Science in emergencies: UK lessons from Ebola Contents

Conclusions and recommendations

Increasing the UK’s preparedness for major disease outbreaks

1.The rapid transmission of disease surveillance data to those with the ability to interpret and act upon it is a vital component of disease control. In its absence, we have seen, in the case of Ebola, how quickly an outbreak can spread and the devastation it can cause. The lines of reporting of surveillance data must, therefore, be clear and well-understood by those involved to ensure a co-ordinated and timely escalation. We are not convinced that the systems in place for interpreting, sharing and escalating disease surveillance data across the Government operated effectively during the early stages of the Ebola outbreak. (Paragraph 15)

2.We recommend that the Government sets out, in its response to this report, how surveillance data is escalated, both within Public Health England and across Government, and identify the triggers that would prompt warnings to reach ministers and senior officials with the capacity to act. We also ask for an update on the Chief Medical Officer’s work with the World Health Organization to develop systems to share disease data. (Paragraph 16)

3.Part of the suffering seen throughout the Ebola outbreak resulted from a long-term market failure to invest in interventions for rare, but potentially catastrophic, disease epidemics. Through a combination of public and private investment, the UK now has the opportunity to capitalise on its world-class strengths in the field of tropical medicine, and reverse decades of underfunding in vaccine, treatment and diagnostic R&D in emerging infectious diseases. We welcome the Government’s recent announcements of much needed research funds in this area. (Paragraph 22)

4.To maximise the effectiveness of these funds, we recommend that the Government works with leading experts to publish an ‘emerging infectious disease strategy’. This should set out a long-term plan identifying the ‘priority threats’ the UK wishes to address, how much funding will be directed to each threat, as well as how action will be delivered and outcomes evaluated. The strategy should outline how coordination across funding streams will be achieved, so that there is no unnecessary duplication of research. Open knowledge and data sharing should be set as default conditions for those receiving public funds. (Paragraph 23)

5.The rapid diagnostic antigen test is an example of the innovations that can be achieved in Government research and development facilities, working in conjunction with private partners and clinicians. The UK should be proud of the efforts made by all of those involved. We were therefore disappointed to learn that, despite the promise shown by the test, and the production of 10,000 test kits, it has not been operationalised. The different explanations advanced for not deploying the test suggest a worrying lack of co-ordination across the key Government departments and agencies that were at the forefront of delivering the UK’s response to Ebola. Along with other evidence we received, we are concerned that this is indicative of more systemic co-ordination problems, and an accountability deficit, for key aspects of the UK Ebola response. (Paragraph 29)

6.The Government must clarify, it its response to this report, why the rapid diagnostic antigen test was not released for use during the Ebola outbreak, distinguishing any technical, commercial and budgetary factors involved. We ask that the Government also sets out what steps it will take to ensure a joined-up, cross-departmental approach, with clear lines of accountability, to address future outbreaks.
(Paragraph 30)

7.The lack of capacity to manufacture vaccines places the UK in a vulnerable position when the next epidemic strikes, whether for use overseas or at home.
We urge the Government not simply to encourage private sector investment in vaccine manufacturing capacity, but to negotiate with vaccine manufacturers to establish pre-agreed access to capabilities that can be called upon quickly when the next epidemic emerges. In the longer-term, this may not be sufficient. We recommend that the Government commissions the UK Vaccine Research and Development Network to:

a)identify the actions required to address the UK’s deficiency in manufacturing capacity and;

b)investigate the public health, economic and regulatory feasibility of establishing investigational stockpiles of vaccines that would be ready for Phase 2 trials during an outbreak. (Paragraph 34)

Responding to major disease outbreaks

8.We agree with Sir Mark Walport that the Ebola Scientific Advisory Group for Emergencies (SAGE) should have been established earlier. Convening a SAGE, however, currently requires a request from COBR in the Cabinet Office. It is not clear how, and when, COBR makes an assessment of whether there is a need for a SAGE to assist its response. We recommend that the trigger for the formation of a SAGE should be a formal recommendation from the Government Chief Scientific Adviser. This would ensure a more robust, evidential basis for convening a SAGE. (Paragraph 39)

9.The Government should review its Enhanced SAGE Guidance to establish a clear mechanism for experts on the ground, in affected countries, to participate in a two-way exchange of information during a disease emergency originating overseas. (Paragraph 46)

10.If the Government sets up the new ‘Research UK’ body advocated by Sir Paul Nurse in his review of the research councils, it should include in its remit a responsibility to act as an evidence conduit between academia, industry and Government when a SAGE is established. This should provide a single point of entry for expert advice and evidence, beyond the SAGE membership, to feed into the Government’s emergency response. (Paragraph 47)

11.One of the strengths of the UK science advisory system is its depth and breadth, with over 70 standing scientific advisory committees and councils, tasked with helping Government departments interpret, understand and make judgements about scientific information. Exactly how these committees operate during an emergency situation, however, is currently covered by a single paragraph in the Code of Practice for Scientific Advisory Committees. Furthermore, despite the Enhanced SAGE Guidance encouraging such advisory committees to be utilised by a SAGE, there was no formal interaction between the Advisory Committee on Dangerous Pathogens and the SAGE during the Ebola outbreak. We are concerned that this may be indicative of a broader failure by the Government to access, and use, the range of high-quality scientific advice available to it. (Paragraph 51)

12.To take full advantage of the work and knowledge of a scientific advisory committee during an emergency, we recommend that its chair is invited to sit on the SAGE as a full member. The Code of Practice for Scientific Advisory Committees should be expanded to provide guidance on the procedures that these bodies should put in place, so that they are in a position to provide advice rapidly in an emergency.
(Paragraph 52)

13.We recognise the enormous efforts made by governments, universities, regulatory bodies, humanitarian agencies, pharmaceutical companies and others to ensure that clinical trials for Ebola vaccines, treatments and diagnostics were launched in record time. But such efforts do not obscure the fact that the UK and other countries were not ‘research ready’ when the outbreak began, prompting a less than optimal and uncoordinated research response. The failure to conduct therapeutic trials earlier in the outbreak was a serious missed opportunity that will not only have cost lives in this epidemic but will impact our ability to respond to similar events in the future. (Paragraph 67)

14.Research during an outbreak must be initiated rapidly, while still being designed and conducted to the highest possible standards. While we recognise the difficulties that arose in this outbreak, they are inherent to all epidemics; therefore, if we want to improve our response, we must address the weaknesses in our research readiness that this epidemic exposed. We recommend that the Chief Medical Officer urgently takes forward the work of the UK Vaccine Research and Development Network to negotiate new processes for embedding research into the emergency response. This should establish protocols for facilitating research that positively contributes to the emergency response, and should address the following questions:

a)Where do the key gaps in our knowledge of emerging infectious diseases lie and what research questions or projects need to be prioritised before the next epidemic?

b)What types of trial design can be readily used during an outbreak, and will be accepted by regulators as producing data that reliably demonstrates the efficacy of vaccines, treatments and diagnostics, thereby providing a pathway to licensing?

c)What ethical and cultural issues need to be considered before going into the field? Discussions should include patient consent, the use of placebos, and equitable access to the outcomes of the research, such as new drugs or diagnostics. These matters will need to be revisited and adjusted at the start of an outbreak to take specific local circumstances into account.

d)Who is best placed to coordinate the research effort, prioritise studies, and ensure that researchers are adhering to the agreed research plan during the outbreak?

e)How can a mechanism be established that enables open data sharing in real-time during a disease emergency? (Paragraph 68)

15.Through the Chief Medical Officer’s membership of the World Health Organization Global Advisory Committee on Health Research, this work package should feed in to, and learn from, discussions taking place at the international level about research governance during an outbreak. (Paragraph 69)

16.Communication with the public is one of the most important aspects of any emergency or crisis situation. The Government provided good quality, accessible and accurate health information on Ebola, and provided balanced communications of the risk of the outbreak to the UK. It is disappointing, however, that it failed to explain clearly its rationale for going against guidance from both the World Health Organization and Public Health England by introducing entry screening for Ebola at UK ports. (Paragraph 78)

17.When interventions are made during a future disease emergency that are intended to protect the UK, such as entry screening, we recommend that the evidential basis for—and purpose of—the intervention is made explicit. This information should be clearly communicated, especially if it goes against established guidance from trusted advisory bodies. (Paragraph 79)

Governance of emergencies

18.We recommend that the Government supports the reforms proposed in the Stocking Report and the Harvard-LSHTM Independent Panel, as well as the WHO ‘Blueprint’ initiative, to ensure that the World Health Organization is fit for purpose and equipped to deliver international leadership when the next major disease emergency strikes. (Paragraph 84)

19.We appreciate the Chief Medical Officer’s reassurance that protocols are in place to respond to different types of disease emergencies, according to their transmission mechanism. However, the groupings she described do not feature in the 2015 edition of the National Risk Register: Instead, the broad category of ‘emerging infectious diseases’ is used. This is the same broad category which has been in place since 2008, yet it did not prepare our research, science advice or political response systems for a public health crisis on the scale or time-frame of the Ebola outbreak. We are not convinced that this wide-ranging category is sufficiently detailed to enable responders without clearance to view the National Risk Assessment to prepare adequately for the next disease outbreak. Furthermore, given the far reaching lessons learnt from the Ebola outbreak, it seems extraordinary that the Government does not appear to accept the case for refining its emerging infectious disease risk assessment and protocols. (Paragraph 88)

20.In its response to this report, we ask the Government to set out with which responders it shares its respiratory, blood-borne, vector-borne and food-borne emergency response protocols. These groupings should be used to structure the ‘human diseases’ section of the next edition of the National Risk Register. (Paragraph 89)

21.The Government’s ‘Health is Global’ plan states that the Government will “protect the health of the UK proactively by tackling health challenges that begin outside our borders”. It is not clear, however, what would prompt the UK to intervene overseas, or what level of capability and capacity the UK should be able to deploy in such situations. (Paragraph 95)

22.We recommend that the forthcoming National Bio-security Strategy sets out what would trigger an in-theatre response by the UK to a disease outbreak overseas. In addition, the Strategy should make clear what level of capability and capacity the UK should be readily able to deploy overseas in the event of a disease epidemic or pandemic. This should include details of the roles and responsibilities of relevant Government departments and how they would deploy sufficient resources. (Paragraph 96)

23.We can only admire the courageous and selfless actions of UK volunteers, and their West African counterparts, throughout the Ebola outbreak. However, some employers lacked the capacity to release their staff or to manage their return. Some individuals were left on their own to negotiate a leave of absence from full-time clinical roles and research to assist in West Africa. We are concerned that the ad hoc nature of these arrangements made our clinical response more fragile than it needed to be. This is a structural weakness that should be addressed. (Paragraph 98)

24.In some situations, Public Health England’s capacity may need to be augmented by volunteers drawn from across the NHS, public sector, universities and beyond. We recommend that a clear framework facilitating the timely deployment of volunteers overseas, in response to an epidemic, is agreed and put in place now, ready for use in the future. We encourage the Government to consider the model used by NHS Trusts when employing staff with Reserve Forces commitments who may be subject to short notice mobilisation in conflict zones. (Paragraph 99)

© Parliamentary copyright 2015

Prepared 21 January 2016