HC Deb 28 April 2003 vol 404 cc38-52 4.31 pm
The Secretary of State for Health (Mr. Alan Milburn)

With permission, Mr. Speaker, I wish to make a statement on severe acute respiratory syndrome. SARS was first reported to the World Health Organisation by a number of countries in south-east Asia in mid-February this year, although subsequent information from the Chinese authorities suggests that it probably started to emerge in southern China during November last year. It presented initially as an unknown illness causing fever and severe chest symptoms, including pneumonia. Since then, laboratories around the world, including those in the United Kingdom, have been working to pinpoint the precise cause of this serious new illness. At this stage there is neither a test to diagnose SARS, nor an antidote to treat it.

SARS has spread to 26 countries, but it has been concentrated in a handful of areas, with major outbreaks in Hong Kong, Hanoi, Beijing and other parts of China, Singapore, and Toronto in Canada. According to the most up-to-date information, which I received from the WHO this morning, there have been 4,836 probable cases of SARS worldwide and 293 deaths.

There are, of course, understandable public concerns about the impact that SARS might have in the United Kingdom. I can confirm to the House that in this country to date there have been just six probable cases of SARS. The last reported case was admitted to hospital on 10 April. All the patients involved were quickly identified and have been successfully looked after by the NHS. All have now returned home and are well. The chief medical officer, Professor Sir Liam Donaldson, has advised that at present SARS poses a low risk for people in this country, so, serious though SARS is, it is important to keep it in perspective.

Our response has been to take a precautionary but proportionate approach. The handling of SARS in this country has been informed, as it must continue to be, by the best scientific and medical advice. In particular, the chief medical officer and the new Health Protection Agency, in advising Ministers and the health service, have been working extremely closely with the World Health Organisation, which has the global responsibility for dealing with the disease. Throughout, we have followed WHO advice to the letter.

It might help the House if I set out the action that has been taken to date and the further action that we now propose.

First, we have provided early, accurate information to both the public and the health service. The CMO contacted all doctors on 14 March and subsequently on 7 April with detailed information on the symptoms and signs of SARS, and what to do if they encountered a possible case. Up-to-date information on SARS is also available to the public on the WHO, HPA and Department of Health websites, as well as through the NHS Direct telephone helpline, which many members of the public have contacted.

Secondly, we have put in place high-quality public health surveillance to enable the disease to be tracked closely. In early March, the Health Protection Agency set up a system for reporting suspect and probable cases. Thirdly, the chief medical officer issued advice to people travelling abroad on 2 April and, subsequently, on 23 April in line with WHO recommendations. He strongly advised against travel to specific SARS-affected areas. That remains his very strong advice.

Fourthly, the WHO has advised that passengers should be screened on departure from the countries affected, and as a further precaution, in line with that WHO guidance, information has been distributed to the main airports in this country giving advice to returning travellers on SARS.

Fifthly, we have laid down, in line with WHO advice, specific requirements through guidance issued by the CMO on 14 March and 7 April on the management of patients within NHS hospitals to reduce the risks of cross-infection.

Sixthly, and perhaps most importantly for the long term, we have put our country's considerable scientific expertise to work in helping to identify a causative organism for SARS. The HPA central laboratory in Colindale was a key part of the international collaboration that led to the identification of the likely cause. It is also at the leading edge of work to discover an accurate diagnostic test.

Over the past few weeks, we have been able to draw on the UK's strength in public health and infectious disease control to deal with the threats posed by SARS. I must stress, however, that this is an evolving situation. We are keeping our plans and policies constantly under review, learning lessons where they need to be learned, building on good ideas wherever they are to be found and, especially, tracking the disease very closely in collaboration with our counterparts in other countries throughout the world. For example, this week we sent an expert from the HPA to Canada to assist, but at the same time to learn as much as possible from the unfortunate events in Toronto so that we can build the lessons learned there into our own plans here.

So far, the approach taken on dealing with SARS in this country has proven effective. There is, however, no room for complacency. My clinical and scientific advisers have stressed that we need to retain flexibility in how we respond, not least because we do not yet fully understand how SARS spreads. We do know that most of the cases have been transmitted between people who were in close contact with one another—for example between health care workers and SARS patients—rather than through normal social contact among the wider population. However, we cannot at this stage reliably predict whether the SARS virus will maintain its current pattern of attack, change in infectivity or find new routes of transmission. That is why it is so important to strike a balance on how we respond to it.

Some have asked why we do not adopt a policy of screening all entrants to the United Kingdom from countries that have had cases of SARS. The problem is that there is no such test. Screening involves asking people a series of questions about their health to identify any signs or suspicious symptoms. That is being done, according to WHO advice, at airports in the areas most affected.

I am advised, however, that the early signs and symptoms of SARS occur commonly in the general population and are associated with a cough, cold or minor viral infection. Air travel, with its propensity to induce dry throats and coughs, is also a potential source of a large number of false leads, so trying to identify a genuine case of SARS is, as the CMO has put it, like looking for a needle in a haystack. With 4 million British and other visitors travelling between this country and the most affected areas each year, quarantining all those with such non-specific symptoms would be simply impractical. Indeed, I have been advised by our scientific experts that none of the six probable cases of SARS so far identified in this country would have been prevented or detected by screening at points of exit or entry, and still less on aircraft themselves. Instead, each case was picked up because of the patient's awareness of SARS and, of course, because of the high level of awareness among NHS staff.

Fortunately, the evidence so far is that people transit SARS only once they have symptoms of the disease, and not before. With a disease incubation period of up to 10 days, successful identification and treatment of SARS sufferers has so far been achieved by concentrating public health expertise on people who have returned to this country and developed the disease in the succeeding days. However, this is a changing situation globally and if our experts advise changes to our approach, we will not hesitate to introduce new measures.

Others have asked why we do not make SARS a notifiable disease. In this early and important stage of the SARS outbreak it is vital that we find out about all cases of the disease through rapid notification of cases rather than through the slow and bureaucratic processes associated with the notifiable disease regime. Unfortunately, that regime has become associated with significant under-reporting of disease. In any case, it is extraordinarily unusual for a person in this country suffering from an infectious disease to refuse treatment, reject advice and persuasion and necessitate calling the police compulsorily to detain them. We do not foresee that that power will be necessary in detaining people who fall ill with SARS at this stage.

For the benefit of the House, however, I should mention that the Public Health (Aircraft) Regulations 1979 do provide the power to detain for examination any person leaving an aircraft where there are reasonable grounds for suspecting that they are suffering from or have been exposed to infection. The Public Health (Ships) Regulations 1979 contain a similar provision. I can tell the House that should the CMO advise me that wider powers have become necessary, SARS will be made notifiable. I am advised that, if necessary, we could make it so within 48 hours.

We remain vigilant to the threat posed by SARS to public health in our country, so I can also tell the House today that I am taking further action following advice from the CMO. First, following emerging evidence from the main affected areas that SARS spreads through poor cross-infection control measures, all chief executives of NHS organisations are being reminded to ensure that rigorous controls are in place when treating a patient with possible SARS. That communication will also include an instruction to defer the start date of appointments of any foreign recruits to the NHS from SARS-affected areas.

Secondly, I am taking steps to check that the exit screening from ports of departure is indeed robust. The UK is this week sending observers to those areas to ensure that passengers are being screened in line with WHO guidance. Where we have doubts that that is the case, we will consider screening passengers on specific flights on entry to Britain, including asking them to make a signed declaration that they have not been in close contact with SARS cases and do not have symptoms themselves.

Thirdly, I intend with my right hon. Friend the Secretary of State for Transport to ask airlines returning passengers from SARS-affected areas to distribute information along with boarding cards. We also intend to discuss with the airlines other means of informing passengers about SARS on all long-haul flights from affected areas.

Fourthly, I remind all airlines of their obligations to provide a declaration of health when a plane arrives in this country.

Fifthly, next month at the World Health Assembly in Geneva, I will meet other Health Ministers to discuss whether any further measures above and beyond those already taken could be put in place at a European or international level.

The whole House will want to pay tribute to staff in the NHS for their prompt, effective and successful action in responding to SARS. The best advice that I have is that the UK, alongside many other countries that have experienced a very low incidence of SARS to date, may see further cases over the months ahead. Given the importance and ease of global travel, we cannot isolate ourselves from the rest of the world. Given the complexity of detection, the test of success of our disease control policy rests on keeping to an absolute minimum the spread of the disease and successfully treating those affected.

To date, the NHS has met that challenge because of the precautionary but proportionate approach that has been taken. We will continue to be vigilant, we will take whatever means are necessary to safeguard the public health of our people and we will continue working with the international community to tackle and, in time, defeat this serious new disease.

Dr. Liam Fox (Woodspring)

I am grateful to the Secretary of State for his statement and I thank him for making it available to the Opposition in advance.

He is absolutely right in the main thrust of his comments about the present situation in the United Kingdom. We are fortunate, especially given the amount of passenger traffic coming into the United Kingdom, that we have not had more cases of SARS, as has happened in Hong Kong and China. The staff who have looked after the cases in this country are to be congratulated on that. The question is, however, whether we are doing all that we can to keep it that way.

I am sure that the Secretary of State would be the first to agree that reports that the worst is over might lead to complacency, which would be highly regrettable. The outbreak in China is still gathering pace and is certainly not contained. If we look at the measures that have been taken in Asia over the past few days, we see that Taiwan has imposed a two-week ban on the entry of visitors from badly affected areas after the island announced its first SARS death on Saturday, that South Korea and the Philippines are taking new measures, and that in Singapore, although cases are declining with the imposition of stringent measures, including thermal imaging of air passengers, the quarantine regulations are being strictly enforced. To those who say that those Governments are going over the top, I point out that the director general of the WHO said this morning that such measures are not over the top, but prudent and necessary.

The Secretary of State said that we have had just six probable cases in the UK. Are any suspected or probable cases being investigated at the present time? If so, how many?

The issue on which I have the greatest disagreement with the Secretary of State is that of the notifiability of the disease. He says that it is extraordinarily unusual for a person in this country to reject advice and persuasion and to require detention. That is, of course, correct, but his approach is based on the presumption that somebody who is unwell with a high fever will act rationally. He says that if the situation gets worse, the Government will make it a notifiable disease, but, by his argument, they will do so only if the processes that have already been put in place have failed. The 1979 regulations that he mentions are inadequate, because they allow only for individuals to be detained for examination: they do not require someone to be quarantined and treated. Why are the Government denying the protection that the Public Health (Control of Disease) Act 1984 was introduced to provide? It is pointless to say that if the situation gets worse we will use the powers that we already have, as we should be using them to ensure that it does not arise in the first place.

I welcome what the Secretary of State said about increased information for passengers—that should have been done long before now—but I wonder whether the checks that are supposedly taking place at airports of departure are really taking place. I can say from my own experience that when I recently passed through Singapore as a passenger I was not given proper information about what would be happening in relation to SARS.

May I ask the Secretary of State about one or two of the measures that he proposes to introduce? He says that he will defer the start date for those coming into the United Kingdom to work in the NHS. For how long will he do so, and how will that be determined? Will that measure be kept in place until the entire SARS outbreak is under control? He says that if we send observers to airports of departure and they see that checks are not being made, he will ask for a declaration from passengers that they have not been in contact with SARS and do not have the symptoms of SARS. How will people who have been in Hong Kong or Singapore know whether they have been in contact with someone who has had SARS? That makes such a declaration utterly meaningless.

I am sure that the Secretary of State's officials looked at all the tests that could be of assistance, given that he said that we may find that passengers are not being properly screened before arriving back in the United Kingdom. For example, what advice has he received from his officials about using an actin serum screening test, which was originally developed as a screening test for blood transfusion, to act as an early marker for infection of donated blood?

It is used widely in Belgium and Germany. Someone who contracts a virus has an increased rate of apoptosis—more cell death—which produces actin fragments in the blood stream. Although it is non-specific, it becomes positive during the incubation period. Will the Secretary of State and his scientific advisers re-examine the experience of the use of the test and its possible application in the case of the failure of policies in airports to which he referred? We should use everything at our disposal to maximise public safety.

The judgment is not whether all that needs to be done but whether all that can be done is being done. The last thing we want is an increase in the number of cases when we could have taken action to prevent that.

Mr. Milburn

I thank the hon. Gentleman for his comments and questions. He said that we were fortunate not to have more cases in this country. I believe that it is a not question of good fortune but of good policy, good judgment and, most important, the action of the NHS and our public health services in this country. We are extremely fortunate to have one of the best public health systems in the world. The hon. Gentleman is aware of that and the measures that have been taken in the past few years to strengthen that system, most notably the creation of the Health Protection Agency. Steps have also been taken to strengthen public health powers locally through primary care trusts and regionally through the appointment of directors of public health.

The hon. Gentleman asserted that the spread of SARS was gathering pace. He should be cautious. Before I came to the House, I heard the latest advice from the WHO. It said that although there were major anxieties about China, it was pleased with progress in other countries, notably Singapore and Vietnam. It is important to maintain a sense of perspective and proportion. Otherwise, we simply will not get the policy right. The hon. Gentleman and I want to get it right.

The hon. Gentleman asked about the number of suspected cases as distinct from probable cases. The WHO has advised that we should try to identify the numbers of suspected cases and probable cases. In the latter, the balance of probability is in favour of the presence of a SARS infection. At this time of year in the part of south-east Asia that we are considering, there is a high incidence of flu-like illnesses alongside the new and emerging infection of SARS. It is therefore unsurprising that some people who return from those countries report symptoms that could be a cough, a cold, flu or, in the worst case, SARS. To date, about 50 suspected cases have been investigated and dismissed. The number of definite probable cases remains six.

The hon. Gentleman mentioned notifiability and considered whether the powers under the 1979 aircraft and ship regulations give us powers that he claimed that we did not have. Our lawyers advise me that we have precisely the powers that we need both to take people off a plane and ensure their hospitalisation.

I have taken clinical and scientific advice about the start date for new staff. We are proposing a 14-day breathing period to the NHS. Again, that is a precautionary approach given that the incubation period for SARS appears to be two to seven days or perhaps 10 days.

The hon. Gentleman asked whether the declaration from passengers would mean anything if we took that route. He will find on examination that that is being done in other countries. I am not sure whether it is done in the United States but, for example, Air France has adopted such a policy. It is important to get some indication in the absence of any screening test. The hon. Gentleman knows the science as well as I do. There is currently no diagnostic test.

There is no blood or urine test to detect whether a person has SARS. The only screening that can be undertaken is to ask people some questions, and that is precisely what we propose to do.

I should have thought that the hon. Gentleman, who has been droning on on the radio and on television over the past few days, although thankfully he kept his remarks to a minimum today, would welcome the measures that we are taking because they are precisely in line with the precautionary but proportionate approach that is necessary.

The proof of the pudding will be in the eating, but what the hon. Gentleman cannot get away from is that, despite the many visitors that we have each and every week from those areas that have been affected by this appalling new SARS virus, the cases that have presented, precisely because of the precautionary and proportionate approach that has been put in place, number just six. That is not a ground for complacency, but it is the foundation on which we seek to build, and it is important that we do so on the basis of the best scientific and clinical advice and avoid the situation that we have seen in previous public health scares, including those under his Administration, where it is politicians who decide the course of clinical and scientific policy.

Mrs. Gwyneth Dunwoody (Crewe and Nantwich)

The Secretary of State is sensible to make it clear to the population that there is a problem but that it should be kept in proportion, and both his Department and, in particular, the chief medical officer are to be congratulated on the sensible advice that they have given. However, will my right hon. Friend keep reminding those who are most at risk—primary care and emergency workers and those in A and E departments—that they must continue to be vigilant? It would be particularly sad if they were to relax their vigilance, even for a short time, because they believed that the problem had been dealt with. Will he offer to areas such as Hong Kong and Singapore, which have a high standard of public health, any possible support that can be given by the NHS and its specialised services?

Mr. Milburn

I very much agree with my hon. Friend, and I echo the tribute that my hon. Friend paid to the chief medical officer, Professor Sir Liam Donaldson, who throughout has played an important and leading role in handling the SARS problem.

My hon. Friend is also right about the need for vigilance. We have distributed two alert notices to doctors in the NHS already, of which I think she is aware. We have also provided further detailed guidance through the web so that doctors can access information quickly and easily.

I also agree with my hon. Friend's point about our international responsibilities. Our predominant responsibility is to serve this country and to ensure that we protect its public health, but we also have some wider international community obligations, particularly in countries that have been more adversely affected. As I said, experts from the HPA will travel to Canada this week and we will also send HPA experts to other countries that have been adversely affected.

Dr. Evan Harris (Oxford, West and Abingdon)

I, too, welcome the statement and the advance sight that we had of it. We share the concern of the House about the potential impact of the epidemic, not only on Britain's public health and on the well-being of world economies, but particularly on populations in developing countries that have neither the hospitals nor the public health structures adequately to treat the infection or to contain its spread. In that respect, reports of cases in India now are extremely worrying.

Liberal Democrats believe, as I think does the Minister, that in public health matters it is important to take advice from professionals and from the science base, which is now global. But is it not also incumbent on Ministers, when formulating policy to tackle an epidemic such as this to set out the detail of the advice and the reasons why those decisions have been taken?

For example, with regard to the MMR vaccine, the right hon. Gentleman will know that Liberal Democrats have no criticism of Ministers' decisions, nor of the way in which they explained precisely why they took such an approach, but does he understand why it is difficult for those of us who broadly support the Government's approach to understand why Ministers do not take the opportunity now to require SARS to be notified in order to give environmental health departments and hospital authorities reserve powers to insist on compliance with public health authorities? He needs to explain why that is not happening.

The Minister with responsibility for public health has merely cited the chief medical officer's advice, without setting out the evidence and reasons for it. Given the potential seriousness of a UK outbreak, does the Secretary of State accept that claiming that notification would be too bureaucratic is not a satisfactory reason for not making the disease notifiable and providing those powers? Is it not the case that the so-called bureaucratic system of reporting need not replace the current system? If the Secretary of State believes that the Public Health (Control of Disease) Act 1984 is unwieldy, does he not agree that it is regrettable that successive Governments have not followed the advice of the chief medical officers, given in 1988 and more recently, to update that legislation?

On airport screening, does the Secretary of State accept that, while World Health Organisation guidance recommends screening at the airport of departure, it does not advise against screening at the airport of arrival? Would it not be appropriate to use our immigration and entry system to provide the information needed and, possibly, to provide temperature screening? Will he also explain what advice he has had from the chief medical officer on asking passengers to sign forms when they might not even have the language skills to do so? No clinician would take such an approach, as such action would require a consultation.

Does the Secretary of State agree that the isolation of asymptomatic people—even if they have passed through Singapore, as the hon. Member for Woodspring (Dr. Fox) has done—is, as the CMO advises, unnecessary? It could be counter-productive, as it could lead to unjustified discrimination and stigma, and might deter people with symptoms from coming forward. This problem is going to be with us for months, at best, and probably for years. The worst-case scenario is that it could affect the world for decades. The House must revisit the problem, and I hope that the Secretary of State will take the opportunity of forthcoming health legislation to provide the framework to update our public health legislation in the way that has been recommended serially by chief medical officers over the last 14 years.

Mr. Milburn

I am grateful to the hon. Gentleman. I think that isolating the hon. Member for Woodspring (Dr. Fox) would be rather a good policy. The hon. Member for Oxford, West and Abingdon (Dr. Harris) must have written his speech—I know that it is only hand scribbled, but for him that is progress—before having read my statement, because I have tried to explain precisely the reasons for our decisions on the notification of SARS. We keep an open mind on that matter, however, and if I get the advice from the CMO to change that, I will.

The hon. Gentleman made two important points. First, on the modernisation of public health legislation, the chief medical officer made recommendations to us about modernising the notifiable disease framework within a broader context, and I have some sympathy for them. We shall obviously keep that issue under review. The second point that the hon. Gentleman made, which is extremely important in dealing with these issues, is that while our action must be proportionate, it must also be based on the best scientific and clinical advice that we can get. There are good reasons for that. Anyone who remembers the outbreaks of bovine spongiform encephalopathy and variant CJD will know how important it is for Ministers not to give false assurances from the Dispatch Box, but to rely in as open and transparent a way as possible on the best scientific and clinical advice that we can get, precisely so that we can take a precautionary and proportionate approach.

Dr. Howard Stoate (Dartford)

May I congratulate my right hon. Friend and the chief medical officer on the measured and sensible way in which they are handling this situation? It is very reassuring for everyone in the country. I also thank my right hon. Friend for his assurance that he is to send observers to other parts of the world to ensure that, as far as possible, people are screened before they get on to aeroplanes. Clearly, the most effective way of controlling this outbreak is to ensure that people who are suspected of having the disease are prevented from travelling before they can spread it any further.

Will my right hon. Friend comment on recent reports that China has severely under-reported the number of cases there? There has certainly been a big stir in the media about that. Is he now confident that the Chinese Government have a policy and measures in place accurately to report the number of cases, so that we can be sure that we are getting the full facts?

Mr. Milburn

I am grateful to my hon. Friend. So far as observers are concerned, we have been in contact with the various British embassies in the affected countries about the situation. As I said in my statement, we shall be sending observers during the course of this week, particularly to the worst-affected areas, to double-check that the procedures that those countries say are in place are properly in place and that they comply with WHO guidance.

As for the under-reporting of the number of SARS cases in China, we rely not only on our excellent embassy staff in Beijing, Hong Kong and other parts of China that are affected, but on the guidance and expertise of the WHO. If the WHO is satisfied that the reporting in China is now accurate, we can also be satisfied that that is so.

Mr. John Wilkinson (Ruislip-Northwood)

Those of us with constituencies in boroughs containing major ports of entry into the United Kingdom will not be wholly reassured by the Secretary of State's statement. Will he institute right away a proper screening of inbound passengers from areas that are already seriously affected by the disease? Is it not better to be over-cautious than under-cautious, especially in view of the great risk of further spread of the disease in environments such as the London tube system, where as everyone knows there is close contact between individuals? What measures are airlines taking to protect air crew, especially flight attendants?

Mr. Milburn

The hon. Gentleman asks me to do the impossible and to come up with a form of screening that can detect the virus. We do not have the technology or the science to enable us to do that.

Mr. Wilkinson

Temperature screening.

Mr. Milburn

Temperature screening does not give us an indication either. The virus, particularly in its early presentation, shares many symptoms with coughs, colds and other viral infections. There is not a simple test. If there were, we would put it in place, as would Governments throughout the world. I am sure that the WHO would quickly advise us to do so. The only screening that we can do is to try to ascertain from passengers coming from SARS-affected areas whether they have been in contact with the disease. I realise that that is far from perfect, but the hon. Gentleman must understand that this is a new and emerging infection, that we are trying to learn as we go, and that the best scientific experts in this country and throughout the world are being deployed on that task.

The hon. Gentleman said that he was neither satisfied nor reassured by my statement. I accept that he has a view about that. However, if he is not prepared to believe me, I hope that he will believe some of the leading scientific and clinical experts in this country. Professor Roy Anderson, who is a leading epidemiologist from Imperial college in London, was interviewed by John Humphrys on the "Today" programme on Saturday. John Humphrys asked: Professor Anderson, are we sufficiently on top of this one do you think? Professor Anderson replied:

I think so, yes. I think the sort of doom and gloom predictions have been rather exaggerated. This is not a highly transmissible infection. It's been effectively contained in most of the developed countries in the world with very limited number of cases, Britain being a good example".

Jon Trickett (Hemsworth)

I feel reassured by the Secretary of State's statement, and I have absolute confidence that a properly funded national health service with an effective public health infrastructure is the best way to deal with this problem. I want to refer to an issue that was raised by one of my constituents on Thursday last. She is a parent escort for nine special needs children. She accompanies them back and forth to school, and one of them has just returned from a SARS-affected area. My right hon. Friend can understand the concern of other parents in the school or on the bus each morning. The local education authority was unable to give effective advice, except to monitor the progress of the child who had come back from the far east. What information does my right hon. Friend have about the level of infectivity prior to the display of symptoms? Can he reassure the House that there is proper liaison at local level between the health service and LEAs and other public bodies?

Mr. Milburn

Separately but in tandem with the advice that the chief medical officer has distributed to the national health service at local level, the Department for Education and Skills has also distributed information to LEAs through its channels. If it is helpful to my hon. Friend, I shall get a copy of that advice sent to him.

Fortunately, to the best of our knowledge, at this moment in time at least, people with SARS are not infectious until the symptoms appear. People with flu are highly infectious during the period leading up to the appearance of symptoms, but this disease appears on the face of it to be different. That should give us ground for optimism.

My final point is a response to my hon. Friend's first. A situation such as this clearly reveals the considerable strengths of a single national health service for our country, which are integrated provision and the integration of public health services at local, regional and national levels. That is why we on this side of the House, at least, intend to maintain a national health service.

Mr. Patrick McLoughlin (West Derbyshire)

Can the Secretary of State assure us that the advice given by the chief medical officer about areas that people should not visit is reflected in that given by the Foreign and Commonwealth Office?

Mr. Milburn

Yes it is, as far as I know.

Mr. Tam Dalyell (Linlithgow)

If I may be forgiven a constituency question, the Secretary of State may or may not know that after Glasgow and Edinburgh, Toronto is the third most populous Scottish city in the world. Many of my constituents go to and fro between Scotland and Toronto, particularly when taking their holidays. The big issue is whether they should cancel, or indeed in some cases book, trips to see their kin and loved ones in Toronto in July, August, September or October. What advice should we give to them?

Mr. Milburn

I am extremely reluctant to get involved in Scottish matters in general and Scottish holiday matters in particular. The best advice to which I can refer my hon. Friend is that given by the chief medical officer, and if it will help him, I will make sure that he gets a copy of it.

Dr. Andrew Murrison (Westbury)

Officials within the Secretary of State's Department have said that it is bureaucracy that is preventing this disease from being notifiable; in fact, the problem is under-reporting and under-notification through current legislation. Does he agree that his officials' comments have further undermined professionals' confidence in the reporting and notification system, and that those comments have not helped during the current outbreak? If he genuinely believes that the level of bureaucracy is at fault and that it is the reason why notification reporting has not been used for SARS, how does he intend to remove or to improve it?

Mr. Milburn

As far as under-reporting is concerned, the fault lines in the official notification system have been a cause for some concern not only for people in my Department but for public health professionals. As the hon. Gentleman must be aware, under-reporting has got progressively worse, rather than better, over many years. However, he will also know from the variant Creutzfeldt-Jakob disease episode that other systems of reporting can be at least as effective—they are often more effective—as the official disease notification system. Indeed, to the best of our knowledge, at least, vCJD is almost 100 per cent. successfully reported. All of the cases that are identified are properly reported.

The hon. Gentleman will share my desire—particularly in the early phase of what is a serious outbreak of this disease—that all cases be reported as quickly as possible with the minimum of bureaucracy, and that is what is happening. Cases are being reported directly to the chief medical officer and also to the new Health Protection Agency, rather than going through the form-filling exercise of which the hon. Gentleman is doubtless painfully aware.

Geraint Davies (Croydon, Central)

Given that the disease is much more well established in China, what is known about its profile in the later stages of its evolution in China in terms of spread, growth, transmission and mutation? Indeed, what is known about the actions that the Chinese are taking to combat the later stages of its evolution? Would it not be a good idea to take such actions in a pre-emptive way as a precautionary measure?

Mr. Milburn

As far as action in China is concerned, I understand that the Chinese Government are taking the matter and the accurate reporting of cases extremely seriously. Without accurate epidemiology, this or any other country will simply not be able to deal with the problems.

We know that the worst cases of the spread of SARS—including, tragically, not only those in China but in Toronto—have occurred where there have been inadequate cross-infection control procedures, particularly in hospitals.

We know from information from the Canadian authorities and through the World Health Organisation that, because several cases in Toronto hospitals were not spotted quickly, the isolated nursing procedures now recommended by the WHO were not put in place, leading to the fairly rapid spread of SARS. Many people adversely affected have been in close contact with SARS sufferers, so they tend to be close members of the family or, sadly, health care workers who have had to treat SARS patients. We know that much, and, because we know it, we can act appropriately and proportionately. That is why we are providing the advice and adopting the approach that we are.

Mr. Peter Luff (Mid-Worcestershire)

In his statement today, the Secretary of State was dismissive of the notifiable disease regime, effectively ruling it out as an effective tool in the battle to secure public health. If it is really as bad as that, what does he intend to do to reform it?

Mr. Milburn

The hon. Gentleman was present during my statement and he knows full well that I did not say that. I said that if I received advice from the chief medical officer that further powers were necessary, on top of those already available in legislation through the 1979 regulations, we would not hesitate to take them. However, I hope that the hon. Gentleman agrees that it is important to take decisions on the basis of the best clinical and scientific advice, which is what we will continue to do. The fact that we have done so to date is one of the reasons why we have so few SARS cases in this country so far, and we shall continue to adopt the same approach in the weeks and months to come.

Mr. George Foulkes (Carrick, Cumnock and Doon Valley)

Should we not put SARS more into perspective, as I am probably in greater danger of catching malaria? Should we not be more worried about the three children in hospital in Scotland with E. coli? Does not the panic caused by outrageous statements made in the media by Tory and Liberal spokesmen—I am glad that they were a little more responsible today—create tremendous problems? We should tell people that of course it is safe to go to Toronto. If we continue with this panic, not only transportation, but our economies will be adversely affected. If that happens, many more young children in the developing world will die of malnutrition as a result, which is something that we should really be worried about.

Mr. Milburn

I think that it is right to take the SARS outbreak seriously, but I also think that it is important to keep it in perspective and in proportion. I read with interest in one of the weekend papers an article by Dr. Robert Baker, who is a specialist in infectious diseases at King's College hospital in London. He reminded us that in the course of a day, 3,000 children die of malaria worldwide; that nearly 3 million more people will have died of tuberculosis by the end of 2003; that 40 million people have died from AIDS; and that in the USA, ordinary influenza kills between 20,000 and 30,000 people each and every year. There are also several thousand such deaths in this country alone. However, that is not to downplay in any way the significance of a new and serious illness.

My right hon. Friend is right that we have to keep a sense of proportion about SARS. I simply refer him to what Dr. Vivienne Nathanson, head of science at the British Medical Association, said about the problem: It is extremely important that the public does not panic over Sars. The Department of Health, the Health Protection Agency and the World Health Organisation are taking all appropriate steps.

Pete Wishart (North Tayside)

What particular measures has the Secretary of State taken to ensure that SARS does not spread to the nations and the regions of the United Kingdom? Given the current purdah in the Scottish Parliament, what discussions has he had with representative bodies in Scotland to ensure that the disease does not spread there?

Mr. Milburn

The hon. Gentleman will be aware that the chief medical officer in England has discussions, through the Health Protection Agency and the usual channels, with chief medical officers in the other countries of the UK. On public health issues, we try to maintain as far as possible a UK-wide response, so our response in England is largely mirrored in Scotland, Wales and Northern Ireland.

John McDonnell (Hayes and Harlington)

Given that the largest number of people entering this country from SARS-affected areas will come through Heathrow airport in my constituency, will the Secretary of State or a member of his ministerial team meet local Members of Parliament and representatives of primary care trusts and the local authority to discuss the resource implications of these incidents, especially in the light of his second recommendation that there should be wider screening of incoming passenger flights under certain conditions?

Mr. Milburn

My hon. Friend has written to me about those issues and I know that he has received several representations from members of the community and possibly from staff at Heathrow. I thank people who work there, especially those working in public health and the environmental health officers who have behaved extremely responsibly. Indeed, they have, off their own bat, introduced a system of random boarding of aircraft arriving from some SARS-affected areas to ensure that airlines are fulfilling their international health obligations. That is very welcome and if we can extend that system we should do so.

My hon. Friend asks about a meeting with a Minister from the Department of Health. I am sure that we can arrange that.

Dr. Vincent Cable (Twickenham)

What advice and reassurance can the Secretary of State offer the family of a teenager in my constituency who has a severely damaged immune system? They have already withdrawn her from school so that she does not come into contact with children returning from seriously affected countries after the Easter holiday. Would it not be helpful if the Secretary of State's guidance to local education authorities included information about the number of children returning from such areas and monitoring of their health?

Mr. Milburn

The best advice that I can give is to refer the hon. Gentleman and his constituents to the information that is widely available through various websites, including NHS Direct. If he or his constituents have been unable to obtain access to that advice, I shall be more than happy to provide it in written form so that he can pass it on to them.

Mr. Paul Burstow (Sutton and Cheam)

Given the importance of rigorous control of cross-infection, to which the Secretary of State referred, does he share my concern that scrupulous attention to hygiene and infection control in the NHS—for example, by hand washing—should be a key ingredient to ensure that not only SARS but any infection does not spread? Given that only a few years ago an Audit Commission report showed that hand washing was not being adequately done and given the fact that it is still not being adequately done, can we be as confident as the Secretary of State that the matter will not become a wider problem in the health service?

Mr. Milburn

The hon. Gentleman is right to raise those concerns, which many of us share. That is why we have sent two communications to the NHS—a third will be sent either today or later this week—stressing the importance, at senior and chief executive level, of ensuring that the appropriate infectious disease control mechanisms are in place in NHS trusts. It is not simply a question of hand washing; probable SARS cases will need to be treated in an isolated environment. The WHO recommends barrier nursing. So far, such processes have proven effective in that they have successfully looked after six people with probable SARS and limited further spread. It is that—the limitation of further spread—which is so important in dealing with this serious illness.

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