Examination of Witnesses (Questions 180
THURSDAY 27 OCTOBER 2005
Professor Nigel Mathers, Dr Richard Jarvis, Ms Lynne
Young, Professor David Menon and Ms Helen Young
Q180 Chairman: To your knowledge,
there is no dipstick test, as we have described it, for this at
Professor Mathers: The sensitivity - that is
the chances of being right - would depend a bit on how common
the disease is. The sensitivity is around 30 to 40 per cent of
a nasal swab. That means that you are less likely to be shedding
the virus if it is negative and you are less likely to be infectious.
That could be, but that is a pretty low sensitivity and will be
affected by prevalence as well.
Ms Lynne Young: On the issue of regulations,
there are one or two regulations in place that need to be confronted
if we are to do what is required. It may not be an issue but there
is a regulation on the use of unlicensed drugs. I would like the
committee to be aware of that. If nurses and others are to give
mass vaccinations and other drugs within what is called patient
group directions, which prevent the use of an individual prescription
for each patient, the unlicensed drug matter would have to be
dealt with. Am I clear with that? You cannot give an unlicensed
drug within a patient group direction. That is the issue.
Q181 Lord Taverne: May I follow up
on the question of research? Obviously any research that has to
be done has to be done very quickly; it is very urgent. Are there
any regulatory obstacles that have to be overcome to ensure that
you can do the research quickly enough?
Professor Menon: There is a question of time
because it takes a certain amount of time. In our experience,
because of the issues about the Clinical Trials Directive, if
you wanted to assess, for example, whether steroid dugs which
reduce inflammation are helpful in the most sick patients, that
would have to be run as clinical trials. It takes three to four
months to go through the regulatory hoops to get approval for
a clinical trial. This may be quite appropriate, but the point
is that we need to do it now. Generally, there is an issue of
time. We need to get started now. For specific groups of patients,
again there are issues, for example, with children. I have not
addressed the issue of children. We have been talking about ICU
expansion. It is important to realise that many children may become
infected with this agent. If we have to expand paediatric ICU
facilities, that raises a whole different series of problems.
Maybe we should talk about that separately. Children are one issue.
People who get so sick that they cannot provide consent to research
are another issue. Finally, the whole issue of taking blood and
keeping it for DNA so that we can look at the genetic associations
to determine which patients get the sickest and which patients,
if they get the sickest, survive, will all mean that the requirements
of the Human Tissue Act will have to be fulfilled. Some of those
are not in place as yet. The regulatory framework is not in place
yet. We need to reach an accommodation that allows us to proceed
with this research if we want to do it.
Q182 Baroness Finlay of Llandaff: May
I follow up on that, Professor Menon? Are you implying that there
is a need for a new statutory instrument to be brought in, in
the event of there being a pandemic, to override some of the bits
of legislation which are in place at the moment which are impeding
immediate research on patients who lack competence to give consent
and whose families cannot give consent in relation to things like
the Human Tissue Act?
Professor Menon: I think that would be very
valuable, provided we have the safeguards. We have to take the
public along. We need to make clear that providing patients are
not being harmed, and providing for the issue of confidentiality,
we should undertake such research because then the greater public
good demands this. However, we have to have the safeguards to
say, You are not going to be harmed". This is important.
God knows, the medical profession has a record of not communicating
well. We need to get that right, but, if we do, I think the public
would be supportive.
Q183 Lord Patel: My question relates
to the current organisation activity that is going on in the NHS
or reorganisation, that you partly referred to early on. The whole
ethos of that is to devolve down the responsibility. Do you think
that kind of devolution of responsibility is going to be effective
in delivering proper care in a pandemic situation? That takes
you away from a pandemic situation where you want central command
Professor Mathers: That would be precisely the
issue that I raised earlier. In such a situation of a flu pandemic,
you would need command and control. It would not be enough to
leave it to individual practices, or even individual PCTs, to
deliver the necessary care.
Q184 Lord Patel: Are you currently
addressing that issue?
Professor Mathers: We are in the College. We
prepared a major incident and disasters plan two years ago in
which there are details of how such a command and control system
Q185 Lord Patel: Are you addressing
that with the Department of Health?
Professor Mathers: The Department of Health
has been part of that, yes.
Ms Lynne Young: I would like to make a point
about the state and robustness of the Primary Care Trust at this
time. The reality is that there is complete pandemonium out there.
For example, in the north-east of England, 16 Primary Care Trusts
will go down to two. This is causing huge anxiety and huge distress.
For very understandable reasons, I think people are looking at
their jobs and where they will be in the next few months rather
than keeping the eye and the focus of attention on what local
people require from health services. I think that has to be taken
very seriously at the highest level. That is how it is at the
moment. We are hearing from our nurse members every day about
what utter chaos and confusion there is in Primary Care Trusts
at the present time.
Professor Mathers: My Lord Chairman, I would
Q186 Baroness Finlay of Llandaff: I
am a great fan, of course, of GPs, having been one myself. What
authority does the College of General Practitioners have nationally
to take command and control? Is that being recognised by the Department
Professor Mathers: I would not suggest that
the College took command and control at all. I think our role
is to inform and certainly encourage our members as to best standards
and what is appropriate. We work very closely with partners. I
think command and control lies with the Primary Care organisations,
whatever they happen to be.
Q187 Baroness Finlay of Llandaff: At
that level and not higher?
Professor Mathers: We would input higher up
but I do not think we would want the College to be in the position
of being in command and control. There is also the whole question
of rationing. If there is insufficient antiviral and it is effective,
then in the College we would not want individual doctors to be
engaged in deciding who was treated and who was not - dispensing,
Q188 Lord May of Oxford: As a supplement
to that, are you happy that you have been consulted as an institutional
body adequately? In particular, we keep using the word pandemic"
and talking about just the UK, but it is very likely that by the
time we come to be talking about the UK, there will have been
a great deal of experience elsewhere already. In the light of
that, could I also ask you, while we are dealing with that: are
you happy with the degree to which the plans assume that the public
will behave calmly and will not be badgering you unduly, particularly
as they will be well aware that Tamiflu can be used both to treat
people who are diagnosed but also as targeted prophylaxis? Are
you happy that the current plans that it would just be given to
people who are sick are going to stand up when people in the same
house or the same school class are going to be pressing you for
Professor Mathers: My Lord Chairman, this is
a key issue. We are very heartened by the response of NHS Direct,
who I think will play a crucial and critical role in the necessary
information campaign. There need to be very clear guidelines as
to what your doctor or your nurse can and cannot do for you, how
antivirals should be used in the community, if at all, and who
should make the decision. Those issues are not clear from the
current pandemic contingency plans.
Q189 Lord May of Oxford: May I ask
the others how they feel about that? It is going to make your
life very difficult.
Professor Menon: Clearly there are going to
be issues about rationing of intensive care if this gets as bad
as we hope it does not. We have some basis for doing this. The
natural thing that is trotted out is age, but the key factor is
not age; but the presence of pre-existing co-morbidites - diseases
in other organs. Patients may have a bad heart and bad respiratory
disease and then, if they get an acute flu infection, their chances
of survival are going to be quite small. Those are issues which
have to be discussed, I suppose, at some stage. Again, it would
be useful to have this discussed nationally rather than each individual
intensivist having to make the strategic rather than the tactical
decision. As far as experience from abroad is concerned, there
are two areas where we have had a lot of discussion. One concerns
the Far East, and colleagues in Hong Kong have been very helpful.
Tom Buckley, one of the intensivists there, has been in communication
with us. They may have the scar of SARS on their experience, and
it is going to be very difficult for us to try to get up to their
levels of preparedness. For example, his intensive care unit in
one hospital has nine negative-pressure isolation rooms. The number
of negative-pressure isolation rooms over Hong Kong for a total
population of a couple of million runs into several hundred. These
are ICU negative-pressure isolation rooms. We would be very lucky
if we had that within the UK for a much larger population base.
The other set of people we have talked to a lot are the Canadians,
again because of SARS. We have learnt a lot from their publications
and talking to them has provided added value. In answer to your
question, yes, we are talking to them.
Q190 Lord May of Oxford: Would you
feel that the institutions you represent are adequately involved?
Professor Mathers: As of the last couple of
Ms Lynne Young: You may not know about this
but the United Kingdom National Influenza Committee has just been
set up. That is due to meet in the next couple of weeks. We will
be involved, as, I imagine, will all the organisations. Obviously
sub-groups will be set up under that umbrella. We will be very
involved with that and that is good news. May I say this, and
it may be a depressing note on which to finish, that we also have
to acknowledge that if there is a great acceleration in deaths,
that will have to be handled. I think it was three winters ago,
when there were was a flu epidemic, there problems disposing of
bodies in a dignified way. We have to talk about prevention and
management but there will be more deaths. We have to manage that,
too, with dignity.
Ms Helen Young: In response to a question in
relation to whether we have been consulted as a national organisation
within the NHS, yes, I can give a reassurance that we have been
consulted and we have played a role both nationally and with the
Department of Health and other colleagues, but we have also been
consulted and involved regionally and in some of our regional
areas also locally with partners. I have mentioned already the
role that we all play in public information, public health and
education. We are additionally working with the Department of
Health on an advertisement campaign that is a pre-runner to any
potential outbreak or pandemic, which will give the public information
specifically on all signs and symptoms and access to the emergency
services. We are fully aware, as a national organisation, of our
gateway role and the need to be both resilient and robust in order
to protect other parts of the NHS. I can give some reassurance
that we are aware of gravity and scale. We are planning to do
everything we possibly can both in advance, during and in a protective
role to help the elements of the NHS that will need to be utilised
for face-to-face consultation.
Dr Jarvis: On the question about being consulted,
the BMA has been relatively poorly consulted up until the last
two weeks, but we have encouraged the Chief Medical Officer to
set up multi-agency stakeholder meetings to address this issue
as a matter of urgency. Regarding overseas co-operation, the virology
and epidemiology aspects in this country are led by the Health
Protection Agency Centre for Infection, in Colindale. There are
very good links through the World Health Organisation with all
other countries that are likely be to be affected by this, particularly
the Far East, so I would like to reassure you that those surveillance,
epidemiology and virology networks are in place.
Q191 Lord May of Oxford: I perhaps
folded too many bits into the question, but could you say a little
bit more about how you feel about what is (as best we could gather
the other day) the current idea that if one person in a household
is infected they get Tamiflu but that it is not currently envisaged,
and it would have to be a very deliberate thing, to offer it to
others, when your information system will have told other people
in the household that there is a prophylaxis purpose and I can
even see parents with flu giving their children their drugs if
you do not give it to them. To what extent, particularly as a
GP, do you envisage handling that at the surgery?
Professor Mathers: That is a very difficult
question to answer individually.
Q192 Lord May of Oxford: Generally?
Professor Mathers: From my own point of view
I think that it would be sensible to restrict Tamiflu to treatments
and not to prophylaxis because the Department of Health plans
include 14.6 million doses which is enough for 25 per cent of
Q193 Lord Patel: Are you suggesting
that is inadequate?
Professor Mathers: If it were to be used as
prophylaxis then you would need a dose for everyone in the country
which I think would be unreasonable because there are suggestions,
although I am no expert in this area, that should a pandemic occur
then its virulence will diminish in order to facilitate transmission
person-to-person. That is my understanding, in which case it would
seem logical to me that Tamiflu should be restricted to those
who actually do have the disease rather than those who have been
in contact. The Department of Health calls for voluntary quarantine
for those. I think it is an issue that needs to be discussed.
Q194 Chairman: But is it your recommendation
or would you support the relatively small number of doses of Tamiflu
that have been ordered? Would it not be a good idea to order more?
Professor Mathers: Not everybody, as I understand
it, and again this is not my field of expertise, will catch the
flu. Lord May was saying earlier there are people who are asymptomatic
and in the cases that have been reported the 50 per cent mortality
may just be the tip of the iceberg. There may be plenty of other
patients out there who have had the disease and not come to the
attention of the surveillance procedures or the surveillance mechanisms.
It is still full of uncertainties.
Q195 Chairman: Is it consistent to
be ordering 120 million doses of vaccine and only 14.6 million
doses of Tamiflu?
Professor Mathers: I think that is a question
for the Department of Health to answer.
Lord May of Oxford: Very quickly on this.
First of all, the roughly quarter is a very soft number, you understand.
For example, Imperial College modelling of what they think is
the most likely, but with a wide range of possibilities, beginning
in South East Asia, is assuming that in the absence of intervention
two-thirds could be infected, it is a very soft number and it
could be fewer and it could be more. Secondly, all these plans
are assuming that everybody behaves in a quiet way rather than
getting very upset. Thirdly, the notion - and the evolution of
virulence in infectious disease actually happens to be one of
my academic subjects - that you can rely on it becoming less virulent
as it goes on is a very out-of-date notion and a very frail read
to depend on in the opinion of the informed frontiers of the subject
Q196 Chairman: Just one more point
from each and then we are going to have to wrap this up.
Professor Menon: I would just make the point
that if you are using Tamiflu for targeted prophylaxis you would
not need 60 million courses, you would need much more than that
because the pandemic is going to go on for eight to twelve weeks
so you will need eight to 12 times the population.
Q197 Lord May of Oxford: Depending
on the extent to which we could be effective in containing the
foci by using targeted antiviral prophylaxis.
Dr Jarvis: Just to return to something I said
at the outset, which is there is a great deal of uncertainty about
this, and I think the numbers of vaccines and the amount of drugs
that are purchased is based upon planning assumptions which may
vary from what happens in reality. The second point that I would
like to make is that when we are considering who should be given
the vaccine and who should be given the antivirals, it will depend
very much when in the pandemic, when in the epidemic curve we
are actually at present and how much of that medicine is available.
So where I draw that to is that the algorithms and the decision
aids that we would use to assist GPs and nurses actually doing
this would change during the pandemic. My absolutely final point
is that under no circumstances can we let individual GPs and nurses
on the frontline have to make decisions of that magnitude; it
needs to come from the centre.
Q198 Chairman: Alright, thank you
very much for your evidence. Did you want to make just one more
Professor Mathers: Just one last point. I think
that we have made a good start with this contingency planning
and I think we have got time to continue the work.
Chairman: Good. If you have other points
you would like to make, we are always open to that input so get
in touch, write to us, submit more if you have more to say. Thank
you very much indeed for coming this morning.