Examination of Witnesses (Questions 40-59)
PROFESSOR COLIN
BLAKEMORE, DR
ALAN HAY,
PROFESSOR ANDREW
MCMICHAEL
AND PROFESSOR
ANNE JOHNSON
30 NOVEMBER 2005
Q40 Mr Newmark: Yes, I am.
Professor Johnson: Clearly the
pattern of infection in the 1918 outbreak was that of affecting
young people, with less of the infection occurring in the elderly—or
there was a different pattern of infection. There are a number
of theories about why that might have been the case, due to viral
exposure or to the state of the population at the end of the First
World War. There is also information about population movements
at that time, and some of that has been highlighted in historical
data that has been looked at around the 1918 epidemic. So the
emergence of epidemics is, as always, an interaction between the
biology of viruses and the behaviour of populations. One of the
things that I think has been going on is the very difficult problem
of communicating risk to the population in a situation where there
is uncertainty. That is where we find ourselves. Some of you may
have heard Lord May on the Today programme this morning
talking about the problems of communicating uncertainty. In the
field of public health, I think it is essential to communicate
uncertainty. We had to do this in my own area in the context of
the AIDS epidemic in the early 1980s. In that field this country
achieved a great deal by its public education efforts, in achieving
one of the lowest rates of HIV in the world and in achieving quite
remarkable changes in behaviour. You could say that is perhaps
not relevant, but the relevance or the translation of that is
communicating risk to the population. That is what I think is
going on. The preparedness for pandemic flu lies of course in
the hands of the Department of Health and with the Chief Medical
Officer and that aspect of pandemic planning is not directly the
concern of the Medical Research Council. The concern of the MRC
is to ensure that we can contribute by the kind of underpinning
research which could help that. In the field of epidemiology,
we were impressed on our visit to Vietnam and to China at the
efforts that were going on to account for cases, to investigate
them, but there is nevertheless a need to underpin that general
surveillance with a good research programme that understands some
of the questions you are asking. With H5N1 human influenza, there
are just over 130 cases worldwide. That is a very small—thank
goodness—human experience, but it is essential that the
world responds to this in such a way that we understand the clinical
cause of the disease, the people it is affecting, and that we
go a little bit further in the outbreak investigations, to use
active epidemiological techniques—sometimes called "shoe
leather epidemiology"—which is to get out into the
field and look at these outbreaks in greater detail. That may
be very difficult—and when I say "in greater detail"
one has the cases and one finds the individual cases, but it is
the kind of work Dr Hay has been discussing, where one might look
around an outbreak in greater detail, at what is going on in the
human population and the avian population, looking at: Are we
missing milder cases? and so on. Some of that work has been going
on but it could be done in a more systematic way with more research
investment. I think that is really the arena in which the MRC
can contribute.
Q41 Chairman: Do you agree with the
50,000 figure that Sir Liam Donaldson put forward?
Professor Johnson: These figures
have been based on the best estimates from mathematical models
and from an understanding of what went on in the 1918 epidemic.
I must return to this question of uncertainty. If or when—because
pandemics of influenza have occurred throughout history—the
next big flu problem arises—and it may not be H5N1, it may
be another virus—when this transmits between humans, we
cannot be certain about what the clinical course will be, and
we cannot be certain that the high mortality associated with the
current avian-to-human transmissions will be maintained—and
I think Dr Hay will be better able to comment. Precise statements
of what exact number might be the excess mortality—and remember
that we are talking about excess mortality here—is liable
to vary according to those parameters, as we have seen from different
epidemics: the case fatality in the 1918 epidemic was much higher
than it was in the subsequent epidemics in the 1960s and so on.
So there are uncertainties, but those are the best estimates that
have been given to Sir Liam by those who have looked at this in
great detail.
Q42 Chairman: Would you like to comment,
Dr Hay, before we move on?
Dr Hay: I do not have much to
add. I think it was very important that Sir Liam did stress the
seriousness of the situation and what could possibly happen. The
50,000 quote is the lower estimate and is based really on what
happened in the Hong Kong pandemic of 1968.
Q43 Bob Spink: If 55,000 (I think
it was) is the lower estimate, what would be the highest?
Dr Hay: We really do not know.
As Anne has indicated, the course of infection in these patients,
which has been studied in Vietnam and other countries, is different
from the short, acute infection that we normally have from human
flu. Of course the age range affected differs from those that
are non-vulnerable in our community. So there is a lot we do not
know of what would happen and what will happen when the next pandemic
strikes.
Chairman: Moving on now to scientific
advice.
Q44 Adam Afriyie: I must first declare
a personal interest, in that I have a cold virus today, but I
am not going to submit my body to medical research! I am interested
in examining the scientific advice and the process by which the
Government gets that advice and whether or not they use that advice.
My first question is to Professor Blakemore. What role has the
MRC played in advising Government on a strategy in avian flu?
Professor Blakemore: The Government
has a mechanism for soliciting scientific advice. MRC is not a
central part of that mechanism. The mechanism is managed by the
Chief Scientific Advisor, Sir David King, and there are equivalent
Chief Scientific Advisors in many government departments. They
coordinate their activities and their patterns of advice to Government.
They will consult as widely as they need to gain expert information
and we are certainly consulted from time to time. But, for instance,
Sir David King, who is about to leave for China, has asked the
MRC for a briefing on the outcome of our visit there and we are
regularly in contact with Sir David, feeding into the advisory
process.
Q45 Adam Afriyie: Let us say in the
last year, have you as Chief Executive of MRC fed any information
or advice directly to ministers or civil servants or has it all
been via Sir David King?
Professor Blakemore: There have
been discussions with, for instance, colleagues in the Department
of Health, Sir Liam Donaldson and Dr David Harper, who is leading
the Department of Health pandemic flu preparedness programme.
I have, as you have implied, spoken to Sir David King, and certainly
with a wide range of other colleagues. Not with ministers—but
I am quite sure that the information is being coordinated at a
civil servant and ministerial level.
Q46 Chairman: You are quite sure?
Professor Blakemore: Yes, I am
actually. I attended, for instance, a briefing dinner, organised
by Sir Liam, with full representation of government agencies and
very comprehensive discussion and coverage about flu preparedness,
which raised my confidence in the degree of coordination of both
advice and planning across government departments.
Q47 Adam Afriyie: That leads me to
my key question: Has there been a case in the last year or two
years where you feel that the scientific advice that you have
given and the strategic advice that you have given, via whichever
route to government, has not been listened to in full or not been
taken on board in full? If so, what was the situation?
Professor Blakemore: No, I can
think of no such situation. We have been developing our own plans,
as I think I made clear earlier, over the past year, and so have
other government departments. I think it is quite understandable
that the degree of coordination across government should have
been continuously improving during that period of time. One could
not have expected a response to an unusual and unpredictable situation
to have been perfectly planned from the very start, but I think
you can be assured that we are very well joined up now.
Q48 Adam Afriyie: In summary, you
are satisfied that what the MRC have been advising has been fully
taken on board by government in a way that you think is appropriate
and reasonable.
Professor Blakemore: We have not
been giving advice to government directly. That is not our role
in this case. The sort of advice about which presumably government
is most concerned would be coming from the Department of Health
and it would be contingency planning for things like surveillance,
quarantine, restriction of travel, how to deal with schools, plans
in hospitals, distribution of therapeutics and so on. That is
not MRC territory, so there has not been either an avenue or a
need for the MRC to be feeding specific advice into government.
We have been doing our own thing—and, I hope you will agree,
doing it well—and we are well coordinated with all those
other activities across government.
Q49 Chairman: In terms of the research
evidence, your advice must underpin what advice Sir Liam Donaldson
gives. It must underpin the way in which the government goes about,
for instance, issues of buying vaccines and what-have-you. From
this line of questioning, we are trying to get at how joined up
the whole process is. You have not given me, if I am honest, Professor
Blakemore, a reassurance that ministers have a direct track into
the evidence which you provide government.
Professor Blakemore: Then I—
Q50 Chairman: Is that another unfair
comment?
Professor Blakemore: Chairman,
I have obviously failed to convey to you my own confidence in
that process. I can only emphasise that it is not the principal
responsibility of the MRC to be advising government on its flu
strategy. Of course, our research will inform that process. I
should point out that the workshop which we are holding next week
will be attended by representations from the Department of Health,
from the Health Protection Agency, from the other research councils
and so on. The outcome of that discussion will therefore be feeding
into the general process of advice. I have also mentioned that
I participated in the comprehensive dinner discussion organised
by Sir Liam Donaldson, where again there was promulgation of option
and advice. But, of course, advice depends on evidence. While
we have a core of evidence, a bedrock of evidence—and Alan
Hay is a good example of MRC's contribution of that—this
is, as we all know, a changed and evolving situation, so the evidence
will be developing, and the MRC is playing its part in making
sure that we have the evidence that will be necessary in the future.
We have information about the clinical pattern of this disease
and the epidemiological spread of the disease; the identification
of new viral strains; and appropriate—possibly new—ways
to approach development of antiviral drugs and vaccines.
Q51 Dr Iddon: Dr Hay, you have been
saying for a long time that a flu pandemic is an ever present
threat, based on the work you have been doing and the scientific
evidence that you have been collecting. Do you think the Government
has been listening? Or have you felt there has been an uphill
battle to get people to listen in Government circles?
Dr Hay: From my perspective, this
country has always had this major commitment in terms of doing
its bit in monitoring influenza and the changes that occur in
the viruses in terms of a necessity to update vaccines, for example,
and in terms of monitoring for the emergence of another pandemic.
Who should be doing what? If we go back to 1997, far less people
were involved in the question of whether that particular H5N1
might emerge as a pandemic and the communication was much more
on a personal level and we transmitted information and the Chief
Medical Officer called appropriate meetings, etcetera. Now, of
course, we are dealing with a situation which has been around
for almost two years now, where people have become more and more
concerned gradually, a lot more people have become involved and
governments have made comments about it. What has happened over
the past few years is that clearly more and more people have realised
that this threat really might just be round the corner. I do not
think it is so surprising that this has been a gradual learning
process for most people.
Q52 Dr Iddon: The media attention
on this particular virus must have helped your cause.
Dr Hay: I think the media attention
really is important, as in any situation of common interest, to
make people aware of what is going on and to stimulate interest
and action in particular and to get more resources to focus on
the problem at hand, which again is finding out as much as we
can within the region, in South-East Asia, where this is happening,
to put more resources into the WHO in terms of their coordinating
activities and to get more resources as well within various countries
in terms of being prepared to deal with a pandemic when that should
strike.
Q53 Dr Iddon: As Head of the World
Influenza Centre, you must have a special ability to see what
is happening in every leading country which is doing scientific
research in this field. I am particularly interested in the way
that governments use the scientific advice available from people
like you in policy making. Where do you think Britain fits on
the scale? Are we one of the best, are we in the middle or could
we be doing more?
Dr Hay: I think we have been doing
quite well. It is very difficult to plan for something that you
really do not know the characteristics of and people have realised
that this is a difficult task and have put a lot of effort in
to that in many countries and in particular in this country.
Q54 Dr Iddon: You feed information
into the World Health Organisation as well as into our own Government
circles. Is there any difference in the way that you talk to these
two bodies?
Dr Hay: I am probably tied in
closer with the World Health Organisation, the international network,
than within the national networks since that clearly is our prime
role. I think it is important to realise that the WHO plays an
extremely important role in collating information and providing
advice. This was evident at the time of the SARS emergency. It
was the existence of the WHO influenza network that actually made
it possible to monitor the development and spread of that particular
infection. As you will recall, it was the WHO that was providing
mainly information and recommendations regarding travel, etcetera.
It is really wrong not to realise the impact of the international
recommendations and information from the WHO. It is crucial in
terms of how the Government would respond to what was happening.
Q55 Dr Iddon: Are you saying that
perhaps the World Health Organisation in advising our Government
has more clout than if you have advised them directly?
Dr Hay: Certainly. The advice
from the WHO is usually made on the basis of communal consultation
which I am very often part of.
Q56 Dr Iddon: Could you ever see
a situation where the World Health Organisation and our own Government
would reach a disagreement, and what do you think should happen
if they did?
Dr Hay: I guess our Government
has to decide what it wants to do.
Chairman: That is a very diplomatic answer.
Q57 Bob Spink: I wanted to address
the area of what we do if we get a pandemic, how we approach that
and so on, focusing on vaccine development and manufacture and
distribution if vaccines are scarce. First of all, we understand
from Dr John Wood of the NIBSC and his evidence to the House of
Lords Select Committee that the Government has got a stockpile
of the H5N1 vaccine. Is that just a placebo, a PR exercise or
could it be genuinely useful?
Dr Hay: I think it certainly could
be genuinely useful in terms of vaccinating key workers who are
at the frontline and most likely to be infected in an initial
exposure of this country to a pandemic.
Q58 Bob Spink: What is the probability
that that vaccine would reduce mortality and morbidity? Can you
put a figure on that?
Dr Hay: We really cannot. If it
is an H5N1 virus, we do not know the characteristics of that virus
yet. We know, for example, that the viruses which have infected
people in Indonesia are distinguishable from the viruses that
have been infecting most of the people in Vietnam. The experimental
lots of vaccines that have been produced to date are based on
the Vietnamese virus, so we do not know how effective that vaccine
would be against the Indonesian virus, but we can be sure that
it would provide some reasonable level of protection, probably
at least to minimise the death rate. It is very important to have
at least something in your arsenal to use in the event of a spread
to this country.
Q59 Bob Spink: I would like to look
at the timescales now. There are two stages. The first one is
identifying the strain and developing a vaccine once a pandemic
starts and then there is manufacturing that vaccine. Based on
the evidence given to the House of Lords Select Committee, it
seems that identifying the strain and the development of the vaccine
stage would take about 10 or 11 weeks and that the manufacture
stage would take about five or six months. Does that seem reasonable
to you? Is that achievable?
Dr Hay: Yes. The timelines vary
somewhat depending on who one is talking to. Clearly in five or
six months' time the manufacturer might be able to make the first
lots of vaccine in less time than that. All we can say is it will
be done as quickly as possible, but a vaccine will not be produced
in any significant amounts ahead of the actual pandemic being
initiated and us knowing what the characteristics of the viruses
are.
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