STATES OF JERSEY
Health, Social Security & Housing Panel
Panel:
Deputy A. Breckon of St. Saviour (Chairman)
Deputy R.G. Le Hérissier of St. Saviour
Deputy S. Power of St. Brelade
In attendance:
Mr. M. Orbell (Scrutiny Officer)
Mr. C. Ahier (Scrutiny Officer)
Witnesses:
Dr. R. Geller
Dr. I. Muscat
Mr. M. Long
Ms. T. Fullerton
Mr. R. Pearson
Senator B.E. Shenton
Senator J.L. Perchard
Deputy A. Breckon of St. Saviour (Chairman):
Welcome, everybody. The reason we wanted to meet, as you know, the States debate is coming up on P.67/2008 and we might be asked to comment or we might care to comment on that because this has been ongoing for some time and there have been a number of presentations, et cetera, and paperwork attached to it, so we decided to hold this hearing. We are recording it and we will record it all. The reason for that is it is a sort of accurate reflection of this meeting and it will be transcribed. At the moment we are in open session and I will do the intros in a moment, but we will consider closed session if there is anything that is considered to be commercial confidence or particularly sensitive and maybe there is a reason for not discussing it in open session. So we will come back to that. As you know, I am Alan Breckon. I chair this panel, and the other panel members are Deputy Sean Power and Deputy Roy Le Hérissier. We have apologies from Deputy Judy Martin, and the Scrutiny Officers, as you know, are Malcolm Orbell and Charlie Ahier is doing the recording. Just for the benefit of the tape, Minister, could I ask you to introduce the people in the room, and that is just for the benefit of the tape, really.
Senator B.E. Shenton:
Yes, okay. We have Ivan Muscat, who is ...
Mr. I. Muscat:
Microbiologist.
Senator B.E. Shenton:
Microbiologist.
Deputy A. Breckon:
I knew that, by the way.
Senator B.E. Shenton:
I knew that, but I did not know whether you had some other highfalutin title that I should have known about.
Dr. R. Geller:
We also have another title, which is consultant in communicable disease control, which is good.
Senator B.E. Shenton:
There you go. Then Russell, who is our Finance Director who makes sure all the money is well spent; Rosemary, who is Medical Officer of Health, who spends the money. [Laughter] And Tracey, what is your official title?
Ms. T. Fullerton:
Assistant Director of Corporate Planning.
Senator B.E. Shenton:
Assistant Director, Corporate Planning. You see, I am from the private sector where we have nice short titles, you see, and I notice in the public sector they love acronyms and long titles, so there you go.
Deputy A. Breckon:
And we have the Emergency Planning Officer might be joining us a little bit later as well?
Senator B.E. Shenton:
That is right.
Deputy A. Breckon:
Thanks for that. It will assist, as I say, for the benefit of the tape. Welcome to everybody. Nobody is on trial here or anything. What it is really, it is just, as I say, there are some things that we wanted to explore a little bit further and we did send out a series of questions and obviously that was just sort of an aide memoir of where we might go. But perhaps it might help - it is up to you, Minister - if somebody perhaps could give us an update of where you are, because obviously the proposition has been before the States and then withdrawn and is now back down for debate. We have had presentations from the officers on various issues. Perhaps if you could just give us the latest situation as they see it and I am sure that questions will, and indeed should, flow from that.
Senator B.E. Shenton:
Well, I mean, just to give you a sort of background more on the political side of things, the first I knew about pandemic flu was when I read about it in the Evening Post that the Council of Ministers had announced that they would give vaccinations to every member of the public, which was before I was Health Minister. The announcement at the time, actually, I found rather annoying inasmuch as it was made by the Council of Ministers whereas, in fact, it really should have been an announcement by the States Assembly because it was funding outside the budget of health, so that was one issue. When I became Health Minister I also had questions with regard to the guarantee of supplies and the liability with regard to the vaccination if there were side effects that we had not foreseen, who would pick up the liability, because I have been aware that with specific vaccinations - you have to remember I am a layman - but with specific vaccinations of this nature there could be a liability to the government. Obviously if you have drugs that have gone through the long laborious process of trials and so on and so forth, the drug companies pick up the liability, but with vaccinations of this nature it is the government. I may be corrected on that. So with regard to that point, and because I had put everything on hold and also because we had certain distractions at a political level last year where we had the situation where the Tamiflu part of the package had been purchased slightly prior on the assumption that the funds would be made available - and certainly the funds were eventually made available after taking a proposition to the States last year asking for that side of things to be covered - what we are coming to the States with now is the final part of the complete package. From my point of view the questions with regard to liability have been answered, the questions with regard to guarantee of supply have been answered, and the recommendation of the ... is it the Pandemic Flu Panel?
Dr. R. Geller:
Pandemic Flu Steering Group.
Senator B.E. Shenton:
Steering Group, was very much that we do need to take these precautions and I think it would be a very brave Minister that would turn round against all medical advice and turn around and say that we do not. So that is where we are today.
Deputy R.G. Le Hérissier of St. Saviour:
Two issues, Ben. You said the issue of liability had been sorted out. Can you tell us in what manner it has been sorted out?
Senator B.E. Shenton:
Well, I think it has been sorted out inasmuch as it has now been made clear that it is not a case of ... I think when you deal with anything, you have to deal in an open and honest manner and the liability was always there but it had not been sort of brought to the surface. Now, within the proposition it makes it very clear that if there are any side effects the government will be accepting liability for that, but on a statistical basis the calculation is very much that this is fairly unlikely to be a significant sum of money given previous side effects and causes. I think the swine flu outbreak in the U.S. (United States) did cause deaths and did cause the U.S. Government to pay up, but on the basis of the number of people vaccinated and the size of the liability, it was relatively small. We did look at insurance but, of course, insurance companies just quote ridiculous figures. It just did not seem to be worthwhile.
Dr. R. Geller:
If I could just underpin what the Minister said there, we did a calculation. If we assumed ... the side effect from the swine flu vaccination in America was something called Guillain-Barré Syndrome, which is a neurological syndrome, which obviously is quite serious. But they vaccinated a huge number of people and we worked out that for Jersey and the number of people we have in the Island, if we had that level of side effects it would be between 0.1 and 0.2 Islanders. That means that it is unlikely to happen and if we were really unlucky there would be one person, if that were the case.
Deputy R.G. Le Hérissier:
What is this group called the Pandemic Control Group or ...?
Dr. R. Geller:
The Pandemic Flu Steering Group. I chair the group and we have representation from a number of departments. We have a heavy representation from health, as you would expect. We also have representation from other departments. We have Michael Long, we have legal experts, we have the police. Trying to think who else we have ...
Mr. M. Long:
We really have every department represented who would have an interest in responding to an outbreak, to a pandemic influenza.
Dr. R. Geller:
We answer to the Emergency Planning Board. We report to the Emergency Planning Board.
Mr. M. Long:
That is chaired by the Chief Executive and that effectively reports to the Emergencies Council, which is chaired by the Chief Minister, and they have obviously in an emergency to create emergency powers to deal with any situation which was out of normal control.
Deputy A. Breckon:
I wonder as a starting point, when you did the presentation, I just remind you, you gave us ... that was some of the information that you gave us relating to 1918, 1957 and 1968. Is there anything that has happened in the last few months that strengthened your view or evidence that would support the fact that we must do this? Anything that has changed in the last few months?
Dr. R. Geller:
Well, what I would say, the only thing that we have had further information about over the last few months is that the pre-pandemic vaccine that we are recommending has proved in trials to be even more effective than had been found to date with the research. So there is more research coming through which is suggesting that if - and we think it is likely - the pandemic is the H5N1 pandemic, or at least an H5 derivative, that the vaccine that we are recommending would reduce the impact to that of seasonal flu, which is a very good result indeed if we could achieve that result for Islanders in the event of a pandemic. But that description that you pointed to which shows how flu viruses keep constantly changing is why we are concerned that the current bird flu which has infected some humans so far will change. It only has a number of amino acids to change in its makeup, a few, and it becomes a virus which can readily spread between people and that, of course, is when we will get the announcement from the World Health Organisation that the pandemic has started.
Dr. I. Muscat:
One difference between the historic pandemics that you mentioned, 1918, 1957 and 1968, and the current situation is that we remain liable to having a pandemic similar to those in the past because of the way they came about, but additionally, as Rosemary was suggesting, we additionally have the threat of this happening with a very virulent type of virus, the H virus, which to date when it affects man has a very high mortality: 50 to 60 per cent, a much higher mortality than that seen with the previous types of pandemic viruses.
Deputy A. Breckon:
Just for the record because obviously we have been to presentations, what is the sort of transfer rate to humans and how that would spread from human to human? What would be the cause of that?
Dr. I. Muscat:
Currently avian flu, the H5 virus affecting poultry and other birds, does not transfer readily to man. It does if there is close contact and there have been more than 350 cases, which globally is not a large number but when it has crossed it has caused a high morbidity and high mortality. By and large, though, the concern is not the current rate of transmission, which in the fullness of things is not huge, but the continuing change of the virus. It continues to move closer to being able to affect more species and man in a slow stepwise fashion and drift, as is the nature of flu viruses. It can also suddenly change overnight by mixing with another virus which particularly affects man.
Dr. R. Geller:
Sorry, in direct answer I think to your question, there has been no change in the virus reported in the last few months. We are still on amber alert with the World Health Organisation, that the virus has passed into man but is not yet readily transmissible between humans. So no, there has been no change in the status of the alert situation.
Deputy A. Breckon:
For our benefit, really, can you just say how this is being monitored at the moment? It is just by reporting through the World Health Organisation?
Dr. R. Geller:
Yes. It is totally appropriate - and we would not set up another system - that the World Health Organisation is monitoring this. The World Health Organisation is so concerned that it has a large team of people on surveillance all over the world and Dr. Muscat is constantly reviewing the World Health Organisation reports and he will alert us as soon as something changes that we need to move into a more acute and active part of our plan.
Deputy A. Breckon:
Do you think there is any benefit at this stage of informing the population of this, you know, the fact that you are doing it and that there is a state of preparedness, if you like, rather than spring it on people that we are on high alert and they say: “Well, where were we before?” Is there any benefit in doing that now for public information?
Mr. M. Long:
Yes, perhaps I could give a little bit of background on that. I think the answer is yes, we need to now start to engage the public but we have to be very measured and calculated how we do it. In fact, that is a process that is actually underway. We have done ... Ivan and Dr. Geller have already done several presentations to wider audiences, and myself. There is no secret about what is happening with pandemic influenza. If you look at any emergency planning websites whether in Jersey or in the United Kingdom or the wider world, it is the number one risk. So I think we are obliged to keep the public on side and that, in fact, will help our response to any outbreak of pandemic influenza. Because if people have knowledge ... I have just come now from the meeting of the Constables to actually start promulgating work which will support the health aspect and, in fact, if the States agree, of course, the impact of pandemic influenza on Jersey would be significantly reduced, which will obviously be a good thing.
Deputy A. Breckon:
The reason I say that is it sort of leads into the first couple of questions: what will be the trigger for local action? Firstly, people must have information about where we are now and, you know, what are the possibilities and what then would tell a decision to act. Sometimes I think the public have information without ... I know what you are saying because there is a danger that the media could sort of blow some of this out of all proportion, so it needs to be sort of managed how it is done.
Mr. M. Long:
We are, in fact, having a meeting next week with the news editors of all the news outlets in Jersey to give them a top level strategic briefing. It is not a news opportunity; it is a briefing to ask them how they can help us with what would be a massive communications exercise. So that is in place; that is happening next Thursday. In terms of the notification, as Dr. Geller and Ivan Muscat mentioned, they are monitoring the World Health Organisation information. They will also get linked in I think from the public health in the United Kingdom. We have an activation plan in Jersey and we would inform our Chief Executive who chairs the Emergency Planning Board, but more importantly the Emergencies Council who would ... there is an assumption that they would sit and start then putting into place any emergency provisions we would require to manage the situation in Jersey, which would include vaccination immunisation programme.
Deputy A. Breckon:
Again, if we think of foot and mouth as an example of where the Island took precautions to a situation, then perhaps if the public were aware that there were contingency measures, then perhaps the scare is not the scare because they think somebody is doing something about this. I understand where you are coming from, but the other thing with this is bearing in mind, you know, getting information, where does the Jersey public fit in on this? Do you think we could do more, you know, transmitting some of that just as general information?
Dr. I. Muscat:
As Mike and Rosemary have said, a lot of information has already gone to the public, both from international sites and also, of course, locally. It is again coming to the fore with the forthcoming States debate and that seems like a natural opportunity to further brief the population on where we stand and where we are going and so on. It is fitting in rather naturally.
Deputy A. Breckon:
Of course, the other thing I think flowing from that, people might ask: “Well, what measures could we take as an Island to stop whatever it might be” - foot and mouth is an example - and people have been in general sympathetic to that at the ports and the airport, wherever it may be. So, I think, with respect, I know what you are saying but if some of the information was generally available then it is not a sensation to people.
Mr. M. Long:
We do actually have on the health website general information about pandemic influenza and, of course, I think the medics can give you a better explanation on how and what precautions you can take, but there are significant precautions individuals can take about personal cleanliness and sneezing and what have you. That information is all in the hands of the States Communications Unit which would obviously be significantly supported by health to give them the right information at the right time to promulgate this information through our media channels, through our websites. That is constantly being built and improved upon and certainly we will be ready ... it is ready now but obviously constantly being revised to go out on a massive publicity campaign.
Deputy S. Power of St. Brelade:
I was just going to ask Dr. Muscat a question. There is some evidence out there that a human being that has a reasonably robust and healthy physical disposition and immune system, that the majority of those healthy human beings, for want of a better phrase, in the majority of cases can fight some of this pandemic themselves and that those that are really exposed to risk are the young and the elderly. Is there any change in that or would you disagree with that?
Dr. I. Muscat:
It is conflicting and I will tell you why. The current H5N1 virus seems to affect ... it is so virulent because it affects the lower parts of the lungs.
Deputy S. Power:
Yes, respiratory.
Dr. I. Muscat:
That is right. When it does, it causes an explosive inflammatory response and that is what causes the damage. Now, in order to create an explosive inflammatory response, you actually have to have a healthy immune system. If you do not have a healthy immune system you are less likely to do that, and indeed some individuals have considered the possibility of using drugs which as a side effect have immune suppression effects in order to reduce that. This is all theory; it is not what is going to happen in practice. Having said that, obviously if you are already weak, then it may very well be that lower inflammatory response is enough to cause you serious damage. If you look at the 1918 pandemic, then a huge number of people that died were in the 20 to 40 year-old age group and those were people with a very good immune system. It is thought again that the reason that they had such a bad outcome with influenza at that time was because they actually had a very good immune system and, therefore, had a cytokine explosion, a cytokine storm in their lungs.
Deputy S. Power:
Okay. Would you agree that the diet ... the immune system of 80 years ago and the diet of 80 years ago and given the time of year when it happened 80 years ago might have been a contributory factor in some of those fatalities? For instance, the intake of fruit, vegetable and fibre is much higher now than it would have been in 1918. That would have made our immune systems today more robust than 80 years ago.
Dr. R. Geller:
Could I comment on that? I think the fruit and fibre and so on was better in 1918 than it is today unfortunately, which is something ...
Deputy S. Power:
The quality was, but the actual quantity digested was not, was it?
Dr. R. Geller:
Well, what I would say, just to underpin what Dr. Muscat was saying, in the pandemic and with the H5N1 that we are worried about that is coming from the birds, it has a different mode of action from the usual seasonal flu because it is less adapted to humans and it is more catastrophic. It is the people with the better immune systems who react worse to a pandemic, particularly in the 1918 one and today’s threat. Those that were dying in 1918 were actually the fittest people. Whether if they had had a better diet, I think they probably would have died even more quickly if they had had a better diet because it was those who were the fittest who were dying from it because it was a different type of problem to seasonal flu, where it is the older people who are weak and then they get a chest infection which is secondary to the flu. It is a different way of happening.
Deputy S. Power:
That is why I asked the question about this conflicting evidence. It is confusing.
Dr. R. Geller:
It is confusing.
Dr. I. Muscat:
The 1957 and 1968 outbreak pandemics were again different to that in 1918, so we need to think, as we have said before, about both possibilities. We need to think about the possibility of a pandemic that takes the characteristics of 1957/1968 and one that is actually much more difficult, like that which can occur following the spread of H5.
Deputy R.G. Le Hérissier:
Building up on this precautionary issue, are there any ways in which behaviour or society can work at this so that we can really put in place actions or we can put in place behavioural changes that will minimise its impact, or is it just a question, as Michael said, of ensuring we do not sneeze too closely to people and so forth? In other words, can we really set up some kind of aggressive precautionary programme which can really reduce its impact?
Dr. I. Muscat:
I think the most important response to that is that any response that there is has to be a series of defences and not just one defence. There has to be a concentric series of walls to try to keep the virus under some degree of control. On an international scale via W.H.O. (World Health Organisation) the surveillance and intervention at focal points of activity is hugely important in preventing the initiation of something. It is reporting to various bodies pretty rapidly is a huge reassurance that something is happening and what is happening. The development as a consequence of that sort of scrutiny of the virus of appropriate vaccines, of appropriate antivirals and their continuing evolution is yet another part of the lines of defence. On a port entry basis, that had worked in the S.A.R.S. (severe acute respiratory syndrome) epidemic, in the S.A.R.S. outbreak, because you were only actually infectious to other people if you had symptoms. So if you did thermal imaging or whatever and picked someone up with fever and they ended up with S.A.R.S. and you took them off the plane and whatever, that actually worked. With influenza that will not work because you are infectious to other people before you develop symptoms and half the people with influenza do not have symptoms anyway; this is seasonal flu. So, in fact, port entry restrictions is estimated to only reduce the risk of ... to only pick up about 18 per cent, 17 to 18 per cent of people with flu. The closing borders to again, you know, try to reduce entry into countries and so on is certainly not something that people are chasing up on an international basis and it is thought that even if you have a 99.9 per cent efficient strategy to prevent people coming in, you will only delay the entry of flu into that country by a matter of weeks and not longer than that. So that is actually a useful snippet because if, for example, we are giving pre-pandemic vaccination and we have not quite managed to vaccinate everyone because the flu has arrived here before flu has arrived in Europe, U.K., Holland and so on, before the anticipated 4 weeks, then we may take the view that closing the borders until we actually capture the whole population in terms of vaccination will be a good thing. So there are things, you know. In terms of what happens when it is inside the country, then obviously it is transmitted from person to person directly and indirectly; directly from being within about a metre of someone else and sneezing, that way you get it straight into the respiratory tract, but very importantly transmission indirectly through surfaces, through hand to hand contact also occurs and the virus will survive 72 hours on a solid surface, 24 hours on clothes and about 5 minutes on a hand. So minimising contact, appropriate respiratory hygiene when you sneeze and cough for whatever reason, like washing your hands, cleaning surfaces, washing your hands on a regular basis, all that will be very important indeed.
Deputy R.G. Le Hérissier:
I realise in a sense we are compromised because obviously some of the purchase has gone ahead, but just to rehearse it in public actually so we have it on the record, why was option 1 discounted in terms of healthcare professionals only being focused upon?
Dr. R. Geller:
Shall I answer that? It was thought that it would be too difficult to make a decision of who should and who should not receive the vaccine or the Tamiflu. That was thought in the discussions that took place in the Council of Ministers to rule out that option, the difficulty of deciding who was to receive it. This debate I believe is underway still in the English Government discussions.
Mr. M. Long:
Yes, absolutely. In fact, they have been debating it for, you know, 3 or 4 years that I am aware of and they still have not been able to arrive at a decision. They have identified as their priority groups obviously healthcare, and the latest information we have from the U.K. is that, in fact, prioritisation will probably be done on a regional basis if pandemic influenza struck the United Kingdom and it would be left to the regional emergency resilient structures to identify in those areas, which itself could be quite difficult.
Senator B.E. Shenton:
When I announced that everything was going on hold and there was a bit in the paper saying that we were going to look at that option again, which was that “key workers” is the phrase I think they used, I did get quite a few quite agitated correspondence along the lines of: “I suppose that is the politicians” and: “I am all right, Jack”, sort of: “And what about the rest of us?”
Deputy R.G. Le Hérissier:
Why though, Dr. Geller, if you were able to draw the boundaries, why would the health option be ... or could, sorry, the health worker option be a viable one? Could it?
Dr. R. Geller:
The health worker option one is that we keep the health workers well to care for the sick and dying. The option 2 was we give everyone all the protection and we reduce the sick and dying to a minimum. If you go for the first one, we could still run it like that, I could run it like that and Dr. Muscat could run it like that. It would be very difficult but we could run it like that, but that is what you are choosing between, if that answers the question. That is what you buy with the option where you just do the essential workers, is you keep the essential workers going in order that they can look after the sick, but if the pandemic flu based on H5N1 has as high a mortality as virologists are predicting, there is not very much that the healthy healthcare workers will be able to do to support those who get the flu. If it is more like ... if it is not an H5N1, which is less likely but possible, it may not be as serious and that option could work. But we do not want to take that risk, really.
Deputy S. Power:
Just for clarification on the H5N1 distribution, is the ambient air temperature relevant to increased risk of distribution or is it relevant at all? In other words, is a summer environment more conducive to spread or is a winter environment less conducive or vice versa? I cannot remember what ...
Dr. I. Muscat:
Sure. The pandemics can occur at any time of the year, in contradistinction to seasonal flu which is largely restricted to the winter season, both in the northern hemisphere and in the southern hemisphere. It is thought that the winter season favours seasonal flu because people tend to aggregate in the indoors more often in winter than in summer. So presumably close contact will be greater ... between people will be greater in winter whether it is pandemic or not, but pandemic certainly spreads irrespective of the season.
Deputy S. Power:
Okay. So the risk of spreading a pandemic such as the H5N1 is more conducive in an enclosed environment such as a room, a school room or winter conditions where people are not out in the open so often?
Dr. I. Muscat:
Yes.
Deputy R.G. Le Hérissier:
Switching to the vaccine, I think it was you, Dr. Geller, who said that Tamiflu was indeed improving in its ability as I recall. I cannot remember your exact words, but I think it was the drift of your suggestion. Are we absolutely wed to it and, again speaking out of total ignorance, if there were to be an epidemic and we were to find ourselves with a virus which we had not quite sort of got a palliative for, how would we deal with that?
Dr. I. Muscat:
Am I right in thinking that you are saying how useful would Tamiflu be?
Deputy R.G. Le Hérissier:
Yes, that is the first part, how useful is it and can we be assured that ... well, just to develop that a bit further, can we be assured that in the light of current knowledge, both the efficacy of that particular palliative and what you anticipate in the development of the virus, can we be assured that we are, you know, generally speaking taking the right decision in the purchase of Tamiflu?
Dr. I. Muscat:
I think we are making the right decision in purchasing Tamiflu. I do not think anyone can guarantee that it is the perfect answer to a pandemic strain because we simply cannot know that. But the alternative drugs to Tamiflu are Zanamivir and the Amantadine-type drugs. Now, with H5N1 the virus largely affects the lower part of the lungs and can also be found outside the lungs, which is very different to seasonal flu where by and large it is affecting the upper part of the lungs. Tamiflu is taken by mouth and can reach all those parts and it is easy to take as a tablet or a suspension if you are a child. It does not have much in the way of side effects as such.
Deputy S. Power:
Sorry, in adult and child?
Dr. I. Muscat:
It can be ... yes, I can expand on a second question about side effects, but if I ...
Deputy S. Power:
Sorry.
Dr. I. Muscat:
No, that is fine, I will focus on this for a second. With Zanamivir, which is Relenza, which is a similar drug except that it has to be inhaled, inhaling the drug requires much more articulation, if you like, on the part of the patient. So if you are seriously unwell, that is going to be difficult. Furthermore, if you do manage to inhale it, you are only going to by and large hit the upper part of the airways; you are not going to get to the bottom part where the virus is and you most certainly are not going to get outside the lungs into the blood stream. So if it is H5 you are not getting the drug to where the virus is. Furthermore, it causes bronchospasm, which is like asthma. So if you inhale it, you may very well constrict your airways, which are already being clogged to start off with and you are much more likely to have that problem, of course, if you are asthmatic to start off with or if you have obstructed airways disease. So it is not ... whilst resistance has been described with Tamiflu and it has also been described with Zanamivir, the better bet at the moment is Tamiflu. Zanamivir is also much more bulky, so it is much more difficult to stockpile, but that is a minor sort of in brackets consideration. Amantadine, which is one of the older anti-flu agents, or the Amantadine-like drugs, are firstly not as effective even if you have a sensitive strain. They do not cause as much damage to the virus as the newer drugs. Resistance to it is actually very frequent indeed. So no one really is putting that on their shelves any more.
Deputy S. Power:
Can I just ask you to clarify the side effects?
Dr. I. Muscat:
Yes. I think I will expand on this if you wish, but I think what raised the subject is side effects in children or adolescents and children. That story, as I understand it, arose initially in Japan where they noted something like 128 or so children with neuro-psychiatric side effects having taken Tamiflu, with the slight majority being in the 10 to 19 years-old and a less majority in the under-10s. What they reported there was an association with the side effects. They did not prove that the drug caused the side effect, they just said ... because that is the way drug side effect reporting goes. If you are taking a drug and you notice an effect you did not expect you report it irrespective of the presence or absence of causality. That is what they reported on. So then they took it one step further and a chap called Ropoto(?), I think, studied something like 2,800 children, some of whom had ... not children, children and adolescents, some of whom also had Tamivir, Tamiflu, and some of whom did not. The frequency of neuro-psychiatric complications in the 2 groups, those with and those without drugs, were the same. Neuro-psychiatric side effects have also been reported almost as frequently, not as frequently, with Zanamivir as with Tamiflu. Now, Zanamivir, if you go back to the previous question, is not terribly well absorbed so it cannot really get to the brain much, but these sort of neuro-psychiatric effects were reported with Zanamivir as well. They are also reported with the old Amantadine-type drugs. Finally, influenza itself causes psychological side effects, which is what you would expect because the chemicals you make in your body when you fight your flu naturally do have psychiatric effects and when you purify those chemicals, if you like, and give them to someone repeatedly, it gives you that effect. So considerable ... whilst it is reasonable to be alert to all that, it does not carry much weight.
Deputy S. Power:
Okay, thank you. Can I ask a question of Mr. Long? You mentioned the ... sorry, Dr. Geller. You mentioned the Pandemic Flu Steering Group that you chair. To what extent and how frequently do you have to liaise with, say, Hampshire County Council or the U.K. or the nearest point of contact, although that is probably slightly irrelevant with regard to airlines, and with the French, with the French Health Ministry? Is that part of your brief? Do you have to stay in touch if it kicks off? If we have a 3 to 6-month lead-in?
Mr. M. Long:
Certainly in terms of the World Health Organisation notification, that would come through the U.K. as the doctors have said.
Dr. R. Geller:
Through the Health Protection Agency. We are linked into the Health Protection Agency and Ivan has a particular link with the southeast node of the Health Protection Agency.
Mr. M. Long:
I think much broader than that, I mean, I am in regular contact. The States of Jersey have aligned themselves to the Government Office of the Southwest, which have a reasonable resilience planning forum. I attend those meetings bimonthly. I also retain and maintain first contact with various working groups and as we get new information from the Cabinet Office in particular, who sort of orchestrate this in the U.K., that is circulated within our resilience community in Jersey. So we are not isolated.
Deputy S. Power:
Do we have a point of contact with Normandy or Brittany or the French?
Mr. M. Long:
I certainly have a point of contact with my opposite number in the Prefecture of St. Leu(?), but I have not progressed that work really into pandemic type. It is about emergencies around Flamanville(?) and that sort of ... but we do have that contact. But the World Health Organisation would go directly into the U.K. and they would let us know. We would know ... we would not be any later with our notifications than France or anyone like that.
Dr. I. Muscat:
Can I just add a small sentence to that, add to it slightly? The International Health Regulations that W.H.O. have brought about initially in relation to S.A.R.S. but capitalised(?), of course, by the threat of pandemic flu has resulted in the setting up of a system whereby if W.H.O. sees something it reports it to various large national groups. The national focus point in the U.K. region is the Health Protection Agency in London and they will automatically once they receive something send it out to the periphery, and we are part of that periphery. We would hear at the same time as other parts of the U.K. Equally, if we notice something happening locally, we are obliged to report upwards upstream through the same system as well and that has been extant now for about a year or so and it appears to be working very well.
Deputy A. Breckon:
I wonder if I can just ask the Emergency Planning Officer, you mentioned earlier that you were sort of talking to the Comité des Connétables about maybe some of the issues in the community, but are you looking at sort of Island life in general and plans of, say, movement of goods and people and, you know, watching the Island, what would need to get into the Island and, indeed, the effect it might have on business, work, schools, public gatherings? Is that the sort of thing that you are ...?
Mr. M. Long:
Yes, I am undertaking a specific piece of work which I will be reporting to the Emergency Planning Board next week, in fact, in relation to essential services and supply of food, fuel, essential supplies and essential services: water, electricity, gas and what have you. That is some work which is unique to Jersey, of course, because we are an Island. We are obviously resilient by nature but we are also very dependent on daily deliveries of key essential items. So that would be an issue and there is work well in hand to look at that. I can also say that we met recently and held a seminar with our utilities - water, gas, electricity - and our suppliers, the freight companies - Condor - to talk about ... to talk to them about their business continuity plans, how they will be able to maintain streams of essential supplies to the Island. You touched on Education, Health, Sport and Culture as well. That is information that I have recently passed to them as well on the most current good practice or good advice as to what sort of proportions and what action we would take within schools and public meeting places. Again, it is very much dependent on the circumstances at the time, but the consensus of opinion at the moment is that schools would close. But that would be a decision that would be made by the States and the appropriate Minister.
Deputy A. Breckon:
From an emergency planning point of view, then, where would this be on a scale of one to 10, 10 being the sort of highest priority? You mentioned Flamanville before. Would it be seen as a higher priority than Flamanville?
Mr. M. Long:
The planning for pandemic influenza?
Deputy A. Breckon:
Yes.
Mr. M. Long:
I can reassure you that pandemic influenza is the top risk not only in Jersey but in the United Kingdom and other countries specifically because of the impact it would cause. I mean, it would be pretty catastrophic and that is why we are focusing our planning. We are not ignoring these other areas of work, clearly, but we are focusing quite specifically on pandemic influenza and work that would fall out of that, unfortunately, things like the management of death and how we are going to actually vaccinate the population, which is obviously a demanding and complex issue in itself.
Deputy R.G. Le Hérissier:
Thank you. In terms of the Tamiflu itself, you have guaranteed supplies, is that correct, Rosemary?
Dr. R. Geller:
We already have stockpiled the amount of Tamiflu we need to treat every Islander and that includes some paediatric suspensions for children.
Deputy R.G. Le Hérissier:
Just again to pander to my ignorance, when you give them the dose, that is it, essentially? There is no repeat, there is no extension, there is no renewal required, is that correct?
Dr. R. Geller:
Well, only if we are able to implement the plan in the way we have proposed because we want people to take the Tamiflu after they have started with symptoms within the pandemic. Because if they take it before they get symptoms, they will have finished the course, they will have no resistance, they will have had their one shot at the Tamiflu and they will be vulnerable again to catch the circulating pandemic which will probably be around the world for about 6 months or possibly subsequent waves as well. So the plan is that we would only give the Tamiflu out to Islanders after the World Health Organisation have announced the pandemic and there would be detailed instructions given both verbally and in writing as to when and how to take the Tamiflu. In the U.K. they are proposing to give Tamiflu after a diagnosis and only hand it out once the flu diagnosis has been made by a healthcare professional. We do not think that will be quick enough in the Island because pandemic flu will sweep through the Island in an estimated 4-week period and we want people to be ready because Tamiflu is much more effective if you take it within the first few hours of symptoms rather than by the time you have called out somebody who is already busy to come and so on.
Deputy R.G. Le Hérissier:
Other than the groups that Dr. Muscat and Sean mentioned, the young and the elderly, are there any other vulnerable groups? Any occupational groups that are more exposed to it than others, for example?
Dr. R. Geller:
Well, healthcare workers would be more exposed to it.
Deputy R.G. Le Hérissier:
Healthcare workers, yes.
Dr. R. Geller:
I do not think there are any others.
Dr. I. Muscat:
They are the people at most risk.
Dr. R. Geller:
What I would say is that we are all at risk. None of us will have immunity and even as Deputy Power was raising a question, even those with a strong, healthy constitution will be at severe risk in the event of a pandemic.
Deputy S. Power:
Or even slightly more at risk, depending on how you interpret world statistics.
Dr. R. Geller:
Slightly more at risk, yes.
Deputy S. Power:
Whereas somebody’s mother-in-law who is in her late 80s or 90s may be slightly less at risk because they have a less robust ...?
Dr. R. Geller:
Well, I think what will happen, if it is an H5N1 what will happen is that the young will be most affected but the very old and weak will also be affected but for a different reason.
Deputy S. Power:
But if the pattern of 1918 were to repeat itself, the most at risk are those supposedly healthy males and females between 20 and 50?
Dr. R. Geller:
Well, there were not a lot of elderly infirm in 1918 as there are now.
Deputy S. Power:
That was my next question.
Dr. R. Geller:
Yes, so I think we will have. But to be honest I think it will be catastrophic for everyone, no one will have the immunity they need to fight this infection.
Deputy S. Power:
The acid test is that everyone in this room, for instance, is as much at risk as the young and the elderly.
Dr. R. Geller:
Yes.
Dr. I. Muscat:
Those with a strong immune system are at risk because they have a strong immune system and, therefore, have a large storm going on if it behaves in the sort of 1918 fashion or in the way H5 is behaving at the moment. Whereas those who are very old will have a weaker immune system, may actually have less of a storm but being old and infirm may actually be less able to sustain a lesser storm.
Deputy R.G. Le Hérissier:
Clearly there will be casualties even in the case where you launch this programme. Are the hospital services all geared up for the various contingencies that will arise?
Dr. I. Muscat:
We have drawn up a model based on previous pandemic, epidemics and so on whereby 35 per cent of the population will become affected. Now, I am not saying that that is what the case will be with deployment of a pre-pandemic vaccine and appropriate deployment of Tamiflu for home-start(?) therapy, but leave that aside and just look at that 35 per cent model which is used by many developed countries. In Jersey those 35 per cent will be affected over a 4-week period and that means that there will be in weeks 2 and 3 the peak incidents, something like 450 admissions per week potentially, assuming the proportion of people becoming sick with complications is what the model says. Of course, our hospital is only 250 beds. So there will definitely be a lot of pressure on the acute services if you simply have an unmodulated model of 35 per cent attack rate and the complications that will flow from that. However, with pre-pandemic vaccine and with home-start to Tamiflu the pressure on the community and the pressure on the hospital will be significantly less. What is difficult to work out on a piece of paper is precisely how much less. No one can say that.
Deputy S. Power:
Are there any assumptions that are modelled based on ... it says 25 per cent could become affected. On an Island population of 90,000 that is 30,000 people. Given whatever evidence is out there with the World Health Organisation, do you have a model as to how many of the 30,000 and a third could need to be hospitalised?
Dr. I. Muscat:
Yes. It will be about 1,200 will be hospitalised over a 4-week period.
Deputy S. Power:
Over a 4-week period?
Dr. I. Muscat:
With the peak admission rates being about 450 per week in weeks 2 and 3.
Deputy S. Power:
Okay. The provision for beds, then, would you use Overdale or would you use old wards or how would you ...?
Dr. I. Muscat:
Well, what I am saying is that with a hospital which is 250 beds large ...
Deputy S. Power:
It could not cope.
Dr. I. Muscat:
You cannot cope. But this is a model without the additional sort of input to try to reduce that number of admissions, to try to reduce the number of people infected with the disease and the complications that ensue from that. So, in addition ... I forgot to mention earlier, in addition to the pre-distribution of Tamiflu there will also be the pre-distribution of antibiotics to prevent secondary bacteria and pneumonia in those most susceptible.
Deputy A. Breckon:
Can I ask in some of the circumstances that have been described, do you have a sort of health plan for people who are qualified to assist where you can call on people to help in the extreme case that perhaps you describe there? Do you know who is qualified and where they are and are they involved?
Dr. I. Muscat:
We are certainly looking at trying to garner as much help as possible from both the healthcare professionals who are perhaps retired or working only part-time and so on, on the one hand, and also various other people in the civil service who can help working in the background to free people up to do other health-related matters at the frontline.
Deputy S. Power:
So if there was a strike, Dr. Muscat, of, say, 450 admissions in a worst case scenario over a 4-week period, you intend to have a voluntary training programme to bring in because the existing core hospital staff would not be able to cope with that?
Dr. I. Muscat:
I think if that ... I think if that were to happen, we would really have a problem in that we would have to put up beds for ... in places other than the hospital. We will not be able to just put people in the hospital; the physical space is not there. So the plan of action would be to have those in most need of medical input in the hospital, whereas those who need less medical input will be in other places, for example either Overdale, St. Saviour’s or hotels even, where due nursing care can be delivered. So people may not actually need oxygen, drips and so on and so forth, but they will need to be looked after because they simply will not be able to look after themselves at home.
Deputy S. Power:
Can I have one follow-on question on that? Can I ask Mr. Long or Dr. Geller, the provision of voluntary support staff that would be needed if in a worst case scenario, do you intend to find out who is available in the Island community as to who might have some basic training or who could be brought forward in training to prepare for the 3 to 6-month lead-in?
Mr. M. Long:
In terms of our general resilience ability across the Island, there is a lot of work being conducted at the moment to broaden our bottom line resilience benchmark, to be honest with you, but certainly in terms of the immunisation programme we are going to have to find a lot of ... you know, we are going to have to prioritise certain aspects of medical work to find 100-odd nurse immunisers and the doctors and we are talking people like St. John, Red Cross ... well, not Red Cross so much but the various voluntary agencies who would be able to support us. Family Nursing are looking at their provision as well. So that work is all going on under the working groups, the strategic operations, strategic flu working groups, yes.
Deputy S. Power:
I do not know, but I am sure there might be a pool of residents who might have some basic training that would on a voluntary basis be brought forward at short notice.
Mr. M. Long:
The problem we have, I think, if we are now talking about we are in a pandemic period is ... it is very similar to the work about social care and vulnerable people, really. We do not know who they are going to be next week and in 2 or 3 years’ time and in 8 years’ time if it is that long before it comes. So very much the consensus of thinking at the moment is we are identifying key people and key organisations who know where these people are so we can actually go then ... we will be in an emergency situation so it will not be work as normal in the ... this is not the pre-pandemic stage, this is when we are putting people in hospital. So I think we can talk generally but I think it might be not useful to actually try to pin down what we would do because, you know, if it is a very high attack rate those medical professionals who may be retired will be similarly depleted as well.
Deputy R.G. Le Hérissier:
On the issue of finance - time to draw in finance here - has the money been ring-fenced or will the money be totally ring-fenced or will it just be added to this very large budget which is mentioned in the proposition? Or will you actually ring-fence the money so that Dr. Geller and Dr. Muscat have instant access to it?
Mr. R. Pearson:
That is right. Obviously some funds have already been made available for the first stages of the preparation of the pandemic and that has all been ring-fenced and was effectively spent on the things that were in the plan that were identified, and this would be exactly the same. This would be money that we set to ... in the event ... sorry, to purchase these items and then in the event of the flu pandemic occurring.
Deputy R.G. Le Hérissier:
Who organisationally is responsible in health for the pandemic, were it to occur? Who would people go to and say ... could press the button and get things organised? Who is that person?