Memorandum by the Department of Health
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
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;
- commission research and development;
- provide essential medicines, vaccine
and other supplies;
- produce timely public information and
- 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
- 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
- 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
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
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
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
- 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
- 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
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
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
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
- 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
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
has pandemic material available including:
- The UK Health Departments Influenza Pandemic
- Operational Guidance for NHS planners;
- The Chief Medical Officer's guide Explaining
- 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
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
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,
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
- developing mock up" or prototype
- the production of vaccine seed
- 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
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.
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.
1 available at www.dh.gov.uk/pandemicflu Back