Motion to Take Note

Pandemic Influenza: S&T Committee Report – in the House of Lords at 4:23 pm on 7th December 2009.

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Moved By Lord Sutherland of Houndwood

That this House takes note of the Report of the Science and Technology Committee on Pandemic Influenza: Follow-up (3rd Report, Session 2008-09, HL Paper 155).

Photo of Lord Sutherland of Houndwood Lord Sutherland of Houndwood Crossbench 4:34 pm, 7th December 2009

My Lords, I shall speak about the report of the Science and Technology Select Committee on pandemic flu and the Government's response to it. I propose to take the House through the main points, knowing that my colleagues will be eager to participate on specific issues. I thank the Government for a careful and, I have to say, at points a helpfully detailed response. That done, I of course immediately say "however", but I shall leave that for a moment or two because I also want to thank colleagues on the committee, including the co-optees-the noble Baronesses, Lady Finlay of Llandaff and Lady Whitaker, and the noble Lord, Lord Jenkin of Roding. With our excellent special adviser, Dr Sandra Mounier-Jack, and superb help from the Committee Office, they produced an important document that has provoked an important response from the Government.

The report was an update by the committee on a report of October 2005. The follow-up report was published on 28 July this year. We thought it necessary because the reaction to our 2005 report left us with a number of concerns about the adequacy of government preparedness for the possibility of a pandemic outbreak. We had expected it to be a short and fairly quick report; we had planned to do it in autumn 2008 and had a useful session with government and departmental spokesmen in November 2008. However, that evidence session did not convince us that all the questions that we thought ought to be publicly aired had been, so we decided to extend our report and prepare for two further sessions in spring 2009. The first was in February, when we had an excellent team of specialists from the appropriate areas of science and medicine to work with and advise us. For the second, on 17 March 2009-I stress the date, as it is important-we had departmental representatives and a ministerial presence.

One day later, on 18 March 2009, the virus H1N1 was identified in Mexico. That virus became known as possible "swine flu" because it could transmit from pigs to human beings and, as it turned out, from human beings to human beings. Therefore, the stage was set for some important and worrying consideration to be given to it. By 27 April, there was confirmation of cases in the USA, Canada and Spain, with suspected cases in several other countries including the UK. Within five or six weeks, we had moved from taking evidence on 17 March that was, in a sense, theoretical-for a table-based report-to a pandemic flu situation.

By 11 June, the World Health Organisation confirmed that we were at phase 6 alert in the pandemic period measurements, which was the first such alert for more than 40 years. Of course, that affected the nature of the Select Committee's work and the way in which it would go about its business. Quite properly, it also affected the nature of the government response to the Select Committee inquiries at that stage. So there were complications for the Government and complications for us. They were responding to a series of questions, some of which were originally asked in 2005, and the importance of the answers was becoming more evident day by day throughout the summer. It might be thought that the Select Committee showed some prescience in choosing this topic, but I have to say that we do not claim any special knowledge. Rather, the committee sees the continuing importance of these questions, so they must be kept alive. If they are not, that would be complacent and we would not be able to respond to a potential pandemic.

A pandemic is different from an epidemic in so far as a pandemic includes the possibility of risk to individuals worldwide. The virus that particularly concerns us at the moment is H1N1, which has the capacity to transfer from pigs to human beings and thence from some humans to others. One has learnt, not being an expert in these matters, that viruses are tricky customers. Evidence in Wales shows that this virus has already developed a resistance to Tamiflu, which is the first line of defence available to us. There are also major concerns about the evidence that the virus has already manifested itself in communities where avian flu virus is still present, perhaps because all the chickens were not killed. The possibility of mutation or a mixing of the different viruses is high and potentially very dangerous. We have to watch this because it is occurring in certain parts of the world, so the issue may not leave us in our current comparatively quiet state.

That is the context. The committee's response to the government reply is positive in terms of the way in which the current epidemic has been handled by the department and the Government. A number of good things have been done and, as we will hear later, international comparisons bear out the view that we have an alert and responsive Government and department. There is always a "but", however, which leads me on to two or three specific points.

First the "but", which is not carping in tone, but realistic. The virus and its effects in this country have, for most people so far, been comparatively mild in terms of the symptoms. Sadly, that is not true for everyone and there have been deaths, usually associated with other medical conditions. Nevertheless, it is a dangerous virus, as are they all. But so far, the symptoms of the virus have been mild. That has been a positive help to the Government and the department in their response; I shall come back to that in a few moments. However, there is a considerable possibility that a second and more virulent wave of the virus may come through, in which case the symptoms will be much more pressing and potentially more dangerous than they have been across the piece. Moreover, as I have suggested, there may be mutations which inevitably we are unaware of at this point and which produce a much more dangerous virus. We have dealt with the wave so far, for which congratulations are due to all concerned, but there is the possibility of further dangerous developments.

I now want to make one general and three specific points in the remaining time that I have available to speak. The general point is to ask whether, although we have been fortunate in that the virus has been comparatively mild and government systems have been able to respond, there are lessons to be learnt. Are there issues that we can pick up on and take forward into the future from the experience of the last five or six months? I am sure that there will be none of this in the Minister's speech, but the danger is that folks in the department might become a little complacent. They might ask, "Well, so far, so good-what were all those irritating questions about that we were getting a year ago? There has been a pandemic, we are dealing with it effectively and the number of cases is falling in this country, so what's the fuss about? We coped; why go on about it?". One sometimes had the impression that members of the department implied, "It'll be all right on the night", but was it? When we were pressing for system-wide review and testing, there was just a hint of that coming through.

If that were the reply-that they had coped, that it was all right on the night, so what was the fuss about?-it would be wrong on two serious counts. The first, as I have suggested, is that it would be complacent. Fears of complacency are what stimulated the Select Committee to go back and produce an update after its 2005 report. There are risks of becoming complacent. More significantly, such a reply would ignore the most important contextual key point: this virus, I stress, has so far been only moderately virulent in its attacks and in the symptoms that it has produced. The systems that we have to deal with the symptoms have of course been tested under real enemy fire, so to speak. The department would be right to say, "Well, we have had pandemic here and we have coped", but the testing has not been comprehensive because there have been hot spots across the country where the virus has been claiming significantly more victims than it has elsewhere. A continuing concern for the committee is that the system testing has not been end to end, as we called it; it has not looked right down the chain to see that every stage is fit for purpose and will link up well and appropriately.

There has been system testing in the presence of a pandemic, but that has been of a comparatively mild one, whose impact has been patchy throughout the country. So far, the testing of systems has also been by and large desk-based. I am sure that the very strong recommendation from the committee would be that there are lessons to be learnt. We have been given a living laboratory; let us ensure that there is a proper report looking back to see what happened and how well or how ill it happened, as the case may be.

On my specific points, first, the evidence that we have on scientific infrastructure is that it has been good and has worked well. The World Health Organisation has labs in place throughout the world. It is functioning and has been able to bring reports on how the virus is spreading-some this very week. The UK lab system has, from the evidence that we have, been alert and ready to respond. UK scientists are currently trying to get ahead of the game. They are in jurisdictions where avian flu still exists and swine flu may be present and they are looking for the earliest dangerous signs of mutation-again, all credit to them. A pandemic brings out-this one has brought it out as well as any-how we are dependent on other jurisdictions. This is an international risk that we run and it might be worth asking the World Health Organisation to think about the lessons learnt in terms of international preparedness and co-operation.

The second specific issue that I want to take up is the provision of acute facilities. We were concerned about this from the earliest evidence taking, when we had some important evidence from those who work in the provision of acute beds in hospitals. Again, I am pleased that the Government plan-this emerged after our report was published-to double the readiness of intensive care beds. That is a better response than we had from them in oral evidence in July this year. However, they have moved from there and their response is important. It is a significant improvement on July and on a meeting that I had on behalf of the committee in May with the then Secretary of State and his advisers. The reaction from the advisers showed that they had not been thinking carefully or systematically about this matter at that stage; there was, I have to say, evidence of complacency. However, the Government have moved enough to be commended.

Equally, a recent Cambridge study casts doubt on whether even that preparedness will in fact deal with the situation. It says that some regions could come under particular pressure-patchiness again, but a different form of it. For example, the south-east coast region, which has only one relevant intensive care unit in Brighton, could see five times as many patients as it has beds for. That is a serious question being raised by a serious research team and there ought to be answers, even if they are not available today. We ask the Government to look at their improved policy and, in the light of what this study is giving to us, at whether further strengthening of the provision of intensive care beds would be sensible.

My final point is about communications. There have been good developments; we pressed this quite hard early on. There is good progress on the Department of Health website. The Government have sponsored the preparation of a leaflet on the most-asked questions to be distributed to key workers, which is good, as is the way in which private sector or professional groups have been involved-for example, the BMA's General Practitioners Committee and the Royal College of General Practitioners. I commend the latter body particularly because it was kind and gave me an honorary fellowship, so I have access to its website and its weekly bulletins, which have been first-class, and GPs have benefited from them immensely.

However, there are dangers with multiple sources. Having a lot of sources is good, but to which source does the worried individual go? Should that be looked at? I commend that to the Government. Are all the sources singing from the same hymn sheet? The answer is so far, so good.

The phone line has coped. The demands on it have not been as great as was predicted because of the nature of the pandemic, but there are still questions in the committee's mind about whether separating the number from NHS Direct was helpful. I gather that this was not done in Scotland. I understand the Government's reasons for wanting to do it here, but the number that a patient confronting the situation thinks of first will be NHS Direct, not a separate phone line whose number may be printed on a scrap of paper that came through the letterbox.

If the communications have gone really well, the impact will be great. However, a recent survey of 2,000 people suggested that almost half of them doubted whether they would be happy to accept a vaccination. There is a communication issue still to be faced there. Fewer than 10 per cent of the children coming into hospital had had antivirals and, of the whole population going into hospital, fewer than 15 per cent had done so, which suggests that there is a gap. Of the 10 million vaccination doses that went out, we have evidence so far of 1 million being used. The numbers may have improved, but why the gap between 1 million vaccinations and 10 million doses?

In conclusion, we have made some good moves and I commend the department for that, but there are lessons to be learnt. I commend all those on the front line who have been doing such marvellous work, but I also commend to the Government continuing vigilance. I beg to move.

Photo of Lord Crickhowell Lord Crickhowell Conservative 4:55 pm, 7th December 2009

My Lords, I must first thank our chairman, our clerks and our advisers for all the work that they put into the preparation of our report. I shall make one general comment before I concentrate my remarks on a specific topic.

In the face of criticism that preparedness and testing had been too long delayed, it is hardly an adequate response to say that the H1N1 epidemic has effectively proved an end-to-end test of preparedness. If the epidemic had been more serious at this stage than it has proved to be, the Government would not have found that response acceptable, particularly by those who have suffered most from a worsening of the epidemic.

When the Minister, Gillian Merron, gave evidence to the committee in July, I suggested that there was a need for much clearer advice to be given to pregnant women about the steps that they should take to protect themselves and their unborn children from the effects of the pandemic. Based on the experience of one of my daughters, it seemed to me that even good hospitals and GP practices were not doing enough to remove the understandable fears of women or making clear exactly what they should or should not be doing. It was relevant in that context that the Royal College of General Practitioners reported:

"Concerned family doctors have also been in contact seeking the latest recommendations on the protection of pregnant healthcare workers that might come into contact with possible swine flu patients. It appears guidance on this issue is not very clear".

In response, the Minister referred to the detailed information available on the Department of Health's website and that of the Royal College of Obstetricians and Gynaecologists. I suggested that there was a need for clear leaflets on the subject to be available. Anticipating that the committee might pursue the point and urge clear guidance for this and other particularly vulnerable groups-the noble Lord our chairman has just referred to the importance of guidance-the Government announced positive action just before our report appeared. I shall have more to say about antivirals and vaccinations in a moment. Perhaps the strongest advice given to my two pregnant daughters has been to isolate themselves as much as possible before the birth, and to isolate their babies in the months after and to avoid crowds. That is clearly sensible advice, although not every mother will be able to do that.

We learnt in evidence from the Department of Health-I refer to page 37 of our report-that neither oseltamivir, which is Tamiflu, nor zanamivir, also known as Relenza, is licensed for use in pregnant or lactating women, but that Tamiflu is licensed for use in children over one year old and that solutions of very-low-dose oseltamivir were being prepared by hospital pharmacy units for use with children under one. Zanamivir is not licensed for children under five years old and is not available in a suitable paediatric presentation. Rather confusingly-it is the very same paragraph-we were told that zanamivir was the preferred drug for pregnant and lactating women. We were later told in a supplementary paper-I refer to page 66 of our report-that, in general, Tamiflu may have additional benefits over zanamivir by being more systematically available against a wider spread of infection in the body and, again, that it can be given to younger children over one. However, zanamivir, more commonly known as Relenza, has fewer side effects. Trials have supported the effectiveness of both in alleviating and reducing the duration of symptoms. On the advice of the Scientific Pandemic Influenza Advisory Committee, Tamiflu has been selected as the main antiviral, except in the specific instances where it is unsuitable, which include pregnant and lactating women who are treated with Relenza. The Minister, Gillian Merron, confirmed this in response to a question from me in her evidence on 2 July, adding,

"because we of course know from SAGE that pregnant women, amongst others, are some of the most at risk should they contract swine flu".

I asked about possible allergic reactions and was told by Professor Sir Gordon Duff that the indications were that Tamiflu is as safe as any drug ever is, but that up to 10 per cent of people report nausea. He did not say anything about the side effects of Relenza, and I do not think I ever got an answer about allergic reactions to flu injections. I referred to the case reported of a child at a Dulwich school, who had a very mild attack of swine flu and a very violent reaction to Tamiflu. The Daily Telegraph reported on Saturday that European regulators had said that children receiving their second dose of the swine flu jab may develop a high fever. We have also heard reports of the development of some resistance by the virus to Tamiflu and the transmission of a Tamiflu-resistant strain in south Wales. Again, this was referred to by the noble Lord, Lord Sutherland.

Perhaps more serious questions arise about the effect of vaccines on pregnant and lactating women and young children. The committee had completed its work by the time that swine flu vaccines were made available and approved as safe. Because of the brevity of the testing period and the relative lack of experience worldwide of the effects of having the vaccine, it is hardly surprising that there is quite widespread anxiety, particularly among pregnant women and the parents of young children, who feel that as the effects of swine flu seem to be relatively mild in the great majority of cases, they would rather not risk any as yet undisclosed hazards arising from the vaccination. They tend to point to past disasters with new products that were initially said to be safe but were later the cause of tragedies.

It is a fundamental fact of nature that pregnant mothers should worry about their unborn children, and that mothers should be concerned about the safety of their children. During recent months, with two pregnant daughters, one of whom has just had her baby, I have been a particularly interested and concerned observer of their experience. Most doctors and midwives, if asked for advice, follow government guidance and recommend vaccination. However, if you then ask, "What would you advise if it was your wife or daughter who was pregnant?", or, in the case of a female doctor, "Would you have it if you were pregnant?", the responses are very different and equivocal. Quite often the answer is, "No, I would not". It is only the pregnant woman or mother who can take the decision. If the effects of swine flu remain relatively mild in most cases, it is hardly surprising that many women decide that they would prefer to accept that risk, rather than the unknown hazards of a form of vaccination that they feel has not yet been adequately tested. If we move into a phase when the virus takes a more malignant form, opinions may change.

After I had drafted that section of my speech, I read in the Daily Telegraph on Saturday a report that said:

"Midwives are being sent letters about the safety of the swine flu vaccine after it emerged that some pregnant women were being refused the jab ... A letter being circulated to midwives says: 'All pregnant women in the UK have been prioritised for the H1N1 vaccine as an "at risk" group.

'However, there has been evidence that some nurses and midwives are either refusing to immunise pregnant women or strongly advising women against this option. While some resistance to new vaccines is understandable, we are writing to reassure nurses and midwives of the safety of the H1N1 vaccines, and the increased risk of complications in pregnant women who contract the virus, compared with the rest of the population'.".

The Royal College of General Practitioners said:

"The college had received dozens of emails from GPs who had been confronted by women who said their midwife had given them conflicting advice".

Clearly, this is a vivid and real current issue.

In addition to giving the best advice that they can, it is important that the Government should collect the fullest possible statistical and other evidence as the pandemic continues about the number of pregnant women who are vaccinated and the number who are not and their subsequent medical histories, so that future advice can be given with greater and greater confidence. As far as possible, the evidence must be accumulated on a worldwide basis and, as there are different types of vaccine, should differentiate between the types used.

I understand-again, the noble Lord, Lord Sutherland, referred to this-that since the start of the vaccination campaign only about 1 million people have reportedly been vaccinated out of 10 million vaccines distributed to GP practices. There may be a good many reasons for that, but it would be particularly interesting to know how many pregnant women had had vaccinations and what information is available about the proportion of pregnant women who have chosen to have vaccinations and the proportion who have not. I would also like to know how many children it is intended should be vaccinated, together with current information about the way in which children have responded to antiviral treatment. Another question that I hear raised is about the possibility that the virus from a flu vaccination or antiviral can be passed on by a breast-feeding mother to her child. Again, it would be helpful if clear advice could be given on that issue.

My final question for the Minister is about the provision of paediatric intensive care beds. What specific preparations have been made in light of the fact that those in this age group who are affected are very often affected most severely and are sometimes desperately ill?

It will be clear that I have no medical qualifications and I understand that medical experts have to deal with complex questions in a changing and developing situation. I commend the efforts being made to clarify the issues and to give good advice based on sound evidence, but it would be helpful if the Minister in responding could provide further information and reassurance and continue to look at the advice being made public to this particularly vulnerable and sensitive group.

Photo of Lord May of Oxford Lord May of Oxford Crossbench 5:07 pm, 7th December 2009

My Lords, I begin by thanking my noble friend Lord Sutherland, who so ably chaired this committee. I also thank the secretariat, the special adviser and all the speakers in the seminar that we put together, the summary of which should be published as a separate document because it provides an exceptionally insightful and helpful background.

I shall now make what many noble Lords, possibly with some justification, will find an excessively academic contribution to this debate. Infectious diseases-viral, bacterial and others-have been with homo sapiens, and have killed lots of people, since we first invented agriculture, began to interact with domesticated and other animals and, most importantly, began to gather in large aggregates in villages and cities. We are still doing that.

In 1967, in one of the most foolish things ever written, the US Surgeon General, as the epigraph for his annual report, said:

"The time has come to close the book on infectious diseases".

Nothing could be further from the truth. HIV-1 and HIV-2, which came from chimpanzees and macaques, and SARS, where we got lucky, underline that for us. The combination of still-growing populations, poverty and climate change is a real problem.

On the other hand, we have weapons to combat such diseases these days. They are all relatively recent, beginning with vaccination, which is a few centuries old and which we hit upon phenomenologically; we still do not fully understand it, which is why we cannot yet produce a vaccine for malaria or HIV. Fifty years ago, we added to that armamentarium antibiotics, which kill bacteria in the body. Much more recently, we added antivirals, which are very different in what they do; they suppress viral replication within cells, but they do not attack a virus in the body. I will return to that point, because it is fairly important, in a moment.

So much for what we can do with the interaction between infectious disease in an individual and the treatment of that individual. Even more recent-surprisingly, it is only about 30 years old-is our increasingly sophisticated understanding, which has developed rapidly over the past 30 years, of the engagement between infectious disease and whole populations of individuals. Here I declare an interest, and, indeed, an egotism, because I think it fair to say that the canonical text on that subject is still the one written by Roy Anderson and myself. It illuminates such things as why we could control SARS and stop it spreading, and why we cannot do that with influenza.

Against that background I return briefly to the topic itself. I was going to mention four things, but I shall mention four and a half, the half prompted by the very interesting presentation of the noble Lord, Lord Crickhowell. The first is complimentary to the Department of Health. I wish to emphasise this at the outset in view of the constructive criticisms-as I would like to think of them-that will follow. I happened to be living at Princeton in the United States in the 1970s when it had an experience with swine flu that was little short of calamitous. It was mismanaged, first, by muddled information being distributed, which made people excessively agitated, and then by distributing a vaccine which had various problems. The Secretary of State for Health, a lawyer called Joseph Califano-the situation was not his fault-afterwards wrote a brilliant, short book on lessons learnt, of which the primary one was, in his words-it has resonance right across the spectrum-"I always thought science told me the answers. What I have learnt is it is a very effective tool for asking the right questions, but the answers are often not easy".

That brings me to my other comments. We revisited the inquiry into pandemic flu not least because the first inquiry showed a marked confusion in the Department of Health as regards antivirals and antibiotics. Until just before the advent of H1N1, the policy was that antivirals, such as Tamiflu, would be given to people who had come into the surgery and been diagnosed with flu. The idea behind that is sensible if you are confused about antivirals and antibiotics because any agent will, if sufficiently used, provoke an evolutionary resistance; it is just a matter of time. The best defence against that is using the thing only when you really need to. That is true for antibacterials-antibiotics. Antivirals are effective if they suppress replication initially and give the natural immune system a bit of a jump start, but are best taken in the first 24 or 48 hours after infection. By the time you are really symptomatic and going to the doctor, the correct policy is to give them to your children or other contacts. In short, if you are dealing with something serious, the correct use of antivirals is targeted local prophylaxis; that is, giving them to other members of the family and other members of the schoolroom.

It took several years for this lesson to be absorbed in the Department of Health. Pleasingly, that followed immediately the advent of the first case of H1N1 swine flu in this country. Happily, the noble Lord, Lord Darzi, was able to reply by saying that the department had implemented this policy. It did not, of course, halt the spread of the virus, but were it more serious, doing that would buy you time. Even now, the policy should be followed as regards the more vulnerable contacts of people diagnosed with H1N1 swine flu, even though for most people the virus seems to be no more troublesome than the usual unpleasant seasonal flu. We should still use targeted local prophylaxis for people at special risk.

Secondly, on a separate subject, in 1993 the John Major Government implemented one of the manifesto commitments of the Labour Party, which lost the election, by creating an Office of Science and Technology and brought in the Chief Scientist as a Permanent Secretary. Shortly after, guidelines on science advice and policy-making were issued. There are echoes here of the Nutt affair, and of others. One of the central tenets of these guidelines is that you should admit uncertainty. There is an uncomfortable dissonance between the desire to give people certain messages and the fact that often the best we can do is offer approximations. On occasion, the Chief Medical Officer has not fully comprehended the need to admit uncertainties. Statements such as, "There will be 70,000 deaths from swine flu", apart from being silly, reveal a lack of comprehension of how that number could be expressed as a best guess with huge variants. It is important that such a statement should not be repeated in any way other than by underlining that it is a best guess with huge variants.

That brings me to my third-and-a-half point. I have been vaccinated against swine flu. If I had a pregnant daughter, I would unhesitatingly recommend that she be vaccinated. If I had a small child, I would wish it to be vaccinated. It is true that sometimes there are miniscule risks from vaccinations, typically of the order of, at best, one in 100,000. The risks are very hard to document, but you cannot rule them out. It does not help to tell a sceptical public that there is absolutely no risk, as distinct from no evidence of a risk. However, you can be sure that there is a much greater risk even from ordinary seasonal flu. Going back to MMR, the chance of serious damage to a child who catches measles is about one in 1,000. That is two orders of magnitude worse than any conjectured risk from the vaccine. That is what the Department of Health should have said in that case, instead of evoking resonance with BSE by saying, "There is no risk at all".

My final message is that the Department of Health does a superb job these days in putting together expert committees to advise it. The people that it chooses and the advice that is given are good. The ineluctable process aspects of much of what follows from that mean that too often there is not as strong a connection between the implementation of good advice and the excellence of that advice. That is where the Department of Health is doing well, but could do better.

Photo of Lord Jenkin of Roding Lord Jenkin of Roding Conservative 5:19 pm, 7th December 2009

My Lords, after that speech one is tempted to say, "Answer that". It was invaluable to our inquiry that we had real experts on the committee, such as the noble Lord, Lord May, and the noble Lord, Lord Patel, whom we shall hear later.

It is no secret that I was one of those who urged that the Select Committee should revisit its report of October 2005. The noble Lord, Lord May, has rehearsed at least one reason-there were others-why it was thought that we should return to it, although there was at that stage no more than anxiety that we might face a serious pandemic flu outbreak. Therefore, I was immensely grateful to the noble Lord, Lord Sutherland of Houndwood, when he, as chairman of the Select Committee, agreed. I was also grateful to be co-opted to serve on the committee. Of course, I echo his thanks and that of others. I was particularly impressed by the session that we had with five of the leading experts in the country on this subject.

One may have had to push to have a fresh look at this, but in the circumstances I am in no doubt whatever that it was worth while and that the follow-up report has a lot of important matters in it. As our chairman said, it has evoked important responses from the Government. The truth is that we-the committee and the Government-were overtaken in the middle of our work by the arrival of the H1N1 virus in the UK just six weeks after it had first been identified in Mexico.

I have several general points to make and I shall then return to a specific one. First, it has been rightly said that H1N1 is a very much less severe strain than H5N1, which was the strain that had been originally feared following some cases reported in the Far East. Of course, as has been said, for some H1N1 was fatal, and a few-very few, compared with the total who contracted it-were very ill. For the most part, those diagnosed with H1N1 had probably a milder illness than a normal attack of winter flu might have been. I cannot claim a direct connection, as my noble friend Lord Crickhowell did when he referred to a friend of his daughter, but my daughter-in-law had two nephews who were sent home from school along with all the others. That resulted in the then Secretary of State for Health going to the Cabinet and saying, "Prime Minister, we have closed Eton at last". Eton was closed for two weeks because there was a fear of disease spreading among the boys. This time, we have got off lightly compared with what a full, serious pandemic might have produced, as in 1918.

Secondly, I think that H1N1 arrived before the Government had completed their preparations and in particular before they had conducted what has been referred to as an end-to-end test of the whole procedure-that especially applied to the distribution of antivirals. I shall come back to that in a few moments.

Thirdly, the outbreak has provided a valuable real-time test bed for the extensive and, let me say at once, welcome prior preparations that the Government had made. I refer in particular to the decision to order and store large quantities of antivirals-enough to treat several millions of people. The committee was right to applaud the Government's foresight.

We have now reached the second phase, or so one is given to understand-the figures are not always clear. There is no doubt that the H1N1 virus now seems to be tailing off, certainly in this country and in certain others.

However, the latest figures, which I saw this morning, suggest that there is still wide variation. Therefore, I reinforce the point made by the noble Lord, Lord Sutherland, in opening the debate: it is hugely important that there are full reviews of all the experiences of the past nine months, so that the lessons can be learnt. It has been in that respect a valuable test bed. Systems have been tried and operated. We need to know what the lessons are.

We may not have seen the last of H1N1. There may be a further phase, as predicted by some of the experts. If we had those lessons-if we had the results of those reviews-we would be better prepared for that and for the arrival of what may eventually emerge, as a result of mutation or whatever, as a more serious strain, or as a more serious virus in future.

There are many issues, but I shall refer to only one. I was going to talk about communication, but I have nothing to add to what the noble Lord, Lord Sutherland, said on that. Like him, I have found the regular bulletins issued by the Royal College of General Practitioners an extremely valuable update. I am not on the subscribing list for all the others, but I believe that there have been a lot. I echo his question: is there sufficient co-ordination between all the various sources of advice so that they are consistent? My noble friend Lord Crickhowell said that there seems to have been a good deal of doubt about the proper treatment for pregnant women and very young children. If there has been conflicting advice, it must be for the department to co-ordinate that and sort it out.

The main point to which I want to return-this will not surprise my colleagues-is the distribution of antivirals. I shall refer to them by their short names, Tamiflu and Relenza. Yes, we had millions of doses originally. It was also originally proposed right back in 2005 that we have a national flu line. We were told during our evidence that that was to be manned by up to 7,500 people to diagnose, triage and authorise over the phone the issue of millions of antivirals from some hundreds of nominated collection points. Given that that programme had been outlined to us three or four years earlier, we were surprised and, to some extent, dismayed that it had not gone much beyond the planning stage when we began our study. We were told about a major exercise that had been carried out, called Winter Willow, but it was made perfectly clear that that did not include the question of the distribution of antivirals-that was not part of the exercise.

However, in the event, as I said, we and the Government were overtaken when H1N1 arrived, but the Government managed to set up what the Department of Health originally called an interim programme for the National Pandemic Flu Service, with the expectation that, by the autumn, there would be an enhanced programme. I must state at once that the way in which the professionals in the National Health Service and beyond coped with having to take on board at very short notice an interim service has been nothing short of wholly admirable. No praise is too high for the people who had to operate a system for which, as it happened, they were largely unprepared. I said several times to witnesses to our inquiry that I had yet to find anyone in the National Health Service who could tell me what they were going to do in the event of the national flu line being activated, with all the rest of it. Clearly, there were people who were able to respond quickly and effectively. The National Pandemic Flu Service was tried out on the ground. It was the first time that it had operated; there had been no test.

I have a number of questions. As H1N1 is continuing, although at a diminishing level, can the Minister tell us how antivirals are now being distributed? Is it all being done through GPs or is the flu line still operating? What about the collection points?

My second point was prompted by the noble Baroness, Lady Finlay of Llandaff, who has sent her sincere apologies for not taking part in this debate. She is just taking off from Heathrow for an engagement to which she was committed. She asked me to raise the point that there is a need to ascertain how many patients were misdiagnosed with H1N1 because it was done over the telephone. How many times were patients wrongly prescribed Tamiflu as a consequence? The noble Baroness points out that diagnosis is not done over the telephone in Wales; it is done by professionals who see the patients. It would be helpful to have numerical data to indicate the accuracy of telephone diagnosis. The noble Baroness believes that Wales has operated an effective system at lower cost. Are there lessons that ought to be taken on board for England by the Department of Health? I understand, but I may be wrong, that we are the only country adopting the national telephone flu line. It is important that we know how it has worked. If telephones are still being used, is there a system to monitor what is going on?

Last month, the Chief Medical Officer stated that only 20 out of 219 children and 55 out of 381 other H1N1 patients admitted to hospital had had an antiviral-I think that the noble Lord, Lord Sutherland, mentioned these figures. That is 10 per cent of children and 15 per of adults. Why is that? Were people wrongly diagnosed as not having it when it turned out that they did? If they were properly diagnosed, did they understand the instructions? If they understood them, did they fail to follow them up by collecting and taking the antiviral? This emphasises that there must be an early evaluation of the future of flu line services. The Government changed tack twice during the early part of this year as they were overtaken by the epidemic and it is hugely to the credit of the staff that they made the services work.

I hope that this is not the last word. When, four years ago, we debated the Science and Technology Select Committee's previous report on flu, I asked the then chairman, the noble Lord, Lord Broers, whether the Select Committee would return to this matter. To paraphrase him, his answer was yes. In the event, we did, but I think that this follow-up report must not be the last word that this House has on this vital matter. Compared to some of the other threats that the human race faces, it may be that pandemic flu is not the most serious, but it could be. I do not think that we should leave it here.

Photo of Lord Patel Lord Patel Crossbench 5:35 pm, 7th December 2009

My Lords, I am very pleased to be able to take part in this debate. I was not part of the current inquiry, but I have read the report fully. I took part in the previous inquiry and have read the Government's response. I had a few points to make, but, having listened to the previous speakers, I have now cast aside my notes.

I strongly reinforce what my noble friend Lord May of Oxford said. During the previous inquiry, we agreed about how antivirals should be used. Like him, I do not care whether everybody who got antivirals was proven to have the H1N1 infection so long as the spread of the disease was contained. The effective strategy for using antivirals is to give them to all the contacts of people suspected of being infected with H1N1. Equally, if I were a practicing obstetrician, I would recommend to every lady who attended my clinic that she be vaccinated with the H1N1 vaccine that is currently available. I shall return to these two points. The noble Lord, Lord Sutherland, raised issues about communications failure, and I shall return to that in a slightly different context.

Overall, despite our early anxiety, the UK's response has been effective. We should, as all the other speakers said, congratulate the department on that. This is due partly to the fact that the pandemic has been mild. However, we should not be complacent. We have had 178 deaths, and there are 747 patients in hospital today, 161 of whom are in critical condition. The number of deaths is increasing despite the fact that the disease incidence is decreasing. Last week there were 37 cases per 100,000 of the population. The incidence could also increase as we might be about to enter another wave of infections. Historically, the peak infection rate for influenza occurs from week 52 to week 6, and that time has not yet come. Unfortunately, this period also covers the holidays when services might not be fully geared up to meet the demand. In the week to 26 November 2009, there were 21 deaths in England, which is the highest weekly total so far. Is the disease pattern about to change? We do not know. There are higher incidences among the under-fives and pregnant women; 7 per cent of hospital admissions have been in those categories. We should not get complacent and give the public the impression that all of this is overblown and we do not need to remain vigilant about this disease and the pandemic.

We need to remain vigilant because we do not know what the second wave might bring. It might reach epidemic levels of 300 cases per 100,000 of the population. If that happens, it will be the real test of whether the system can cope. We do not know how much Tamiflu we have stockpiled or how it will be delivered. We hope the Minister will tell us that we have an adequate number of Tamiflu doses to cover the whole population, and that if resistance to Tamiflu, which is currently low, increases, we have enough Relenza-the trade name for zanamivir-to cope. It is important that we have enough vaccine stockpiled. I understand that hitherto only 1 million doses have been used, that 9 million doses are currently available to general practitioners and that a further 4 million doses are in stockpile. We will need much more than that. While some of the contingency programmes have been effective, they have been falling behind. We are responding to events as they happen rather than being ahead of them. If the pandemic really takes off we will need to be ahead of it. In Sweden 50 per cent of the population is already inoculated while we are nowhere near that-only 1 million doses have been used so far. Do we have a big enough stockpile of vaccines coming onboard to cope with the second wave if it occurs?

I hear that general practitioners have been asked to immunise all the target groups by Christmas. How are they going to do that when only 1 million have been immunised so far? Are all the front-line workers immunised? I understand that around 275,000 of them have taken advantage of the vaccine. We need to get the message across more loudly and clearly to priority groups that the vaccine is currently available to them. The noble Lord, Lord May of Oxford, has had the vaccination. If someone was to offer it to me right now I would take it. That is the message we need to get across to people-to the pregnant ladies and the children under five. There is some suggestion that 30 per cent of the children under five have had swine flu already. We do not know that but we do need to immunise them, otherwise we will need more paediatric intensive care units. If we get the vaccination programme running properly we will not have this problem.

Of course there are questions to be asked-about what data collection we are undertaking, and what epidemiological research we have put in place-so that we can answer questions such as that asked by the noble Lord, Lord Crickhowell, regarding the complication rate. The noble Lord, Lord May of Oxford, noted that in the 1970s the American vaccine programme was chaotic, as was the vaccine. The data we have today which suggest that the vaccine might be harmful come from that time. Even then, the incidence of serious disease such as Guillain-Barré syndrome was one in 100,000 people vaccinated. We have now vaccinated a significant number of people, so we should collect data, including among special groups, about the side effects of this vaccination programme.

Despite the widespread use of Tamiflu, the incidence of resistance is actually quite small. Yet there are scare stories that we must not dish this out as it will create resistance. As the noble Lord, Lord May of Oxford, clearly explained, antivirals act differently to antibiotics. They do not produce the same degree of resistance. There are questions to be asked. It is a pity that some countries in Europe are not using Pandemrix, a vaccine produced by a British company, because it contains adjuvants such as squalene. There are suggestions that squalene is harmful but there are no reports of it. In the UK this is not the view. Of course there are questions to be asked; of course we need the answers, but we need properly collected data so we can learn from this, but we do need to remain vigilant.

G

In this debate of December 2009, Lord Patel concluded about vaccine adjuvants that "Of course there are questions to be asked; of course we need the answers, but we need properly collected data so we can learn from this, but we do need to remain vigilant." I can now inform you that his wise call for properly collected data and vigilance has fallen on deaf ears, blind eyes and stone hearts at the Joint Committee for Vaccinations and Immunisation (JCVI). That committee is supposed to give advice to Ministers based on the best evidence reflecting current good practice and/or expert opinion. The process is supposed to involve a robust, transparent, and systematic appraisal of all the available evidence from a wide range of sources. Regarding those enigmatic medical conditions including post-vaccination phenomena, by July 2010, scientific publishers Elsevier had accepted a scientific review entitled Adjuvant Syndrome, which cites 51 scientific references. 1 + 51 = 52. This 5-page review on Autoimmune/inflammatory Syndrome Induced by Adjuvants ‘ASIA’, by Yehuda Shoenfeld and Nancy Agmon-Levin is freely accessible at http://www.mednat.org/vaccini/Adjuvant_syndrome.pdf Yehuda Shoenfeld MD has responsibility for several scientific journals and he has authored numerous publications. http://en.wikipedia.org/wiki/Yehuda_Shoenfeld The authors point out that currently the most widely used adjuvant in medicine for vaccines is aluminium. They state clearly in the abstract: "...In recent years, four conditions: siliconosis, the Gulf war syndrome (GWS), the macrophagicmyofasciitis syndrome (MMF) and post-vaccination phenomena were linked with previous exposure to an adjuvant. Furthermore, these four diseases share a similar complex of signs and symptoms which further support a common denominator. Thus, we review herein the current data regarding the role of adjuvants in the pathogenesis of immune mediated diseases as well as the amassed data regarding each of these four conditions." On discovering this long-awaited paper and then asking a FOI question, the DH and JCVI Chair did agree to my request to discuss the paper at their February 2011 meeting. However, the draft minutes show that this important item was left till the end. It was item number 61 out of 63. That meeting was 5 1/2 hours long, and out of the 16 committee members, 6 were making declarations of interest in specific vaccines that day. The draft JCVI minutes read as follows: “The committee discussed a review paper by Shoenfeld and Agmon-Levin (2010) on autoimmune/inflammatory syndrome induced by adjuvants, in particular on the role of adjuvants in the pathogenesis of four conditions: siliconosis, the Gulf war syndrome (GWS), the macrophagic myofasciitis syndrome (MMF) and post-vaccination phenomena. The committee considered that the paper did not provide convincing data on the role of adjuvants in these four ‘enigmatic’ medical conditions and that the review did not raise safety concerns about the use of adjuvants.” I consider that the closed-mindedness and rather obvious bias of the committee shows no element of vigilance here, nor any expert knowledge on the role of adjuvants in these four previously enigmatic medical conditions – nor, I would add, any moral concerns about vaccines safety. So The JCVI ignored the expertise and dedication over recent years from the 212 scientists and physicians who authored those 52 carefully selected, peer-reviewed and successfully published papers. The JCVI has shown disrespect to world-class research establishments in at least 9 different countries. The publishers, universities and funding bodies (including the UK Wellcome Trust) are probably used to such rebuffs at lower levels and now top level where the JCVI is official...

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Photo of Lord Colwyn Lord Colwyn Conservative 5:43 pm, 7th December 2009

My Lords, scientists have been warning for several years that a global outbreak of influenza was due. Following the development of the H5N1 strain of avian flu, the H1N1 strain from Mexico arrived and developed much more quickly than anticipated. The US Centers for Disease Control and Prevention found that the H1N1 strain was so unlike existing flu viruses that most people had no immunity and there were no relevant existing vaccines. As we descend the speakers list the points to make become less and less. However, I should like to thank the noble Lord, Lord Sutherland, for his authoritative chairmanship of the committee and Sandra Mounier-Jack, the expert, and Christine Salmon Percival for their help.

Although there were some serious delays in the development and testing of NHS plans, the overall preparedness for an influenza pandemic and the government response to the committee's concerns have been good. The Department of Health pandemic influenza team aimed to provide support for the development of pandemic preparedness which included guidance to GPs and primary care organisations. Operational guidance for GP practices was developed in conjunction with the Royal College of General Practitioners and the British Medical Association. It focused on continuity planning, dealing with symptomatic and asymptomatic patients and access to antivirals. The use of the Flu Line Professional, which was meant to allow GPs and other healthcare workers to validate users, update the system and process patients who had been correctly diagnosed, was, like the Pandemic Flu Line, announced but delayed in its implementation.

Although plans took much longer than expected, the national swine flu hotline and online symptom checker that enabled people to obtain antiviral drugs without seeing a doctor was launched at the end of July. Swine flu was remotely diagnosed and patients with symptoms answered a diagnostic questionnaire online and received a numeric code that could be exchanged for Tamiflu and collected by friends or relatives. Medical leaders and charities were concerned that this remote diagnosis might lead to other serious infections or conditions, such as meningitis, being missed or the "worried well" applying for medication which was not needed. My noble friend Lord Jenkin has already made that point.

After a period when everyone who could possibly have come into contact with a swine flu patient was given antiviral treatment, the mild symptoms of most cases and the effect of the antivirals caused a change of plans in August when scientists announced that children who catch swine flu should not necessarily be given antiviral drugs as the risks probably outweighed the benefits. They urged the Government to reconsider their pandemic strategy after an analysis of four studies published in the BMJ showed that the benefits for children were slight. Many health workers were concerned that Tamiflu was being handed out too easily and that little notice was being taken of possible side effects-some, including diarrhoea, vomiting and hallucinations, being quite serious.

One in 20 children given Tamiflu suffered vomiting as a side effect, which can lead to dehydration and the need for hospital treatment. A study published by Eurosurveillance listed common side effects: nausea, stomach pain or cramps and problems sleeping. Almost one in five had a "neuropsychiatric side effect", such as inability to think clearly, nightmares and "behaving strangely". There was also a danger of hypersensitive reactions to the drug, which have included anaphalaxis, erythema multiforme and Stevens-Johnson syndrome.

The researchers found that antivirals preventively reduced flu transmission by 8 per cent, meaning that 13 children would have to be treated to prevent one additional case of flu. It is not clear to me who has the professional responsibility for the prescription of antiviral drugs and for follow-up treatment if any unforeseen problems were to arise. Does the Minister know whether any deaths from swine flu have in fact been caused by administration of antiviral drugs?

Peter Holden, the BMA's expert on swine flu, also suggested that Tamiflu was being overused. He agreed that the National Pandemic Flu Service had been a great success and had taken the pressure off GPs. He said that for patients who are not in the high-risk groups, the virus typically causes mild symptoms and does not require a course of Tamiflu. Higher-risk patients, such as expectant mothers and asthma patients and those with respiratory problems, should see their GP, who would use their clinical judgment. In view of the decrease in numbers of anticipated cases, I hope that the Minister can update the House on how antiviral drugs are currently being distributed.

Recent studies by Professor Wendy Barclay warned that the virus had become more virulent and, in high doses, could penetrate deeper into the lungs. This might be an explanation for why different people react differently. For the first time we are experiencing a global infection in an era when we have knowledge of the sequence of our own genome. There may be genetic factors that determine how a person copes with a virus infection that are only just becoming evident. We can also study the virus's own genome, knowing from our experience with other flu strains that very small changes in the virus sequence can have important effects on its virulence.

We know from previous pandemics that there are usually two or more waves of disease, but we do not understand why. Whether the virus in the first wave was a milder form that mutated into something more deadly or whether other factors, such as changes in climatic conditions, enhanced the spread and infectivity of the virus is not clear. If a second wave arrives, vaccination will be our major public health defence.

Vaccination for vulnerable groups became available at the end of October, and front-line health workers have been encouraged to take the vaccine because they are at an increased risk of exposure to the virus and an increased risk of transmitting the virus to vulnerable patients. The committee recommended that steps should be taken to identify front-line healthcare workers who should be encouraged to be vaccinated.

A pandemic could place severe pressure on critical care capacity. I should be grateful if the Minister could provide more information on how critical care facilities, including staffing, could be increased in the event of a winter or spring pandemic. Should these staff be encouraged to be vaccinated, and what is the value of an advance course of antiviral drugs? During an oral evidence session I suggested to the Minister that medical and dental registration bodies should maintain a list of retired practitioners who have the experience to help with antiviral and vaccination policies should extra staff be necessary. I wonder whether the Minister agrees.

As the noble Lord, Lord Sutherland, mentioned, health workers reported 10 days ago identifying a strain of swine flue that was resistant to Tamiflu. Five people at the University Hospital of Wales, all of whom have serious underlying health conditions, have developed resistance to the antiviral drug. There have been several dozen reports around the world of people developing resistance to Tamiflu, but there has been only one recorded case of person-to-person transmission of a Tamiflu-resistant strain. The World Health Organisation has reported 57 incidents of Tamiflu resistance.

Dissemination of information could be a problem. The committee was concerned about the number of organisations that issue recommendations and the discrepancies between them. Will the Minister comment on the committee's recommendation of a national reference point for use by GPs from which they can request advice on the treatment of high-risk groups? The noble Lords, Lord Sutherland and Lord Patel, and my noble friend Lord Crickhowell have asked the Minister to explain why only 1 million people have been vaccinated using the 10 million doses of vaccine distributed to GP practices. What plans are there to explain the benefits of vaccination for both adults and children? Are the Government content with the current campaign to support those benefits?

Photo of Baroness Tonge Baroness Tonge Spokesperson for Health 5:53 pm, 7th December 2009

My Lords, I congratulate the noble Lord, Lord Sutherland, and all members of the committee, on producing this report and on being so diligent in taking pre-emptive action during the potential pandemic. As we have heard, the report came out just as the flu really hit us in this country. I, too, commend the seminar, as did the noble Lord, Lord May, within the report. It is very interesting reading and very informative. I also thank the members of the committee for the 10-minute seminars that I have received today. They, too, have been informed and interesting.

I commend the report and the Government's response, which has been timely and measured. They have taken this seriously and have done very well. As the noble Lord, Lord Jenkin, pointed out, the vaccine and antiviral store was quickly built up. He also mentioned the NHS workers. We should all pay tribute to the people in the NHS who have taken this very calmly. I no longer work in the NHS, but I am still in touch with a lot of colleagues who are, and they are calm and organised, a point to which I will return.

I do not think that anyone has mentioned the 1918 flu epidemic which killed 50 million people. That was far more than the number of people who died in the First World War. Flu has to be taken seriously. One of the slightly frightening things about the current flu epidemic was that it was said to be attacking the same age group of people as the 1918 flu epidemic. So it rang lots of bells. My family also do not have to be told how serious flu can be. Only nine years ago, a 32 year-old woman in my extended family died of myocarditis two days after contracting flu. My lot are all a bit flu-sensitive and take it very seriously.

Consequently, when two of the grandchildren in one branch of my family developed very high temperatures two weeks ago, all the bells started ringing and they rang mum and dad to find out what to do. Since we were not within visiting distance, we decided to test the system. This is a bit more coal-face experience for noble Lords. In the report, some delays in the setting up of the National Pandemic Flu Service were pointed out. But it now operates well and was used by my family. My family went onto its website and it answered all the questions. The other night, in preparation for this speech, I went onto that same website. I realised that I was doing something wrong, but I wanted to see how it worked. The questions got so detailed and complicated that I gave up and rang my family to find out what they had done.

They answered all the detailed and comprehensive questions. Eventually, they were told that it sounded like the children had swine flu. They were given a magic number, like an airline booking number, to give to their flu buddy, the next-door neighbour, who was sent to a centre to get Tamiflu-just like that. I was a little concerned about that and a number of noble Lords, especially the noble Lord, Lord Colwyn, have expressed anxieties about this. No swabs were requested. Despite the seminar saying that a very good system of diagnosis had been set up with laboratory confirmation, I would like the Minister to tell me why this has been stopped. I appreciate that numbers are difficult to cope with, but there needs to be confirmation of diagnosis. We do not seem to be getting that. So no diagnosis was made and they were sent to get Tamiflu.

The children became very sick. The little one started vomiting and was quite ill. The older child could not swallow the Tamiflu capsules, which made her a bit sick as well. There was the usual family chaos. They were told that no suspension was available. Indeed, last week I was in Chicago and there were notices up at all the pharmacies saying that no suspension was available for children. This clearly is a problem that the Minister might like to address. I do not expect him to be responsible for the USA, but I should like to be assured that there is enough suspension here.

Finally, when my family rang their GP to get advice about the children who were really quite poorly he was furious. He said that it was too late to give the children Tamiflu anyway. He did not agree that Tamiflu was the right thing to take. He said that it should be given, as the noble Lords, Lord Patel and Lord May, eloquently said, as a preventive, if not in the first 24 hours. He said that he had had lots of experience of children becoming ill on Tamiflu. I should like the Minister to address that problem and tell us what the Royal College of General Practitioners says about Tamiflu. I appreciate all the points made by the noble Lords, Lord Patel and Lord May, about the usefulness of antivirals, but it is the way in which they are being distributed which may be the problem.

I should also like to reinforce what the noble Baroness, Lady Finlay, has asked the noble Lord, Lord Jenkin, to say. If no further laboratory diagnosis is taking place, how do we know that it is H1N1? How do we know what we are dealing with? Is it being treated in the right way, or has it mutated-if viruses do mutate? I cannot remember: it was a long time ago. There is a real hole in our information. We are assuming, from telephone calls and website questionnaires, that the disease we are dealing with is the H1N1 virus, but we do not know. I would like to know.

I will make a few more short points. Will the Minister tell us what progress has been made on vaccination? I agree with all that has been said about pregnant women and the value of vaccination; indeed, one of my daughters-in-law, who is pregnant, dashed to get her vaccination straightaway. However, she cannot get it for her child who is under five. Our GP has kept up and was fully prepared. He did all his vaccinations for the elderly early this year because he knew there was going to be a big rush for the flu vaccine once it came through. He has already vaccinated all the pregnant women and vulnerable people, but he has run out of vaccine, and as he is still waiting for more he cannot do the under-fives. This is quite a serious problem which needs looking at. The noble Lord, Lord Sutherland, and others dealt with intensive care capacity. We need reassurance that if a second wave of the flu comes, there will be enough intensive care beds to treat patients.

My final point is that I was, as usual, quite amazed to see some American television last week. Most of it really is quite awful. However, I was very impressed to see every 10 or 15 minutes the messages about flu that my children had received from the website here; about what to do if you think someone in your family has flu and the various points and symptoms to check out. This was on television at regular intervals. I do not watch much television in this country, but I hope the Minister will tell us that the Department of Health will start using television much more for health messages. It is such a useful medium. Many people, particularly the elderly, cannot be bothered to go on to computers or websites; we should be using prime-time television much more.

Photo of Earl Howe Earl Howe - Shadow Minister, Health 6:02 pm, 7th December 2009

My Lords, the House will be grateful to the noble Lord, Lord Sutherland, for having given us the opportunity to return to the subject of the H1N1 pandemic. I congratulate the noble Lord and his committee on producing such a useful short report. The fact that events have moved on since its publication is neither here nor there: it contains both evidence given and conclusions drawn which are of lasting value for future policy-making and which therefore merit the closest attention.

At the beginning of their remarks, the committee make a point of commending the Government on the steps it has taken to prepare for the current pandemic. We can all echo the spirit of that commendation, because while big questions remain about the pace at which the National Pandemic Flu Service was commissioned-and my noble friend Lord Jenkin is right that we should not gloss over this-there is no doubt that the Department of Health has done well in delivering a good state of national preparedness for dealing with a flu pandemic, and with this pandemic specifically. I am sure that the early stockpiling of antivirals and the prompt commissioning of the H1N1 vaccine from manufacturers represent at least part of the reason why the WHO has been so complimentary about this country's state of readiness in comparison with that of others. As an aside, I think it has been helpful that we have had a broad degree of political consensus on what needed to be done, borne largely on the back of clear and expert scientific advice.

Nevertheless, some of the decisions taken by Ministers have not been straightforward. The original emergency plan, based around an H5N1 pandemic, presupposed that there would be no attempt at any sort of containment strategy, yet when H1N1 first broke, the immediate policy was to try to contain it. This was not a case of Ministers acting like King Canute, but rather a deliberate and sensible effort to delay the worst of the outbreak in the lead-up to a specific vaccine becoming available. Even with hindsight it is impossible to say whether this policy actually worked. The likelihood is that it succeeded in delaying the spread of the virus during the school summer term, though by July of this year very significant numbers of cases were being reported. Those numbers dropped rapidly during the school holidays, but then again rose sharply during September. The latest data indicate that the numbers are levelling out, and perhaps even diminishing a bit, but the burden on the NHS remains significant. It would be helpful to hear what the Government's predictions now are of the worst-case scenario as regards the national infection rate. Is it still, as they were saying earlier this year, 50 per cent of the population?

There is one basic problem with H1N1, referred to so well by the noble Lord, Lord May, which is that the science surrounding it is still unclear. From a political standpoint, that is unfortunate. The public are in the habit of demanding absolute certainty in the advice they get from Government, but here absolute certainty is impossible. We can say that the virus appears to be less lethal than the virus which gave rise to the last major pandemic in the late 1960s, but that it has none the less proved lethal in a number of instances. We can say with confidence that some people are more at risk from the virus than others, yet we must also say that some healthy people, who do not currently appear to be at risk, will die from it. Nor can we quantify the number of cases. The statistics that we have are based not on swabs, but on the number of consultations which GPs have recorded, a methodology which is wide open to inaccuracy and distortion. No doubt some sort of a picture will be emerging from the experience gained by the National Pandemic Flu Service. It would be interesting to hear what the Minister has to say on that score, bearing in mind the warning note sounded by the noble Baroness, Lady Finlay, via my noble friend Lord Jenkin.

The scientific uncertainty over H1N1 was brought home to me by one particular press release from the department in August, which announced 14 new research projects into swine flu. These included a project to establish how long someone with the virus is contagious and what a "safe distance" is from a swine flu patient-in all circumstances, fairly basic facts. It would be helpful to hear whether the department has had sight of any findings from this research.

We do of course have the benefit of data collected in other countries. In the United States, the Center for Disease Control has recommended that children and young people should be vaccinated as a priority group, because a large number of cases have been seen in children who are in close contact with each other in school and daycare settings, and in healthy young adults who live or work in similar close proximity. The hospitalisation rates among nought to four year-olds and five to 24 year-olds are the highest, and the incidence and severity of swine flu is significantly greater in these age groups than in the rest of the healthy population. I therefore need to ask whether the Government are considering rolling out the vaccination programme to all children and young people under the age of 24, as opposed to just those in the seasonal flu at-risk groups.

Photo of Lord Fraser of Carmyllie Lord Fraser of Carmyllie Conservative

Last week the noble Lord, Lord Patel, was made a Knight of the Thistle, for which I am afraid that modesty is not part and parcel of the requirement, as my noble and learned friend will understand particularly clearly. On listening to the debate and on reading the report, I have to say that the scientific community in Scotland is particularly pleased that such a brilliant report should have been received by your Lordships' House in these circumstances.

Photo of Earl Howe Earl Howe - Shadow Minister, Health

My Lords, my noble and learned friend has brought the House's attention to a happy award. I extend my own congratulations to the noble Lord, Lord Patel, on his honour.

It is also clear that the elderly who catch swine flu do badly, and many doctors consider it regrettable that not all the elderly are to be offered the vaccine. I fully appreciate that supplies of the vaccine are limited and that its distribution must be prioritised. However, it would be helpful to have the Minister's comments on that point.

One issue which the committee considered was the need for clear advice to be available to high-risk groups about the virus and what to do. The recommendation that emerged-my noble friend Lord Colwyn mentioned it-was that it would benefit GPs to have one central source of up-to-date advice which could be accessed as necessary. What has been done about that? The idea has particular relevance in the context of antivirals. As we have heard, anecdotally there is a reluctance on the part of many GPs to prescribe Tamiflu, because its side effects can be nasty compared to the symptoms of the virus itself. There is also a fear that those who take Tamiflu now may develop a resistance to it, which could prove counterproductive were the virus to mutate. I follow my noble friend Lord Jenkin in asking what is now the official medical advice as regards taking Tamiflu.

The committee also looked at the vexed question of critical care capacity. I wonder whether the Minister could update the House as to how well the NHS's critical care services are standing up to the test of swine flu alongside the beginnings of seasonal winter flu. It was encouraging to read the evidence presented to the committee that, should circumstances so demand, critical care capacity could be doubled. How precisely that could be done is still unclear, at least to me, and I hope that the Minister will take the opportunity to explain. Looking at interim measures, I should be interested to know what arrangements have been made for NHS trusts to help each other when the system comes under pressure.

Looking back at the events of the year, I think that many would say that there were lessons to be learnt from the way in which PCTs communicated-or in some cases failed to communicate properly-with GPs; undoubtedly some GPs felt unreasonably excluded from the planning process. The approach adopted seemed very much one of command and control, which in an emergency may be all very well, so long as the plan actually works and makes sense. By some accounts the messages promulgated were not always as consistent and clear as they should have been, and I frankly do not understand why members of the medical profession were not given more of an opportunity to contribute to the logistical planning process than they were. There was time to do that. It seems that the departmental failings on which the committee has put its finger, as well as a lot of the unanswered questions, all fall under the broad heading of communication. As we look ahead to what may lie in wait for us around the corner, as we must, it would be good to hear from the Minister that, when the threat from this virus is behind us, there will be a small list of issues in the department headed "Lessons to be learnt" which can be addressed and resolved before the next such crisis occurs.

Photo of Lord Tunnicliffe Lord Tunnicliffe Government Whip, Government Whip 6:14 pm, 7th December 2009

My Lords, having lived in crisis situations, I know that one of the points at which you are running out of options is when you count your problems rather than weigh them. Today, I feel that I have been barely able to count the number of questions, never mind understand or possibly respond to them. Therefore, I make a blanket commitment-I apologise to officials for it-that we will write to noble Lords. There must have been 100 questions and we shall try to cover them. I shall make an overview speech and then touch on the major issues raised.

I thank the noble Lord, Lord Sutherland, for tabling the Motion, and thank all members of his committee for their insightful report. It is a welcome recognition of the strength and quality of the UK's pandemic plans. The UK remains one of the leading global players in planning and preparing. WHO declared a global influenza pandemic on 11 June, which means that we have an entirely new virus. At the beginning, we have little information, and you cannot wait to see how it develops before deciding how to respond. That is why we invested so much time and effort in planning and preparing. But plans need to be adapted as information becomes available.

Throughout the pandemic we have drawn on national and international expertise to track how swine flu has developed. We have constantly adapted our approach and continue to do so. As many noble Lords have noted, to date the pandemic has been milder than it might have been. Most illnesses continue to be mild. However, some people are much more seriously affected. Our best estimates for England suggest that around 790,000 people have been ill with swine flu. Tragically, as of 2 December, there had been 178 confirmed deaths. I express my sincere condolences, and those of the Government, to the families and friends of those who have lost their lives.

We have been able to understand past pandemics only retrospectively. This is the first time we have been able to deal actively with a flu pandemic in real time. We are now in the second wave of the pandemic and case numbers are decreasing. That gives a great opportunity to roll out the vaccination programme and limit further the impact of the virus this winter and in future years. First, we have offered the vaccine to the most vulnerable clinical risk groups. We have also made it available to all front-line health and social care workers so that they can protect themselves and those whom they care for. Enough vaccine has been delivered into the UK to cover all those groups. So far, around 1.9 million doses have been administered in England.

We have taken the advice of the independent Joint Committee on Vaccination and Immunisation. The vaccine will next be offered to children over six months and under five years of age. Children under five who get swine flu are more likely to need hospital care than other age groups and are more likely to need critical care. Parents and carers of those children will be contacted when the NHS is ready to start that second phase of vaccinations, which I understand will be very soon. Vaccine will also be offered to main carers of older people and of people with disabilities. That phased rollout of vaccinations allows us to focus on those most at risk and to use vaccine stocks as they become available. We also have to recognise that there are limited capabilities for delivering the vaccine, which is why the phased and prioritised approach is so important. We will continue to review the best evidence to support any decision on wider vaccination.

Another key element of our response to the pandemic in England has been the National Pandemic Flu Service, which went live on 23 July, as soon as there was a significant upsurge in cases across the country. It allows people to have their symptoms assessed automatically by a dedicated website or phone. People who have flu-like symptoms can then ask a "flu friend" to collect the drugs for them. Antivirals help to reduce symptoms and the risk of complications. The service has given patients swift access to antivirals. It has discouraged people from spreading flu and has allowed GPs and other healthcare workers to focus on other sick patients; that is an important part of the service. A recent study of swine flu patients in hospital showed that they had a better chance of recovery if they received antiviral treatment within two days of having symptoms. That supports our precautionary approach and the use of the service to ensure prompt access to treatment.

As I said, the UK is one of the best prepared countries in the world. The NHS has planned and prepared extensively for pandemic flu and continues to do so. Our pride in that achievement, and the way it has been echoed around the House, does not mean that we are complacent. This has been a serious event and learning experience. The NHS is potentially facing a very tough winter, but it is in a strong position to cope.

The 10 English strategic health authorities have each led an exercise to test and improve their preparedness for a second wave of swine flu this winter. The results of these exercises have been published and copies placed in the Library. NHS boards have also published statements of their readiness to respond to swine flu. These show that there are robust leadership and governance arrangements in place to deal with the pandemic. One key service that can come under severe pressure in a pandemic is critical care. The NHS has demonstrated how it could, if necessary, double its ventilated critical care capacity during the peak weeks of the pandemic. Fortunately, although demand for critical care has increased during the pandemic, the NHS has coped well without having to surge capacity. However, it is absolutely right that we are prepared for the possibility of doing so.

As highlighted in the committee's report, we know that during a pandemic some healthcare workers will be concerned about risks. The Government have taken precautions to protect these essential workers. We have developed detailed guidance and we have stockpiled face masks and respirators. We are now encouraging front-line health and social workers to be vaccinated. To keep the public informed, there has been a mass public health campaign with print, TV and radio adverts. The adverts remind people about good respiratory and hand hygiene. The "Catch It, Bin It, Kill It" message has been pushed hard.

A tremendous amount of work has been done since the outbreak of swine flu both at the front line and behind the scenes on trying to limit the effects of the virus. On behalf of the Government and the whole House, I would like to thank everyone involved in helping to respond to the pandemic. But we must not underestimate the continued threat that swine flu still poses, so we continue to monitor the situation closely, reviewing our plans and maintaining a precautionary, flexible and proportionate approach.

I move now to some of the particular points made by noble Lords. The noble Lord, Lord Sutherland, set out the interesting story of the committee's involvement in this debate. One of his points was that the questions raised must be kept alive. He commended the Government for being alert and responsive but quite properly warned that complacency can be a problem and that lessons must be learnt. We will not be complacent.

There has been much discussion both in the report and during today's debate about the concept of end-to-end testing. I have probed this at some length and I am assured that the experience of the pandemic, together with the exercises carried out over the summer by all the strategic health areas to assure ourselves that the various plans that we have put in place will work, has effectively been more powerful than the end-to-end testing originally contemplated in the evidence to the committee. While the exercise has been desk-based in one sense, I would say, as someone who has been involved in emergency plans, that it can be powerful. However, as the noble Lord commented, we have had a living experiment and we are committed to learn from it. We will also pick up on his point about the importance of involving other jurisdictions.

On the issue of the lack of beds in the south of the country, those areas that are less affected by the flu at any one time would help areas that are more affected. This is a mutual aid exercise and follows an approach frequently taken by the NHS. All regions have well developed systems of critical networks in place to make sure that adult patients have access to critical facilities.

The noble Lord, Lord Crickhowell, concentrated particularly on concerns related to pregnant women and workers. I think that the advice is clear: pregnant women should be vaccinated. However, I will ensure that we touch on this point in our response to all Peers who have taken part in the debate. On the issue of the limited reach of the vaccination programme, it is vital to realise the importance of prioritisation. Public communication material for surgeries, including a leaflet, was launched and this has raised awareness and understanding of the swine flu immunisation programme. Also, vaccine records have been created. We are collecting data from GPs and all other sources so that we have a ready database for the learning programme.

I was asked whether the vaccines are safe for pregnant women. The simple answer to that is yes. While it was explained to us that the phrase "absolutely safe" is unrealistic, the vaccines achieve the levels of safety reached by other vaccines. Both vaccines have been licensed for use in pregnant women. Licensed vaccines, including influenza vaccines, are subject to a very high standard of safety and they would not be licensed if they were considered unsafe.

The speech of the noble Lord, Lord May, was in a sense a useful teaching exercise for noble Lords. The only area that I would dispute is that at some point we said that there would be 70,000 deaths. Someone else mentioned the "dilemma of communication", which is an important point. On the one hand we want transparency-I believe in it strongly-while on the other hand we do not want to frighten the horses. The problem with transparency is that people can be frightened. What we have been publishing throughout the process is the worst-case scenario, because that is what we ask our organisations to respond to. I have not been able to cross-check the figures, but I believe that at one point fairly early on it was said that there might be as many as 70,000 deaths. Today's view is that there will be, at the most, a further 1,000 deaths. Once again, that is a worst-case scenario. Indeed, all the other figures for planning purposes are related to the worst-case scenario option.

The noble Lord, Lord May, discussed the use of antivirals as a prophylaxis. That is absolutely valid and we agree with him. In many ways, it is why we have set up a system that is automatic in nature. Some people have said, "Going to a web page or making a telephone call does not constitute a proper diagnosis". This is all about judgment, and the Government are responsible for those judgments. The question here is one of proportionality: what is the risk of very serious complications perhaps leading to death through use of the antivirals? The judgment is that it is low compared with the advantages of easy access through the rapid rollout system that we have created. We take the view that the method of distribution both was and continues to reflect the right balance of judgment. The role of government is to be responsible for that kind of decision.

I turn to the issues raised around lessons learnt. We have learnt a lot about swine flu and we have tested our plans. We will conduct a full review of the national framework next year and will revise and update the content in the light of emerging information about the pandemic. I cannot give the detail of how we will conduct the review because lessons being learnt in a live situation are a continuing process-you learn the lessons and put them into your system. However, we will also go through a formal lessons-learnt process to ensure that we learn all that we possibly can from the experience.

The noble Lord, Lord Jenkin, asked whether the service was misdiagnosing people. As I have said, the system has been developed with specialist help. The causes of illness are not always clear, but we believe that the proportionate effect that was delivered was right. Wales, Scotland and Northern Ireland have not used the same system; that is quite correct. They generally have a more dispersed population and have chosen to use GPs to distribute the antivirals. That is not considered the best option for most people in England. However, we have always recommended that people in high-risk groups, including pregnant women and children under one, should consult their GPs.

The noble Lord, Lord Patel, particularly stressed that we should remain vigilant. I may be new to this subject, but I have been probing officials over the last couple of days and I am convinced that we are very seized of the importance of vigilance and of not being complacent. The targeted group approach will mean, for instance, that children under five should all be vaccinated by the end of this month. We are not changing the access to antivirals, which continue to be accessible now through the flu line and the website, as they were before. Our current stockpiles of antivirals are good; there is a stockpile sufficient to treat 50 per cent of the population, should they become ill.

I was about to say that the vaccine is available to GPs; it is available to virtually all GPs. Data about the uptake are just starting to come in, but it is early and I cannot deliver any more precise answers about uptake today. The full or enhanced national pandemic flu line is only modestly different from the interim one that was delivered. It allows for a better relationship with NHS professionals. When it is used, it will be more flexible in its approach.

On the points raised by the noble Lord, Lord Colwyn, we have concentrated on making sure that GPs get a consistent and correct answer to questions, whatever the source of the advice. We have worked closely through the Royal College of General Practitioners and the BMA General Practitioners Committee and we have provided advice on policy and context issues to GPs. We resisted the idea of a specialist channel, because these are well developed and trusted ways of communicating with GPs; we thought it more important to enhance them and to make sure that single, consistent messages were coming through those regular channels than to create some other channel where you might end up with two messages. So far there have been 178 confirmed deaths in England. None of those was from an antiviral. As with any drug there is always a potential risk, but most reactions are short-lived.

I think that the comments from the noble Baroness, Lady Tonge, have largely been taken up. We are relying on a clinical diagnosis, not a laboratory confirmation. However, we have well established seasonal influenza surveillance systems to monitor the spread and activity of swine flu and we are getting a strong enough picture from those. We are very clear about the importance of data. We are still finalising the logistics of how the vaccine will be delivered to children over six months and under five years, but we expect that general practitioners will want to continue to be a key component in that delivery. We are currently working with the BMA and national health organisations to agree exactly how.

Finally, the noble Earl, Lord Howe, asked a list of questions, as ever. I will take praise from him as from everybody else on behalf of the Government in his general comment echoing how we have done relatively well. I am looking at this as having been quite a good job from the Government. To pick up on his particular points, the containment worked; the numbers are levelling out. He asked about numbers and where we are now with the guidance. I think that the last guidance was on 22 October. In that revision of the planning for a worst-case clinical attack rate, we revised the numbers down to 12 per cent-up to 7.5 million people. The reasonable worst case is that a further 35,000 people may need to be admitted to hospital, with up to 5,300 requiring critical care. A further 1,000 people might die, but once again that is the worst case. At the moment, all our plans show that our critical resources can cope with that situation.

Yes, there were 14 research projects; I feel that we are damned if we do and damned if we don't. The questions may have seemed straightforward-how long, when, and so on and so forth-but it seems to me entirely proper to have started those 14 research projects. I understand that four of them have interim reports, but since they were launched only in August we do not expect results until-

Photo of Earl Howe Earl Howe - Shadow Minister, Health

My Lords, the noble Lord should not misunderstand me. I was commending the Government for having commissioned the research and merely commenting in the context of my general point about scientific uncertainty that that went to prove how much we still had to learn about the virus. In no way was I criticising the department.

Photo of Lord Tunnicliffe Lord Tunnicliffe Government Whip, Government Whip

It is always a delight to agree even more with the noble Earl.

On the groups, the six-month to five-year group is in hand and the other group of young people is under consideration, but at this time we have certainly not decided to go ahead with that. We are not going ahead with the 65-plus group at the moment. They are in the same general position. I emphasise that we are strongly encouraging anybody who is 65 or older and who is in an at-risk group to be vaccinated. That is available now. Anybody listening to the debate who is 65 or older and in any of the at-risk groups should be off to their GP, seeking a vaccination.

I have made the point about the central source and I think that most of the points raised by the noble Earl have been covered. I thank noble Lords for this excellent and wide-ranging debate and I apologise to my team for the length of the letter that will have to be written.

Photo of Lord Sutherland of Houndwood Lord Sutherland of Houndwood Crossbench 6:37 pm, 7th December 2009

My Lords, I thank all who have taken part in the debate, including my colleagues from the Select Committee and the noble Lord, Lord Patel-my friend and a Knight of the Thistle, as was properly recognised in the discussion.

Noble Lords:

Hear, hear.

Photo of Lord Sutherland of Houndwood Lord Sutherland of Houndwood Crossbench

Yes, hear, hear. I also thank the two opposition Front-Bench spokespersons, the noble Baroness, Lady Tonge, and the noble Earl, Lord Howe. I particularly appreciate how there is, on the Front Benches opposite, a non-party-political approach to the issues as reports come from this committee. That is true of the Government, too. There is no point-scoring; we are concerned with real issues. There is evidence available-it may not be perfect, as the noble Earl, Lord Howe, pointed out-but that is the basis on which we go ahead.

I add just one more commercial. This further justifies to me the need to retain in this House the level of expertise that we have in the membership here. That being said, Members will appreciate very much the quality of advice that we have, both from within this House, on the committee, and from the experts who have come to attend our seminars and to talk to us. It was also evident to me that there is almost an increase in interrogation skills that my colleagues develop as the discussion goes on. I am tempted to say that there is a sort of terrier-like doggedness in how they pursue things, but one occasionally has to add to the word "terrier" the other words "pit bull", as one or two witnesses might well testify.

I thank the Minister for his response-for the overview, the detail and especially the promise. I appreciate that many of the questions that we have asked could hardly be answered from the Bench now and, equally, that the many requests that we have made for additional updating of figures could not possibly be satisfied in the course of the debate. We very much look forward to the Minister's and the Government's response on this.

One of the most important questions in the debate was asked by my colleague and noble friend Lord Jenkin, who asked whether the Select Committee would return to the matter. The answer is not to that question; the answer concerns when we will return to the matter. The practice of the Select Committee, over the last two or three years, has occasioned no fewer than eight follow-up reports, because we do not let a matter rest until we are reassured that it has been, to carry on the metaphor, worried to death both in report and in this Chamber. Perhaps I might conclude by telling the Minister, on behalf of the committee, that when the follow-up comes the first question will be, "What did we learn this time?", and the second will be, "What additional data did we collect that will help us in the future?".

Motion agreed.