Select Committee on Science and Technology Minutes of Evidence


Memorandum by the Department of Health

INTRODUCTION

  1.  The Government particularly welcomes the House of Lords Science and Technology Committee's initiative in conducting an inquiry into the United Kingdom's preparations for an outbreak of pandemic influenza, which is both timely and topical.

  2.  In response to the call for evidence, this memorandum outlines the cross-government work the Department of Health (DH) is leading in conjunction with the Cabinet Office Civil Contingencies Secretariat (CCS), Devolved Administrations and other government departments and with support from the Health Protection Agency (HPA), to:

    -   improve UK health preparedness and response;

    -   strengthen international and national influenza surveillance capacity;

    -   improve assessment;

    -   commission research and development;

    -   provide essential medicines, vaccine and other supplies;

    -   produce timely public information and advice;

    -   develop arrangements at national, regional and local levels to manage the wider impact and co-ordinate the response to such an event.

  This work is being co-ordinated through a cross-government group which includes membership from the key departments involved in planning for an influenza pandemic.

How is the risk of pandemic influenza emerging/spreading assessed, can it be improved?

  3.  The widely held expert view is that there is a continued risk of pandemic influenza emerging from south east Asia; either arising from re-assortment of the currently circulating avian H5N1 viruses or another new virus subtype emerging. This risk is assessed on the basis of:

    -   the extent and geographic spread of the current H5N1 outbreaks in poultry and in migrating aquatic and other birds;

    -   the extent, severity and geographic incidence of avian flu in people;

    -   the extent of antigenic change in current H5N1 viruses, compared to the viruses which first emerged (in 1997);

    -   historic knowledge of the evolution of influenza viruses and of previous influenza pandemics;

    -   the demography of the region and opportunities it provides for interchange of genetic material between influenza viruses from different species.

  There is a possibility that a pandemic could emerge in another part of the world if the outbreaks of avian flu in poultry spread further than south east Asia. The risk of a pandemic originating in the UK is considered to be remote.

  4.  The epidemiological and virological information for assessing the risk is collected and interpreted by the World Health Organisation (WHO) and World Organisation for Animal Health (OIE). The European Commission (EC) undertakes assessments on behalf of Member States of the European Union and assessments are also undertaken by HPA and by the Veterinary Laboratories Agency to inform contingency planning by the DH and the Department for Environment Food and Rural Affairs (Defra).

  5.  UK modellers are amongst the international leaders in using mathematical modelling to assess the risk of the emergence of pandemic influenza and - once confirmed - the time it might take to reach this country. One group has recently published (in Nature) an assessment of the possibility of averting a pandemic spreading from a source in south east Asia following identification of the earliest cases. DH is drawing together the conclusions from UK modellers, including outputs from the HPA, in its preparatory work for a possible pandemic. The results from the modelling work stream are also reviewed by the DH Scientific Advisory Group.

  6.  Data on the extent to which less severe and sub-clinical infections are occurring in south east Asia - and from ongoing detailed characterisation and phylogenetic analysis of the prevalent viruses to detect antigenic drift or shift - are amongst some of the most crucial evidence. National and international efforts, co-ordinated by WHO, to ensure that appropriate epidemiological (including serological) studies are being performed and that a suitable range of viruses are sent to specialist virology laboratories for analysis, would improve assessment and increase confidence.

How great are the risks, what confidence can be put on assessments?

  7.  As we have never been in such a position before, the risks of a pandemic emerging can only be based on informed expert judgement. Projections of the likely impact of a pandemic are included in the UK Influenza Pandemic Contingency Plan.[1] Those are the best available based on current knowledge, previous experience and mathematical modelling, in which the UK is acknowledged to be one of the world leaders. The Plan therefore provides ranges of potential impact as well as the ­most likely" scenario for planning purposes. Those projections would need reviewing and revising in the light of emerging evidence as a pandemic develops. The Office of Science and Technology is leading on the Foresight project on the detection and identification of infectious diseases, sponsored by Lord Bach, with the support of DH, other departments and international organisations such as WHO, FAO and OIE. This international initiative will assess the nature of future risks (10-25 year horizon) and explore how the novel and innovative application of science and technology might feed into the new systems to affect step-changes in capabilities to detect, identify and monitor infectious diseases. The results, due to be published in spring 2006, will aim to inform strategies for the long-term management of the risks of infectious diseases in animals, humans and plants and explore potential synergies between them.

How is the UK working with international bodies to monitor the development of the virus and reduce the risk of pandemic influenza emerging and spreading?

  8.  The UK is active in supporting international efforts to detect, contain and respond to a pandemic. It leads the influenza pandemic work stream of the Global Health Security Action Group jointly with the USA, has hosted a meeting of mathematical modellers and participates fully in WHO and EU work on influenza.

  9.  The UK hosts one of the four WHO Collaborating Centres for Influenza at the National Institute for Medical Research. The Institute receives viruses for detailed virological analysis and its laboratories - with those of the National Institute for Biological Standards and Control and the national influenza reference laboratory at HPA - work together closely and are all involved in advising WHO.

  10.  The UK has also given WHO additional funding to improve surveillance in south east Asia and a senior UK epidemiologist - now seconded to the European Centre for Disease Prevention and Control to co-ordinate their influenza work - has assisted in the risk assessments.

  11.  UK modellers from HPA and Imperial College London are involved in advising WHO on the likely impact of public health measures and on the possibility of early intervention controlling spread. The UK continues to share and exchange experience in pandemic preparedness planning at EU and WHO levels and to contribute to their efforts to support those countries whose plans are less developed.

  12.  The Department for International Development (DfID) also provides funding to WHO and has encouraged UN agencies to use existing resources to focus on avian flu as a potential precursor for a flu pandemic. It is also urging relevant UN agencies to work with affected countries to develop affordable plans for tackling avian flu and improving wider pandemic preparedness. DfID may devote further resources if additional support is needed. Defra has also provided technical supplies and expertise to WHO, FAO, and to individual countries.

  13.  Health Ministers are open to preliminary WHO proposals to establish international stockpiles of counter measures providing it can be shown that they could be deployed effectively and would actually help reduce the risk or delay international spread.

What is the current assessment of the likely impact of pandemic influenza on the UK in health and wider terms?

  14.  Based on current knowledge, analysis of past pandemics, published evidence and mathematical modelling, the likely range of health impacts and various planning assumptions are described in the Influenza Pandemic Contingency Plan. The Plan also describes the most likely scenario for planning purposes. This assumes that around 25 per cent of the UK population will suffer from flu over the course of the pandemic. The modelling also suggests that at least 80,000 people will require hospitalisation and a minimum of 50,000 people may die.

  15.  Meeting the additional demands of a pandemic would be a major challenge for all health and social care organisations. Higher staff absences, any travel difficulties, possible shortages of essential supplies and disruptions to the wide range of basic supporting services on which modern health services rely are examples of the type of factors likely to add to response pressures.

  16.  A Ministerial Group on Consequence Management and Resilience oversees UK preparations to respond to a pandemic and to manage its consequences. DH, with CCS support, leads cross-government work to assess the impact, develop plans and to mitigate the wider social and economic consequences of pandemic influenza. That work recognises that:

    -   an influenza pandemic is potentially a major disruptive threat to every part of the UK;

    -   robust and resilient inter-agency contingency plans are required to mitigate its effects;

    -   plans must be inclusive and recognise inter-dependencies;

    -   clear leadership at all levels will be a critical success factor;

    -   arrangements for clear public advice and communications are essential;

    -   effective co-ordination is vital at national, regional and local levels.

  17.  Cross-government work-streams are also making good progress in addressing non-health issues. They include social interventions, maintaining essential services, dealing with fatalities, business continuity planning in non-health sectors and care of British nationals overseas in conjunction with the Foreign and Commonwealth Office (FCO).

  18.  A pandemic will have a major international impact on trade, travel and the world economy. It has the potential to increase international tension given likely disparities in its impact and differences in the economic and infrastructure capacity of nations to respond. Securing supplies of essential materials and priority for pharmaceutical products are examples of potentially difficult international issues.

  19.  The UK economy would be affected by an influenza pandemic. Preliminary estimates of the impact can be made based on the planning assumptions in the UK Health Departments' Pandemic Influenza Contingency Plan ie absenteeism from work (cumulatively 25 per cent of workers off sick over the pandemic period) and a case fatality rate of 0.37 per cent.

  20.  Undertaking an economic assessment of a hypothetical event like a flu pandemic is inevitably difficult and subject to significant uncertainties. Moreover, the actual economic impact would be conditional on the nature of the pandemic virus and on the prevailing economic circumstances. The overall effects would also depend on how companies and individuals adapt to the onset of a pandemic. The assessment is therefore relatively simplistic and should be regarded as being for illustrative purposes. In particular, it is likely to represent upper bounds of the potential impact of an outbreak. It suggests that illness-related absenteeism from work by 25 per cent of employees could reduce the year's GDP by £3 billion-£7 billion or 0.3 per cent-0.6 per cent. Premature deaths could reduce the year's GDP by a further £1 billion-£7 billion depending on whether case fatality rates are low (0.37 per cent) or high (2.5 per cent) and on whether earnings or gross output is used in calculation. In the longer term, the impact of premature death could reduce future lifetime earnings by £21 billion-£26 billion at a low and by £145 billion-£172 billion at a high case fatality rate.

Are measures described in the Plan adequate, what more could be done?

  21.  The UK Influenza Pandemic Contingency Plan, revised in March 2005, reflects the most current information, advice and assumptions at the time of publication. It sets out a range of contingency measures that are proportional to the potential threat and designed to improve health and wider preparedness. It also provides advice and information to support local preparations and the UK's progress in developing contingency arrangements has been recognised by a WHO visiting team and others as an example of good national planning. However, planning is ongoing and knowledge developing. In keeping with the intention that it be a living document, a further revision will be available later this year.

  22.  The scale and nature of the challenge leaves no room for complacency and the Plan recognises that gaps remain. Domestic and international vaccine development and manufacturing capacity, expanding community and acute health provision, increasing laboratory capacity, maintaining essential supplies/services, modelling the potential health benefits of various social measures and exploring whether priority access to treatment or prevention for essential workers could be effective are examples of further work in hand.

23.  Self-help measures for the public and private business continuity planning across all sectors will be key to minimising effects of a pandemic. The interdepartmental group has been promoting and encouraging business continuity planning across all sectors in preparation for possible pandemic; building on greater awareness and emphasis on key business activity over recent years.

How well prepared/coordinated are health, emergency and other services?

  24.  The UK has well established civil contingency mechanisms at national, devolved, regional and local levels to co-ordinate the response to any major disruptive challenge, including influenza. Within that mechanism, DH is the lead department for a pandemic. It has formed a National Influenza Pandemic Committee to provide specialist advice on the health response, supported by a Scientific Advisory Group to provide detailed scientific advice. Strategic Health Authorities (in England) are responsible for overseeing health planning and coordinating the local response.

  25.  Operational guidance - issued by DH in May - requires health organisations to focus on pandemic influenza as part of their contingency planning with advice, expertise and support from HPA. DH also produced a planning framework for using antiviral medicines in September, national guidance on clinical management, and guidelines on infection control are due to be released shortly and planning advice and information for influenza vaccination is being developed.

  26.  Regional Resilience Forums have greatly increased the focus on business continuity, maintaining essential services and planning for the wider aspects of pandemic preparedness. Health organisations participate in those forums and Regional Directors of Public Health help ensure that plans are harmonised and coordinated. International, national, regional and local exercises have been organised with HPA support to test various aspects of the arrangements and an on-going exercise programme arranged.

  27.  This is underpinned by the statutory duty in part one of the Civil Contingencies Act, which comes into effect in November 2005 and requires all category one responders to plan for emergencies and to have effective business continuity planning arrangements in place.

What is being done to increase public knowledge and awareness?

  28.  An effective communications strategy is a major component of the Government's pandemic preparations. Research commissioned by DH earlier this year suggested that the general level of awareness and understanding of influenza amongst health professionals and the public is currently very limited. Timely advice and information will help prepare the population for the potential impact of a pandemic and be critical to its management.

  29.  The DH communication strategy is based on increasing understanding of seasonal and pandemic influenza before any pandemic and preparing materials and systems to:

    -   convey accurate, timely and consistent advice to the public and health professionals if alert levels increase;

    -   promote awareness and understanding amongst the general population;

    -   explain how the NHS, DH and government as a whole intend to minimise the impact of a pandemic as far as possible and some of the constraints;

    -   give advice on self help and preventative measures.

  30.  The FCO provides routine advice to travellers. Further work underway, led by DH, includes communicating with ­hard to reach" groups, building a portfolio of stand-by broadcast/print materials, developing an advertising brief, producing leaflets on antiviral use and vaccination, research and material pre-testing and training materials for frontline health staff.

  31.  In addition to material to increase awareness of seasonal influenza the DH website[2] has pandemic material available including:

    -   The UK Health Departments Influenza Pandemic Contingency Plan;

    -   Operational Guidance for NHS planners;

    -   The Chief Medical Officer's guide ­Explaining pandemic flu";

    -   A Pandemic flu key fact sheet;

    -   Frequently asked questions;

    -   An information leaflet ­Pandemic flu, important information for you and your family" - also available in health clinics and surgeries.

  32.  The Government's News Co-ordination Centre is set up to manage the communications aspects of a crisis, emergency or other disruptive challenge and supports DH as the lead government department by providing co-ordinated media and public communications.

Is the UK's stockpile of antivirals adequate, how will it be distributed, what steps to ensure access to antiviral treatment and vaccine in a pandemic?

  33.  Until an effective vaccine is available - or as an adjunct to vaccination - antiviral medicines may lessen the severity and duration of illness, reduce the need for antibiotics and lower demand for hospital care. Antiviral medicines are used to treat seasonal influenza but normal stock levels would be inadequate in a pandemic, international demand is already high and rapid post-event supply would be unlikely. UK Health Departments are therefore building stockpiles of 14.6 million treatment courses of oseltamivir phosphate (Tamiflu) which will be complete by December 2006.

  34.  The UK is securing one of the largest stockpile of antivirals as a proportion of population, which will allow for treating all influenza patients at a cumulative clinical attack rate of 25 per cent or less. It is impossible to predict the attack rate, but 25 per cent is generally considered prudent for planning purposes and is recommended by WHO as the basis of national plans. Should the actual attack rate prove higher - or until the stockpiles are fully established - priority for treatment will be given to those frontline health staff at higher risk than the general population and patients considered at most clinical risk of complications.

  35.  A planning framework describing arrangements for the storage and distribution of antiviral medicines, their use and the local planning needed to make them rapidly available to patients was issued to health planners by DH in September and is available on the website.

What is the role of vaccine development, manufacture, distribution?

  36.  Although it remains the most effective countermeasure, a strain specific vaccine is unlikely to be available at the start of a pandemic. To produce an influenza vaccine, manufacturers need a suitable reference strain of influenza from which to derive seed stocks. This has to be produced from the wild-type strain causing disease by re-assortment or reverse genetics and must be safety tested before use. Developing the seed stocks normally takes around two months. It would take about six months in total before production can start in earnest, but that is dependent on manufacturers changing use of their facilities from routine to pandemic vaccine production.

  37.  It may be possible to shorten the time to develop a vaccine to two months by having already prepared and tested a library of reference strains, which is constantly updated as new strains emerge. This depends on the existing strain being reasonably close to the pandemic strain and providing cross-protection. A small amount of additional time could be saved if seed stocks for manufacture were prepared in advance and by undertaking tests on candidate material for vaccine production in parallel rather than in sequence could also assist.

  38.  Once developed, demand would far exceed international vaccine manufacturing capacity, which is currently based on seasonal influenza vaccine demand and globally sufficient for only about 5 per cent of the world population. Supplies could be limited to those countries that have negotiated the advance purchase of manufacturing capacity in the first instance. In conjunction with the NHS Purchasing and Supply Agency (PaSA), HPA and vaccine manufacturers, DH is actively exploring a range of preparatory steps to improve the prospects of early delivery of pandemic influenza vaccines. This work - much of which is commercially sensitive - includes:

    -   developing ­mock up" or prototype vaccine;

    -   the production of vaccine ­seed stock";

    -   encouraging manufacturers to submit dossiers on prototype vaccine for regulatory approval;

    -   exploring the possibility of reducing the time needed to determine the pathogenicity of reference strain;

    -   investigating novel methods of manufacture;

    -   discussing options for priority supply;

    -   purchasing a supply of H5N1 vaccine to protect health and other front line workers required to respond to an influenza pandemic arising from the strain currently circulating in south east Asia (currently being finalised).

  39.  Whilst research to accelerate pandemic flu vaccine development may benefit from international co-operation, sharing inadequate supplies may be counter productive. DH officials have met representatives of all appropriate vaccine manufacturers to discuss vaccine development and capacity issues.

  40.  DH officials have also met with a company that is developing DNA influenza vaccine - which might be a longer-term possibility - and have commissioned and received a consultant's report on antigen sparing methods such as intradermal innoculation and other ways to extend supplies of vaccine. DH has also commissioned an external independent expert review of what possible role national institutions such as HPA Porton could play in accelerating protection against emerging infectious diseases such as pandemic influenza.

What is the long term strategy for reducing the pandemic threat?

  41.  The influenza virus has already shown its adaptability and resilience. Eradicating the threat is unlikely to be achievable in the immediate future. A range of veterinary and social strategies - particularly improved animal husbandry, veterinary control and education - in potential source countries would help reduce the risk of antigenic shift and improving understanding, research, mathematical modelling and surveillance will assist in developing more effective counter measures.

  42.  Advances in pharmaceuticals and other health care improvements can reduce the transmission and severity of influenza illness: thus reducing morbidity and mortality and slowing or limiting a pandemic's spread. DH is also working with Research Councils UK to take forward issues relating to the UK's national preparedness and response strategy.

CONCLUSION

  43.  The UK has made good progress in preparing for the health and wider effect of an influenza pandemic and raising awareness of its potential. Its high-probability, high-impact nature leaves no room for complacency and demands on-going attention to ensure the progress made is maintained and improved. The Government is committed to maintaining that momentum.

September 2005


1   available at www.dh.gov.uk/pandemicflu Back

2   www.dh.gov.uk/pandemicflu Back


 
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