Meeting of the United Kingdom National Influenza Pandemic Committee (UKNIPC) held on 16 May 2006

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1. Introduction and Welcome
The chair welcomed everyone to the meeting. He introduced Professor Lindsey Davies in her role as the National Director for Pandemic Preparedness.

2. Minutes of the meeting held 18 July 2005
The Committee agreed the minutes of the last UKNIPC meeting - paper UKNIPC 04/01.

An amendment to add David Salter to the attendee list was agreed.

3. Matters Arising
3.1 The Secretariat will shortly circulate the minutes of the last Scientific Advisory Group as paper UKNIPC 04/02.

3.2 Following the last UKNIPC Meeting, Dr Shukla presented paper UKNIPC 04/08, 'A report on flu-like illness following an influenza B outbreak in the Birmingham and Black Country area' which mainly affected school-aged children.' The experience raised a number of issues for influenza outbreak planning. These included:

• Surveillance - this was highlighted as a problem, especially the point at which surveillance systems should be switched on, case definition and reporting by schools;
• Differences in the trigger for school closures. This was the head-teacher's decision and based on staffing levels and health and safety.
• NHS staff absenteeism - this was within the average for staff sickness levels;
• The impact on primary care staff was still unclear,
• Tracking data - this was a labour intensive task. It had proved difficult to obtain data. Staff had resorted to directly calling GPs;
• Media reporting which had increased levels of anxiety and concern across the region; behaviours had been different those from expected

3.3 The Chair explained that the impact of school closures was being discussed by the cross-Whitehall MISC32 Committee. The development of policy would take into account the impact of school closure on the progression of any pandemic in the UK; and the practicality of identifying thresholds of illness and death at which to take action. There would be a need to communicate with teachers on their role in national infection control at the appropriate pandemic phase.

3.4 Dr Harper explained that the wider impacts of closure were being considered by MISC 32. The group was concerned about the "ripple effect" in numbers of those affected, such as parents and carers. The Civil Contingencies Secretariat (CCS) had commissioned work on this. Dr Harper asked for the West Midlands data to be fed into this work and that the Committee notify the Secretariat if they had further data for input.

3.5 The following issues were also raised:

• There had been insufficient evidence of the impact on operational areas. It had not been possible to distinguish between absences for sickness and carers during the Birmingham outbreak;
• It would be helpful to access required levels staffing in schools once schools closed; Lambeth PCT was mapping its potential staffing levels should schools close and would be happy to share this information, and
• There was a need to include and engage the independent school sector.

4. Developments since the last meeting
Dr Harper updated the Committee on the latest developments based on the paper UKNIPC 04/03.

4.1 Avian influenza

There had been infrequent cases of highly pathogenic avian influenza H5N1 infection in some people who had been closely exposed to infected poultry. In the current outbreak there had been, to date (15th May 2006), 208 cases in people, 115 of whom had died. Currently there was concern about a family cluster of cases in Indonesia which was being investigated by the World Health Organization.

H5N1 had been confirmed in a Whooper swan found dead in Scotland. Protection measures in line with those applied elsewhere in Europe had been put in place around the location. There had been no other cases of H5N1 identified in birds in the UK.

There had been widespread and sporadic detections of HPAI H5N1 in dead wild birds in many locations across Europe, as well as in cats and a stone marten.

These developments had not changed the European Centre for Disease Prevention and Control's risk assessment's conclusions stating that the risk to humans was almost entirely confined to those who had had close contact with infected domestic poultry.

The UK had not lost its status as being officially free from Highly Pathogenic Avian Influenza, according to the criteria of the World Animal Health Organisation.

Low pathogenic H7N3 avian influenza had been confirmed in samples taken from chickens found dead on a poultry farm near Dereham in Norfolk. In accordance with Defra's contingency plans for dealing with outbreaks of avian flu, birds on the premises had been culled and a 1km restriction zone had been placed on the farm.

4.2 Avian influenza in humans

One poultry worker from the Norfolk poultry farm had been confirmed as suffering from conjunctivitis caused by the H7N3 avian influenza virus.The worker had experienced no other symptoms and was well. 107 individuals had been provided with Tamiflu and 86 with seasonal flu vaccine.

4.3 Domestic preparedness
Recent developments included the following:

• Orders had been placed with Chiron and Baxter for 3.7m doses of H5N1 vaccine, of which 2.6m are for England;
• Antiviral treatment courses delivered currently totaled 8.1m; we were on target to complete the stockpile by September 2006, and
• Tenders for sleeping contracts for 120m doses of pre-pandemic vaccine were currently being considered.

4.4 Scientific Advisory Group
The March 2006 meeting had progressed many issues. The minutes from the meeting would be circulated shortly.

4.5 Clinical Management Guidelines
The Clinical Management Guidelines had been revised and would be published on the DH website.

4.6 MISC32
The committee had met a number of times and considered various pandemic planning issues. The meeting scheduled for this week had been postponed until June.

4.7 International preparedness
David Harper reported that:

• The Austrian Presidency Health Council had met in April. The EU antiviral stockpile had been discussed;
• The first G8 Health Ministers had been held in Moscow in April. MS(HS) attended, and there had been considerable discussion on pandemic influenza;
• A follow-up meeting to the Beijing pledging conference had been scheduled for early June in Vienna, and
• On 3rd May, President Bush had unveiled the US Implementation Plan on Pandemic Influenza. This was a useful document and could be accessed at http://www.hhs.gov/pandemicflu/plan/

4.8 In the ensuing discussion:

• Professor Donnelly detailed the Scotland experiences with the Whooper swan. Though the media interest had been predictable, it had been nonetheless extraordinary, and it had become important to maintain public confidence. The Chief Veterinary Officers had made deliberate attempts to separate bird and human disease. This had worked well and the media had been able to distinguish between pandemic and avian flu in reporting. The Scottish Executive had gathered much useful experience from the exercise, including the importance of the links with London, and the availability of additional support because of the speed of events.
• Dr Lysons commented that although there had been practical problems for Defra, management of the dead swan issue had generally gone well. Lessons learned included how to handle a massive increase in the number of carcasses reported in the UK. In Africa avian influenza had been reported in seven countries, and 7,500 birds had been tested across surveillance sights, with negative results. In wider Europe three distinct clusters had been identified for tracking progress - Baltic and Reugen Island, Eastern Europe and Eastern Turkey.
  

5.Health Control and Coordination in a Pandemic (UKNIPC 04/04)
Gron Roberts explained that this paper was instigated following Exercise Common Ground and discussion at the last UKNIPC meeting. There had been a need for a more consistent operational approach and more guidance on NHS coordination and control. A number of members of UKNIPC had provided comments which had been incorporated.

5.1 The paper (UKNIPC 04/04) proposed using, as far as possible, the building blocks already in place. It also emphasised the importance of integrating health and wider coordinating arrangements at local and national level.

5.2 The ensuing discussion raised the following issues;

• There would be two tests of the model:
  1. How well it stood up against health emergency co-ordination arrangements that were already in place for incidents such as terrorist attacks, and
  2. How well it was understood and communicated on the "front line" to ensure the clinical engagement of every GP, practice nurse, etc.;
• Timing would be an important issue and changes in the organisation of the NHS should help simplify the control and co-ordination arrangements;
• Much of the NHS activity would be at primary care level and the Department would need to communicate direction and support to the field;
• Concerns about aspects such as protective equipment, supply and financial costs were the main issues raised at local level. More information on national thinking would be helpful and training was a particular issue that needed to be higher on the agenda;
• An exercise had taken place which had demonstrated that people were comfortable with the command and control system but there was some confusion about health leadership. Other issues likely to cause concern were how the reorganisation of the SHA & PCTs would integrate nationally with the central system for command and control, media handling; and the level of public confidence. A specifically trained cadre of specialists and generalists for command purposes was suggested.
• There was a gap between written plans, capability and understanding. Scotland was using an A&E consultant to check, chase and test clinical plans with the health community of fifteen health boards. Engaging with primary care was critical and they were holding a 'Best Practice Day' to examine how they would cope using the models.
• The paper was considered a useful stimulus for discussion, but needed to go further. Societal/economic impacts or the issues faced by other agencies with implications for the health sector couldn't be ignored. They were of fundamental importance and UKNIPC should not give the impression that health issues sat alone;
• The involvement of the Department of Health resilience mechanism was important. The unit was experienced in initial crisis management. The consequent management should then be provided by the specific planning arrangements. However, there was overlap and no distinct cut off point.
• There was an existing emergency planning training programme for directors of SHA's, with a second and third module due online. Emergency Preparedness Division and the HPA had developed an off-the-shelf exercise to test response plans, which could be used as required.
• Critical care and hospital business was being addressed by Emergency Planning and Clinical Leadership Group so that trigger points and supportive care could be identified.
• Exercise Shared Goal next month would identify the cross-government issues for attention.
• The current arrangements for health emergency co-ordination would need to be altered to reflect the forthcoming organisational changes;
• It was felt that business continuity and local level health protection issues should be included in the broader framework so everyone was working to a common template, and
• The revised arrangements could be discussed again at a future meeting.
  
  

6.Delivering Out of Hospital Care
Gron Roberts presented the revised version of UKNIPC 04/05 for information only. A number of options for strengthening and focusing care outside hospital through general practice and primary care were being modelled to take into account capacity and resilience. A proposed model was due by the end of May. A rapid appraisal group and RCGP were looking at this.

6.1 The following points were made in discussion:

• SHA directors would like to enable patients to self manage. The Department needed to work through the practicalities, possibly aided by management algorithm, and
  
• There was a network of 10,000 pharmacies that could be used to form part of the required out of hospital care team.
  
  

7. Modelling the Pandemic and the Effectiveness of Countermeasures -
UKNIPC 04/06
Dr Grove presented a summary of the most important results from each of the modelling meetings. Paper UKNIPC 04/06 set out the consensus of the group on the probable development of a pandemic and the effectiveness of countermeasures.

7.1 Following the presentation the following points were raised;

• Whether the impact of an animal pandemic had been included in the modelling. Dr Harper responded that we were specifically looking at human health from a human pandemic virus, and
• Whether a pre-pandemic vaccine would be a real option due to the time required for its manufacture (as was the case with pandemic specific vaccine). Dr Harper replied that it was likely that a poorly matched vaccine would be available prior to a pandemic as production could be scheduled in between production of seasonal vaccines. Dr Grove said that there was probably a window of six weeks following the first efficient human-to-human transmission before the first cases were seen in the UK and this was enough time to vaccinate the entire UK population.
  

8.Preparing UKNIPC for the June COBR Exercise - UKNIPC 04/07
It was suggested that the forthcoming national pandemic flu exercise, Exercise Shared Goal, being held on 14th and 15th June would be a good opportunity to involve UKNIPC and test the response mechanism of the committee at Phase 5. This could involve volunteers being available via telephone link to offer input as required. Exercise Shared Goal was a cross government exercise led by the Department of Health. The main objective was to involve other government departments and test a range of health and wider areas. Players in the exercise would include the East Midlands and South East regions.

Ministers would participate on the second day. The exercise would be based around WHO Level 5 scenario. A further exercise would take place in January 2007 to test Phase 6 response.

The committee expressed interest in UKNIPC meeting during the exercise via teleconference. This would test the practicalities of this method of communication.

It was agreed that the probable UKNIPC role at phase 5 should be replicated in the exercise with minimal disruption to members. Members should send their contact details to the Secretariat who would be in contact about the next steps.

9. Date of next meeting

The proposed date for the next meeting was Wednesday 27th September, 10am -12.30pm, Room 149

The Chair asked members to send suggestions for future agenda items to the Secretariat.

10. AOB

David Jones explained that he was assisting Kathryn Hudson in the social care work area to identify stakeholders that need to be involved in health and social care strategies.

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