HC Deb 11 April 1968 vol 762 cc1619-30

1.16 p.m.

Mr. Timothy Kitson (Richmond, Yorks)

I am grateful for the opportunity to raise on the Adjournment the problem of the gastro-enteritis outbreak among infants on Tees-side during November and December last year.

I am sure that we should all like to convey our sincere condolences to the parents of the 15 children who died. All of us on Tees-side have been concerned at the brevity of the Report produced by the Newcastle Regional Hospital Board, and there is in the area a good deal of anxiety and bewilderment following the paucity of information that we have been able to glean from the Minister of Health and the Regional Hospital Board.

I was particularly disappointed that the Minister would not let me join the deputation which met him following the publication by the Ministry of Health of the Report of the Regional Hospital Board. On the day that this meeting took place with the other three Members of Parliament, I received a message to say that the Minister was not prepared to see me with them but would see me on a separate occasion. I should have thought that on a matter of this gravity, in which my own constituency was involved—12,000 of my constituents live in the Borough of Tees-side—nothing which was to be said in front of the other Members could not have been said in front of me.

This has given rise in my mind to suspicions about why this arose and the necessity this morning to raise the matter so that the Minister can be more definite in the House since the people on Tees-side would like a great deal more information than they have so far received. When 15 children have died, I should have thought that a Report containing only 16 lines on foolscap paper, with some background notes to editors, was totally inadequate and completely misunderstood the situation.

I have a particular interest in this problem, and I hope that when the Minister replies he will tell us the problems with which the medical profession was faced, because antibiotics which should have effectively controlled the illness failed to have any result on the children, and eight antibiotics were used before one was found to give the necessary results.

In July, 1966, in a debate in the House, I pointed out the dangers of transferable drug resistance and particularly with reference to the use of antibiotics in animal husbandry. I should like to read the very brief notice put out by the Regional Hospital Board on the results of the inquiry. It stated: The Newcastle Regional Hospital Board has made an inquiry into the circumstances which attended the outbreak of gastroenteritis among infants on Tees-side during November and December, 1967. In brief, the results of this inquiry, which have been studied by the Ministry of Health, show firstly that this was a community outbreak of only moderate proportions; secondly, that the deaths which occurred were mainly in weakly babies suffering from some other abnormal condition and were not large in number when compared with similar outbreaks which have occurred from time to time in the past; thirdly, that the clinical care of the babies appears to have been skilfully managed even though it was complicated by infection with intestinal organisms resistant to the action of several antibiotics; fourthly, that local arrangements for the interchange of information during outbreaks of infectious disease need review. This review is now being undertaken by the Regional Hospital Board. Then there were some notes to editors.

We felt that this was inadequate. Although I am sure that the medical profession on Tees-side did all that they could to combat the outbreak and to control and reduce the risk, for which we are all grateful to them, they ran into the problem of transferable drug resistance. This is a field to which the Minister must urgently give attention, and he should recognise the dangers which lie ahead. Some very important work has been done in this field and a great deal of research is being done, but I must stress the concern of those in the medical profession and draw the Minister's attention to some of the articles which appeared at the time of the outbreak.

The Leader in the British Medical Journal on Saturday, 3rd February, 1968, headed "Transferable Antibiotic Resistance on Tees-side", said: Resistance of bacteria to drugs, often to several at a time, can be transferred from organisms of one species to those of another by contact in the intestinal tract. This process can nullify the potential benefits of antibiotics … The subject was discussed in this journal in 1965… in connection with the studies by E. S. Anderson… It went on to say of Salmonella typhi-murium: This organism, originally resistant to two drugs, successively acquired resistance to several more, and caused 1,200 known infections in animals, mainly calves, and 500 in man, these being clearly derived from animal sources. Its resistance was transferable, and this illustration of how an organism can become drug-resistant in cattle and thence spread to man, with the likelihood of transferring its resistance to other human intestinal bacteria, led to a demand for ' a re-examination of the whole question of the use of antibiotics and other drugs in the rearing of livestock. ' The New Scientist at the same time, under the heading "A bitter reckoning", said: The outbreak of gastro-enteritis on Teesside which has resulted in the death of 12 ciildren is caused by an organism that is resistant to the antibiotics which would normally be used. An expert argues here that this resistance may have resulted from an uncritical use of antibiotics, and suggests essential precautions for the prevention of yet graver results in the future. The article said: What can be done to improve the situation concerning drug resistance in the intestinal bacteria? A number of measures suggest themselves. In the first place, the use of antibiotics in human medicine should be placed on a more rational footing. Man has been coping with infection since long before the advent of the antibiotics, and he has not lost the mechanisms that enable him to do this. It would do no harm—and from the point of view of the development of immunity it would probably do good—to allow him to resume his personal fight against the less serious infections, reserving the antibiotics for cases in which they are justifiable on clinical or bacteriological grounds, and for infections such as typhoid fever, where they are unequivocally necessary. Secondly, measures should be taken to improve the practice of intensive farming, in order to limit the initiation and spread of intestinal infection in livestock. Thirdly, the use of antibiotics in animal husbandry, long overdue for revision, must be re-examined. The studies of various authors suggest that the antibiotics should be classified under three headings:

  1. 1. Those that could be used as feeding additives.
  2. 2. Those that could be used in animal medicine.
  3. 3. Those that could be used in human medicine."

At the same time, the science correspondent of the Observer wrote an article in which he said: The Tees-side outbreak of gastro-enteritis, in which 12 babies have died, is adding more fuel to the controversy about the use and abuse of antibiotics. I think that it was significant that, at about the same time, on Thursday, 1st February, the Daily Mail carried an article headed, "Disease Fears 'Unfounded'", in which it said: Fears that the widespread use of antibiotic drugs could lead to a massive growth of drug-resistant diseases were discounted last night by … one of the leading drug firms. At a special conference in London, the group urged the Ministry of Health, the Public Health Laboratory and drug firms to investigate the problem to show how small it really was. What many of us want to know now is, who is right? I would accept the thoughts of the medical Press as being correct far more than those of the drug firms.

On 28th July, 1966, I initiated a debate on cross-drug resistance, which came under the Ministry of Agriculture, and also dealt with the problems of salmonella typhimurium. I said: There is no doubt that the build up of drug resistant organisms, both in animals and in human beings, will increase unless a firm approach is made to the problem. Only too often before have I seen the findings of eminent research workers in these fields, when recommendations and papers have been produced, being shelved for future consideration, and the British Medical Association and the British Veterinary Association have supported the views of those doing the research that action should be taken immediately with regard to transferable drug resistance.

In reply, the Parliamentary Secretary to the Ministry of Agriculture said: I turn now to antibiotics. Some criticism has been made of their use. The problem of what is called 'infective drug resistance' has been mentioned. There is no evidence based on field experience to show that this problem is in any material degree due to the use of antibiotics in the treatment of animal disease. It would not, therefore, be right to prevent veterinary surgeons from using these drugs to cure or prevent illness in animals."—[OFFICIAL REPORT, 28th July, 1966; Vol. 732, c. 2059, 2062.] He said that he was awaiting the report of a joint committee of the Agricultural Research Council and the Medical Research Council, and that the Ministry's Scientific Advisory Panel was reviewing the use of antibiotics in food and agriculture.

What has happened since then? With the greatest respect to the Minister, and although I am sure that he recognises the importance of this problem, we are letting this situation drift. I have consistently pressed for further committees to be set up to investigate the position and to try to discover what is going on in this field. I was extremely disappointed by the Minister's reply on 26th March. To my Question, …if he will set up a new committee of inquiry into the problems of transferable drug resistance", he replied: As regards the public health implications of the use of antibiotics in agriculture, I have nothing to add to the reply my hon. Friend gave to the hon. Member on 19th March. I am not aware of any evidence justifying the setting up of a new committee of inquiry."—[OFFICIAL REPORT, 26th March, 1968; Vol. 761, c. 246–7.] Since then, the Ministry of Agriculture has set up a committee. In my debate in July, 1966, I asked that there should be a much better liaison between the two Ministries. The Parliamentary Secretary said then that he was quite satisfied with the present arrangements. I certainly am not.

The Japanese discovered the problem of transferable drug resistance in 1959 and a great deal of research has been done in this country, but we do not seem to be getting any action yet from the Ministry of Health. I hope that the Minister will tell us today what he envisages doing to get more control of this matter.

The Tees-side outbreak was a tragic affair and there are many lessons to be learned. I beg the right hon. Gentleman to turn his attention to this problem. Please may we also have more information about the outbreak? Will he take note of the fact that many people are very disturbed about the way in which the Regional Hospital Board has handled this? When the Minister's Press release was published, and only under pressure from the Press and hon. Members—because, I think, the Ministry of Health instructed the hospital board—did it send anyone to Tees-side to explain the facts of the inquiry. The board would have been quite happy to leave someone on a telephone in Newcastle to explain to the Press what had happened.

I hope that the Minister will be a little more forthcoming, so that the worries and fears of those on Tees-side about what happened in the past will be allayed.

1.30 p.m.

Mr. Maurice Macmillan (Farnham)

I do not wish to prolong the debate or to take too much of the Minister's time, particularly as my hon. Friend the Member for Richmond, Yorks (Mr. Kitson) covered the problem fully. First, however, I should add my expression of sympathy, which we all share, with the parents of the babies concerned in the incident. We have an example, among other things, of how anxiety has been allowed to grow partly because of ignorance of what has been done, either officially or unofficially, to deal with the problem and of the research on which future proposals will be based.

I wish to make three comments. The first concerns the use of antibiotics particularly in the treatment of patients, especially children, within the framework of the Health Service. It is becoming more and more accepted that it is unwise to use antibiotics for trivial complaints, in many cases simply to shorten the period of treatment, when the treatment of the past has been equally effective—the patient going to bed and staying there and allowing Nature to take its course. That is particularly true of children. The use of antibiotics is particularly unwise in childish ailments from which children recover relatively easily, because it prejudices the effectiveness of those antibiotics later in life. In cases within my family I have felt reeassured when our family doctor has said that there is no need for the use of antibiotics. There is always danger if we use them too freely on trivial matters, because that can build up a resistance which could be critical later in life.

My second comment concerns the agricultural aspect. I am thinking not so much about the build-up of resistance in persons who are being treated as about the transfer of resistance either from other human beings or as a result of catching a resistant strain of an organism from animals. Will the Minister indicate the relative degrees of risk for adults and children, partly owing to the consumption of milk and from other considerations?

Thirdly, I hope that the Minister will indicate the extent to which the risks which my hon. Friend described so fully in the use of antibiotics are present with other forms of drug resistance, with the organism building up resistance to drugs other than antibiotics.

This is a curiously well-timed debate because it coincides with a discussion on a related problem in Standing Committee on the Medicines Bill. The discussion in that Committee has shown clearly the veterinary complications which can arise from the treatment of animals, either in curing animal diseases or from the straightforward practice of animal husbandry. I do not suggest that the Minister should go too far in the debate today, gut in discussing the general problem of cross drug resistance, it is important to consider the effect on human beings of the treatment and feeding of animals and the use of insecticides and herbicides. It would be helpful if the Minister indicated what difference, if any, the establishment of a Medicines Commission is likely to make in the methods of dealing with this range of problems in future. Collectively we have been rather slow to reach conclusions in the matter, but much research and much work has been done, and it is reasonable to suggest that some guidance could have been given earlier, even if that guidance had been based on suggestions of probability rather than on any proposals to lay down hard-and-fast-rules or recommendations.

What will be the effect of the passing into the law of the Medicines Bill? Will the Minister comment on the positive side of the research and explain what steps he proposes should be taken? We should all be grateful to my hon. Friend for raising the matter and for the objective and serious way in which he dealt with it.

1.36 p.m.

The Minister of Health (Mr. Kenneth Robinson)

I am aware that a number of hon. Members have a particular interest in the subject which has been raised by the hon. Member for Richmond, Yorks (Mr. Kitson) and I appreciate the very moderate way in which he put the case, when I know that he feels very strongly about certain aspects of it. I am also grateful to him for giving me this opportunity of explaining, at greater length than I have hitherto had the opportunity of doing, the true significance of the events of the latter months of last year in certain of the Tees-side hospitals.

May I deal with a point which he mentioned at the beginning of his speech? He referred to my unwillingness to see him alongside three Tees-side hon. Members who had asked to discuss the report of the Regional Board with me. His request was a last-minute request. The reasons why I said that I should prefer to see him separately were, first, that I understood his interest to be the wider interest which he has developed today of the transfer of drug resistance and, secondly, that I under-estimated the extent of his constituency interest—and for that I apologise. Had I known that his constituency interest was as great as that which he described today, I should have gladly seen him alongside the three Tees-side Members. I ask him to accept that there was nothing suspicious in my suggestion that we should meet separately.

I would express, together with both the hon. Member for Richmond, Yorks and the hon. Member for Farnham (Mr. Maurice Macmillan), my deepest sympathy with the parents of the children who died in this outbreak. We must all be affected by any occurrence which causes the deaths of children. But health authorities must discipline themselves, even in an atmosphere of some emotion, to consider these events objectively to see what lessons can be learned from them. The dissatisfaction of the hon. Member for Richmond, Yorks with the statement which I made in answer to his Question on 7th March stems, I assume, from the fact that he had already formed the view that this outbreak of gastro-enteritis among babies on Tees-side was an event of unusual and exceptional severity. I emphasise that, having understood and appreciated the feelings of the bereaved parents, it is my duty to assure the House that, in objective terms, the outbreak was not one of exceptional severity. This was the finding of the expert inquiry carried out by Professor Green and Doctor Brewis which was undertaken for the Regional Hospital Board, and which my advisers have endorsed. I tried to make this clear in my statement on 7th March.

I should also emphasise that the inquiry concluded that the handling of the outbreak from a clinical standpoint was perfectly adequate, although it was complicated by an outbreak of acute respiratory illnesses at the same time. There is no desire on my part to understate the seriousness of the event, but it must nevertheless be viewed in proper perspective and, of course, without any desire to exculpate anyone. It is quite inappropriate, for example, to refer to the outbreak, as many Press reports did, as an epidemic, which suggests an event of unmanageable proportions. The number of babies up to the age of one who die from gastro-enteritis each year is, I fear, not inconsiderable. In 1965 the number was 341 in England and Wales, and in 1966, 378.

In his Motion the hon. Gentleman refers to the death of 15 babies. This figure was, of course, obtained from Press reports which were based on statements made by the local hospital group at the time the deaths occurred, and not from my more recent statement. Detailed investigation after the event showed that of the infants found to be infected with the organism known as E.coli 0128, enteritis was regarded as the principal cause of death in 11 cases.

My statement of 7th March referred to 11 deaths and hon. Members will also recall that I stated that of these 11 infants, nine had either been born prematurely or were already suffering from some congenital or other abnormality and therefore less likely to survive an attack of gastro-enteritis. This feature is illustrated in the table of birth-weights of the infants which I provided in answer to the hon. Gentleman's Question of 25th March.

In some quarters my statement has been described as totally inadequate— although it was 1,000 or so words in length. It attempted to present not only the salient features of the outbreak, but also to include also a fair amount of technical explanation. The hon. Gentleman will appreciate that it is difficult briefly and clearly to comment on occurrences which are from a medical and scientific point of view extremely complex.

I am sorry if I failed to satisfy him in this regard. Had I done so, by including a detailed discussion of the bacteriological and epidemiological features of the case—in which I believe he has a particular interest—those most directly concerned might have felt, with some justification, that I was attempting to confuse the explanation by undue reference to sophisticated medico-scientific terms—in short, that I was trying to blind them with science.

I come to some more general aspects of the case. I am aware of the apparent increase in strains of bacteria which have developed resistance to antibiotics, but it is not possible at present to determine whether the source of such resistance originates from the use of antibiotics in human or veterinary medicine.

Most antibiotics of therapeutic value are already controlled under Part II of the Therapeutic Substances Act, 1956, and can be sold or supplied only against the prescription of a doctor, dentist or veterinarian. Regulations permit the use of three antibiotics—penicillin, chlortetracycline and oxytetracycline—to be included at very low levels in feeding stuffs for non-breeding pigs and poultry. This type of control is due to be re-enacted by the Medicines Bill which is now before the House.

The use of other antibiotics—for example, tylosin and hygromycin—which are not at present subject to control under the Therapeutic Substances Act comes within the scope of the Veterinary Products Safety Precautions Scheme which operates under the aegis of my right hon. Friend the Minister of Agriculture, Fisheries and Food.

On the question of whether or not an antibiotic should be controlled under Part II of the Therapeutic Substances Act, I am advised by the Medical Research Council and by the Antibiotics Panel of my Chief Medical Officer's Committee on Medical Aspects of Food Policy. These bodies, together with the Agricultural Research Council, also advise on the desirability of regulations relaxing this control. In making recommendations, the research councils and the Antibiotics Panel are naturally very aware of the problem of transferable infective resistance.

However, as the House will appreciate, this is a complicated problem. The phenomenon has been studied in the laboratory, but evidence from actual experience is not easy to obtain. It was with this in mind that my right hon. Friend and I began discussions about the expert review body recommended by a joint committee of the Agricultural and Medical Research Councils, known as the Netherthorpe Committee. Hon. Members will know from my Answers to recent Questions that we hope soon to announce more details of this body, which will be looking at the use of antibiotics in animal husbandry And veterinary medicine. I expect that he Veterinary Investigation Service and Ate Public Health Laboratory Service will assist them.

The report of the Hospital Board was mentioned. This was a report commissioned by the Newcastle Regional Hospital Board, which is responsible for the hospital services in the region. Its authors were not asked to compile a report suitable for publication, and they did not do, o. They prepared a report for the Board, which wished to have an expert assessment of the occurrence from persons not connected with the hospitals concerned so that it might consider what action, if any, by it might be needed to improve the functioning of the hospital services in the region. Apart from commenting in detail on a number of highly technical matters, the report refers to individual patients by name and discusses their clinical progress. It is not the practice to make such information generally available, and publication of the report would, or these reasons, be quite inappropriate.

I should add, to be blunt, that there has been present in this affair an element of exaggeration, even distortion, through- out this unfortunate occurrence, and although some of the underlying difficulties—for example, those of transferable drug resistance—remain obscure in the present state of our knowledge, I am satisfied that no useful purpose would be served by the publication of the report in full. My statement of 7th March, was intended to fulfil that purpose and it has been amplified by a series of Answers to specific Questions, and still further in this debate.

The Newcastle Regional Hospital Board is now undertaking a review of the organisation and work of control of infection committees, at group and hospital level, throughout the region. I shall be very ready to make available to hon. Members who are interested the results of this review.

On what I might call the management aspects of the case, this conclusion to review the Control of Infection Committees was in my judgment the most important reached by the Regional Board requiring further action. There will, however, be a number of more detailed questions requiring further study by the Regional Board of the hospital management committees concerned. For example, one of the difficulties which arose was the pressure on accommodation, and the Board will be considering whether present arrangements in the Tees-side hospitals need to be improved. I have already made it clear that the outbreak was perfectly adequately handled from the clinical point of view but, even so, I would be surprised if the clinicians concerned did not find a number of matters worth discussing further with their colleagues on medical advisory committees.

I repeat my thanks to the hon. Member for giving me this opportunity to deal at some length with this most unfortunate Tees-side outbreak. I hope that what I have said this afternoon will have allayed any residual anxieties that may linger in the area.