Examination of Witnesses (Questions 20-39)
PROFESSOR COLIN
BLAKEMORE, DR
ALAN HAY,
PROFESSOR ANDREW
MCMICHAEL
AND PROFESSOR
ANNE JOHNSON
30 NOVEMBER 2005
Q20 Chairman: Okay. Professor Blakemore,
we understand you signed a memorandum of understanding with your
Chinese counterparts in the Academy of Sciences. What was the
significance of that? What does it actually mean in practice?
Professor Blakemore: There are
more memoranda of understanding than there are—
Q21 Chairman: There seem to be a
lot of them about.
Professor Blakemore: Exactly.
I was making exactly that point, Chairman. A memorandum of understanding
does not guarantee research collaboration but it is usually a
necessary condition for such collaboration. It is an expression
of intent and I think you can see from Professor McMichael's comments
that the intent is certainly there in the case of China, with
several plans which are rapidly evolving. We have already made
a commitment that part of the new funding will be used specifically
for an exchange programme with China. Could I add, Chairman, that
we hope to increase our collaboration with Chinese scientists,
not only in the area of emerging infectious disease but other
areas too. So the memoranda of understanding—there were
two of them—will underpin those wider collaborations.
Q22 Chairman: Given that this is
an issue which affects the whole of Europe as well, were there
similar moves from European research councils going out to China
and Vietnam as well at the same time?
Professor Blakemore: I turn to
my colleagues, in case they know of them. I am not sure. I think
we can be confident that every research active government around
the world and agency around the world is thinking about interactions.
I should mention that the Pasteur Institute, based in Paris, France,
has already established a research facility, a Pasteur Institute
in China, in Shanghai, and presumably that is the basis of their
interest in emerging and infectious disease in China. But there
could be other collaborations that I do not know about. I could
perhaps mention the United States—
Q23 Chairman: Just trying to follow
my line, are we simply continuing to duplicate across the whole
of Europe, given that we have now seen cases in Romania in terms
of avian activity there, diseased birds.
Professor Blakemore: There are,
I think, more opportunities for joining up the reactions of agencies.
But we would all be criticised if we had not acted as quickly
as we could and I think we need to move towards joining up internationally
what we do. Could I point out that I will be going to China again
in three weeks time for a meeting of a committee of heads of international
biomedical research organisations, and of course infectious disease,
and especially flu, is a large element of the agenda for that
meeting. The heads of agencies from all around the world, from
Europe, Australia, North America, China will be able to compare
notes and strategies on their approach to avian flu.
Chairman: We will return to this in a
second.
Q24 Mr Newmark: Did you take the
opportunity to gather information about surveillance and avian
flu in China? How reliable are the statistics relating to avian
flu that we have from China?
Professor McMichael: The surveillance
in birds comes mostly from Harbin. Alan Hay knows a lot more about
that than I do, because I was not on the Harbin branch of the
visit. Surveillance in humans, Anne may be able to comment on.
While we were there, there were two possible cases identified
or reported in the media. Indeed, we could not meet the Chinese
Centre for Disease Control because they had all gone out to look
at those. Subsequently, there were three cases confirmed in China
as human cases—the first three.
Q25 Mr Newmark: Are you concerned
that the Chinese authorities seem to have performed a u-turn regarding
recent human cases of avian influenza in the Hunan province?
Professor McMichael: We do not
know it was a u-turn. Those are the cases I was referring to.
They were cautious initially, but they subsequently agreed. One
of them, the girl, was cremated, and there was no scientific data.
On her brother, that was confirmed as a positive case.
Q26 Mr Newmark: My next question
is to Dr Hay. Given that you said in December 1997 that ".
. . surveillance in China is a real problem. We have to think
of beefing up monitoring there . . ." do you think this visit
was a case of too little too late?
Dr Hay: I think it is important
to recognise that the MRC has had a long-term commitment to international
collaboration in influenza via the World Influenza Centre that
was established in 1948. We have continued to collaborate since
then. The WHO global influenza programme now comprises four international
collaborating centres, of which we are one, and some 120 national
influenza centres in countries scattered around the world, including
an influenza centre in Beijing and a recently established national
influenza centre in Hanoi. The response in 1997 was much more
low-key than it has been recently, for obvious reasons—well,
not so obvious—but we dealt with it in the same way then
as we do now, as a response to an emergency which is coordinated
by the WHO, and we play a full part in this. The research which
we do at the National Institute for Medical Research relates to
much of our interests in the WHO influenza centre.
Q27 Chairman: Are you satisfied,
in answer to Brooks' question, that the surveillance in China
is now of an appropriate order? Because that is not the impression
you gave, Dr Hay.
Dr Hay: The interaction could
clearly be better in terms of information transfer. The WHO, together
with ourselves, established an animal influenza network—around
2002, I think it was—in relation to an international project
which included Hong Kong, in fact, and this helped to spark the
establishment of this particular network which was focused on
avian human influenza in South East Asia. This small network included
the Harbin laboratory, which is the national centre for avian
influenza in China. So we were able to learn the extent of this
network, and that in fact the surveillance in birds in China is
really quite good; it is just: How much do we learn about what
is going on? Clearly the information we get is less than we would
like. Certainly, in terms of the human cases in China, this is
also an issue, but, as you know, recently the Chinese authorities
have invited the WHO to send a team into work together with Chinese
medical scientists to evaluate the suspected cases of H5N1 and
to evaluate whether there is more extensive infection within China.
Q28 Dr Iddon: We are dealing with
three difficult problems here. First of all, the World Health
Organisation only announced laboratory confirmed cases of this
disease.
Dr Hay: Certainly.
Q29 Dr Iddon: Secondly, we are dealing
in South Eastern Asia with some very remote areas. Thirdly, of
course you have already implied that there may also be some political
difficulties, in that countries like China, for example, might
not want to announce the real truth. My real question is: Do you
really have an accurate picture of avian flu in that part of the
world because of those three difficulties?
Dr Hay: We really rely very heavily
on the WHO to coordinate the activities and acquire as much information
as we can. This is why, in confirming cases, it is important that
we have really accurate information on that. There has been a
considerable concern, particularly in Vietnam, that there would
be much more widespread H5N1 infection in people, even at a sub-clinical
level. A lot of the people involved are working flat out all the
time, but there has been probably a difficulty in getting specimens,
in terms of doing sero-surveillance, for example, to evaluate
accurately the extent of the possible spread. But the information
that is available to date, which has been acquired with the assistance
of WHO and shared with the group that is involved in monitoring
H5N1 viruses, which includes our own laboratory, is that there
is no evidence of extensive infections, very extensive infections.
But much of this information we have, of course, is not necessarily
published.
Q30 Mr Newmark: Reading between the
lines—and I am not trying to put words into your mouth—notwithstanding
the series of facts that we have set out as to surveillance, what
is happening there and how you are beefing up monitoring, the
reality is that the Chinese are the gatekeepers of the flow of
much of the information, which means we are very reliant on what
they choose to give us. And, while there has been some improvement
towards an independent monitoring of what is happening there,
it is still relatively poor.
Dr Hay: Yes, we are reliant on
the goodwill of people to provide information about issues in
which we are interested. This pertains not simply to countries
of Eastern Asia but also to European countries. It is very important
to remember that the crisis at the moment is a crisis in poultry.
We are dealing with an avian virus that has caused widespread
outbreaks in poultry in these regions which has been devastating
for various reasons, whether for commercial reasons or more at
the family level in terms of people's livelihoods, and this is
an agricultural-veterinary problem. On the human cases—there
have been relatively few, as you know, sporadic human cases—we
want to know as much as possible. But getting information on what
is happening in the poultry populations in other countries, in
Russia, Romania, et cetera, all takes time as well. We again are
dependent on people providing that information. We cannot go in
and demand it.
Q31 Bob Spink: Is it not a fact that
once you get the mutation, so that you get a true human-to-human
pandemic developing, it will be so infectious and virulent that
we will find out pretty damn quick, because, given air travel,
people will start to go down around the world? There is no way
they are going to be able to hide when this virus mutates, if
that is what it does. Is that not so?
Dr Hay: That is true. That is
why there is tremendous effort going into analysing as many viruses
as possible, from birds and from people, to detect as early as
we can any changes that appear to be occurring which might influence
the ability of the virus to infect and transmit between people.
A lot of information is being collected. As I say, it s not widely
publicised. There is a group of H5 reference labs, coordinated
by the WHO, and we are collecting as much information as we can
and sharing that information. Based on the information we have,
WHO continues at time to make available relevant conclusions regarding
the information. So we have quite a lot of information on bird
viruses and a lot of information on the human viruses and the
interrelationship between these. Of course we would like to have
more information.
Q32 Chairman: You have given an extra
£0.5 million to WHO in terms of surveillance. That seems
to be a drop in the ocean, if you do not mind me saying so. Do
we need to spend more in that area? You have not mentioned surveillance,
for instance, in places like Cambodia and Indonesia, where it
is even less sophisticated than in significant parts of China.
Dr Hay: That is right. The surveillance
in those parts of the world has been relatively poor compared
with in many other parts. There are other parts of the world,
such as India also where surveillance has been very poor. So there
are many black holes in the WHO network. The WHO has been aware
of this and has been trying to increase surveillance in these
areas over the past few years with a global agenda which it established
some years ago. The United States certainly has put a lot of money
into improving surveillance in South East Asian countries, and,
as you say, the Department of Health has made a contribution also
in this respect. So a lot is being done and WHO tries to take
a coordinating role and a proactive role in stimulating increased
surveillance and increased interaction.
Chairman: Thank you, Dr Hay. We are going
to move on now to risk.
Q33 Dr Iddon: I am wondering if there
is any real way of estimating the current risk of avian flu on
the worldwide population but more importantly to our own citizens
in this country.
Dr Hay: That is very difficult.
Really we do not know what it will take for this virus to become
established in the human population. We are also keeping our eye
on other viruses. The focus on H5N1 is because it is a very nasty
virus, a very virulent virus for people as well as for birds.
The contrast, to some extent, was when there was the outbreak
in the Netherlands in 2003 which caused some 90-odd cases of conjunctivitis
and we did not take a lot of notice until there was one that nearly
died of the infection. A lot of the interest is because of the
virulence of this virus and the mortality associated with it,
but there are other viruses out there that have caused human infections
that we know about and which actually have some characteristics
which suggest they may be more likely than H5N1 to cause the next
pandemic. We are keeping an eye on all these aspects. There is
quite a lot of work going on in the background with regard to
the development of strains of virus that it would be appropriate
for making a vaccine against, not only H5 but some of these other
viruses, should it prove necessary.
Q34 Dr Iddon: When the virus was
isolated in Turkey and Romania, did that cause a greater level
of risk with our own population in Britain, do you think?
Dr Hay: I do not think so, not
directly, because I think the risk still is certainly very much
focused in South East Asia. However, it does expand the area,
increasing the number of outbreaks in poultry, and of course there
is a greater risk of infection to the local population and in
particular those who are culling poultry. But the risk in terms
of the virus changing to a human virus is still focused in South
East Asia. I think also the implications of the spread of the
viruses to Europe and the potential spread to Africa raise real
concerns.
Dr Iddon: When does the level of risk
start to ring real alarm bells in the Department of Health and
the world? Is it when we see the first case of avian-to-human
transmitted disease? Will we start to get very excited by that,
or would we wait until human-to-human transmission became a real
possibility?
Q35 Chairman: Specifically in the
UK.
Dr Hay: It is very difficult to
look specifically at the UK. Flu is an international disease.
The MRC treats it as such. That is our perspective. In terms of
the UK, having plans in place to deal with the pandemic goes back
quite some way, to a time when they were one of very few countries
that had such a plan. They have been increasing the detailed aspects
of this plan over recent years and are well recognised to have
one of the best developed plans, and much of what is done in this
country by the Department of Health through the HPA is recognised
as an example of how other European countries should be developing
plans and other countries around the world. But, once again, the
WHO has developed key plans, provides assistance to anyone who
wishes to develop plans, and has had many meetings on these subjects
over the last couple of years and even more. The whole thing was
stimulated in 1997. It was not simply that we had a resurgence
of interest in 2004: the interest in developing, being more prepared
to combat a pandemic, has really been going on since 1997.
Q36 Dr Iddon: How do you see the
media having handled the topic of avian influenza? Do you think
they have panicked the general population? Do you think they have
overdone the risk of a pandemic or not?
Dr Hay: I think in terms of the
media it is difficult, whether it is the media that does it or
people's response to it. If you focus on the fact that there have
been 130-odd cases confirmed and half of those have been fatal,
this is something which some people would find extremely worrying
and concerning. Others may view it that this is largely an avian
disease: there have been a few, sporadic human cases and the chance
of it spreading within the human population is probably remote.
This is the difficulty of taking a very objective view of what
the risk really is. I think it is understandable that some people
will get very concerned; other people probably will not take much
notice. Certainly it has been unfortunate that people have identified
the normal annual flu vaccine to protect people against flu this
winter to be of any use against this H5 virus and that people
would go and get vaccinated for that purpose. I think that sort
of message is very unfortunate.
Professor Johnson: If I could
add a comment about media coverage. I think this is a classical
example of the divergence of practice in the media. We are all
aware of the screaming sensationalism of some of the front page
headlines about risk which certainly generated some panic and
irrational behaviour. On the other hand, as is so often the case,
if you were to turn to the science pages you would find informative
and very valuable coverage of the nature of flu and pandemics
and historical experience—which I do think will have helped
to raise public awareness. This is a more general issue, but I
think the media in this country is paradoxical, in the sense that
they have some of the best science journalists in the world and,
frankly, some of the worst news-desk coverage of issues that involve
science. I think the public is certainly more informed about the
issue now. That has generated some difficulties in behaviour—particularly
the run on seasonal flu vaccinations and private sources of Tamiflu
(the antiviral) and so on—but actually in the long-run I
think we will see that the little episode of media coverage will
have helped to keep the public informed.
Q37 Bob Spink: Do you think the Chief
Scientist's intervention in this was helpful? Do you think he
was accurate in saying that this virus is likely to mutate human-to-human;
that that is highly likely to happen at some stage; and that when
that happens we will be looking at 55,000 deaths in this country
as a result of that? Do you think that was helpful? Do you think
the media acted responsibly reporting that? Do you think that
helped to cause a shortage of the current flu vaccine for those
who are frail and vulnerable, who need that vaccine now and are
being denied that vaccine?
Professor Johnson: Perhaps I could
respond first to that, Chairman. I think you are referring to
Sir Liam, the Chief Medical Officer.
Q38 Bob Spink: Yes, I am.
Professor Johnson: I think you
have accurately reported what he said and I do not think one can
fault what he said, that there is a probability of this virus
mutating or recombining in a way that could cause a pandemic,
that if there were a pandemic then we would have to be predicting
considerable fatality, given the case fatality for the present
infections of H5N1 at approximately 50% (given the historical
record of case fatalities for the 1918 pandemic, which was a very
similar virus according to the analysis done at the National Institute
of Medical Research). So we have to be prepared. This is all guesswork
at this stage, but certainly it is not unreasonable to think in
terms of thousands or tens of thousands of people dying. 250,000
I think died in the 1918 outbreak in this country. I think the
Chief Medical Officer would have been criticised for being complacent
if we faced this year—and let us hope it is not this year,
next, or in the future—a pandemic with high case fatality
if he had not pointed out that possibility.
Chairman: Could we ask Dr Hay and Professor
Johnson to comment on that question as well, please.
Mr Newmark: Maybe as something to think
about while they are answering, Chairman: my colleague referred
to the frail and vulnerable as the people that we should be caring
about, but actually, it is more likely the robust and healthy,
like my colleague here and I ,who are more likely, as I understand,
to be affected by this than either very young people or very old
people. Is that true or not true?
Q39 Bob Spink: Perhaps I might explain
that I was referring to the frail and vulnerable in respect of
the current flu risk, not H5N1.
Dr Hay: This is an interesting
point, Mr Newmark, and perhaps Professor Johnson could comment.
I think you are probably referring to the pattern of infection
in the 1918 outbreak.
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