Download Health inequalities in London

Appendix 2
Health and Public Services Committee
12 January 2011
Transcript of Item 5: Health inequalities in London – Update on Flu situation
James Cleverly (Chair): The main point of this agenda item is to explore health and inequalities
in London, particularly in light of the proposed changes to the structure of health provision in
London.
Before we do that I was wondering, Simon, if I could invite you to give us a brief update on the
situation of influenza in London, particularly the provision of vaccinations.
Dr Simon Tanner (Regional Director of Public Health, NHS London): I am pleased to be
here to let you know what is going on. You will know that we are now in a seasonal flu period, it
is not unexpected. What it is, I think, that is unexpected is we did not know precisely how things
were going to be after the pandemic of last year, which you will remember we had quite a lot of
talk about.
The issue that we have got is that the normal seasonal flu is now circulating. Within that, a lot
of this you will have heard through our other sources on the television, but you will hear it from
me as well. The swine flu virus of last year H1N1 is circulating as part of the seasonal flu, that is
not unusual. We see that after a pandemic, we see that that virus then becomes part of the mix
that is in the air, that is floating around the globe and is creating the issues. There are two
predominant viruses involved, the H1N1and the familiar influenza B. There is a third but it is a
much smaller part of the mix.
We were seeing that activity increase and it started to increase quite markedly up in the cold
period just before Christmas. Although that peak is still quite high, it is still not at the sorts of
levels that we would expect in for normal seasonal flu.
We saw the General Practitioner [GP] consultations go up for influenza-like illness and we have
now got the opportunity and ability to test for the different viruses. There has been rather more
testing than there has been in past years. Nevertheless, also a greater number of people
hospitalised than we have seen before. The significant thing about this period this year and the
reason why you have seen activity and people getting concerned is: that we are seeing larger
numbers of people being admitted to hospital and needing critical care. In fact we have had more
people in critical care beds in London during the course of this last few months than we had at
the time of the Swine flu.
I came here today to warn you that Swine flu is a very nasty illness, which indeed it is. We have
actually had more people in critical care over this last period which has put pressures on the
National Health Service (NHS). However, the NHS is actually coping very well. It is partly
because of the processes that were put in place around the pandemic, so there is a very good
history of collaborative working. There were lessons learned during that about how to maintain
critical care capacity and in particular how to make sure that the beds are there for those that
need it.
There is at the moment, I suppose, the big question of where we are at in this curve. Variously
there are some people that are saying that things look as if they are tailing off. We would expect,
normally, the epidemic curve to last about six to eight weeks and we are in that period at the
moment. It is too early to say precisely whether that is happening. By next week or so we
should have a clearer view of that. I am not going to sit here and say that we are at peak but
there are some suggestions that it might be slowing down a little.
You will have read that there was a decision from the Government and the Department of Health
last week to allow the use of the stocks of the H1N1 virus that we have in place for the pandemic
to be used, because there were some difficulties in the obtaining of vaccine and that was about
vaccine being in different places from where it was required, because as we see in most of these
epidemics you get areas with high incidents and areas with not so high incidents.
Now there is a national definition of the people who are at risk from flu. Again, the other notable
issue for people has been who is eligible for the vaccine. The Joint Committee on Vaccination
and Immunisation is the Government Advisory Group on this and they have been advising
consistently throughout about the at-risk groups: these are people with underlying health
conditions, pregnant women, health care workers and people that are looking after those that
need support are as well important in order to maintain those services, and children as well if
they fall into those high risk groups. They have repeated their advice that at this stage they have
not been recommending the vaccine for healthy children.
I think you are becoming rather veterans of virology and we did discuss it all last year. The very
important thing to note about flu is that it changes and it changes its genetic make-up. At any
time in a pandemic or at any other time the concern of the virologists and the clinicians is that
the virus will mutate in some way and then there will be a larger group of people who are not
immune to it. There is no evidence that that is happening with this virus as things stand at the
moment. That is not just the experience in the UK that is the experience across the world.
Where we are at at the moment is: the figure that I have here for Wednesday 12 January 2011
are that 119 patients are in critical care in London with confirmed or suspected flu; that is a large
number of people who are sick. Nationally we have, as you know, announced that there have
been over 50 deaths. That just goes to underline the fact that here is a disease that is potentially
lethal. It is occurring in the groups that one would expect it to occur in, that has been younger
people. There is some evidence that older people all through the years have developed some
immunity to these types of flu but younger people less so. This is why particularly young people
in vulnerable groups, those with underlying health conditions are really quite high up on the list
of priority to get vaccinated.
I think I can reassure the Committee as I did last year that this is being taken very seriously by
the NHS. Despite some of the reports that you may have read, the NHS has not been
overwhelmed by this, it is a very large organisation and it is used to dealing with these peaks
every winter. However, it is a serious illness and there have been some tragic deaths across the
country. We are still very keen to ensure that people who are in need of vaccination do indeed
get it. At the moment we have still not vaccinated nationally as many people as we would have
liked to have done in those high risk groups.
Of course, public reporting of this helps because that was part of the problem with the difficulty
with supply, because a good job was done in terms of people recognising the difficulty. There
was also an issue about the obtaining of the vaccine. We do not see that as an issue now, we are
not having that reported from our Primary Care Trusts.
Richard Barnbrook (AM): You mentioned that there had been no signs as yet of mutation
within the swine flu or the H1N1 and yet it is inevitably across the media all the time. There was
one story that came up about what appeared to be a very healthy young girl who showed no
symptoms of any type of flu of any strain that died in a very short period of time: no headaches,
no sweating, no sore throat. If you normally have flu of one type or another, you normally have
symptoms. They are not always as clear as we would like but they have symptoms. What
happens in the case that there is a mutation? Does it show up the fact of other symptoms or
could it possibly show up no symptoms at all? In this particular one case, how clear are we on
what is actually taking place and how signs can be shown? She was a healthy young girl that
just died with no symptoms.
Dr Simon Tanner (Regional Director of Public Health, NHS London): Obviously I do not
know the clinical details of that case other than what you are telling me. When I talk about the
mutation of the virus, I am talking about on a global scale. There are millions of these things
around and they are replicating all the time. If they keep replicating and their DNA1
[deoxyribonucleic acid] stays the same then that is fine, but it is the nature of flu viruses to
slowly mutate. This so called genetic drift is why every year there has to be reformulation of the
vaccine. So it is not the same thing, it is not possible to say in an individual case, “That might
have been because the virus has mutated”, that is not the way it works. It is the whole population
of the virus as it is out there, the millions and billions of them that are floating about the
atmosphere. As they start to change they would change, antigenic shift.
Richard Barnbrook (AM): This case was reported in a national newspaper, and I think it was
followed in two other papers, - I cannot remember their names. If it is showing the possibility
now of symptoms not being clearly visible and yet people are dying due to this virus, how is it
possible for NHS to actually govern who is vulnerable and who is not?
Dr Simon Tanner (Regional Director of Public Health, NHS London): It is not the NHS
that makes those decision it could be an advisory group of experts which has been around for
more than 30 years and it is one of those groups that has a hugely solid reputation. It may base
its advice on national evidence about the way in which the virus works. They would look at the
way populations work, they would look at the likelihood of any individual group of people being
more susceptible. It is very clear that people, pregnant women for instance, are by nature of the
fact that they are pregnant as a group more susceptible to this virus, hence the reason for putting
them into the vaccine group. From your example, tragic though it is, it is not possible to say
from that one case that that would change the advice about risk groups.
Navin Shah (Deputy Chair): First thing is about the scale of epidemic. How does London
compare with the national outbreak?
Dr Simon Tanner (Regional Director of Public Health, NHS London): It has been the North
West that has been mostly affected, so the North West was under pressure before London. In
terms of the size and the challenge that London has, it has a challenge proportionate to its size as
a population of 8 million people. We have not seen and we would not be able to say that we have
had it, that it has hit London worse than it has hit other places.
Navin Shah (Deputy Chair): In terms of deaths, how many people have died in London?
Dr Simon Tanner (Regional Director of Public Health, NHS London): We do not keep those
figures. We have made a decision that that is not information to put out, partly because there is
guidance about the numbers of deaths that one releases, small numbers and identifiability. At the
moment there is no policy decision to release numbers at London level.
Navin Shah (Deputy Chair): Can you possibly have that for us?
Dr Simon Tanner (Regional Director of Public Health, NHS London): I am not going to be
doing that. The Chief Medical Officer every week is producing the national figures and if a
Following the meeting, Dr Tanner’s office explained that influenza virus has an RNA [ribonucleic acid] genome,
rather than DNA.
1
decision is made that there is going to be some breakdown beneath that then that will not be a
decision for me. It will be a decision for the Department of Health.
Navin Shah (Deputy Chair): You mentioned that it is children who are at a greater risk. Can
you tell us what age group roughly we are talking about?
Dr Simon Tanner (Regional Director of Public Health, NHS London): Well, I said that
children who are in the high risk categories are clearly ones that we need to focus on, in terms of
vaccination policy. However I said young people generally. So in fact, in terms of the people
nationally that are overrepresented in the sick, it is the young adult age group: it is the teenager
through to 45 age group; a younger part of the population rather than the older part of the
population. I am not saying that the preponderance of this is in children.
Navin Shah (Deputy Chair): We had some form of awareness campaign and advice or guidance
to schools etc. Is this an area we might need to revisit or is there something that you are doing
to advise schools and other bodies such as those about it?
Dr Simon Tanner (Regional Director of Public Health, NHS London): You will have seen
that the Government have reinstated the “Catch It, Kill It, Bin It” campaign. In general the
message about good hand hygiene, good hygiene in general, using tissues etc, is precisely the
right message. Though I think some people think it is a somewhat boring message but it is true,
it is right. In terms of children, I do not think that there is any distinction in terms of that
advice, other than the obvious thing of teaching your children how to use a tissue.
Regarding schools, we are targeting them. Anything that actually allows us to be putting the
message around about good hygiene is important. I do not think we need to put out special
messages about children at a higher risk. Unless we are talking for instance, if you remember
last year, very sadly I was on the television quite regularly announcing deaths of children and
they were very often children in special schools and children with developmental delay and
neurological problems. One felt then that it was added to the tragedy that these were already
vulnerable children.
Navin Shah (Deputy Chair): Do we have adequate supplies of vaccine in London?
Dr Simon Tanner (Regional Director of Public Health, NHS London): Yes we do. Even at
the time when there were reports of difficulties which were real. Some of the reporting started in
London and they were real. They were dealt with quite quickly and then the release of the
Pandemrix has made a huge difference.
Navin Shah (Deputy Chair): This is my last question. You mentioned that a greater number of
people have been hospitalised due to the epidemic. Does this put any pressure on bed spaces?
Dr Simon Tanner (Regional Director of Public Health, NHS London): Yes it does. There
was a plan that was developed during the pandemic last year about how organisations in London
would work together to ensure that there was always sufficient availability. I am not an expert in
the way that critical care and beds are managed but there are ways of increasing capacity when
necessary and then reducing it later; these have all been brought into play. There is a network of
hospitals, a network of critical care clinicians who work on this. As I say, although this is a
pressure, I think I said it is 119 people on Wednesday, today, who are in hospital who we would
very much rather were not in critical care, but that is not the sort of number that is going to
make the system fall over.
Richard Barnes (AM): The Medical Officer of Health has reported the national figures for
deaths. Can we put that into context? The 50 that have been reported, are they all H1N1
related?
Dr Simon Tanner (Regional Director of Public Health, NHS London): I have not got the
breakdown here Richard but they are probably well nearly all. The last time I heard them there
were less than a handful that were not H1N1 and I think that has been nationally, I just do not
have it with me today, but I think that is what it was last time. We would expect that at the
moment because we do know that of these viruses the H1N1 appears to be a more difficult virus.
We knew that.
Richard Barnes (AM): Is that 50 the total number of flu related deaths recorded so far?
Dr Simon Tanner (Regional Director of Public Health, NHS London): It is very good
question. It is very carefully described as 50 deaths from H1N1 or Flu B. It has been confirmed
by microscopic examination which is what happens. If anyone reads behind those headlines, it is
very clearly stated that there may be other deaths from influenza which, of course, we do sadly
expect at this time of year out in the community, sometimes frail and elderly people who may
have the flu, it may be that their flu is not recorded. You can be absolutely certain that the 50
deaths for instance that are reported nationally at the moment will have been in critical care and
well known to hospitals etc. That is where that information is coming from.
Richard Barnes (AM): It is that sad relationship with expected flu deaths on an annual basis
that I am trying to put the 50 in. Is this an extraordinary number? Does it compare relatively
favourably well than in previous years?
Dr Simon Tanner (Regional Director of Public Health, NHS London): I think it is a little
bit about ‘apples and pears’. We have been used to having figures, sometimes quite large figures
bandied around year on year about how many people die from flu every year. Of course that was
in a time when we were not testing all the time for them so they would have been on a clinical
presentation. I think we have got a presentational issue that we have got a number of absolutely,
solidly confirmed deaths that have gone into hospital, in critical care and they are reported
nationally. We do not do that normally, we do not report those sorts of figures every year in that
way. It is not easy to compare the 50 that the Chief Medical Officer is talking about with the
sorts of numbers that are in common parlance about hundreds if not thousands of people die
every year from flu. You hear that said but it will have been based upon a clinical presentation.
Richard Barnes (AM): How do you take that off the shelf, your advice to set up central
distribution points for viruses and anti-virals? Are we in that emergency planning stage which
we were in last year?
Dr Simon Tanner (Regional Director of Public Health, NHS London): We are not setting
central distribution points for the virus, let us be clear. We are not in a situation that we were in
last year about central distribution of anti-viral medicines. That was clearly set up - and you will
remember all the panoply of things that we had to do then - because there was still a planning
possibility of very many thousands of people getting this and needing to be treated. We are just
not in that scenario. The short answer is no, we are not going to be adding that. Though, of
course, the advantage of having that experience last year is that if we needed to, we could do it
quite rapidly actually.
Richard Barnes (AM): The number of people in ICU/ITU beds is 119. Is that on a decreasing
curve at the moment?
Dr Simon Tanner (Regional Director of Public Health, NHS London): Yes, it is on a
decreasing curve but it is only slightly less.
James Cleverly (Chair): Simon, thank you very much for that.