Written Evidence Submitted by the Institute of Civil Protection and Emergency Management (ICPEM)

(CLL0054)

The Institute of Civil Protection and Emergency management (ICPEM) is a learned society from which emergency professionals, academics and businesses collectively champion civil protection and emergency management. Our mission is to bring together professionals, practitioners and academics in order to provide an informed and influential voice on all aspects of civil protection and emergency management.

Reasons for submitting our evidence align with the objectives of the Institute:

• To represent the views of its members to government and other bodies
• To promote public safety and to protect the lives and property of citizens Worldwide
• To advance education in the science or art of civil protection
• To promote the highest standards of study and research into all aspects of emergencies and disasters
• To disseminate recognised research and information which could beneficially influence public and private emergency management practices

A note on the authors:

The authors of the submission, Dr Ken Hines, Dr Karen Reddin and Gordon MacDonald, are all experts in health emergency Preparedness, Resilience and Response (EPRR). All have worked at strategic and operational levels improving public health preparedness, response and recovery.  Their work not only has included responding to health emergencies but also building capacity and capability in planning and preparing for such events. Their experience includes:

• Leading the UK’s national response to the 2005 H5 N1 (Avian Flu) outbreak,
• Leadership, and management for the preparation for and management and co-ordination of the Public Health England response to the 2009 Swine Flu pandemic,
• Influenza pandemic planning for the Department of Health,
• Preparing for and management and co-ordination of the Public Health England response to the 2014 Ebola outbreak in West Africa,
• Typhoid epidemic tracing in Rwanda, and
• Responsibility for the development and maintenance of Crisis Management Centres across PHE.

They have variously worked and advised at the most senior levels of the Health Protection Agency (HPA), Department of Health, Department of Health and Social Care, and Public Health England (PHE).

A submission, in three parts, to the Joint Health and Social Care and Science and Technology Committees Inquiry into lessons to be learned from the response to the coronavirus pandemic so far

Dr Ken Hines

Dr Karen Reddin

Gordon MacDonald

Executive Summary

At the onset of the current Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pandemic, the causative virus of coronavirus disease (COVID-19) (from here referred to as COVID-19), the Institute of Civil Protection and Emergency Management (ICPEM) commissioned a small committee, formed from within its membership, to study and subsequently report on the United Kingdom’s Pandemic preparedness and response activities with special regard to the Pandemic. A paper entitled ‘The Historic Background to Contingency and Emergency Planning to Combat Pandemics in the UK’ produced by that committee towards recognising and understanding any significant learning points from previous pandemics was completed in August 2020.  It researched the historic background to pandemics, response strategies and associated contingency planning, specifically that applied in the UK. The period reviewed covered antiquity through to July 2020 and incorporated a review of lessons identified, learned or not, from previous pandemics. Recent pandemic emergency preparedness, response and resilience plans were scrutinised and the implications for future planning were discussed and recommendations for further pandemic preparedness actions were offered.

The paper has not yet been published and a condensed version of the lessons section is presented as the Institute’s submission to the Health and Social Care Committee and the Science and Technology Committee joint inquiry into lessons to be learned from the response to the coronavirus pandemic.  The full paper is available to the Joint Committee through the Institute.

This submission comprises three parts, the first concentrates on pandemic lessons throughout history to August 2020, the second looks at the tier warning and messaging systems, and the third summarizes the recommendations offered throughout this document. The author’s biographies are attached as an annex to the document.

It was quite a challenge to produce a research paper that explored an enduring pandemic, currently affecting communities globally, that examined strategies to combat the virus worldwide, which may change rapidly, and thus negate some current assertions prior to the publication of the paper. A case in point was the contention, within the paper, that the replacement of the UK Health Protection Agency by Public Health England (PHE) in 2013 may have had an adverse impact on the UK initial COVID -19 pandemic response, and that PHE may not prove an adequate body in that respect. The UK government announced it is to replace PHE with a new body entitled The National Institute for Health Protection (NHIP). Undoubtedly, other arguments within the paper may well be overtaken by events.

The complete paper illustrates that during its history, humankind has recognised the enormous catastrophic impact that communicable diseases has on their lives. From the horrific deaths caused by plagues throughout the Middle Ages, Smallpox and Cholera epidemics in the 18th and 19th centuries, Influenza epidemics and pandemics in the 19th and 20th centuries and now in the 21st century we face novel diseases from Ebola and Coronaviruses that cause major epidemics and pandemics threatening the world population.

It describes how the human race has reacted to these diseases from a standpoint of little understanding of the causal agents of the outbreaks to a highly scientific knowledge of the pathogens and their structures.  The societal response from quarantine, respiratory and hygienic protection and immunisation is explored over the ages and successful outcomes identified.  These outcomes led the authors to compile a number of lessons identified and how these have transitioned into lessons learnt through understanding and communication also leading to plans and response strategies.

The paper scrutinised the major preparedness and planning for responding to a pandemic in the UK and concludes that complex and robust plans were in place for responding to an Influenza pandemic, on the scale of the 1918/19 Spanish Flu, and had worked effectively in Swine Flu Pandemic of 2009. But, although recognised as a highly significant threat through the SARS and MERs outbreak, the Coronaviruses as a pandemic causing pathogen seemed to take second place to the Influenza planning.

This planning did help us to respond initially but as has been recognised, COVID-19 is a unique disease that is not progressing as we might expect and new strategies must be utilised along with the other lessons learnt for this disease to be mitigated against.

Contents

Part One – Lessons Learned Past, Present and Lessons to be Identified

The Historic Background to Contingency and Emergency Planning to Combat Pandemics in the UK

1.0              UK Actions Taken to Combat the Pandemic Compared to the Rest of the World

Pandemic planning has historically focused on pandemic influenza and not other potential causes. Exercises to test pandemic plans have tended to focus on the health system response rather than a wider systems approach which, as we have seen in the current COVID-19 pandemic, is key to delivering the required capacity and capability. It would also be beneficial, as part of the preparedness process, to learn from other outbreaks of both animal and human diseases that have the potential to cause pandemics.

2.0              Lessons Learnt from Previous Pandemics

2.1              Quarantine and the Plague

It was the Venetian merchants who realised the importance and value of quarantine during the Bubonic Plague pandemic. They instructed the Port Health Authorities to insist that all ships arriving in the port were to drop anchor and be isolated just outside of the port for 40 days. Remember, in the middle 14th Century there was no concept of a pathogen causing the disease, it would be a few hundred years later before the germ theory of disease was acceptable. At this time, it was still considered that the wrath of the Gods could play a part. They had however, realised that close contact played a part and that there was an incubation period during which, if people were isolated from others, they could not catch it. This was the foundation stone for all modern infectious disease management.

Buboes on the leg, caused by bubonic plague (Photo -CDC PHIL)                           

Finding cases and isolating them was vital in preventing spread of disease. Remember the sacrifices made by the people of the village of Eyam (para 2.2). The village had become infected following a delivery of cotton from London. The villager’s isolated themselves from the rest of the World, allowing no one in or out. Some 250 villagers lost their lives, but there was no further spread across Derbyshire.

There was a lot of face covering used, it was common for a Plague doctor to arrive dressed in black with a large facemask, often in the form of a beak which would be filled with aromatic items, to protect the wearer from the putrefied air; which, was believed to be the cause of the infection at that time. There were no antibiotics and so there was no effective treatment. Those treatments that were tried, were often worse than the disease.

2.2              Cholera and Track and Trace

Cholera epidemics were common in England in the 19th Century. One particular epidemic in London in 1854 was investigated by Dr John Snow. He was a well-known anaesthetist at that time but, was also renowned as a Public Health Physician and probably the father of modern Public Health. He walked from one location to another in the Soho area, taking a detailed history of when cases had begun and who they were in contact with. He drew maps street by street, documenting who lived at the address and who was or was not infected and, most importantly, where their water supply came from. He realised quite quickly, that all the infected cases had drunk water that had been drawn from the Broad Street Pump.

After a battle with the authorities, which involved removing the Pump handle, the Pump was closed down and new cases stopped.  His obstetric and anaesthetic skills were noticed by Queen Victoria who had him give her chloroform as pain relief during her painful labours.

              This shows the Broad Street Pump, with the John Snow Public House in the background.

2. 3              Smallpox and Vaccination

It was Dr Jenner who developed a smallpox vaccination, the first vaccine ever produced which dramatically reduced the number of smallpox cases so that it was the first and still only infectious disease to be totally eliminated from the UK. Despite several well-known contraindications like eczema in children, its use was compulsory for children and adults in many countries, unless excused because of side effect risks. This allowed for significant herd immunity to develop. Health Care staff all had to keep immunity up to date. Other adults only needed it travelling to an affected area and they had to be re- immunised every three years. This was a considerable achievement by the WHO. They also almost got to the point of eliminating poliomyelitis and succeeded in restricting the disease to small and volatile areas of Afghanistan, Pakistan, and Nigeria. Unfortunately, civil strife and unrest made the work of the WHO unsafe, and they had to withdraw for their own safety before completing the task. To date Polio vaccines have proven both safe and effective and are often administered as a nasal spray.

                            Dr Jenner vaccinates James Phipps 14 May 1796

2.4              Surgical Face Masks

              The Plague Doctor                                                       

The first recorded use of a facemask was by the French surgeon Paul Burger during an 1897 operation in Paris and, quickly became standard practice in the operating theatre and other clinical situations such as treating burns patients. The general public started using them widely in the 1918 Influenza pandemic but, they had also been worn during the 1910-1911 Manchuria outbreak of Pneumonic plague. A specially designed mask by Wu Lien-teh was made for the Chinese imperial court. In 1940 a facemask made of cheesecloth was claimed to protect nurses from tuberculosis. In 1918 in the city of Seattle USA, the Red Cross enlisted 120 workers who made 260,000 masks in 3 days.

Red Cross workers making Face Masks in 1918              Red Cross nurses moving Spanish flu victims

                            Members of the Public wearing face coverings -masks during the Spanish Flu

In the London Smog’s of the 1950s, it was not unusual to see members of the public wearing them in an attempt to reduce the harmful effects of the particles in the air. Similarly, they were popular in markets in cities in the Far East, and still are.

Police officers in the London smog of 1962.

Many people living in the heavily polluted cities got used to wearing protective face masks and it followed that they were willing and keen to wear them during outbreaks and epidemics in the 20th century such as SARS and MERS.  It was accepted culturally that masks were a good thing to use to protect yourself from smoke and smog. In the present COVID-19 pandemic there was considerable debate about the value of wearing them it was generally accepted that in smog they protected the wearer, and it did not matter if it was touched or handled.

With a virus epidemic, the masks were claimed to work in reverse and protected others from the wearer. The extent to which this is true remains very controversial still today. Many consider that the use by the general public may in fact be more harmful to the wearer than not wearing one. There is a lot of evidence that people tend to frequently touch their facemasks and often wear them with the nose exposed. Others have cut holes in them to allow food and drink to be consumed whilst wearing them or even to smoke. The conflicting scientific opinions about the value of face masks has not helped the man in the street evaluate whether they can be of use. The approach has changed during the current pandemic and it has been demonstrated that a considerable psychological benefit may help people to remember the basic rules of hand hygiene and social distancing if a mask is being worn. There may be some benefit if worn properly, in protecting others from possible contact with the COVID-19 virus droplets released from the wearer’s nose and mouth. Previous pandemic planning has always suggested that masks should be worn only by trained Health Care staff and not as a general rule by members of the public. Very little training or guidance was given.  It is most important that this issue is reviewed in detail once this pandemic is over. If face masks or coverings are to be recommended in future pandemics, the stockpiles will have to be greatly increased to avoid shortages and consequent black market activities selling masks, that has occurred recently for NHS staff and others who cannot function safely without them.

Volunteers can rapidly produce considerable quantities of washable and re-useable masks as was seen both with 1918 flu pandemic and now the current COVID-19 pandemic.

2.5              Surge Capacity

Pandemics will always cause pressure on health services, requiring hospitals to rapidly increase both the number of beds available and the numbers of staff to manage them. With increasing technological advances, much more specialised pieces of equipment are also required. The pictures below show first, a large ward created at Camp Fuston in the USA to accommodate the large number of soldiers affected by the 1918 Spanish flu. The next shows the result s of a rapid construction of a Nightingale Hospital at the ExCeL Centre in London Docklands. This was built in 9 days and could accommodate up to 4000 patients. There have been similar reports of enormous emergency hospitals being built in China in under 2 weeks. The number of ventilators normally available to the NHS  is about 4000. This was rapidly increased to 30,000 at the beginning of lockdown for COVID-19. Many companies changed their normal working practices and output to produce more machines for the NHS; a highly successful initiative.