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It is important for us to bear it in mind that in 1976 in north America an H1N1 virus circulated. It was not particularly severe. It did not have a clinical attack rate on the scale of that in 1918. Quite properly, the American
Administration at the time developed a vaccine, but in the expectation that the virus would recur in a second wave, in the way it had done in 1918, they vaccinated the whole population, which, as it turned out, was an error; they should not have done so. There were significant side effects. There was not a second wave. Clearly, with the benefit of hindsight, it is clear that the proper public health response would have been to acquire the vaccine—to stockpile it—and then to see whether there was an intimation that a second wave was coming. I hope that the Secretary of State does not dissent from that.
That is not to say that we necessarily know what the strategy needs to be, but it is important that we do not make an assumption at this point about the future profile of the spread of the virus. For that matter, we do not know whether there will be sustained transmission in other countries. Clearly, from Mexico to America, between, it turns out, the middle of February to the middle of April, there were significant opportunities for the virus to spread from Mexico to America, which made it very difficult for the Americans to achieve containment. However, in many other countries, we are achieving containment. If we can continue to do so, we may find that we can delay phase 6 until we have made dramatic progress in the development of a vaccine. That is important to bear in mind.
I confess that this is entirely speculative, but when one looks at the genetic make-up of the virus—as I know will be done, not least in Mill Hill—and compares it to viruses in the past, it is interesting to see that it emerged in north America, and that H1N1 in 1976 was, to some extent, related to the outbreak in 1918 in a very limited way. It is also interesting that in Mexico, the virus has impacted on younger adults. Arguably, it is possible that some older adults in Mexico had some vestigial immunity from exposure to it in 1976. It may or may not bear some genetic relationship to the H1N1 that circulated in 1976, but if it does, that would point to it being less likely to be virulent and severe than was originally feared when it first emerged.
The Secretary of State and I share a view about how to respond to this matter. I score no points on this. The Opposition have raised issues with Ministers on 77 occasions since June 2004, and we have talked to Ministers repeatedly, including the Secretary of State’s predecessors, about the importance of pandemic preparedness—admittedly in the context of H5N1, which would be a major threat. Issues such as the antiviral stockpile, the stockpile of face masks, and the need for critical care capacity and for an advanced purchase contract have all been the subject of our questions to and responses from Ministers.
My only reservation about Britain’s preparedness was that the extension of the antiviral stockpile could have been initiated sooner, rather than when H1N1 emerged in Mexico. Clearly there is the issue with the national flu line, which I asked the Secretary of State about, and the Government would have achieved that sooner had it been possible to do so. As for stockpiling face masks and gloves, the French bought 200 million, from recollection, in about the latter part of 2005, so there is a gap between what we were asking about and what has been achieved. None the less, we are among the best prepared countries in the world, and I will return to what that might mean in terms of our obligations in relation to other countries.
I want to raise about half a dozen points, both to express a view and to see whether the Minister can add anything beyond what the Secretary of State has already said when she replies. The Secretary of State knows the Opposition’s view on vaccine availability, because he has kindly involved us in conversations about it from time to time. By way of a brief detour, I should say we must not get this out of proportion. The Imperial college modelling talked about a central estimate of a 30 per cent. clinical attack rate, and a 0.4 per cent. fatality rate, but that was on a global basis. The virus may spread to a quarter or more of the British population in the longer term, but we have good reasons at the moment—not least because in America there have been just three fatalities compared with more than 3,000 confirmed cases—to hope that the fatality rate in this regard in a developed health economy will be low, and barely more than for seasonal flu. That being the case, it does not suggest that it is in the interests of a country such as Britain for seasonal flu vaccine production to be diverted at this point to pandemic flu vaccine production. Our view, which I expressed to the Secretary of State earlier in the week, is that we would certainly support the continuation of seasonal flu vaccine production, not least because we are probably only about two months away from the point at which, in a normal process, availability its would have been achieved. That gives us the basis on which we could move on towards pandemic vaccine production immediately.
We would support the securing of an additional supply of a vaccine for the novel H1N1 virus on a pre-pandemic basis in parallel with seasonal flu vaccine production if that is possible, as the Secretary of State says. If the seed strain is available in a matter of days, we may infer that, probably by the end of September, supplies of a vaccine would, if necessary, begin to become available for health care workers and others who are most likely to be at risk. The chances are that any second wave would be initiated by an event such as the return of children to school—schools tend to be the so-called super-spreaders and the virus tends to spread faster among young people, meaning that it could be transmitted through the population.
Mr. Syms: In recent years, there has been a lot of emphasis on GP surgeries writing to people on their lists to ask that they be vaccinated from ordinary flu. What advice ought the Government give to GPs about communicating with people who use their surgeries? Should surgeries hold back, or should they go on with the traditional campaign, which has increased the rate of vaccination quite substantially?
Mr. Lansley: I understand my hon. Friend’s point. My answer—I hope the Secretary of State agrees—is that we would normally expect to invite people to come for seasonal flu vaccine in late September or early October, and I see no reason why we should do differently. The period between now and then gives us the opportunity to learn far more about the nature of H1N1 and whom it is likely to impact.
It is important to remember that we may be dealing with very different kinds of flu. Obviously, seasonal flu tends to have an impact particularly on older people, which is why they are summoned for seasonal flu vaccination, but H1N1 has an impact on younger adults,
so by late autumn we may be dealing with different vaccination programmes with different population groups being targeted as priorities.
To be absolutely clear about the use of the antiviral stockpile, I think we agree that for the time being, we are devoted to containment, which requires post-exposure prophylaxis, meaning that everyone who is known to have come into contact with the virus should get the antivirals. We should sustain that for as long as we know that containment stands a chance of success. However, it is important for the public to know something about the trigger for shifting from a strategy of containment to one of mitigation. For example, when we reach 200 cases of seasonal flu per 100,000 population in a week—that is on the Royal College of General Practitioners flu line—we say that the virus is circulating in the community. Are we talking about a similar or a lower number of cases in relation to the novel H1N1 virus? Are we talking about the point at which significant numbers of people are confirmed as having the virus but we cannot identify how they contracted it? What sort of volumes are we talking about? What are the triggers to shift from containment to mitigation?
Once we are in mitigation, I cannot see, given what we know about our access to antivirals now and for the rest of the year, why we should not sustain a policy of household prophylaxis to support families by reducing the impact, and post-exposure prophylaxis for health and social care workers to keep them at work. That will not stop people getting flu, but it may well mean that large numbers of people find they are affected very little. They can then be vaccinated which, in the long run, will reduce the number of people who have to be hospitalised or, indeed, the numbers who die.
The Secretary of State did not talk about school closures, but I should like to inquire whether the Government wish to have a debate on the matter. The Americans have moved quite quickly from a policy of closing a school at the point when a case is confirmed in the school to a policy of not closing schools but carrying on, because the economic detriment is greater than the benefit to be derived from school closure and the virus is now assumed to be circulating generally in the population in America. Those are difficult judgments, because one is balancing, on the one hand, the pace of spread of a virus with a health impact on the population against, on the other, the economic, educational and other impacts of maintaining a policy of school closures. The Americans have chosen the path of stopping automatic school closures quite quickly. Clearly, in our present circumstances, it is right for us to implement school closures where cases are confirmed. The Government’s contingency plan does not contemplate moving away from a closure policy, but given the American experience and the nature of the virus, is it not time for us to think about and discuss such a move?
Mr. Syms: Whose decision is it to close a school? Is it the Department of Health, the chief executive of the local authority, the education authority or an independent body? Who decides and what is the policy?
Mr. Lansley:
The decision is taken by the head teacher and governors of a school, but essentially the head teacher, on the advice of the health protection unit. My
assumption is that if we were experiencing a pandemic involving a virus with very severe effects, it would be possible for local education authorities to take a general decision, which clearly they would do based on advice from the chief medical officer and the Government. However, I do not think that we are contemplating anything of that nature; at present, the decisions are made by schools. I do not anticipate head teachers, where they have a confirmed case and where the health protection unit is pursuing a containment strategy, would do anything other than close the school, for at least a week and perhaps, it could be argued, for a little longer.
I should be grateful for further opportunities to discuss the policy and what the modelling might tell us about the benefits and costs of a different strategy on school closures. The original scientific modelling of a pandemic suggests that a school closure strategy with prophylaxis would have a significant benefit, but of course that modelling related to a virus that probably had more severe effects than the one we are dealing with now.
We have not previously raised this in detail with Ministers, because it seemed premature to do so, but given what the Imperial college modelling suggests about the impact of the virus, I think it is appropriate to do so now. The Americans have a 5 per cent. hospitalisation rate, so although they are handling the virus successfully, not all victims are staying at home. Our critical care capacity compared with that in other countries is therefore an important matter for us. I hope that the Minister of State will be able to tell us what measures the Government have taken to support additional critical care capacity—for example, ensuring additional ventilators are available.
The latest data on adult critical care services in a number of the most developed health economies are found in the Society of Critical Care Medicine’s 2008 study. It sets out the number of adult intensive beds per 100,000 people—that is the relative measure. France has 9.3 per 100,000, Canada 13.5, the Netherlands 8.4, Spain 8.2 and the United Kingdom 3.5. The House will note the apparent substantial disparity in the availability of critical care capacity in this country and in many other countries.
Anyone who has visited critical care units recently will know that they are generally full. The ethical and prioritisation impacts of a pandemic are therefore likely be encountered rather faster in this country than in many others. Fairly quickly, we will have to turn beds that would otherwise be occupied by elective patients into beds where there is some degree of high-dependency support for patients suffering the complications of flu, because we do not have spare capacity in our critical care units.
My last point, which we have discussed during each statement that the Secretary of State has made, is about what we can and should do—alongside our primary responsibility to ensure that Britain is as well prepared as it can be for a pandemic—to support other countries. The Secretary of State will know that the Department for International Development has made additional money available to support the relevant UN unit and £5 million in special support to the World Health Organisation. When the Minister of State, the right hon. Member for Bristol, South (Dawn Primarolo), replies, however, will she say some more about our approach as time goes on, not just as a contributor of financial support to other countries, but in respect of
critical resources, particularly antiviral stockpiles and vaccines, when—later in the year, perhaps—we know that we are relatively secure against the impact of the virus while other countries may be anything but, having neither antivirals nor vaccines, poor surveillance and limited health care resources?
There are relatively few cases in Africa, but the WHO in Africa is already only too aware of the risk. To add to the risk, southern Africa in particular has large immune-compromised populations as a result of HIV. There may come a time, if the virus were to spread as a pandemic, when we have to make tough ethical decisions about the proper use of our stockpiled resources for the greater good, rather than for pure self-interest. I am grateful to the Secretary of State for giving us a further update and enabling a discussion of the issues, and I look forward to the right hon. Lady’s response.
2.52 pm
John McDonnell (Hayes and Harlington) (Lab): I shall briefly raise some constituency concerns about the issue. I must apologise, however, because I am supposed to be chairing another meeting so, although I shall try to return for the ministerial response, if I cannot, I look forward to reading Hansard or any correspondence that I receive.
With Heathrow in my constituency, there is a particular concern about the vulnerability of its staff and the wider community. It is the largest airport in the country, so, naturally, it is potentially the country’s largest entrance point for virus carriers. Concerns have been raised about cabin staff, but the issue goes wider than that, because anyone entering the country will come into contact with other passengers, cabin staff, immigration officers and staff in the wider terminal. Our concerns are that the infection could spread to the wider community and place demands on our local services.
I should welcome information, advice and assurances about the procedures that have been established to deal specifically with ports of entry. In particular, I should like assurances about the dissemination of information to staff, their training to spot the factors that they must consider regarding passengers, including the symptoms that passengers report, and the advice that staff relay to passengers about the actions that they should take. The issue is about ensuring that not just cabin staff, but a wide range of staff are properly informed and advised.
In addition, has there been any consideration about additional protection for staff members at ports of entry? There have been discussions about masks, but it is also important to bear in mind that, apart from health staff and others, staff at airports may need priority vaccination.
I am also concerned to secure assurances about the resourcing of Heathrow’s health unit, because, over the years, I have made representations about its funding. The unit now comes under the Health Protection Agency, and the Government have allocated additional investment over the years, so I hope that we have resolved many of those past complaints. However, there have been some media reports about under-resourcing at the health unit at Heathrow. I would welcome assurances on that and on what discussions and consultations are taking place, particularly with staff at the unit, about the need for additional resources to cater for the virus.
The other issue for me is that if a carrier infects members of staff at Heathrow, they will in turn infect the wider local community. I welcome assurances that the situation is to be specifically monitored in my area. If we find higher incidences of infection there, what resources will there be for the local primary care trust and, in particular, for Hillingdon hospital? Over the years, the hospital has played a vital role in responding to passengers’ health needs as those needs are identified at Heathrow; if a passenger becomes particularly ill, Hillingdon hospital will normally deal with them.
There might, however, be a wider incidence of infection among the local community as a result of Heathrow staff’s vulnerability, so I would welcome information about what discussions have taken place with the primary care trust and Hillingdon hospital trust about planning for that situation and the additional resources required. The issue is not about raising fears and anxieties among the local community, but about reassuring airport workers that their concerns are being taken into account and that plans and consultations are taking place to ensure that they are properly protected. The wider community will also be protected as a result of such efforts.
I am not yet aware of the various structures that have been put in place. The Secretary of State referred to industry discussions; I would welcome further information on those and his assessment of how the industry and the individual companies are responding to their discussions with the Government. I am particularly interested in the response from the local primary care trust and Hillingdon hospital itself. I should like to know about what additional briefings have been provided to my local general practitioners. As I said, I do not mean to raise anxieties, but Heathrow is the largest point of entry so there is a particular vulnerability. I would welcome assurances that the issue was being specifically addressed.
Heathrow has learned lessons from various health incidents, and that has enabled the development of a robust system that has stood the test of time. However, our anxieties about the scale of the potential pandemic mean that we in the local area need to be even more assured that the Government have given attention to Heathrow, its role with regard to the virus and the additional resources which may be required and which the Government are willing to allocate.
2.58 pm
Norman Lamb (North Norfolk) (LD): I start by expressing my appreciation of the fact that this debate is taking place; it is an opportunity to discuss further the development of a potential flu pandemic. I join the hon. Member for South Cambridgeshire (Mr. Lansley) in thanking the Secretary of State for updating us between the debates in Parliament; that is appreciated, and helpful from our point of view. Finally, I pass on my thanks and appreciation to national health service staff—pathology staff, in particular; the hon. Member for South Cambridgeshire also referred to them. They are working beyond the call of duty at the moment, and that is appreciated by all. The Secretary of State gave encouraging news about a pre-pandemic vaccine. That is an encouraging development.
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