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Infections Resistant to Antibiotics

5.55 p.m.

Baroness Masham of Ilton rose to ask Her Majesty's Government what steps they are taking to combat the growing problem in hospitals and the community of infections resistant to antibiotics.

The noble Baroness said: My Lords, I am grateful to have been given time in your Lordships' House to ask the Government this Question. I consider it to be a matter of vital importance. With trust hospitals competing against each other, and the contracting purchaser-provider policy now in place, it is only too possible that when infections break out a cloud of secrecy may come down. Would the Minister agree with me that infection control is far too important a matter not to be treated in an honest and open way? Should it not now be put at the top of the health agenda? All patients, their supporters and staff inside and outside hospitals should know what to do and how to deal with infection control.

With no slack in the system and nurses, doctors, domestic and therapy staff working hard, how easy it must be to cut corners. As one patient leaves a hospital bed another one goes into it. How thorough is the cleaning of mattresses, equipment and dust? Do doctors and nurses always wash their hands between treating patients? In many hospitals, bank and agency nurses are employed who do many different jobs in many different hospitals. In all hospitals, but particularly in large inner city ones, keeping infection under control needs constant vigilance.

About 18 months ago I visited a large hospital outside London. One doctor said to me, "I think the bugs may win". I felt that that was a matter to be discussed in your Lordships' House. The microbiologists and the infection control doctors and nurses are of immense importance.

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They should be given full support and all hospital departments should have clear guidelines which are adhered to.

Methicillin-resistant staphylococcus aureus (MRSA) is a bacterium resistant to treatment with a wide range of antibiotics. It can become a major infection in hospitals. It is also becoming a problem in nursing homes and in community settings. MRSA is not necessarily any more virulent than other infections but the range of treatment options is more limited because of patients' resistance to antibiotics. Hospital-acquired infections, which are thought to affect 1 million people on any one day, increase patients' discomfort and their time spent in hospital. Lives can be put at risk. There is public concern that hospitals are no longer safe places in which to be and hospital staff are also at risk of infection. Infection increases the cost of treatment. How much are these infections costing the National Health Service today?

Failure to control the spread of MRSA is likely to result in serious infections which are difficult to treat, increased drug and other treatment costs, closed wards or special units and disruption to the normal running of hospitals. The number of infections acquired is a good measure of the standards of care in a hospital. The inclusion of hospital rates of infection in league tables could act as an incentive for improvement. Is it not time to make MRSA a notifiable condition?

Infection-control nurses can reduce the risk of infection both in hospital and after patients are discharged into the community. However, more are needed. A community physiotherapist from Bradford told me that she had had returned a wheelchair cushion on which was written, "patient died from MRSA". She was not sure what the correct procedure should be. Dr. Sandy Macara, chairman of the British Medical Association, states:

    "There is a real prospect that the majority of our antibiotics could become impotent for the purposes on which we have relied upon them for 40 years".

Doctors in Gloucestershire believe that they have found evidence of a link between meningitis and the over-use of antibiotics after comparing prescribing patterns in areas of high and low incidence of the disease. The WHO warned recently against the global spread of bacteria resistant to antibiotics. But the spread of resistance to anti-malaria drugs may pose a greater threat. Man's ability to stay one step ahead of the mosquito-borne malaria parasite is in doubt.

There is concern about the continuing increase in cases of food poisoning, with more than 88,000 people affected seriously last year, costing the National Health Service about £30 million per year. A dangerous strain of salmonella typhimorium DT104, which is resistant to antibiotics, is increasing at an alarming rate.

Multi-drug resistant strains of tuberculosis have been on the increase world wide as a result of misuse of antibiotics that were expected to rid humanity of the condition. With the expansion of air travel, highly resistant strains are now only a few hours flying time from western Europe. Studies in the US have shown that

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the multi-drug resistant TB kills 45 per cent. of people with healthy immune systems within two years. In patients carrying the HIV virus, the mortality rate is 85 per cent. Outbreaks inside prisons and among the HIV community in New York infected hundreds of people, most of whom have died.

If multi-drug resistant TB is allowed to spread in Britain, just think what it might do if it circulated around the Chamber during a long debate in your Lordships' House.

Much has been said this year. The World Health Organisation report in 1996 stated:

    "We are standing on the brink of a global crisis if infectious diseases are not controlled. No country is safe from them. A major cause of the antibiotic resistant crisis is the uncontrolled and inappropriate use of antibiotics globally. They are used by too many people to treat the wrong kind of infections at the wrong dosage and for the wrong period of time".

Greece is an example of a country where one has been able to buy antibiotics over the counter for years. It is essential to limit the use of important new antibiotics in both human and veterinary medicine and not to employ them as animal growth promoters which give cross-resistance to those used in human medicine.

As resistance spreads, the life span shrinks. As fewer new drugs appear, the gulf widens between infection and control. Last Monday, Channel 4 presented "Cutting Edge" on the problem of multi-resistant TB. I found it to be most concerning and profoundly sad. Mistakes have been made. If Ministers in the Department of Health have not seen the programme, they should do so. I hope that everyone learns from it. One must ask what the guidelines were on infection control at St. Thomas' Hospital and the Chelsea and Westminster Hospital where patients died. Perhaps the Minister will tell the House.

I hope that when patients have to be treated in isolation, they will be treated as humanely as possible. I hope that TLC will not be forgotten, even though stringent precautions must be taken.

The World Medical Association met last week in South Africa. It declared that the global increase in resistance, including the emergence of bacterial strains resistant to all available anti-bacterial agents has created a public health problem of potentially crisis proportions.

With Unstarred Questions, there is no way of thanking all noble Lords and Baronesses for taking part at the end of the debate so I do so now. Thank you.

6.5 p.m.

Baroness McFarlane of Llandaff: My Lords, I thank the noble Baroness, Lady Masham of Ilton, for bringing this Question before the House and giving your Lordships an opportunity to discuss a matter of such concern in health care.

I started training as a nurse just over a year before the inauguration of the National Health Service. Antibiotics were not in widespread use in those days and penicillin and streptomycin were only gradually making their impact. In those days, we treated infections with great respect and the protocols for the prevention of

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cross-infection were followed with meticulous precision. We knew that the lives of patients and staff could depend upon them.

I am by no means wanting to make the case that practitioners of that bygone era were more efficient or more conscientious than the practitioners of today. But I wonder whether the broad range and ready availability of antibiotics have made us rather too reliant on them and less meticulous in our care.

I felt grossly out of date as I came to this debate and so I consulted Margaret Worsley, the deputy director of nursing of the North Manchester Health Care Trust, who has an international reputation as an infection control sister. She brought me a vast quantity of literature. I was impressed by the size and complexity of the problem and the fact that the problem is global and knows no national boundaries.

I believe that the three major problems with resistant strains include methicillin resistant staphylococcus aureus (MRSA) and epidemic MRSA, multi-drug resistant tuberculosis (MRTB), which the noble Baroness, Lady Masham, mentioned, and vancomycin resistant enterococci (VRE).

It is interesting to look at the Communicable Diseases Report Weekly over the past year. In June of this year it stated:

    "The number of hospitals referring isolates of the commonest strains of EMRSA has continued to rise".

In August 1995 it stated:

    "The first reported outbreak of hospital acquired multidrug resistant TB (MRTB) in England and Wales has occurred on an HIV unit in London".

In December 1995 it stated:

    "Vancomycin resistant enterococci (VRE) pose an increasing risk to hospital patients in the UK".

Indeed, another article suggests that the potential for more widespread resistance is quite disturbing and the public health authorities in the United States fear that vancomycin resistant straphylocaccus is a disaster looming on the horizon.

Infectious diseases resistant to bacteria, as the noble Baroness, Lady Masham, said, know no boundaries. They are found in hospitals, in the community and in residential and nursing homes. The noble Baroness talked about the scale of the problem. The latest figures I have relate to 1987 when it was estimated that the infections cost the health service approximately £115 million and there were 95,000 lost bed days.

In the face of those problems, I believe that action is needed. It is true to say that the problem of antibiotic resistant bacteria is largely a consequence of the manner in which we use antibiotics. Once regarded as "wonder drugs" for use in exceptionally severe infectious illnesses, we now use them on a far more routine basis. Many operations are performed under a broad spectrum antibiotic umbrella and infections from earache to acne are treated with antibiotics.

There is widespread advertising of new antibiotics and it is a temptation to assume that if the older drug

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does not work, then a new one will be suitable. In that way, we have newer drugs which are usually more expensive and delays are caused in finding the antibiotic of choice for the particular bacterial infection. So we have sometimes a careless use of antibiotics. Yet the protocols for the administration of antibiotics are there. They are provided in the British National Formulary and they are there for every doctor to follow. But, in face of the problems, it is clear that there is a need to apply a far stricter antibiotic policy.

The Department of Health has published guidelines for control of the environment in nursing and residential homes. The Public Health Medicine Environment Group published Guidelines to the control of infection in residential and nursing homes in 1996, and in 1994 the joint tuberculosis committee of the British Thoracic Society published a code of practice which emphasises the importance of infection control, particularly in tuberculosis. However, those protocols need to be more stringently applied. It is part of the role of the infection control nurse to make them known and to monitor their effectiveness. It is the view of the Royal College of Nursing that the guidance needs to be collated by the Department of Health and tackled on a national basis and that the Clinical Standards Advisory Group has an important role to play in issuing guidelines as a matter of priority. We look forward to hearing from the Minister about the intentions of issuing those guidelines.

I have a feeling that at the basis of the problem there lies very basic nursing care. Many of the practices that need to be encouraged are matters of basic nursing care--hand washing by both patients and staff. I have to say that medical staff are not immune in that respect. One of the articles that I read showed that there was a variation of between 22 per cent. and 63 per cent. compliance among different groups of doctors in hand washing. I have watched a consultant doing a round and going from patient to patient without hand washing in between and, indeed, even prodding infected wounds with a pencil. I am sure that nurses do equally horrific things. However, that implies that facilities have to be provided if there are to be safe practices. It is my view that we need to monitor and order the routines and the guidelines that we impose.

One of the interesting facts that emerges from the literature is that the protocols and guidelines issued are often ineffective because of lack of compliance. We must accept professional responsibility for that throughout the health professions. I look forward to hearing too about the very dominant role that needs to be played by the Department of Health.

6.13 p.m.

Earl Baldwin of Bewdley: My Lords, there is no doubt that we have a major problem and we are all grateful to my noble friend Lady Masham for raising it this afternoon. There is also no doubt that a partial

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answer is to use fewer antibiotics, something doctors are constantly urged to do. Let me suggest another solution: invest more in complementary medicine. I speak here as a patient and student of complementary therapies, with a very modest pecuniary involvement as part-time chairman of the British Acupuncture Accreditation Board.

There are a number of distinguishing features of complementary approaches to health care. One is that they are seldom aggressive. This is in marked contrast to the high technology approach of modern Western medicine, whose tendency is to go in with all guns blazing when disease manifests itself. The lesson we have learnt the hard way is that when you do this the bugs fight back. On the other hand, when you treat with herbs, homoeopathy or acupuncture, this does not seem to happen. Garlic, echinacea, tea-tree oil, thyme all have a useful role in clearing up infections.

I spoke to a herbalist friend only last week who was having much success with a combination of echinacea and burdock with the current throat bug that is going round, for which some of the local doctors were using antibiotics. I also spoke to a researcher who is doing some interesting laboratory work with essential oils, specifically targeting the colonisation by MRSAs that we have heard about. Because of the variety of these oils, and the complexity of their molecules in contrast to those of antibiotics, resistance can much more easily be avoided, and I understand that the results so far are promising. Homeopaths will draw attention to the spectacular success of the Royal London Homoeopathic Hospital in the cholera epidemic of 1854, with a mortality rate of 16.4 per cent. as against in the mainstream hospital average of 51.8 per cent.--figures, interestingly, that were suppressed at the time.

A second reason why complementary treatments do not stir up resistance is that many of them work to bolster the overall health and vitality of the patient rather than simply attack the infection. Of course you often need both. But a distinguishing mark of much of complementary medicine, usually overlooked by conventional commentators, is its focus on the host milieu rather than the external pathogen. After all, our guts are full of all kinds of assorted bacteria with which, when generally healthy, we live in harmony.

When a herbalist, using (as it might be) Siberian ginseng, works on a patient's non-specific immunity, there is less need to engage in chemical warfare with invading forces, and with acupuncture and homoeopathy it is no different. It is remarkable what the body itself can achieve, given the right conditions. This again is something the modern doctor has largely lost sight of, with sometimes dire results. I have always been impressed by the story of the professor, in the early days of bacteriological research, who swallowed a whole phial of TB bacilli in front of his astonished class because he was so confident of the ability of his immune system to deal with the consequences.

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Anything that reinforces a person's immunity and general well-being will reduce the impact of infectious agents and lessen the need to weigh in with antibiotics and provoke all the counter-attacks that we have been experiencing. A good diet based on fruit and vegetables is one such factor. Decent housing, sanitation and welfare are others. I suggest that the Government can perhaps do more in these areas to promote not just freedom from disease but positively good health.

Of course I am not claiming that non-conventional medical approaches have all the answers. I well remember the herbalist who told me for heaven's sake to go and take an antibiotic because that was the appropriate treatment in the circumstances. What I am saying is that some of the well-established complementary therapies can do, without side-effects, much of what modern drugs are doing with the consequences that we have been hearing of. And if the Minister, who has heard me say this before, is not disposed to rely on the results of many centuries of clinical experience in a number of healing disciplines, perhaps, as I have also said before, she will help to promote further well-conducted research into the anti-viral and anti-bacterial properties of these treatments. The practitioners cannot do it all on their own.

For I fear that, unless we come up with some radical thinking in this area, we shall only perpetuate the vicious circle of resistance, to say nothing of the other unwanted side-effects that accompany our present system of drugs-based medicine. It is noteworthy that the World Medical Association is currently calling for the development of "innovative" anti-microbial agents. Whatever else the Government propose to do, I do hope that they will not ignore this particular approach, which, as countless surveys have shown, is also what more and more patients are calling for.

6.20 p.m.

Lord McNair: My Lords, I think this will be the third time that I have spoken about oxygen therapies in your Lordships' House and I do so on this occasion with gratitude to the noble Baroness, Lady Masham, for introducing this debate.

When I first mentioned my intention to speak about hydrogen peroxide to my noble friend Lord Harris of Greenwich he said he thought it was only for whitening hair. My own hair has considerably lightened since I first took my seat but I can assure him that this is due to the passing of years and not to the application of hydrogen peroxide.

So, if not for changing hair colour, nor for rocket fuel, what relevance do the oxygen therapies have to healthcare and to antibiotic resistant pathogens? The answer is: a very great deal. We are trying to answer this Question tonight precisely because antibiotics have failed us. That has been graphically underlined by the description of the problem which the noble Baroness gave. The situation we face is the logical outcome of the choices made by medical policy

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makers and those involved with the training of doctors at about the beginning of the century, but I shall return to that later.

In our debate on 2nd December 1994, on the Motion of the noble Baroness, Lady Masham, about the health of drug users, and in our debate on 10th January of this year on the Motion of the noble Earl, Lord Baldwin, on non-conventional medicine, I explained the evolutionary basis of the effectiveness of ozone and hydrogen peroxide in maintaining health and the ways of using it. I shall only add that ozone turns into hydrogen peroxide on contact with water or blood. Hydrogen peroxide is what the white blood cells use to destroy viruses and bacteria, so it has a crucial role to play in the immune system.

Hydrogen peroxide is used for cleaning work surfaces; ozone is the most effective fumigatory gas known. The use of the various forms of oxygen for medical purposes should be considered not only for treating individuals suffering from infectious diseases but also for making sure that when people go into hospital they do not acquire new infections.

Since my attention was first drawn to this issue in 1993 I have, as I said, spoken about it three times. I have also met the Minister who will reply to this debate with her advisers on two occasions and I have engaged in quite a protracted correspondence with her. It will therefore be no surprise to her that I raise the matter again. In her most recent letter to me she suggested that before the Government could fund any research into the possible benefits of hydrogen peroxide there had to be a corpus of knowledge about it. Earlier this year I sent her a book which is a facsimile reproduction of one published in the first decade of this century. It contains 300 articles from medical journals which speak highly of hydrogen peroxide. There are in existence, I understand, over 6,000 such articles dating back to the second half of the previous century when oxygen therapies were first discovered in Germany. How much of a corpus of knowledge do the Minister and her department need?

I may seem to have digressed a little but the point I wish to make is the following. The very fact that I encountered this issue and have so assiduously pressed a vast body of information on the department should indicate not just that the subject warrants intensive research, which should include those already expert in the oxygen therapies, but also that if the benefits are as great as I and others have claimed, then by failing to investigate thoroughly the present Government and the department lay themselves open to charges of negligence on a vast scale.

I referred earlier to the direction taken by medical policy and medical education about 100 years ago. The then recent discovery of the pharmacological possibilities offered by the new science of organic chemistry based on the oil industry offered the prospect of rich rewards for the oil barons of the day and as a consequence treatments such as the oxygen therapies fell by the commercial wayside. I was interested in the reference that the noble Earl, Lord Baldwin, made about the suppression of the success

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of the homoeopathic treatment of a cholera outbreak in 1854. It seems that little has changed. The repercussions of that decision 100 years ago are still reverberating round Whitehall because during one of the meetings I had with the Minister, a Department of Health official insisted that there could be no benefit from oxygen therapies if no commercial benefit would follow from research. That astounded me. The commercial benefit to the Government would be immense and the health benefit to the nation even more so.

The facts that we have heard this evening from the noble Baroness, Lady Masham, and from the other two speakers have made my case with chilling emphasis. I had no idea before the debate started just how widespread and serious this problem is. It is made more serious by the department's intransigence about hydrogen peroxide and ozone.

6.25 p.m.

Lady Kinloss: My Lords, I am very pleased to support my noble friend Lady Masham of Ilton in her Unstarred Question this evening. On 1st February this year at col. 1554 of Hansard the noble Baroness asked a Starred Question on this particular subject, in which I asked a supplementary question of the Minister. It was whether she could comment on a report that the Heriot Watt University was researching into the use of seaweed to combat at least some of these infections. Could she say what progress has been made and whether it has yet had any trials? The Minister also said at the time that guidelines had been issued to hospitals in regard to treating infections in wards. Can she say whether the hospitals have been able to use the guidelines successfully and whether they are allocated any extra funds to acquire the necessary equipment to clear the infections?

My interest in this subject arises from the time, some years ago now, when our son at the age of 10 contracted staphylococcus aureus in his leg. We and he were very lucky and grateful that he was cured by penicillin which was still effective then against this illness.

Research in Australia has demonstrated the effectiveness of tea tree oil in eradicating MRSA in hospitals there. I understand that there have been recent demonstrations of the use of tea tree oil in this country. Would the Minister say whether the Department of Health is interested in the effectiveness of this product, and will it consider conducting research into tea tree oil?

By chance last week I was talking to my younger daughter and mentioned tea tree oil. She said, "Oh yes, it is wonderful stuff, I use it whenever one of my three young sons cuts himself, or even for bad scratches". She uses tea tree ointment. It not only helps the wounds to heal, but it is also an antiseptic against possible infection. I believe I am right that it was originally used by the Aborigines of Australia.

There is a very interesting statement on resistance to antimicrobial drugs adopted by the World Medical Association in South Africa last week. Among its

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recommendations it advises that national medical associations should encourage their governments to fund more basic and applied research directed towards the development of vaccines and other antimicrobial agents. It also recommends that these antimicrobial agents should be available only on prescription. Can the Minister say whether the Government are accepting the recommendations, and in particular whether they should be available only on prescription?

A British Medical Association press release of last Friday, 1st November, drew attention to the problem of the increase of one form of salmonella. Dr. John Cowden of the Scottish Centre for Infection and Environmental Health in Glasgow, warns in this press release that this type of salmonella is increasingly resistant to many antibiotics. May I hope that the Government will take heed of the warning.

6.28 p.m.

Lord Broadbridge: My Lords, it is with some trepidation that I address your Lordships' House on a bacteriological subject since we number many doctors in our membership, quite apart from those who may be actively involved in the field of drug resistance. However, rather than declaring an interest--which usually means financial--I declare some acquaintance with the topic of today's debate in that, after obtaining my first degree in chemistry at Oxford I spent a year and a half being supervised by Sir Cyril Hinshelwood, a Nobel prizewinner, on a thesis entitled "The mechanisms by which bacteria resist the action of drugs". However, alas, all this is some 35 years ago, and I did not follow a microbiological career.

Broadly, infections can be split into viral and bacteriological infections. There is little that medicine can do for viral infections. Keeping the blood sugar level up certainly helps; but broadly the advice is similar to that given to TB patients earlier in the century--that is, good food and rest. I suppose that the father of modern bacteriology is Sir Alexander Fleming, through whose window at St. Mary's Hospital, Paddington, a penicillin mould floated in and killed everything on the agar growth medium plate on which it landed. Fleming did not develop this observation at the time but most fortunately made a careful record of it. It was left to Sir Howard (later Lord) Florey in the late 1930s with his team at Oxford to develop this crucial observation. Without the formality of first testing it on an animal chain, he treated a policeman, who was dying of blood poisoning in the Radcliffe Infirmary, with startlingly positive results. Thus, by research and development at Oxford and, because of the war in America, penicillin and its derivatives were born. Simultaneously other antibacterial agents were developed in other places, such as the sulphonamides in, I think, Germany.

This has led to a culture where over the past 60 years or so friends and relatives have said, in the vernacular, "Go and see doctor and he will give you something for it". And he does. And it has worked. This brings us to the heart of today's debate: increasingly, the antibiotic does not work and, in the

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words last week of the World Medical Association meeting in South Africa, (and your Lordships may already have heard them but they bear repetition),

    "The global increase in resistance, including the emergence of bacterial strains resistant to all available antibacterial agents has created a public health problem of potentially crisis proportions".

Mechanistically, a bacterium's objective is rather like that of the human race: to survive and multiply. There are two theories about how that occurs. One is that a few members of the bacterial population are better suited to survival than the others--one might perhaps call them mutants--and multiply. The other is that after a lag in growth, all members of the bacterial population adapt and grow. My humble piece of research indicated that the former mechanism prevailed. Like human beings who, if subjected to a nasty shock, adapt their behaviour accordingly, bacteria when presented with a hostile antibacterial agent have, over a considerable time, learnt to do the same. Actually it is probably not their behaviour that they adapt so much as their structure.

A principal factor leading to this state of affairs has been over-reliance on and over-prescribing of antibiotics. As the WMA states, mutation to antibiotic resistance has been exacerbated by the availability of antimicrobial agents without prescription in many developing countries. I have direct experience of this. Developing an abscess on a tooth last month while on holiday in Greece, I was able to buy amoxycillin, a wide spectrum antibiotic commonly prescribed in the UK, over the counter with no prescription. Perhaps I was being naughty but it was what my doctor had prescribed the last time I had an abscess.

Another problem is the necessity for repeated courses of drug treatment because patients either are not advised or take no notice of the fact that it is essential to complete the course of treatment. As a poster on my doctor's wall reads, "Don't stop the treatment just because you feel better". The mean growth time, or mgt, of a bacterium is commonly about half an hour and that is the time taken to double the population. So if at midday you have a million cells, by half past twelve you have 2 million cells, by one o'clock, 4 million, by half past one 8 million, and so forth. Bacterial growth is very rapid, increasing the problem presented by resistant strains.

The only solution to the dramatic and disastrous increase in the prevalence of resistant strains must surely be research, research and more research. This, of course, is going on among participants which may perhaps be likened to a spectrum. At one end there are the heavyweight players, the national and international drug companies, for there will be great profit as well as great good as a reward for a solution. At the other end, there are the more academic research bodies such as universities, colleges, hospitals and institutes. Human invention is a nebulous business and no one can say from where the successful inventive spark may come except that statistically surely the more minds and resources devoted to the problem, the more likely will be success. Chance, luck, intuitive thinking, analysis, a corporate strategy and plan for research all play their part. But if the advanced nations

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of the world's governments can fund such work to the limits of their reasonable resources, a solution and progress is that much more likely.

I thank the noble Baroness, Lady Masham, for bringing this vital, in the true meaning of the word, topic to our attention and await eagerly the reply of the noble Baroness, the Minister, who speaks with the great experience of having previously been chairman of a huge health authority.

6.36 p.m.

Lord Fitt: My Lords, I congratulate the noble Baroness, Lady Masham, for bringing this subject before your Lordships' House. As a former Member of Parliament, there have been times over many years when I have questioned whether the existence of this House was relevant. However, I believe that the debate this evening should alert people at the other end of the building; in the final analysis they are the people who will have to take steps to deal with this subject. I approach the matter both on a personal basis and from the point of view of the whole country. I do not wish what happened to me to happen to any other individual or family.

The noble Baroness rightly drew attention to many aspects of the spread of disease. I do not believe that enough stress has been placed on this matter. I hope that people in another part of this building will consider it. The world health authority has said that antibiotics given to animals can ultimately have an effect on human beings when they are treated with antibiotics. Everyone knows of the effect of BSE on animals and CJD on humans. But we are discussing a completely different subject. Attention should be drawn to what has been said by the world health authority: that what has been given to animals can have an effect on people in receipt of antibiotics.

MRSA is a real danger to people in this country and all over the world. It has been said that the problem is out of control because antibiotics have been so freely available. They have been used in an indiscriminate way so that the bacteria themselves have become used to them, and the infection cannot be treated.

I believe that it is the duty of the Government to use all means in their power to find a way to remedy the awful effects of MRSA. I could talk at length on the subject, but let me put the facts before your Lordships in graphic terms. My wife and I had been married for over 48 years. She had suffered from asthma all her life. She had been taking cortisone and the various treatments that are available to asthma sufferers. I spoke to her doctor, who thought that she was taking too much cortisone. He asked her whether it would be possible for her to go to one of the foremost hospitals in Europe, the Chelsea and Westminster, which was built at a cost of millions of pounds. He said that she would be there for only two or three days and staff would try to find a substitute for the cortisone that she had taken over so many years.

I listened to him making that request and, unfortunately, I agreed with him. I took my wife in a taxi to the Chelsea and Westminster hospital. When we

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arrived on the first floor I noticed that there was some debate going on as to which ward she would go. I subsequently found out that there are some hospitals in this country where staff look at your birth certificate rather than the ailment you have. If you are over 70, you are admitted to the geriatric ward, whatever your complaint. Obviously that was what the debate was about.

My wife was eventually admitted to the Nell Gwynne ward. I went to see her that evening, and the next day. On the third day I visited her, she said, "Gerry, there's a woman at the end of the ward who has some sort of hospital bug, and they're all very concerned about her". They had screens around that patient. I put my hands to my head and said, "Jesus, Ann, if there's a hospital bug, you're going to get it". The next day I went to visit my wife and they gave me rubber gloves and an apron. She had contracted the bug as a result of going into that hospital. I only wish now, in retrospect, that I had never agreed to let her go there. She and the other woman who had MRSA were put into a side ward, an isolation ward. The ward she had been in was a geriatric ward and there were other patients in it; that is exactly the ward in which vulnerable people should not be placed. All people over that age are vulnerable. They are all receiving intravenous injections. As the world health authority states, once you receive an injection you are liable to pick up infections that are there in the ward.

From the day that my wife contracted that infection her health went totally and absolutely downhill. I was with her, as were my five daughters, two of whom are nurses. We stayed with her every second of every day during the time she was there. Eventually, the bug that had entered her respiratory system was creating such havoc that she had to be taken into intensive care. She was on an intensive care machine for 21 days. She was then transferred from the Chelsea and Westminster to one of the foremost chest hospitals in the world, the Brompton hospital in London. When she was transferred there and was admitted to the ward, as I walked down the corridor all I could see was, "No admittance", and again, "No admittance". There were 17 cases in the hospital. People enter that hospital with chest complaints, and all those had contracted MRSA. Again, to transfer patients from one hospital to another only creates further strains of this devastating infection.

The hospital was treating my wife with Vancomycin. Evidently, that is the only drug that can deal with MRSA, but it causes devastation to the human frame. The side effects of the drug used to combat MRSA are horrendous. Patients become incontinent; and they cannot breathe. I decided that MRSA was killing my wife. Eventually, after she had spent so many days there, I told the doctors that I intended to take her out of there. I took her to my home in Kent where there were washing facilities. In September last year, on the day I took my wife out of the hospital, the consultant said to me: "By the way, your wife is very weak". He did not have to tell me. I could see it at every second. He said that MRSA had created such devastation that she would never again be able to deal with an attack of 'flu. He

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said that if she ever caught 'flu she would not be able to combat it.

However, I took my wife out by private ambulance. In Kent I and my daughters stayed with her every second of every day. We began to build her up. She still had MRSA when she left hospital. She was still taking Vancomycin. On 4th January this year she had to go back to the Brompton hospital for a test. There they said that she had made remarkable progress and that she should return to the hospital in June. When I took her back to Kent, she asked me for the loan of my handkerchief and said, "Gerry, I've got the 'flu". That was exactly what had been predicted by the consultant. So devastating had been the effect of MRSA that she caught 'flu and within a week she had died.

I have a long script in my hand, and there are many things that could be said in this debate. I understand this subject from a very personal point of view. The Government should use all means at their disposal to do what they can to educate nurses, consultants and doctors to wash their hands. Some medical staff think that they should not be forced to accede to such an obligation. But the Government should take any measures they can to bring to their attention the devastating effects that this infection can have.

I should say that, although I have criticisms in relation to what happened to my wife, and will have until the day I die--I took her to hospital for an asthma attack and that eventually led to her death--the intensive care unit at the Chelsea and Westminster hospital must be recognised as one of the foremost clinical and compassionate organisations in this country, and in the world. There was nothing staff could have done to prevent the terrible onslaught of MRSA in my wife's case.

I look upon this debate on MRSA as a matter that is very personal to me. I do not want the same to happen to anyone else. Had it not been for the fact that I took my wife to hospital for an attack of asthma, whereupon she contracted MRSA, I should have been celebrating my 49th wedding anniversary tomorrow.

6.48 p.m.

Baroness Hayman: My Lords, after hearing from my noble friend Lord Fitt that enormously moving expression of the devastating personal and family consequences that MRSA can have, I believe the whole House would wish to extend sympathies to him and express our appreciation of his courage in talking personally when so often we talk in the most general terms in this House. We also express our thanks to the noble Baroness, Lady Masham, for initiating the debate. It is about large numbers of people and about international trends. But it is also, as we heard, a debate about individuals and the suffering that those individuals can undergo.

The noble Baroness who introduced the debate spoke about the tendency in hospitals sometimes to hide the fact that they have antibiotic resistant infections. They have nothing to hide, sadly, in Great Britain at the moment because there is a very high incidence among

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hospitals many of which are prestigious, highly efficient and high quality hospitals. But perhaps, in the spirit of openness for which the noble Baroness called, I should declare a rather unusual interest. I am the chairman of a London hospital which today has 18 beds closed to admissions because of MRSA on the wards. That is not an unusual phenomenon either in London or throughout the country.

In fact, as was pointed out by the noble Baroness, MRSA is not a notifiable disease. It can be carried by many people without ill effects. Looking at the figures which the Public Health Laboratory Service has recorded, in 1994 there were 1,081 cases, in 1995 there were 1,670 cases and in the first nine months of 1996 there were already 1,666 cases. If the trend continues, we shall be talking about a doubling of MRSA cases within two years. That is a very serious issue for us all.

So far, I have spoken about MRSA. But, as has been pointed out, the issue extends to other diseases. The case of tuberculosis which is resistant to antibiotics is particularly worrying. One has seen the devastating effects that it can have, particularly on populations whose health is compromised, such as the elderly but also those who are HIV positive. It is a new and worrying phenomenon.

It was said earlier in the debate, I believe by the noble Lord, Lord McNair, that the problem was that antibiotics had failed us. That is too sweeping a statement. Many people in this House, elsewhere and throughout the world have good reason to be extremely grateful for the benefits of antibiotics and antibiotic therapy, which in the main have been life saving. What I believe we have seen is the profligate use of antibiotics and it is our failure to control their use, nationally and internationally, that has led to many of the problems. Of course, it is a failure, as was mentioned in the debate, not only in human medicine but also in farming and in veterinary medicine. Those are areas about which we ought to be concerned.

But I should like particularly to dwell today on my concern that many of the trends that we see at the moment in terms particularly of MRSA are intensified by the problems that we are experiencing in our acute hospitals at the moment. Previous speakers have already made reference to how measures that need to be taken to prevent outbreaks of MRSA and to control outbreaks when they have occurred are absolutely crucial to our ability to deal with this problem. The noble Baroness, Lady McFarlane, spoke about the importance of hygiene and also about the importance of having the resources to deal with the issues within hospitals that are affected by MRSA.

I have to say that at the moment it is well acknowledged--press coverage over the past couple of days cannot leave any of us in any doubt--that hospitals are working under enormous pressure. That pressure leads to very high bed occupancy. It leads to a very high and rapid turnover of patients. It leads to patients being moved around the hospital from ward to ward because they are admitted to the first available bed and transferred later to a place where they can be more appropriately nursed. When there are crisis situations

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during the middle of the night and when trying to avoid trolley waits in casualty departments, beds are being put up within ward areas which are closer together than they should be. We all know that proximity increases the spread of disease.

We also know that the staff who work in such wards are working under very intense pressure. Although we have to keep the training, re-training and very high standards in personal hygiene to the forefront for everyone who works within the hospital service, it is undoubtedly true that low morale and increased workloads lead to less rigorous enforcement of the personal hygiene that is so essential if an impact is to be made on these areas.

Perhaps I may ask the noble Baroness who will reply and who, I know, has taken a great interest in these matters and takes them very seriously, whether she can answer a range of points and tell us what we need to know. First, this evening we have spoken about hospitals and the prevalence of antibiotic resistant infections within hospitals. There is also the issue of its prevalence within the community, which has an impact on the discharge of patients who are no longer sick but who may still be infected by MRSA, particularly into community nursing homes.

One aspect that we should not neglect is the danger of stigmatising people who are no danger to themselves or anybody else by horror stories about the effects of being an MRSA carrier and of ostracising them in some way from the community or feeling that they cannot live within a residential home or within a community nursing home. The advice put out by the department has made quite clear that, if proper precautions are taken, that is not so.

Will the Minister say something on that issue and particularly on whether she feels that the number of community control of infection nurses is at a satisfactory level? If it is not, what will be done to promote the employment of community control of infection nurses? I hope that we shall not receive the answer that it is up to local decision-making. The noble Baroness, Lady Masham, raised this matter as a question when the House debated previously this issue and there was a great deal of emphasis in what the Minister said about it being a matter for individual hospitals to have their own policy and that what should be done was a matter for local decision-making on the control of infection. The evidence is very clear. It has been set out in the contributions tonight. This is not a local problem but a national problem. We need a concerted national approach if we are to tackle it.

I also ask that we strengthen and encourage the compilation of national statistics as well as national advice, guidelines and monitoring the effectiveness of that advice and those guidelines from the department. That is tremendously important.

Many speakers referred to the statement a few days ago by the World Medical Association in South Africa and to its recommendations that we tackle these problems internationally both through agriculture and in the field of medicine. I wonder whether we could be given some idea about government policy on that issue.

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Finally, does the noble Baroness accept that the pressures, the high levels of bed occupancy, the rapid turnover and the shortage of trained nursing staff all increase the risk of MRSA outbreaks? If so, what action do the Government intend to take to prevent the present over-heating in our acute hospital services?

7 p.m.

The Parliamentary Under-Secretary of State, Department of Health (Baroness Cumberlege): My Lords, I too am grateful to the noble Baroness, Lady Masham, for raising what I believe to be a very important subject. Once again she has put her finger on the pulse. I agree with her too that infection control is too important not to be treated in an honest and open way. That is why we have invested so much in training clinical staff and making managers aware of bacterial resistant diseases.

I congratulate the noble Baroness, Lady Hayman, on her first occasion winding up for the Opposition Benches. Like her, I too pay tribute to the noble Lord, Lord Fitt. So often the noble Lord has displayed enormous courage, both in the Province and in your Lordships' House as he has tonight. Of course, I am speaking for the Government on this occasion and have to speak in general terms, but I carry the sorrow and anguish of those who, on occasions, are failed by the National Health Service.

Without doubt, the discovery of penicillin and other antibiotics has revolutionised health care. They have provided untold benefits to patients. They have been in the vanguard in helping to control the spread of infection and made an enormous contribution to advances in medicine and improvements in post-operative care. Simply put, they have helped to save the lives of literally hundreds of thousands of people. It is not surprising, therefore, that any suggestion that we are heading towards a "post-antibiotic era" generates fear and anxiety.

The ability of bacteria to develop resistance to antibiotics is not a new phenomenon; it was identified at a very early stage in their use. That was countered by conventional infection control techniques and other intervention strategies which included limiting or rotating the use of antibiotics. I agree with the noble Baroness, Lady McFarlane of Llandaff, that it is not just medicines and drugs on which we should rely, but good clinical practices in both doctors and nurses. Although successful, those methods were overshadowed by what seemed to be a plentiful supply of new antibiotics. Between 1939 and 1972, for example, over 30 new antibiotics were discovered. Not surprisingly, however, in more recent years the number of new antibiotics has fallen. Microbial antibiotic resistance has always been an issue, but the need to address it has now become more urgent. In considering new strategies and policies to combat its spread, we also need to ensure that the best use is made of the antibiotics currently available and, perhaps, to relearn certain lessons from the past.

I should also emphasise that the development of antibiotic resistant bacteria is not unique to this country. Indeed, the noble Lord, Lord Fitt, mentioned the

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comparison between this and other countries. In many countries, the spread of these types of micro-organism has now been accepted as more or less inevitable. That is not the case in the UK. One of our most effective weapons is the high quality of the infection control systems in our health service. We also maintain very strict controls over accessibility to antibiotics by making them available only on prescription. That is generally not the practice in other countries. Indeed, in those countries with the greatest problems, as the noble Baroness, Lady Masham, said, it is often the case that antibiotics--even ones we would restrict for the treatment of certain specific conditions--can be bought over the counter. By contrast, other countries, particularly in Scandinavia, have been relatively successful in containing the rise in problems of resistance.

I am grateful to the noble Lord, Lord Broadbridge, for his expose of that difficult subject. Perhaps I can assure him that the situation in the UK is much better than in other countries. However, there is no room for complacency and I am sure that there is much we can learn from the successful experience of others.

What I should like to do is spend a few moments talking about MRSA, as it is the one antibiotic resistant infection which, in recent months, has tended to attract the most headlines and has clearly proved to be of great concern to your Lordships' House tonight. Phrases such as "killer bug" and "super bug" have been used by the media and are ill-founded. They have invoked anxiety among many patients, their families and friends. They have also conjured up images of our modern day health care system hurtling towards an imminent and inevitable doomsday. That does not mean to say that I wish to minimise the difficulties created by MRSA and other antibiotic-resistant infections or the importance we attach to tackling them. I hope that, through my remarks, I shall help to allay some of the fears and anxieties that have been generated.

MRSA is a relatively antibiotic-resistant form of the bacterium staphylococcus aureus. Staph aureus is one of the commonest of all the bacteria--so common that about one-third of us carry it quite harmlessly on our skin or in our nose and throat. Normally, the bacterium does us no harm, but if the skin is cut, or if resistance to infection is lost or compromised, the germ can multiply and set up an infection. Mostly, it is a trivial infection of the skin, but among patients who are in hospital it can sometimes become more serious. This is because resistance to infection may be poor on account of their illness or treatment. Catheters or drips going through the skin can also provide the germ with a route of entry, as can a surgical wound. In those instances, the bacterium can cause more serious infections, such as septicaemia or pneumonia. Staph aureus has the ability to cause a range of infections from the trivial to, as we heard tonight, the most life-threatening.

MRSA is the antibiotic-resistant variety of the same bacterium and acts in exactly the same way. The infections it may cause are no worse than those of ordinary staph aureus. The reason why MRSA is seen as more of a problem is that if an infection develops it

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is more difficult to treat because many of the commonly used antibiotics are not effective against it. The infection is not, however, totally untreatable. There are antibiotics that can be used but they may produce more side-effects and they are more expensive. Those factors justify efforts to prevent vulnerable patients coming into contact with MRSA.

Over the years a range of clinical guidelines specifically on MRSA has been produced. They include guidance on methods for the control of MRSA, published jointly by the Hospital Infection Society and the British Society for Antimicrobial Chemotherapy in 1986. That guidance was updated and republished in 1990 and formally commended by the department to the NHS in 1994. The department is now working with professional groups on yet a further revision, as the noble Baroness, Lady McFarlane, mentioned, to take account of the needs of hospitals with high and low prevalence of MRSA and units with various degrees of risk.

The noble Baronesses, Lady Masham and Lady Hayman, raised the question of the growing problem of antibiotic resistant infection in the community. The fear of MRSA has created a great deal of anxiety among owners and managers of some nursing and residential homes. It has also caused distress to residents and their families. Those concerns are founded on a misunderstanding of the nature of the bacterium and the type of infection that it may cause. Residents in most of those homes are at no greater risk of infection than the general population. They do not have medical devices such as drips penetrating the skin and they do not have surgical wounds. There has never been an outbreak of infection due to MRSA in a nursing or residential home, nor do we consider one to be likely.

However, in response to the obvious anxiety, the department worked with the professional organisations to produce guidance on MRSA in the community, and the control of infections more generally. That was issued in May. The guidance stated that a person carrying or infected with MRSA was not a risk to other residents and that routine arrangements designed to prevent all types of infection, such as good personal hygiene, are sufficient to deal with it. To underscore those messages, the department also issued a leaflet on MRSA to health authorities, social services departments and nursing and residential homes. We have also held seminars for managers of those homes, their insurers and the staff responsible for their statutory registration.

I should not like to give the impression that MRSA is the only antibiotic-resistant infection that hospitals have to contend with. As the noble Baroness, Lady McFarlane, said, there are several other types. These mainly affect patients in specialist units, such as intensive care or transplant units, where patients are particularly vulnerable. In such circumstances, there is often a need to use broad spectrum antibiotics to combat complex infections, which, ironically, as the noble Baroness suggested, may also provide ideal conditions for the bacteria to develop resistance.

I should like to say a brief word about TB. The rates of drug resistance to tuberculosis also remain at low levels. This is not to say that we should in any way be

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complacent, and I am aware of the recent outbreaks of multi-drug resistant TB within two London hospitals. Perhaps I may say to the noble Baroness, Lady Masham, that I did watch the television programme.

One of the aims of our national tuberculosis policy is to prevent the emergence of drug resistant disease. Drug resistance can often be attributed to poor compliance with treatment. Guidance issued this year from the inter-departmental working group on tuberculosis on the prevention and control of TB makes recommendations for ensuring that TB patients complete their full course of treatment. However, it is inevitable that occasionally drug resistance will emerge, and also that some patients who have acquired their disease abroad will have drug resistant disease. In these cases it is important that healthcare workers are aware of the possibility and that appropriate infection control measures are in place to prevent spread to other people, especially in hospitals. The principles for the control of tuberculosis are well established. More detailed guidance on drug resistant tuberculosis is in preparation. We have paid for a nurse education video and pack produced by the RCN on our behalf. The video has been shown four times on TV. It has been widely circulated and, I know, has been much appreciated by nurses.

The noble Lord, Lord Fitt, and the noble Baroness, Lady Hayman, raised the issue of a link between antibiotics and food. At its meeting in January this year, the Advisory Committee on the Microbiological Safety of Food concluded that an in-depth review of the role of food in transferring microbial antibiotic resistance should be undertaken. A multi-disciplinary working group under the leadership of the committee's chairman, Professor Georgala, has now been set up and is currently gathering evidence. The group is aiming to report next year.

The noble Baroness, Lady Hayman, spoke of ward closures. I know she believes, as I do, that the welfare of patients is of foremost importance to hospitals. When an outbreak of infection occurs, the need to protect patients from infection has to be balanced against the implications of disruption to the hospital's routine services as a result of infection control measures. Sometimes, to prevent the spread of infection, it is necessary to close a ward or a specialist unit temporarily to new admissions. Such a decision can only be made by the experts on the spot after careful consideration of the options and having regard to the type of infection and the way it spreads, how vulnerable to infection other patients on the ward are likely to be and the availability of alternative facilities for both infected and non-infected patients.

Guidance from the department has made clear that hospitals and purchasers of their services need to ensure that they have adequate routine provision for isolation of infected patients; nevertheless, in an outbreak some disruption may be inevitable, but it will always be in the interests of promptly controlling the risk to patients.

I am aware that there is a good deal of support available to help combat the development of antibiotic-resistant infections. Leading the fight are consultants in communicable disease control, infection

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control nurses and microbiologists. The new specialty of consultant in communicable disease control was established in the NHS in the late 1980s, implementing the recommendations of an expert committee chaired by the then chief medical officer. These new specialists are more highly trained than their predecessors and take a more proactive role in combating communicable disease and infection in the population.

In 1995, the department issued guidance strengthening previous recommendations that hospital infection control teams and hospital infection control committees be established. It advised that within hospitals an effective infection control programme with defined objectives should be set in place and kept under regular review. It also recommended that surveillance of hospital acquired infection should become routine and that purchasers should include enhanced surveillance, prevention and control in their contractual requirements. To strengthen these recommendations, specific objectives aimed at ensuring that appropriate arrangements for communicable disease and infection control are in place feature in the planning and priorities guidelines for the NHS for 1997-98.

The noble Baroness, Lady Masham, raised two specific instances where prevention has clearly not been effective. I do not want to go into detail on the cases at St. Thomas's Hospital or the London Hospital which are the two most recent ones. I can assure her that a full report on the incidents at St. Thomas's is being prepared but has not yet been produced for us to see. The other case was at the London Hospital. A patient with HIV was infected. Clearly a good deal of work is being carried on at the moment as a matter of urgency to trace other individuals and contacts.

I should like to address the issue of complementary therapies. The noble Earl, Lord Baldwin, and the noble Lord, Lord McNair, explored the role of these therapies. I appreciate the strength of the range of complementary therapies and how many of them are very effective for certain groups of people. I know that noble Lords are very anxious that we should carry out research into their effectiveness. That is appropriate today when the whole focus of the National Health Service is on evidence-based medicine. But we have to have research protocols produced of institutions such as the MRC and other research institutions. It is not for us to produce those proposals but for those interested in this area of work. I know that will not satisfy noble Lords but I am afraid that is the position.

The noble Lady, Lady Kinloss, asked about the research which has isolated a substance which is active against MRSA and other antibiotic resistant bacteria. I think probably she was also referring to research in Australia on the effectiveness of teatree oil. We welcome that research. However, other such substances have turned out to be too toxic for clinical use, so it is too soon to say that these may be a new treatment. We are cautiously optimistic.

Finally, I should like to address the issues put forward by the noble Earl, Lord Baldwin, about prescribing and the use of drugs within general practices. That is where the bulk of prescribing takes place. The number of

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prescriptions issued and dispensed for antibiotics has grown more slowly than the total for all drugs dispensed in England between 1991 and 1995. Rigid national policies on antibiotic prescribing are not appropriate because patterns of resistance vary from place to place and only the doctor in charge of the patient is in a position to decide on the best treatment for that individual. Local policies are being developed by clinicians in consultation with microbiologists, often through area prescribing committees. A great deal more

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is being done by the British National Formulary, which is published twice a year, and other prescribing journals. We keep the issue closely under control.

Antibiotic resistant infection represents a considerable challenge, but it is a challenge which we are rising to meet and are determined to combat and overcome. We are not complacent. But compared with many other European countries, our record is enviable, and we shall strive to keep it that way.

        House adjourned at twenty minutes past seven o'clock.

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