Select Committee on Science and Technology Minutes of Evidence

Examination of Witnesses (Questions 154 - 159)


Professor Nigel Mathers, Dr Richard Jarvis, Ms Lynne Young, Professor David Menon and Ms Helen Young

  Q154  Chairman: May I welcome our five witnesses to this session this morning and members of the public and the media who are attending. This meeting is being webcast and the webcast may be filmed by the broadcasting companies as well, so this is very much a public meeting. An information note is available for everybody. May I ask the witnesses to be as concise as you can in your answers because we have a number of questions and, with five of you, we would like to hear from you on these issues and time will slip away? Will you each introduce yourself for the record?

  Dr Jarvis: I represent the British Medical Association today. In my normal work I am a consultant in health protection in Cheshire and Merseyside working with the Health Protection Agency.

  Professor Menon: I am Professor of Anaesthetics at Cambridge. I am a working as an intensive care doctor and representing the Intensive Care Society

  Professor Mathers: I am Chair of Research at the Royal College of General Practitioners. I am also Professor of Primary Medical Care at the University of Sheffield. I am a GP working in inner city Sheffield.

  Ms Lynne Young: I am a primary health care adviser at the Royal College of Nursing, so I am a community nurse by background. I am not a scientist but very much in touch with nurses who will be dealing with the programme.

  Ms Helen Young: I am the Executive Director of Nursing for NHS Direct. I am also Clinical Director for that organisation.

  Q155  Chairman: Thank you. I start with the first question, which is directed to the ICS. Can you outline what impact you would expect a flu pandemic to have on your work?

  Professor Menon: The impact is going to be critically dependent on how virulent the virus is. There is a whole range of possibilities. We know that avian flu infection, the one that is transmitted from chickens to people but not between people, has a mortality of about 50 per cent, so you could expect about half of the patients who come into hospital to require intensive care. At the other end of the spectrum, we have started to put together some information that suggests that if you look at winter flu surges, about 3 to 4 per cent of that range of patients who come into hospital will require intensive care. What we did was to use some software developed by the Centre for Disease Control in Atlanta to try to estimate what the impact on intensive care would be in the event of a possible pandemic. They have assumed a 7.5 per cent requirement for mechanical ventilation - the need to go on a breathing machine. With that, at peak epidemic, we would anticipate that bed occupancy would be 230 per cent of our current intensive care capacity. Clearly, that could be mitigated by things like antivirals, or we could increase that capacity temporarily. Those are things we may want to discuss later.

  Q156  Chairman: Could we hear from the others on this general question?

  Dr Jarvis: The BMA recognises there are a great number of uncertainties relating to the pandemic flu: whether it will happen at all, what its attack rate will be, what the mortality rate is likely to be. It estimates that the effect on society as a whole will lie somewhere between major and catastrophic. However, we want to make the point that the pandemic planning that is being undertaken at present has our full support and is as good as that of any country in the world in order to meet this particular threat. This does not get past the major hurdles that we have in meeting the possible pandemic. Those are: an increase in the number of patients requiring treatment by the NHS, by general practitioners, by secondary care trusts; a decrease in the number of staff available due to illness themselves; and, finally, the generalisation which has to do with the condition.

  Q157  Lord Patel: May I ask a supplementary to Professor Menon? I am pleased to hear that there is some thinking being done and contingency plans developed based on that thinking, The thinking, to a degree, is pessimistic in terms of the numbers we might get, which is probably good too. Yes, the beds might be available but what about the equipment?

  Professor Menon: In simple terms, if we have an increased load of intensive care patients, we need three things: somewhere to take care of them; equipment with which to take care of them; and people to take care of the equipment and the patients. In terms of space to take care of patients, one possibility is for us to utilise the space that would otherwise be utilised for other things. For example, normally, operating theatres have ventilators, monitoring equipment and so on, as do operating theatre recovery areas. You would anticipate that in a pandemic those would not be used for elective operating lists. We have made the suggestion that hospital trusts look very carefully at how they could expand those areas and that would, to some extent, also provide us with essential equipment. The difficult thing is going to be people. We are going to be limited in terms of nursing and medical staff. I should preface all of this by saying that most intensive care units in country, in the absence of a pandemic, run at about 85 to 90 per cent occupancy, going up to 100 per cent from time to time. In an intensive care expansion scenario, the problem is, just as 25 per cent of everyone in this room will become infected, 25 per cent of the staff in intensive care will become infected. There has been some work done in the States where they went and asked nursing staff, ­Would you be willing or able to come in to work in an emergency?" At one end of the spectrum, if there was a building collapse and a lot of people died, all the nurses said they would turn up. At the other end of the spectrum, if there was a snowstorm and all the roads were blocked, none of them would be able to come. With a pandemic or a bio-terrorist surge in demand, the problem is that some nurses may not be able to come because of transport. In addition, others may not be able to come in because many of them will be naturally scared, either for themselves or for their families. I think we ought to say that either because of sickness, or fear, or inability to get there because the infrastructure has collapsed, we should anticipate that we will lose 20 to 50 per cent of our nursing staff in ICU anyway. We have to expand from there to the normal level and beyond. There are ways we can do this. What we have suggested to the Chief Medical Officer's colleagues is that we train nurses who normally work in wards and operating theatres in some of the core clinical care skills so that they can actually come and support critical care nurses, and do the same with doctors. That is something we have to put in place now. We are trying to work out a core curriculum for both medical and nursing staff and how we can try to implement that.

  Q158  Lord Howie of Troon: I think Dr Jarvis said that if an outbreak were to occur, it might be either major or catastrophic. My question really is this: is the planning which is being arranged now aiming at major or catastrophic?

  Dr Jarvis: A number of assumptions are made in the plans, based on realistic estimates of attack rate and mortality rate. The planning assumptions derived from those are based on middle of the range estimates. I think we have to plan for what is reasonably foreseeable at a level that is reasonably foreseeable.

  Q159  Lord May of Oxford: You have said that case mortality in the people who have contracted it directly from the animals they work with is about 50 per cent, or 60 out of 120. I wonder whether in the dominator there of 120 there may be many people who have been infected but not seriously enough to be recognised in the system. I am ignorant on this but there are quite a lot of zoological studies of people who work with poultry, and I think about 1 in 1,000 show antibodies to H5N1, which suggests some sort of reaction. That adds up to quite a lot of people. I wonder to what extent that 50 per cent may be slightly higher than the real number.

  Professor Menon: I think that is a very fair point. Happily, it is not something that we have to deal with. What we have concentrated on asking is: if patients are sick enough to come to hospital, what proportion of those would require intensive care services? That, I suppose, is the crucial test as far as we are concerned. That, at least, allows us the luxury of dealing with harder data.

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