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Baroness Farrington of Ribbleton: My Lords, may I remind the House that my noble friend the Minister will not have time to reply to the many questions asked if noble Lords overrun their time?
Lord Chan: My Lords, I congratulate my noble friend Lady Masham of Ilton on securing this short debate on two important infections which are very relevant to the health of our nation.
Tuberculosis is an ancient infection found in Egyptian mummies which still affects some 7,000 people every year in England and Wales. Conversely, severe acute respiratory syndromeSARSis a new infection which is probably caused by a new variant of the coronavirus. It was first reported last November, and within three months has captured headlines worldwide because of the fear it has generated in East Asia and in Toronto, Canada. Thankfully, there have not been a significant number of SARS infections in Britain. However, our communities at risk, such as the Chinese community, are as fearful of SARS as their counterparts in China, Hong Kong and Singapore. That is one reason why we should be considering this new infection for which there is no known treatment and from which some patients die within a week or two of falling ill.
Tuberculosis cases have increased 27 per cent in the past 10 years, to 7,000 cases reported in England and Wales annually. Communities at high risk of TB tend to be new arrivals from Bangladesh, India, Pakistan, Africa, South East Asia and some countries from eastern Europe including Russia. They account for the high incidence of TB in some inner-London districts. People with HIV/AIDS, particularly those from sub-Saharan Africa, tend to be malnourished, to have reduced immunity and to be prone to TB infection. Some have come to Britain for treatment.
Physicians treating tuberculosis, specialist tuberculosis nurses and NGOs focused on TB have designated 24th March as Concern for Tuberculosis Day. The
SARS is a new infection which originated last November in China and spread to Hong Kong, Singapore and Toronto through an infected person spending a night at the Metropole Hotel in Hong Kong, infecting people living on the 9th floor of that hotel. The spread of SARS to Singapore and Toronto has been traced in detail by epidemiologists. Deaths have been highest among family contacts and healthcare staff. The death rate has risen from 4 per cent to nearly 10 per cent. Children are least affected and older adults most likely to die. There is no specific treatment for this pneumonia-like infection.
In Britain we have had only six probable cases and all have recovered. However, high levels of fear are present in the Chinese community, particularly as they watch satellite television from Hong Kong and erroneously assume that precautions recommended there, where SARS infection is still active, should be implemented in Britain. Fear of SARS has drastically reduced the number of diners in Chinese restaurants in London's Chinatown. Chinese students attending boarding schools in England have been kept in quarantine in schools in the Isle of Wight and in Knutsford, although all have been in good health and, as far as we know, have not been in contact with SARS patients in Hong Kong or China.
Will the Minister please give us assurance with regard to the system of SARS infection surveillance and indicate what advice should be made available to the Chinese community here? I look forward to her reply particularly as regards reassuring Chinese families that cutting themselves off from other Chinese who may have recently visited South East Asia is unnecessarily contentious. It would be more practical for all with coughs, colds and fever who have been travelling and have come home to consult their GP as soon as possible.
Baroness Gardner of Parkes: My Lords, I thank the noble Baroness, Lady Masham, for initiating the debate. It is a subject which interests me as years ago the Brompton Hospital had a huge basement full of TB records. When the new hospital was being built and we discussed what we should do with the TB records some people said that they were history and that TB had gone for ever. However, those records were not thrown out in the expectation that one day someone would sort them out.
No one then imagined that TB would come back in the way that it has. The tubercle bacillus is as serious today as it was when it caused such damage in the past.
As far as we know, SARS and TB have a common form of transmission. We believe that they are both transmitted by air or in sputum. As the noble Baroness said, the world is small and jet air travel has made it even smaller. On 10th April during Starred Questions I asked about airlines and air circulation in aircraft. The Minister gave a satisfactory reply but subsequently I received an excellent letter from British Airways. Your Lordships may like to know that British Airways takes these matters very seriously and more than meets the World Health Organisation requirements. The letter states that,
However, it is less reassuring to read the newspaper headline:
Reading that latest scare story it seems to me that we still do not have any real idea of how SARS is transmitted. We are more able to deal with TB as we know how it is transmitted. We must be vigilant in that regard.
When I first raised the issue of SARS in the Chamber during Starred Questions on 25th March the Minister told us that there were very good procedures for warning GPs about infections such as SARS. The noble Lord, Lord Soulsby, asked whether we had isolation facilities. When I was chairman of the Royal Free we were responsible for the isolation hospital which was equipped to deal with the Ebola virus, which is much more serious. It was scary to see the ward in which people were to be nursed. The entire bed was encased in plastic. No hand came into contact with the patient. Even any food to be given to them had to put in one little hatch and taken out of another. We
Let us hope that this country never sees an infection like the Ebola; that would be just too terrible. I was very disturbed to read in, I think, the Sunday Times, an article written half-jokingly about that terribly serious subject. If what we are talking about tonight is serious, that is even worse. To write about it in that way was not good news.
We will all be interested in what the Minister has to say. The financial implications for the world are very serious, and there must be some overlap between financial concern and health concern. People worry about how they will survive, which could be damaging in itself. There is awareness in this country and across the world, and we now simply have to proceed and do whatever we can.
Baroness Finlay of Llandaff: My Lords, like others who have spoken, I am most grateful to the noble Baroness, Lady Masham of Ilton, for having introduced the debate. I must declare an interest as a member of the Science and Technology Committee's sub-committee on fighting infection.
I shall confine my remarks to SARS. In doing so, I pay particular tribute to my friends and colleagues who have been at the forefront of dealing with the epidemic. I suggest that it is because of the vigilance of healthcare workers, their quest for knowledge so that they can understand what is happening, the research they have undertaken and its rapid publication, the sharing of all data, and the rigour of applying isolation procedures that we do not have a much worse situation on our hands.
The Hong Kong Hospital Authority website is excellent. It records that, as of yesterday, there were 187 deaths in Hong Kong, principally among those who had a history of chronic disease. The authority also records that 20 per cent of cases are among healthcare workers and their families and the volunteers working with SARS patients. It seems that hepatitis B and chlamydia are co-factors in the disease, and may account for children having a less severe and aggressive clinical course with their disease.
I wish to read briefly from an e-mail from a friend of mine who is at the forefront of the battle. She is chairman of the Hong Kong Society of Palliative Medicine and describes its involvement, stating:
In Hong Kong, a SARS task force has been set up, and in Beijing the experience is similar. A doctor from Beijing has told me that approximately 8,000 people are in quarantine there. At great speed, a 2,000-bed isolation hospital is being built by the army on the outskirts of Beijing. It is anticipated that the epidemic there will peak in the next two weeks.
Research among healthcare workers in Hong Kong has shown that those who have become infected have had a significant failure in using one of the protections, particularly a surgical mask. Paper masks are inadequate, but it seems failure in the use of a surgical mask has accounted for infection. Some of the others who have become infected have failed in the use of gloves, hand-washing or gowns.
The cost of containment is massive and is resulting in a radical change in society. I quote an e-mail from another friend and colleague. She says:
This week's edition of the Economist and, today, the Financial Times have highlighted the effect on the economy. But what are some of the lessons that we have to learn? The Corona virus has been identified. It is a very tough virus. It survives cold; it survives on surfaces for at least four days; it may continue to be excreted in the faeces, particularly of those with diarrhoea, for about 42 days or longer. There may be others who are excreting the virus for even longer.
Long hospital stays are required. In Hong Kong it is reckoned that 23 per cent of sufferers have required intensive care and ventilation. I ask the Minister: could we cope with such a situation here if we had a similar number of sufferers? Could we cope in terms of the supply of masks? In Hong Kong there has been a major voluntary fund-raising effort to buy enough equipment to provide the staff with adequate masks, gowns and gloves.
Are we accepting adequate precautions here? Why did the department's advice on the way in which healthcare workers should be advised appear only on 30th April when our postgraduate students from
Lord Clement-Jones: My Lords, first, I congratulate the noble Baroness, Lady Masham, on initiating a debate on these twin, but related, issues which are both very important. The expert contributions that we have heard have been illuminating.
Last week we had an interesting exchange of views on SARS following the Government's Statement. I do not believe that any of us underestimated the seriousness of SARS, but the general view of this House was that the Government, advised by the WHO, the Chief Medical Officer and the Health Protection Agency, backed by the expertise of the NHS, had struck the right balance.
Our main area of criticism on these Benches related to the visibility of Ministers and to the need to provide reassurance, and to the reasoning behind the decisions that were made in response to some fairly alarmist press coverage. This was largely remedied in our view by the Secretary of State's Statement last Monday.
It is now good to see that the UK has been taken off the WHO list of countries affected by SARS, as the number of the six original cases has not grown any higher. It is also good to seean area of major concernthat India is judged by the WHO to be SARS free. However, we must not be complacent in the UK or internationally. I hope that the Minister will confirm that the HPA and other agencies will remain vigilant. In particular, we must all hope that the Chinese authorities, after a bad start, now with a new policy of public openness, manage to bring SARS under control. In Hong Kong, however, despite the graphic and interesting consequences mentioned by the noble Baroness, Lady Finlay, the outbreak does appear to be coming under control.
We should also welcome the meeting today of European Health Ministers in Brussels, which is designed to ensure that the virus does not gain a larger foothold in Europe, and that there is a properly co-ordinated response to SARS. Public health is increasingly a matter that governments accept should be dealt with at the European level, in view of the speed of cross-border transmission, as we have seen with SARS.
During the Statement last week, I asked whether there were sufficient resources for our infection control teams. The Minister replied that all necessary resources must be provided. She did not say how the HPA or the department would audit that. I asked the same question in the debate on MRSA in light of the survey findings of my honourable friend Paul Burstow; that is, that the perception in the survey of the infection control teams was otherwise. However, on neither occasion did the noble Baroness give me an
I believe that TB is a major contrast to SARS in being much longer-standing as a killer disease. As the noble Lord, Lord Soulsby, mentioned, it is ultimately more serious. If I had a better memory, I could recite which of the Dickens characters suffered from consumption, which was so rife in our cities. As the noble Baroness, Lady Parkes, said, the worry is that it appears to have returned in spite of our belief that it had been conquered. Disastrously, TB still has a massive impact worldwide. Eight million people a year develop its most active form and 2 million people a year die from it. A total of 900 million people are infected with TB. Someone dies from TB every 15 seconds. Even in the UK, we have had outbreaks over the past few years in Leicester, Glasgow, Kent, Dundee and in particular London, where the majority of cases are now diagnosed.
There are major questions about resources, which the noble Baroness, Lady Masham, raised, and in particular about vaccinations. London is a hotspot, as the noble Lord, Lord Soulsby, said: 50 per cent of the cases that come to the notice of health authorities are in London. There are major questions about the way in which that is being tackled in the area.
At the end of the day, there are 7,000 cases in the UK. The key problems are on the international front. I welcome the actions by the World Health Organisation and the Stop TB Partnership, which is sponsored by it. I welcome the appointment of the next director-general of the WHO, Dr Jong Wook Lee, who spent the past two years as director of the Stop TB Partnership. Clearly, TB is high on the WHO's list of priorities. The UN has set the target of halving and reversing the incidence of TB by 2015.
There is no doubt that the DOTS programme has had some major successes, particularly in China and India. However, in some sub-Saharan African countries and countries of the former Soviet Union, TB is still growing unchecked.
Many of the answers lie not domestically here with the Department of Health but with DfID, the Treasury and the Foreign Office. We cannot isolate the UK from TB as it rampages in developing countries. We need action on a global scale. The WHO described it as the disease of the disadvantaged. It identified a funding gap of some 300 million dollars. What is the Government's view of whether there are adequate resources to fight it in developing countries? What pressure is being applied to pharmaceutical companies to prevent them from pricing treatment in developing countries out of the market?
As regards the UK, apart from our international aid efforts, TB must be stopped in its tracks on every occasion at which it is detected. We must ensure that our surveillance is excellent domestically and on our borders. There are signs that TB is becoming resistant to antibiotics and that drug cycling is necessary to
Finally, it is important that our public health legislation is fit for the purpose. The Minister made it clear that the Government have accepted the fact that our public health legislation needs an overhaul. I hope that when she replies, she will cast more light on that and say when it is planned and of what it will consist.
Earl Howe: My Lords, the coupling of SARS and TB in the noble Baroness's Question brings home to us, as she explained so well, the urgency and difficulty surrounding issues of public health. Last week we had quite a full and helpful debate on SARS on the back of the Government's Statement to Parliament. I do not believe that it would be fruitful to go over for a second time all the territory that we covered on that occasion. I said then, and I repeat, that I welcome the measures that the Government have taken to prevent the further importation of the virus into this country and to ensure that if it does arrive, sound protocols are in place to minimise the risk of it spreading.
Yet even in the past few days events have moved on. No new cases of SARS, thankfully, have occurred in the UK. There are signs that in the Far East, with the glaring exception of mainland China, the disease is being brought under control. It would be useful if the Minister could give us an up to date bulletin of new cases recorded in countries around the world over the past week and the progress made in stemming the progress of the disease.
One obvious difference between SARS and TB is that, whereas we know a very great deal about the latter, the same is not true of the former. New facts and new theories are emerging about SARS with every day that passes. We cannot devise robust strategies for controlling the spread of SARS without clearer knowledge of the ways in which the virus can be transmitted; how long the virus survives outside the human body; and who is most at risk of getting it. The precautions that have been taken to date are sensible only in the context of current ignorance.
It is certainly in no one's interests to exaggerate this scare in any way. The CMO has stated that the risk of catching SARS is low, yet, as my noble friend Lady Gardner said, the known facts inevitably change. Only a short time ago we were told that the SARS virus could live for a short time on the button of a lift but that the main route of transmission is through coughing. Now we understand that it can survive for up to 24 hours outside the body and that it can be transmitted via sewage. On top of that it appears that the virus can mutate quickly.
As was said last week, two things above all will help to defeat SARS: flexibility of response and vigilance. Setting aside the difference of view between the Opposition and the Government about making SARS
What we would do and how we would cope if there were a major outbreak of SARS in this country is another question. The British Lung Foundation has expressed its grave concerns about the shortage of respiratory physicians. A third of all advertised respiratory consultant posts remained unfilled last year: and the number of consultants in the UK per head of population is under half the European average. In simple terms there are not enough chest specialists to cope with the present workload, let alone a bigger one.
That sobering fact, on which I hope the Minister will comment, is relevant to TB, which is now officially a global health emergency. The noble Baroness drew our attention to the steadily rising incidence of TB notifications nation-wide and its worrying prevalence in particular hot spots such as London, where the rate of infection in certain boroughs is higher than in some developing countries. None of us can be complacent in such a situation. Still less can we be complacent in the face of new strains of TB that have proved to be antibiotic resistant. As with SARS, the strategy to counter the spread of TB must be twofold: prevention and containment.
On prevention we have to face the fact that the rise in TB prevalence in this country is attributable principally to Africa and the Indian sub-continent. Individuals who arrive in this country either through the normal channels or as asylum seekers do not as a rule have to undergo medical screening, as they would have to in many other countries. I believe that we have to question whether we can continue to justify a policy of blissful ignorance about the health of those who apply to live permanently in the UK. Not to conduct basic checks for serious diseases such as TB or HIV both disadvantages the applicant and overloads the NHS. Compulsory screening of asylum seekers originating from TB hotspots is necessary. That is also the view of, among others, the BMA and the British Thoracic Society.
But TB can of course also be prevented by vaccination. I should be glad if the Minister could say whether she is satisfied with both the availability and the potency of current BCG vaccine supplies. Can she also tell us what has happened to the action plan for TB in London which was promised some time ago and whether the TB Awareness Campaign launched last year by Yvette Cooper has had any success in reaching ethnic minority communities?
In London we must be frank and recognise that strategies to control TB have thus far failed. London has the highest rate of drug-resistant strains and half the entire country's tally of TB cases. The action plan for London is of vital importance and will require both resources and a high level of commitment from all arms of health and social services. That commitment needs to extend across the country to our prisons. DOTS should be central to that. I hope that tonight
Baroness Andrews: My Lords, I am extremely grateful to the noble Baroness for enabling us to have such an interesting and incredibly expert debate. I am grateful to all noble Lords who spoke of their personal, professional experience and indeed of their many contacts on the frontline in order to inform us about what is going on in the most seriously affected parts of the world regarding SARS.
There is an ingenious link between TB and SARS. Given more time and based on my previous existence as a historian, I would have been able to dwell for many minutes on the gift that TB presented to Victorian novelists and sociologists. We are extremely grateful that those days have passed. By the mid-17th century, one in five deaths in Londonas recorded in the Bills of Mortalitywas due to TB. The disease became known as the "White Plague". The 19th century estimate of the world-wide TB death rate was 7 million per year. London, as now, was one of the worst affected cities. There was an apocalyptic vision that by the end of the 19th century TB would decimate the country.
So there are extremely interesting parallels, not only in the nature of the disease and the impact that SARS and TB might have, but also in the challenge that those diseases present to our public health system. Over a century later, just as tuberculosis helped to shape and strengthen our public health system and our ability to deal with infectious diseases, so now SARS has benefited from our having in place a robust public health system and our understanding of ways to prevent the spread of disease.
The contrast between SARS and TB is that for TB we have diagnostic tools; we have the BCG vaccine and effective drugs. Those, together with improved nutrition and improvements in the public health environment, have played their part in reducing the number of cases in the UK. They reached 50,000 in the 1950s and dropped to 5,087 in 1987. As regards SARS, the brilliance of our researchersand we pay tribute to them and to their outstanding contribution made in recent weeks in the discovery of the Coronavirus and so onnow means that we know a lot more about the SARS virus. But diagnostic tests are still in the early days of development and there is currently no specific treatment.
My information to date is that there have been 6,583 cases of SARS reported from 27 countries and 485 deaths. Here, the control of SARS depends more on the traditional public heath measure of identifying and containing cases. Furthermore, as noble Lords have said, we have been successful. We have identified only six probable cases. The one case where infection was acquired in the UK, and as a result of which the WHO temporarily listed Britain as an affected area, was now more than 20 days ago. I am pleased to report that the UK, along with the United States, has now been removed from that list.
Of course, as the noble Lord, Lord Clement-Jones, said, we must not be complacent. Although the situation seems to be improving in the most affected areas, including Vietnam, Singapore and Canada, in mainland China the number of people affected is still rising. The noble Baroness, Lady Finlay, pointed out in graphic detail what it means to be on the frontline and fighting the disease. That brought home to us, as nothing else could, what those health workers are facing on a day-to-day basis. I am very grateful that she brought that evidence to us.
Our knowledge is changing. From recent evidence, we know that the virus may survive on door handles and in human waste longer than we had previously thought. We have to build that into our assumptions. It emphasises the need for infection control. Here, the Chief Medical Officer has issued very strong and stringent advice to chief executives about infection control systems. As I informed noble Lords last week, we are keeping our plans under review. We must do. We are learning lessons where they need to be learned; we are building on good ideas wherever they are to be found; and we are in daily telephone contact with the WHO. So we know exactly what is going on and, in response to the noble Lord, Lord Soulsby, our researchers are in close contact.
There are similarities also because both SARS and TB appear to be spread mainly through a chain of person-to-person contactfamily and household members and, with SARS, especially among healthcare workers. But it is with TB that we face a new threat.
As the noble Lord, Lord Soulsby, said, we thought that we had achieved control over TB by the 1980s, but it has re-emerged as a public health problem, largely as a result of increased migration from areas of the world where TB is most prevalent. It is important to put that in context.
During the past 10 years, cases of TB have risen in England and Wales to about 7,000 cases a year, bringing the long, steady decline to an end. I was grateful for the example provided by the noble Baroness, Lady Masham, of how it can affect all of us, including a Member of the other place. We are delighted that he recovered so well. It is a global emergency, as designated by the WHO, which estimates that one third of the world's population is infected with the bacteria that cause it. Two million people die each year; and 8 million people develop the disease. It is important to stress that it is a curable infectious disease.
In the UK, our highest levels of infection are among the Indian sub-continent and black African communitiesand, of course, in London. TB has been identified by the CMO as one of the four infectious diseases requiring intensified control measures. It has given rise to the TB action plan, which I should like to describe, which was preceded by three initiatives to which I draw the House's attention.
First, there was the TB awareness campaign, launched by the Department of Health, which hit its target audiences in the Asian, African and eastern
Secondly, we have responded to concerns about people arriving. Immigration officers at inward ports are instructed to refer passengers who arrive from relevant areas who plan to stay for six months. In 200102, nearly 150,000 passengers were referred at Heathrow. About 57,000 chest X-rays were performed; 138 people were referred for further investigation; and 94 were found to have TB and followed up with therapy. So we know that that form of surveillance seems to be working. Thirdly, we have completed a pilot in asylum induction centres in Kent, which is also picking up susceptible people. There has been a positive take-up by asylum seekers.
We must regain the upper hand over TB and acknowledge that control has not been consistent across the country. The three main targets are to ensure that all people with TB receive high quality treatment and care; to reduce the risk of people acquiring new infections; and to maintain low levels of drug-resistance.
The Chief Medical Officer will shortly announce the plan, but we want to develop strong co-ordination to deliver a national TB programme with a clear focus. That includes staffing planswho we need, where we need them and how to get thembecause so many people are involved in TB, whether communicable disease staff, GPs or nurses. Co-ordination is essential.
We have worked hard on action in cities that have the highest burden of TB, and among population groups at risk, which obviously include the homeless and people in prison, for example. We shall ensure that patients are seen promptly and receive the aftercare that they need to support them during the six months for which they need to keep taking antibiotics. They do not enjoy it; but it is extremely important to support them in doing so, which is precisely where our strategy for fighting drug resistance is involved. We need patients to be seen more promptly and the laboratory services to work more quickly.
Perhaps I may quickly answer a few questions. We are satisfied with the BCG immunisation policy. We have sufficient BCG vaccine. We had a shortage last year, but that is now entirely solved and overcome. We provide BCG immunisation mainly to babies at high risk of exposure to TB and previously unimmunised school children aged 10 to 14.
In response to the noble Baroness's question about whether we could cope, we have in place contingency plans for outbreaks of infectious disease. We have no problem with the supply of masks at present.
In response to the noble Lord, Lord Chan, who has been carrying out stalwart work with the Chinese community, we understand the need for reassurance. We will make an effort to provide further advice to the Chinese community. But, of course, the same advice that helps others in the community applies to the Chinese community. On resources, I say to the noble Lord that we have had an historic uplift in the NHS
In conclusion, last week, in a Statement to the House, I mentioned five actions that we were taking in response to the SARS outbreak. The letter to the chief executives that I quoted was certainly circulated. We have now sent observers to look at screening mechanisms in Hong Kong and Singapore, and we are negotiating with Beijing. We have written to airlines to remind them of their responsibilities under the l999 aircraft regulations. We are making substantial progress in information going on to airlines themselves. In the meantime, we had a European meeting today on co-ordination and development. We look forward to seeing what will come out of that.
The UK has a very strong record of surveillance and management of cases. We observe the DOTS strategy set out by the WHO. I hope that, in response, noble Lords will appreciate that we are doing our very best in relation to both TB and SARS.
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