Notifiable Diseases

On 12 November, a man travelled to the UK on a small boat across the Channel. On arrival in England, he was taken to Manston processing centre in Kent. On the night of 18 November, he became unwell and was taken to hospital. He died the following morning. The Home Office said there was ‘no evidence’ that he had died of an infectious disease. A week later, a follow-up PCR test came back positive for diphtheria.

Manston was apparently empty on 22 November, but before that it had been housing thousands of people in overcrowded conditions, many for days or weeks. After the Home Office reported a ‘very small number of cases’ of diphtheria at the end of October, I looked at the Notifications of Infectious Diseases (NOIDs) system. It publishes weekly reports of notifiable diseases – the ones medical practitioners have a legal duty to report to public health officers – which include diphtheria. A month ago, the data showed a scattered run of eight cases of diphtheria around England, suggesting they were associated with people who had passed through Manston.

In the UK, babies are protected from diphtheria by three doses of the 6-in-1 vaccine, which covers a range of infectious diseases. But in some countries the disease is endemic. In October, the European Centre for Disease Prevention and Control noted a rise in cases among migrants in Europe. The report emphasised that ‘limiting situations of overcrowding in migrant centres’ was an important control measure. At Manston’s peak occupancy, there were four thousand people in a space meant to hold no more than 1600.

On 11 November, the UK Health Security Agency (UKHSA) published new guidance for the control of diphtheria in ‘asylum seeker accommodation settings’. Faced with the inadequacy of usual approaches for diphtheria arising from sporadic cases, the guidance recommended mass treatment. In ‘high volume reception settings’, everyone would be given a single-shot diphtheria vaccine and a six-day course of the antibiotic azithromycin.

Azithromycin has a global origin story. In 1949 Abelardo Aguilar, a doctor in the Philippines who also worked as a representative for Eli Lilly, sent the US pharmaceutical company a soil sample from a cemetery in Iloilo City. They were able to isolate the antibiotic erythromycin, made by the organism Saccharopolyspora erythraea. Eli Lilly patented it in 1953. Aguilar never received compensation. In the late 1970s in Yugoslavia, a company called Pliva chemically modified erythromycin’s structure to make azithromycin. They patented it in 1981, but it wasn’t until they struck a deal with Pfizer in 1986 that it reached a global market. It’s now on the WHO list of essential medicines and the World Intellectual Property Organisation uses it as a patent success story. MSF and other organisations recommend its use as prophylaxis for close contacts of diphtheria; in effect, everyone at Manston was being treated as a close contact.

Given this, I was surprised that the NOIDs weekly report on 6 November had showed no new cases of diphtheria. The following three reports showed only a single case each week: in Manchester, Eastbourne and Hounslow. But on Sunday the Home Office confirmed around fifty diphtheria cases ‘linked to Manston’. The reason for the huge discrepancy between the NOIDs data and the Home Office figures is that the latter are based on laboratory testing of swabs rather than diagnosis by a doctor. A UKHSA report on diphtheria in asylum seekers was published on Monday. There have been fifty cases this year, most in the last few weeks: 18 in October and 27 in November.

It may seem surprising that there have been so few cases reported through NOIDs. The government has said that Manston had ‘24-7 health facilities’ and ‘trained medical staff’. As the government's own ‘warn and inform’ letter for close contacts explains, ‘when a doctor suspects that someone has diphtheria they must inform the public health authorities.’ Yet doctors apparently haven’t been following this requirement.

This isn’t a new problem. In 1992, when a survey was carried out to see whether GPs and junior doctors knew which diseases were notifiable, diphtheria wasn’t even included on the list. It’s true that diphtheria can be symptomless: 14 of 50 asylum seekers with the disease had no apparent respiratory symptoms. But ‘the majority of cases’ have had ‘cutaneous skin lesions or wounds’. This suggests that medical practitioners in a high-incidence setting for diphtheria, issuing mass prophylaxis for the disease, were not filling out NOIDs forms for suspected cases.

Public health bodies need stability and institutional memory. Their recent history in the UK shows little of either. UKHSA became fully operational in October 2021 as part of reforms to replace Public Health England (PHE). The government had introduced it under a different name, then spent £560,000 on consultants to provide it with a ‘vision and purpose’ – suggesting to some observers that ‘policy makers did not have a clear plan in mind’.

Part of the rationale for replacing PHE was its perceived failures during the early stages of the Covid-19 pandemic. The new agency would supposedly be better at dealing with outbreaks in a globally connected world. PHE itself was a legacy of Andrew Lansley’s reforms and the Health and Social Care Act of 2012, which transferred responsibility for public health from central government to local authorities. Directors of public health are appointed by local authorities and the Home Office has said they ‘work closely’ with local officials.

But one local health director told the Times that public health officials hadn’t been told when people had been sent from Manston to accommodation in their areas, having to find out ‘by accident’ or ‘word of mouth’. In some cases, officials only found out they had asylum seekers in their area ‘when they turned up at A&E complaining of rashes’. The head of the Association of Directors of Public Health, Jim McManus, said the Home Office had ‘rebuffed’ offers of collaboration.

The UKHSA report uses symptom onset to estimate that most of the diphtheria cases among asylum seekers have been contracted ‘along the extended travel route through Europe or at country of origin’. The crisis thus seems to play into the hands of anti-immigrant politicians, despite its being exacerbated by overcrowded conditions that were firmly within the government’s control. The focus is on borders, but public health means what happens within them.

The government has said that ‘Covid-style isolation hotels’ will now be used for anyone entering Manston who presents with diphtheria symptoms. This should have been the bare minimum of a response in early October. Instead, the government delayed looking for appropriate accommodation and engaging the existing public health apparatus. The Home Office didn’t seem to think that an outbreak among asylum seekers was a public health issue. The situation gives clarity to the boundaries of who they think is, and isn’t, a member of the public.