Oral evidence: Science in emergencies: UK lessons from Ebola, HC 469Tuesday 24 November 2015

Oral evidence, 24 November 2015.

Witnesses

Professor Sir Mark Walport, Government Chief Scientific Adviser, Government Office for Science, Professor Dame Sally Davies, Chief Medical Officer, Department of Health, and Brigadier Timothy Hodgetts, Medical Director, Defence Medical Services, gave evidence.

Chair

Welcome, and thank you for coming to give evidence today. This is our second and final session on science in emergencies: lessons learned from Ebola. I know that all of you were closely involved in the UK Government response to the Ebola crisis. We have just been hearing evidence on various in-country response issues but also Public Health England’s response. Brigadier Hodgetts, could I start by asking you a question arising from our previous panel? We heard from Dr Johnson about an effective diagnostic test for Ebola which was developed by the MOD’s Defence Science and Technology Laboratory and tested in-country. Dr Johnson was involved in the testing. He understands that 10,000 of these tests had been produced and were effective, particularly because they do not have to be refrigerated, which is very useful in-country, but they have not been released for use yet in West Africa. He has expressed concern about this. He gave evidence also to the International Development Committee and said this was his single biggest criticism of the UK response. Could you help us try to understand what is going on?

Brigadier Hodgetts

I can certainly help you understand some of the diagnostics we were involved with. I am not sure whether it relates exactly to the test you are talking about. We deployed a machine called the BioFire FilmArray, which had been developed by the Defence Science and Technology Laboratory but had not been fielded before. This works on the polymerase chain reaction, which identifies a tiny piece of virus and gives you the diagnosis. It is a bench-size piece of machinery. It is simple to use and very effective. It was tested against the gold standard PCR machine. A recent publication and statistical analysis shows that they are both equally effective. What we did was evaluate a piece of machinery that had not been fielded before and showed it to be very effective. This adds to our armamentarium for the future to put smaller machinery into the field. It is also a safe test because it relies on a heat-treated blood sample, so we can assure improved safety for laboratory staff as well as effectiveness in diagnosis equal to some of the more sophisticated, perhaps harder-to-move-around machinery.

Chair

That is very encouraging. I think Dr Johnson was referring to in‑clinic tests. He described it as a little like a pregnancy test. You put a drop of blood on the test and it gives you a very quick diagnosis, and it is very accurate, apparently. You are not aware of this test.

Brigadier Hodgetts

I am not able to give you anything right at the moment. I am sure I could look into that for you.

Chair

That is very kind of you. Would you like to give us a brief description of your understanding of the role that the military played in-country? We have heard glowing reports of how the military came in and provided much needed leadership at a time when it had been lacking from the UN previously and WHO. Could you give a brief description of your understanding of that situation?

Brigadier Hodgetts

Of course. The time between receiving the activation order and getting boots on the ground and treating patients was a total of six weeks. During that period we were building facilities; training staff on new procedures and assuring that training so that they were protected as much as they could be; and procuring new equipment and familiarising people with that. Our principal task was to build and operate an Ebola virus treatment unit in Kerry Town. Initially, that task was for six beds and we thought it was going to be for 60 days, but over the course of time we needed to stay longer and surge the capacity up to a maximum of 20 beds. We also conducted strategic evacuation to the UK of patients, or exposed individuals who might potentially develop the disease, using the air transportable isolator. With our engineers, we provided support and supervision to help the Department for International Development build an additional six Ebola virus treatment centres. We also deployed at short notice 5 Medical Regiment and, within a month of their task, they were on the ground training local healthcare workers in infection prevention control measures. Overall, they trained about 4,000 of the local nationals before handing on that responsibility to another organisation. We worked with the Department for International Development and the Government of Sierra Leone to help establish both national and regional response centres to give them a command and control infrastructure to support the management of the crisis. It is also important that back in the UK not only did we train our own personnel but we were able to train the first tranche of national health service personnel before they deployed, and then do a train-the-trainer course for the charity UK-Med who could then continue to train NHS staff. We also provided training for international partners—for the Canadian defence forces who deployed with us, for Norwegians, Danes and the Irish charity GOAL.

Chair

One report we received from Dr Johnson was a clear message that the internal organisation of the British response in Sierra Leone—DFID, the High Commissioner and yourselves—was outstanding, but he was a little concerned that because of the strength of the internal command there was not always the same strength of relationship between that and the national response. How do you respond to that? Do you think that the engagement between the British response and what was going on in-country was as strong as it could have been?

Brigadier Hodgetts

I do not feel that I am in a position to comment on that accurately. I was not in-country experiencing that. I could seek advice from those directly involved.

Graham Stringer

Dame Sally and Sir Mark, we have just heard from Public Health England that the first outbreaks of Ebola were in December 2013 and PHE started publishing papers in March 2014, but action did not really start until August 2014. As the main advisers to the Government, were you satisfied with the detailed advice you got from Public Health England, and the timing of it, and do you have any other comments?

Dame Sally Davies

The first case, on detective work, turned out to be in December, but I do not think we were aware until February/March about that case and the tracking back. Public Health England is the public health arm and agency of the Department of Health, so its work is part of our shared Government response. Because it was outside our borders and it was a poor country, DFID played a role and on 14 March they sought advice from SHED. I will have to look up what that is.

Sir Mark Walport

Science in Humanitarian Emergencies and Disasters.

Dame Sally Davies

Thank you. Meanwhile, in February the Advisory Committee on Dangerous Pathogens convened as a standing committee to look at the haemorrhagic fever advice. That is the expert committee that advises so that Public Health England can translate it into guidelines which we can then agree and sign off. As we went through the summer, we were aware of it building up and were concerned. Indeed, in July I wrote to all doctors in the country highlighting the issues so they were well aware, and in mid-July we were into our third ACDP committee. By the time WHO called a PHEIC—a public health emergency of international concern—on 8 August we already had a lot of work in play. You could ask whether they should have called it earlier. In retrospect, yes, but it just gave more emphasis to what we were doing; it did not change the direction of travel.

Sir Mark Walport

I agree with everything Dame Sally has said. The work of Public Health England was, if you like, always peer-reviewed internally as part of the committee structures we had. Dame Sally assembled health advisory committees. Those morphed into an Ebola scientific assessment research group, which in turn morphed into SAGE, and there was continuity between all of them. While it sounds like a rather complicated series of structures, there were similar people and overlap was involved all along. Public Health England were in that. Their modelling was tested by external experts on modelling. All aspects of their advice were being tested, so we were very supportive of what they were saying on the basis of peer review evidence.

Graham Stringer

Dame Sally has just said that it probably could have been a quicker process. Do you have any recommendations as to how the internal communications between the bodies will be different in future, so that if a similar crisis occurred it would be a speedier response?

Dame Sally Davies

I would agree with Sir Mark that communication was good. Whenever I got experts together, Sir Mark was invited and sent someone so he was there, and we morphed the groups from one to the next to the next in order to have the right experts in the room giving the right advice. When Sir Mark finally stood up the SAGE, it was only a variation on a previous group, the Ebola advisory group, a couple of meetings of which I had co-chaired with Jeremy Farrar from the Wellcome Trust. It was important at that point to have a SAGE so that Sir Mark could commission the modelling. There were various groups working on modelling and it needed a formal system not only to commission it but to say, “We want one answer that is a consensus.” Sir Mark set up a sub-group, which brought together DH modellers, Public Health England modellers, London School modellers and Imperial College modellers, and we had an Oxford modeller on the SAGE committee looking at the final product, because that modelling drove the in-country response in Sierra Leone.

Sir Mark Walport

From the very beginning when Science in Humanitarian Emergencies and Disasters were requested by DFID to get involved, because at that stage it was a west African emergency and DFID were taking the lead, the advice from that group went to the CSAs, me, DFID, FCO, MOD and Department of Health. It has been joined up from the very beginning.

Graham Stringer

The London School of Hygiene and Tropical Medicine and the Harvard Global Health Institute have just published a very critical report on the World Health Organisation. Do you agree with their conclusions and severe criticisms? Do you have any other recommendations you would make because, after all, we are part of the World Health Organisation?

Dame Sally Davies

You should know that I sit on the executive board representing the UK. They are right in their analysis of the delay and that it probably meant that lives were lost, and that they found it very difficult to negotiate round the world the resources needed, but I do not think we need separate systems. Our belief as a Government and all of us together is that we need significant WHO reform, which we are working towards. They had a major external review chaired by Barbara Stocking. They are following all her advice. She used to be a health service manager and then ran Oxfam, and she is head of a college in Cambridge. She led an external expert group looking at it. If we have a totally separate system, it will not work. We need to have the WHO as the lead for the health cluster in humanitarian responses, working with the rest of the UN humanitarian response. They are trying to set up an emergency contingency fund. We have committed $10 million to it for if there is another one. They need $100 million that they can just call down overnight. They were stuck because people were not giving them money to mount the response they needed to. They also need a command and control structure and they are developing it. In our health reform under the previous Government, despite the changes, there is still in this country a strong command and control system for emergencies. They are working on it and we are pushing them very hard.

Sir Mark Walport

My comment is that it is a very good report. I think they have analysed it very carefully. I do not want to read it to you, but in panel 1 they divide it into four phases. The initial phase was “inadequate national investment and donor support for building national health systems capable of detecting and responding to disease outbreaks,” so a lot of that is about inadequate health systems in some developing countries. That is a profound problem. It is easier to make a diagnosis than provide a straightforward treatment. The second phase, April to July 2014, is interesting: “Little incentive for countries to report outbreaks early,” so some of it was about inadequate reporting and data sharing, an issue about which Dame Sally and I have recently written to The Lancet. WHO were “slow to mobilise global attention or assistance.” One has to recognise that there is a regional as well as the Geneva component to WHO. I think the incentives there did not work properly. Then it picked up in phases 3 and 4. I will not go through all the details, but that was the point at which the UK kicked in on a very large scale and committed £427 million, and you have heard something about the response.

Graham Stringer

Public Health England suggested to us in the previous session that part of the problem was that there is either no crisis or a major crisis. If this is not a contradiction in terms, they were suggesting an intermediate level of crisis so they could alert earlier. I know you have not heard that before, but do you have any response to that suggestion?

Dame Sally Davies

I have discussed with Barbara Stocking and the director general of the WHO whether they should have a more modulated scoring, and they are considering it. At the moment I think they have review overload and it is proving quite difficult to deliver their work and respond to all the different reviews. There are of course two more major reviews due, one by the National Academy of Medicine in the States and the other commissioned by the secretary general, so they have their own, the follow-up to their own, this and more coming.

Sir Mark Walport

It is always difficult at the very early stages of an infectious disease outbreak to know exactly what is going to happen, so modelling at that stage is very uncertain with very wide confidence limits. It is only as the epidemic progresses that you can narrow those. That is one of the challenges with infectious diseases. For example, we have MERS floating around—middle east respiratory syndrome. We got on to MERS a bit faster, but I think the learning from Ebola is that in terms of modelling what is going to happen it is very, very difficult.

Dame Sally Davies

Yes. For instance, at the end of May we had a meeting of experts looking at MERS because of the Korea outbreak, so while we were doing all this we were not taking our eye off other issues.

Brigadier Hodgetts

May I say something positive in response to the critique in The Lancet? Their third recommendation was about the production and sharing of data, knowledge and technology. This is something we have been very keen to do. We have been very keen to exploit as much as possible the experience from Ebola and to share it. To date, we have had 19 articles published, excluding editorials and letters, and we have another series of articles in preparation. That covers issues such as innovation in training, using an ultraviolet tracer to map whether or not you have effectively decontaminated yourself, which led to a huge surge in the confidence of our staff before they deployed. We also developed rubber sleeves to go over the arms and chests of simulation casualties so that we could practise cannulation on real people, interacting with them as if they were genuinely seriously ill. We are improving our understanding of the disease. We have a study running with St Thomas’s Hospital—we received authority to bring samples back to the UK—to characterise the coagulopathy, the abnormal blood-clotting associated with this haemorrhagic fever. We looked at the value of a whole host of specific interventions and published on the value of giving blood transfusion to people with abnormal blood-clotting; the value of putting in central lines early—lines into a big vein in the neck—to improve patient comfort and reduce the number of times you have to assault the patient with a needle, and also to improve carer safety. The fewer times you use a needle, the less you will be exposed potentially to needlestick. We are also looking at how we target resuscitation using an ultrasound probe that is passed down the oesophagus, down the gullet, and at targeted replacement of electrolytes. We mentioned some of the better diagnostics in terms of the BioFire FilmArray, but we also fielded from the University of Birmingham the MinION, which is effectively the size of a large USB stick and is a portable genome device. It can generate real-time genomic data. There was a real learning point from this, in that we had quite a lot of difficulty getting local ethics approval. We were absolutely adamant that any research we did was going to be ethically sound. It was approved in the UK through our MOD research ethics committee, but finding the processes in-country to make sure that it was approved by the local Sierra Leonean ethics committee was very difficult and took a number of months. It took so long that by the time we got approval, we were over the shoulder of the outbreak and lost some of the potential in being able to exploit that device. We did not give up. Instead, we have made multiple attempts at sequencing bacteria isolates, shigella isolates, rather than the Ebola virus, at least to prove the principle. We continue to work on that as another potential portable analyser for the future, and to give understanding of the genomics of the outbreak in real time. Do you want me to stop? I could lecture.

Chair

I wish you would. It is fascinating, but I must be fair to colleagues.

Matt Warman

Sir Mark, you described the evolution from one committee to another and another that ended up in SAGE. Am I right in thinking that SAGE was ultimately established at the request of COBRA? Could that have happened earlier? Should it have happened earlier?

Sir Mark Walport

That is a good question. The protocol at the moment is that it is established through the Civil Contingency Secretariat as part of the COBRA process. I think that one of our learnings from this is that we probably would have established it a bit earlier. Having said that, I was perfectly satisfied that Dame Sally had an advisory process in the Department of Health that was keeping all of us informed, so I do not think that the quality of science advice suffered in the least bit from the fact that SAGE did not occur until then, but if we were doing it again we would probably do it a bit sooner.

Matt Warman

Dame Sally, does that chime with your view?

Dame Sally Davies

Yes. I do not think we needed to do it earlier, because the science advice was coming in and being acted on, and we were all taking that advice and sharing it. That is what matters.

Matt Warman

Exactly. You mentioned the Wellcome Trust earlier. Is it reasonable that we had to rely on a charitable institution to help? Is that what you would expect?

Dame Sally Davies

I invited Jeremy Farrar to our expert groups because he is an infectious disease expert. He served for 18 years in North Vietnam and is one of our country experts, so it would have been wrong to leave him out. Because of their opportunities and his experience, he led a discussion on vaccines on 12 August over there and helped fund a number of the vaccine studies, so his expertise played a significant role.

Matt Warman

Would our response have been as good as it was had we not had help from a charity?

Dame Sally Davies

We have plenty of other people advising, but he happens to be an acknowledged expert. DFID also funded vaccine studies. We had a Government route through DFID and MRC to fund them, but the Wellcome Trust is able to do things rather faster.

Sir Mark Walport

First, I should declare an interest. I was the director of the Wellcome Trust from 2003 to 2013. I just comment that when we were involved, for example, in H1N1 influenza, the Gates Foundation was similarly involved in the United States. In a sense, the UK and the US are fortunate to have large foundations that support research in these areas and, therefore, contribute to the critical mass. I do not view it as a charity substituting but as a synergy, because we have the good fortune to have a major foundation that supports infectious disease research in the UK.

Chair

We have taken evidence from a number of researchers who have been involved in this process. Some have been on the clinical side, some have been involved in vaccine research and some sat on the various advisory bodies. They all feel that this has been a huge achievement, but the two words that keep coming up in this context are “ad hoc”. There is a sense that there was reliance on relationships rather than a very strong command and control structure in terms of scientific evidence. Dr Johnson, who was here just before you, was in-country and said that he had very strong relationships with senior people in the British Government, but he could not have said who the one person responsible for the scientific advice he was giving back was. We are trying to chime the different evidence we are receiving. Obviously, a lot of scientific evidence was coming in and it was very well used, but we keep getting evidence about ad hoc structures and we are trying to understand whether or not that matters and whether it needs to be changed for next time.

Dame Sally Davies

Let me take responsibility for the beginning. It was ad hoc, because at the beginning we did not know how bad it was going to be, but we were making sure we got advice, not ad hoc, from ACDP and SHED, bringing that together and looking at what more we needed and getting in experts. When the PHEIC was called we had the SAGE, so we moved to formal. I was very clear publicly in many places that we wanted to hear all views and they could come directly to me, my office or through Mark. If Dr Johnson did not know that he could go in either through DFID and Professor Whitty as their chief scientific adviser or through us, I am surprised.

Chair

To be clear, we also heard from the Wellcome Trust and a number of others. It has not come from one source. I do not think it is supposed to be a criticism. I think it is more the way—

Dame Sally Davies

But they were on the committees and groups, and we had a fair number of them. We had the first ACDP meeting in February and the third meeting on 14 July, and they went on; we had health advisory committees on 5 and 11 August; we had an ethics committee on the 9th; and we had another committee on the 12th and 19th. We were very flexible. If people said they wanted to give us advice, we invited them in. We were rolling very fast in order to make sure we addressed everything speedily, and that everyone got their say and we heard it.

Sir Mark Walport

I think there are two elements of ad hoc-ness. The first is that every single disease outbreak is going to be different. Our knowledge was contingent at the start and remains incomplete, in the sense that the persistence of the virus came as something of a surprise—the extent to which it would persist—so the science does emerge. Was there a single source of wisdom? Certainly, from a Government perspective it was highly co‑ordinated, but there were an awful lot of people talking, so science was coming from all directions to some extent. Within the Government set-up we were very well co‑ordinated throughout, so we never had committees duplicating each another. For example, during the SAGE we had sub-committees looking at modelling and the social science. Of course, the social science was extremely important in controlling this outbreak. Were there other voices speaking? There were American and French voices; there was international noise. It is inevitable that in an emerging epidemic there will never be a pure, single source of wisdom. Did the UK Government communicate coherently? I believe they did.

Chris Green

It sounds as though SAGE is working fine. Is that reasonable, Dame Sally?

Dame Sally Davies

Yes.

Chris Green

Dr Jeremy Farrar from the Wellcome Trust advocated establishing a standing advisory body on emerging infections that could meet regularly to ensure the UK is ready to respond to the next outbreak. If you are happy with it as it is, are there any particular weaknesses in that suggestion?

Dame Sally Davies

You need to be aware of what we already have. We have nationally an advisory committee on dangerous pathogens—the ACDP; we have nationally an advisory committee on UK zoonoses, or animal diseases and infections. Feeding into both of those we have another advisory committee: the human-animal infections and risk surveillance group. We have one about new and emerging respiratory diseases called NERVTAG which feeds into that. We have a structure of standing advisory committees which meet regularly to make sure that the advice is updated and they scan what is out there. There is SHED as well. What we have been talking about is how they have fed in, but in the heat of theatre, almost, as the epidemic built up, we needed to bring in more people, because we had to look at how it would impact on the NHS. We had as a third sub-group of SAGE a clinical trials group chaired by Professor Deborah Ashby, bringing in the MRC clinical trials group and industry partners, and CDC dialled in from the States, to look at trial methodologies to try to inform the different companies so that when they planned to use their vaccines in a phase 2 or 3 there was from this country some methodological support. I remain to be convinced that we need more than that.

Sir Mark Walport

I want to comment on the structure of SAGE itself. The important thing about SAGE is that it has a structure that can deal with a variety of different emergencies. There is a SAGE secretariat which lives in the Government Office for Science. It works extremely closely with the Civil Contingencies Secretariat and with the national risk assessment as well so that, as far as possible, we can make sure that it has the key risk. But the whole point about SAGE is that it is bespoke to individual emergencies. Therefore, the experts we would have for Ebola would be similar to but to some extent different from the membership for MERS, for example, and would be dramatically different from the membership for a SAGE dealing with flooding or an earthquake. What SAGE does is bring together the CSAs from the different Government Departments involved: Dame Sally, Chris Whitty from DFID and Robin Grimes from the Foreign Office. Then it brings together organisations, such as Public Health England—Sir Paul Cosford came along to SAGE—and experts from outside, depending on the nature of the emergency. As Dame Sally said, we had modellers, infectious diseases experts, Mike Jacobs, a clinician who looked after patients, and vaccine experts. It is always bespoke for the particular emergency, so it is a structure that has the flexibility that we need. We constantly work so that we can anticipate where expertise is needed, although inevitably when an outbreak occurs we do further research and build up expertise. It is a bespoke mechanism for each thing, but it has a standing structure so that SAGE can be called very quickly indeed.

Chris Green

It can respond to each crisis.

Sir Mark Walport

Each crisis is slightly different; even each infectious disease crisis is slightly different.

Chris Green

The Government told us that the Department of Health is working with the Government Office for Science to rationalise the processes for obtaining advice during a health emergency. What parts of the process are you aiming to rationalise?

Dame Sally Davies

We have been looking at this. We have been quite clear: we think it worked well. What we like is the way everyone communicated. The debate is about whether we would stand up SAGE a little earlier and, if so, how? But that is the debate and actually we will not know until we get the next infectious outbreak.

Dr Mathias

We understand that the national risk assessment process is being reviewed. I want to ask all of you, if relevant, whether you have any concerns that the risk assessment process is not identifying the best available scientific data.

Sir Mark Walport

I do not have a concern about that. The Government Office for Science is an integral part of the updating of the national risk assessment. As part of the work around the national risk assessment we also do rehearsals so that we can plan and learn from table‑top exercises and even bigger exercises, but science is an absolutely integral part of that. We are involved, and I am not concerned that science has been diluted in any way at all.

Dr Mathias

How do you contribute to that?

Sir Mark Walport

The secretariat works with the Civil Contingencies Secretariat. We are involved in the meetings that have reviewed the national risk assessment, and we work with them on national contingency exercises, so we are fully integrated.

Chair

In light of the fact that the national risk register had infectious diseases on it in 2008 but identified Ebola only this year, essentially, what is your view about having protocols for the top 10 risks that might be in place? Do you think this is a logical response? It is one that has been proposed to the Committee.

Dame Sally Davies

The way it is structured is that we are concerned about respiratory illnesses—blood-borne, vector-borne and food-borne—and we try to have, and we do have, protocols in place for those groupings that we can fine-tune if something comes: “There we are, Ebola blood-borne.” We have had cases of Lassa fever and Crimean-Congo haemorrhagic fever before, but the basic protocols are there for different things. I agree about the importance of practising. For instance, in the respiratory field we had to postpone a pandemic flu exercise; we are going to do that next year. I have asked for one that devolves on everyone, and we will be supported by the Government Office for Science, on MERS-CoV early next year and a food-borne E.coli. During the Ebola outbreak we had three practices: a national one, a desktop Four Nations one and a local resilience fora one across the country. We all learned a lot from that—they are very useful—as we will from the three coming in the first quarter of next year.

Derek Thomas

Dame Sally, you have just referred to the next infectious outbreak. What we are trying to find out is how well we do it, how we can avoid it and what we can do to be prepared for the future. We heard recently that the UK does not have any capacity to manufacture vaccines; Professor Hill described it as a “national security issue”. If you agree with that—or not; you are welcome to disagree—what advice have you provided for the Government about how we prepare for the next infectious outbreak in terms of vaccination?

Dame Sally Davies

It is important to start by saying that worldwide the UK is recognised as having one of the strongest preparedness and resilience systems in the world. For that reason we have, for instance, a stockpile of Tamiflu. The PAC berates me about the cost of this insurance package, but the science is clear. I think it is needed, and I have advised that. We do not stockpile vaccines. You have to have the right vaccine. For instance, there are three common strains of Ebola. This was the Zaire strain, and possibly a fourth is emerging. Either you have to have a vaccine that covers all of them or you might have the wrong Ebola vaccine, so it is quite difficult. Clearly, we need to do more work in this field. In the Budget in the summer, we were given £10 million of ODA and £10 million from the research councils to set up the UK vaccines network, which Professor Whitty is chairing. That brings together not only Professor Hill but other vaccines experts, modellers, industry and everyone to discuss what is needed. The money can be used for the activities of the network, but particularly the pull-through animal to human. You may have noticed this weekend the announcement by the Chancellor of the Ross Fund, which is about trying to eliminate malaria and nasty emergent diseases. In that, there is another £100 million of overseas development aid to develop vaccines that are needed for neglected diseases that have emerging potential. Clearly, now we know that what was trailed in the manifesto is a reality, the network and others are going to have to get together and give advice on how it is best spent.

Derek Thomas

That sounds good. To pursue it, in the scenario of a pandemic where we are competing with other countries for the drugs we need for our own people, are you worried about that, or do you feel we have the capacity to manufacture the vaccines we need?

Dame Sally Davies

We cannot manufacture the vaccines. We have some manufacturing capability in the north-west near Liverpool, but it is degraded and we are looking at how we can try to attract companies back to do some manufacturing here. Apart from that, on pandemic flu, I should highlight that we have a special contract—I am trying to remember the proper term—that we can activate, which gives us first call on a certain number of vaccines of the strain. As you know, it takes a number of months to make, because it is still made in eggs. It takes at least four to six months. We have the capability to do some of the early trials; a lot of them are done in Oxford by colleagues of Adrian. Then we get first call for coverage of, I think, 40% of the population. If you want to know the amount I will have it looked up and send you a note.

Derek Thomas

You would welcome a company coming to manufacture these vaccines.

Dame Sally Davies

Of course we would. It is very good to have vaccine development and manufacturing in a country for many reasons, such as high-grade employment and the linkage with our academic sector. We would very much like to see that. [Interruption.]

Chair

Order. I am afraid we have to go and vote. We will resume the session when we are quorate and take the next evidence from the Minister, who has been waiting very patiently. I am grateful to her for that. Can I thank this panel for the evidence you have given? It is very kind of you to take the time today. Sitting suspended for a Division in the House. On resuming— Examination of Witnesses

Witnesses

Jane Ellison MP, Parliamentary Under-Secretary of State for Public Health, Department of Health, Campbell McCafferty, Director of Civil Contingencies Secretariat, Cabinet Office, and Dame Sally Davies, Chief Medical Officer, Department of Health, gave evidence.

Chair

Minister, thank you for waiting patiently and returning after the vote. I am very grateful to you. You heard the evidence from Dame Sally and Sir Mark in the previous session, so you will be well prepared for some of the questions we are going to ask you. I know that you are on a very tight schedule, so we will truncate our questions and try to make sure we stick to the point. My first question is about the national risk register, which we touched on right at the end of the previous session. As we mentioned, the broad category of emerging infectious diseases has been on the register since 2008, but Ebola did not make it on there until this year. We had a bit of a discussion about how we could strengthen that category going forward, and we heard some commentary from Dame Sally. What do you think about the proposal maybe to flesh out that category with the top 10 risks that are out there, and have protocols for each of those?

Jane Ellison

We have good systems for horizon scanning both here and internationally. We learned a lot about that process through Ebola, and it has all been fed back to the Cabinet Office’s thinking about it. We have some very solid systems in place. We would still say that the main risk remains pandemic influenza, but we recognise a range of other infectious diseases, such as those talked about in the previous session. As far as the register goes, my slight concern would be that ultimately there is a dynamic situation, as was described by the previous panel, and I would be a little worried if it tempted us into complacency and we thought, “Well, here’s our top 10 and here’s our plan,” and ticked the box. What really matters is to have a core capability to respond to whatever is emerging, with a sense of what is out there. What are the particular threats? What is most likely? I would be a bit nervous about something as pinned down as a top 10, because if we had a plan for those we would be tempted to take our eye off surveillance and horizon scanning.

Chair

Progressing that argument, we have had infectious diseases on there since 2008, yet you could say that what happened with Ebola took everybody by surprise. Obviously, there needs to be an improvement in the protocols in place to make sure that next time we are not taken by surprise. It is not likely to be Ebola but something a bit different that we have not seen before. What needs to be done with the national risk register to strengthen the protocols in place to make sure that we have horizon-scanning capacity but also the quick responsiveness that is necessary in an unexpected scenario?

Dame Sally Davies

It goes back to the kind of transmission. Is it respiratory, blood‑borne, vector-borne or food-borne? We need to have, and it is pretty well in place, protocols for all those, because we do not know which blood-borne virus will emerge, but you protect in the same way regardless of which one it is. The level of PPE relates to the infectiousness and the outcomes. I would argue that that is the right approach. I was told by a virologist earlier this year that he had looked at all the viruses in bats in southern China—SARS came from bats, and this Ebola may have come from a bat—and there were at least 21 more viruses that could jump. If we put one down, we will get the wrong one. It is about the groupings and how you respond to them, and having good surveillance systems. Public Health England, on our behalf, is linked into all the international surveillance systems and reports on our behalf as a category 1 responder.

Campbell McCafferty

On the national risk assessment and our process of dynamic risk assessment and identifying things, I would argue that it did work from a UK perspective. We heard from Paul Cosford earlier about the advice that was going out—travel advice for people travelling to West Africa. What we learned from Ebola was about the international aspects; the world is much more interconnected and the link to the UK and its role in dealing with them has changed. Within the Civil Contingencies Secretariat, working with Sir Mark Walport’s GO‑Science team, we are looking at how we can improve overseas horizon scanning. Our domestic horizon scanning has worked successfully for some time, so we are looking to put in place processes to improve our international horizon scanning. Some of the wording in the national security strategy published yesterday supports that, in terms of looking at how we can help develop the resilience of countries overseas. Some of the tools we have talked about, for example, the rapid response team, are about identifying that we did not have capability that could deploy quickly and looking to fill that gap as we move forward.

Jane Ellison

That is a really important point. One of the big lessons we learned within the Government and as a nation is that our best protection at home is helping to fight disease abroad. Thinking of it like that was quite a turning point for the nation. I genuinely think that was how the UK responded. I was incredibly proud of the way the whole nation responded; it was a generous response to the overseas approach. We will look back on that as the moment we really understood that our world is so interconnected that our best defence at home is by making sure we invest in and support work abroad effectively.

Dame Sally Davies

Have we told you about the rapid response team that we are developing?

Chair

We heard that from Public Health England. I would want to hear it from you, except that I am conscious of the amount of time we have, so I won’t ask you to deal with that.

Graham Stringer

You heard the questions I asked Dame Sally and Sir Mark about the quality of the advice from Public Health England and the speed of it. Were you as the Minister responsible satisfied that information was coming to you in the right format so that you could take decisions as quickly as you would wish?

Jane Ellison

Yes, I was satisfied. I was involved from early in the summer last year. We met over the summer recess a number of times, which gave me a lot of opportunity to talk to my officials. Dame Sally always started every meeting by saying, “These are the people I have spoken to; these are the groups I have convened; these are the people I have pulled into it.” The same goes for Paul Cosford who is my lead person in PHE. I was very happy with the advice I was getting. As a non-scientist and non‑clinician by background, I would go through an assurance process myself as to how I could test the advice. I often saw it as my role to push, prod and test the advice and say, “Well, I’ve read this from CDC or another publication. What’s your response?” The thing I got reassurance from was that the advice was dynamic and responded to situations as they emerged. There was great willingness to pull in experts. One of the things you realise is that there is a very small pool of experts in certain areas of very specialised science, and sometimes you know the two or three people in the world you need to go to for advice, so it was good to hear that we were bringing in people like that. There was an international element. On behalf of the Government, I attended a number of meetings, principally European, but we also had a number of phone conversations with other health Ministers, mostly to encourage a response in terms of sending people, supplies and so on to West Africa. That was also a useful opportunity. Often they would be accompanied by their chief medical officer who would contribute to the discussions. All in all, I felt I was getting good advice. I was also happy with the way I tested it, because I was able to draw information from other sources and put it to Dame Sally, Paul Cosford and others. I was very satisfied with the responses I received.

Graham Stringer

Can you remember formally when you were first involved in the process and started getting advice on the issue?

Jane Ellison

I have a timeline somewhere.

Dame Sally Davies

It must have been in June.

Jane Ellison

That sounds about right.

Graham Stringer

Are you concerned that there is a gap? Public Health England started publishing papers in March, and you were informed in June. Do you think that three-month gap was necessary?

Jane Ellison

I think I was informed earlier than that in terms of written submissions. We started meeting more regularly from the summer onwards.

Graham Stringer

Inspiration is coming.

Dame Sally Davies

No. All I am doing is showing the graph of the number of patients, and why we expected our public health agency to do preparations in case it took off, but it had not taken off. Indeed, in May it looked as if it might be receding a bit. We did not have a full-blown response at that point, whereas at the beginning of June we saw it begin to change.

Jane Ellison

Clearly, DFID is the lead Department overseas. I am conscious of my role in terms of public protection and public health in England, but the situation evolved in terms of where the emphasis was, whether it was an overseas emergency and then, essentially, it became a global one which we all had to respond to and protect ourselves against. As you might expect, our reaction to that evolved as well.

Graham Stringer

You heard references to the report that was critical of the World Health Organisation. Do you as a politician and a Minister have any response to that report? Do you agree with the recommendations?

Jane Ellison

I have not read the report in detail because I really look at the domestic side, which I alluded to just a moment ago. However, I was very involved in the whole process and had a good sense of what was happening in terms of the international response. I had a number of conversations with Dr Margaret Chan about it, and with Barbara Stocking; I had the opportunity to talk to her at the World Health Assembly in May. In terms of the overall criticism about speed of response, the need for WHO reform and so on, those are criticisms that the WHO have accepted and they are certainly ones I have spoken to the director general about. I know they are looking to respond.

Dr Mathias

A question we put to the previous panel, and which follows on from your role, is about the co‑ordination or duplication of WHO and European people, military and civilian. The concern is about how the command will be if it happens next month. We got good news about what the British did, but I am still confused as to co‑ordination in the field. What do you feel?

Jane Ellison

I might ask Dame Sally to respond in a moment. You would probably want to ask colleagues from DFID to respond to that specific point, because it is a little outside my remit. As to the general criticism of WHO, they have accepted it and broadly it is right. It is something I have discussed with them. In terms of how they might reform themselves, they have a reform programme that the director general has talked about publicly. I do not think it is necessarily an easy process, but it is something on which DFID will be working with them even more closely.

Dame Sally Davies

There is no doubt who co‑ordinates: for the health cluster issues within the UN system, it is the WHO. Their immediate or recent reform is to have a new deputy director general post in charge of emergencies. In this arena they have appointed Bruce Aylward who led very effectively.

Dr Mathias

I agree. What I am trying to work out is whether it has an impact on the Minister’s role if there is a problem next month. Does lack of leadership in the field affect your work as a Minister?

Jane Ellison

My role is a domestic one principally.

Dr Mathias

That is what I am asking.

Jane Ellison

In the strictest sense, no, but in the slightly broader sense I was part of a Government team response. I am sorry to be a bit vague about this.

Dr Mathias

No. That is reassuring.

Jane Ellison

I also have some international aspects, for example, things like the global health security agenda. There are aspects of that which I talk to my opposite numbers about and on which I lead, but principally on something like this DFID led the international aspect. In taking forward the lessons learned and what other countries of the world are putting in place, in terms of assurance processes, higher standards and preparedness, those are conversations that I take forward with opposite numbers in international fora, but more broadly than a crisis response in-country.

Dame Sally Davies

Our lives became much easier on 8 August when we were formally asked as the UK to lead the response in Sierra Leone and, therefore, co‑ordinate with WHO. We immediately put in military and a senior DFID person into their Government. It was much easier when we had control of our bit and the French were given Guinea and the Americans Liberia. That did not mean other countries were not helping; everyone co‑ordinated.

Jane Ellison

What we tried to do was encourage countries that wanted to contribute people and experts but not in great numbers. We would often try to act almost as a clearing house to be able to direct them to where they were most needed. Those were a lot of the conversations I had. We worked very closely with DFID, because as soon as we had NHS volunteers and PHE people out there it became immediately apparent that the domestic and the international merged to a large extent. I had lots of conversations with Chris Whitty, and often we were all at the same meetings.

Campbell McCafferty

If I may make two very quick points, the first is that COBRA would be co‑ordinating the domestic and the international. That is where it is brought together. Based on our experience of Sierra Leone, we would be supporting DFID in trying to clarify that leadership role much earlier because of the problems it caused. The second piece, which comes out of the national security strategy in the SDSR yesterday, is that clearly there is difficulty for fragile states to accept the level of support they are given when they suddenly find themselves in crisis, so the Civil Contingencies Secretariat will be working closely with DFID to try to build capacity for crisis management in a number of fragile countries.

Matt Warman

We heard earlier about COBRA asking SAGE to be formed. From a ministerial point of view, does that evolution of committees tally with your sense that you were getting the advice you needed throughout the whole process?

Jane Ellison

Yes. I was aware that committees were being convened and that particular experts were being brought in as different challenges emerged. As I said, Dame Sally always started every meeting by saying, “These are the people I have brought together; this is the committee I have convened; this is the advice.” Often if I asked, “When will we know about X? When will we have some clarity about that?” she would say, “We’ve got a group meeting next week. That is exactly the question we’re going to ask them. We expect to get some read-out.” I appreciated having that clarity about where the advice was coming from and how it was being reached. That was helpful for my personal assurance process. It was not that Dame Sally would turn up and say, “This is the advice. There you go.” I had a sense of its being dynamic and of people being brought in to contribute to it. It gave me a chance to say, “What about such and such? We’ve just heard from CDC. What’s our response to that? Are we doing the same thing?” If I spoke to other health Ministers they would raise things. There was a very regular opportunity to do that through Dame Sally and in very regular meetings with Paul Cosford. At one point I had time in my diary for that pretty much every day. I did not always need it, but it was always there in case it was needed. We gradually stood that down as we needed it less.

Matt Warman

Does it help your job to have a committee set up rather than conventional advice coming from the chief medical officer?

Jane Ellison

The advice did come from the chief medical officer and from Public Health England. All I am saying is that I think it is helpful for me to know the process by which the chief medical officer reaches the point of being able to advise. I found it very reassuring that at times something was so new that someone would say, “We don’t yet know that. We are getting the best advice together to look at that, but there are things we do not necessarily know.” I would much rather someone said, “Here is the process by which we are going to try to find out the answer to that question,” than that they were absolutely certain about everything, because in a dynamic situation you need the ability to respond as it changes. To be clear, my advice came through two key routes, the chief medical officer and Public Health England, but it was useful for me to be sighted on how they had reached it and the people they were bringing in.

Chris Green

We have heard the case being put for the establishment of a standing body on emerging infections, but we have heard very strongly that it is not actually necessary. Minister, have the Government considered implementing that approach?

Jane Ellison

We already have the Advisory Committee on Dangerous Pathogens, so I think the infrastructure we have is solid. There are things we will look at and learn from Ebola, but we have the ACDP; we have the ability to stand up the committees Dame Sally described earlier; and we have the interrelationship with COBRA and SAGE, so we have a structure to be able to give Ministers advice.

Chris Green

So it has been considered and rejected.

Jane Ellison

I am not quite sure whether you are saying this is advice the Committee might suggest we look at. I would never be so bold as to say that we would not look at anything the Committee suggested. All I am saying is that I do not think there is a major problem to which that is the answer.

Chris Green

Mr McCafferty, Christina Scott, former head of the Civil Contingencies Secretariat, told our predecessor Committee that work was under way to set up a national risk assessment scientific review group for the 2012 NRA. What happened to that group?

Campbell McCafferty

We now regularly review the methodology on a bi-annual basis. We used to produce the national risk assessment annually; we now do it every two years, so that we can work with scientific experts to make sure that the methodology remains best in class. We believe that the NRA is, and it is recognised as such in many parts of the world, but we know that we cannot rest on our laurels, so we have maintained the review process. This time around we have been asked to look at, for example, what we might describe as sensitivity analysis—a risk is there but what happens if that risk is a little bit worse? What should Departments think about that? We will look at how we include that. We have also been asked to look at better formalising the economic impacts, which is how we evaluate many risks. If a risk is realised, knowing how much it will cost will support arguments to do more on prevention, rather than waiting to respond. Those are just some of the examples we have been given this year to try to keep the methodology at the top of its game.

Chair

Thank you, Minister. We have more questions we would like to ask regarding vaccine manufacturing and other issues, but we will write to you, if that is all right, because we are aware of your time.

Jane Ellison

That is very kind. It may be that in some cases those questions should be directed to other colleagues in the Government, but of course we will respond in full.

Chair

That concludes our evidence on the Ebola inquiry. Can I thank all of you for the role you played in responding to the outbreak? As a country we can be very proud of the role we played. Thank you for the time you have taken and the patience you have shown in waiting for us. Oral evidence: Science in emergencies: UK lessons from Ebola, HC 469 21