FOOT AND MOUTH DISEASE - LESSONS LEARNED INQUIRY
The most important lesson to be learned is that it is morally indefensible for any Government to devise and implement disease control policies without cognisance of their socio-economic effects.
How adequate were the contingency plans at national and local levels for dealing with foot and mouth disease in Great Britain? What were the specific strengths and weaknesses?
1. It must be accepted that the killing of some 10 million animals during this epidemic means that the contingency plans were inadequate at national and local level, furthermore, it appears that there had been no paper or computer simulations to test the plans in the UK. There was widespread ignorance of the existence or possible contents of contingency plans by permanent employees of MAFF/DEFRA, and it must be said that the same was true of the 1968 Northumberland Report. During the epidemic the provisions of Viper Chapter 3 (FMD regulations of the State Veterinary Service) were constantly modified, so that as temporary veterinary inspectors (TVI's) we were frequently working under a cascade of different emergency regulations on an almost daily basis. This would suggest that the contingency plans were both ineffective and outdated. We finally obtained a copy of the contingency plans in February 2002 and can confirm that they are both outdated and impractical; it is telling that so many revisions to the plans took place in March and April 2001. The whole point of contingency plans is that they should be in the public domain and widely available and it is axiomatic that they must be practised to ensure that they are realistic.
2. There appeared to be a real reluctance on the part of the centralised bureaucracy in Page Street to involve temporary veterinary inspectors in any kind of scientific dialogue, despite the fact that some had considerable experience of FMD. The worst aspect of the centralised bureaucracy was that some changes of policy emanating from Page Street seemed to be absolutely divorced from the reality of what was happening in the field and more related to concerns about local and general elections. As an example, some veterinary surgeons were informed that they had to reach an immediate on farm decision as to whether an animal was infected or not, without any recourse to a second opinion, a wait and see approach, or laboratory confirmation. This is not in line with the written recommendations of the State Veterinary Service (Viper Chapter 3) and put unfair pressure on inexperienced TVI's. More worryingly, the reverse was also true and Page Street refused to accept the diagnosis of FMD from some TVI's with considerable experience of the disease, for example veterinary surgeons from South Africa.
3. People from many different backgrounds worked well in a crisis and became good friends in the process.
4. Centralised bureaucracy in Page Street created problems, the system was unwieldy and inefficient. It was very difficult to speak to people in authority with the requisite knowledge and it was often difficult to find anyone who could explain how some of the emergency regulations were supposed to be put into effect.
5. There were insufficient State Veterinary Service (SVS) veterinary surgeons, many of whom were poorly trained, provided ineffectual leadership and were ignorant of the relevant scientific advances. There are notable exceptions to this broad generalisation, but the centralised bureaucracy of Page Street reduced the potential for the application of science based on local knowledge.
6. There was very poorly organised recruitment of additional veterinary surgeons to act as temporary veterinary inspectors. There was no formal system for assessing the ability of those recruited and for training those who needed training. Very poor use was made of experienced veterinary surgeons to supervise inexperienced veterinary surgeons in the field and to provide an organised back up for difficult decisions. There was neither quality control nor quality assurance of those employed (e.g. contractors, slaughterers, and veterinary surgeons).
7. There were no detailed plans of the other personnel to be recruited and the urgency with which they should become involved (e.g. Armed forces, Environmental agencies, Department of Health, Religious organisations, Counselling services).
8. The 'system' was overwhelmed early in the outbreak because of the failure to stop livestock movements, the lack of effective contingency plans and inadequate numbers of trained staff. There was misleading information on animal holdings, with parallel incompatible systems within DEFRA (and a general failure to put information technology to good use within the State Veterinary Service). The numbers of sheep movements and farm fragmentation came as a surprise to MAFF and that is inexcusable. Even more inexcusable, however, is the apparent failure of MAFF to realise the high risk of Pan-Asiatic serotype O entering the UK, despite official published warnings that Europe was at risk.
How effective and timely was the Government's response to the emerging crisis nationally and in local communities?
9. The Government's response was ineffective and untimely. Government should have imposed a complete standstill on animal movements when the first cases were suspected (Feb 19th), but at the very least on Feb 20th, when the first cases were confirmed at Cheale Meats. This is especially important, given that the first cases occurred at an abattoir with multiple (600) possible sources of primary infection. Delay of the national ban on animal movements until Feb 23rd allowed much wider dissemination of infected animals than would have occurred had an earlier ban been imposed (Gibbens et al, 2001).
10. At almost every turn of this national crisis the Government's response simply served to underline their ignorance of farming and the countryside. Attempts to smear the entire farming community at various stages of the crisis (overcompensation, poor biosecurity, the price of cleansing and disinfection, "resisting the cull") were shameful.
What roles did MAFF/DEFRA, the State Veterinary Service, the devolved administrations in Scotland and Wales, local government, the Armed Forces and others play in the crisis? Were they adequately organised, co-ordinated and resourced to do so?
11. We have insufficient experience to comment on the devolved administrations and local government, except to say that infectious diseases are not particularly good at spotting boundaries so it is obvious that genuine national contingency plans must take account of this simple fact.
12. We have added the Government to this list, as we fear that they turned this national crisis into a national disaster as far as farm animal welfare and human suffering is concerned. Government interventions seemed to owe more to election dates than science. The air of panic so apparent in the field was almost certainly mirrored in Downing Street and the Cabinet. It probably led directly to the Prime Minister's personal intervention and resulted in additional quite unacceptable losses of healthy and often highly prized, sometimes genetically unique, livestock.
13. All the MAFF/DEFRA Government ministers were poorly briefed and regurgitated inaccurate and out of date information at regular intervals.
14. In the 2001 epidemic, the delay between the assumed date of infection of IP4 (Heddon-on-the Wall), the first diagnosis at IP1 (Cheale Meats) and finding the index case at IP4 was around 21 days (Gibbens et al, 2001). Farmers' support and co-operation are required in order to achieve earlier detection and reporting of notifiable diseases. This will not occur unless animals are valuable, or unique enough, to warrant veterinary inspection and unless farmers themselves are motivated to remain vigilant. The latter is not likely to occur if the farming industry is alienated by the imposition of illogical culling policies and draconian legislation designed to facilitate such policies.
15. The contingency plans make a number of references to "the worst possible scenario" without actually defining what this means. Brief perusal of the contingency plans indicates that the size of the SVS was insufficient to cope with a major epidemic of foot and mouth disease, let alone the worst possible scenario. In addition, the SVS was inadequately organised, co-ordinated and resourced. Most resources were addressed after a few weeks and then the problem became one of financial accountability. Complacency within the State Veterinary Service needs to be reduced, for example the concluding paragraph of an article by Mowat in the State Veterinary Journal stated "as the result of experiences gained in the 1967/68 episode and the advances in our knowledge of the disease and its diagnosis, the Veterinary Services of the UK are now better prepared than ever, should the disease appear again". This is actually true as far as the science is concerned, but it is the implementation of the science that the SVS seems incapable of achieving. The SVS must learn to collaborate with non-SVS scientists who have first hand knowledge of the relevant diseases as a matter of urgency. The increased potential for bioterrorist attacks and emerging exotic and zoonotic diseases make reorganisation of the SVS a high priority and there has never been a better opportunity for liaison between veterinary, medical and pure scientists.
16. Extremely professional, but many expressed the private opinion that Government policy appeared irrational. They questioned the necessity to kill so many healthy animals and newly born lambs, kids, piglets and calves, especially as they saw so little evidence of actual FMD infection in the field. Undoubtedly many of those involved in the slaughtering were emotionally affected by the brutality of mass culling.
How ready was the farming industry to handle a major infectious disease like foot and mouth and did the existing national and EU regulatory regimes have any influence? What more could be done to prepare for possible future outbreaks of infectious disease?
17. It is likely that FMD was present in the UK well before identification of infection at Cheale Meats' Abattoir, which would suggest that some farmers, and possibly also veterinary surgeons, failed to recognise the clinical signs of disease. Poor farming skills and dubious livestock dealing were key factors in the spread of the disease, so it must be recognised that these are both areas where education is needed. There are strong arguments in favour of ensuring that those who keep animals are fit to do so and this specifically relates to farm animals in this context. It is also essential to produce a workable system for the identification of individual livestock, their movements and location, but with the important caveat that any such system must take full account of the different types of farming in the UK.
18. The readiness of the farming industry involves umbrella organisations like the NFU as well as individual farmers. The NFU did not represent those farmers at the heart of the crisis and, for example, they should not have entered into the debate on vaccination as they were, with some honourable exceptions, woefully ignorant.
19. Farmers were obviously vulnerable as far as FMD was concerned because policies to keep the virus out of the country were not stringent enough; indeed import controls remain almost non-existent (see below). There is widespread variation in the measures taken by individual farmers in relation to infectious animal diseases and that is why it is so important that Government policies take account of local veterinary expertise when formulating control measures; for those working within the locality will have the necessary knowledge of individual farmers.
20. As far as future outbreaks of infectious disease are concerned it must be made absolutely clear that the UK has to make strenuous efforts to prevent infectious diseases such as FMD entering the country. If this cannot be achieved in the UK (and many other countries achieve it, for example, Australia, New Zealand, Canada and the USA) then it is utterly unrealistic to attempt to maintain FMD-free status. Our country is already becoming an attractive one for those who wish to import illegal food products and, in addition, our ineptitude makes us an easy target for bioterrorist attacks. It is quite shocking that over a year after confirmation of FMD so little has been done to prevent the import of infected material into the country. The relevant posters could have been produced on the day that FMD was confirmed and distributed to all UK entry points within a week. Sniffer dogs might take a little longer to train, but are a very cheap way of detecting meat and meat products.
Once the scale of the crisis became clear, was the response proportionate to the impact on the wider rural and UK economy?
21. No. The Government's response again revealed their ignorance of the countryside. It seems inconceivable that they had not realised the wide-ranging socio-economic effects of the measures adopted to control the epidemic, which devastated those directly and indirectly affected. Furthermore, we would regard it as indefensible if Government policies for the control of FMD did not change to take the socio-economc consequences into account in the event of further outbreaks. It must be clearly stated that FMD is a high morbidity low mortality disease. For example, despite a fully susceptible livestock population in the UK this serotype produced only short-lived clinical signs in many affected adult sheep; a situation that raises ethical questions as well as economic ones about the measures adopted to contain the disease.
22. The impact on the wider rural and UK economy makes sober reading. The export market for meat at the time of the outbreak was worth some 570 million pounds, foot and mouth-related costs are about 2.7 billion pounds and when other factors are included this figure exceeds 10 billion pounds.
Would the use of vaccination have made any difference to the scale and/or duration of the outbreak, and its wider impact?
23. Yes, effective protective vaccination policies would have reduced both the scale and duration of the epidemic. Vaccination has a much lower negative impact on animal welfare than emergency slaughter.
24. Comparison of practical strategies using both culling at different levels and realistic vaccination strategies should have been carried out at the start of the epidemic (or, preferably practised before, using a range of epidemic scenarios InterSpread, as used by the VLA modelling team, for example, has been available for years). Realistic strategies should have been described in the FMD contingency plans. Both epidemic simulation and cost-benefit analyses should have been carried out.
25. Note that the vaccination strategies that were modelled mathematically were not realistic (Morris et al, 2001) and none of them would have been adopted for the epidemic. Vaccination has been used in many parts of the world to contain epidemics of FMD and in the elimination of FMD from Europe. The whole question of vaccination was dealt with appallingly badly during the UK 2001 outbreak. It was shameful for Government spokesmen and the NFU in particular to suggest that the public would not wish to eat meat or drink milk from animals vaccinated against FMD. Some 70,000-100,000 tons of meat from countries with endemic FMD, many of which employ vaccination, apparently entered the UK for human consumption over a 12 month period in 2001. Europeans ate vaccinated meat during the period (prior to 1992) when vaccination was used so successfully to eliminate FMD from Europe. The considerable amount of information on modern vaccines, and the readily available expert opinions from those who wished to help, were studiously ignored by those who expressed such ignorant and outdated views.
26. In terms of the wider impact, the socio-economic benefits would have been enormous if vaccination had been adopted. The ethical and welfare problems that arose as a direct consequence of the policies used to control the epidemic would not have arisen if a vaccination policy had been used and the world would have been spared the countless images of piles of dead and burning animals. Protective vaccination would allow a decrease in epidemic size, and a decrease in "pre-emptive" culling. We feel that suppressive vaccination, after which animals are killed, is unnecessary and this accords with experience in the Netherlands where veterinary surgeons will no longer support the pursuit of this policy in the event of future outbreaks.
There are many other potential benefits of vaccination as it would allow:
7 The countryside to be re-opened once the livestock population was immune from infection. The socio-economic benefits of this are enormous.
7 Increased movement of animals, and therefore a reduction in the disastrous welfare problems seen in 2001 due to movement restrictions. This would also have the benefit of reducing/removing the need for "welfare slaughter".
7 The selective vaccination of valuable animals (in personal, economic and genetic terms).
7 A reduction in the necessity for movement of people and equipment between farms, with all the implications for disease spread. Vaccination, unlike slaughter, can be carried out by properly trained farm personnel.
What could have been done differently to alleviate the economic, social and animal welfare impact of the unprecedented level of culling and disposal?
27. Use of rapid diagnosis (on-farm if possible) to reduce delays between suspicion and slaughter and reduce the "guesswork" involved in diagnosis. Although not 100% sensitive or specific on an individual animal basis, it would be easy to calculate how many samples would be required to give the desired level of confidence in diagnosis.
28. Concentrating on rapid culling on laboratory-confirmed, or clinically confirmed where there is no doubt, infected premises (IPs), should have taken precedence over the contiguous cull (CC). This would have avoided diverting essential, and limited, resources away from the control of infection on IPs. Delays and vacillation early in the epidemic ensured a rapid spread and induced the government to introduce the newly 'invented' CC policy. If adequate movement restrictions and rapid slaughter on true IPs had been carried out at the start, there would have been no excuse for panic measures such as the CC policy.
29. Laboratory confirmation should have been required for all uncertain cases. Veterinary surgeons should not have been asked to choose between definitely infected with FMDV and definitely uninfected with FMDV purely on the basis of clinical signs and under pressure from Page Street. This would have led to decreased levels of culling, purely because farms contiguous to doubtful slaughter on suspicion (SOS) cases would not have been slaughtered out.
30. The contiguous culling policy almost certainly resulted in increased spread of disease due to increased movement of vehicles and personnel. The contiguous culling policy must be evaluated objectively by truly independent scientists in the light of the existing epidemiological data. It is possible that the CC policy increased the size of the epidemic (net negative impact), given that the epidemic peaked before the CC policy took effect, that it was never fully implemented and that its implementation may have led to increased spread of disease. It also diverted resources away from essential disease control efforts and, indefensibly, most animals killed under the CC and 3km policies had not been exposed to infection. If "pre-emptive" culling is to be employed, it must be based on knowledge of how the virus spreads, and local risk assessment, not be determined by mathematical "contiguity".
31. Greater use of regionalisation would decrease socio-economic consequences in unaffected regions. Note that the same regional boundaries should be used by all the parties involved and not as happened with MAFF/DEFRA having different boundaries from, for example local councils and parishes.
32. Information must be recorded more accurately, particularly the clinical signs and how those signs are interpreted and differentiated (from other vesicular diseases, foot rot and orf, for example). Adequate numbers of samples must be taken, for instance, taking an epidemiological bleed from all farms, in order to estimate the date of infection would have reduced many of the uncertainties which still remain about the epidemic of 2001. Most notably, how many recorded "cases" were actually infected? Evidence to date suggests that an alarmingly low proportion of farms recorded as IPs were actually infected, the situation becomes even worse for SOSs.
33. Diverting veterinary and lay resources away from contiguous culling and onto epidemiological information collection would have had many benefits and brought some science into the management of the epidemic. It is worth noting that use of ring vaccination would relieve the time pressure to kill on IPs, because the risk of transmission to surrounding farms would be greatly reduced. It must be stated that the epidemiology expertise of the Veterinary Laboratories Agency in Weybridge was underused.
34. Paying slaughter teams per head of stock slaughtered and recording targets for slaughter as "livestock units per minute" led to inhumane slaughter techniques on occasions, especially so as some of the slaughter teams were not good enough. This was a widespread problem in many parts of the country and in Northumberland we know of a number of occasions when live animals were found wandering around burial sites, some time after they were supposedly slaughtered. Overstretched veterinary resources led to individual veterinary surgeons having to supervise slaughter on up to ten farms simultaneously and this seriously compromised the veterinary duty of care to animals and broke the law in relation to welfare regulations.
35. Government must take full account of animal welfare concerns if a "stamping out" policy is used for any disease, bearing in mind the Government's desire to bring in yet more draconian legislation in relation to the Animal Health Act. Humane field methods of slaughter require urgent investigation as there was no universal policy during the epidemic and MAFF/DEFRA tried to make policy (i.e. emergency updates of Chapter 3 regulations) as 24 hour and 48 hour culling targets were imposed. There are welfare implications of in utero death from, for example, asphyxiation when pregnant animals are killed and the killing of young and newly born animals was utterly distasteful to many of those involved. Finally, we must never again witness the scenes of stampeding terrified bullocks being chased across fields and of sheep and lambs being slaughtered in full view of private houses by inept "marksmen".
36. Moral and ethical concerns must be used to balance political expediency in the determination of disease control policy. Science must be objective but "Scientists are part of society, therefore should not be detached from the consequences of their work." (Alan Holland, AWSELVA workshop 2001). Scientists with direct experience of FMD control were sidelined and the Government recruited some rather unusual and inappropriate scientists to help them. It must be clearly understood that the Science Group did not contain the necessary mix of those with first hand expertise in the science of and control of FMD - such people exist and had offered to help.
37. There were immediate psychological effects of the slaughter policy on rural communities, veterinary surgeons, slaughter teams and Armed forces personnel. It is known that there have been a number of suicides and at least 60 deaths amongst farmers have been directly attributed to distress arising from FMD control measures. Many children were intensely traumatised by the events they witnessed, but in general it is difficult for those remote from affected areas to begin to grasp the abject misery and overwhelming sense of despair of many local communities. Many of the farmers directly caught up in the crisis behaved with quite extraordinary dignity and it was a privilege to meet them. There is little doubt that many of those directly affected will never recover from the experience.
How effective were the communications systems for handling and responding to the outbreak?
38. In general communications systems were poor. If one single improvement is to be achieved after all the inquiries it is that the culture of MAFF/DEFRA must change. They must communicate openly and honestly with others and they must recruit or collaborate with staff of scientific ability from outside the organisation. They must realise, or be made to realise, that their own inadequacies cannot be hidden beneath draconian and unscientific measures such as contiguous culling policies and the proposed amendments to the Animal Health Act.
39. The widespread use of abbreviations and acronyms was potentially highly dangerous for new recruits. On the first day of employment it may not be easy to grasp the different approach required for designations such as IP, DC, SOS, CAR, CNAR, as well as the critical relevance of forms A,B,C,D,E etc. There are more than 100 MAFF/DEFRA forms relating to FMD alone!
40. As there were no available contingency plans many people felt that they were working in total chaos devoid of clear policy, this led to rapid demoralisation as the work was often harrowing. Organisational problems were often rectified by the TVIs playing a greater role in management and decision making and to some extent this was driven by the effectiveness or otherwise of Divisional Veterinary Managers.
41. Major problems related to the ineffective communication, both within Page Street and beyond Page Street. On average it took at least 10 minutes to get through by telephone, the telephone numbers kept changing, the emergency lines for reporting were closed down overnight and sometimes responses regarding urgent policy implementation were not forthcoming.
42. There were, however, also difficulties of communication between groups in the same building. Communication was not aided by the huge amounts of paperwork involved. Paper trails and files were sometimes deliberately disrupted or destroyed, presumably to prevent contentious issues being scrutinised in public at a later date. Many permanent employees of the SVS were not computer literate and some were neither good communicators nor effective managers.
43. Although the MAFF intranet system was comprehensive, the cascade of daily new instructions did not inspire confidence. There was no internet access, so people often worked in complete ignorance of what was happening a few miles away. This had other consequences, as colleagues from abroad could not keep in touch with their families by email.
44. The variations between MAFF boundaries/AICS boundaries/Parish boundaries etc was inexcusable and potentially lethal. Several farms lost livestock because of inaccurate grid references, a situation that also emphasises the bullying tactics employed by those who were in the wrong place, but with such dangerous powers that they could kill out the wrong farm despite the farmer's protestations. The consequences of this type of mistake are appalling, but would be repeated on an even larger scale if the Bill to amend the Animal Health Act becomes law.
Dr Sheila Crispin
Dr Sarah Binns
10th March 2002
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