Examination of Witnesses (Quesitons 240-259)
MRS DAWN
PRIMAROLO, MR
JIM FITZPATRICK,
MRS SANDRA
WEBBER, DR
RAY JOHNSTON
17 JULY 2007
Q240 Lord Patel: Do you get the feeling
just now in your discussions that they are likely to take the
matter as seriously as the Aviation Health Unit currently do?
Dr Johnston: The answer is I do not know until
I speak to them in more depth. I think we take it very seriously.
This unit is a world first, and I would hope EASA would take it
seriously also.
Q241 Chairman: You are happy with the
UK representation on EASA?
Dr Johnston: Yes, I think I am. I think that
EASA has legal powers. I think the UK is very forceful and is
very determined to make sure that the accident rate in the United
Kingdom, which is second none, is not eroded, and I think high
standards will be preserved.
Q242 Chairman: How many members does
it have? Is every member of the EU represented?
Dr Johnston: I do not have that information
to hand, but I can provide it.
Mrs Webber: I think EASA represents, in a collective
sense, all the Member States of the European Union[2]
but has a management board which has fewer than 27 on it, otherwise
it would be unwieldy, but we can provide that information. At
the moment EASA is a relatively new agency and it is gradually
acquiring functions which were individually carried out by the
national aviation authorities—the CAA in the UK and the
EU equivalents—and they are gradually being accrued to EASA
as it builds up its competence. It has not yet really begun to
tackle the health issues, as opposed to certification of aircraft,
but that is something that it is looking to develop.
Q243Lord Colwyn: We have had many letters on
this issue, as you can imagine. I do not want to spoil your day,
Dr Johnston, but can I quote to you from one letter we had. This
is a lady who suffered ill-health, she felt, from a fume event
possibly: "The CAA was the biggest fiasco I encountered with
telephoning and being passed around so many departments, no-one
knowing who should deal with this. I sent several emails regarding
passenger health and received two emails back stating that passenger
health was not within their remit and was a matter for the airline,
as was consumer issues."
Dr Johnston: I know the case to which you are
alluding, and, with respect, my Lord, when this individual lady
contacted the Aviation Health Unit I offered to review any medical
data that she cared to provide. That medical data was not forthcoming
and I repeatedly requested her to provide that information and
it has not been forthcoming. I would be happy if she wishes to
telephone me again. Myself and my secretary have been in contact
with this individual.
Q244 Lord Colwyn: I picked it at random.
Dr Johnston: I am sure, my Lord.
Q245 Baroness Platt of Writtle: What
Government sponsored research into aviation health has been and
is being carried out in the UK since 2000?
Dawn Primarolo: The first major piece, I think,
which you will be interested in is the WRIGHT Phase 1. That was
looking at the specific proposition: is risk associated with long-haul
over four hours qualitatively, different from other forms of travel?
That work, which was partly funded by the Department for Transport
and the Department of Health, indicated that risk in certain groups
can double for over four hours but that the increased risk is
with all travel. It is about sitting still in confined spaces
for a long time. As a result of that research, firstly the findings
were put onto both the Department of Health website in advice
on travel and the Department for Transport. The World Health Organisation
has recently published a final overview by the researchers, which
we will need to look at very carefully to make sure that all the
items are covered and refer it to our expert group. There was
another much smaller study also commissioned on the use of aspirin,
the perception of passengers, and whether there were significant
benefits or differences. I should stress, this was a small study.
Passengers were asked did they know about the use of aspirin,
and there was a high response that they were aware of aspirin,
but then why or when they should take it or if they should take
it was a very low awareness. In stressing that this is a small
study, there is no indication from that study that actually aspirin
is effective in reducing risk because, as you will see from the
Department of Health advice on its website, it makes it clear
about higher risk groups and what they should do, because obviously
there are some risks associated with taking aspirin as well under
certain conditions which, again, the traveller may not be aware
of. That has led to, I think, across all, the way advice is given
to travellers, quite clear advice on when they should consult
their GP, under what circumstances. If I could go on, what is
necessary and what is being considered now is, if you like, a
Phase 2, which will need to be a much larger project. Phase 1
is UK-led, UK-funded and I think an absolute first in terms of
consideration. I am sure Dr Johnston would be able to talk more
on this. Phase 2 is to look at what is effective use when a risk
is identified, whether socks or aspirin under certain conditions.
To actually try and get that we need a much, much larger study
for that, which means it has to go beyond the UK, and obviously
we will look at contributing to it, but those discussions are
now taking place. My apologies; that is rather a long answer.
Q246 Chairman: Can I follow up there,
I am sorry to interrupt, Lady Platt. How much of the Phase 1 study
was carried out in the UK?
Mrs Webber: There was a consortium, some UK
academics and a particular academic in the Netherlands; so some
of it was done on Dutch subjects and some it was done in the UK.
Q247 Baroness Platt of Writtle: We heard
from Professor Michael Bagshaw in evidence on 10 July and he told
us that not enough research was being conducted in the UK. Indeed,
he himself was unable to get funding for research. What can be
done about that?
Dawn Primarolo: Forgive me, I am not aware of
this point having been made. I think that the work that has been
undertaken to date was looking specifically at the identified
areas of concern in health, to make sure that we were giving correct
advice and understood the risk. So early on it was about assessing
risk; now it is moving forward. I do not know whether Dr Johnston
would want to add any more. Now is the time in looking at what
is effective against the scale of risk. I am not fully aware of
the particular that you are referring to, but if that is in the
area of how to deal with the procedures, then that is where we
are moving now.
Dr Johnston: I think that your question is more
about what contribution has the Government made in relation to
research, and Sandra might like to give the figures on that and
then I would be happy to address the Phase 2 questions.
Mrs Webber: Yes, in terms of DVT in particular,
our contribution was 1.8 million euros, which is something over
a million pounds obviously. In addition, we have spent money on
the normal cabin air environment—I do not have the figure
to hand but we could get it—and the research that we are
just embarking on, which we will talk about later in relation
to the fume events, we imagine might cost in the order of a couple
of hundred thousand pounds. So, I think in general, in terms of
the general call on Government research projects, we have earmarked
money for the priorities that were identified and, I suppose,
if anybody came to us with another aviation health research proposal,
we would consider it on its merits.
Q248 Baroness Platt of Writtle: Does
the Government have a strategic remit in this area?
Mrs Webber: I think the Minister mentioned the
new duty that the Government took upon itself in the Civil Aviation
Act 2006 to take measures to safeguard the health of passengers
on board aircraft and I think we would regard conducting research
fully within that remit.
Q249 Baroness Platt of Writtle: Section
23 of the Civil Aviation Act 1982 restricts the CAA on how they
can use information from pilots' medical examinations for research
purposes. Does the Government have any plans to amend the Act
to facilitate the epidemiological studies?
Jim Fitzpatrick: We are aware that this is a
restriction, and the matter has been raised before us. We have
not made judgment on it yet. It is something that we are prepared
to consider in due course, because we do recognise that there
will be value in sharing medical records for research purposes.
So, we have not made that decision so far, but it will be coming
up in due course.
Q250 Lord Paul: Phase 1 of the WRIGHT
project found that the relative risk of developing VTE for passengers
with existing medical conditions was doubled. In view of this,
what advice should be given to airline passengers to prevent VTE?
Dawn Primarolo: The advice is provided, firstly,
in a summary of the initial findings which was published on the
Department for Transport website in December 2005 and on the Department
of Health website, and that is to reflect the findings of that
report. Now the World Health Organisation overview study has been
published, it would be appropriate to look again, with our expert
advisers, on whether or not this continues to cover all of the
advice that should be given. Should there be further changes necessary
as a result of this most recent overview, these will then be discussed
between the Department for Transport, the CAA and the Aviation
Health Working Group, amongst others. I should add that it is
very early days, but the Department of Health is also considering
whether it should develop, if you like, a travel-related risk
toolkit that is able to be slightly more interactive than the
advice that we currently have, and, of course, the same advice
appears on other websites. It is also on the Foreign Office and
the Department of Health websites.
Q251 Lord Paul: There are various people
but, looking at it, who should be responsible for this advice
and what should be the role of the Government?
Dawn Primarolo: Clearly the Aviation Health
Working Group has responsibilities in making sure that the issues
are properly addressed, and there is advice to us, and then the
departments have to ensure that they are giving the correct advice
on their websites. Lord Paul, I do not know whether you have seen,
for instance, the Department of Health website. At the moment
it flags up advice on what you should do under certain circumstances;
it does not give you direct health advice. I think the onus is
on all of us, as I understand it, I take very seriously my responsibility,
as the Minister for public health, to make sure that the Department
of Health is up-to-date and co-ordinated and clearly cross-referenced
to any other advice, and it is about access points. I do not know
whether, Dr Johnston, you could explain the way that the advice
is interrelated so the access points can be numerous but still
end up with the correct advice.
Dr Johnston: If I may, Lord Paul. On the Aviation
Health Unit's website we have constructed frequently asked questions
on the basis of the inquiries we have had over the past year or
so, and there is a specific one for deep venous thrombosis which,
I think, summarises the situation, and we have inserted the links
into the WRIGHT study. If I could talk basically, although Phase
2 will address the specific issue of this risk environment, in
general terms what came out loud and clear from the WRIGHT study
was that immobility was an important risk factor. Therefore I
think it is essential to encourage mobility, and many airlines
have helpful advice in their in-flight magazine and, indeed, one
airline has a video showing you specifically what to do, because
they take health and well-being very seriously. If one is in a
specific risk group, extrapolating (and I accept it is extrapolation)
from the current risk groups in a surgical environment in which
there has been much interest in recent publications in the British
Medical Journal, if we look at a hierarchy of risk, low risk
mobility alone, as one enters a higher risk—recent surgery,
hormone replacement treatment or the contraceptive pill—one
might think about stockings, properly fitted as they are in hospital,
and the next stage will be pharmacological agents such as Heparin
or, indeed, Warfarin if the individual, on specific medical assessment,
is deemed fit to be treated in such a way. But I think the message
is loud and clear, if it is immobility, that which works on immobility
in a surgical environment, in the interim, until Phase 2 is done,
would be reasonable advice, but it should be specific advice for
the specific individual and the specific environment.
Q252Lord Paul: All these airlines are giving
you advice that there should be movement, etcetera, but when the
flight is really full where does the passenger go and walk? The
moment he gets up he is told, "Can you sit down, please?"
Dr Johnston: Having spent time in that part
of the aircraft to which you allude, the fundamental important
piece of mobility is to improve the venous return, the blood flow
in the leg, and one can actually move the feet up and down even
in the particular seats to which you allude, and, if one wants
to spend money, there are little devices which will assist to
actually do that, but simple measures such as that, which often
people think are not important, are fundamental to improving venous
flow. The simple things are often much more effective than the
highly expensive drugs, which will have side-effects, and I think
that needs to be stressed.
Q253 Lord Paul: What else can be done
to reduce this risk for vulnerable people?
Dr Johnston: As I say, one looks at the individual
and their particular risk and targets that risk. If one was in
a very high risk group, one might think of what is called low-molecular-weight
subcutaneous heparin, a simple injection, with a low risk of bleeding,
which could help prevent deep venous thrombosis.
Q254 Lord Paul: The report of Phase 1
calls for further studies to identify effective preventive measures,
which will comprise Phase 2 of the WRIGHT project. What plans
will the Government have to fund Phase 2?
Dr Johnston: I would hand that to my colleague,
Sandra Webber.
Jim Fitzpatrick: If I may, Lord Paul, the final
results of Phase 1 of the WRIGHT study was published by the World
Health Organisation on 29 June 2007. The WRIGHT team are seeking
funding for Phase 2, which will aim to evaluate different preventative
measures and look into the effects of interventions. The proposed
cost of a Phase 2 study is four million euros. The UK would support
the principle of further studies but cannot pay for it alone.
Given the international nature of the work, we do believe that
European or global collaboration is the way forward, and that
is the basis we are working on.
Q255 Lord Paul: Your new minister has
all the experience of finding the money!
Dawn Primarolo: Lord Paul is referring to the
fact that I was a Treasury Minister for ten years. I think it
is not true that we bury the money in the Treasury, Lord Paul.
If we did, I would know where it was.
Lord Patel: Would you spill the beans?
Q256 Lord Paul: Can I come back to low-molecular-weight
heparin. How would a passenger know that they might be the kind
of person who would benefit from that?
Dr Johnston: I think anyone who travels (and
travel, like any other pastime, is a risk, and it is not a zero
risk environment), if they have a medical condition, I think they
should discuss it with their physician. I think the knowledge
has increased over the past few years to general practitioners
and specialists about the risks of venous thrombosis, and I think
that, if you are in a high-risk group, speaking to your specialist.
There was a very good review article in the British Medical
Journal.
Q257 Lord Paul: You and I might read
that, but is every passenger likely to read that?
Dr Johnston: No, they are not reading that,
but the physicians do, and I would hope they would read it regularly
and be updated. The BMA has published guidelines on air travel
and I think that many members of the medical profession are members
of the BMA, and there is information there too and I think they
can, when appropriately questioned, give information to their
patients.
Q258 Lord Paul: So can we be sure that
none of these categories of patients travel without the advice?
Dr Johnston: Obviously it is very difficult.
The responsibility is on the individual to seek that advice. An
individual may not seek the advice because they do not know where
to seek it, although I think there are multiple sources now and
that has vastly improved, or they may not seek the advice because
they feel that, if they sought the advice, travel might be impeded
and therefore they go unannounced. It is interesting to note that
the vast majority of in-flight emergencies are for conditions
unknown prior to travel.
Q259 Lord Paul: I am being difficult,
deliberately trying to get you to a point where I hope we might
get. For instance, everybody knows that pregnant women beyond
a certain stage should not travel. The public knows about that
and they know they ought to ask their GP or something. Why do
we not give advice that says, if you have a cardiac disease or
if you have hypertension, cardiac failure or whatever, you should
seek advice?
Dr Johnston: On the websites which were alluded
to in the final submission there is information, and I think that
physicians do offer advice. I would take minor issue with the
pregnancy statement, because many people know there is a problem
travelling in pregnancy but do not know the cut-offs and I think
information is provided by airlines to clarify that, and, indeed,
major airlines, one in particular, has a very helpful website
with health information and, indeed, a select bit of the website
for medical practitioners which allows that transfer of information.
2 All the member States of the EU are represented
on the Management Board of EASA. Norway, Iceland, Liechtenstein
and Switzerland participate without voting rights. Back
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