I welcome Dr. Jim Kiely, chief medical officer, Department of Health and Children; Dr. Darina O'Flanagan, director, Health Protection Surveillance Centre; Mr. Gavin Maguire, Health Service Executive; Mr. Dermot Ryan, Department of Agriculture and Food; Dr. Kevin Kelleher, Health Service Executive, and Mr. Chris Fitzgerald. Before the presentation begins, I remind delegates that while members of the committee have absolute privilege, the same privilege does not apply to witnesses appearing before the committee. I remind members of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the House or an official by name or in such a way as to make him or her identifiable. I ask Dr. Kiely to make the presentation. I understand Dr. O'Flanagan will make a Powerpoint presentation. Given the time constraints, I ask them to limit their presentations to 15 or 20 minutes in total. There will then be a question and answer session.
Avian Influenza: Presentations.
I thank committee members for giving me the opportunity to discuss this important issue. In addition to the persons mentioned by the Vice Chairman, Dr. Sally Gaynor from the Department of Agriculture and Food is also present due to her expertise in this matter.
My apologies to Dr. Gaynor.
I thank our colleagues from the Department of Agriculture and Food for attending this presentation. We have submitted a ten point document to the committee which identifies and clarifies some of the major issues in respect of avian influenza, its relationship with human health and potential relationship with pandemic influenza. With the committee's permission, it could be used as the document of record for our submission. Dr. O'Flanagan can expand on some of the more important points. Given the Vice Chairman's exhortation regarding time, I will hand over to Dr. O'Flanagan to enable her to make her presentation.
Have each member received a copy of the presentation from Dr. Kiely?
I do not have a copy.
A copy will be circulated.
Dr. Darina O’Flanagan
In view of the time constraints, I may pass over some points quickly. However, the details are available to the members in hard copy form.
Dr. O'Flanagan should not feel pressurised.
Dr. O’Flanagan
I wish to discuss some of the issues surrounding human influenza, avian influenza and the potential for a pandemic. Essentially, there are three types of influenza virus. Type A causes us the most problems as it affects all age groups. There are both human and animal reservoirs. Type B causes milder epidemics and primarily affects children and young adults, while type C is so mild that it usually only causes subclinical infection.
Type A influenza is differentiated into subtypes determined by surface proteins. There are two types, namely, haemagglutinin, or H, of which there are 16 subtypes, and neuraminidase, or N, of which nine subtypes have been identified. In the main, humans are only affected by three haemagglutinin types, namely, H1, H2 and H3, as well as two neuraminidase types, namely, N1 and N2. Recently, however, as members have seen, we have encountered problems with some of the avian influenza strains.
It is important to note that influenza is a serious illness. Normally, from year to year, it causes major complications and hospitalisation, particularly in the case of very young children and people over the age of 65 years. As those over the age of 65 years account for more than 90% of the deaths associated with normal influenza, we conduct an annual influenza immunisation campaign. The aim is to have at least 75% of the over-65s immunised against influenza. The effort to encourage people to avail of the vaccine which is free and available from general practitioners represents a major task. While the hospitalisation rate, particularly among very young children, may be increased, it is rare to have death associated with it.
I will outline how we normally manage to survey influenza rates. In conjunction with departments of public health, the National Virus Reference Laboratory and the Irish College of General Practitioners, we operate a sentinel surveillance scheme which covers 43 sentinel general practices, comprising 89 GPs, from which we receive good data. I have a Powerpoint slide which shows the data we possess for the years 2000-01 to 2005-06. The blue line shows the number of patients who came into the practices with influenza-like illnesses. Members can see that the figure peaks every year and that some years are worse than others. The red and yellow bars show whether the incidence for a particular year is predominately type A or type B influenza. In general, type B influenza is milder. If members consider the most recent data for 2005-06, a relatively mild year, Type B influenza has been dominant. Because of the threat of an influenza pandemic, we have improved the scheme by recruiting more general practitioners and extending the scheme to cover the summer season. Although we do not normally experience influenza during the summer, the HSE has recruited more practices to provide us with status reports during the season because there can be a pandemic at any stage.
I will discuss the totality of influenza viruses, including avian influenza. The important point to note is that wild waterfowl are the natural hosts of all influenza viruses. As members may have heard in media reports in recent days, wild waterfowl are the transmitters and carriers of the H5N1 strain and have brought it to many countries. Many species, including humans, can be infected, as can animals such as domestic poultry, cats, seals, cattle and horses.
Currently, we are worried about the highly pathogenic avian influenza caused by H5. While other subtypes can cause highly pathogenic avian influenza, mainly H7, the real concern is with H5N1. We are concerned with the major epizootic — similar to a pandemic among humans — among poultry throughout the world. It started in South-East Asia and, as members are aware, subsequently spread to Russia and eastern Europe. Despite the culling of more than 150 million birds, it has become endemic in parts of South-East Asia.
We know the virus managed to reach parts of Africa, so there are major problems. The next slide illustrates what took place in Turkey in January and February and shows the places where the 12 human cases of avian influenza occurred. Most of these were located in eastern Turkey. The following slide reveals temperatures in the areas affected by avian influenza, where temperatures plummeted around Christmas. It is customary in these areas for families with small backyards plots to bring poultry indoors when temperatures drop down to -30°. This was the reason behind the sudden and dramatic increase in human cases of avian influenza in Turkey in January, particularly among children and young adults.
Even if there was an outbreak of avian influenza in Ireland, the same circumstances, which would put humans at the same level of risk of contracting the disease, would not be replicated. However, everyone is worried about H5N1 reassorting with the human influenza virus, possibly as a result of the next pandemic. Domestic ducks have been shown to excrete large quantities of H5N1 without any signs of illness. This is very difficult to control. The H5N1 virus has become more lethal in the past year. When mice and ferrets are experimentally infected with the virus, it reveals an increase in pathogenicity. The range of animals affected by the virus has expanded and it has been shown to affect tigers and domestic cats. This development is unprecedented and my veterinary colleagues may wish to comment on it.
For the first time, there have been unprecedented numbers of deaths among wild birds and these are associated with H5N1. The next slide shows some of the flyways of migratory birds. Members can see the red flyway which passed down and through Turkey, where a variety of problems have been encountered, and Nigeria. Ireland is, I hope, outside this flyway but there is always an element of risk. Sally Gaynor may be able to comment on this issue with more expertise but there is always the potential for wild birds within the next year to bring this virus to many countries, as they have already done in many countries throughout Europe. It is difficult to control the spread of the virus from wild birds.
It is very rare for humans to become infected but when they do, it can be a very severe and aggressive clinical course, with severe disseminated disease affecting multiple organs and systems. There is a rapid deterioration and a high fatality rate. It has caused deaths in over 50% of people who we know have been infected. Many of these cases have been in healthy children and young adults.
The next slide illustrates the number of cases. Up to 14 February 2006, 169 cases and 91 deaths occurred. No cases have occurred in Vietnam in 2006, which previously experienced considerable problems with the virus and had the highest number of cases and deaths. However, it appears to have managed to reduce human exposure to the virus. It is possible to manage to reduce the potential for human exposure to avian influenza if the general public is educated about it.
The national disease surveillance unit has sent guidance to accident and emergency departments and GPs about assessment of people who return from affected countries with acute respiratory illness. Travel advice is that people need not avoid travelling to countries affected by the virus but if they do, they should avoid contact with wild birds and ensure that poultry products are well cooked before consumption. If people become ill after returning from affected countries, they should inform their GPs and tell them about the countries they visited.
Poultry workers in Ireland have been offered the normal human influenza vaccine. This will not protect them from H5N1 but it will reduce the potential for simultaneous infection with both human and avian influenza if avian influenza does enter Ireland. If there is an outbreak of avian influenza in Ireland in birds, there are systems in place to ensure that those responsible for culling birds will be given prophylactic drugs such as Tamiflu to protect them.
Three influenza pandemics took place in the last century, the most severe of which was the Spanish influenza pandemic in 1918. The next pandemics, which took place in 1957 and 1968, involved Asian influenza and Hong Kong influenza. These were less severe and approximately 1 million people died in both. These pandemics can arise when the avian and human influenza viruses mix or when the avian influenza virus adapts slowly to become more infectious to humans. People will be looking out for any signs of human-to-human transmission in countries where humans have been infected with avian influenza. Human-to-human transmission of the virus has been very rare to date. There has been a minority of small family clusters of infection. It is difficult to disentangle whether members of these families were exposed to the poultry at the same time or whether there was human-to-human transmission of the virus. There is no clear evidence of human-to-human transmission.
Based on our knowledge of past pandemics, we know that they are unpredictable and do not always occur in winter. There are considerable variations in mortality, severity and illness. There can be a rapid surge in the number of cases over a brief period, which is often measured in weeks, and cases often tend to occur in waves. For example, there were three waves during the 1918 pandemic. The severity of those waves will be influenced by the availability and effectiveness of anti-viral drugs and vaccines. In respect of the emergence of a pandemic, we have two of the three requirements indicated by the World Health Organisation. The first is that we have a new virus subtype and the second is that it can replicate in humans and cause serious illness. However, we do not yet have efficient human-to-human transmission.
There are different levels of World Health Organisation alerts and we are currently at alert level three. Evidence of increased human-to-human transmission would lead to a move to alert level four. The EU also has alert levels, which depend on whether there are human cases of avian influenza or widespread activity in EU countries.
What is the expected level of severity of an outbreak of avian influenza? It could be as mild as the 1957 or 1968 pandemics or it could be as bad as the 1918 pandemic. We have estimates of excess deaths of up to 5,000 and excess hospitalisations of 14,000 but it could be more severe. Nobody will know for sure until the pandemic begins. Based on previous experience, it is possible to produce models of what can be expected. Our model demonstrates how we would expect a pandemic to progress in Ireland, the number of weeks it would last, the number of hospitalisations and the number of deaths per week. The line displayed on this graph, which is called the reproductive number, or RO, is the average number of people that one person will infect. If one person infects 1.8 people, it will be very severe but if that person, on average, only infects 1.2 people, it will be less severe.
The extent to which the virus is infectious or transmissible will influence the progression of the pandemic in Ireland. This has implications for the number of the anti-viral drugs we must stock. Such drugs only need to cover 12% of the population to have maximum impact if the pandemic is very mild and if the average person only infects 1.2 people. If the average person is much more infectious, anti-viral drugs need to cover approximately 25% or up to 28% of the population. These are the kind of figures that influence what the Department of Health and Children has done in respect of ordering anti-viral drugs. We are well on our way to having enough anti-viral drugs to cover 25% or more of our population. In addition to the Tamiflu drug, the Department of Health and Children is making arrangements to bring in another drug, zanamivir. We would be covered by the number of anti-virals we have.
If there is a pandemic, it will have a significant impact on businesses, schools and services. A total of 25% of the workforce will take at least five to eight working days off over a three month period. The impact will not just be on the health services but right throughout the system, including the Garda, Army, essential services and food production, distribution and transport. These aspects must be considered when planning for a pandemic.
A national pandemic flu expert group under the aegis of the Department of Health and Children and chaired by Professor Bill Hall is producing expert guidance. Mr. Gavin Maguire, the HSE's assistant national director of emergency planning, is leading a national implementation group. A number of committees have been formed under his direction and are working hard to implement the plans. A generic public health emergency plan with a specific section on the flu contingency plan has been released by the Department. The key components of the plan have been outlined but I will not go through them all now.
In public health interventions it is important to try to reduce the average number of people infected by others. Simple as it sounds, one of the most effective ways to do so is to ensure people frequently wash their hands during a pandemic, cover their noses and mouths if they have a respiratory infection and, if they are sick, stay at home. One of our main problems with flu in general is that people struggle in to work and infect everyone there. We will tell people that, if they are sick — especially at a time of a flu pandemic — they should stay at home. Other possible interventions would include restrictions on travel and mass public gatherings, school closures, isolation of cases at home and the possible voluntary quarantine of contacts with known cases.
The Government has stockpiled enough anti-viral drugs to treat 25% of the population or more. A total of 600,000 doses are already in stock and the balance is due before the end of 2006. The normal routine vaccine will not provide protection. Once the onset of a pandemic occurs, it will take approximately four to six months until a vaccine is available. The first wave may have come and gone before the vaccine is available but it would hopefully be available for the second and third waves if they occur. The aim would be to immunise the entire population and it is probable that a two-dose schedule would be needed.
If we get the vaccine, it will be given to priority groups such as providers of essential services, health care workers with patient contacts and those who are at high risk, including pregnant women, very young children, over 65 year olds and people with chronic heart disease and diabetes for example. Work is under way to get a vaccine matched against the current circulating strain of H5N1. Hopefully, the vaccine will be available before the summer. It will be held in reserve and may be used to prime health care workers against infection. The difficulty is that, if the virus subsequently drifts, the vaccine will be no good.
Pandemic influenza poses a serious threat and may have a substantial impact. H5N1 is a cause of concern but it is possible that it will not cause the next pandemic. It is important to differentiate an outbreak of avian influenza in that, if there is an outbreak of it here, it will not signal the start of the next pandemic. It is possible that there may be no human cases. Preparedness planning is crucial and we must ensure the strengthening of the public health infrastructure.
I thank Dr. O'Flanagan. Many members wish to ask questions but I will comment before they begin. None of us can underestimate the threat posed by avian flu. A graph of the migratory pattern of wild birds that was shown seems to suggest they travel from eastern Europe to Africa. How can the stories in today's newspapers of birds infected as far west as Germany be explained?
What is the percentage chance of mutation? If the virus mutates, we will be in an incredibly difficult situation. This relates to the Department's current travel advice. Some people are concerned that, if mutation is occurring now, we will not know about it for some time. However, the advice is that people should go about their normal business to countries where there is active infection. They may bring back some of that infection if mutation has occurred. We have no way of knowing. The infection will be detected retrospectively rather than in advance. Is it true to say that anti-virals will have no real effect against the active disease and that we need vaccines but cannot have them until we know for which virus they are to be produced?
We will bank some of the questions. As Deputy O'Connor has another engagement he will ask his questions first.
It is important that we are having this meeting. As I know I am among experts in this room, I will be careful. People will listen very closely to Dr. O'Flanagan's statement. I have often referred to the importance of Oireachtas hearings and, as this hearing is particularly important, I hope the media will co-operate in getting the message across. Like others, I do not want to panic anyone.
The Vice Chairman has asked a number of relevant questions that I will not repeat. This morning, the media made clear the potential threat. Points have been made about the spread of avian flu through migrating birds and other means. We are no longer speaking about countries we only know from maps. We all go on holidays, to football matches and so on to places where avian flu has occurred.
A number of my constituents who knew about today's meeting compared the current reaction to that during the foot and mouth disease outbreak. This may be unfair. I mean it in no flippant way when I say that perhaps the former Minister for Agriculture and Food, Deputy Walsh, should be here. We took the outbreak very seriously, understood the threat to public health and so on. The public will want us to represent this point.
A public awareness campaign is needed. A few people will watch this meeting on "Oireachtas Report" tonight, although is it not Deputy Rabbitte who states that only drunks, insomniacs and politicians stay up that late? However, this is vital business, as was our earlier discussion on cancer. I hope the Department will understand the need for a definitive public awareness campaign without frightening people. Although The Irish Times frightened people this morning it made people aware of the issue, which is what people want. People ask me what precautions they should take. Perhaps we should do simple things such as washing our hands without waiting for a news broadcast to tell us to do so. I compliment the Vice Chairman, Dr. O’Flanagan and Dr. Kiely on the information, which we should build on in a positive way.
I refer to the figures in the delegation's presentation. The expected scale severity of the outbreak is between 1,000 and 5,000 deaths in Ireland while the United Kingdom expects a minimum of 50,000 deaths. The maximum expected excess hospitalisation figure for Ireland is 14,000. For every person that dies, three will be hospitalised. Perhaps this figure is too low because in cases of serious acquired infections such as MRSA or the winter vomiting bug, the ratio between hospitalisation and death is higher than three to one. Staff in hospitals remain at home in the case of an outbreak but elderly people are hospitalised for quite some time.
We are far from an outbreak of avian influenza and we would not be capable of implementing the measures used to contain the foot and mouth outbreak as people would not accept burning bodies.
Are we ready for an outbreak? The public health and acute hospital services could not cope with the excess work the outbreak would entail. We must allow for between 8% and 10% of health care staff, including general practitioners, public health nurses and hospital staff, being sick. If there were an outbreak of avian influenza tomorrow, does Dr. Kiely think the health system could cope? Vaccinations and anti-viral treatments have a limited impact.
Senator Browne
We have deferred discussion on the avian influenza crisis for some time but this presentation has focused our minds. Has the Department learned lessons from the iodine tablet episode, which did not reflect positively on the country? Has the distribution of face masks been considered? Dr. Twomey alluded to how plans may not correspond to reality when the virus arrives. The viral strain could mutate and the anti-viral treatments we have may not be able to cope with this.
Some 300 people are lying on trolleys in our hospitals, which are at full capacity at present. If a pandemic occurred, how would we accommodate these patients in hospitals? To where would current patients be transferred? Would all non-emergency operations be cancelled?
France operates a policy of filling a maximum of 85% of bed capacity in hospitals, yet it could not cope when it had a heatwave some years ago. Ireland uses 100% bed capacity in hospitals so we would require tents or temporary prefabs. Closing schools has a major effect on parents engaged in work elsewhere. Will the Department advise schools to close or remain open where possible?
It is time to hold a public information campaign, including television advertisements and a website, to provide the public with the information it needs. How will people know they have contracted avian influenza as opposed to ordinary influenza which we all get from time to time? Most people may not be aware of the symptoms of avian influenza. This applies especially where people are travelling all over the world every week.
We will not allow Senator Browne enter the country if he contracts avian influenza.
There are a number of threads running through the questions but perhaps each questioner would prefer a question to be answered individually. Concerning the Vice Chairman's question on migratory patterns and the apparent deviations from the norm, I invite the officials from the Department of Agriculture and Food to reply.
Dr. Sally Gaynor
I am not an ornithologist but the Department is in contact with colleagues in the national parks and wildlife service and Birdwatch Ireland. While these migratory routes are general patterns, local factors also affect movement, particularly weather conditions. A big freeze in eastern Europe has pushed these birds further west and south.
Does this increase the chances of the birds coming to Ireland?
Dr. Gaynor
As the disease advances, the threat increases through migratory birds, movement of people and vehicles. The disease has been found in swans, particularly mute swans. We understand the mute swan population in Ireland resides here all year round and is not migratory.
The Chairman asked about the chance of a mutation occurring. I cannot provide a figure for this.
Dr. O’Flanagan
I agree. The more humans infected, the greater the likelihood of simultaneous infection by a human virus and an influenza virus. This is the more immediate risk. The more humans infected, the greater the potential for gradual adaption. While we cannot provide exact figures, the threat increases as there are more avian influenza outbreaks. As avian influenza outbreaks occur, we must reduce human exposure as much as possible. In the case of a country with avian outbreaks, the public awareness campaign is crucial to educate parents of young children that they cannot go near poultry.
Two other questions referred to current travel advice and the effectiveness of anti-viral treatments. The current travel advice we offer is based on intelligence from the World Health Organisation on the situation in Asia. It believes the most practical advice is to avoid poultry farms or markets. We continually monitor the WHO's statements on this. In the event of any change occurring in its intelligence, and the advice based on that intelligence, we will certainly respond to it.
The other question related to the effectiveness of anti-virals.
Dr. O’Flanagan
The anti-virals have a good effect if they are administered early enough. The key is that they must be given within 48 hours of the onset of illness. The tragedy in some of the recent Turkish cases was that a number of the children were sick for a week before they were eventually hospitalised. At that stage, it was late to intervene. It is crucial to administer the anti-virals early.
In a human case, the current anti-virals, if given early enough, can be effective.
Dr. O’Flanagan
Yes. They would reduce the rate of complication by approximately 50%. That is why we are stockpiling. We know that we may not have a vaccine for the first wave. The use of anti-virals will be one of the key measures during that wave. This is why developed countries are stockpiling anti-virals.
Senator Browne
How long will the anti-virals remain in date?
Dr. O’Flanagan
Approximately five years.
It was stated that ducks could be infected without showing any signs of illness. Is it possible that 48 hours might pass without a human showing any sign of illness?
Dr. O’Flanagan
A great deal of surveillance work is being done. The only way to check is to take blood samples and see whether antibodies show that somebody has been infected. Many studies have been carried out on the family members of those infected with H5N1, or health care workers who have come in contact with it, to see whether any asymptomatic infections have occurred. The rates are extremely low. There have been none among the recent cases in Vietnam. While it can occur, so far it seems to be extremely rare. The position as regards transmissibility across the species barrier is quite marked at present. It is difficult for the disease to spread. People are closely monitoring it and that is the key. In all countries where cases have occurred, the WHO is checking all of the people around the victims to see whether anybody has been ill and checking blood tests to see whether anyone has been infected.
If a person is infected, are their symptoms obvious immediately or does it take three or four days before they become obvious?
Dr. O’Flanagan
It can start with a fever, similar to that which occurs with a flu-type illness. The only people who have become infected are those who have handled sick, dying or dead birds. If one has not had that exposure, one is not likely to be at risk. The question asked was whether a person will get it from someone with a respiratory illness. There is no evidence that clusters occur or of an increase in transmission. We do not have to worry about contact with other people. Only those with direct exposure to sick or dying birds are at risk. The majority of those who contracted the illness are those defeathering, butchering or slaughtering infected birds.
I thank the Vice Chairman. I also thank Deputy O'Connor for his kind words which are appreciated.
Deputy O'Connor asked about public concern regarding the fact that migratory patterns have altered to the point where Germany has become involved. People are concerned about whether they should travel to Germany. The Deputy also mentioned football matches and perhaps he had in mind the major event in the summer. That will be a major issue, not only regarding Germany but also for people asking advice as to where they can travel on their summer holidays.
As I mentioned in response to the Vice Chairman's question on travel advice, we will closely monitor what happens in individual countries throughout Europe. We will take advice from the World Health Organisation and, particularly with regard to Europe, the European Centre for Disease Control, which was established last year and which is extremely active in this area. We will make available to the public that advice on an ongoing basis, particularly coming into the summer when hundreds of thousands of people travel.
An issue raised by Deputy O'Connor and Senator Browne was a public awareness campaign. This is becoming an important issue as the ante has been raised with the arrival of bird flu in European countries. A balance must be struck in regard to the notion of being too proactive, unnecessarily raising people's concerns and providing a level of sensible, practical and rational information. The HSE website is available and contains much of the required information.
We took it upon ourselves some months ago to hold a briefing for spokespersons from the Dáil and Seanad on this matter. We also briefed the media to explain the background. Dr. O'Flanagan made a presentation similar to that she delivered earlier. There may be a case for widening that information loop and for giving more proactive public information. We will take that decision soon, with a view to striking a balance between unnecessarily raising concerns and giving people appropriate, rational and sensible information on which they can base their decisions.
Deputy Twomey raised the issue of figures and projections. In respect of a phenomenon that simply has not happened, one can only speculate, draw up models and make projections, while taking into account certain assumptions. Dr.O'Flanagan produced the figures so perhaps she might like to expand on them. This is an extremely imprecise science. Predicting infection, mortality and admission rates is extremely imprecise and speculative. It is, therefore, liable to be misconstrued or misinterpreted.
Dr. O’Flanagan
The figures are based on UK estimates of what might be the possible numbers of deaths and hospitalisations. They are similar to the figures produced by the WHO. I am sure Deputy Twomey is correct that it is possible it could be far worse. I am sure members have seen the tension between the United Nations, which produced figures towards the severe end of the scale, and the WHO, which produced figures towards the less severe end. The question is whether the system will cope during a pandemic. We will be hard pressed. Perhaps Mr. Gavin Maguire would like to comment on that. The simple truth is that any figure could be given because we will not know how bad matters will become until the pandemic occurs.
I wish to focus on our acute hospital sector, which has approximately 12,000 beds. At any one time, approximately 70% of those beds are occupied by medical patients. All we have to play around with are the approximately 3,000 surgical beds. Assuming that there will always be traumas which must be dealt with and surgical procedures that must be carried out and that a number of six-bed wards would be closed down during a significant pandemic, how would the delegation deal with hospitalising 1,000 patients who turned up at the same time?
Mr. Gavin Maguire
We can argue the precise figures based on the modelling. It is important to understand that we will not build extra hospitals for an anticipated pandemic. The definition of emergency planning, including for a pandemic, is reorganising the resources that one has to try and manage the situation. The focus of emergency planning in the HSE is diverting resources, both staff and bed capacity, to deal with the accident or, in this case, pandemic. Within the acute system, that entails cancellation and postponement of all non-emergency procedures. The figures involve a guessing game. There is clearly a point in time at which capacity is stretched to breaking point. That obtains not only in the acute system and throughout the health services but in every sector of Government, including, transport systems, energy production, water supply and food distribution. We are conscious that at the peak of the first wave or shortly afterwards, absenteeism will become a serious problem in all sectors. Our contingency plans include the need to cope with that problem throughout the health sector. I do not have a simple answer for the Deputy to that except to say we are planning to create capacity in each element of the health sector. Our general plan for coping with an influenza pandemic, should one arise, includes spreading the load throughout the health system to utilise all available resources.
Will it not have to be treated as an infectious disease, with the implication that patients cannot be treated in ordinary hospitals? Are plans in place to take over hotels, gymnasiums or other spaces? It would be sensible to put such plans into operation.
Dr. Kevin Kelleher
The primary objective of the plan is to look after as many people as possible at home in order that they are not on the streets and infecting others. We are investigating ways to reduce the numbers of people presenting to hospital and to keep them at home, which helps to isolate them. We are not contemplating the use of sports halls, except where special facilities will be needed for the homeless or for people with social problems.
We are also investigating how to bring the capacities of non-acute hospitals, such as orthopaedic single speciality centres, into the system. The primary concern will be to treat people at home wherever possible and our resources will predominantly push in that direction. It is hoped that the vast majority — in excess of 95% — of people with flu will be given anti-virals and medical support while remaining at home. We are exploring how to get the community side right because that will have a major impact on hospital capacity.
Will the small percentage who stay in hospitals be treated as patients with infectious diseases and will they be barrier nursed?
Dr. Kelleher
The first few cases will be isolated in single rooms in hospitals, but as numbers increase over time, people will be cohorted and treated in entire wards. We are also looking at plans for dealing with people who will need to be ventilated. It is estimated that we can rapidly create extra capacity in wards during these phases by cancelling elective surgery. This has been done in the case of other emergencies.
According to Dr. O'Flanagan's figures, we will probably have a degree of warning because the virus will progress elsewhere in the world before arriving here. Even if it starts in Ireland, it will build up slowly over two or three weeks before the big hit. During that time, we can try to create capacity by minimising elective work and by keeping people out of hospitals.
The problem is that once the big hit arrives, many people will descend on accident and emergency units. Mr. Tom Clonan, who carried out an analysis recently on the coping abilities of our accident and emergency units, estimated that real problems would arise within 20 minutes. How well can the units cope and will people be refused admission to them?
Dr. Kelleher
Our aim is to conduct a major communications campaign in order that people understand that their first point of contact should be a telephone helpline, which they can ring to learn where they should go. They will then be diverted for treatment either to a general practitioner or to a flu clinic. We will be advising people against presenting at accident and emergency departments and that the only people who should go to hospitals will be referred there by doctors and admitted directly. We recognise the issues raised by the Deputy and are trying to avoid them by putting a system in place whereby people are diverted away from accident and emergency departments. We are currently looking into the details of the content and method of transmission of the communication campaign because the front end elements are important in terms of keeping as many people as possible away from the hospital system.
In answer to the questions raised by Deputy Twomey and Senator Browne on capacity and Senator Browne's further questions on school closures and other issues, we will have to wait until the situation arises and observe the epidemiology of how the disease presents to make the most effective public health interventions. If, as is likely, schools are closed, Deputy Twomey raised the question of who will take care of the children when they are sent home. Will they be taken care of by parents who work in the health services or in Dáil Éireann? Such decisions have significant collateral consequences and wide public service and delivery ramifications. None of these matters will be easy to address. They will have to be based on the best evidence available.
Dr. Kiely did not list members of Government as part of the priority group.
That was a given.
I assumed they would be included. In addition, the Dáil would have to suspend and, perhaps, elections be postponed. This is a huge imponderable because, while I understand the surveillance unit is speculating in the dark, I would hate to think that we will only get our act together when a flu pandemic hits. At present, I do not see the vigilance at ports and airports, which obtained for foot and mouth disease. Will the matter become serious only when a pandemic breaks out? In other words, is the unit making a distinction between a flu pandemic and avian flu? We need to understand whether a significant difference exists in terms of the approach because I believe the message is that it may not become a pandemic. On the other hand, the literature I studied suggests that is inevitable. Will the delegates agree that a flu pandemic is inevitable at some stage?
Some 80 to 90 deaths were reported in Asia and 12 in Turkey. How accurate are those figures? I find it strange that Vietnam, which previously had these problems, now reports it has had no deaths. Is this a case of denial or must they be forced to admit to deaths? If it becomes wide knowledge that they have these problems, it will cause other problems for those countries.
What are the signs and symptoms of avian flu? We know the early signs and symptoms of meningitis and have early detection. What is the incubation period between contact and developing symptoms? I am concerned about the stockpile of vaccinations. The 600,000 doses would cater for approximately 300,000 people because one needs an initial dose and then a booster.
Dr. O’Flanagan
We are talking about 600,000 anti-viral treatment courses.
Other countries have established the right to develop and supply their own drugs if Roche cannot supply enough. Do we have similar plans? In my constituency of Cavan-Monaghan there is a high incidence of poultry farming. It is the poultry capital of the country. Are people close to poultry farms at greater risk? Has there been an uptake of the flu vaccine there? Do we import poultry from any of the countries that have reported the disease and are we cancelling those imports? What steps are we taking to ensure we do not import poultry from these countries? Could the witnesses comment on Taiwan which is not allowed into the World Health Organisation to avail of the knowledge on avian flu.
I do not want to stray into the Department of Agriculture and Food's brief where responsibility for dealing with bird flu rests until it becomes a pandemic. If this happens, what is our level of preparation and has the system been tested? Any previous emergency in which the system would have been tested would not have exceeded 300 cases. What preparations have been done? I have not met a general practitioner or public health nurse who has participated in a discussion on how to deal with a pandemic and the criteria and protocols. I am aware that the former South Eastern Health Board bought a decontamination van but we have never had any discussion on how it would work, for example, if 10% of the GPs or public health nurses were sick. What level of system testing has been done to indicate the problems that could occur?
Deputy Gormley talked about the inevitability of this. All the evidence and intelligence on this issue indicates it is a question of "when" rather than "if" a pandemic will occur. The question is when and what will cause it. It is not inevitable that the bird flu will cause it. Although it is the most likely candidate because of its prevalence in the areas where it occurs and the fact that it can be transmitted to humans, there is no certainty that if and when a pandemic comes it will be the H5N1 virus. The only certainty is that there will be a pandemic some time.
The only intelligence we have on the validity, accuracy and sustainability of figure from other countries, for example, Vietnam, is that the WHO and the international public health organisations, including the veterinary public health people, have been involved closely over recent years in such countries. They have helped these countries implement improved and enhanced surveillance systems and continue to help. We do not know if these figures are reliable and valid but we must depend on the figures as validated to the greatest extent possible by the WHO. These are the only figures we have on which to base our assumptions and it would be invidious of me to suggest that countries were not being upfront. I would not want to do that.
The Department has entered into agreements to stockpile many hundreds of thousands of doses of antivirals, enough to treat 25% to 26% of the population in the event of an emergency. This figure is generally recognised around Europe as being sustainable and credible. Our colleagues from the Department of Agriculture and Food might have an answer to the question about poultry imports.
Have we a backup plan to make our own drug in the event of supplies from Roche being inadequate?
Dr. O’Flanagan
No. The manufacture of the drug, Tamiflu, is a difficult technical process and there is no way we could do that ourselves. We are making arrangements to get back-up supplies of an alternative drug called Relenza or Zanamivir. The main reason the Department took that decision was because of reports of cases of resistance to Tamiflu.
Many reports have stated it is not as effective as assumed. How true are those?
Dr. O’Flanagan
There have not been many but there has been a number of isolated reports of resistance, especially among people treated with it prophylactically who then became ill. The treatment dosage is double that for prophylaxis. If a person develops symptoms it is important they go on the larger treatment dose. Given the isolated incidents, we are seeking additional supplies of an alternative drug.
Is Relenza more reliable?
Dr. O’Flanagan
As it must be inhaled, it is not suitable for young children or for the very elderly. Widespread resistance to Tamiflu is not inevitable. Although recent viral isolates from Turkey have shown no resistance, it is possible that there will be pressure. The more people receive Tamiflu, the more likely it is that resistance will emerge.
Dr. Gaynor
There is a ban in place on imports of live poultry, other birds and poultry products from any affected countries with the exception of heat-treated products. Therefore, one can import cooked poultry meat from countries authorised to send meat to the EU. That does not include all countries, but we can import cooked poultry meat from Thailand.
Does Ms Gaynor think that is good advice or should it be changed?
Dr. Gaynor
That is good advice because temperatures greater than 71 degrees Celsius will kill the virus.
Deputy Connolly asked about Taiwan and its role in the public health response. That he asked the question suggests he is aware of the broader one of Taiwan's inclusion in the WHO. It comes up every year at the World Health Assembly and is a political issue.
If there is a potential pandemic such issues should be swept aside. A country with a population of 23 million should be included in the equation.
I appreciate that point.
What is the uptake of the vaccine in Cavan-Monaghan?
Dr. Kelleher
We have offered vaccines via general practitioners and, where possible, directly, to people working in all the main poultry industry centres around the country. The initial uptake when we offered them before Christmas was not high, which is a classic example of what happens when people do not regard the risk as high. In the past week to ten days requests for vaccines have increased substantially and we have supplied the routine flu vaccine to make sure, as Dr. O'Flanagan said, we do not get mixed up in the event of an outbreak. It will not, however, protect people against avian flu. We have some 30,000 doses left in the country which is more than adequate for what is envisaged at present. We have also arranged a special weekend clinic for the poultry industry in Monaghan, which is being advertised to local firms.
Dr. O’Flanagan
It is interesting the UK does not offer vaccines yet. They will not start vaccinating poultry workers until they get a poultry outbreak.
Mr. Dermot Ryan
Given the concentration of the poultry industry in places like Cavan and Monaghan it is now a statutory requirement that all poultry flock owners register with the Department of Agriculture and Food and there has been a good response to this. We have compiled information and advice in a booklet which we have now posted to every flock owner in the country, containing much that is useful on biosecurity, travel and how employers should deal with people who come on to their farms. As that advice is taken it will be of great assistance in preventing the spread of the disease to the domestic population were we to have an outbreak of avian flu in wild birds.
Dr. Kelleher
It is important to dispel the notion that the health services are not preparing for a flu pandemic. We have done much work to prepare the system for such an eventuality. The Department produced its first plan for a flu pandemic back in 2002. We are in the process of updating the content of that plan and, under the chairmanship of Mr. Gavin Maguire, we are considering how the health services should act. That is being done first at a national level, after which we will consider in more detail the systems around the country.
Although preparations are under way, when it happens we will be hard pressed and probably will not be able to cope, because of the scale of what is predicted. We have a much greater armoury with which to combat it than we had in 1919 but the scale would still overwhelm us. We recognise that and are preparing our system to deal with it as well as possible. We will take on board everything members have said. We must launch a major publicity campaign to ensure people understand the nature of the problem. If we do so too soon, however, people will forget. Therefore, we must proceed carefully but the issues of communication and the support we get are important for us.
Dr. Kelleher talked about preparations within the health services. Mr. Fitzgerald will speak about the broader public and Government policy issues.
It is important to emphasise the point raised by Dr. Kelleher. There is a high level of preparedness and it is constantly under review. We are working very closely with the HSE, with colleagues in the Department of Agriculture and Food and internationally with the WHO, ECDC, the Commission and other member states. Nationally, we have concentrated on interfacing very quickly with the education sector, the defence forces, the gardaí and with industry. To that end we have established a high level interdepartmental group which will meet in the next week or so when all of these issues will be surfaced. One of the challenges will be for departments to think quickly and actively about how the sectors with which they interface are preparing. In the agriculture and health sectors we are highly prepared but we need to prompt people in financial services, in food supply, in transport, the defence forces and in the education sector to begin their own plans. They will need to be bolted onto the matrix we are developing.
Dr. Kelleher
The system has been already involved in a number of exercises to test how prepared we are. We have been involved in one such exercise with European colleagues and in a number at desktop level in the HSE. We undertook some exercises last summer and will undertake more this year as we get more detailed information. We carried out desktop exercises with the agricultural sector in Cavan and Monaghan which yielded very important information about how the system can react and what is required.
We have close relations with our colleagues in the North and have had a series of meetings with people from the health services there on how we will interact in the event of an outbreak.
Dr. O’Flanagan
There was a question on the incubation period and how avian flu can be distinguished from influenza. The incubation period for avian flu is, on average, two to four days but can be up to a week. The main presenting symptoms have been fever, cough, aches and pains and a sore throat. Some children have presented with bleeding from nose and gums, breathlessness and diarrhoea. There have been only approximately 160 cases worldwide, of which two presented with severe brain failure or encephalitis. The initial symptoms of avian flu will be similar to the symptoms of ordinary human influenza. The main indicator will be whether a person has been in contact with sick or dead birds.
People who are relatively healthy will survive, as if it were ordinary flu. Only the most vulnerable will be badly affected.
Dr. O’Flanagan
That is not necessarily true. Most of the deaths from avian flu so far have been of young and healthy people. In this country most deaths occur in the elderly who had some predisposing illness such as chronic heart disease but avian flu has heretofore occurred in either healthy children or young adults.
Dr. Kelleher
That was the same in 1919.
Do we know why that is?
Dr. O’Flanagan
No. It is one of the questions on which the European Centre for Disease Control has set up scientific panels. They will look at why there has been predilection so far for young and healthy adults and children.
The witness has mentioned tests in the system. I have a question to which I will not require an immediate answer. Where has the test system been activated as opposed to the desktop exercises which have been discussed? The accident and emergency consultant in St. James' Hospital at one stage activated the national emergency plan. Where this has been activated for an emergency or perceived emergency, how successful was it and could it be related to what may happen with regard to this issue? As I am sure this will require a detailed answer, perhaps the witnesses could supply a written answer.
I thank the witnesses for a very comprehensive presentation. The joint committee has clearly indicated its concern over the threat posed. If any message is to go out, it is that the public must be kept informed. I hope we will not have to see the witnesses before the joint committee again, but I fear we may.
On behalf of my group, I thank the Vice-Chairman and the members of the joint committee for the courtesy extended to us today. We are grateful for the questions asked, as they have produced a number of issues for us which we need to think through. I thank our colleagues in the Department of Agriculture and Food. I reassure the joint committee that we are keeping close and continuing contact with the Department on the issue. We will provide any further information required.
Senator Browne
May I ask for ComReg to be brought before the joint committee?
We will do that.
The joint committee adjourned at 12.30 p.m until 9.30 a.m. on Thursday, 2 March 2006.