Written evidence submitted by Department of Health and Social Care (EMD0052)

Written Evidence to the Science and Technology Committee Inquiry: “How Prepared is the UK for the Next Pandemic?”

Introduction

1.      This written evidence has been compiled by the Department for Health and Social Care (DHSC) and represents evidence from the department, NHS England (NHSE) and the UK Health Security Agency (UKHSA).

2.      We work closely with Cabinet Office (CO), Department for Environment, Food, and Rural Affairs (DEFRA) and other government departments who may also provide separate evidence to this inquiry.

3.      DHSC is the lead government department and owner for the National Security Risk Assessment (NSRA) risks pertaining to the management of emerging infectious diseases (EID) and the preparedness for, response to, and recovery from pandemics. DHSC works closely with its executive agencies, arms’-length bodies, other government departments and the devolved nations to collectively prevent, prepare, and respond to pandemics. UKHSA is responsible for the management of EIDs and implementing relevant pandemic preparedness measures including but not limited to surveillance and countermeasures.

4.      Pandemic preparedness is a cross-cutting issue; this evidence statement focuses on preparedness in the health and care sectors.

5.      In the UK, healthcare is primarily a devolved matter. Therefore, the detail within this statement should be considered as applying to England only unless specified otherwise.

How the Government is applying lessons from the COVID-19 pandemic

6.      The department expects the COVID-19 public inquiry will provide the definitive narrative on lessons learned from the COVID-19 pandemic.[1] We are and will continue to respond to the independent COVID-19 Inquiry. We will provide the Committee with a further COVID-19 lessons learned update in due course. The remainder of this response is specific to questions posed by the Science and Technology Committee and should therefore not be considered as the comprehensive and exhaustive account of the response to, or learnings from, COVID-19.

7.      We would invite the committee to consider the Technical Report on the COVID-19 Pandemic in the UK published on 1 December 2022/23.[2] This report is written for a specific audience: future UK Chief Medical Officers (CMOs), Government Chief Scientific Advisers (GCSAs), National Medical Directors and UK public health leaders facing a new pandemic or major epidemic in the UK. It may be of interest to others, and it has been made public for any wider audiences who wish to read it, but it is in places inevitably technical given this specific audience. It is not an attempt to describe policy choices or formation, or to analyse operational delivery; in some places operational elements are described but this is for context rather than analysis.

8.      The Technical Report covers the following topics: understanding the pathogen, disparities, research, situational awareness analysis and assessment, modelling, testing, contact tracing and isolation, non-pharmaceutical interventions (NPIs) including in education settings, care homes, pharmaceutical interventions, therapeutics and vaccines, improvements in care of COVID-19 and communications.

9.      The Government has established the United Kingdom Health Security Agency (UKHSA) which has brought together staff and capabilities of NHS Test and Trace, the health protection elements of Public Health England, the Joint Biosecurity Centre, Vaccines Taskforce functions, and the Managed Quarantine Service to strengthen health protection capabilities across the UK. UKHSA is our permanent standing capacity to prepare for, prevent and respond to threats to health and its priorities are set out in the remit letter to their Chief Executive published on 12 August 2022.[3] UKHSA is also providing written statements to the Public COVID-19 Inquiry.

10.  Lessons are being continually learned in relation to the COVID-19 pandemic and we would invite the committee to consider the Government’s Response to the Health and Social Care Committee and Science and Technology Committee Joint Report: Coronavirus: Lessons Learned to Date.[4]

A capabilities-based approach to pandemic preparedness

11.  No one can predict the characteristics of future novel pathogens or pandemics. Experts are clear however, that it is a case of when, and not if, a future pandemic will occur. Infectious diseases can spread through five main routes of transmission: respiratory (including droplet/aerosol), vector-borne (mosquitoes, ticks, sandflies etc.), contact (touch), oral (food/water), sexual/blood (including mother to child transmission). While further work is required, major elements or changes to the departments and UKHSAs pre-COVID-19 approach are moving from COVID-19 response and pandemic influenza preparedness to one that covers these five main routes of transmission. UKHSA has publicly outlined the current infectious diseases threats through the dominant routes of transmission and has highlighted preparedness work within the organisation.[5]

12.  The approach taken to the assessment of the pandemic risk in the 2022 National Security Risk Assessment reflects a broader range of pathogens, and ensures that it includes diseases spread through the five main routes of transmission. This approach provides emergency planners with the assumptions required to prepare to flexibly respond up to and including a disease-agnostic reasonable worst-case scenario.

13.  In line with our updated risk assessment for pandemics, the department has adjusted its pandemic preparedness governance and assurance process to reflect the focus on all pathogens with pandemic potential. Planning and assurance is managed through an updated Pandemic Preparedness Portfolio (PPP). The revised portfolio development has included consideration of lessons learned from the COVID-19 pandemic and the work required to ensure that COVID-19 capabilities are prepared for future use in a pandemic emergency scenario. 

14.  UKHSA also established the Vaccine Development and Evaluation Centre (VDEC) at the end of 2022, building on the legacy from the pandemic, which will undertake a pathogen prioritisation exercise across the five main transmission routes.[6] Led by VDEC, the Medical Entomology team, JCVI, the Genomics programme and the All-Hazards Intelligence team

15.  The Government’s objective is to ensure we hold a range of well-tested pandemic and EID response capabilities that can address all routes of transmission. These capabilities allow us to flexibly respond to future outbreaks, protect the health of the UK population, and contribute to minimising the wider societal disruption that pandemics and infectious diseases can cause.

16.  Non-exhaustive examples of the UK Government’s pandemic and response capabilities include:

17.  Surveillance, which enables early identification of potential outbreaks alongside identification of infected individuals and disease characteristics. UKHSA has strengthened surveillance including by building on investments made during the pandemic. In the context of an increased risk of new vector-borne diseases in the UK, UKHSA are working to strengthen vector surveillance and all five routes of disease transmission.

18.  UKHSA monitors and assesses global public health events and epidemiological intelligence and horizon scans for EID events daily using government, open-source data, and partners around the world through genome sequencing, bioinformatic assessment, characterisation of variants, risk assessment and immunological testing of detected variants of concern (VOCs). Other forms of surveillance UKHSA undertakes across various outbreaks (in the UK and internationally) include environmental surveillance, syndromic, virological, and serological surveillance. UKHSA has worked directly to support development of the WHO Berlin Hub and is invited to join future leadership of the new International Pathogen Surveillance Network.

19.  UKHSA also has standing diagnostic assays for known pathogens with outbreak potential in the UK that allow a rapidly scalable response. An example of this in operation is Mpox, where diagnostic capacity was ramped up within UKHSA and support for NHS testing enabled timely diagnosis of infected individuals.

20.  UKHSA is establishing scalable diagnostic processes to effectively accommodate a significant outbreak and that can be implemented for a new pathogen.

21.  Laboratory capacity and testing were critical elements of the work to mitigate the spread of COVID-19. UKHSA (and PHE and NHS Test and Trace before it) supported the rapid development and approval of new COVID-19 testing technologies, including validation of lateral-flow test devices and rapid point of care testing. VDEC provides a focal point for laboratory evaluation of vaccines from COVID-19 to Ebola, as well as development of priority evaluation of candidate products for new and emerging infections.

22.  Technology and data are crucial to inform a pandemic response. NHSX (now part of NHSE)[7] undertook significant work on the technology and data that underpinned the COVID-19 vaccination programme and developed systems and capabilities including text-messaging systems to contact those self-isolating at home and test kit home delivery services. UKHSA, including Test and Trace, has also been able to capitalise on short term investment enabling the modernisation of COVID related aspects of the data infrastructure. UKHSA is continuing to build on the initial transformation and is seeking to strengthen mobility and access to data relating to other infectious diseases and hazards.

23.  Vaccines were central to the COVID-19 response and £405 million has been invested to secure and scale up the UK’s vaccine manufacturing capabilities. This continues to ensure a robust response to COVID-19 and prepare for potential future health emergencies. This work includes £10.65 million of additional funding to support the launch of the RNA Vaccine Centre of Excellence, which will support the development, scale-up and manufacture of new RNA therapies and vaccines.[8]

24.  Additionally, the UK has agreed a 10-year-partnership with Moderna, who will invest in mRNA research and development in the UK. Moderna will build a state-of-the-art vaccine manufacturing facility capable of producing up to 250 million vaccines a year, with the potential to target a range of illnesses.[9] UKHSA will work with Moderna and other potential on-shored companies to ensure early vaccine development, supporting the G7 mission to get from variant to vaccine in 100 days and greater UK manufacturing capacity.

25.  Th G7-led 100 Days Mission (100DM) is a global public-private effort to harness scientific innovation to have safe and effective diagnostics, therapeutics, and vaccines (DTV) ready to be deployed within the first 100 days of a future pandemic threat being identified and be ready to do so equitably by 2026. UKHSA now provides the scientifically supported secretariat team to drive forward UK activities contributing to achieving this mission.

26.  In addition to the 100DM, the department supports world-leading research through the National Institute of Health and Care Research (NIHR). Since 2014, NIHR has funded Health Protection Research Units (HPRUs) as partnerships between universities and UKHSA across the whole of the health protection field. These act as centres of excellence in multidisciplinary health protection research in England[10].

27.  A clinical countermeasures programme provides a core capability to respond to potential diseases. DHSC and UKHSA maintain a centralised stockpile of relevant clinical and non-clinical products stored on a Just-In-Case basis and a contract for the provision of a pandemic specific influenza vaccine at the time of a pandemic. These products include personal protective equipment (PPE), hygiene consumables, and therapeutics, such as antivirals and antibiotics. We also have several storage and distribution contracts to ensure that the right product can be delivered to the right place in the right quantity when needed. This is complimented by scalable operational capabilities such as the National Pandemic Flu Service for symptomatic patients who need to access influenza antivirals and ImmForm for the NHS to order products more generally.[11]

28.  We continue to take every opportunity to engage with our international counterparts, through the G7, G20 and Global Health Security Initiative, with the WHO and with the EU as set out in the EU/UK Trade and Cooperation Agreement. International engagement enables access to further surveillance functions through the Global Health Security Initiative Early Access and Reporting (GHSI EARS) and European Centre for Disease Control (ECDC) EpiPulse.

29.  The UK engages with a range of international partners and biosecurity initiatives. DHSC leads the Government’s relationship with the WHO, the Global Health Security Initiative, and the Coalition for Epidemic Preparedness Innovations while working closely with the Foreign, Commonwealth and Development Office (FCDO).

30.  UKHSA participates in global initiatives such as the International Pathogen Surveillance Network and deploys its international genomic sequencing capability through the New Variant Assessment Platform.

31.  Infectious disease response capabilities are regularly tested and exercised to test preparedness. UKHSA maintains a Training and Exercising Team within its Emergency Preparedness, Resilience and Response Directorate (EPRR).

The causes of zoonotic disease emergence and ‘spillover events’

32.  Responsibility for leading on animal diseases resides with the Animal and Plant Health Agency (APHA), an executive agency of Defra. APHA responsibilities include:[12]

32.1.       identifying and controlling endemic and exotic diseases and pests in animals, plants and bees, and surveillance of new and emerging pests and diseases.

32.2.       scientific research in areas such as bacterial, viral, prion and parasitic diseases and vaccines, and food safety; and to act as an international reference laboratory for many farm animal diseases.

33.  When new infectious diseases emerge, particularly from the animal-to-human interface, they are detected if they cause significant human disease.

34.  UKHSA identifies many (35) zoonotic diseases as being endemic to the UK, including Lyme Disease and Hepatitis E. COVID-19 was a new infectious disease that emerged from the animal-to-human interface.

35.  There is currently an unprecedented global outbreak of avian influenza in birds and associated increases in levels of avian influenza circulating in England. The dominant subtype currently circulating in avian species across England is highly pathogenic avian influenza (HPAI) A(H5N1). The public health risk is that the virus could move to infect humans, either directly from birds or through other animal species, and for human-to-human transmission to develop. In February 2022, the WHO recommended that member countries enhance preparedness activities for avian influenza.

36.  On 30 January 2023, UKHSA updated its technical risk assessment[13] for avian influenza and assessed the outbreak as remaining at risk level 3.The current level of risk is unprecedented. UKHSA will continue to closely monitor this risk and inform the key healthcare delivery partners, and government officials should the situation change.

37.  To date, no sustained human-human transmission of H5N1 has been confirmed, and only limited non-sustained spread has been reported in healthcare-associated or familial settings outside the UK, where there was also possible common exposure.

38.  UKHSA is working with the APHA to identify where people may have been exposed to avian influenza to ensure timely identification of possible human infection and appropriate follow-up. UKHSA is conducting activities at pace such as asymptomatic human surveillance studies, wider surveillance (i.e., supporting APHA’s genomic analysis of animal samples), and hosted a tabletop exercise in January 2023 with NHSE and four nation participation.

39.  The Department coordinates preparedness activities in the event of an escalating outbreak, this includes vaccines, antivirals, PPE, diagnostics, and surveillance.

40.  UKHSA provides secretariat support to JCVI and works closely with the Committee to provide evidence-based advice on the safety and effectiveness of vaccines, data on disease incidence, vaccine coverage, and vaccine safety.

UK preparedness for an emerging disease outbreak with pandemic potential

41.  In addition to the response capabilities detailed, UK preparedness is based upon the ready availability of high-quality scientific advice and expertise and well tested incident response structures. Specialist emerging infectious disease response measures, cross-government coordination and a wider focus on biological security are all part of UK preparedness measures.

Scientific advice and expertise

42.  The health system benefits from expertise from a variety of sources such as Chief Medical Officer (CMO), Deputy Chief Medical Officer (DCMO), UKHSA, NHSE and Medicines and Healthcare products Regulation Authority (MHRA).

43.  Departmental expert advisory groups support health planning and response across all four nations, unless otherwise specified. These include (but are not limited to):

43.1.       The New and Emerging Respiratory Virus Threats Advisory Group (NERVTAG) – NERVTAG is the primary expert advisory committee advising DHSC and the UK government on new and emerging respiratory viral pathogens.[14]

43.2.       The Advisory Committee on Dangerous Pathogens (ACDP) – ACDP’s role is to provide scientific advice on the risks of exposure to various pathogens.

43.3.       The Human Animal Infections and Risk Surveillance (HAIRS) Group – HAIRS is a multi-agency, cross-government horizon scanning and risk assessment group, to identify, and risk assess emerging and potentially zoonotic infections that may pose a risk to public health.[15]

43.4.       The UK Zoonoses, Animal Diseases and Infections (UKZADI) Group – UKZADI works to promote activity to better understanding of zoonoses and the risks to public health across government and the UK. Where necessary, UKZADI seeks risk assessment advice from relevant expert advisory bodies with an interest in the field of zoonotic diseases and animal diseases and infections.[16]

43.5.       The Scientific Pandemic Infections Group on Modelling (SPI-M) – SPI-M’s purpose is to provide expert advice on scientific matters to DHSC and the UK Government on scientific matters relating to the UK’s response to a pandemic, based on infectious disease analysis, modelling, and epidemiology. The group may also advise on EID threats as required.[17]

43.6.       Scientific Pandemic Insights Group on Behaviours (SPI-B) – SPI-B provides independent, expert behavioural science advice to SAGE during a pandemic. This advice helps ensure adherence to interventions recommended by medical or epidemiological experts.[18]

43.7.       Joint Committee on Vaccination and Immunisation (JCVI) – JCVI advises on immunisation, making recommendations concerning vaccination schedules and safety. It has a statutory role in England and Wales, and health departments in Scotland and Northern Ireland may choose to accept its advice.

43.8.       Scientific Advisory Group on Emergencies (SAGE) – SAGE brings together scientific and technical experts to ensure co-ordinated and consistent scientific advice to underpin the central government response to an emergency. SAGE can advise the Devolved Governments. Decisions on activating a SAGE would be taken by the Cabinet Office in consultation with the Government Office for Science and the Lead Government Department of said emergency.[19]

Emergency response structures - DHSC

44.  The Secretary of State of Health and Social Care is designated as a Category 1 responder under the Civil Contingencies Act 2004 (CCA). The Secretary of State discharges these duties through policy and emergency preparedness teams in the Department and through the Department’s executive agencies and arms-length bodies. UKHSA and NHSE are also Category 1 responders under the CCA.

45.  DHSC maintains a dedicated Emergency Preparedness Resilience and Response function. The function leads on planning and responding to all incidents where DHSC has the cross-Government lead, including pandemics and EIDs. The Directorate also coordinates the health and social care sectors’ response to incidents where other government departments have the lead, for example, weather-related events such as flooding, and malicious attacks.

46.  Pandemic scale risks have cross-cutting impacts on society and, should an incident require escalation to manage impacts beyond the health sector, COBR Unit in the Cabinet Office will be engaged. This may trigger a convening of the Scientific Advisory Group for Emergencies (SAGE).

Emergency response structures - UKHSA

47.  UKHSA also holds an Emergency Preparedness, Resilience and Response function (EPPR) which leads preparedness for, and resilience to, all incidents, including pandemics and infectious diseases.

48.  UKHSA established a Centre for Pandemic Preparedness (CPP) in June 2021 following the 2021 G7 health leaders’ summit. It aims to ensure the UK’s future pandemic response is faster, more effective, and more efficient to minimise any negative impacts of health threats to the UK. The CPP works by:

48.1.      Coordinating and collating the evidence base and data to support efficient, targeted pandemic preparation and response.

48.2.      Supporting development and coordination of a network of expertise across government, academia, and the private sector to provide high quality scientific evidence enabling the government to identify, assess and mitigate the impact of future pandemics.

48.3.      Ensuring that lessons learned from COVID-19 are reflected in the future approach to health security, and that the UK has access to the necessary infrastructure, expertise, and capability to respond to pandemics.

49.  UKHSA also maintains critical national infrastructure and specialist capabilities required to respond to emerging and high consequence infectious diseases, such as high containment laboratories and specialist diagnostic equipment.

50.  UKHSA’s National Incident Response Plan (NIRP) establishes how UKHSA will respond and recover from any significant public health or business continuity incident and has been an active document since UKHSA’s formation. It sets out the approach across the spectrum of health security threats and hazards. It describes the mechanism for leading an incident, decision-making processes, and response governance. The NIRP undergoes regular review and updates in response to lessons learned and changing structures and processes within UKHSA.

Emergency response structures - NHSE

51.  NHSE leads and oversees the NHS[20]. It is accountable to the Secretary of State and holds local commissioning organisations (Integrated Care Boards (ICBs)) and NHS providers to account. NHSE is an executive non-departmental public body of DHSC.

52.  All NHS Clinical Commissioning Groups (CCGs) have an executive lead for pandemic preparedness activities to undertake business continuity planning, develop communications plans, develop surge plans for elective work, and provide assurance of the impact of pandemic plans on commissioned services.

53.  NHSE expects all NHS-funded organisations to have an AEO (accountable emergency officer) as a core part of their organisation’s governance and operational delivery programmes.

54.  In the context of pandemic preparedness, NHSE’s responsibilities include:

54.1.   Making arrangements for NHS providers to deliver certain health services to patients

54.2.   Allocating funds to NHS CCGs, so they can arrange with providers for the remainder and the majority of NHS services to be provided to patients

54.3.   Ensuring that both itself and NHS CCGs are properly prepared for dealing with emergencies (including a pandemic)

54.4.   Monitoring NHS providers’ compliance with the arrangements imposed upon them to ensure that they are properly prepared for emergencies.

Specialist response capabilities

55.  In the case of a high consequence infectious disease emergence (HCID), containment and response is managed through a coordinated approach across NHS and UKHSA. The Rare and Imported Pathogen Laboratory (RIPL) at Porton Down, other UKHSA labs and the Imported Fever Service provide advice to NHS on diagnosis and early management. UKHSA also deploys local containment measures (for example through its HCID network of clinicians) by ensuring admissions to hospital are in isolation to specialist commissioned centres with agreed standards for infection control.

56.  Alongside the initial steps for addressing an infectious disease, all NHS Ambulance Trusts have the capability to deploy specially trained staff as part of a Hazardous Area Response Team (HART). This helps to rapidly commence containment of HCIDs and ensure that medical assistance and transportation can be assigned to potentially infectious individuals prior to their arrival at an HCID unit.

57.  To contain outbreaks and prevent them from spreading within the UK, NHSE has two specialist ‘contact’ High Level Isolation Units in England and five specialist ‘airborne’ HCID treatment centres in England. These centres provide expert infection prevention and control capabilities that allow clinicians to provide care to patients with HCIDs, including the provision of medicines, use of specialist equipment and the administration of post-exposure prophylaxis where relevant.

58.  To support the containment of HCIDs, UKHSA has retained proportionate capability developed as part of Test and Trace, enabling scaled contact management, including contact tracing, enquiries, guidance, and compliance where necessary.

59.  In the context of Containment Level 4 (CL4) laboratories, which are designed to handle the most dangerous and exotic pathogens, UKHSA is responsible for regulating and overseeing their use. UKHSA also works closely with CL4 laboratory personnel to provide training and support, as well as to investigate any incidents that may occur. In the event of an outbreak or emergency involving a dangerous pathogen, UKHSA may work with CL4 laboratories to provide diagnostic testing, sample analysis, and other necessary services to help manage the situation.

60.  UKHSA works with CL4 laboratories to ensure they adhere to strict safety protocols and guidelines, such as the Health and Safety Executive’s (HSE) Advisory Committee on Dangerous Pathogens (ACDP) guidelines. This involves assessing the risk associated with working with specific pathogens and developing protocols for their safe handling, storage, and disposal.

Biological Security Strategy

61.  The upcoming HMG Biological Security Strategy, refreshed to consider the rapidly changing risk landscape, will set out the Government’s renewed vision, mission, outcomes and plans to protect the UK and its interests from significant biological risks. The strategy will provide the overarching strategic framework for mitigating biological risks. It will include a package of scalable capability development proposals, which will enhance the UK’s resilience to a disease outbreak with pandemic potential.

March 2023