I welcome Dr. Jim Kiely, chief medical officer, Dr. John Devlin, deputy chief medical officer, Mr. Michael Kelly, Secretary General of the Department of Health and Children, Dr. Darina O'Flanagan and Dr. Robert Cunney of the National Disease Surveillance Centre, Dr. Fenton Howell of the Irish Medical Organisation and Mr. Michael Lyons, chief executive of the Eastern Regional Health Authority. Perhaps the delegation might outline as briefly as possible the issues faced by Ireland regarding the world-wide threat from the SARS virus. I do not want to discuss the ongoing public health dispute. I wish to confine discussion to SARS, and I ask all speakers to be mindful of that.
SARS: Presentation.
I will bear that in mind, Chairman. Thank you for the opportunity to report to the committee on SARS which has been the subject of much recent commentary and analysis in the general and specialist health media. I have included as an attachment to this statement a copy of the Department's publication, Frequently Asked Questions, which gives comprehensive but concise information on all aspects of the subject and I will be glad to clarify any issues raised in this document either here or at any time after the meeting. I will first give a brief overview of SARS and why it has become such a topic of world-wide public concern.
Severe acute respiratory syndrome, SARS, is an acute respiratory illness of unknown origin, which was first recognised in South-East Asia in February 2003. Owing to the serious nature of the infection, its high mortality, and its spread to a number of different countries, it was declared a threat to international health by the Director General of the World Health Organisation in March 2003. As part of its world-wide surveillance of the syndrome, the WHO has requested member states to provide information on their experience.
As of 29 April 2003, a cumulative total of 5,462 probable SARS cases have occurred, with 353 deaths, and these have been reported from 29 countries to the WHO. To date, Ireland, in accordance with WHO guidelines, has confirmed to that organisation that it has one probable case, reported a number of weeks ago. The 15 European Union countries between them have 32 probable cases with no deaths. Our nearest neighbour, the United Kingdom, has six probable cases. I have circulated to members a table which indicates the global picture. Areas of Asia account for the vast majority of cases and deaths and, in the Western world, Canada has been most affected.
As the WHO recognises, the case definitions which it has provided to member states to assist in global surveillance are subject to limitations due to the evolving nature of the illness. They are based on current understanding of the clinical features of the disease and the available epidemiological data and may be revised. Allowance is also made for the fact that countries may need to adapt the definitions to their own disease situation.
The case definitions have been the subject of much recent commentary and contention. The definition of a suspect case provided by the WHO is a person presenting after 1 November 2002 with history of high fever and cough or breathing difficulty and one or more of the following exposures during the ten days prior to onset of symptoms: Close contact with a person who is a suspect or probable case of SARS; history of travel to an affected area, or residence in an affected area. Alternatively, it may be a person with an unexplained acute respiratory illness resulting in death after 1 November 2002 but on whom no autopsy has been performed and with one or more of the following exposures during the ten days: Close contact with a person who is a suspect or probable case of SARS; a history or travel to an affected area, or residence in an affected area.
The definition of a probable case is a suspect case with radiographic evidence consistent with pneumonia or respiratory distress syndrome on a chest X-ray or a suspect case with autopsy findings consistent with the pathology of RDS without an identifiable cause. I apologise for the technicalities, but it is important to put on the record that there are very specific definitions covering these matters.
As the WHO points out, however, SARS is currently a diagnosis of exclusion and the status of a reported case may change over time. In its documentation, it describes a number of scenarios in which this process could occur. Examples include a suspect case who, after investigation, fulfils the probable case definition should be reclassified as probable, or vice versa; or a case initially classified as suspect or probable for whom an alternative diagnosis can fully explain the illness should be discarded.
With regard to the recent action taken in Ireland, when the existence and possible implications of this condition were first identified internationally in March, the National Disease Surveillance Centre, NDSC, and staff from my office spent St. Patrick's weekend making the appropriate international contacts and literature searches to fully assess these factors and, having done so, put in place the initial comprehensive public information and professional guidance which has been the basis for our approach since. In this context I wish to put on the record my own and the Department's appreciation to Dr. O'Flanagan, Director of the NDSC, and her staff for the great efforts made in this regard over that weekend and I also include Dr. Connolly and Dr. Devlin of my own office who also contributed significantly to this initial effort.
On receipt of the initial report of the position following the St. Patrick's Day assessment, the Minister established an expert group under the chairmanship of Dr. O'Flanagan to advise him on the issues and to make recommendations as to what actions would be appropriate to prevent the establishment and spread of SARS in Ireland. The group includes representatives of the Department, the health boards, and the various clinical disciplines appropriate to the task, including the NDSC. This group, which I currently chair, has met 12 times to date and continues to meet twice weekly.
The deliberations and recommendations of the group are based on a number of sound, well tried infectious disease surveillance, control and prevention principles that are internationally accepted and are exemplified in the guidance on this issue published by the WHO, the Centre for Disease Control in the United States and a number of other reputable international public health institutes, including the NDSC. These include accurate, well informed and easily readable public information; sound practical preventive measures; early identification of cases; effective clinical care, including good hospital infection control; effective follow-up and management of contacts; and rational travel advice for people travelling to and from areas which are affected by SARS.
To give legal effect to recommended measures, where appropriate, the Infectious Disease Regulations 1981, were amended on 28 March to include SARS as a statutorily notifiable disease. This step has been taken in some countries in Europe but not others. Members may be aware of the debate on this matter in the United Kingdom, where the authorities are cogitating as to whether they should make it a notifiable disease.
Guidance provided by the group is disseminated through the system for use by health professionals, management staff and others. Examples of the work of the group include first, protocols and guidance for hospitals and health professionals which describe the syndrome and provide advice on how cases should be clinically diagnosed and managed. These have been developed and widely disseminated. Second, guidance for laboratory and infection control staff and, on the basis of guidance from the expert group, the Department has advised individuals not to undertake travel to SARS-affected areas including China, Hong Kong and so on. However, such is the evolving nature of the situation that this aspect of advice is subject to rapid change and as the infection has been brought under control in recent days both Vietnam and Toronto, which had been the subject of travel advisories up to this week, have now been removed from the WHO recommended travel advisory.
Recommendations have been made as to the nature of the public information which should be made available. Arrangements have been put in place to give effect to this and, early in the process, information was made available initially by way of notices in airports to alert travellers to the issue. This effort was expanded recently and with effect from Monday, 28 April, arrangements were made to hand out information leaflets on all incoming flights to Ireland and at other points of entry, ports and the Enterprise train line. It is estimated that approximately 100,000 leaflets per day will be distributed through these channels. Public announcements are also being made on incoming flights and ferries. SARS information desks have been set up at arrival terminals in all airports and ferry ports. A national freephone line has been set up with effect from 28 April and full information is available on the Department's website, which is updated daily at 1 p.m.
Consideration is also being given by the group to the issue of the public health implications of participation by a number of countries in the Special Olympics. The Department has also produced a detailed frequently asked questions document. In addition to being available on the Department's website, it has been circulated to other health agencies and organisations, including trade unions, educational institutions, professional bodies etc. for circulation and display on their websites. A copy of the document is provided for the information of the committee.
The organisational framework for action based on this advice has been established. It has clear lines of responsibility and its function is to ensure that the recommendations of the expert group across the entire range of activities I have outlined are implemented in their entirety. The interdepartmental planning group led by the Department comprises representatives from the Department of Health and Children, the Department of the Taoiseach, the Department of Finance, the Department of Sport and Tourism, the Department of Transport, the Department of Communications, Marine and Natural Resources, the Department of Foreign Affairs, the Department of the Environment, Heritage and Local Government, the Department of Enterprise, Trade and Employment, the Department of Agriculture and Food, the Office of Emergency Planning in the Department of Defence and the Government Information Service. This group has particular responsibility for co-ordinating the measures needed in other areas of public policy or public services to support the protection of public health. The group also has responsibility for feed back on the ongoing effectiveness of measures taken considering, in the light of SARS developments nationally and internationally, any further measures required, and recommending a course of action to particular events, an example being the Special Olympics.
The second leg is the health service implementation group whose membership comprises senior management of the Department of Health and Children and the chief executive officers of the health boards. It is chaired by the Minister for Health and Children, Deputy Martin. This group has responsibility for ensuring full response by all aspects of the health system to the SARS threat. This includes providing arrangements for treatment of SARS cases, both in hospital and the community; adequate public information and advisory services locally; adequate protection of health service staff; manning of information points at airports; system of notification of potential cases and prompt follow-up of contacts; arrangements for isolation and quarantine where necessary; and prompt flow of information to the Department of Health and Children.
The communications group is led by the press office of the Department of Health and Children in liaison with the Government Information Service and the communication officers of each health board. This group is responsible for co-ordinating all communications relating to SARS, including information to the public, statements to the media and daily press briefings.
In summary, SARS is a new and unpredictable condition. More than 5,000 cases have been identified world-wide with 350 deaths. While the rapid spread of the disease has been facilitated by rapid international travel, the actions of the WHO and individual countries have allowed a remarkably rapid identification of the features of the syndrome, its causative organism, rapid progress towards the elaboration of a reliable diagnostic test, and the implementation of a series of public health measures. This has allowed for the control of the outbreak in a number of countries in which it was established and prevention of its wider spread.
However, the continuation of the outbreak in the most populous country on earth gives serious cause for concern. It emphasises the need for continual vigilance and for the effective implementation of the public health measures which to date have allowed countries in the European Union, including Ireland, to control the outbreak. Approximately 32 cases have been notified in seven countries in the EU. We are determined to continue to draw upon the most up to date international and national information and expertise to inform our approach to this disease; to continue our collaboration with EU and WHO partner member states in the fight against SARS; and to maintain a state of readiness to deal with the illness as it evolves over the next number of months.
Dr. Darina O’Flanagan
I thank the committee for inviting us here today to discuss severe acute respiratory syndrome. I will begin by outlining how it started from the Irish perspective.
On Wednesday, 12 March, the World Health Organisation issued a global alert about cases of atypical pneumonia occurring in Hanoi, Vietnam and Hong Kong. The WHO also indicated that further investigations were ongoing regarding an outbreak of respiratory illness in the Guangdong province of China. The alarming feature of these outbreaks was the rapid spread to hospital staff with 20 hospital staff in Hanoi and 23 hospital staff in Hong Kong falling ill. The WHO recommended that patients with atypical pneumonia who may be related to these outbreaks be isolated with barrier nurse techniques. At the same time, the WHO recommended that any suspect cases be reported to national health authorities. I immediately forwarded this alert to the appropriate authorities within Ireland. This was followed by a second alert on Friday, 14 March by the European Commission to all ministries of health and to all national surveillance institutes. This alert was also immediately disseminated by NDSC to health boards for cascade to all health care professionals.
The situation rapidly evolved over the St. Patrick's weekend. The German authorities reported the first case in Europe on Saturday evening. That evening I was contacted at home by the director of CDSC Colindale, my counterpart in the UK, consultant epidemiologist Dr. Angus Nicoll, who invited me to participate in an emergency UK teleconference on Sunday morning.
With this information, I assembled, with the help of the Department of Health and Children, an emergency response team that Sunday to urgently develop guidance for health care professionals and the public in Ireland on SARS, and how to limit its spread. The guidance included case definitions to recognise a case, reporting arrangements, suggested diagnostic tests, management of suspect and probable cases and their contacts, infection control procedures, advice on travel for international travellers and advice for airlines. A frequently asked question document for the general public was also prepared. This guidance was on the NDSC website by midnight. I alerted health professionals through the Radio 1 programme, Morning Ireland, the following morning about SARS and the guidance. Since that time, the guidance has been regularly updated as the information and knowledge on SARS has evolved. There has been ongoing communication with health care professionals via daily website updates and e-mail cascades, as well as consultation with WHO and other international partners. A helpline for the public was also maintained by public health doctors within NDSC.
SARS is a respiratory illness, which appears to be caused by a new coronavirus, which may result in a severe pneumonia in a small percentage of cases, and death in up to 10% of cases. The diagnosis of SARS is a clinical diagnosis. The symptoms are fever, cough, or breathing difficulty, in a person who either was in contact with another known case of SARS, or who recently travelled from an area affected by SARS, such as Hong Kong or China.
Once a person fulfils the above case definition, he or she is further classified as either a suspect or probable case of SARS. If there is evidence of pneumonia or respiratory distress syndrome on chest x-ray, the person is considered a probable case of SARS. If such findings are not present, the person is considered a suspect case of SARS.
There is, as of yet, no definitive test to confirm SARS. The National Virus Reference Laboratory has been working closely with international colleagues in setting up and establishing the validity of current tests. Further information on laboratory investigation of SARS and the infection control measures to limit the spread of infection has been prepared by Dr. Cunney and is provided in the information pack.
SARS is spread from person to person mainly through droplet infection, which requires close personal contact with an infected person. The incubation period for SARS, that is the time from infection to onset of symptoms is two to seven days, but may be up to ten days.
As of 30 April, 5,663 probable cases of SARS have been reported world-wide in 26 countries, with 372 deaths. The countries and areas most affected are China, Hong Kong, Singapore, Canada and Taiwan.
As of 11 April, reports of 14 cases of SARS had been notified to the NDSC, and Dr. Kiely updated the committee on more recent dates. Six of the 14 notified cases were admitted to hospital. Following further investigation, one case was classified as probable, and all cases are recovering or have recovered. Since 11 April, NDSC staff, at the request of the strike committee, have responded to two further SARS notifications, one from the ERHA and one from Waterford.
There is an urgent need for a structured out-of-hours public health service to manage SARS. The legislation allowing for quarantine and other public health measures needs to be reviewed, including designating suitable facilities for quarantine. There is also a need for a formal review of the requirements for isolation beds to deal with SARS and other emerging infectious diseases. A cascade system for rapid dissemination of advice to health care professionals is required.
There is some encouraging information from Hanoi, Vietnam that it is possible to control SARS, as this country has not had any new cases for more than 20 days now, and is no longer considered an affected area. Similarly in Canada, the magnitude of probable cases has decreased, and more than 20 days have passed since the last community transmission of illness. These successes have been as a result of classic public health interventions, such as early detection, contact tracing and isolation where needed. However, in China, the spread to other provinces, and the large numbers of new cases being reported on a daily basis continues to be a cause for concern.
From Ireland's perspective, SARS remains a potential threat to public health. There is a need for vigilance by all - the public in reporting any symptoms early, health care workers in taking appropriate precautions and public health professionals in maintaining strong surveillance, contact tracing and implementing control measures. The control measures need to be measured, and based on the evidence available.
With regard to the Special Olympic Games, the imminent visit of a WHO representative to Ireland to advise us is a welcome development. Regardless of the final decision on whether to allow competitors from affected areas to attend the Special Olympics, it will be essential to have a strong and active surveillance system for all infectious diseases during the games.
The epidemic of SARS is only months old, and it is entirely too soon to predict its ultimate scope and magnitude. The challenge for us all is to provide clear and consistent information to the public in an evolving situation and where there continues to be uncertainty.
Two issues struck me in Dr. Kiely's presentation. His action commenced around 17 April and Dr. O'Flanagan indicated that her action commenced on 14 April, when she was notified and asked to participate in the teleconference. Will Dr. Kiely outline the conflicting signals that seem to be emanating from the health board, the Minister and himself on what was probable or otherwise?
What interaction was there between Dr. O'Flanagan's centre and the Department of Health and Children during those early stages of notification?
Is the question on the issue of conflicting signals about the difference between the definitions generally, or——
In the dates, first of all. Dr.O'Flanagan indicated that everything commenced for her around the 14th of the month. Dr. Kiely's statement indicated that his involvement commenced on the weekend of 17 March. In the early stages, the criticism was that conflicting signals were coming from health boards, the Minister and Dr. Kiely. When did proper interaction occur between both centres?
Thank you for that clarification. The National Disease Surveillance Centre is the identified national surveillance centre and early response part of our system. Dr. O'Flanagan would have been aware, in the course of the week she identified, of developments regarding SARS. She outlined the number of international contacts she made, the call conferences etc., and that would be the function of the NDSC. Over the weekend, the active involvement of the Department of Health and Children began when Dr. O'Flanagan contacted it. Over that weekend, with the aid of the Department and of Dr. O'Flanagan's staff, the initial development of guidance and public information commenced. There really is not a conflict about when action commenced. The activity did not begin in one place at one time and in another place at another time. It was simply a continuum of activity initiated by the National Disease Surveillance Centre in its capacity as the first point of contact for international surveillance and response. The involvement of the Department in the wider policy and operational issues ensued from that. It is simply that the active involvement of the Department in the development of the response began over the weekend. The information on which that active involvement was based was being generated in the course of the week beginning 12 March. That is probably the explanation. Perhaps Dr. O'Flanagan would like to comment.
Dr. O’Flanagan
On Wednesday, 12 March, when the WHO issued a press release the NDSC received it by e-mail and sent it to all the appropriate authorities, including the Department of Health and Children. At that time the issue related to what mainly seemed to be an outbreak occurring in Hanoi, Vietnam so there was not a huge amount of concern. We transmitted the information in order that people would be aware if cases did occur but it was considered to be unlikely.
On Friday, 14 April, I made contact and had discussions with my counterpart, the deputy CMO in the Department of Health and Children, to discuss the alert issued by the European Union and we both agreed that the NDSC would circulate that alert to the relevant authorities and the directors of public health for cascade on to accident and emergency units and general practitioners. When I received the telephone call on the Saturday, I was in immediate discussion with the deputy CMO and I agreed to review the situation with him after the Sunday morning teleconference, which I did. We then agreed to assemble in the NDSC on the Sunday afternoon. There was good communication between the two centres.
What about the conflicting signals regarding the health board, the Minister and, finally, Dr. Kiely on the way to the conference in Killarney about the "probable" classification?
Thank you, Chairman, for giving me the opportunity to discuss this. With your permission, I will not discuss the detail of an individual person, which has been thrashed around the media inappropriately over the past week. Can I explain the context in which what the Chairman describes as conflicting signals might arise? I established at the start of the presentation that there is provision in the World Health Organisation definitions for what they call reclassification of cases. It states that SARS is a diagnosis of exclusion so that the status of a reported case may change over time. The WHO outlines at least half a dozen examples of where things can change over time.
Does this happen? Does the definition of a case shift as between a suspect case and a probable case, between a probable case and a suspect case or between a suspect case and not being a case at all? It does and this has happened on a number of occasions. It happened last week in a particular case. I draw the committee's attention to a statement from the Department, the ERHA and the NDSC on 20 March, which states:
The Department, the NDSC and the ERHA have today [ Thursday, 20 March] announced that both patients under investigation in Dublin for SARS have been denotified to the World Health Organisation as suspect cases.
In other words, on the basis of preliminary investigation and analysis, they may have been suspect cases, were notified as such and were subsequently denotified. The process of arriving at a conclusion about somebody and then changing it is something for which provision is made and of which there is experience already in the country. The declassification of the case of 20 March was put up on our website. It is in the public domain and was not the subject of any comment.
Does this happen in other countries? I draw the committee's attention to Dr. Ryan of the WHO, who has been regularly in the media over the last while. When he was asked about this case on "Morning Ireland" recently he replied, "This is not an exact science. We go through this process on a number of cases with a number of countries". In the context of a situation where the World Health Organisation itself makes provision in its definitions for reclassification of cases, in which the WHO engages in this reclassification procedure with a number of countries and in which there is already evidence that declassification has previously occurred in this country there is no conflict in saying, at one stage of a process, that a person is X and, at another stage of the process, that he is Y. This is perfectly acceptable, standard and routine. It should not cause any concern and has not previously done so.
If there were, for example, several hundred probable or suspected cases of SARS in Ireland, would we be ready to deal with that? Would the necessary medical services be available to do so? Doubt has been expressed as to whether they would. If such a situation were to occur, would there be implications for other people who are ill at the moment? Would services be withdrawn in any area to cater for it?
While I do not want to mention the strike of the public health doctors or the issues around it, there is the question of the effect of the absence of the public health doctors on the situation. I received a telephone call last Friday from a GP who contacted the Mid-Western Health Board and asked for clinical advice on how to detect or diagnose SARS. He was put on to a non-clinical official who said he would contact the IMO with any request for information. The Minister's response was that the public health doctors were on strike. The Minister has made an issue of this but I am not making any comment on the rights or wrongs of the dispute.
Concern is also being expressed to me about the accident and emergency situation in hospitals. Are these services ready or what response has been advised to a suspected case of SARS presenting at accident and emergency? Some doctors have said that a patient suspected of having SARS would sit waiting in accident and emergency the same as anybody else. Has that position changed since Friday? The members of the delegation say it is a diagnosis by exclusion yet the first statement we heard was that the tests were negative. How could that statement have been made if it is a diagnosis by exclusion given that the initial tests on one of the people were negative?
This is a very important discussion. The general view of the public looking at the response of the Government to the SARS outbreak would be that it has been a bit of a shambles. We have seen in the past few days the kind of approach that should have been adopted weeks ago. There has been no clear strategy. Information has been extremely patchy. Health workers have not been protected or guided in the way they should have been. There has been a debacle regarding the patient who presented in St. Vincent's Hospital and was sent back to a busy hostel, even though she had symptoms and came from an infected area in China. The conflicting messages that came from the hospital and the health board were only part of a situation that could have been extremely serious. At one point, the patient left the hostel and went out into the city.
People should be honest about how serious that incident was and the implications in terms of the risk to public health inherent in what happened and what did not happen. The people who transported the patient were not protected. This raises many questions and it would be better if there were a clear admission that the system failure in that case was extremely grave. We are fortunate indeed that to date, no major effects have resulted from it. The public health doctors' strike has shown that the people who can provide best reassurance to the public have a very valuable contribution to make. That they were not in place has meant that the strategy that should have been up and running simply was not set up. That does not in any way negate the responsibility of the Minister and his senior officials.
I would like to concentrate my question on the issue of travel control. I represent County Wicklow and live in Bray. We want to welcome the Chinese delegation for the Special Olympics and obviously we want to ensure that the public health of our town is fully protected. At the moment, the lack of controls at airports and other points of entry is such that people are travelling from infected areas into this country and there are no adequate controls, if any, regarding their movements. We probably have a better chance of ensuring public health measures regarding the Special Olympics delegations because they are identifiable and can be put into quarantine or whatever is necessary.
The travel that occurs at the moment is not being dealt with in a way that is acceptable or represents best practice. I hope that people will not take offence if I compare this to the outbreak of foot and mouth disease. At that time, had the transport of hundreds of sheep from Cumbria been permitted there would have been uproar, yet we do not have proper controls in airports to ensure that people coming into this country from infected areas are interviewed, tracked and advised. If they present SARS symptoms, we do not have a system in place that would protect people in our A&E departments. Do we have a system in place whereby doctors will go to such people? Do we know who they are or where they are? I am concerned about travel controls because, without them, we will find ourselves in a position where we really will not know whether we are on top of this until something terrible happens. The Department's record has been lamentable. I welcome the fact that it is getting its act together now but we should have had reassurances before this and we still require reassurances, particularly on travel controls. The other area of concern relates to health workers. Given what happened in Toronto among people working on the front-line who should have been protected, we must learn how to protect the people working in our health service.
Regarding ethics in public office and as representatives of the IMO are present, I would like to declare that I am a paid-up member of the IMO. Enormous publicity has surrounded SARS. It is a new disease that has obviously struck great fear in the general public and I welcome the opportunity here this morning to hear the presentations on the actual position. I have three or four brief questions. How are we dealing with the threat posed by SARS compared with how it is being dealt with by other European Union member states, for example, the United Kingdom? I note in the presentation by Dr. O'Flanagan that there are six probable cases in the UK. How have we performed regarding the European communicable diseases regulations?
I am somewhat disturbed to note that there were 11 probable cases prior to 19 April and two cases since then. Enormous publicity has surrounded those two cases and, as a doctor, I find it somewhat repugnant that any patient could be in any way identified in the public media as potentially suffering from a disease. Why is the expert group, set up by the Minister under the chairmanship of Dr. O'Flanagan, now under the chairmanship of the chief medical officer? Does this have anything to do with the current industrial relations difficulties?
I shall take the last question first. Dr. O'Flanagan was initially appointed as chairperson of the expert group. The industrial relations dispute intervened and I have had to take over as chairperson.
Does the industrial relations dispute extend to the point that Dr. O'Flanagan would have to give up chairmanship of such a very important group?
Dr. O’Flanagan
Yes, that was the position. We do not intend to discuss the rights or wrongs of the dispute but public health doctors feel that the availability of an out-of-hours service is crucial. Many of the problems in the handling of some of these cases came about because there are no public health doctors out-of-hours. For us, that meant that we could not properly handle SARS or any other infectious disease. This is a key point and that is why public health doctors have gone to the extraordinary length of taking industrial action.
Does it strike Dr. O'Flanagan as director, looking at what other directors did in past public disputes, that she can stand back and have a derogation from the dispute while staying at the centre of what is a most important post?
Dr. Fenton Howell
I can answer that. May I just clarify one point? I understood that I was here to make a presentation but that may not be the case. I had prepared a submission to be circulated but it is all right if that is not necessary.
The doctor may state his case. We will not go into the dispute now.
Dr. Howell
No, I will avoid it. I was invited to make a statement to the committee but I will expunge issues relating directly to the dispute. That is fair. I understand that and members have the material in front of them.
My colleague, Dr. Joe Barry, our president, who is away due to personal family circumstances sends his apologies. I will not go into the medical aspects of SARS because the issue has been dealt with more than adequately. I need to deal with the issues surrounding the IMO and to put some matters into perspective.
The committee will appreciate that several elements are required in managing infectious diseases. In the first instance, an individual patient who suffers from the disease needs to be managed appropriately. That is usually done by the general practitioner or hospital consultant and happens as a matter of course. In some situations a wider community based approach is necessary in order to identify other individuals who may suffer from the same infectious disease and to prevent the spread of that disease. This occurs with SARS. In that instance, public health doctors of all grades play a major role in the management and control of infectious diseases. We have been likened to medical detectives in that we track down the index case, identify contacts and put in place medical or environmental controls, as is relevant in the case of SARS, to help prevent the further spread of disease.
It is necessary to adopt this dual approach - somebody looking after the individual and somebody looking after the community-based aspect - on a 24 hour a day, seven days a week basis if we are to successfully manage any infectious disease situation. We all know the industrial dispute has hampered the response. We know the arguments are long-standing but we will beat them out elsewhere. We need to ask ourselves, for any infectious disease such as SARS, why we need an out-of-hours service. Is it just a fiddly requirement? It is not, because we all know that infectious diseases such as SARS have no respect for time, do not know about nine to five hours or whether it is Saturday or Sunday.
We have a problem on that account because it gets us into the arguments.
Dr. Howell
I shall step out of the arguments. I take the Chairman's point. Regarding how the cases were managed, it is relevant to say what happened during the industrial dispute in order that we have an understanding on the record. There was a work to rule and the Department requested the assistance of Dr. O'Flanagan over the St. Patrick's Day bank holiday weekend. The minute contact was made, Dr. O'Flanagan and her colleagues were immediately made available to assist, as has been acknowledged. We have put in place a helpline for all of the health boards to make contact with us for all infectious diseases, including SARS. We have received 80 calls to that to date, some of which have related to SARS. When we received SARS-related calls, we responded immediately. We took people off the picket line immediately in Dublin to deal with the St. Vincent's case and they worked 20 hours non-stop to deal with it. We dispatched people from the NDSC to Waterford to deal with the case there.
We feel we have responded and managed the situation in a wholly professional manner. We have reviewed what our public health doctors did in those cases. We feel we would do exactly the same again, given the information we had at that point in time. What other people said or did is a matter for them. Our doctors did the right thing at the right time with the information they had. It is important to make that point.
I assure the committee that our helpline is still in place and if anybody telephones from the health boards about a SARS case, he or she will be responded to appropriately, professionally and quickly. That is what will happen. We can discuss SARS in isolation but it exists in a context. There are 40 different notifiable statutory diseases with which we have to deal. SARS is only one of them. We need to have safe systems in place in order to deal with that.
There are safe systems in Northern Ireland and the UK. Public health doctors work around the clock in those countries and have requested similar measures here. We need to do that. We need those measures in place or we will not have a safe system. We need to remember also all those other diseases such as meningitis, tuberculosis, leptospirosis, legionnaires' disease, salmonella etc. While we are talking about SARS, they are all occurring in our population. We will respond appropriately throughout.
I will now answer the question as to why Dr. Darina O'Flanagan did not absent herself from the situation? There are several reasons for that. Like practically every other public health doctor in the country, she is a member of the Irish Medical Organisation. We considered those issues quite carefully. There is a quid pro quo in all of this. We are not going to start talking about the delay but if people expect the directors of an organisation to give up their constitutional right to go on strike, that should mean that the grievances should be dealt with speedily and quickly. We all know the history. That just has not happened. Had Dr. O'Flanagan gone to work in the National Disease Surveillance Centre on her own, with everybody else on the picket line, it would have been an appalling fig leaf, which would have conveyed the message that we had no troops on the ground to deal with the issues. We actually need all those people. Think about it. We sent six people out to deal with the case in Dublin and they worked 20 hours around the clock. Dr. O'Flanagan could not do that on her own.
I know we are not entering into debate about the industrial relations dispute here but in response to some of the points that have just been made by Dr. Howell, I would like to make a couple of brief points. First, I acknowledge in a positive way the contribution that has been made, through the IMO strike committee, to managing difficulties during the period of the dispute. That is beyond dispute and we acknowledge that. The Minister has done so on a number of occasions.
Members of the committee have asked if we are hampered as a community in our response to SARS and other infectious diseases by the absence of public health doctors. The unequivocal response to that is that we are. That acknowledges the contribution made by public health doctors. I suggest there is a further question. Would our response have been assisted and supported by the fig leaf, as Dr. Howell described it, of people in senior positions being in place? I would say it would.
There is no longer a dispute about the need for out-of-hours cover. That is the very reason it is incumbent on all of us to put our best foot forward in the process that is just starting in the industrial relations context to resolve the outstanding issues. That is the spirit in which those discussions will shortly commence. On the out-of-hours question, we need to get into a process to sort out those arrangements, not whether they will be in place but what will be their nature and what will be the system of remuneration.
Can we deal with the very serious questions raised about accident and emergency front line people and travel arrangements?
Thank you, Chairman. I will take some of those questions and my colleagues will answer others. A question was asked about the European Union. Comparisons are obviously difficult and odious in these situations. There are 32 cases in seven European countries but that is not really a measure of anything, it is simply a reflection of the fact that people have travelled from affected areas and have arrived in these countries. There has not been transmission in Ireland.
On how we interact with Europe, we are members of the European Union communicable diseases network. We continually attend meetings either in person or by way of call conferences. We are guided seriously and significantly in our approach to SARS and indeed to the whole range of other infectious diseases which Dr. Howell mentioned by the guidelines and guidance that emanates from those discussions. In terms of an approach to this particular problem, all of the European Union countries are guided by the WHO guidelines and the communicable diseases network guidelines. There may be some occasional deviation from these as both the WHO and the European Union agree can and should happen to take account of individual countries' requirements. In terms of the European Union we are consistent with and up to date with the most appropriate and effective actions being determined at European Union level both by the committee and by the European Commission.
Members asked about travel controls, screening and other issues such as health workers. The guidance that issued from the NDSC initially and Dr. O'Flanagan, covers the whole range of activities within the health system which relate to SARS and its management and control and infection control in particular. This up to date guidance is effective and has been disseminated right through the system, particularly into the hospitals where isolation and case management are most relevant. If there are problems with it, the expert group continues to state and I reiterate that if there are problems with the guidelines in terms of understanding and suggestions for their update, we are always ready to receive submissions. Over the period of the last month the expert committee has received many inquiries and suggestions from individual practitioners who have encountered problems in their own areas. They sought advice, which has been given. In the context of a broad framework within which all these guidances are being disseminated, there is provision for dealing with individual cases or institutional cases. If a group of practitioners feels that the guidance is not up to date or relevant, we are more than happy to listen to them and take their concerns on board.
Some GPs received masks from health boards around the country. I do not know if they all did but quite a number of them did. Nurses who are working in GP surgeries did not receive them and neither did other health professionals. Why is that so?
Mr. Michael Lyons
I can answer that question by saying that every GP in the country has been given a supply of masks. They have been given an average number of between two to five masks which are reusable and have a fairly long shelf life. The masks can be used by other persons working in the surgery.
Perhaps the Department can ensure they are given five masks that are clearly identified as either GP or nurse's masks.
Mr. Lyons
While we are on the subject of the protective masks, the ERHA is co-ordinating the procurement of masks on behalf of the health boards and the acute hospitals. At present we have ample stocks in place to cover both primary care and the acute hospitals system. We are ordering further stocks as a contingency plan and they can be distributed quite easily on request or in the event of an emergency. We normally hold about six months' stock but we are holding 18 months' stock at present. We have a threefold stock on hand in the event of any difficulties arising.
We have some questions about travel.
Travel is obviously a difficult issue. In arriving at travel advisories and travel advice, we are particularly guided by the WHO and our European Union partners. The issue of screening at receiving airports has received a great deal of consideration and has been the subject of much discussion and analysis. The consensus between all the advisory organisations is that screening is not effective; there is no screening test. The facilities and resources available to deal with this problem are the public health measures Dr. O'Flanagan and I mentioned earlier. They are accurate, well-informed public information; early ascertainment of cases; proper treatment; good follow-up and rational travel advice. That is the advice given by all the international organisations, from WHO and the European Union. Screening is not effective.
In the European Union, the spread of the disease has been managed in the context of applying those basic public health principles. The issue of screening has been addressed and deemed not to be effective, as one of the documents states.
A question was asked about the individual case but I cannot go into detail on that case. Lessons need to be learned from any failures regarding the treatment of any patient. If lessons are to be learned from this, I am confident that they will be learned and applied. If there were deficiencies and difficulties in the manner that case was handled, they should not happen again.
The issue of what a negative test result signifies was raised. The WHO defines this disease by reference to travel history, clinical symptoms and X-ray. There is no reference to or utilisation of blood tests whatsoever. The issue of blood tests in a SARS case revolves around doing blood tests for a range of other things to exclude SARS. A negative SARS test does not mean the patient does not have SARS. The test is non-specific at the moment. It is not sufficiently sensitive and therefore is not utilised in the case definition. The case definition is travel history, clinical symptoms and chest X-ray. Blood tests play no part in the diagnosis. They may do so when a sensitive and specific test is developed. Currently, there is no room for blood tests in the definition of SARS cases.
On the issue of A&E services I am not aware of individual situations as described by the Deputy. All I can say is that guidelines as to how SARS cases should be presented to A&E via GPs or through an A&E department itself, have been developed and disseminated within the system. A number of situations in which patients have presented with symptoms suggestive of SARS have been dealt with adequately and effectively. Many of those patients are doing very well and have recovered. If individual A&E departments are having particular problems or difficulties either in understanding or applying the guidelines they wish to bring to our attention, we would be more than happy to listen to them and, if required, define the guidance in a different way or make it more relevant to them or whatever. We are willing to listen all the time to people's experiences. We are one month into this and there is a huge amount of learning involved. We can learn a great deal from experience.
Mr. Lyons
While I am here as chief executive of the ERHA, I cannot speak on behalf of the ten health boards. In terms of contingency planning, we are working within the guidelines set down by the WHO on isolation and other accommodation facilities required for the management of probable SARS patients in an in-patient setting. As Dr. Kiely said earlier, the requirements in descending order of preference are: negative pressure rooms; single rooms with their own bathroom facilities; and cohort placement of patients in a dedicated area.
There is significant response capacity in the public acute hospital system in terms of the facilities available for the clinical management of SARS. There are in excess of 1,400 single rooms in the acute hospital system of which approximately 1,000 approximately have en suite facilities. The indications are that of this figure of 1,000 single rooms, there are 60 negative pressure rooms, in excess of 80 isolation rooms and approximately 850 other single rooms with en suite facilities. Of this number, 46 negative pressure rooms and over 300 en suite single rooms are in the ERHA area. There is significant capacity in the system that can be sourced immediately if problems of the sort mentioned by Deputy Neville occur.
We are also providing for co-operation between health boards in the event of there not being sufficient capacity in one area. There will be shared arrangements between health boards of the facilities available.
I thank the Chairman for facilitating this opportunity to discuss an issue of huge concern for Ireland and the world. I understand Dr. Kiely was invited, but the Minister has seen fit to send his entire A-team, the members of which are all very welcome. It is a reflection of the fact that the Minister at last recognises the gravity of the threat we face with SARS.
Looking back over the past three weeks, there was a clear failure to engender confidence in the public that somebody was in charge and could manage a major threat of this order. Nobody blamed the Minister, the Department or the public health doctors for the arrival of SARS, legionnaires' disease or any of these things. However, there was an apparent absence of decision-making, bad management, lack of administration and a total lack of communication for which the Minister and the officials advising him stand indicted. In that cauldron of apparent ineptitude, rumour prospered and panic and fear grew in the population. For all that we talk about politics and attribute very grandiose motivations and reasons for politics and governments, the reality is that people elect governments to protect them. In this case there was a perception that nobody was protecting the public, which frightened people.
I am here to participate in a discussion and have waited three weeks for this opportunity. Today it is SARS; it could be something else next week. It is the handling of the matter that is up for discussion here. Although we were extremely lucky on this occasion, I am not convinced we are out of the woods yet. I heard on the radio this morning that in Hong Kong people may be suffering relapses of the disease. The critical issue about SARS is that it is an emerging disease about which we know little. Confidence is important to prevent panic. We needed to have somebody who was seen to be in charge and taking decisions on the public's behalf.
People wonder what would have happened if it had been a more virulent and infectious disease. From this we must learn the importance of our public health doctors and of disease control. I will not go into the rights and wrongs of the dispute. However, I criticise the Department and the Minister for the handling of the dispute, first in allowing it to fester so long and, when it was recognised that talks should occur, people unfamiliar with the issues were sent to the talks. It shows a lack of——
I cannot allow the Deputy to make a Second Stage speech. It is unfair to the other members who wish to ask questions.
I want to ask about the Special Olympics, which is the next issue of critical importance to us. Ireland will be very much in the spotlight. A disease outbreak of any sort would be extremely serious, not only for the indigenous population, but also for the visiting population. The mishandling of a disease outbreak would be catastrophic for the country because the whole world will be looking at us.
People are naturally concerned about others bringing illness into the country and it is understandable that the people of Clonmel decided not to accept people from Hong Kong. This happened in the absence of the sense that somebody was protecting their interest and against a background where they felt nobody was in charge or could guarantee their safety.
The real problem for the Special Olympics is that the participants are vulnerable people. As a result of their condition, many of them have significantly lowered immune systems. They are extremely vulnerable to illness and disease outbreak. I address this question to the public health doctors from the National Disease Surveillance Centre. Given that the strike has lasted three weeks and that there is a major emerging disease about which we still know very little, can we be sure that we have the competence and systems in place to protect both the visitors and the indigenous population if the Special Olympics proceed?
The Department issued a statement on, I believe, Tuesday indicating no information would be given about the race, gender, occupation or location of the patients. I completely understand not giving information about race or gender because that is irrelevant. However, in order to contact and trace others who may have been in contact with a patient, surely a patient's location, if not occupation, should be communicated to the public. Is that the kind of statement public health doctors would have made had they not been on strike or was this made up by the Department? Does the Department still stand over this statement? Does it still think it is sensible not to tell people the location of a suspect SARS patient?
Given what has happened in recent weeks and what we now know about the handling of the cases, if a similar incident were to recur, what would the chief medical officer and the Secretary General do differently to engender confidence in the public that we can cope with disease outbreaks of this nature?
I welcome the opportunity to contribute to this meeting and I thank those who made presentations. I was very interested in Dr. O'Flanagan's presentation, in which she stated:
It is possible to control SARS, as is now being done in Vietnam. This success has resulted from classic public health interventions such as early detection, contact tracing and isolation.
I am concerned that we may be going backwards. In the past, we had outbreaks of TB, polio and diphtheria. Yet, fever hospitals were closed down and infectious diseases were given a low priority. That was part of the run-down of health services in my county, Mayo, and in Cherry Orchard and elsewhere. My point is that those diseases have not gone away. As a GP, I have seen some terrible situations over the years and despite single rooms in general hospitals, there were serious consequences for people with gastroenteritis. More recently, problems have been experienced regarding measles infection but there are no facilities.
Dr. O'Flanagan's second point was that "there is an urgent need for a structured, out-of-hours public health service to manage SARS." That is obvious to anybody. In that regard, what steps has the Department of Health and Children taken to ensure that arrangements are in place to deal with urgent incidents of infectious disease or environmental hazard occurring outside of normal office hours? Second, has that Department been informed of the dangers of the lack of an out-of-hours service and has it responded to that information?
I thank and welcome the delegation. Due to the mixed messages relating to the one probable SARS case we have had, there was a public perception of bungling by the Government. I regret the Minister for Health and Children is not here this morning to answer questions directly. I have a number of direct questions for the delegation and I will take up where Deputy Cowley left off. I found the presentation by Dr. Darina O'Flanagan very interesting. She said that legislation on quarantine and other health measures needs to be reviewed, including the designation of suitable facilities for quarantine. I wish to ask Dr. Kiely if the Department is preparing such legislation, which now seems to be required. Dr. O'Flanagan also said there is need for a formal review of the requirements for isolation beds to deal with SARS and other emerging infectious diseases. What action is the Department taking in that regard?
Mr. Kelly stated very clearly that the dispute is hampering the Department's handling of the situation and I welcome his frank statement. However, Dr. Howell, in his written presentation, made the very blunt point that "there is no safe system in place to deal with SARS." I regard that as quite an indictment and I ask Dr. Kiely to comment directly on that point.
While I am not a medical expert, I know that a virus can change and mutate. Is there a possibility that a much stronger version of SARS could emerge, with the potential to kill more people? I would welcome comments on that. On the Special Olympics and the Clonmel decision to stop athletes from coming to the town, does the delegation agree that decision is regrettable and does not address the SARS issue in a proper manner? If one restricts travel by athletes, one only deals with one section of a population, whereas many other people may come into this country from the affected areas. Finally - and I have asked this question of medical people - why does the virus affect individuals in different ways? In one case, a 46 year old doctor, who discovered the virus, actually died from it. On what basis do some people recover while others die? I am concerned that medical people to whom I have posed that question have not been in a position to answer it.
Dr. O’Flanagan
On the mutation question, it is, indeed, possible that further mutations could occur. Coronavirus is one of those which is known to mutate regularly. Dr. Cunney may wish to expand on this. That is one of the concerns regarding vaccines. As is well known, coronavirus is one of the causes of the common cold, for which we have been unable to come up with a vaccine. Due to the mutation aspect, we will have to continue to monitor the epidemiology on the spread of the virus because it too may change.
It was asked why some people have more serious illness than others. A striking feature of this virus is that young children seem to escape satisfactorily. Throughout the world, it does not seem to have affected young children but is more serious in adults. That is the position for a number of infectious diseases, such as chicken pox and measles. Many of these viral illnesses can be more severe in adults than in children, as is apparent in this particular virus.
I will deal with a number of the questions, starting with the Special Olympics issue. This is a very important issue for us. We have had a number of meetings with the Special Olympics committee and with ambassadors from countries deemed to be affected countries. We need to bear in mind that, of some 161 countries involved in the Special Olympics, only three or four are currently on the WHO list of affected areas. Accordingly, this problem does not apply to 157 of the 161 participating countries.
On the question of our capacity to deal with the Special Olympics, I believe we have the expertise, capacity and resources to do this. We just need to apply them in the right way and at the right time. Without moving into the industrial relations issue, it is crucial that we have the capacity to manage the situation and to structure and organise ourselves accordingly.
My question was really as to whether there is still time to put plans in place. That work would normally have been ongoing over the past several weeks.
Yes, that is correct. Some preparation has been made but, obviously, it has been somewhat impeded by the current situation. However, with goodwill on all sides, I believe we are in a position to make the appropriate arrangements.
On the wisdom of mentioning a location, that is not an easy question. There have been some recent adverse reactions on the identification of particular locations of SARS infection. In the context of creating an environment in which people will come forward for treatment and so on, it would be useful to identify locations. Regarding patients, the more confidential we can be, the better. Over recent months, there has been only one probable case and a small number of suspect cases. By identifying the areas in which such people live, one is, to a large extent, almost identifying the individuals concerned. I believe that would be counter-productive. Apart from indicating that we may have a situation in a particular health board area, I believe it is reasonable, in the interests of confidentiality, to leave it at that.
Deputy Cowley mentioned the broader issue of infectious diseases and whether we thought we had left them behind us. I believe experience over the past 20 years has demonstrated the contrary. There has been the advent of HIV, the issues of variant CJD, antibiotic-resistant tuberculosis and, now, SARS. We cannot be in any way complacent regarding communicable diseases. I know in recent years a number of infectious diseases consultants have been appointed. We have established the NDSC and been very lucky in the calibre of people who run it, and that has made a huge difference. We have trained infectious diseases epidemiologists within our broader system.
There is a recognition that infectious diseases are not a thing of the past but of the present, and that they could be a thing of the future. We must make provision for that and I think we will.
What arrangements has the Department of Health and Children made to deal with incidents of infectious disease or environmental hazard that occur outside of normal hours?
Mr Lyons will deal with that. Deputy Gormley mentioned quarantining. As I mentioned, under the infectious diseases regulations the Minister signed an order on 28 March making this a notifiable disease. There is a section within the infectious diseases regulations which allows diseases to be identified as a "quarantinable" - if that is the word - disease. We are in the process of signing that order, and it will be done shortly.
Is there no need for legislation, as was said by Dr. Darina O'Flanagan?
The infectious diseases regulations are governed by primary legislation, the Health Act 1947.
Does that need to be updated?
I would bow to superior knowledge on that as it is a legal issue.
Dr. Kiely can come back to us on that.
I will. With regard to how the disease affects people in different ways, the committee has not received a direct answer yet and, unfortunately, I cannot give one here. It is the same as a range of other conditions. People react for a variety of reasons to different insults to their bodies. Some survive while others do not. That may be for constitutional or environmental reasons, or otherwise.
What of the facilities required to deal with infectious diseases?
Mr. Lyons
A number of issues arise in regard to notification arrangements for infectious diseases out of hours and the subsequent contact tracing and surveillance arrangements in the absence of the public health doctors, and the question of suitable facilities for dealing with possible cases of infectious disease.
I reiterate what previous speakers have said in that this is an area which highlights the key role of the public health doctors in infectious disease control. While the health boards could be said to be doing their best in regard to notification and contact tracing, we are severely hampered by the current dispute. Health boards have in place arrangements for the notification of infectious diseases to the administrative staff in public health departments during office hours. Out of office hours arrangements have been made, certainly in the ERHA region, to notify such cases to a designated person.
On contact tracing and surveillance, where appropriate, the area health boards in the eastern region are making arrangements for tracing and follow-up, and will continue to endeavour to do so during the current dispute.
With particular reference to SARS in the context of the issue raised about designated facilities such as old fever hospitals etc., the three area health boards in the eastern region have identified facilities in each of the board areas for the observation of contacts of suspect or probable cases of SARS. Those facilities are immediately available.
I welcome both groups and thank them for attending. As SARS is such a new disease, was it necessary to introduce a ministerial order for it to be recognised as a notifiable disease? If so, when did that happen? Deputy Devins asked about the position in the EU. I want to ask whether we are ahead of or behind other EU states, particularly the UK, with regard to our protocols. On the expert group, does Dr. Kiely, as its chairperson, feel that Ireland compares favourably with other expert groups in other jurisdictions?
Earlier this week in the Irish Medical Times, the new president of the IMO said that responsibility for the lack of information given to the public about suspected SARS cases clearly lay with the Department of Health and Children. I have heard Dr. Kiely say that the website is updated at 1 p.m. every day and I have heard Dr. Howell say that if people telephone from health board areas, their questions are answered. Are there two distinct lines of communication? While the Department is in a position to give information to the National Disease Surveillance Centre, is anybody available to take that information?
How many public health specialists are there? I am roughly aware that there may be about 300 public health doctors but how many of those are specialists? Finally, I will ask the question everybody wants answered: does Ireland have a problem with SARS?
The level of information available to the public is still woeful. To hide behind a departmental website just will not do. Somebody has to tell people that SARS is identified by clinical diagnosis and tell them the symptoms. I realise that the Department has a fact sheet available but it must contain words of one syllable. X-ray diagnosis is what confirms whether pneumonia is present, making it a probable case. The misinformation and confusion about negative blood tests was dreadful. People should have been told that blood tests are only to rule out other diseases such as psittacosis and other forms of pneumonia. The public should have been told this weeks ago and needs to be told it now. Referring people to a website simply will not suffice.
The possibility of ten relapse cases in Hong Kong was mentioned. Is this true and, if so, how important is it? The death rate in Toronto is very high despite the city's excellent medical services. Many of those deaths were of younger adults. The authorities in Toronto at one stage suggested that they were dealing with a different coronavirus. Does the Department have more information on that? Naturally, it is very serious if there are already mutations in other locations.
With regard to the Special Olympics, we must be careful to stop looking only at our indigenous population and to remember that a considerable number of those coming in are immune or compromised, those with Down's syndrome in particular. We must be careful to have a system in place to protect these people.
I have one brief question which demands a one word answer. Given that we do not have direct flights or access to high threat areas, on a scale of one to ten, how much of a medical threat is this to Ireland?
I will be as brief as Deputy O'Malley. Given that the disease seems to have come from China, I am concerned that at Dublin Airport there are no bilingual signs requiring people to turn themselves over. The successes have been the result of classic public health interventions such as those in Vietnam and Canada. Despite all the funding and the controls, we seem to be like China in that we did not introduce classic health intervention. We are not up there with Canada and Vietnam, rather we are with China which is a cause for concern. Where are we going from here?
Most of the questions I would have put have already been asked. I congratulate the delegates on their successful efforts of recent days. The information that has been made available is particularly helpful and has started to assuage much of the fear and concern that existed. I would like delegates' views on the need for balance in this debate. The Canadian Government has shown concern in terms of the outlandish statements that it is not safe to travel to Canada. What are the delegates' views on that in terms of Ireland and the necessity for us to have balance in the debate rather than creating fear and hysteria which has a knock-on effect on tourism or other commercial activities?
Does the delegation think there has been much ado about nothing? From the presentations I have heard, we could be dealing with the common cold or a mild chest infection as they present at any surgery any morning. Has the matter been hyped out of all proportion? Have we lost our sense of proportion in this case?
The Chairman was to get back to me with regard to my last question.
There is a general theme of communication to which I want to refer. In a situation such as that of recent weeks, effective communication is one of the main strands in the provision of reliable, timely information to members of the public. Dr. Kiely and Dr. O'Flanagan referred to that earlier. There is a need to provide technical information to professionals who are in a position to use it and for constant updates of that information as time goes on.
Deputy Olivia Mitchell raised a number of questions earlier and while I do not wish to return to them all, it was suggested that there had been "bungling" in terms of perception. As the person accountable within the Department for the effort put into this and other challenges, I stand over the professionalism of those who worked hard in the NDSC, the Department and other parts of the health system since the SARS threat first became known. In response to questions of proportionality, it is important in the handling of any public issue, particularly one of public health, that we establish a sense of proportion and a context within which to adopt measures. There is also a need to communicate those. I am perfectly prepared to accept the charge that we did not fully communicate the extent of what was being done by professional bodies such as the NDSC, the Department and the health boards, even during the dispute by members of the IMO, whose communication was very good. I am not prepared to accept the charge that in any sense the response by the Government to this cross-departmental challenge was bungled or less than what was required.
I did not use the word "bungled". I did not accuse the Department, I said the perception was that in terms of engendering the confidence of the population, the handling of this matter was an unmitigated disaster. The critical issue was that confidence among the population was not engendered by Mr. Kelly or the Minister.
I am defending the professionalism of people who worked on this in the Department.
I did not question anybody's professionalism and I did not say that people had bungled. I said they failed to engender confidence in the Department and the Minister.
Allow Mr. Kelly respond. I will provide Deputy Mitchell with the opportunity to speak afterwards.
The perception that most interests me is the perception of the WHO. We have had constant comment by the relevant WHO expert that the Irish response was proportionate, effective and commensurate with the level of threat we faced. By comparison with our peer countries in Europe, our response was held to be up to standard. That view by a professional arbiter of the Irish response should help to create confidence in the public mind in the measures which have been taken.
I assure Senator Henry that we have not hidden behind a website. From the outset, there have been press notices and, more recently, clear information leaflets have been distributed. This week, bilingual leaflets——
Why did people telephone me at home on Easter Sunday morning to say they could not get information? This is what has been very irritating.
I am quite prepared to admit that a watertight response to a new problem cannot be developed immediately. It has taken us a little time to develop a response in stages. We have done what we needed to do to identify the actions required in line with WHO advice. In the context of proportionality, we do not have a significant SARS problem in Ireland. We are observing the WHO guidelines and are up to par in terms of our performance as it relates to other European Union member states. We should maintain some perspective from a public health point of view as we manage this particular threat.
On a scale of one to ten, what is the level of that threat?
I am surrounded by people who might hazard a guess.
How great a threat to public health is SARS?
Dr. O’Flanagan
It is too early in the evolution of this epidemic to say clearly where it will go. The threat is currently very low. We have seen one probable case.
We do not have a SARS problem in Ireland.
Dr. O’Flanagan
I agree, but that is not to say——
There was one outbreak of foot and mouth disease and a great deal of protection was put in place.
Dr. O’Flanagan
We do not know how the epidemic will evolve in China, which is why we cannot say whether we will be at continued risk. That is the important point. As other colleagues have said, other illnesses in Ireland are of far more concern than SARS. I am far more concerned about legionnaires' disease and TB, for example, which are among the illnesses causing trouble at the moment.
I agree with Dr. O' Flanagan. We do not have a problem at present, but the existence of this outbreak in the most populous country in the world continues to pose concern. We have responded to that concern. We have put in place the mechanisms, the organisation, the advice and so on that we know can actually deal with this because they have dealt with it in other countries. We are operating on the basis of the best international guidelines. While we do not have a problem, we remain vigilant to ensure that a problem does not arise. I am very confident on the basis of the organisation, the structures, the activities and the professionalism of people in the system that this situation will not deteriorate.
A number of other specific questions were directed at me regarding the regulation to make SARS a notifiable disease. The regulation was introduced on foot of a recommendation from the expert group on March 28 which is just over a month ago. It was asked whether other countries did this. Some other countries have provisions. In our nearest neighbouring country, the debate still rages as to whether they should do this and they have not yet done so.
On how our approach compares with other EU countries, I mentioned that we are constantly in touch with our EU counterparts. I am in contact on a bilateral basis with my chief medical officer counterparts. The approach is very much the same. In some areas and in some of the information campaigns we have been ahead of certain countries but in general the approach we have is consistent with the best of what others in the EU are doing.
I am glad I was asked about the expert group because it gives me the opportunity to put on the record that both under Dr. O'Flanagan's chairmanship and, subsequently, under mine, the expert group has performed remarkably well. This is a most difficult evolving situation and the work of the expert group in helping us to understand it and to respond effectively and professionally with up to date guidelines has been absolutely first class. I wish to put on the record my thanks on behalf of the Department to the expert group.
Does Dr. Howell wish to come in?
Dr. Howell
There are currently 45 to 50 specialists in public health medicine in the country. In the past, public health medicine wasable to attract doctors of the calibre of Dr. O'Flanagan, Dr. Kiely, Dr. Devlin and the other officers in the Department of Health and Children to train in public health medicine. Unfortunately, some of our colleagues who trained here have gone abroad because of issues we cannot discuss here.
Strike that from the record.
Dr. Howell
Our problem is that we are having difficulty in recruiting young doctors to replace Dr. Kiely, and Dr. O'Flanagan and probably the likes of me.
Are we getting rid of them?
Dr. Howell
We are older than people might think. As a doctor I wish to respond to some points that were raised. One would almost get the impression that people are asking if we have over-reacted to the SARS situation? Is there a problem or is there not, or should we have all just gone home? We will know the answer if we have a lot of cases. We will know we will not have over-reacted if we have no cases. That is the problem in the business of preventative medicine. No one hears about the successes of having nothing. That is crucial to the matter; success is hidden. We have to respond positively. In the past - and the committee members are aware of this - we have dealt with tribunals because some people for whatever reason may not have thought hepatitis B was a major problem. Those issues become problems. Let us be vigilant now and put systems in place. If, in ten years' time, we do not have any SARS outbreak in Ireland and nobody has died from the disease, then the Irish people will thank us. That is the way we need to look at all infectious diseases.
I am going to wrap it up now. One very brief question, Senator Henry.
What about the situation in Hong Kong and Toronto?
I just want to come in briefly. Deputy Fitzpatrick said it was like the common cold but it is not; there is a 10% death rate. We are between the devil and the deep blue sea as regards infectious diseases and we have been for some time. I am not satisfied with the answer I received. There is no proper out-of-hours service and I did not receive a response to the question of whether the Department of Health and Children has been informed of the dangers of the lack of this service or if there has been a response from it in regard to this matter. Let us face it, we are very exposed. SARS has been there for some time. As a GP, I am aware that something must be done in regard to meningococcal meningitis, measles and gastroenteritis. It is about preventative medicine and prevention is better than cure. It is too late when it has already happened and we have an epidemic.
Can I just say——
Can I ask Dr. O'Flanagan about Toronto afterwards?
The Senator can have a chat with Dr. O'Flanagan afterwards. On behalf of the committee, I thank the witnesses for coming before us today and outlining what are key issues for the country. It has certainly enhanced our understanding of the issue and the nature of the virus and how it should be dealt with nationally. Generally speaking, we are quite pleased with the systems that are now in place. We feel quite confident that we can avoid this virus. The committee exhorts both sides in the dispute to get on with the talking and get back to work.
Members
Hear, hear.
I did not impugn anybody's professionalism.
The joint committee adjourned at 1.27 p.m. sine die.