Sir Liam Donaldson is the United Kingdom's Chief Medical Officer. This interview, with Panorama's Jane Corbin, was recorded at the Department of Health, Whitehall on 28 October 2005. These are edited highlights.
Jane Corbin: How likely is the emergence of a human flu pandemic and what sort of time scale are we talking about?
Liam Donaldson: We've had three pandemics within living memory, 1918-19 the Spanish flu; 1958 the Asian flu; and 1968-9 the pandemic strain of Hong Kong flu, so there is an inevitability about these pandemics. They come in natural biological cycles of between 10 and 30 or 40 years, and so it's inevitable that at some point we'll have another one. It could be next year, it could be in five years time. It could even be in 10 years time, but we're preparing as if it's coming sooner rather than later.
Jane Corbin: If it comes this winter, we're not fully prepared for it, are we, as yet?
Liam Donaldson: We have a very strong contingency plan which many other countries in the world don't yet have, so from that point of view we are in quite a strong position.
We have a stockpile of some antivirals. We are tendering for a contract for the H5N1 vaccine for essential workers. We're also putting out a sleeping contract for 120 million doses of the pandemic flu vaccine so that vaccine manufacturing capacity is in place whenever we need it. So we've done a lot but there's more still to do.
Obviously, if it comes later rather than sooner we'll have done even more preparation and we'll be much more pleased about that.
Jane Corbin: Now what is it about the situation in the Far East that makes us more concerned about a human flu pandemic?
Liam Donaldson: There have been outbreaks of bird flu in the Far East over the last 5 or 6 years. So far, although any death is a tragedy, it's killed just over 60 people but there have probably been maybe a billion exposures to Avian flu to people. So we do know that Avian flu is very difficult to transmit to people, but the risk is, that with a strain of Avian flu like this that it will either mutate into a human form of the virus and then be easily transmissible from person to person, or more likely it will mix with a human flu virus to create a hybrid strain which is easily transmissible from people to people and then we will have a pandemic strain.
Jane Corbin: Although there have been relatively few cases in the Far East, they are increasing. Doctors there expect more this winter. So aren't the chances of that mixing occurring increasing all the time?
Liam Donaldson: The statisticians would tell you the probability is the same as it's always been but that's a bit of a technical argument. I think we can say that because this Bird flu strain has been around, we have remained very, very concerned about it, but it has been around for 5 or 6 years, we've had 60 deaths, probably a billion people have been exposed to it, so at the moment it's not showing any signs of mutating into a human strain, or mixing with a human flu virus, but it could happen in the short term or it might be quite a long time before it happened, or even a third scenario, it could be an entirely different bird flu strain that we don't yet know about. So all of those scenarios are possible.
Jane Corbin: If it emerged, if it became really transmissible human to human, sparking a pandemic, what could we do? Could we, for example, shut down airports, would that make a difference?
Liam Donaldson: It probably wouldn't make a great deal of difference. The modelling suggests that if you closed all international borders, even to a 99% rate of success, you would probably slow the pandemic by about 3 to 4 weeks which is not a great deal of time. And against that you'd have to balance the fact that if you shut down international borders, there would be many essential things that wouldn't be able to get into those countries. So it could be possible that by doing that, you'd be causing more harm and more deaths. So I think it's a much more practical idea to look at the contingency arrangements within a country which might involve some measures to reduce social mixing and movements of population. But I think closing international borders when the disease is so easily transmissible, and when you might be denying some countries essential supplies is a very, very difficult matter.
Jane Corbin: That brings us back to preparedness, the state of preparedness here inside Britain. What are the essential features that the Department of Health plan?
Liam Donaldson: The main ingredients of the plan are: having good international cooperation so that we can identify the strain of the pandemic flu whenever it emerges, possibly in the Far East, possibly elsewhere in the world. Secondly, ensuring that we have the ability in our laboratories to isolate the virus quickly and start the early steps of preparing a vaccine, and we have some of the best flu scientists in our laboratories in Britain in the world. Thirdly, that we stockpile antiviral drugs which will help to reduce the impact of a pandemic, they will not stop it from coming but they will help to reduce its impact. Fourthly that we have good preparations in the NHS so that they've looked at the capacity of their services and made local plans, and fifthly that we have planning across government so that all government departments, essential services and even the slightly more depressing measures that you have to take in a situation like this, looking at burial and disposal of the dead, that all of those measures are in place as well.
Jane Corbin: The NHS is already overstretched. There are no extra resources from ventilators and intensive care beds to simple face masks at the other end of the scale. Is there extra money for this?
Liam Donaldson: If you go back ten years the NHS was not very good at coping with the normal winter flu outbreaks that we have. Over the last ten years, planning of the NHS for contingency in winter has improved enormously, so we are much better at dealing with these surges of extra cases that you get when you get outbreaks of flu. If a pandemic came, obviously there would be much greater pressure on the NHS, it would be same for any health system across the world. But there are very good planning mechanisms in the NHS. We saw how the NHS dealt superbly with the terrorist emergency, the bombings in London a few months ago, and so the NHS is on a high state of alert to produce those local flu plans, look at their capacity against the possible extra demand and do as much as it can to cope with it.
Jane Corbin: The pandemic flu could last for weeks or months, unlike a terrorist attack, and primary care trusts are concerned they don't have the resources, they don't have all that they need to actually implement these plans.
Liam Donaldson: In the last few years, as everybody is aware, a great deal of extra investment has gone into the NHS, building up to giving us one of the best publicly funded services in Europe. So the infrastructure of the NHS has expanded enormously in the last few years.
Jane Corbin: So there's no extra money for pandemics?
Liam Donaldson: No, but it will be a question of priorities within the existing NHS resources. If the pandemic comes, it will be a public health emergency. It will be an emergency for the NHS and some of the work will need to be reprioritised, and obviously some non-essential procedures would not take place on the time scale that they were originally scheduled, and the NHS would switch over into emergency mode, and it would deal with that just as it would deal with any other sort of emergency that led to many more people becoming ill.
Jane Corbin: Some hospitals will be designated as front line units if the pandemic comes, but the staff don't seem to know which hospitals these are. Will they know this or again will you have a problem perhaps with an element of panic and concern about infection within hospitals like that?
Liam Donaldson: I've never known a situation where NHS staff have panicked. They go to work. They do a great job looking after patients and we would expect them to do that. At the moment we've asked all local services to produce a local plan to fully engage their staff, so that everybody knows what their role will be in the event of a pandemic and what part they will have to play in responding to the extra demand which is inevitable.
Jane Corbin: Will you close schools or will you recommend the closing of schools if the pandemic strikes?
Liam Donaldson: It's a possibility. There is always a downside to any intervention of that sort. If parents, for example, had to stay at home, then how many essential workers would be amongst those parents. Children are likely to set up other social networks so it's not as if they can be isolated from all other people. But at the height of a pandemic, when were trying to slow it's spread, it might be sensible to consider measures like that. We're keeping our minds open on that. It is in the contingency plan as a possibility, but we wont be able to make a judgement about that until the cases of flu start to arrive on our shores.
Jane Corbin: Are you concerned that perhaps you're erring on the cautious side with the mortality figures that you've put forward? Some doctors believe that we could be at the high end of the scale around three quarters of a million dead and that perhaps you don't wish to emphasise this because of fears of panicking the public.
Liam Donaldson: We've put out a range of figures produced by statistical modellers in our March plan and we put them out again a few weeks ago. As with any long range forecasting, there is always a range of possibilities because nobody is sure what strain of virus will eventually emerge, whether it will be a mild one or whether it will be a more severe one.
Jane Corbin: How many people could die at the upper limit?
Liam Donaldson: The upper limit is, as you'll see from the plan, 750 000. It could be a lot lower than that. Our planning assumption is 50,000 or so, but we work very flexibly, and if, when the virus emerges, the strain is more virulent than that, and would lead to extra cases and deaths, then we would take that into account at the time. These figures have been public for a long time.
Jane Corbin: How do you strike a balance between public fears and giving the public information of something like a pandemic?
Liam Donaldson: I think we have to proceed on the basis that it's much better for the public to know as much as we do. I think we've gone past the days of concealing information from the public in order to stop them being alarmed. That's a rather paternalistic way of going on. We've tried to be completely open. It always is difficult to strike a balance between apathy and fear, and of course most of the public don't hear their information directly from us, they hear it through journalists. So journalists and the broadcasts and print media have a big part to play in the way that they present the information which we are often giving to them and they are giving to the public.
Jane Corbin: What is the strategy with antivirals with Tamiflu?
Liam Donaldson: There are a lot of scientific uncertainties in this whole field of planning for pandemic flu. Antiviral drugs have been developed largely for treating seasonal flu in developed countries. They have not been tried in a pandemic situation. But bearing in mind what the current evidence shows, we would expect that if antivirals were given early in an attack of flu, they would be able to reduce the severity of that attack, to reduce the length of illness and possibly also reduce the mortality rate. Antivirals are a measure which is used to reduce the impact of pandemic flu. They cannot cure it or make it go away.
Jane Corbin: Are we pinning too many hopes on it? It's not been tested in anger before and indeed there are cases of drug resistance beginning to emerge with Tamiflu?
Liam Donaldson: The cases of drug resistance are relatively few and far between, and indeed, amongst the small number of cases of resistance that have been reported, they've actually had a positive effect on the virus in that they've made it weaker and more difficult to transmit. So we haven't seen a lot of antiviral resistance so far. We know it exists, but antiviral provision is one of our key strategies and we can't deny the public the opportunity to benefit from it, even though we're not 100% sure of what it's full impact will be in a pandemic situation.
Jane Corbin: We won't have a sufficient stockpile of Tamiflu for some months yet, not till getting on towards the end of the next year. If the pandemic comes before then, how will you tell some people they can have it and others that they can't? It's going to be tough.
Liam Donaldson: There will have to be prioritisation but we are further ahead with stockpiling than many other countries of the world. We will be ready by September 2006 and we will have our full stockpile in place. It's coming in at a rate of 800,000 a month at the moment. It will be going up to closer to a million a month nearer to the time. If the pandemic should come sooner rather than later, we will have to prioritise people at the highest risk. Front line NHS workers will be the priorities.
Jane Corbin: You've explained to me that you've now put out a tender for the vaccine. But a lot of doctors would say why didn't we get going earlier on this whole business of the vaccine. We know what the current strain is, we should have gone ahead and got production of that vaccine, it would have given some protection and we would have been well down the road by now, and instead, effectively, at the moment the cupboard is pretty bare.
Liam Donaldson: Flu vaccine has to be made according to the exact strain of the flu virus that comes round. We would not have a problem if science could give us a vaccine that worked against all known flu strains, but there are very many strains, each of them has it's own genetic signature, so if we want to combat the flu and give people proper protection then the vaccine has got to be designer made to that particular strain. We can't easily do it in advance, but what we can do is to try and shorten the period of vaccine production to get scientists to give us the best lead time possible on production, and we can also give the vaccine manufacturers an assurance that when they produce the vaccine, we will pay for it, which is why we've put these sleeping contracts out to allow the vaccine production capacity to be built up in advance.
Jane Corbin: Most scientists believe that the H5N1 strain at the moment is the one we should worry about. It's the one that has been identified in the Far East, the one that's been found in migrating birds closer to our shores. Should we not have at least started down the road of developing a vaccine in answer to that problem?
Liam Donaldson: We have already ordered 2½ million doses of the H5N1 strain but we cannot have tunnel vision with this, we've got to recognise that the flu strain that emerges is likely to be different to the exact strains that are around at the moment, which are in any case viruses that affect birds. They haven't yet mutated or mixed with a human flu virus and gone into a human strain that's easily transmissible from person to person.
Jane Corbin: If it breaks out this winter, you've about 2 million doses on hand, are you worried there will be difficulties in prioritising who gets that limited amount that we have at the moment?
Liam Donaldson: The H5N1 vaccine is a contingency and it will be arriving early next year. Having a vaccine of the H5N1 is very much a long shot and a contingency but that's what we've ordered for essential workers.
Jane Corbin: Of course Britain's not alone in this, we act in a European context. Are we prepared to share what we have and what we know with less prepared European partners if we come down to the wire on this one?
Liam Donaldson: We're sharing all the knowledge we've got. Almost every meeting in Europe that we have at the moment on a health matter is discussing the approach to pandemic flu. Most European countries are active on this front and we're all thinking along similar lines.
Jane Corbin: Is the answer containing it in the Far East? Can we realistically do this?
Liam Donaldson: I think it's something that needs to be thought about but it's a long-shot, very much a long-shot. There are 80 million people in Vietnam. Do you think it's feasible that in the first 24-48 hours of emergence of a pandemic strain of flu, somewhere in a remote village of Vietnam that we would be able to isolate it and get antivirals into that village quickly to stop it spreading? It is theoretically possible, but if we put all our eggs in that basket and believe that we can snuff out the pandemic in the Far East and stop it from coming to western shores, I think it would be a very unwise course of action. So we need to try everything we can, but accept that it's a long-shot rather than a certainty.
Jane Corbin: The appearance of the virus in migratory birds in Europe, dead parrots here in the UK, should these give us cause for concern ? Is it inevitable that this will end up on our own shores via birds?
Liam Donaldson: I don't think it's inevitable that that will be the route, and indeed it's rather ironic given the billions of people living in the Far East and the much larger outbreaks there that everybody should be thinking that these recent events mean that the pandemic will start in Europe. It could but I think it's far more likely that it will start in the Far East.