Tuberculosis and SARS

HL Deb 06 May 2003 vol 647 cc1026-42

8.1 p.m.

Baroness Masham of Ilton

rose to ask Her Majesty's Government what is being done to combat the spread of tuberculosis and severe acute respiratory syndrome; and what facilities for treatment and after-care are available in the United Kingdom.

The noble Baroness said: My Lords. my Question on tuberculosis has been queuing up for several months—well before the problem of severe acute respiratory syndrome was made public—but, as much TB is caused by the bacteria mycobacterium tuberculosis and is spread through the air like a common cold, I thought that the subject of SARS would fit into this short hut none the less important debate, and so I have included it.

SARS is easily transmitted by droplets that can travel two to three feet when an infected person coughs or sneezes. Some people are saying that it is a difficult disease to catch. There are confusing messages and the public should know the truth.

TB is of high prevalence in China, where SA RS originated. As a cousin of mine who visited the street markets in southern China said, "They are too horrible for words" and perfect breeding grounds for bugs. In southern China some people live close to birds and animals. Historically the region has been an important source of epidemics, and some diseases can be transmitted from animals and poultry to humans.

I am most grateful to all noble Lords and noble Baronesses who will speak today. I could not have asked for better Members of your Lordships' House. As the House will know, the noble Lord, Lord Soulsby of Swaffham Prior, is a world expert on zoonoses and other infectious diseases, including tuberculosis. I hope that the Minister will be able to answer some of the questions we will raise in the debate.

I recently asked two nurses, who work as district nurses in London, what we should do to stop TB. They both said, simultaneously, "Stop people spitting-. Spit had landed in the eye of one of the nurses. I checked to see what legislation there is and the Library drew a blank. It seems that footballers who spit at opponents on the pitch are the only people who get fined. When I was young, there used to be signs in trains and public places stating that you could be fined for spitting. Is it not now time that this was brought back as a matter of public health?

SARS has made the world realise how important are new infectious diseases. We should be looking with equal interest at diseases such as HIV/AIDS and tuberculosis. As Sir William Stewart, the Chief Scientific Adviser to the Cabinet, said: It is the combination of global bugs in global numbers, all with a propensity to mutate across the globe, that is an increasing concern". There is concern that the scale, the size and the resources of publicly-funded research facilities no longer match their equivalents in the US, Canada, the Netherlands and Germany. The Public Health Laboratory Service, now being subsumed into the new Health Protection Agency, operates from one floor in Colindale, North London, and yet it is expected to deal with a huge range of infectious diseases such as the current avian influenza, Lassa fever, Ebola and the threat of bioterrorism. The Government have laid all these problems at the door of the HPA, which faces the massive task of rebuilding our research base.

One of my cousins is a microbiologist and loves research. When he was working in Leeds he got frustrated as he did not have time to do his clinical research in the way he felt it should be done. He is now working in Western Australia, with a well-settled family, enjoying sport and his work, which gives him time for research. Unless the Government are prepared to give scientists the backing that they need, it will be a long time before Britain can again take its place in the front ranks of medical science.

I was most impressed when I heard the right honourable Ian McCartney speak in a personal capacity at a campaign to stop TB. Perhaps he was not what most people expect as typical of the person who gets TB. He was well paid, well housed, well fed; he is white, middle aged and a Member of Parliament. He had become increasingly tired and listless and developed acute abdominal pain in his left side, and the symptoms spread to his groin and testes. It was all put down to stress. Finally, after months, he was diagnosed and treated for non-respiratory TB. This is an example of how TB can affect anyone, anywhere in the body. After the right honourable Member for Makerfield was treated, he suffered a great deal of pain which, after years, was found to be from adhesions.

The right honourable Member's case illustrates the need for correct diagnosis and for more specialists who can diagnose and treat patients with the expertise they need. I have been in touch with the right honourable Ian McCartney, and I told him about this debate.

One has to ask what happens in the UK to those on the street or those who have a chaotic lifestyle. The simple requirement of a regular supply of fresh running water is difficult for many, yet to fail to maintain the drug regime is potentially disastrous for the individual and for society as a whole as we see the emergence of drug-resistant strains of tuberculosis.

Three million people a year die from TB and about 7,000 people are affected in England and Wales every year. There are outbreaks from time to time all over the country in places such as Leicester, Glasgow, Kent and Liverpool, but the highest numbers are in London, which have been compared with third world countries. The areas affected are Newham, Brent, Tower Hamlets, Ealing, Hackney, Islington and Camden.

With the increase in active cases which is expected in the future, the correct treatment is vital. The most common cause of treatment failure and acquired drug resistance is non-adherence. Predicting non-adherence is highly problematic. Directly observed therapy is the most effective means of combating non-adherence; intermittent—less than daily—regimes facilitate the therapy. Testing the susceptibility of mycobacterium tuberculosis to drugs is essential for identifying resistance and tailoring treatment. Managing multi-drug-resistant tuberculosis is complex and should, when possible, be done in specialised programmes.

In New York, DOTS was tried, and it worked. The World Health Organisation recommends it throughout the world. Is DOTS currently carried out in Britain and, if not, why not? I was concerned to read in the press that of 43 TB hotspots in England and Wales 86 per cent had insufficient staff to treat patients with the disease.

As we know, the modern world is small, and air travel is fast. Many of the people developing TB here in the UK have lived abroad; many with HIV/AIDS also have TB. To know the approximate numbers is important for planning health services. Perhaps the Minister can tell us what is being done about testing and ensuring there are adequate treatment and aftercare facilities. Is BCG vaccination being given in schools, and how effective is it?

It would be most helpful for a global, unified response to the WHO's global fund to fight AIDS, tuberculosis and malaria, as it needs more support from most donor countries. The WHO predicts that by 2020 nearly 1 billion people will be newly infected with TB, of whom 70 million will die.

I look forward to the contributions of your Lordships and the Minister's reply.

8.12 p.m.

Lord Soulsby of Swaffham Prior

My Lords, the House should be grateful to the noble Baroness, Lady Masham, for putting down this debate on these two important entities—the old and the new. The old—tuberculosis—is often called the captain of death, and the newest is SARS, or severe acute respiratory syndrome. I declare an interest as chairman of the subcommittee of the Science and Technology Committee on fighting infection. We take a strong interest in both these entities.

It is not many years ago that we tended to believe that as an island we were secure from many global diseases, but that is no longer so. As the noble Baroness said, Sir William Stewart, the recently appointed chairman of the Health Protection Agency, made the point that global disease entities are our neighbours. As an example of how diseases an spread, he estimates that there were 750,000 flights into the United Kingdom last year, bringing 72 million passengers into this country. We are a nation of 60 million or so, and we are exposed to the infections of 6.3 billion people on a global scale. Global infection is the norm.

Tuberculosis is now classed along with HIV/AIDS and malaria as a major killer. The figures are horrendous, as the noble Baroness said. The WHO has said that between now and 2020 there will be 1,000 million new infections. Two hundred million people will become sick and 35 to 50 million will die. We believed that we had TB under control. Infection rates were progressively declining. But two entities changed the situation, one of which was the occurrence of HIV/ AIDS. The two diseases go together, and the occurrence of tuberculosis is 30 times higher in HIV/AIDS communities. The other important factor is the antibiotic-resistant forms of the tubercle bacillus. In England and Wales in 1987, when we believed that the major problem was over, prevalence rates began to rise again. Whereas, in 1987, 14 per cent of all TB cases occurred in London, now 50 per cent occur there.

As the noble Baroness said, the most effective therapy is directly observed therapy—or DOTS. There are five elements to DOTS, all of which must be accomplished for the programme to be effective. First, there must be political commitment to it. Secondly, there must be case detection, either by sputum testing or possibly by a new blood test, as was mentioned recently. Thirdly, standard treatment must be provided under direct observation. Fourthly, there must be an uninterrupted supply of drugs and. fifthly. standard recording and reporting.

When introduced on a national scale in various countries, the cure rate has been very high. For example, in India DOTS has achieved a 95 per cent cure rate, at a relatively small cost of 6 to 20 dollars per patient. However, it is no easy task to satisfy all the criteria of DOTS. and unsatisfactory completion will lead to failure.

In the United States, especially in the Harlem hospital which members of my committee had the pleasure and honour to visit, there is a very effective programme. They have extensive community outreach. Since the hospital is in a low socio-economic area, incentives for therapy are provided by way of food coupons and travel cards. Most impressive of all was the commitment of hospital staff, from cleaners to the chief medical officer, to getting rid of TB. The concept of the individual patient was that helping himself or herself to be cured of TB helped the community by clearing the infection from the local population and stopping transmission. Thus it became an outreach control programme.

I join the noble Baroness in asking the Minister if such centres exist in the United Kingdom, how they are functioning and what plans there are for their expansion. Other areas on which she may wish to comment are vaccination, especially the availability of BCG vaccine and the development of new drugs to overcome the problem of multi-drug resistance.

In the few remaining minutes I shall refer to SARS, which on the scale compared to tuberculosis is infinitesimal in terms of infection and death rate. Nevertheless, we do not yet know how far it is going to go. The main focus is the Far East, in China and Hong Kong, where there have been hundreds or thousands of infections with hundreds of deaths. We are fortunate in this country that we have had only six reported cases and no deaths. In the European Union, there have been 100 cases and no deaths.

We need to ask about a number of entities in this matter. First, what are the facilities for isolation in this country of SARS cases? Have special nursing facilities been identified? What research developments have occurred in the field of antiviral drugs? Is there good collaboration and exchange of information between this country and the United States, where major developments in vaccines and antiviral drugs are taking place?

SARS is an example of the truth of the adage that the price of freedom is eternal vigilance. We now know that that is best achieved by national and international collaboration, as has been well demonstrated by the response of the global community to SARS.

Baroness Farrington of Ribbleton

My Lords, may I remind the House that my noble friend the Minister will not have time to reply to the many questions asked if noble Lords overrun their time?

8.20 p.m.

Lord Chan

My Lords, I congratulate my noble friend Lady Masham of Ilton on securing this short debate on two important infections which are very relevant to the health of our nation.

Tuberculosis is an ancient infection found in Egyptian mummies which still affects some 7,000 people every year in England and Wales. Conversely, severe acute respiratory syndrome—SARS—is a new infection which is probably caused by a new variant of the coronavirus. It was first reported last November, and within three months has captured headlines worldwide because of the fear it has generated in East Asia and in Toronto, Canada. Thankfully, there have not been a significant number of SARS infections in Britain. However, our communities at risk, such as the Chinese community, are as fearful of SARS as their counterparts in China, Hong Kong and Singapore. That is one reason why we should be considering this new infection for which there is no known treatment and from which some patients die within a week or two of falling ill.

Tuberculosis cases have increased 27 per cent in the past 10 years, to 7,000 cases reported in England and Wales annually. Communities at high risk of TB tend to be new arrivals from Bangladesh, India. Pakistan, Africa, South East Asia and some countries from eastern Europe including Russia. They account for the high incidence of TB in some inner-London districts. People with HIV/AIDS, particularly those from sub-Saharan Africa, tend to be malnourished, to have reduced immunity and to be prone to TB infection. Some have come to Britain for treatment.

Physicians treating tuberculosis, specialist tuberculosis nurses and NGOs focused on TB have designated 24th March as Concern for Tuberculosis Day. The recent campaign to raise awareness of TB among high-risk ethnic minority communities is to be commended. Patients with TB can be successfully treated with a six-month course of anti-tuberculosis drugs. It is essential that patients complete their drug treatment. If they fail to do so, drug-resistant strains of TB may develop and become difficult to treat. As TB can be effectively prevented by BCG vaccination, I look forward to the Minister's report on how BCG immunisation is being administered to prevent TB infection in our children.

SARS is a new infection which originated last November in China and spread to Hong Kong, Singapore and Toronto through an infected person spending a night at the Metropole Hotel in Hong Kong, infecting people living on the 9th floor of that hotel. The spread of SARS to Singapore and Toronto has been traced in detail by epidemiologists. Deaths have been highest among family contacts and healthcare staff. The death rate has risen from 4 per cent to nearly 10 per cent. Children are least affected and older adults most likely to die. There is no specific treatment for this pneumonia-like infection.

In Britain we have had only six probable cases and all have recovered. However, high levels of fear are present in the Chinese community, particularly as they watch satellite television from Hong Kong and erroneously assume that precautions recommended there, where SARS infection is still active, should be implemented in Britain. Fear of SARS has drastically reduced the number of diners in Chinese restaurants in London's Chinatown. Chinese students attending boarding schools in England have been kept in quarantine in schools in the Isle of Wight and in Knutsford, although all have been in good health and, as far as we know, have not been in contact with SARS patients in Hong Kong or China.

Will the Minister please give us assurance with regard to the system of SARS infection surveillance and indicate what advice should be made available to the Chinese community here? I look forward to her reply particularly as regards reassuring Chinese families that cutting themselves off from other Chinese who may have recently visited South East Asia is unnecessarily contentious. It would be more practical for all with coughs, colds and fever who have been travelling and have come home to consult their GP as soon as possible.

8.25 p.m.

Baroness Gardner of Parkes

My Lords, I thank the noble Baroness, Lady Masham, for initiating the debate. It is a subject which interests me as years ago the Brompton Hospital had a huge basement full of TB records. When the new hospital was being built and we discussed what we should do with the TB records some people said that they were history and that TB had gone for ever. However, those records were not thrown out in the expectation that one day someone would sort them out.

No one then imagined that TB would come back in the way that it has. The tubercle bacillus is as serious today as it was when it caused such damage in the past. However, standards of general health have improved and perhaps people now have more resistance. On the other hand, certain strains are resistant to antibiotics.

As far as we know, SARS and TB have a common form of transmission. We believe that they are both transmitted by air or in sputum. As the noble Baroness said, the world is small and jet air travel has made it even smaller. On 10th April during Starred Questions I asked about airlines and air circulation in aircraft. The Minister gave a satisfactory reply but subsequently I received an excellent letter from British Airways. Your Lordships may like to know that British Airways takes these matters very seriously and more than meets the World Health Organisation requirements. The letter states that, approximately 10 cubic feet per minute [of air] is re-circulated and passed through high efficiency particulate filters to remove bacteria and viral particles. These … filters … are the same as those used in hospital operating theatres". That is reassuring for travellers. Indeed, it is believed that, the Coronavirus is too large to pass through the filter". That is also reassuring.

However, it is less reassuring to read the newspaper headline: Touching a door is enough to catch Sars virus". We might have thought that we could prevent airborne transmission by wearing masks. However, now the newspaper states that transmission can occur through, touching a contaminated table top, lift button, or doorknob, rather than being directly exposed to the sneeze or cough of a patient". The paper further states: Globally, according to WHO, Sars has infected 6,234 people and killed 435". It also states: Experiments show that Sars can survive for at least 24 hours on surfaces, and for several days in human waste". It is believed that that was a factor in the outbreak in a Hong Kong block of flats. A man infected with SARS used his brother's lavatory in the block. The sewerage system was defective. It is believed that the infection was transmitted via a tiny crack in a sewage pipe.

Reading that latest scare story it seems to me that we still do not have any real idea of how SA RS is transmitted. We are more able to deal with TB as we know how it is transmitted. We must be vigilant in that regard.

When I first raised the issue of SA RS in the Chamber during Starred Questions on 25th March the Minister told us that there were very good procedures for warning GPs about infections such as SARS. The noble Lord, Lord Soulsby, asked whether we had isolation facilities. When I was chairman of the Royal Free we were responsible for the isolation hospital which was equipped to deal with the Ebola virus, which is much more serious. It was scary to see the ward in which people were to be nursed. The entire bed was encased in plastic. No hand came into contact with the patient. Even any food to be given to them had to put in one little hatch and taken out of another. We have the facilities but, to the present time, we have not needed to use them. The cases that we have had have responded to good nursing and good general care.

Let us hope that this country never sees an infection like the Ebola; that would be just too terrible. I was very disturbed to read in, I think, the Sunday Times, an article written half-jokingly about that terribly serious subject. If what we are talking about tonight is serious, that is even worse. To write about it in that way was not good news.

We will all be interested in what the Minister has to say. The financial implications for the world are very serious, and there must be some overlap between financial concern and health concern. People worry about how they will survive, which could be damaging in itself. There is awareness in this country and across the world, and we now simply have to proceed and do whatever we can.

8.31 p.m.

Baroness Finlay of Llandaff

My Lords, like others who have spoken, I am most grateful to the noble Baroness, Lady Masham of Ilton, for having introduced the debate. I must declare an interest as a member of the Science and Technology Committee's sub-committee on fighting infection.

I shall confine my remarks to SARS. In doing so, I pay particular tribute to my friends and colleagues who have been at the forefront of dealing with the epidemic. I suggest that it is because of the vigilance of healthcare workers, their quest for knowledge so that they can understand what is happening, the research they have undertaken and its rapid publication, the sharing of all data, and the rigour of applying isolation procedures that we do not have a much worse situation on our hands.

The Hong Kong Hospital Authority website is excellent. It records that, as of yesterday, there were 187 deaths in Hong Kong, principally among those who had a history of chronic disease. The authority also records that 20 per cent of cases are among healthcare workers and their families and the volunteers working with SARS patients. It seems that hepatitis B and chlamydia are co-factors in the disease, and may account for children having a less severe and aggressive clinical course with their disease.

I wish to read briefly from an e-mail from a friend of mine who is at the forefront of the battle. She is chairman of the Hong Kong Society of Palliative Medicine and describes its involvement, stating: Just to name a few, both Dr. KS Chan and I have to work as clinicians in the SARS ward in different hospitals. KS volunteered to work in United Christian Hospital … which receives a bulk of very critically ill patients, and co-lead the team with the clinicians. I … have to set up the SARS ward in Caritas Medical Centre, and in-charge of the overall operation … The dying process of a patient suffering from SARS is very different from what we regarded as 'normal' because of infection control policy. To me, it could be the most isolated and lonely path for the dying patients and their families … In Caritas Medical Centre, we have a psychosocial support team comprised of social workers, volunteers, pastoral care workers, clinical psychologist and other supporting staff. They provide services … delivering supply from relatives to patients twice a day, provide brief account of the latest clinical condition, and sending words from relatives to patients by fax. As for the dying scene, I am still thinking hard so as to make it less traumatic … Many of my staff are staying behind to combat a possible outbreak in one of my wards. Many are sleeping away from home. It is time for me to take a break for today as well … The virus is extremely tricky". In Hong Kong, a SARS task force has been set up. and in Beijing the experience is similar. A doctor from Beijing has told me that approximately 8,000 people are in quarantine there. At great speed, a 2,000-bed isolation hospital is being built by the army on the outskirts of Beijing. It is anticipated that the epidemic there will peak in the next two weeks.

Research among healthcare workers in Hong Kong has shown that those who have become infected have had a significant failure in using one of the protections, particularly a surgical mask. Paper masks are inadequate, but it seems failure in the use of a surgical mask has accounted for infection. Some of the others who have become infected have failed in the use of gloves, hand-washing or gowns.

The cost of containment is massive and is resulting in a radical change in society. I quote an e-mail from another friend and colleague. She says: No school … no lessons, no ice skating, no piano, no swimming … no travel … No touch … as the hand is dangerous and the face most vulnerable. Ladies don't play with your hair or touch your glasses … Don't rub your eyes … don't shake hands … don't kiss or hug … No talking … Note three feet apart and be anti-social … No coughing unless you want to have the whole room to yourself … No business … no flights … No banquets, no cinemas, no shopping, not even church … No rings nor earrings … no watches nor badges to work … no photo-frames, no cups nor chopsticks on your work top … Don't leave work with [the] Corona [virus] … shower before you leave. Wash your watch and glasses too. Wash your hair … everyday. Then wash your phone and pager with hexolwipe … Have a clorox towel ready at your doorstep". She goes on: I'm running out of clothes to wear. My whole wardrobe is lined up for the washing machine … the obsessive survive … The staff [are] burning out … When will it end? This week's edition of the Economist and, today, the Financial Times have highlighted the effect on the economy. But what are some of the lessons that we have to learn? The Corona virus has been identified. It is a very tough virus. It survives cold; it survives on surfaces for at least four days; it may continue to be excreted in the faeces, particularly of those with diarrhoea, for about 42 days or longer. There may be others who are excreting the virus for even longer.

Long hospital stays are required. In Hong Kong it is reckoned that 23 per cent of sufferers have required intensive care and ventilation. I ask the Minister: could we cope with such a situation here if we had a similar number of sufferers? Could we cope in terms of the supply of masks? In Hong Kong there has been a major voluntary fund-raising effort to buy enough equipment to provide the staff with adequate masks, gowns and gloves.

Are we accepting adequate precautions here? Why did the department's advice on the way in which healthcare workers should be advised appear only on 30th April when our postgraduate students from abroad had returned to our healthcare institutions on the 28th and went onto the wards? Do we have enough supplies of disposables? Could we cope—or do we have to take the model of the giving people who have worked in healthcare in China and Hong Kong to try to contain the epidemic so as to protect us?

8.37 p.m.

Lord Clement-Jones

My Lords, first, I congratulate the noble Baroness, Lady Masham, on initiating a debate on these twin, but related, issues which are both very important. The expert contributions that we have heard have been illuminating.

Last week we had an interesting exchange of views on SARS following the Government's Statement. I do not believe that any of us underestimated the seriousness of SARS, but the general view of this House was that the Government, advised by the WHO, the Chief Medical Officer and the Health Protection Agency, backed by the expertise of the NHS, had struck the right balance.

Our main area of criticism on these Benches related to the visibility of Ministers and to the need to provide reassurance, and to the reasoning behind the decisions that were made in response to some fairly alarmist press coverage. This was largely remedied in our view by the Secretary of State's Statement last Monday.

It is now good to see that the UK has been taken off the WHO list of countries affected by SARS, as the number of the six original cases has not grown any higher. It is also good to see—an area of major concern—that India is judged by the WHO to be SARS free. However, we must not be complacent in the UK or internationally. I hope that the Minister will confirm that the HPA and other agencies will remain vigilant. In particular, we must all hope that the Chinese authorities, after a bad start, now with a new policy of public openness, manage to bring SARS under control. In Hong Kong, however, despite the graphic and interesting consequences mentioned by the noble Baroness, Lady Finlay, the outbreak does appear to be coming under control.

We should also welcome the meeting today of European Health Ministers in Brussels, which is designed to ensure that the virus does not gain a larger foothold in Europe, and that there is a properly coordinated response to SARS. Public health is increasingly a matter that governments accept should be dealt with at the European level, in view of the speed of cross-border transmission, as we have seen with SARS.

During the Statement last week, I asked whether there were sufficient resources for our infection control teams. The Minister replied that all necessary resources must be provided. She did not say how the HPA or the department would audit that. I asked the same question in the debate on MRSA in light of the survey findings of my honourable friend Paul Burstow: that is, that the perception in the survey of the infection control teams was otherwise. However, on neither occasion did the noble Baroness give me an answer. I do not know whether the answer is a secret, since she has not vouchsafed one so far. Perhaps it will be third time lucky in this debate.

I believe that TB is a major contrast to SARS in being much longer-standing as a killer disease. As the noble Lord, Lord Soulsby, mentioned, it is ultimately more serious. If I had a better memory, I could recite which of the Dickens characters suffered from consumption, which was so rife in our cities. As the noble Baroness, Lady Parkes, said, the worry is that it appears to have returned in spite of our belief that it had been conquered. Disastrously, TB still has a massive impact worldwide. Eight million people a year develop its most active form and 2 million people a year die from it. A total of 900 million people are infected with TB. Someone dies from TB every 15 seconds. Even in the UK, we have had outbreaks over the past few years in Leicester, Glasgow, Kent, Dundee and in particular London, where the majority of cases are now diagnosed.

There are major questions about resources, which the noble Baroness, Lady Masham, raised, and in particular about vaccinations. London is a hotspot, as the noble Lord, Lord Soulsby, said: 50 per cent of the cases that come to the notice of health authorities are in London. There are major questions about the way in which that is being tackled in the area.

At the end of the day, there are 7,000 cases in the UK. The key problems are on the international front. I welcome the actions by the World Health Organisation and the Stop TB Partnership, which is sponsored by it. I welcome the appointment of the next director-general of the WHO, Dr Jong Wook Lee, who spent the past two years as director of the Stop TB Partnership. Clearly, TB is high on the WHO's list of priorities. The UN has set the target of halving and reversing the incidence of TB by 2015.

There is no doubt that the DOTS programme has had some major successes, particularly in China and India. However, in some sub-Saharan African countries and countries of the former Soviet Union, TB is still growing unchecked.

Many of the answers lie not domestically here with the Department of Health but with DfID, the Treasury and the Foreign Office. We cannot isolate the UK from TB as it rampages in developing countries. We need action on a global scale. The WHO described it as the disease of the disadvantaged. It identified a funding gap of some 300 million dollars. What is the Government's view of whether there are adequate resources to fight it in developing countries? What pressure is being applied to pharmaceutical companies to prevent them from pricing treatment in developing countries out of the market?

As regards the UK, apart from our international aid efforts, TB must be stopped in its tracks on every occasion at which it is detected. We must ensure that our surveillance is excellent domestically and on our borders. There are signs that TB is becoming resistant to antibiotics and that drug cycling is necessary to combat that. Work by the University of Tennessee shows that it is most effective on a cross-border basis, which means, for us, on a pan-European basis. Our belief is that health checks should depend on where one comes from, not who one is.

Finally, it is important that our public health legislation is fit for the purpose. The Minister made it clear that the Government have accepted the fact that our public health legislation needs an overhaul. I hope that when she replies, she will cast more light on that and say when it is planned and of what it will consist.

8.44 p.m.

Earl Howe

My Lords, the coupling of SARS and TB in the noble Baroness's Question brings home to us, as she explained so well, the urgency and difficulty surrounding issues of public health. Last week we had quite a full and helpful debate on SARS on the back of the Government's Statement to Parliament. I do not believe that it would be fruitful to go over for a second time all the territory that we covered on that occasion. I said then, and I repeat, that I welcome the measures that the Government have taken to prevent the further importation of the virus into this country and to ensure that if it does arrive, sound protocols are in place to minimise the risk of it spreading.

Yet even in the past few days events have moved on. No new cases of SARS, thankfully, have occurred in the UK. There are signs that in the Far East, with the glaring exception of mainland China, the disease is being brought under control. It would be useful if the Minister could give us an up to date bulletin of new cases recorded in countries around the world over the past week and the progress made in stemming the progress of the disease.

One obvious difference between SARS and TB is that, whereas we know a very great deal about the latter, the same is not true of the former. New facts and new theories are emerging about SARS with every day that passes. We cannot devise robust strategies for controlling the spread of SARS without clearer knowledge of the ways in which the virus can be transmitted; how long the virus survives outside the human body; and who is most at risk of getting it. The precautions that have been taken to date are sensible only in the context of current ignorance.

It is certainly in no one's interests to exaggerate this scare in any way. The CMO has stated that the risk of catching SARS is low, yet, as my noble friend Lady Gardner said, the known facts inevitably change. Only a short time ago we were told that the SARS virus could live for a short time on the button of a lift but that the main route of transmission is through coughing. Now we understand that it can survive for up to 24 hours outside the body and that it can be transmitted via sewage. On top of that it appears that the virus can mutate quickly.

As was said last week, two things above all will help to defeat SARS: flexibility of response and vigilance. Setting aside the difference of view between the Opposition and the Government about making SARS officially notifiable, I believe that the actions that the Government have taken and are taking reassuringly embody those two principles.

What we would do and how we would cope if there were a major outbreak of SARS in this country is another question. The British Lung Foundation has expressed its grave concerns about the shortage of respiratory physicians. A third of all advertised respiratory consultant posts remained unfilled last year: and the number of consultants in the UK per head of population is under half the European average. In simple terms there are not enough chest specialists to cope with the present workload, let alone a bigger one.

That sobering fact, on which I hope the Minister will comment, is relevant to TB, which is now officially a global health emergency. The noble Baroness drew our attention to the steadily rising incidence of TB notifications nation-wide and its worrying prevalence in particular hot spots such as London, where the rate of infection in certain boroughs is higher than in some developing countries. None of us can be complacent in such a situation. Still less can we be complacent in the face of new strains of TB that have proved to be antibiotic resistant. As with SARS, the strategy to counter the spread of TB must be twofold: prevention and containment.

On prevention we have to face the fact that the rise in TB prevalence in this country is attributable principally to Africa and the Indian sub-continent. Individuals who arrive in this country either through the normal channels or as asylum seekers do not as a rule have to undergo medical screening, as they would have to in many other countries. I believe that we have to question whether we can continue to justify a policy of blissful ignorance about the health of those who apply to live permanently in the UK. Not to conduct basic checks for serious diseases such as TB or HIV both disadvantages the applicant and overloads the NHS. Compulsory screening of asylum seekers originating from TB hotspots is necessary. That is also the view of, among others, the BMA and the British Thoracic Society.

But TB can of course also be prevented by vaccination. I should be glad if the Minister could say whether she is satisfied with both the availability and the potency of current BCG vaccine supplies. Can she also tell us what has happened to the action plan for TB in London which was promised some time ago and whether the TB Awareness Campaign launched last year by Yvette Cooper has had any success in reaching ethnic minority communities?

In London we must be frank and recognise that strategies to control TB have thus far failed. London has the highest rate of drug-resistant strains and half the entire country's tally of TB cases. The action plan for London is of vital importance and will require both resources and a high level of commitment from all arms of health and social services. That commitment needs to extend across the country to our prisons. DOTS should be central to that. I hope that tonight the Minister will reassure us that there are credible strategies in the NHS to combat and to defeat this most tenacious of human infections.

8.50 p.m.

Baroness Andrews

My Lords, I am extremely grateful to the noble Baroness for enabling us to have such an interesting and incredibly expert debate. I am grateful to all noble Lords who spoke of their personal, professional experience and indeed of their many contacts on the frontline in order to inform us about what is going on in the most seriously affected parts of the world regarding SARS.

There is an ingenious link between TB and SARS. Given more time and based on my previous existence as a historian, I would have been able to dwell for many minutes on the gift that TB presented to Victorian novelists and sociologists. We are extremely grateful that those days have passed. By the mid-17th century, one in five deaths in London—as recorded in the Bills of Mortality—was due to TB. The disease became known as the "White Plague". The 19th century estimate of the world-wide TB death rate was 7 million per year. London, as now, was one of the worst affected cities. There was an apocalyptic vision that by the end of the 19th century TB would decimate the country.

So there are extremely interesting parallels, not only in the nature of the disease and the impact that SARS and TB might have, but also in the challenge that those diseases present to our public health system. Over a century later, just as tuberculosis helped to shape and strengthen our public health system and our ability to deal with infectious diseases, so now SARS has benefited from our having in place a robust public health system and our understanding of ways to prevent the spread of disease.

The contrast between SARS and TB is that for TB we have diagnostic tools; we have the BCG vaccine and effective drugs. Those, together with improved nutrition and improvements in the public health environment, have played their part in reducing the number of cases in the UK. They reached 50,000 in the 1950s and dropped to 5,087 in 1987. As regards SARS, the brilliance of our researchers—and we pay tribute to them and to their outstanding contribution made in recent weeks in the discovery of the Coronavirus and so on—now means that we know a lot more about the SARS virus. But diagnostic tests are still in the early days of development and there is currently no specific treatment.

My information to date is that there have been 6,583 cases of SARS reported from 27 countries and 485 deaths. Here, the control of SARS depends more on the traditional public heath measure of identifying and containing cases. Furthermore, as noble Lords have said, we have been successful. We have identified only six probable cases. The one case where infection was acquired in the UK, and as a result of which the WHO temporarily listed Britain as an affected area, was now more than 20 days ago. I am pleased to report that the UK, along with the United States, has now been removed from that list.

Of course, as the noble Lord, Lord Clement-Jones, said, we must not be complacent. Although the situation seems to be improving in the most affected areas, including Vietnam, Singapore and Canada, in mainland China the number of people affected is still rising. The noble Baroness, Lady Finlay, pointed out in graphic detail what it means to be on the frontline and fighting the disease. That brought home to us, as nothing else could, what those health workers are facing on a day-to-day basis. I am very grateful that she brought that evidence to us.

Our knowledge is changing. From recent evidence, we know that the virus may survive on door handles and in human waste longer than we had previously thought. We have to build that into our assumptions. It emphasises the need for infection control. Here, the Chief Medical Officer has issued very strong and stringent advice to chief executives about infection control systems. As I informed noble Lords last week, we are keeping our plans under review. We must do. We are learning lessons where they need to be learned; we are building on good ideas wherever they are to be found; and we are in daily telephone contact with the WHO. So we know exactly what is going on and, in response to the noble Lord, Lord Soulsby, our researchers are in close contact.

There are similarities also because both SARS and TB appear to be spread mainly through a chain of person-to-person contact—family and household members and, with SARS, especially among healthcare workers. But it is with TB that we face a new threat.

As the noble Lord. Lord Soulsby, said, we thought that we had achieved control over TB by the 1980s, but it has re-emerged as a public health problem, largely as a result of increased migration from areas of the world where TB is most prevalent. It is important to put that in context.

During the past 10 years, cases of TB have risen in England and Wales to about 7,000 cases a year, bringing the long, steady decline to an end. I was grateful for the example provided by the noble Baroness, Lady Masham, of how it can affect all of us, including a Member of the other place. We are delighted that he recovered so well. It is a global emergency, as designated by the WHO, which estimates that one third of the world's population is infected with the bacteria that cause it. Two million people die each year; and 8 million people develop the disease. It is important to stress that it is a curable infectious disease.

In the UK, our highest levels of infection are among the Indian sub-continent and black African communities—and, of course, in London. TB has been identified by the CMO as one of the four infectious diseases requiring intensified control measures. It has given rise to the TB action plan, which I should like to describe, which was preceded by three initiatives to which I draw the House's attention.

First, there was the TB awareness campaign, launched by the Department of Health, which hit its target audiences in the Asian, African and eastern European communities. We issued that information in all the appropriate minority languages and believe that it resulted in successful take-up.

Secondly, we have responded to concerns about people arriving. Immigration officers at inward ports are instructed to refer passengers who arrive from relevant areas who plan to stay for six months. In 2001–02, nearly 150,000 passengers were referred at Heathrow. About 57,000 chest X-rays were performed; 138 people were referred for further investigation; and 94 were found to have TB and followed up with therapy. So we know that that form of surveillance seems to be working. Thirdly, we have completed a pilot in asylum induction centres in Kent, which is also picking up susceptible people. There has been a positive take-up by asylum seekers.

We must regain the upper hand over TB and acknowledge that control has not been consistent across the country. The three main targets are to ensure that all people with TB receive high quality treatment and care; to reduce the risk of people acquiring new infections; and to maintain low levels of drug-resistance.

The Chief Medical Officer will shortly announce the plan, but we want to develop strong co-ordination to deliver a national TB programme with a clear focus. That includes staffing plans—who we need, where we need them and how to get them—because so many people are involved in TB, whether communicable disease staff, GPs or nurses. Co-ordination is essential.

We have worked hard on action in cities that have the highest burden of TB, and among population groups at risk, which obviously include the homeless and people in prison, for example. We shall ensure that patients are seen promptly and receive the aftercare that they need to support them during the six months for which they need to keep taking antibiotics. They do not enjoy it; but it is extremely important to support them in doing so, which is precisely where our strategy for fighting drug resistance is involved. We need patients to be seen more promptly and the laboratory services to work more quickly.

Perhaps I may quickly answer a few questions. We are satisfied with the BCG immunisation policy. We have sufficient BCG vaccine. We had a shortage last year, but that is now entirely solved and overcome. We provide BCG immunisation mainly to babies at high risk of exposure to TB and previously unimmunised school children aged 10 to 14.

In response to the noble Baroness's question about whether we could cope, we have in place contingency plans for outbreaks of infectious disease. We have no problem with the supply of masks at present.

In response to the noble Lord, Lord Chan, who has been carrying out stalwart work with the Chinese community, we understand the need for reassurance. We will make an effort to provide further advice to the Chinese community. But, of course, the same advice that helps others in the community applies to the Chinese community. On resources, I say to the noble Lord that we have had an historic uplift in the NHS budget, which, I am sure, will make a big difference. We look forward to being able to do the things that we want to do and that we say we will do.

In conclusion, last week, in a Statement to the House, I mentioned five actions that we were taking in response to the SARS outbreak. The letter to the chief executives that I quoted was certainly circulated. We have now sent observers to look at screening mechanisms in Hong Kong and Singapore, and we are negotiating with Beijing. We have written to airlines to remind them of their responsibilities under the 1999 aircraft regulations. We are making substantial progress in information going on to airlines themselves. In the meantime, we had a European meeting today on co-ordination and development. We look forward to seeing what will come out of that.

The UK has a very strong record of surveillance and management of cases. We observe the DOTS strategy set out by the WHO. I hope that, in response, noble Lords will appreciate that we are doing our very best in relation to both TB and SARS.