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... I left the meeting shaken at how little was listened to, as did the guests I was permitted to take with me. In spite of our courteous reception it was evident that our attempts to put the other side were falling on deaf ears. In fact I was too disheartened even to claim my expenses for making the journey from France. ... 

 

Warmwell at Lessons Learned

 

FOOT AND MOUTH DISEASE LESSONS LEARNED INQUIRY

Note of meeting

Date: 23 May 2002

Location: 9 Whitehall

Present: Mary Critchley, Warmwell

Alicia Eykyn, FMD Forum

Nicola Morris

Iain Anderson, Inquiry Chairman

Alun Evans, Secretary to the Inquiry

 

1. Dr Anderson thanked Mary Critchley, Alicia Eykyn and Nicola Morris
for attending the meeting.

The following points were made in discussion:  

2. The crisis was so huge and spread so quickly that it had been a difficult
task to condense thoughts on the outbreak. At first, Ms Critchley had
started the web-site in response to news through letters and telephone
calls from friends and colleagues across Britain. She had begun to ask
herself if Britain could really be a police state? A farmer friend in Dumfries
and Galloway had had his life's work of re-establishing a rare breed of
hardy sheep destroyed. The ewes had just successfully lambed. The
farmer, his vet and Mrs Critchley were all convinced that there could have
been no question of infection. The entire flock was killed in the most
distressing circumstances. This was the catalyst for setting up the web-site.
 
3. She had felt deep concerns that many vets had colluded in the slaughter
policy and had breached their RCVS oaths in which they promise to up-hold
the welfare of their animal charges. The Warmwell web-site was
established in May and gave a daily summary of as many newspaper
reports as possible on the progress of the crisis, offered legal advice to
farmers about their rights, provided a place for people to express their
disquiet and, very importantly, published an archive of the views of vets
and scientists who dissented from the policies being adopted by the UK
authorities, explaining why they felt the policies were wrong.
 
4. The contiguous cull was the single most terrible event during the
epidemic, causing more emotional anguish than anything else. The errors
in the modelling had led to the contiguous cull being established. The
data the modellers were working from were flawed, including the wrong
locations for farms. In addition, modelling a hypothetical species added to
the inaccuracy of the model. It was most unfortunate that Professor David
King's scientific group comprised colleagues who were not conversant
with the foot and mouth virus. Among them, only Dr Donaldson
understood the significance of delayed slaughter times, the nature of
transmission and incubation times. Neither, it seems, had the others
understood how the disease passed quietly through sheep without being
noticed, making the date of infection difficult to calculate.
 
5. No one knows for certain how long the disease had been in the UK before
it was noticed. The movement ban had come into operation on 23
February. It was assumed by the modellers, calculating incubation to be
about 8 days, that any "new" infection spotted after this time must have
been caused by "local" spread. However, Dr Alex Donaldson felt that this
was not the correct view. The fact that the disease is often unnoticed in
sheep flocks meant that it was perfectly possible that "new" outbreaks
were in fact no such thing but that sheep in the infected flock had been
incubating and passing on the disease to each other.
 
6. Until the source of infection was identified for each IP (and 88% were still
not identified) even if 50% of new cases were near other cases this did not
prove that the other cases were the "source".
 
7. The modellers felt that rapid slaughter would not be enough to bring the
disease under control. Given the inadequacy of the data available at the
time, the modellers were simply not in a position to make the statement
"slaughter within 24 hours will not bring the epidemic under control". To
any expert in FMD, given accurate data on a daily basis, it would have
been obvious that rapid slaughter and accurate tracing would bring the
epidemic under control.
 
8. In addition, 25% of the cases after the 23 March were misdiagnosed
(Keeling et al. 2001). The problem with misdiagnosis was twofold:
• Misdiagnosis added cases to the daily totals of IPs, giving the
impression that the disease was spreading when it was not.
• A misdiagnosed case "mimicked" the local spread mentioned in the
models because it generally occurred near other IPs suggesting "local
spread".
Misdiagnosis almost certainly aided justification of the contiguous cull. In
fact there was a fever of misdiagnosis among vets, and most
inexperienced vets were not able to ask more experienced vets for advice
- nor were they given laboratory results of their own clinical diagnoses.
 
 
9. Alicia Eykyn of the FMD Forum pointed out that veterinary training in this
country did not include the study of FMD, so very few vets would have
been old enough to have witnessed the last major outbreak in 1967 so
would have no such knowledge unless they had gained their experience
overseas. Because of this ex-Deputy Director and Head of the
Epidemiology Division at Pirbright, Dr Noel Mowat offered his services,
free of charge, to MAFF, via a colleague then working there. This
colleague thought it a good idea and passed on the suggestion to the
person in charge of the resources and professional recruitment. Dr Mowat
expected to be contacted with a programme of venues at the Divisional
Veterinary Offices. In fact he was never contacted, nor received the
courtesy of an acknowledgement of his offer. Training of vets in the
recognition of notifiable diseases was one of the 1993 EU
recommendations for Member States' Contingency Planning (a
copy of which was passed to the Inquiry).
 
10. By March 21 2001 90% of the Infected Premises were identified by clinical
diagnosis alone (EFRA Committee, Nick Brown). The laboratory tests that
were carried out often came back negative. For the crisis as a whole, out
of 2026 IPs 1324 premises were positive, 401 were negative and 301
were untested. In the case of Worcestershire, for example, out of 26
cases in Worcester, only three were actually positive. (It was known that
two Worcestershire farmers were putting a lot of undue pressure on vets
to identify them as foot and mouth positive, because being under a form D
restrictive notice was more devastating than having one's stock culled.)
 
11. Not enough thought was being given to establishing where the new cases
were coming from and how this other spread was happening. Dr
Donaldson's and Dr Kitching's strong opposition to the novel methods of
control used during the epidemic, in particular the 48 hour contiguous cull,
were overruled by the Science Group.
 
12. Until disease transmission for the epidemic as a whole was studied in
detail (and it was suggested that the IPs should be spilt into three groups:
Positive, Negative and Untested) Britain could not plan for future
epidemics and no useful lessons could be learned or shared. (Contact
tracings were only one element of establishing disease transmission and
the tracings for this epidemic would almost certainly be unique to this
epidemic and of no value for future epidemics.) Contact tracing data was
not available in a useable format when it was needed during the outbreak
and this contributed to the use of the blunt instrument that was the
contiguous cull. It was suggested that Dr Wilesmith should be asked to
advise on this issue in future.
 
13. Dr Anderson pointed out that, whatever the criticisms that could be made
of the involvement of the Chief Scientist's Advisory Group, they could only
refer to the second half of the epidemic from the peak down to the tail,
since the epidemiological modellers had only been involved from the end
of March.
 
14. Ms Morris continued with her analysis of the figures which had led to the
decision to introduce the contiguous cull. At the peak of the outbreak
there had been 802 cases. Just over 300 (this figure may be higher once
the contact tracing project is completed by John Wilesmith) of these had a
proven link to a market. Furthermore of the 802, between 60 and 150 had
no positive laboratory result. So her question was "from where had the
other cases arisen?". Her suggestions included: windborne spread due to
delays in slaughter, some lapses in biosecurity and unintentional spread
by vets due to the practice of 'mouthing' sheep on patrol visits - all of
which possibilities could and should be investigated - if any lessons were
to be learned).
 
15. At the point of implementation of the contiguous cull, the daily cases were
25% misdiagnosis, some untested, some infections which occurred pre-movement
ban were finally identified and some other cases (cause
unknown). Summing up her argument Ms Morris emphasised strongly the
fundamental point that the contiguous cull was implemented because the
necessary data was not made available in full to the Science group, (that
is accurate slaughter times for IPS and DCS) and contact tracing data
were only partially analysed (that is some of the contact tracings were
properly identified but not all, particularly those tracings furthest from the
source infection - indeed the Imperial College team made reference to this
error in their second paper (Nature 4/10/2001 )). She suggested that the
epidemic needed to be properly analysed. Ms Morris suggested a team
comprising Alex Donaldson, John Wilesmith, Paul Sutmoller, Matthew
Keeling, David King, Keith Root, and for practical input, herself (Ms
Morris).
 
16. Turning to the wider issues, Ms Eykyn said that many people could not
understand why the Science Group was made up of scientists, including
the Chief Scientist, and other than Drs Donaldson and Kitching of
Pirbright, that had little or no previous knowledge of FMD and were
certainly not experts in the field. There were many such scientists all over
the world who could have been called on, some of whom, it had since
come to light, did offer their services but were ignored.
 
17. It was deeply regrettable that the groundbreaking Rapid Diagnosis PCR
farmgate test, offered on 9 March through the USDA together with the
expertise of Tetracore, had not been utilised during the crisis, since, even
unvalidated, it could have been of invaluable assistance in diagnosing pre-clinical
FMD.
 

18. The UK Contingency Plan, (approved by the EU in 1992) was wholly
inadequate. An excellent blueprint (passed to the Inquiry by Mrs
Critchley) for Member States to update their contingency plans had been
circulated in 1993 which gave detailed and practical guidance and advice.
All this had been ignored and no updated Contingency Plan was available
at the start of the crisis. There was instead a notorious culture of
complacency and arrogance. The reorganisation of the SVS had to be
seen as a very high priority for the future. It should be government policy
in future to use local expertise and local authorities. People on the ground
know the local situation, the farmers and were trusted by them.
Furthermore they were seen to be accountable for their authority and
power - unlike the lordly and unaccountable-seeming MAFF. The FMD
crisis illustrated the evils of centralisation. Page Street ignored the
expertise of local people and of senior vets. Their insistence on
immediate decisions being made by inexperienced TVIs, no second
opinions allowed, no waiting for blood tests and above all, no scope for
any kind of flexibility caused deep distress. TVIs were working to
constantly changing policies but there was a great lack of openness and
information. All this demonstrated the woeful inadequacy of the
contingency planning. The recommendations of the Phillips Inquiry for
Openness had been ignored. The careful and humane recommendations
of the excellent Northumberland Report of 1968 had also - astonishingly –
been ignored.
 
19. Much of the bullying and moral blackmail was caused by local officials
who had to carry out orders that they themselves did not understand.
Since they could give no rational explanation for the policies some of them
used bureaucratic "little Nazi" tactics. Not understanding the nature of the
virus they appear to have been terrified that their area would become
another Cumbria. Their lack of understanding, MAFF's poor
communication systems and the general air of secrecy caused common
sense to disappear. Many farmers felt a real sense of menace in their
dealings with MAFF/DEFRA. The part played by the NFU in apparently
vetoing vaccination was briefly touched upon - and deplored.
 
20. The Warmwell web-site could do little but publish dissenting views and call
for common sense to prevail. Rather than succeeding in this aim, Ms
Critchley feels it has merely charted a national catastrophe on its
web-site.
 
21. Dr Anderson thanked the representatives from Warmwell and the FMD
Forum for attending the Inquiry. Mary Critchley and Ms Morris left some
materials behind for the Inquiry.
FMD Inquiry Secretariat
July 2002