slovenia, Slovakia,
and the Czech Republic, but rates of around 10% have
been reported in Poland6. There is only limited evidence
of westward spread of the Russian syphilis epidemic15,
but cases of syphilis associated with transmission in
Russia have presented in the UK33.
North America, western Europe, and Australasia
Transmission is almost exclusively a concentrated
phenomenon in these regions: most HIV infections are
acquired through sex between men or in association
with injecting drug use (figure 1). In a few countries
(for example, the UK and Belgium) many infections are
among immigrant populations, mostly acquired abroad
in countries where the prevalence is higher. Between
400 000 and 650 000 people in the US are HIV infected,
of whom probably two thirds are aware of the fact1.
Similar proportions have been suggested for Canada and
western European countries 1,34 . In the US great
92 VOL 2 NO 2 JUNE 1999
differences exist between racial groups, with prevalences
ten or 20 times higher among blacks than whites in some
urban areas. In the same poor inner city areas HIV
transmission has become generalised, with prevalence
rising above 1% among pregnant women1.
HIV transmission in Canada recently increased
from 2500 to 3000 new infections per year from 1989 to
1994 to around 4200 in 1996, an annual rate of 26 per
100 000 adults (compared with 8/100 000 in England and
Wales in the late 1990s)34,35. The rise in Canada has been
attributed to epidemics among IDUs34 . In Europe
transmission through sex between men has on the whole
predominated in northern countries while in south
western Europe (Portugal, Spain, and Italy) most
infections have been associated with drug injecting1,35a.
The incidence of AIDS and HIV related mortality
has fallen in North America, western Europe, and
Australasia since the introduction of highly active
antiretroviral therapy (HAART)4. The improvement
in survival is increasing the prevalence of HIV
infection, especially that of people receiving treatment.
HAART is expensive, so the total costs of HIV care in
these countries have increased enormously and will
probably continue to do so34,36,37.
New variants of HIV
Three new groups of recombinant HIV-1 viruses have
emerged recently in parts of Russia, China, and
Nigeria38. These are apparently sudden reassortments
of previously recognised subtypes, rather than a
gradual evolution of HIV-1. The biological and public
health significance of these recombinants is yet to be
assessed, but their emergence and spread requires
close monitoring.
Effective HIV prevention and prevention
opportunities
Several countries have been successful in either
averting substantial HIV transmission (such as
Senegal, the UK, the Netherlands, and the Nordic
countries) or of reducing previously substantial HIV
transmission (such as Switzerland, Thailand, and to
some extent Uganda). The common factor linking these
countries is centrally supported, multisectoral HIV
prevention programmes, with political support39,40. Per
capita spending on HIV prevention has been lower in
the US and Canada than in the UK and Switzerland,
which are having greater success at containing HIV 41.
Following sustained publicity and much public
awareness of HIV, however, the US has recently seen
improvements in sexual behaviour in its youth42. As the
costs of treatment rise the cost-benefit ratio of primary
prevention in well-resourced countries becomes more
attractive, making effective sexual health promotion
and needle exchanges an even better investment than
before.
It is considered far easier and more cost-effective
to intervene against HIV epidemics at their start before
transmission becomes intense or generalised 43 .
Evidence for this has come from STI intervention trials
COMMUNICABLE DISEASE AND PUBLIC HEALTH
FIGURE 6 Projected changes in life expectancy: selected
African countries with high HIV prevalence, 1955-2000
Average life-expectancy at birth, in years
65
60
55
50
45
40
35
0 top five. In 1998, for the first time, deaths from HIV
1955 60
Source: United Nations Population Division, 1996
(published in UN AIDS/WHO report on the global HIV/AIDS epidemic - June 1998)
in east Africa, which have been effective where the
prevalence of HIV infection is rising, but less so where
infection is already widespread in the population 44,45.
Theoretical work has also suggested that early
interventions should be more successful at preventing
HIV transmission than if the same resource is applied
later to reduce an already high HIV incidence 43 .
Several countries where the prevalence of HIV
infection is currently low but rapidly rising and where
the incidence of other STIs is high – including
Bangladesh, China, India, Nepal, Pakistan, and Russia
– therefore present particular opportunities for
prevention 46. There are other countries where the
prevalence of HIV is already moderate or high but
where infection is still spreading into new populations
and where preventive measures would be a
particularly good investment. These include
Botswana, Brazil, Cambodia, Kenya, South Africa, and
Zimbabwe (table 3).
HIV prevention targeted at new cohorts of young
people remains a good investment in any country
where HIV transmission is substantial. Even in
countries that have reduced HIV transmission still face
substantial problems caring for existing patients.
FIGURE 7 Increase in mortality in men aged 15-60 years,
based on household reports (sibling histories): selected
African countries, 1986 to 1997
Probability of dying from all causes (%)
70
60
1993
50
40
30
20 1988
10
0 (table 1)1. The ability of societies to support orphans
Zimbabwe
Source: Timaeus I, London School of Hygiene and Tropical Medicine, from
Demographic and Health Survey data (published in UN AIDS/WHO report on the
global HIV/AIDS epidemic - June 1998)
COMMUNICABLE DISEASE AND PUBLIC HEALTH
reviews
Thailand and Uganda, although successful in
reducing transmission, are left with a massive legacy
of prevalent infections that will burden their care
Botswana services for many years11,27,47.
Zimbabwe
Zambia
Uganda
Current and future impact
Malawi Mortality
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
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
65 70 75 80 85 90 95 2000
Year exceeded those from malaria2. The extensive early
spread of HIV in east and central Africa means that
the experience there can be taken to show what will
happen in other resource-poor countries if infection
reaches high levels (5% to 10% or more). Population
based surveys have shown that death rates among
adults aged 15 to 60 years have doubled in Malawi,
Tanzania, Uganda, Zambia, and Zimbabwe (figure
6)10. This will progressively reduce life expectancy in
subSaharan Africa (figure 7). HIV is also increasing
child mortality, undoing improvements in child
survival seen in the past 20 years.
One study in Uganda found that HIV was reducing
average life expectancy by 16 years 48. These effects
will next be seen in the next 10 years in southern
Africa. The effect on national and regional
development will be especially potent because age
specific mortality rates associated with HIV are
highest among adults at ages when they are at their
most productive and when they are responsible for
the greatest numbers of elderly and child dependants1,2.
South, South East, and East Asia; the Pacific;
eastern Europe; and Central Asia are only starting to
feel the impact of HIV disease and mortality. Even
before the economic downturn of 1997, secondary
care facilities in Thailand where extensive spread had
arrived earliest were beginning to find it difficult to
cope with HIV associated morbidity 49. Cambodia
presents a more typical Asian picture, where in late
1997 there were an estimated 120 000 prevalent HIV
infections but a cumulative AIDS total of less than 10
000. Irrespective of current and future HIV prevention
1995/96
this picture will change dramatically in the next
decade as HIV associated mortality and morbidity
1994
inevitably increase50.
1995
1991
1989 1990/91 Orphans
1986
The greatest impact of HIV related mortality is among
1990 young adults, often soon after they have become
parents. By December 1997 around 8 million children,
more than 90% of them in sub-Saharan Africa, had
already lost their mothers prematurely because of HIV
Tanzania Malawi Uganda Zambia
varies. In the advanced epidemics of east Africa many
communities retain family networks that can sustain
many children. Such support is less the common in
VOL 2 NO 2 JUNE 1999 93
reviews
urban societies or societies with traditions of migrant
labour.
It is predicted that where nuclear families are the
norm (for example, in Thailand), or where prolonged
wars have prejudiced family networks (for example,
in Cambodia and Angola), societies will be less able
to care for their orphans1.
HIV and tuberculosis
Fifty per cent of young adults are already infected with
Mycobacterium tuberculosis and an estimated 15.3
million people were infected both with HIV and M.
tuberculosis by the end of 1997 (nearly 80% of them in
sub-Saharan Africa) 1. Most HIV negative people
infected with M. tuberculosis will not develop disease.
HIV infection is the strongest risk factor for
progression to active tuberculosis: in areas with a high
prevalence of HIV infection, the incidence of
tuberculosis is also rising 1. People dually infected also
have tuberculosis recurrence rates after treatment that
are far higher than for people without HIV infection.
When the prevalence of HIV infection rises above 10%
in the adult population numbers of tuberculosis cases
double over what was previously expected.
Tuberculosis control programmes in some African
countries are close to being overwhelmed. The clinical
presentation of tuberculosis is less straightforward in
people with HIV infection, challenging tuberculosis
control programmes with difficulties in diagnosis as
well as by increasing case numbers 51. In 1996 an
estimated 7.4 million people developed tuberculosis,
more than 80% of whom were in 22 countries, with
India and China together contributing 43%. Clearly
if HIV transmission becomes generalised in Asia there
will be a major impact on tuberculosis incidence.
Future surveillance (‘second generation
HIV surveillance’)
Numbers of AIDS cases in many resource-poor
countries are swamping reporting systems while the
value of AIDS case reporting in industrialised
countries is diminishing because of the effects of the
use of potent antiretrovirals. In response a number of
counties are developing or enhancing methods for HIV
surveillance – collecting data on the distribution of
HIV infection in the population, describing the
characteristics of those who probably became infected
recently, and studying the behaviour and
sociobiological factors associated with current HIV
transmission. This requires substantial improvement
in existing national and international surveillance
systems.
Industrialised countries are adopting the reporting
of diagnosed HIV infections, if this is not already in
place, and relying less on AIDS case reporting alone.
For developing countries UNAIDS and WHO are
taking a lead in developing ‘second generation HIV
surveillance’. They are being encouraged to develop
or strengthen unlinked sentinel surveillance of HIV
infection, to adopt methods for surveillance of risky
94 VOL 2 NO 2 JUNE 1999
behaviours, and to monitor key associated diseases
(notably tuberculosis) and mortality among young
adults 52 . WHO and UNAIDS have to update
previously published surveillance guides53,54. The
objectives of HIV surveillance need clarifying: there
is as yet no systematic global surveillance for HIV
subtypes. Much development work remains to be
done at international, regional, and national levels.
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23. Fylkesnes K, Musonda RM, Kasumba K, Ndhlovu Z,
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24. Musinguzi J, Asiimwe-Okiror G, Opio AA. Sexual behaviour
change due to HIV/AIDS results of population based KABP
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27. Siriwasin W, Shaffer N, Roongpisuthipong A, Bhiraleus P,
Chinayon P, Wasi C, et al. HIV prevalence, risk and partner
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28. Liu H, Xie J, Yu W, Song W, Gao Z, May Z, et al. A study of
sexual behaviour among rural residents of China. J Acquir
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29. Cleland J, Ferry B (editors). Sexual behaviour and AIDS in the
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Latin America and the Caribbean. Rio de Janeiro: MAP
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31. Gromyko A. Epidemiological trends of HIV/AIDS and other
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WHO Europe, 1997.
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in HIV/AIDS. Geneva: UNAIDS, 1998.
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and international financing of the response to HIV/AIDS
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43. Robinson NJ, Mulder DW, Auvert B, Hayes RJ, Grosskurth
H. Modelling the impact of alternative HIV intervention
strategies in rural Uganda. AIDS 1995; 9: 1263-70.
44. Grosskurth H, Mosha F, Todd J, Mwijarubi E, Klokke A,
Senkoro K, et al. Impact of improved treatment of sexually
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45. Wawer MJ, Sewankambo NK, Serwadda, Quinn TC, Paxton
LA, Kiwanuka N, et al. Control of sexually transmitted
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46. Gerbase A, Rowley J. Heymann D. Global STD estimates.
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Nonothaburi, Thailand: The HIV/AIDS Collaboration,
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the AIDS epidemic: evidence from community studies in
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(editors.) Demographic impact of AIDS. AIDS 1997; 12
(suppl 1): S3-14.
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Demographic impact of the HIV epidemic in Thailand. AIDS
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of tuberculosis and HIV/AIDS – can despair be turned to
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VOL 2 NO 2 JUNE 1999 95
reviews

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

96 VOL 2 NO 2 JUNE 1999 COMMUNICABLE DISEASE AND PUBLIC HEALTH

 FIGURE 1 Duodenal ulcer – mean weekly incidence (per

reviews
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
Male
routinely, but data that relate to influenza and the
Female
interpretation of epidemic conditions are published by 4

the PHLS Communicable Disease Surveillance Centre.

Incidence
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.

1

How the WRS works

Reports from the WRS are based on new episodes of
illness, including ‘first ever diagnoses’. A new episode
occurs when a patient presents with what is clearly a
new diagnosis or for advice and treatment for an
exacerbation of pre-existing illness, but not when a
patient consults simply for management to be reviewed
or to obtain a repeat prescription. The identification of
individual episodes is particularly important for
conditions such as asthma, which are influenced by
seasonal and environmental factors.
Computerisation in general practice in the late 1980s
enabled data to be collected about a wider range of
illnesses. The discipline of data entry increased as
practices began to record assessment diagnoses and the
types of consultation/episode from every consultation.
In 1991, several of the WRS practices contributed to the
Fourth National Morbidity Survey in General Practice 9,
but not all had appropriate computer software. Some
practices recruited for the survey joined the WRS. The
network currently includes 69 practices that care for
570 000 people, and some growth is expected as more
practices become able to communicate electronically.
Data extracts are taken from the practice each
Tuesday night/Wednesday morning and procedures
exist to follow up missing data. Practice computerised
information systems provide tabular data on numbers
of patients consulting with diagnostic Read codes and
information about the practice population, by age groups
and sex. Read codes are mapped to the International
Classification of Disease (9th revision) for analysis. A
preliminary analysis of data covering the seven days
ending on the previous Sunday for a population of
0
1976 78 80 82 84 86 88 90 92 94 96 98
Year
450 000 patients is usually available by noon on
Wednesday. Data are thus reported in the week after
the patient first consulted, and allocated to diagnoses
based on initial clinical impressions. The intention is to
provide information at the earliest possible opportunity.
Notifications from other sources are often delayed until
diagnoses are confirmed by laboratories and by clerical
procedures in clinical settings and departments of public
health, postal delays, and time taken to check and
analyse the data.
The need for information from primary care
Many illnesses, including several of importance to public
health, are treated almost exclusively in primary care -
for example, common childhood infections, enteric
infections, asthma, and epidemic respiratory diseases.
Information about disease incidence in the community
is therefore vital. Microbiological investigation is
undertaken rarely for most disorders; thus diagnosis in
primary care is essentially clinical. Statutory
notifications of some clinical diagnoses places the onus
to notify on the attending physician. Rates of conditions
treated in primary care ascertained through the WRS are
generally higher than those ascertained through
statutory notifications. The difference is particularly
noticeable for enteric infections, for which the estimated
incidence based on the WRS population greatly exceeds
that based on microbiological reports, which in turn
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

45
40 MMR vaccine
35 introduced

30
Incidence

25
20
15
10
5
0
1967 69 71 73 75 77 79 81 83 85 87 89 91 93 95 97
Year

COMMUNICABLE DISEASE AND PUBLIC HEALTH VOL 2 NO 2 JUNE 1999 97

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

35

30

25
Incidence

20

15

10

0
1967 69 71 73 75 77 79 81 83 85 87 89 91 93 95 97
Year

disease of an infectious or toxic nature caused by or
thought to be caused by consumption of food or water’11.
Notifications based exclusively on microbiological
investigation underestimate the problem because
organisms are not necessarily recoverable from stool
specimens examined and because many patients consult
and provide specimens relatively late in the course of
the illness, or indeed provide no specimen, or do not
consult. For the purpose of statutory notification doctors
are required to notify on suspicion of diagnosis12, but
notification is often delayed until a microbiological
diagnosis has been made.
The timeliness of accurate information is particularly
important in the surveillance of influenza. Influenza
activity increases every winter and clinical surveillance
aims to identify its onset and monitor its impact.
Virological surveillance complements clinical
surveillance by identifying and characterising the
causative organism, and in this we have collaborated
with the PHLS Central Public Health Laboratory 13.
Isolates identified in this collaborative project are often
the first to be typed and characterised for antigenic
profile. During the winter season of 1996/97, the first
viruses were identified by sentinel surveillance schemes
in seven out of the eight European countries in which
they operate, as opposed to other sources14.
Sentinel practice data can be used to evaluate the
need for a vaccine and to monitor its effects. Analysis of
WRS data for mumps in 1976 revealed a three yearly
cycle of mumps activity and patient records were
examined to evaluate complications15. The database has
since been used to monitor the impact of vaccination16
(figure 2). Each bar of the histogram represents the mean
weekly incidence (all ages) of mumps reported in a four
week period. The combined measles, mumps, and
rubella vaccine was introduced in 1988 at a trough in
the natural cycle of incidence of mumps, yet the impact
of the vaccination programme was evident within six
months.
For chickenpox the WRS also provides important
data17 on which to judge both the need for a vaccination
programme and to monitor its impact should it be
introduced. Incidence varies year by year, usually
peaking in late spring or early summer (figure 3). About
a fifth of cases are aged 15 years and over.
Monitoring illness in the community identifies
unrecognised or potentially important health problems
that have not been adequately explained. The incidence
of acute bronchitis in children aged 0 to 4 years during
the four winters 1993/94 to 1996/97 varied in magnitude
but peaked consistently in week 51 (figure 4), matching
the pattern of isolations of respiratory syncytial virus
reported to the PHLS. Acute bronchitis is also a problem
in elderly people, however, in whom the incidence peaks
consistently around the first week of the New Year (figure
5), when the death rate (from all causes) commonly,
though not invariably, reaches its highest level regardless
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
Incidence
1200

1000

800

600

400

200

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
Week

98 VOL 2 NO 2 JUNE 1999 COMMUNICABLE DISEASE AND PUBLIC HEALTH

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

reviews
ages): weeks 45-08 1993 to 1997

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

600
15000
500
400
10000
300
200 5000
100
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
Week

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

120 250 30
wrs Flu A
100
hes Flu B 25
80 200
Incidence
60
% difference

20
Virus isolates
Incidence

40 150
15
20
100
0 10
-20
50
5
-40
-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

COMMUNICABLE DISEASE AND PUBLIC HEALTH VOL 2 NO 2 JUNE 1999 99

reviews
elderly people is more difficult than in swabs from
children, yet influenza vaccination policy is justified
largely by the excess deaths among elderly people during
influenza epidemics that are presumed to be due to
influenza virus infection3,4. Delayed consultation by
elderly people may account for the difficulty of isolating
this virus but, whatever the explanation, it highlights
the difficulty of defining a gold standard for diagnosis.
Seroconversion might be considered a more secure
standard but this implies exposure to an organism rather
than illness caused by it.
Some sentinel practice networks stipulate criteria for
diagnosis, but the WRS has not adopted a rigid position.
If criteria are to be useful they need to be specific, based
on objective evidence rather than reported symptoms,
and applicable to patients of all ages and at all stages of
the disease. Some European surveillance networks use
a raised temperature as a criterion for diagnosing
influenza. At the very least this implies that a doctor
cannot diagnose influenza without measuring the
patient’s temperature, and that the diagnosis cannot be
made in a patient once fever has abated. We have
recently confirmed the diagnosis of pertussis in 49 out
of 150 patients with protracted cough, on the basis of
seroconversion (E Miller, personal communication). The
clinical features usually associated with an attack of
whooping cough, if rigidly applied, would not have
enabled us to identify these cases. The children with
pertussis tended to have a milder illness than was seen
before immunisation was widespread. The elderly
people diagnosed would not have been recognised at
all. The diagnoses were made because we did not use
strict criteria and because of improvements in the
microbiological tests available.
Quality assurance
Some degree of quality assurance is provided by
comparing information derived from differing sources,
as was shown above for asthma and influenza. In 1992
a regional comparison of the incidence of allergic rhinitis
during the pollen season (hay fever) demonstrated internal
consistency 22. We have seen that the annual reporting rate
for herpes zoster is remarkably consistent. Timely reporting
is an essential ingredient of an effective sentinel network
and this itself is a measure of quality. It is also relevant
that even at critical times of the year (for example at
Christmas and New Year) the weekly report has been
based on a patient population of 500 000 despite staff
leave and conflicting priorities at such times.
Latest and future developments
During 1998, the data collection system in practices was
completely automated and we began to gather
information from all consultations and not just new
episodes. This allows us to report on consultation
frequencies and opens opportunities to report prevalence
rates based on patients consulting in a year. Methods of
linking routine microbiological data from practices with
clinical incidence material are being developed in
collaboration with Professor T Elliott of the University
Hospital in Birmingham. We plan to disseminate the
100 VOL 2 NO 2 JUNE 1999
results through the internet and through PHLS
publications. WRS data already appear in quarterly
summaries of infectious diseases published as CDR
Supplements. Direct interaction with our practices to
obtain additional information will help us to respond to
specific requests for information.
Acknowledgements
Many thanks to the practices that participate in the WRS
for their enormous contribution, and to Dr AM Ross for
comments on this manuscript. The project is supported
by the Department of Health, which has given
permission to publish.
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