Select Committee on Science and Technology Minutes of Evidence


Examination of Witnesses (Questions 180 - 198)

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 this stage?

  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 and control.

  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 would operate.

  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 support that.

  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 of Health?

  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, for example.

  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 it?

  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 weeks, yes.

  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 the population.

  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 community.

  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 point?

  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.





 
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