Examination of Witnesses (Questions 1040
- 1059)
WEDNESDAY 24 APRIL 2002
DR PAT
TROOP, DR
DAVID HARPER
AND DR
MARY O'MAHONY
1040. I am not a subscriber to BUPA or any of
the private health services, but are they part of this loop if
you are communicating to hospital trusts? Is there any role for
the private health sector? Please do not construe this as a total
endorsement of the private sector but it is a necessary question
to ask.
(Dr Troop) They are linked in with some of the surveillance
work, because obviously they sometimes pick things up, although
most of their work is elective and not emergency. When people
were asked to look at the capacity within their locality they
obviously looked at the capacity they have in total, including
the private hospitals. If we have an emergency message to get
out, I will ask the local DPH when they get their message to alert
the local private facilities as well. Most of the doctors in those
facilities are also in the NHS, and it is mainly through the medical
staff that the message spreads.
Rachel Squire
1041. Picking up your point about challenges,
Dr Troop, although chemical, biological and radiological attacks
or threats are frequently lumped together, they are in fact very
different in how they would manifest themselves and how they would
be dealt with. So whilst certainly looking at the advantages of
bringing different agencies together into one agency, can you
outline what the current responsibilities are for each of those
areas, and what the proposed responsibilities of the new agency
will be, given the very distinctive nature of each of those areas?
(Dr Troop) I think it would be best if I asked Dr
Harper to respond on radiological and chemical aspects because
they are in his area.
(Dr Harper) The current situation with the radiological
area is that the National Radiological Protection Board plays
this independent role as a statutory basis and provides advice
to various government departments on actions that might be necessary
in the case of an incident that is moving as one of the agencies
into the Health Protection Agency and its functions will be protected
within the new agency. So there is not a substantial change in
terms of the minimum level of functions but what we would be looking
to the new agency to provide is some read-across particularly
in terms of emergency response where there is a horizontal issue
that the radiation area is working very closely with chemical
and with micro-biological. On the chemical side, it is a more
disparate range of activities and currently we have a system in
which the National Focus for Chemical Incidents plays the overarching
national role if there were to be an incident. We have, at a regional
level, provider units in Newcastle, the West Midlands and in London,
also in Cardiff and in Scotland, but as far as England is concerned,
which is the remit of the new agency, in the first place, the
functions of those provider units and the National Focus will
be brought together within the Health Protection Agency. There
is also something called the National Poisons Information Service,
and this provides information primarily to clinicians. It is very
closely linked in terms of the expertise and the information that
is used, but is actually a separate entity. In some parts of the
country it works more closely with the provider unit function,
in other parts it is more distinct. Those are the areas that will
be brought together within the new agency.
1042. The second question is that one of the
proposed functions of the new agency will be to deliver a local
health protection service working with the NHS and local authorities,
involving specific functions relating to the prevention, investigation
and control of infectious diseases, as well as chemical and radiological
hazards. Can you explain how that will operate?
(Dr Troop) At the moment we have people working locally
on these areas. We have consultants in communicable disease control.
We have health emergency planners. Increasingly, those staff have
taken on managing chemical incidents and other emergency aspects
of planning. It was very clear that we needed to develop that
service so that we have people who are trained to cover the whole
range of these kinds of emergencies. They have taken it on, they
have taken on training but we need to make it much more recognised
that we need people with this range of expertise. Also, we found
that some of them were working in a fairly isolated way and without,
we thought, sufficient development. The intention is to draw those
people in and develop their skills but also hopefully to draw
others in to cover that range of emergency from the whole of CBRN
and emergency planning. They will be employed by the Agency but
they will be assigned to work at the local level with the PCTs
so they will still be working side by side with them just as they
do now, with the PCTs, with the trusts, with the Ambulance Service
and so on. There will be, also, a core at the regional level to
support the Regional Director of Public Health to have an overview
of all this planning within each of the regions. They will have
a two way relationship. One, vertically within the Agency so they
are part of a larger body so they will have continuing professional
development and training and expertise to draw on, an opportunity
for careers to move around, and at the same time they will have
a close relationship still with all their colleagues in the NHS
in public health and wider and will have a service level agreement
between the kind of expertise they will provide to support the
response of local bodies. That is how we are working towards it
at the moment. There is a huge amount of discussion with all those
relevant organisations to make sure that what we put in place
meets everybody needs.
1043. No small task.
(Dr Troop) No, but it is very exciting. The overall
response to this has been very exciting. People will see that
we are going to have probably one of the best international infrastructures
for health protection. People from the WHO, for example, have
been very excited and they see this as a model that they hope
a lot of other countries might pick up.
Patrick Mercer
1044. In the interests of time, I had a lengthy
question here about the eight areas in Getting Ahead of the
Curve where further action against bio terrorism threats is
concerned. Could we have a written answer from you on that perhaps?[4]
(Dr Troop) Yes, certainly.
1045. Asking about what steps have been taken
in respect of each of these since the publication of the Report?
(Dr Troop) Yes, of course.
1046. Thank you so much. May I ask a couple
of more specific questions. Under the high clinical awareness
category of one of these eight steps, how are you ensuring that
your message is getting out to doctors and nurses in the National
Health Service? Can I encourage you to be as brief as possible.
(Dr Troop) Yes, I am sorry. The first thing is the
PHLS, as I say we have got detailed guidance on their website
which is pretty comprehensive and they have now put on their training
slides and notes for people to use at the local level to back
that up. Virtually all the Royal Colleges involved have had major
conferences and so on and we have been speaking and other people
have been speaking at all those conferences to make sure there
is an awareness across the country. We have now set up a standing
training committee chaired by our Deputy Director of HRD who will
involve all the relevant professional bodies to try and ensure
that it gets built in to all their normal training programmes
so we have got quite a comprehensive approach to it.
1047. What sort of timetable is there on that?
How much urgency is there?
(Dr Troop) As I say, some of that is in place already.
We first had the group set up in December and now this work is
being taken forward. It will partly depend on how quickly people
get into their various curricula and their training programmes.
There are so many different bodies, we will have to rely on them
to take it through and obviously with encouraging support from
us but to make sure they get it into their training programmes.
1048. That is the bit that worries me, the phrase
"we will have to rely on them". I understand that but
is there any urgency that you can dictate to them?
(Dr Troop) I think there is a sense of urgency amongst
all these people. I think the feedback we get is people want this
in their training, they want this on a routine basis. Therefore,
I do not think there is any lack of willingness for people to
build it into their training programmes. Clearly how they do this,
how they build it into general medical training, they will have
to do it, our role is to encourage and support and make sure they
do it.
1049. I understand.
(Dr Troop) That is why we have set up the mechanism
for that to happen. Meantime, as I say, training materials are
out there for them and the other thing that we can do is produce
a lot of training materials that people can use. There has been
training material produced for clinicians and that is available
on the website now.
1050. Under the elements of both research and/or
surveillance and the improvement of both these aspects, do you
expect to be able to detect the relevant micro bio-organisms before
systems appear?
(Dr Troop) That is where it is very difficult. Perhaps
Mary can answer that because she has done many years in surveillance
and picking up outbreaks.
(Dr O'Mahony) What we are trying to do always in surveillance
is to detect a problem early on. There are different ways that
we can detect it. We can detect it because people have symptoms
and they may or may not go to a health care system. The earliest
warning system that we have put in place, that Dr Troop has already
mentioned, is getting information from NHS Direct where the public
are ringing in, potentially saying "I have a problem, I would
like advice". That information is now being collated to see
if we can pick up any shift in patterns of particular symptoms
being reported. This is a new system and its use was one of the
very early things we did in response to bio-terrorism early alert
systems. The next step when people become unwell is they will
present to primary care, and many GP practices have got established
surveillance systems that we are linking in with. On a practical
level this system is used every winter for early warning for flu
and so alerts the NHS to potential problems be around bed usage.
If people are seen by primary care, they may have a sample taken
and that sample will go to a micro biology laboratory. Surveillance
will pick up that result through the NHS laboratories as well
as the Public Health Laboratory Service. In addition, scans are
taken from newspapers and other reports about softer information
which may be around both in this country and abroad. All of that
information is collected constantly and monitored against background
levels. So what we can say every week is "What is the current
levels of infection" and we compare it with the pattern of
previous years and months to detect anything that is unusual.
That is from routine reporting. What is actually very important
in the health service are phone calls. As Dr Troop mentioned,
people ring up saying CDSC "I have got a patient here I am
concerned about," that is often our best indicator. We have
lots of information that comes constantly from within the health
service; colleagues may also give us information from other Government
bodies, e.g. contaminated water supplies or concerns about illness
in animals that we will take note of. That is constantly underway
and we pick up a number of outbreaks every year from such different
sources which we respond to collectively within the NHS, with
other organisations and other Government agencies.
Chairman
1051. Whole academic careers have been made
on analysis and intelligence failures and when I was listening
to you I could think of all the occasions in history, or many
of them, where all the indicators were there that there would
be an attack and it is at the centre, the receiving analysis,
the will to transmit information to a higher level, where the
failures truly occur. Are you satisfied when all this stuff is
coming up that you have a sophisticated centre that is able to
respond very smoothly because, I do not want you to have to read
in The Times tomorrow to give you an indication of what
might be happening? Is there any technology available—in
fact we know that there is—which might help that process
of collating, analysing and deciding what kind of disease or problem
there might be either locally, regionally or nationally?
(Dr O'Mahony) There is a national system in place
as I mentioned already but it can always be improved. We are constantly
looking within the health service, using the new electronic patient
records that will be introduced in the years to come as encompassing
information from many activities in the health service providing
a key indicator for alerting us. Pulling information together
from many sources, not just the health service alone but other
Government bodies, is going to be very important from the point
of view of chemical, nuclear and biological problems. That is
an area that we want to develop further with other Government
bodies. The new Health Protection Agency is one way because there
we will have one main agency within health that other Government
departments can relate to. For example, if there were to be problems
in Zoonoses, infections in animals which may have the capacity
to transmit to man, and we know that many future problems are
likely to come in this route: we will work in terms of intelligence
gathering with other Government departments is a new area that
we will have to develop further.
(Dr Troop) Can I just say our assessment is that we
have a good surveillance system which is better than many other
countries but in Getting Ahead of the Curve we have identified,
also, that the basis of anything is good surveillance. Therefore,
one of the priorities in Getting Ahead of the Curve is
to get to the frontline technology of this to make sure that we
are the best in this. We are good but, like everybody else, we
could be better.
Patrick Mercer
1052. The foot and mouth outbreak obviously
had lessons to teach everybody, I am thinking particularly about
viruses borne by air rather than an epidemiological approach,
which we have heard about. From the purely military point of view
we seem to be a long way off in detecting airborne viruses. Has
foot and mouth helped? Have you made any particular progress on
that aspect?
(Dr Troop) It was not so much on that aspect. We learnt
a huge amount from the foot and mouth outbreak. Our concern from
a public health point of view was burial of animals and the burning
of animals. Transmission of viruses by air which whilst from the
veterinary point of view was important, from a public health point
of view it was not our big issue. But it is an area where we have
a lot of evidence and experience because many of our pandemics
are because of airborne viruses, not least influenza. I think
a pandemic flu would be as devastating as anything else that we
could have and therefore, not surprisingly, that is where a lot
of research in work has been. We have done quite a lot of modelling
of the transmission of some of these diseases, some of these highly
infectious diseases. We have worked with the Home Office, we have
worked with the MoD to draw on their experience of their work,
their modelling experience, and we have put into that in the civilian
situation some of these diseases and how they might transmit and
how they might transmit through a population. So some of our response
plans are based on that kind of modelling work which has been
done. We are continuing to do that modelling and that will be
a feature again when we move to the new Agency. We are well ahead
compared with many other countries in the sophistication of our
modelling. We are leading a piece of work internationally on that.
There is going to be an international conference on that which
we are leading from the UK.
Patrick Mercer: Your answers are more reassuring
than many we have had. I applaud that. The Royal Society in a
report in July 2000 identified 25 micro-organisms or bacterial
toxins which potentially could be used in a deliberate release.
Against how many of these do you hold effective drugs or vaccines?
Chairman
1053. That might be better responded to in private.
(Dr Troop) We will send you that.
1054. Please.
(Dr Troop) We have got a range of counter-measures
but we will send you some detail.
Chairman: We do not want you to provide too
much information.
Patrick Mercer
1055. What assessment have you made of the risks
from genetically mutated micro-organisms?
(Dr Troop) I think we have done that more in terms
of meningitis and flu than we have anything else. In terms of
the others, I think it might be some information we would send
you. The kind of assessment we have done against different potential
agents is information we will probably send you separately if
you are happy with that?
Patrick Mercer: Thank you very much indeed.
Mr Jones
1056. I have three questions to ask you about
the decision of the Government to acquire a smallpox vaccine stock
for the UK. What I want to do is ask each question, get an answer
and then move on. I know time is getting on. Can you tell me what
was the reason for taking the decision to establish a national
stockpile of smallpox vaccine? In doing that, can I give you some
background as to what this Committee's involvement has been in
this so far. We did a report before Christmas on the threat from
terrorism which was published on 12 December 2001. We took evidence
from the Director of Policy at the MoD, Simon Webb, and also the
Secretary of State. I have just re-read the evidence to see whether
there was any indication there that there was a need for this,
I cannot see that. The Committee did in its report actually draw
attention to possible threats and I will just read it very briefly.
"Although we have seen no evidence that either al Qaida or
other terrorist groups are actively planning to use chemical,
biological and radiological weapons, we can see no reason to believe
that people, who are prepared to fly passenger planes into tower
blocks, would balk at using such weapons. The risk that they will
do so cannot be ignored". Now that is actually in the main
report and with all reports we get a response back from the Government
which we published on 7 March. That is highlighted in paragraphs
20 and 21 of the Government's response. There is no mention in
this at all about acquiring a national stockpile of any biological
agent, let alone smallpox. What has changed since 7 March when
the Government responded to our report?
(Dr Troop) The basis of our planning is based on cross
Government working, being advised that we should be prepared for
the range of threats and the choice of agents against which we
have made an assessment. CDC in Atlanta, the Americans have set
out categories of agents against certain criteria about their
ability to create harm within a population and again also looked
at by the WHO and therefore the counter-measures that we have
developed are against those categories of agents that have identified
in those organisations. The overall general planning that we have
for the different kinds of issues we should plan is based on advice
we receive across Government. We are not the MoD, we are not the
Foreign Office, we are not the Home Office, we do not do the assessment,
our role is to develop the plans in response to an agreed set
of problems.
1057. This is the Government's response, I accept
you are not part of the MoD. Therefore, since 7 March when we
got their response something has obviously changed. When were
you asked to have this as a priority, was it before 7 March?
(Dr Troop) We have had some planning for this, as
you gather, for a number of years, it is not a new issue but at
a pretty low level because of the other emergencies we have talked
about like explosions which were always considered to be a higher
risk. After the sarin attack in Tokyo, people also wanted to be
prepared for a chemical attack. As you know there is a sub-committee
of the CCC which is a CBRN sub-committee and we are part of that.
Therefore, our plans that we have been submitting are through
that process.
Mr Howarth
1058. What is CCC?
(Dr Troop) Sorry, the Civil Contingency Committee,
the Cabinet sub-committee. John Denham from the Home Office has
been chairing the CBRN sub-committee and all Government departments
have been represented on that and all Government departments have
submitted plans to that committee and have been agreed and discussed
within that committee. We are working on this cross Government
basis and as part of that our response as professionals is to
provide the details of the response that might be needed.
Mr Jones
1059. I want to move on. Do you not think it
is strange that if there was a threat in, say, December, Mr Webb
or the Secretary of State did not feel a need to tell us? As the
Chairman quite rightly knows, and we all know, we do take things
in private session so we can be told things on a classified basis
and they do not get into the report. You were involved in this
decision, obviously, when was it actually taken?
(Dr Troop) I am not involved in the decision as to
what the various risks are. As I said, we have been planning for
a range of attacks for a number of years.
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