8. Professor Jimmy Whitworth and Dr Charlotte Hammer

PROFESSOR JIMMY WHITWORTH (sworn).

DR CHARLOTTE HAMMER (affirmed).

Questions From Lead Counsel to the Inquiry

Mr Keith: Good morning, Professor Whitworth and Dr Hammer, thank you very much for the preparation of your joint report.

As you give evidence, could I please ask you to keep your voices up. It’s important that what you say is recorded, and more important perhaps still that everybody in the room can hear what you have to say.

If you don’t understand a question, please ask me to repeat it.

There will be a break at lunchtime, there may be an afternoon break if we’re still going, but if you need anything or you need a break, will you please let us know.

You have prepared a joint report.

Could we please have it on the screen. INQ000196611.

On page 2 of that report, you’ve both signed it. Professor Whitworth on 5 June, Dr Hammer on 2 June.

You have both confirmed, is this right, that the report is your own work, the facts are within your own knowledge, and you believe anything else which relates to your report on which you have relied, and you understand your duty to this Inquiry to provide independent evidence, and no doubt you will seek to comply with that duty.

My Lady, may I ask for your permission for the report to be published?

Lady Hallett: Certainly.

Mr Keith: Professor Whitworth and Dr Hammer, I’m going to put general questions. They’re not directly related to one or other of you. Please decide amongst yourselves who will answer the question based upon your specialities and what I understand to be your consideration in advance of the areas about which I’m going to ask you.

Your report, and your own expertise, concerns biosecurity. Could one of you please tell the Inquiry in very general terms what biosecurity is concerned with?

Dr Hammer: Yes, I will take that. Thank you, Mr Keith.

So, in very general terms, biosecurity are those questions that relate to the biological security safety of populations, individuals and societies. So these are things like outbreaks, so outbreaks of infectious diseases, for example, going all the way to pandemics, as we are discussing today. These are also things related to biological terrorism and biological warfare.

Mr Keith: Are you both experts in that field of biosecurity, so the forecasting of epidemic trends, the transmission of diseases, particularly zoonotic diseases, biosecurity countermeasures and the like?

Professor Whitworth: We are.

Dr Hammer: Yes.

Mr Keith: In the report you have set out for us, at page 1, if we could have page 1 of the report, please, a short CV of your most distinguished histories, setting out your expertise.

Professor Whitworth, you are an emeritus professor at the London School of Hygiene and Tropical Medicine. You retired, I think, in 2022, but you were the Professor of International Public Health between 2015 and 2022. Is that right?

Professor Whitworth: Yes.

Mr Keith: You were chair of the ethics committee, you have a vast experience of working in the field of biosecurity, both abroad and in the United Kingdom, you are a fellow of the Royal College of Physicians, the Academy of Medical Sciences and the Faculty of Public Health, and you were also or you are now president elect of the Royal Society of Tropical Medical and Hygiene.

Were you at one stage a member of the World Health Organisation European Advisory Committee on Health Research?

Professor Whitworth: I was, yes.

Mr Keith: May I ask you one or two questions, please, in relation to your work for the World Health Organisation, because it finds reflection in a later part of your report, and it’s an area that one of the core participants has raised questions about, or sought to ask questions about.

Were you a member of something called the Prioritization Committee?

Professor Whitworth: I was, yes.

Mr Keith: And was that a committee that undertook, in 2018, a review of the prioritisation of diseases for what was called the World Health Organisation Research and Development Blueprint?

Professor Whitworth: Indeed, yes.

Mr Keith: Was it essentially concerned with trying to identify and then research and develop countermeasures against the most highly pathogenic, that’s disease-like – or those diseases which pose the greatest concern, including coronaviral diseases?

Professor Whitworth: Yes, indeed. That is looking to identify those diseases that we’re most worried about from the public health point of view for which we don’t currently have good tools.

Mr Keith: How long did you undertake that work for, for that committee?

Professor Whitworth: Since 2015.

Mr Keith: And did it report?

Professor Whitworth: Yes.

Mr Keith: When was that?

Professor Whitworth: After each meeting there would be a report that came out. I think the most recent was 2018.

Mr Keith: Thank you very much.

You’ve also published over 250 scientific papers and you have provided a link to a selection of your most recent articles in the report.

Professor Whitworth: Indeed.

Mr Keith: Dr Hammer, you are the Everitt Butterfield Research Fellow at Downing College, University of Cambridge. You’re based in the Department of Veterinary Medicine, and you’re a member of the Steering Committee of Cambridge Infectious Diseases directorate.

You specialise in the epidemiology of emerging high-consequence infectious diseases, and in health emergency preparedness and response.

So essentially your speciality lies in global health security and public health consequences?

Dr Hammer: Indeed.

Mr Keith: And in 2022, of most relevancy, were you and in fact a consultant epidemiologist to the World Health Organisation Covid-19 Epidemic Intelligence team?

Dr Hammer: Yes.

Mr Keith: And you’ve worked also for another notable and important international network called GOARN, the Global Outbreak Alert and Response Network?

Dr Hammer: I was a deployed consultant with them.

Mr Keith: Thank you.

So in relation to this report, you were instructed in January of this year, on 20 January, and at pages 3 and 4 of the report, we can see the broad areas of instruction, page 3 firstly, issues concerning biosecurity threats, priority diseases, forecasting and epidemic intelligence, international processes dealing with surveillance and the control of infectious diseases.

Over the page, please.

Then you turn in your conclusions to the improvements that you suggest be made in infectious disease surveillance to prepare the United Kingdom for future pandemics.

Hot off the press, in fact this week, did the United Kingdom Government publish its Biological Security Strategy?

Professor Whitworth: Indeed.

Mr Keith: Have you been able to review that and to consider the improvements and recommendations that the United Kingdom Government itself advances against the ones that you have suggested in your report?

Professor Whitworth: Yes, though to some extent since it only came out this week.

Mr Keith: Yes, indeed, but your report, of course, preceded that strategy and its publication, but you’ve nevertheless been able to look at it.

Professor Whitworth: Yes.

Dr Hammer: Indeed.

Mr Keith: Thank you.

Could we please turn to page 5 of the report and the commencement of the substance. May I ask you: what is a pandemic?

Dr Hammer: So, a pandemic in essence is a big epidemic. So an outbreak of proportions that span the world.

Mr Keith: Are they a new development?

Dr Hammer: Pandemics as far as we know have existed as long as humanity.

Mr Keith: And is it self-evident that pandemics may range in – although they are necessarily worldwide, they may range in impact, in their scope and severity?

Dr Hammer: Indeed.

Mr Keith: You’ve set out in the first few paragraphs of your report a number of reasons why we need to be more concerned about pandemics than perhaps hitherto had been the case, because you describe why the potential for infectious disease has in recent years greatly heightened.

Could you please set out the broad reasons why you believe that the potential has heightened?

Dr Hammer: Certainly.

Now, most severe biological threats that we are facing are transmitted originally from animals to humans, so that’s what we call zoonotic diseases, and the risk for a disease to be initially transmitted from an animal to human increases with increasing contact between humans and animals, particularly if these animals and these humans did not have contact beforehand, so they did not share pathogens, diseases beforehand.

Now, with a more and more interconnected world, we do have more contacts with animals, we do have movement of people and animals, meaning new animals are encountering new humans, but we are also impacting what is happening after a disease has jumped from an animal to a human, that is how much contact that human has, how high the likelihood is of that disease then causing wider spread.

Mr Keith: So are there then two broad areas of concern? One is – we may call it the animal environment, the interface between animals and humans, which gives rise to the risk of a virus being transmitted into the human race; and then, secondly, once transmission has occurred, there’s the concern about population density, migration, travel and trade which encourages greater and wider transmission?

Dr Hammer: Absolutely.

Mr Keith: Can that transmission – can the infection point occur at any time, or in any place, zoonotically, that is to say the movement or infection of humans by an animal virus, or are there places in the world where it’s more likely to occur?

Dr Hammer: Generally speaking this can happen wherever an animal has a disease that is suitable to infect a human, and then has contact with a human. There are, historically speaking, some places where this has occurred more often, but that does not mean that this is not possible in other places.

Mr Keith: At paragraph 5 of your report, towards the bottom of the page on the screen, you’ve identified, in fact, a longer list of major drivers. So “microbial adaptation and change”, what does that mean?

Dr Hammer: So when we’re talking about microbial adaptation and change, that is, broadly speaking, which species a microbe can infect, so that would be the potential to actually jump to humans, because at the end of the day we’re just one of a whole range of species, and that is also hinting at antimicrobial resistance, which is another large biosecurity concern.

Mr Keith: We’ll come back to that in a moment.

“Ecological changes favouring the multiplication of a specific microorganism.”

What is that a reference to?

Dr Hammer: So there we are seeing things like, for example, changes related to climate change and also changes related to things that are also mentioned in the further point of land use change, so what kind of environment we have around ourselves, and that impacts both the animals as well as the pathogens, and in between those two also vectors, so think about insects, for example, that have a different range with climate change.

Mr Keith: Is a vector – does the word “vector” mean the means by which a disease may be transmitted to humans, so it could be by way of a flea or an animal or indeed even, perhaps, a surface, or airborne or whatever it might be?

Dr Hammer: There are two meanings to the word “vector” here, the first being what you just described, so where it could also be a surface, so a means of transmission. The second, which is what I was more referring to just now, is usually an insect or a similar entity in which a pathogen can exist, but is not infected. So it wouldn’t be an animal that is infected, but it would be something like certain species of fleas, it would be something like certain species of mosquitoes, that depends on the pathogen.

Mr Keith: All right.

Why is climate and climate change of relevancy?

Dr Hammer: So as you probably are already seeing, these are all interconnected, and climate and climate change are driving certain ecological changes and changes in vector ranges specifically.

Mr Keith: Further down the page, please, or over the page, you’ve referred to “increasing international travel and commerce” already.

Then there are “direct human influences including technology”, which have impact upon agriculture and land.

“Increasing human population”, with urbanisation.

“Human behaviour”, again you’ve covered that.

“Immunosuppression in a substantial group of individuals …”

What is the relevancy of that?

Dr Hammer: So if we have a group of individuals, especially a group of individuals who are in contact with each other, who are particularly vulnerable because they are immunosuppressed, we simply have a higher likelihood of spread.

Mr Keith: You have referred to the word “pathogen” or “pathogenic”; what does that mean?

Dr Hammer: So when we talk about a pathogen, we talk about a microorganism, so that could be a virus like SARS-CoV-2, which is the virus causing Covid-19, that could be a bacterium, it could be a fungus, and so these – we group those and together we call them pathogens.

Mr Keith: All right, thank you.

Now, it’s also necessary to set out some other building blocks concerning the field of biosecurity and pathogenic research.

Could we please have on the screen INQ000207453.

(Pause)

Mr Keith: Professor Whitworth and Dr Hammer, this is a reference table of previous pandemics and major epidemics prepared, in fact, by the Inquiry team. I’m sorry that you haven’t been provided, I don’t believe, with a hard copy. But essentially it sets out the major pandemics and epidemics, obviously, and a certain amount of information relating to each.

I want to just take you through the list, please, very briefly, in order that we may begin to understand the names of and recognise some of the major pathogenic threats that we and the world have faced over time, in order to put coronavirus SARS-CoV-2 in its proper context.

So, commencing towards the top of the page, you will see:

“1918-20, Influenza - H1N1”

We don’t, I think, need to zoom in, because we’re going to look at the table as a whole.

That, of course, is what became known as Spanish flu; is that right?

Dr Hammer: Indeed.

Professor Whitworth: Yes.

Mr Keith: We can see, and the most important part of it, the most important information, is towards the right-hand side of the chart, where information is provided in relation to the number of UK deaths, and the case fatality rate as well as the transmission route.

What is the case fatality rate, as you understand it?

Dr Hammer: So the case fatality rate means the proportion of individuals who have become ill who die.

Mr Keith: Therefore, does the case fatality rate indicate the severity –

Dr Hammer: It does.

Mr Keith: – of the disease?

Influenza H1N1 Spanish flu was a respiratory disease; is that correct?

Dr Hammer: Yes.

Mr Keith: Further down, the next entry on the chart is:

“1957-59 … H2N2”

We’ll come back in a moment to what the H and the N signify, but was that Asian flu?

Dr Hammer: I believe so.

Mr Keith: On the right-hand side of the page, we can see the case fatality rate was very much lower, at 0.017-0.1%, but again a respiratory pathogen.

“1968-70, Influenza - H3N2”

That was known as Hong Kong flu.

What does the H in the lettering indicate, and what does the N indicate?

Professor Whitworth: The H is hemagglutinin, and the N is neuraminidase, so they’re referring to different elements of the influenza virus.

Mr Keith: I knew you’d know the answer, Professor.

Does the H or the N indicate, in broad terms, the source of the genetic make-up of the virus? So, for example, does H indicate that the virus emanated originally from a mammal or a bird or something of that sort?

Professor Whitworth: In broad terms, yes. But you can’t be confident whether it came from a bird or a mammal just from the H and the N nomenclature.

Mr Keith: Right.

Then we can see:

“1977-78, Influenza - H1N1”

That was an influenza that had its possible origins in China or Russia. It became a global pandemic also called Russian flu.

Then:

“2002-03, Coronavirus - SARS-CoV-1”

So SARS plainly stands for Severe Acute Respiratory Syndrome. CoV, coronavirus. 1, this was the first coronavirus; is that correct?

Professor Whitworth: Yes.

Mr Keith: A moment or two on SARS-CoV-1.

It commenced in 2002; is that correct?

Professor Whitworth: Yes.

Dr Hammer: Yes.

Mr Keith: It spread throughout 2003, I think starting in Hong Kong. It was notified to the world by an organisation called ProMED, about which we’ll hear more later.

Towards the middle of the page, it killed 774 people worldwide. In the United Kingdom, there were four cases and no deaths. But the case fatality rate was around 9.6%. So in terms of the severity, it was very much more severe than the preceding influenza and other pandemics to which I’ve made reference?

Dr Hammer: Yes.

Professor Whitworth: Yes.

Mr Keith: “2009-10, Influenza - H1N1”

Was that swine flu?

Dr Hammer: It was.

Mr Keith: Swine flu struck the United Kingdom, amongst other countries. If we go to the right, the middle of the page, global deaths were assessed to – have been assessed at 284,000.

In the United Kingdom, there were 28,000-odd cases, and, tragically, 457 deaths. But the case fatality rate was, by comparison to coronavirus SARS-CoV-1, very much lower, at 0.01-0.02%.

Dr Hammer: Yes.

Mr Keith: Is that why the review into that swine flu pandemic and the British Government’s response and the press and scientific reports have generally described that influenza pandemic as a mild one, at least insofar as the United Kingdom was concerned?

Dr Hammer: Yes.

Professor Whitworth: Yes.

Mr Keith: “2012- Coronavirus - MERS CoV”

Is that the Middle East Respiratory Syndrome coronavirus?

Dr Hammer: It is.

Mr Keith: Global deaths: 866; UK cases: 5; UK deaths: 3. But the case fatality rate was very, very much higher at 34.3%. Again, a respiratory disease.

Professor Whitworth: Yes.

Mr Keith: Can you say anything about the difference between that coronavirus, MERS, the Middle East Respiratory Syndrome, and Covid-19 in terms of whether or not it differed, in terms of whether it was symptomatic or asymptomatic, or whether or not – and whether or not, as a disease, there were different methods of transmission? So, for example, whether or not it was a disease transmitted more by aerosol or droplets from the higher respiratory tract or lower down in the chest?

Dr Hammer: Yes. So, I believe Professor Heymann will go into more detail on this tomorrow as well, but, generally speaking, MERS is transmitted quite differently. We are – there’s two main routes. So MERS is entering the human population primarily from camels, dromedarian camels, so one route of transmission is very close contact with an infected dromedarian camel, who, as far as I understand it, can have MERS asymptomatically.

The other route of transmission, which is the route that the larger MERS outbreaks have gone through, is within a healthcare setting. Again, very close contact. And there you can have either transmission from patient to patient or from patient to healthcare worker.

Mr Keith: But the degree of human-to-human transmission for MERS was very different to that of Covid-19?

Dr Hammer: Yes, indeed.

Mr Keith: So although it could be transmitted human to human, it was only in those very confined healthcare settings that it actually took place.

Then Ebola at 2013 to 2016. So far the highest case fatality rate, 62.9%, but it’s not an epidemic or a pandemic that has afflicted the United Kingdom. There have been three cases and no deaths.

Then finally down to “Coronavirus - SARS-CoV-2”, our Covid-19.

To put that terrible disease in its context, we can see in the middle of the page global deaths range from an upper figure of 30.6 million to a lower figure of 6.9 million. Of course there are different ways of measuring deaths.

In the United Kingdom, more than 90% of the population is assessed to have been infected by the disease, to have caught it, and there we have official figures recounted being 225,668 deaths.

The infection fatality rate is something different to the case fatality rate, is it not?

Dr Hammer: It is, yes.

Mr Keith: What is the difference?

Dr Hammer: So the case fatality rate takes the proportion of cases, so people who have become ill, whereas the infection fatality rate takes the proportion of infected people, including those asymptomatically infected.

Mr Keith: So essentially case fatality rates rest upon a confirmed case of infection, there has to be an identified case, whereas an infection fatality rate is an assessment based on those who have become infected, whether or not that has been confirmed in some way or not?

Dr Hammer: Yes and no.

Mr Keith: Of course.

Lady Hallett: I think I’m going to need you to run it past me again, I’m afraid, Mr Keith.

Mr Keith: Doctor.

Dr Hammer: I’ll try my best to do that.

So with a case fatality rate we usually specify what cases we mean. Do we mean only confirmed cases? If so, confirmed how? Laboratory confirmed or confirmed by a clinician? Or do we also include, for example, probable cases or suspected case?

With the infection fatality rate, this becomes a little more complicated, because it is very difficult to assess the extent of infection, especially with diseases that can occur asymptomatically, which also means that, in many cases, our confidence in the infection fatality rate is lower than in the case fatality rate, because there is a certain amount of estimation of the total number of infections.

Mr Keith: All right, thank you.

Standing back and looking at that chart, in 2019, SARS-CoV-2 was therefore the third coronavirus pandemic but the second SARS pandemic. There had been one SARS pandemic, the coronavirus SARS-CoV-1 in 2002, and then the coronavirus MERS pandemic or epidemic in 2012, and therefore Covid-19 the third in 2019.

Are coronaviruses common in animals such as bats and civet cats and camels and so on?

Dr Hammer: Indeed, they are.

Mr Keith: Are there hundreds?

Dr Hammer: I believe so.

Professor Whitworth: If not thousands.

Mr Keith: If not thousands. But not all of them infect humans?

Professor Whitworth: No.

Mr Keith: Do a significant proportion?

Professor Whitworth: There’s, I think, four endemic coronaviruses that affect humans, and they cause mild common cold symptoms, and then there are these three more recently experienced coronaviruses that have caused epidemics in the human population. So of these thousands of coronaviruses there have been just seven that we’re aware of that affect humans.

Mr Keith: What does “endemic” mean, to which you referred?

Professor Whitworth: Endemic means that it is constantly within the human population.

Mr Keith: Does the fact that there have been three coronavirus pandemics in relatively short order in this century indicate anything at all?

Dr Hammer: That is a very good question.

Mr Keith: I’m very glad to hear that.

Dr Hammer: Probably one that can’t be answered with full certainty.

Now, certainly it does point to the issues we covered before in terms of increasing human-animal interfaces, but beyond that it’s probably very difficult to say anything.

Indeed, what we haven’t covered, what is on the top of this page, but going further back even, we can’t with certainty say how many coronavirus pandemics there have been throughout history.

Mr Keith: Could we then put that chart aside, please, and return to your report at INQ000196611, and page 5. If you could zoom in, please, on paragraph 2.

As you might expect, Professor and Dr, the United Kingdom Government, as with many other governments, has long acknowledged the risk posed by biological or zoonotic diseases and disease generally, and the international nature of biological threats has long been classified as what is called a Tier 1 risk by the United Kingdom government.

Is it obvious that, therefore, such risks have long been part of the United Kingdom’s preparedness planning?

Dr Hammer: I would assume so.

Mr Keith: All right.

You turn, further down the page, to the three broad categories of biosecurity threat that we currently face, and at paragraph 4 you set them out as being in three categories: zoonotic spillover, antimicrobial resistance, and human-origin biosecurity risks.

Zoonotic spillover you have already described as being a leak, if you like, or a transmission between animal and human over the zoonotic interface, but what is antimicrobial resistance?

Dr Hammer: So, antimicrobial resistance is a natural phenomenon of microorganisms, so, for example, bacteria, viruses, adapting to broadly speaking their environment. And that environment for these microorganisms includes drugs we use on them. So things like antibiotics. So that then means that those microorganisms adapt and learn how to deal with those drugs, which brings considerable harm, as it means that things which we thought we could treat become less treatable, even untreatable, and also because large parts of modern medicine, particularly surgery, rely on us being able to control bacterial risks.

Mr Keith: The third category, the deliberate and accidental release of pathogens, the human-origin biosecurity risks, is self-evident, and we’ll come back to the detail of that in a moment. So with those three categories broadly in mind, can we just focus, please, for a moment on zoonotic spillover.

Does zoonotic spillover present a range of risks or effects? Can it be that following a zoonotic spillover that there may be limited or no risk for the human race, or can it have and does the evidence show that it has had potential pandemic impact?

Dr Hammer: Yes.

Mr Keith: Is there anything that can be said about the degree of risk? So, for example, can it ever be known in relation to a zoonotic spillover whether or not the impact will be towards the bottom end of that chart of impacts, or towards the upper end, towards the pandemic end?

Dr Hammer: So we see the whole range, and even within individual pathogens, we can see a broad range. If we take for an example – stepping back from coronaviruses, if we take Ebola as an example, we see quite a number of spillovers of Ebola where we have a handful of cases, and then we also see large outbreaks like the one referenced in the table, the 2013 to 2016 outbreak in West Africa, or the more recent 2018 to 2020 outbreak in the Democratic Republic of the Congo. So there we see even within one pathogen we have considerable variance.

Mr Keith: Can such zoonotic spillovers be viruses or coronaviruses or …?

Dr Hammer: Well, they can be viruses. They can also be bacteria, so this is not just viruses. If we take, for example, the plague, some of you may know that as the Black Death from the Middle Ages, that is a zoonotic organism as well, so I think most of us will probably know the stories from the Middle Ages, a plague coming from rats – with a flea in between, probably – so there you see another example of a zoonotic pathogen, this time a bacterium.

Lady Hallett: Mr Keith, forgive my interrupting you, I think you have been pushing your luck with our very patient stenographer, so would you like to choose a moment?

Mr Keith: That’s an ideal moment, my Lady.

Lady Hallett: Thank you all. Thank you very much, Professor and Dr Hammer. We will return at 1.45, please.

(12.4 pm)

(The short adjournment)

(1.45 pm)

Mr Keith: May we please have the reference table of previous pandemics back up on the screen, INQ000207453, please. Professor and Dr, I wanted to return to an issue that we explored this morning, and just ask you one or two further questions on it, please.

Are the number of deaths caused in any pandemic the result of differences in both transmission of a disease and the severity of the disease?

Dr Hammer: They certainly are. They are also a result of changes in overall population across the planet.

Mr Keith: But once a disease infects the human race and, let’s assume it spreads, the number of deaths will be determined by how transmissible the disease is and how severe the disease is?

Dr Hammer: Yes.

Mr Keith: So on the one hand you may have a disease that doesn’t transmit very well, but if you get it you are in very deep trouble indeed, or you may have a disease that transmits extremely easily but is less dangerous, less severe, and therefore less likely to kill you, and therefore there is a better prospect you’ll survive?

Professor Whitworth: Indeed.

Mr Keith: So MERS, for example, 2012, as you were saying earlier – if we could just highlight – thank you very much – MERS was a virus, I think, originally from local bats, but the reservoir, the carrier of the virus was camels, and camels could then infect humans.

There weren’t very many cases worldwide, and there were certainly very few cases in the United Kingdom, and three deaths, but the chains of infection, that is to say the way in which people infected other people, tended to die out after a few cases, and you could only get MERS, couldn’t you, from very limited scenarios? For example, a healthcare worker treating somebody who was infected with MERS and was capable, therefore, of infecting the healthcare worker?

Dr Hammer: Yes.

Mr Keith: There was known as stuttering transmission, the transmission didn’t flow easily, there wasn’t widespread human-to-human transmission, and therefore the overall numbers were, relatively speaking, very, very low, although of course each death is terrible tragedy, but there was no widespread transmission.

But if you happened to get MERS, the fatality rate, whether judged by the number of overall cases or judged by the number of unconfirmed infections, was very high indeed. Is that the position?

Dr Hammer: Yes.

Professor Whitworth: Yes.

Mr Keith: Whereas, by contrast, swine flu, 2009 influenza H1N1, had a very much lower case fatality rate, and although it tended to spread more easily – it was a flu, it was an influenza pandemic – it had a very much lower case fatality rate. Doesn’t really matter whether it’s a case fatality rate or an infection fatality rate. If you became infected with it there was a very, very, very much greater chance that you would survive?

Dr Hammer: Correct.

Professor Whitworth: Correct.

Mr Keith: So the disease to avoid is a disease that is both transmissible and severe?

Dr Hammer: Yes.

Professor Whitworth: Indeed.

Mr Keith: And that, of course, is the disease that must be prepared for.

Professor Whitworth: Yes.

Mr Keith: My Lady, I hope that answers the question that you posed.

Lady Hallett: Thank you.

Mr Keith: Turning back to your report, please, INQ000196611, at page 7, you describe in your report how there are coronaviruses, and we’ve heard something about the three major coronaviruses which have been of the greatest concern, and you discuss influenza. But you refer in paragraph 8 to something called “disease X”, which you describe as a hypothetical future disease with the potential to cause a global pandemic.

Now, disease X isn’t a real disease, as you say, it’s a hypothetical scenario. What is the benefit in terms of prevention or countermeasures or preparedness of identifying a hypothetical disease which is called disease X? What benefit does that give us?

Dr Hammer: So basically the idea behind disease X is that it is not unreasonable that we will encounter a large outbreak, maybe a pandemic, from a disease that we did not previously know the properties of. Obviously preparing for something that we do not know the properties of, if we don’t have a concept of that, is very difficult. And therefore we have disease X as this hypothetical disease that we don’t know the properties of, just like we might not know the properties of a future pandemic disease.

In a way, then, disease X is supposed to teach us how to prepare for unexpected things, and how not to fall into the trap of preparing for something that we already know and that has happened in the past.

Mr Keith: So, putting it another way, is it a method perhaps of focusing the mind more sharply on a potential future but very real risk?

Dr Hammer: You could say that.

Mr Keith: Has there always been a proper understanding of disease X, or has this approach of trying to identify or focus on a hypothetical disease been a more recent development?

Dr Hammer: So, the idea of preparedness inherently has an understanding of something unexpected potentially happening. Now, if you want to put it like that, operationalising that into disease X has happened within the last decade and a half.

Mr Keith: By that do you mean scientific bodies both in the United Kingdom and abroad, and the World Health Organisation in particular, has started to focus much more on what disease X might be and therefore to try to sharpen its focus on how best to take steps to prevent against what that disease may turn out to be?

Professor Whitworth: Yes.

Mr Keith: Professor Whitworth, you mentioned the Prioritization Committee for the World Health Organisation and your membership of the committee. In a sense, was that committee, by prioritising attention on particular diseases, including coronaviral diseases, trying to identify what that disease X might be and therefore trying to guard against that possibility?

Professor Whitworth: Yes, that would be true. If we think about coronaviruses, we know there are many thousands of those. We had had experience of two coronaviruses, SARS and MERS, getting into the human population during the 21st century, and it was a reasonable bet that another one might come into the human population, which we’ve seen with Covid here. It’s also very plausible that another one might come along in the future.

Mr Keith: If you don’t know whether or not disease X is going to be a coronavirus or a virus or zoonotic or whatever it might be, whatever it might turn out to be, what is the practical benefit to us all of focusing on disease X?

Obviously the precise means of protecting ourselves against a disease depends to a revery large extent on what that disease turns out to consist of.

Professor Whitworth: I think two-fold. I think, one, it encourages us to be flexible in our approach and not to very slavishly think about what we did for the last epidemic or the last series of epidemics like the ones you’ve shown on your chart. But also it allows us to develop a sort of generic framework of how we would deal with a disease that was spread, say, by the respiratory route, was of a certain level of transmissibility, certain level of severity, and think about what measures we would need to put in place to be able to control such a disease.

Mr Keith: Professor, the United Kingdom, like many countries, on the onset of Covid-19, focused its attentions on an influenza pandemic but was struck, of course, by a coronavirus. So, from the viewpoint of December 2019, that coronavirus, Covid-19, was the disease X, it was the disease which struck us. Was there a failure, do you think, by many countries around the world, to identify that possibility? Therefore, that they did over-slavishly focus on influenza and not what the other disease might turn out to be?

Professor Whitworth: I think that’s a fair criticism, but I think we have to remember that when this first struck, we knew very little about the biological properties of this disease, and so at that stage, while we were scrambling to get more information, it would be best to start with a plan of something that was relatively similar but to keep in mind that we need to be flexible to change that as the evidence emerged.

Mr Keith: Quite so, but much of what you’ve said, of course, is concerned with being able to respond and to be flexible sufficiently to be able to respond. But in terms of not seeing, not appreciating, perhaps, the nature of the disease which ultimately struck us, do you believe that there was too great a focus – not exclusively a focus but too great a focus – on a different type of disease? We prepared in the main for an influenza pandemic and that wasn’t the pandemic that struck.

Professor Whitworth: Yes, I think that’s a fair criticism. With the two coronavirus epidemics that had occurred previously, there was quite a divergence in the epidemiological features of that, the transmissibility and the severity and the amount of symptomatic versus non-symptomatic cases that were there, which means that it would be hard to predict exactly what would happen with a new coronavirus that we hadn’t experienced before.

Mr Keith: You’ve explained to us what transmissibility is. Can I ask you, please, to say a little more about what asymptomatic and symptomatic viral infection means?

Professor Whitworth: Certainly.

If one thinks about people who are infected with a virus, they might show symptoms and have disease, or they might not. And if they don’t, but they’re simply infected but otherwise well, they are asymptomatic.

Mr Keith: So flu, influenza, in the main is symptomatic, is it not? You know that you’ve got flu, and you therefore know that you might have to take a step to isolate yourself and go home or go to bed and stop it being passed on?

Professor Whitworth: Mostly. But as we’ve discussed, there was a swine flu epidemic where we had very large numbers of cases and there were many people who didn’t know that they were infected.

Mr Keith: So in fact if you – even if you were to focus on an influenza pandemic, to the exclusion of all other pandemics, you would necessarily have to prepare for both asymptomatic and symptomatic versions of that pandemic?

Professor Whitworth: Indeed, yes.

Mr Keith: But bringing you back to the debate about disease X, if in the scientific community for some time now there was an appreciation of the importance of focusing on the hypothetical disease X to make sure that you weren’t blindsided by an unexpected virus, or pathogen, disease, why then was that perhaps excessive focus on influenza pandemics as opposed to coronaviral or some other form?

Professor Whitworth: I think because that is where we had had the most experience before in dealing with influenza epidemics that occurred previously, and to use that as a starting point of how you would approach a coronavirus epidemic was reasonable while we gathered further information.

Mr Keith: Into that mixture, what about the fact that there had been in very recent history two coronaviral pandemics?

Professor Whitworth: That’s true. That really ought to be factored in as well. But remember that those two were quite divergent in their effects on the human population. So it wasn’t as if you could say, “Ah, this is a coronavirus, this is the plan we need to follow.”

Mr Keith: Thank you. Well, that’s very clear.

Then may we turn, please, to the second of your large – your major categories of risk, antimicrobial resistance, which you address in detail at paragraph 16 of your report.

I want to ask you, please, about the risk posed by antimicrobial resistance. You refer there to the fact that antimicrobial resistance has two features to it. There is, firstly, the issue of transmissibility. That is to say, if you have a disease, a pathogen that can’t be controlled by, for example, antibiotics, then there is the concern that the particular disease or pathogen could spread easily, transmissibility; and also that there is the further issue of transmissibility of resistance genes between pathogens. What does that second reference mean, the “issue of transmissibility of resistance genes between pathogens”?

Dr Hammer: So this is a specific feature particularly of bacteria that develop resistance, and between themselves, by the way of how a bacterium works biologically, there is a possibility of the ability to detect and counter an antibiotic can be shared between bacteria.

Mr Keith: And therefore that has an impact upon the line or the degree of resistance as well as on the future development of the pathogen or the disease?

Dr Hammer: And of the spread of resistance in general.

Mr Keith: So it’s a cascading effect?

Dr Hammer: Indeed.

Mr Keith: All right.

The third broad area of biosecurity – oh, I’m sorry, I should have asked you. In paragraph 16 you refer to the fact that AMR, antimicrobial resistance, has gained the label silent pandemic and that in 2016 it was predicted to kill about 10 million people per year by 2050.

You make the point that the precise future course of antimicrobial resistance is uncertain, but is the point that you make in the paragraph that potentially there could be catastrophic consequences from AMR as well?

Dr Hammer: Yes.

Mr Keith: Has that risk changed over the last few years, at least since the prediction of 10 million people by 2050 was made in 2016?

Dr Hammer: I think it has changed in both directions, so it is probably very difficult to quantify that change, but we have both an increased awareness and, resulting from that increased awareness, increased what we call antimicrobial stewardship, so trying to slow down the spread of resistance, but on the other hand we also still have significant use of antimicrobials that speed up the levels of resistance.

So I would not want to speculate what that would mean for that estimated number.

Mr Keith: All right.

The third broad area of biosecurity threat you identify is what you call human-origin risks, and you deal with that at page 11 – it commences at page 10, I’m sorry, page 10, paragraph 18.

You describe how there is a “non-zero risk of a pandemic originating from either deliberate or accidental human behaviour”.

Have there in the recent past been any significant incidents of human-origin leak, that’s to say by way of, I don’t know, malicious use of a pathogen or a disease, or an accident in a laboratory?

Dr Hammer: So if we look at accidents first, these have happened in the past. So we are aware of four incidents. Involving the first SARS, SARS-CoV-1, for example. The 2007 foot-and-mouth disease outbreak in the UK, which some of you might still remember, that was a laboratory leak. That was an accidental release. Then the largest one that we are aware of was in 2019, and that was a brucella outbreak in China, again associated with a laboratory accident.

Mr Keith: All right.

Now, whether or not a disease infects the human race by virtue of a laboratory accident or malicious use, deliberate infection, bio-warfare, does that matter? In terms of properly preparing ourselves, does it matter whether the infection of humans starts from a zoonotic spillover or an accident or malicious use? The fact is that the transmission has started and must be then addressed.

Dr Hammer: That is absolutely true, and the further along you go, the less it matters. At the point where we have a pandemic, it probably does not matter at all anymore where the first – very first case came from, at least in terms of addressing that particular pandemic.

It does obviously matter in terms of prevention, trying to stop these outbreaks from happening at all. But in terms of the preparedness and response for if it happens, it actually matters very little.

Now, obviously if we talk about things like altered pathogens, there might be slight changes, but then again that would probably fall under disease X again.

Mr Keith: All right. So whereas doctrinally there may be some purpose to be gained in identifying one of these three broad biosecurity threats as being human-origin behaviour, a leak or deliberate use, in terms of focusing on what we can do to protect ourselves and countermeasures and so on, that broad area of risk is of less significance?

Dr Hammer: Well, I think the importance of knowing where something came from is predominantly in finding out if this is an avenue that we can shut down for the future. So is this – for example, on the naturally occurring side, is this a common interaction between humans and animals which can be made safer? On the laboratory side, is this something that we have overlooked in our procedures? Then, obviously, when we talk about malicious use, there are other forensic and security implications.

Mr Keith: All right.

Now, a government in any country, when faced with the outbreak of a disease or a pathogen, however it commences, is faced with a number of conundra, is it not, there are all number of considerations which have to be taken into account when deciding how to react? You set some out at paragraph 22 on page 11 of your report.

I’d like you, please, just to run very briefly through the considerations which you’ve set out there, because they all have an impact on how any government will respond, and of course, therefore, one has to have an eye to them when formulating recommendations or how better to respond in the future.

So the first bullet point:

“A small cluster of infections has variable potential to become widely established in the population, and this is challenging to predict accurately in advance.”

Is that a way of saying that when any outbreak starts, you just don’t know whether it’s going to become an epidemic or a pandemic or how wide it will go, you don’t know whether it’s going to go in that direction or that direction, whether it’s a problem or whether it can be ignored?

Dr Hammer: Yes.

Mr Keith: How, therefore, do governments prepare, in a general sense, against outbreak of disease? When – putting aside the inability to be able to prepare for every single risk and every single disease, when they’re alerted to an outbreak somewhere in the world, how do they know whether or not it requires them to press the red button or whether or not they can say, “Well, let’s just see how it goes”?

Dr Hammer: Initially, with an initial cluster, you might not know. And the response will then vary over time. Initially you will have a team on the ground, a local team, investigating that outbreak, and if possible trying to control and shut it down. Obviously if that fails, you kind of move along that progression.

At the international level there are established mechanisms for determining if something requires you to, as you put it, push that red button.

Mr Keith: The more surveillance you carry out and the more you alert yourself, as a government, to knowing what’s going on in the rest of the world and how many outbreaks are occurring, presumably the greater the risk – or the greater proportion of those will be false alarms. The more alerts there are of which nothing comes, the more false alarms there will have been. So that adds an additional pressure on governments –

Dr Hammer: Yes.

Mr Keith: – because they can’t follow every possible alert, and every time they cry wolf everybody else’s sense of preparedness will diminish.

So why then is surveillance important? You go on to describe in detail the various different ways in which worldwide global surveillance mechanisms are in place. If we cannot respond significantly or fully to every single alert, why does knowing that there are more and more alerts out there help us?

Dr Hammer: So the idea is that what we want is an early alert. The earlier your alert, the more likely you can actually respond to it, because the response will be much, much smaller, and a much smaller response can be mounted more often. It’s less likely to be seen, as you put it, as crying wolf and more like a routine investigation into a case or a cluster of cases. It will also require a different capacity, because obviously when we’re talking about early response here, we’re not talking about the response as we’ve seen over the past couple of years, we’re talking about a small local team investigating.

Mr Keith: To find out what has happened and, if there is a pathogen on the loose, to take steps locally to make sure that it doesn’t become a crisis?

Dr Hammer: Indeed, and in fact one of the very first things we do in an outbreak investigation is to verify there actually is an outbreak.

Mr Keith: That, or any system of global surveillance and local response to prevent, I don’t know, a drama becoming a crisis, requires, therefore, visibility or transparency around the world, because we all have to know, therefore, what’s going on in some other part of the world where outbreaks are occurring.

Is that what you mean when you refer in the next paragraph to the “spirit of One Health”, so ensuring that in general terms response systems are interdisciplinary, they are well funded, that they’re global, that they take account holistically of the whole system, so that we’re not blindsided by something we didn’t see coming?

Dr Hammer: One Health is a bit more specific than that. So One Health is specifically collaborative multi-sectoral transdisciplinary approaches across humans, animals and the environment. So it is the working together of these three sectors particularly.

Mr Keith: Why is a spirit or an approach of One Health of practical assistance to us?

Dr Hammer: Now, if we look at sort of two of the three biosecurity threats that we’ve outlined, zoonotic diseases and antimicrobial resistance, both of those happen at the intersection between humans, animals and the environment, and, for example, if you think about a zoonotic disease, it is not unreasonable to think that you might see something in the animals first. But if the animal health sector and the human health sector do not talk to each other, this becomes very difficult. Whereas if these are integrated systems, if they speak the same language, if they feed into a common system, it’s much more possible to have those early alerts, even potentially before we see the first human cases.

Professor Whitworth: If I may just add to that?

Mr Keith: Yes, please.

Professor Whitworth: If you took a view of human health in a population and you focused it just on what’s happening in hospitals, or just what’s happening in GP surgeries, you’d get a very biased picture, because you wouldn’t see that much wider picture of the interaction in the environment and with other animals.

Mr Keith: So, in essence, it is about trying to understand more broadly but more clearly what’s going on out there and ensuring an early opportunity to intervene to stop a bad position becoming a great deal worse?

Dr Hammer: Yes.

Professor Whitworth: Indeed.

Mr Keith: You describe, in the context of surveillance, a number of different methods of surveillance and alert systems. You describe something called syndromic surveillance and horizon scanning, epidemic surveillance. Are there a number of international and alert systems, and are there a number of different ways of carrying out surveillance?

Dr Hammer: Yes, on both counts.

Mr Keith: Now, in relation to Covid-19, the United Kingdom and the world became – were informed at I think round about the same time, they became informed from doctors in China, they became informed from an entry on the surveillance system ProMED, and the WHO China office also issued an alert. This was all at the end of December 2019.

Provided there is at least one working comprehensive effective surveillance system or alert system, is there a need for more surveillance systems or multiple surveillance systems? And if there is an international surveillance system, does the United Kingdom have to have its own surveillance system? Ultimately the United Kingdom was, with the rest of the world, informed at the end of December 2019 that there was an outbreak.

Dr Hammer: So, taking sort of the national and international, a lot of information from national surveillance systems feed into international surveillance. International surveillance, at least if we’re talking about traditional surveillance, so not looking at media alerts, for example, cannot stand on its own, because it requires lab capacity in every country, it requires clinicians notifying in every country. So you can’t really take the two apart and say we only need one or we only need the other.

Mr Keith: All right.

Was there an independent panel for pandemic preparedness and response convened in 2001? Are you aware of that panel?

Dr Hammer: Erm –

Mr Keith: It’s not something, I confess, that you’ve addressed in your report, but it relates to some of the matters that you’ve covered. If you haven’t got it to hand, then don’t worry.

Dr Hammer: Yes, so that is the report from the independent panel that you are referring –

Mr Keith: For pandemic preparedness and response.

Dr Hammer: Indeed.

Mr Keith: Is that something that you’re able to discuss? I don’t know, Dr, whether or not you happen to have a copy there.

Dr Hammer: Yes, we do.

Mr Keith: We have in our system – could we have INQ000183545, please.

Dr Hammer: It’s number 3 in the witness …

Mr Keith: There it is, “The Independent Panel”, it says in the bottom left-hand corner, “for Pandemic Preparedness & Response”, in very small letters.

“COVID-19: Make it the Last Pandemic”

Could we go forward slowly a couple of pages at a time and we’ll get our bearings. So there are the contents. Recommendations were made by the panel after a review of the “devastating reality of the Covid-19 pandemic”.

Could you please go to page 15 of what I hope are 86 pages. So one of the first points that the panel made was that, before the pandemic, there was a general failure to take preparations seriously, and it says this:

“In under three months from when SARS-CoV-2 was first identified as the cause of clusters of unusual pneumonia cases in Wuhan … COVID-19 had become a global pandemic threatening every country … Although public health officials, infectious disease experts, and previous international commissions and reviews had warned of potential pandemics … COVID-19 still took large parts of the world by surprise. It should not have done. The number of infectious disease outbreaks has been accelerating, many of which have pandemic potential.”

Then:

“It is clear to the Panel that the world was not prepared and had ignored warnings …”

And the panel refer to the SARS epidemic, about which you’ve spoken, in 2003, and then further, later down the page, but we don’t need to go to it, to MERS and Ebola, as well as Zika.

Now, that view, which you may or may not share, would tend to suggest that the prior existence or the prior occurrence of SARS-CoV-1 and MERS should have put the world generally into a greater state of preparedness, that in that very difficult debate to which you refer, about being ready for the right disease but not crying wolf, not being overprepared for something that doesn’t come and being properly prepared for something that does come, the balance may have been out, that there should have been just a higher degree of awareness of a coronavirus and of the possibility that the next pandemic would be a coronavirus. Would you agree with that general proposition?

Professor Whitworth: I think that by the middle of January of 2020, people in the international public health community were aware that this was out of the ordinary, this outbreak, this wasn’t just a small cluster that was going to die away, this looked like it was something bigger than that. And I think by the end of January, people in public health, certainly in the UK, were very clear that this was an impending wave that was coming to the UK, and those of us who had memory of SARS, the parallels with that were something that gave us shivers.

Mr Keith: SARS, of course, was something that had affected other countries as well, or primarily not the United Kingdom, but countries in the Far East.

Professor Whitworth: Yes.

Mr Keith: That gives rise, doesn’t it, to their preparedness, because they had been through SARS in a way in which we had not?

Professor Whitworth: Yes.

Mr Keith: Could we look, please, at page 25.

The panel, in the different context of discussing an approach to responding to pandemics by applying what’s known as the precautionary principle, that is to say assuming when you first become aware of an outbreak that it will have human-to-human transmission and therefore be more transmissible, said this at the bottom of the page:

“While [the World Health Organisation] was rapid and assiduous in its early dissemination of the outbreak alert to countries around the world, its approach in presenting the nature and level of risk was based on its established principles guided by the International Health Regulations … While WHO advised of the possibility of human-to-human transmission in the period until it was confirmed, and recommended measures that health workers should take to prevent infection, the Panel’s view is that it could also have told countries that they should take the precaution of assuming that human-to-human transmission was occurring.”

So what the panel appeared to be saying is: when you have an outbreak, assume the worst, assume it will be human-to-human transmission, and therefore prepare for that worst, assuming of course that the outbreak has got past a certain stage and therefore requires a response at all.

What do you say about the notion or the argument that there should be a precautionary principle applied so that you should assume that the next significant outbreak will be human-to-human transmission or will have significant human-to-human transmission? Is that a sensible way to proceed in your view?

Professor Whitworth: I think there’s a fine balance. As I hope we’ve got across, there are very many clusters of cases which might or might not be an outbreak that we’re aware of on a daily basis. To take the precautionary viewpoint that each one of those could turn into a pandemic would be a huge waste of effort and resources. To have good surveillance so we can see how this is developing and we can sift and we can identify those that we are worried about, until they reach a certain stage, I think is a sensible approach. Once they reach a stage that, “Yes, this is something that we are worried about”, then absolutely, I think a precautionary approach then becomes required. But that will be for a very small minority of all the outbreaks that we are aware of. So it’s quite a tricky judgement call about which ones you want to focus your efforts upon.

And certainly speaking to senior members of UK public health community in late January, they were of the view that they ought to overreact rather than underreact to this.

Mr Keith: And the key word, then, if I may say so, Professor, in your answer is “then”, because you said you can’t treat every outbreak as serious, you’ve got to wait to see how it develops, but you need surveillance to see the outbreaks occurring, and then you can assess and sift.

Professor Whitworth: Yes.

Mr Keith: But then there will be something to be said for applying a precautionary principle.

Professor Whitworth: Agreed.

Mr Keith: So in the case of Covid-19 in your report you identify that the World Health Organisation identified what’s known as a PHEIC on 30 January 2020, a public health emergency of international concern.

So the outbreak had clearly required that level of reaction from the WHO. It hadn’t yet been declared a pandemic, it wasn’t declared a pandemic until March. Is there, however, something to be said or would something have been said for applying a precautionary principle at that stage, when the world began to realise there was an outbreak serious enough to call it a public health emergency of international concern, and say, “Well, let’s assume from then on it will be likely to have or must be approached on the basis it does have sustained human-to-human transmission”? That’s the precautionary principle in action.

Professor Whitworth: I think in this case, in hindsight, yes, I would agree with that. But again, if you declare a public health emergency of international concern, or WHO, then that has huge logistic and resource implications for the world of having declared that that’s the case.

And if you declare too many of those at any one time, then you’re going to divert resources, manpower, time from the ones that are most important. So, again, it’s a bit of a judgement call.

Mr Keith: Can you say what the proportion is of outbreaks, pathogen outbreaks, disease outbreaks, that are declared public health emergency of international concern by the WHO? So if the concern is, and it’s readily understandable, you can’t presume human-to-human transmission for every outbreak, you should only do so in relation to those that are serious or significant or which have the real capacity to cause damage, there aren’t that many diseases that are declared a PHEIC, are there?

Professor Whitworth: Yes –

Dr Hammer: A very small number.

Professor Whitworth: – that’s very true, it is a very small number, and one of the critiques of that system is that it’s, if you like, an almost all or nothing declaration. It either is a public health emergency of international concern or it isn’t, and to have a more –

Mr Keith: Nuanced?

Professor Whitworth: Yes – graded system for being able to respond would be beneficial.

Mr Keith: Right.

Dr Hammer: And maybe also of note here, for something to be a public health emergency of international concern, it has to be of international concern; that does not mean it has to affect the entire world.

So an Ebola outbreak, very unlikely to affect the entire world, but can very well be a public health emergency of international concern.

Mr Keith: Now, whilst we’re looking at PHEICs and the World Health Organisation, is there a legal structure called the International Health Regulations (2005) which underpins the WHO’s approach to outbreaks of concern?

Professor Whitworth: There is.

Dr Hammer: Yes.

Mr Keith: Just for historical interest, primarily, is there a process of assurance or testing or grading of an individual country’s response under the auspices of the WHO and the International Health Regulations?

Professor Whitworth: There is.

Mr Keith: Is that what’s known as the Joint External Evaluation?

Professor Whitworth: Yes.

Mr Keith: As a matter of interest, how did the United Kingdom fare in those international-based but locally assessed assessment procedures, the Joint External Evaluations, before the Covid pandemic?

Professor Whitworth: The UK has never undergone, to our knowledge, a formal Joint External Evaluation. It has participated in the pilot scheme for this, and scored highly, and it has participated in self-scoring, following the same metrics as a Joint External Evaluation, which, again, it has done fairly well.

Mr Keith: Was it also subject to some procedure, some testing process under what’s known as the Global Health Security Index?

Professor Whitworth: Yes, that was also done, I believe, by Harvard, and adopted by WHO.

Mr Keith: And again it did relatively well in that assessment as well?

Professor Whitworth: It did.

Mr Keith: Do you happen to know how well the United Kingdom has fared in any self-assessed voluntary or compulsory evaluation since Covid-19?

Professor Whitworth: I’m not aware –

Dr Hammer: Well –

Professor Whitworth: – of any since.

Dr Hammer: – not after. So the latest self-assessment of IHR indicators was in 2021.

Mr Keith: Yes.

Dr Hammer: In that the UK did fairly well, with a 93% score, so that’s 93% across 15 IHR capacity scores.

Mr Keith: Can we then turn, please, to page 13 of your report, paragraph 27, where you deal with the issue of “Response capacity with scale-up capacity”. And you make the point, which may to some degree be self-evident – that it’s critical that there is sufficient capacity to respond to any alert generated by one or more surveillance systems.

In the body of the paragraph, you refer to a metric or a standard, a target, of a certain number of epidemiologists per 100,000 of the population as being a standard or a metric proposed for scientific response capacity.

Could you just explain to us, please, how, in the context of the response to Covid-19, having more or less or the same amount of epidemiologists might have made a difference in those days of the end of December 2019 and the beginning of January 2020?

Dr Hammer: Certainly.

So what we’re talking here about are what we call field epidemiologists, so that’s applied epidemiologists, that’s people who run surveillance, so there is the obvious link there to actually seeing things early enough, and they are also the people who act upon alerts, who do the local outbreak investigations, so those local teams I referred to a moment ago. These would be primarily staffed by field epidemiologists.

So having those being able to address things in early stages makes a significant difference, but also, obviously, these people then go through the ranks, they will form the body of a lot of intervention strategies in terms of the epidemiological side, so that will be being able to run contact tracing and to oversee that, being able to run dedicated new surveillance systems, even being able to come up with a dedicated new surveillance system, which is not a trivial task.

Mr Keith: So in the context of the United Kingdom, and I appreciate this is a huge, huge area, can you say anything about whether or not, as a country, we were blessed – sufficiently blessed with the right number of epidemiologists and scientists and so on to create both the research base that is required in responding to any outbreak or pandemic, and also to create the response mechanisms, diagnostic testing, vaccines, clinical care and so on and so forth?

Dr Hammer: So, a few things to take apart there, I’m afraid.

Mr Keith: Yes.

Dr Hammer: So, from the field epidemiology side, which only covers a few of those things, primarily surveillance and response to outbreaks, the international standard is one trained field epidemiologist per 200,000. This is a scaled-down version of the US target of one per 100,000, and that is primarily to make it achievable for lower/middle income countries.

This is sort of the minimum standard. It is very difficult to measure how many field epidemiologists there are. There are some proxy measures that aren’t particularly perfect either. I have very little doubt that we are above that threshold in the UK and that we have a fair number of field epidemiologists.

Other things that you mentioned, so things like clinical capacity, things like developing testing, they require a slightly different skill set. Again, from my understanding, the UK has fairly large capacity.

Mr Keith: You address in paragraph 29 on page 14 the general and obvious good sense principle of having sufficient microbiologists, social scientists, clinicians, animal health experts and so on and so forth. Again, relatively self-evident, one might think.

Can you express a view as to whether or not generally across that broad range of professions again we were well blessed in terms of the scientific resource and the clinical and the microbiological and the environmental expertise necessary to deal with a pandemic?

Professor Whitworth: I’d say that generally, yes, we were, but I think the point about co-ordinated, multidisciplinary approaches, we were not necessarily so good at. I think we had these various groups and these various pools, but they were not necessarily interconnected.

Mr Keith: Too much working in silos or the like?

Professor Whitworth: Indeed.

Dr Hammer: Yes.

Mr Keith: All right.

Well, my Lady, that’s an issue which I’m setting the building blocks for which we’ll be looking at in much greater detail later.

Could you now go forward, please, to page 17.

Lady Hallett: Just before you do, Mr Keith, it’s going back a bit, and I just wanted to check firstly with you, Professor Whitworth, that I had accurately noted what you said, and then check whether you, Dr Hammer, agree.

What I have noted, Professor, is that you said it was reasonable to use the plans for a flu pandemic as a starting point until we gathered more data. Is that an accurate record of what you said?

Professor Whitworth: Yes, my Lady.

Lady Hallett: Dr Hammer, do you agree?

Dr Hammer: So, first of all, any plan for a respiratory outbreak will be better than none. A dedicated plan is better than one for something else. But I think Professor Whitworth has quite nicely laid out that there were certain difficulties with this with regard to coronaviruses, particularly the divergence between MERS and SARS. So from that point of view, I certainly do agree.

Lady Hallett: Thank you very much.

Mr Keith: So page 17, please. Thank you very much.

In this part of your report, you list a number of pathogens or diseases which have been prioritised by the World Health Organisation for research and development.

If you scroll down over the next page, please, you list high-consequence infectious diseases which are on the list kept by a committee called the Advisory Committee on Dangerous Pathogens. That’s paragraph 37.

You also list those pathogens or diseases in relation to which the United Kingdom Vaccine Network invests in vaccine development as a priority. Then you actually go on to deal with other lists of pathogens kept by other international bodies and by overseas bodies, for example the National Institute of Allergy and Infectious Diseases in the United States of America.

Is the point about your lists and the fact that these various bodies list these particular diseases as priorities that the danger of listing diseases as a priority is that you may not see the one that comes from the left field, and/or is it the point that in the United Kingdom, in advance of Covid, whilst we had a system in place that was thought to be flexible, that coped with the possibility of a generic pandemic, we didn’t as a country proceed by way of trying to identify every possible significant risk and then planning for it?

Professor Whitworth: I think these lists of diseases are set up for different purposes by different bodies. So with WHO, this is looking specifically to identify: what are the priority diseases for which the world needs vaccines, diagnostics, therapeutic drugs? And therefore we’ll put out a call for work to be done to develop vaccines or whatever for a specific disease, to actually focus academia, industry and so on in developing vaccines for those kind of conditions.

The same sort of thing with the UK Vaccine Network, that had funding to start to develop vaccines for this specific list.

Mr Keith: Right.

Professor Whitworth: For a country to be thinking about what the risks are and how one deals with those, it may be less useful to have a specific list of pathogens. It might be better, as the UK does, to say pandemic influenza and new and emerging infections that are coming up, but the follow-through for that is that one ought to have a plan that is a framework for how you would deal with a respiratory disease or a gastrointestinal disease or so on. If that’s the case, that’s fine not to have a list as such, but you’ve got a framework for how you would deal with categories of disease.

Mr Keith: So just to summarise the position, and I hope I do so correctly, Professor, the approach taken by the United Kingdom, which was and is a sensible one, is not to operate on the basis of a prescriptive list of priority diseases, identifying each disease one by one and saying, “This is how we’ll prepare for that disease, this is how we’ll prepare for this one”; you make plain that in the various documents and the procedures and the processes applied by the United Kingdom, there was a general preparation for a pandemic, influenza pandemic, but also a different style of preparation, although there were overlaps, for what was called a new and emerging infectious disease, the precise nature of which wouldn’t be known.

So that general approach whereby you try to have a broad framework which you then apply to the eventuality, which you apply to the specifics of the disease which actually does occur, is a sensible one?

Professor Whitworth: Yes, I think it is sensible. It allows one to be flexible in one’s approach. So, for example, the list that we’d produced for the high-consequence infectious diseases that the Advisory Committee on Dangerous Pathogens considers, we’ve got a list there that we ought to have plans for, but that ought to be a flexible list, and there ought to be generic plans for how one would deal with contact transmission, how one would deal with respiratory transmission.

Mr Keith: Ah, so in fact what you’re suggesting is that there should be specific plans for specific pathogens on that list, but at the same time alongside those plans a general framework to deal with the unexpected outcome, the disease or the pathogen that takes us by surprise?

Professor Whitworth: Yes, indeed.

Mr Keith: Right. All right.

You then deal with expert advisory groups in the United Kingdom at page 20, and you describe them for us: the New and Emerging Respiratory Virus Threats Advisory Group (NERVTAG), about which, my Lady, we will hear a very great deal more in Module 2; the Human Animal Infections and Risk Surveillance group (HAIRS), the Advisory Committee on Dangerous Pathogens (ACDP), which you’ve just mentioned, and also the National Expert Panel on New and Emerging Infections.

Might it be thought that we have quite a few committees and groups in the United Kingdom dealing with various aspects of zoonotic diseases, respiratory infections, dangerous pathogens, new and emerging infections and the like? Is there an argument for some rationalisation of those bodies?

Professor Whitworth: I think it is useful, as expert groups, to have them focused on the areas where their expertise lies, and I think they do have robust discussions and divergent opinions, so I think it’s useful for them to have that body of expertise to do that. I think what is really important, though, is that the recommendations that come from those bodies are co-ordinated and synthesised within government to get an overarching view of the risks.

Mr Keith: Is that because, by their very nature, by their description, by their scope, each of these bodies focuses in a slightly different area? So NERVTAG only considers respiratory viruses, because it is the New and Emerging Respiratory Virus Threats Advisory Group?

Professor Whitworth: Exactly.

Mr Keith: The Human Animal Infections and Risk Surveillance group considers only zoonotic diseases.

Professor Whitworth: Yes.

Mr Keith: The Advisory Committee on Dangerous Pathogens doesn’t include global surveillance or horizon scanning. And the last body I mentioned, the National Expert Panel on New and Emerging Infections, which I’m sure did exactly how it described itself on the tin, has in fact been disbanded?

Professor Whitworth: Yes, it has.

Mr Keith: All right.

The next area in your report is the area of forecasting, modelling, horizon scanning and epidemic intelligence.

I don’t think, Professor and Dr, that we’ll be assisted by a description of the differences between forecasting, modelling, horizon scanning and epidemic intelligence, but I wanted to ask you about one particular type of epidemic intelligence which you describe at page 24.

My Lady, is that a suitable point for a break?

Lady Hallett: Yes, of course, sorry.

Mr Keith: No, I was slightly taken by surprise.

Lady Hallett: No, I shall return at 3.05.

(2.50 pm)

(A short break)

(3.05 pm)

Mr Keith: My Lady, on a completely different subject, may we have your permission, please, to publish the written statements?

Lady Hallett: You may.

Mr Keith: Professor and Dr, I was in the process of asking you about a particular type of epidemic intelligence ProMED, the Program for Monitoring Emerging Diseases. Could you please tell us something about that process, which you describe at paragraph 58 on page 23?

Professor Whitworth: So, ProMED is a programme that’s actually hosted by the International Society for Infectious Diseases, so a group of scientists, and it’s been going for about 30 years now, and it’s an internet service that identifies unusual health events occurring around the world. There’s a network of people who report these events that are happening. This happens 24 hours a day every day of the week, and so on, and that information is then shared globally.

Mr Keith: That network of people, what sort of people are they? I mean, they’re focusing on social media chatter or health department announcements or stories from small media outlets and they bring it together?

Professor Whitworth: That’s part of it, yes. Many of them are health professionals who will have heard through the course of their work that there’s a few cases of what apparently are related conditions occurring somewhere in the country.

Mr Keith: Will an alert be issued on the basis of a single piece of information, or does the system work on the basis that there must be some confirmation sought before ProMED, as a system, will disseminate an alert?

Professor Whitworth: It’s moderated and edited, but a single report is sufficient to be posted.

Mr Keith: What was the role of ProMED in detecting Covid and alerting the world to the outbreak in China?

Professor Whitworth: The first report of a cluster of pneumonias of unknown origin was first reported by ProMED.

Mr Keith: So is ProMED a device or a source that ought to be protected or perhaps better funded or nurtured, on account of the self-evidently very valuable role that it performed in relation to Covid?

Professor Whitworth: It certainly plays a very valuable role. I have no insight into how robust its funding health is, so I don’t know.

Mr Keith: All right.

Professor Whitworth: But I think, as well as ProMED, there are a number of similar reporting networks, and these are increasingly being co-ordinated and brought together.

Mr Keith: A different aspect of the international situation is the European Union and its institutions and systems.

Could you look, please, at page 29, paragraph 76.

As we’re all aware, following the EU exit, the United Kingdom formally left the institutions and structures of the European Union. Was one of the bodies that we left the European Centre for Disease … and Control?

Dr Hammer: Yes. Sorry, I did not hear the question mark at the end of that sentence.

Mr Keith: Yes, it was a question rather than me giving evidence, I should say.

Could you tell us, please, something about the ECDC, what does it do on the European frame?

Dr Hammer: Yes. So the ECDC is an EU membership – an EU agency of which membership is by EU country and also some other countries, for example Norway is also a member. It has a key role in co-ordinating infectious diseases – cross-border infectious disease threats across the European Union, primarily the European Union.

Quite important to note here that obviously there’s quite a difference between what is needed in a situation like the EU, where you have a union of nation states, versus an individual nation state. So ECDC can be a little bit seen as the response to that additional need in a union of states. So that is with regard to co-ordinating surveillance, co-ordinating surveillance particularly for threats that cross borders, co-ordinating capacity building across borders, and similar cross-border issues.

Mr Keith: But the need for such cross-border capacity and response and alert systems and so on presumably is mitigated to a very large extent if not completely by replication of any individual country’s own response, alert, surveillance systems. So if the United Kingdom has its own alert, surveillance and response capacities, then, of course, there is no need to be part to a European, pan-European structure?

Dr Hammer: I think that again touches slightly on what I mentioned beforehand, that international and national are running in parallel and informed by each other. So every EU country will have that national structure itself as well. It is just that the moment you integrate countries into a union, you will need to have an integrated system on top of that nation state system, rather than replacing it. But that obviously, to a different degree, also applies to other countries that are working together, and for example for that we also have the WHO regional offices, and the UK being a part of the WHO European region, so there’s another level of collaboration in there as well.

Mr Keith: But the United Kingdom is party to all those other non-European international structures –

Dr Hammer: Yes.

Mr Keith: – the WHO, of course, primarily, and has its own structures for surveillance and for response and response capacity and so on.

In practice, if not in law and if not constitutionally, is there an ability for the United Kingdom to take any benefit from the European Union’s early warning and response system if it wished to do so?

Dr Hammer: I believe so. I do not know the specific legal context for that, but I am aware that, in the context of the Covid pandemic, access to the early warning and response system was granted to additional countries by the European Commission and that goes by decision of the European Commission, and examples of that are countries on the EU enlargement scheme and other priority Eastern European countries. Others I’m not aware of.

Mr Keith: All right, thank you.

So post EU exit, the United Kingdom has its own fully fledged substantive and comprehensive system for doing all the things that it might previously have done within the rubric of the European Union.

You talk at paragraph 79 on page 30 of how the United Kingdom’s approach in the form of Public Health England, which of course has now been subsumed into the United Kingdom Health Security Agency – was seen internationally as something as a beacon in the area of public health, for incorporating health promotion with other public health functions.

Have other countries in fact modelled their own approach to this particular area of public health on the United Kingdom approach?

Professor Whitworth: Indeed, there are examples where that has happened. What Public Health England did was it brought together various aspects of public health under the one body, so control of infectious diseases, but also control of non-communicable diseases. Also, bringing together health promotion under the one body was the strategy that they used in Public Health England. That has certainly been used by the French, Santé publique is modelled on that Public Health England model, and I was recently in Singapore, where I was told that their Communicable Disease Agency is also taking on that model. So it is a model that has been followed in other places.

Mr Keith: Public Health England has now been disbanded and part of it subsumed into the United Kingdom Health Security Agency, and I think Public Health England’s functions in part have been split between the United Kingdom Health Security Agency and regional health authorities and, in part, the Department of Health and Social Care.

Professor Whitworth: Indeed.

Mr Keith: Has that division of functions subsequent to the disbandment of Public Health England changed your opinion about the way in which we went about it, in terms of Public Health England, has been admired and emulated? Have we gone now in a different direction to that which we had before?

Professor Whitworth: We have gone in a different direction now and health promotion is separated off from Public Health England –

Mr Keith: Does that matter?

Professor Whitworth: I think it’s a question of preference. My personal opinion is that to keep them all together is beneficial and that there are cross-learnings to be had from having communicable, non-communicable control together and having your health promotion team working together with your disease control teams.

Mr Keith: All right.

My Lady, that’s an issue that we’ll be looking at in the context of DHSC witnesses in due course.

At paragraph 83 you say:

“… the global landscape of surveillance co-ordination for infectious diseases is in flux as changes are being made at several levels and it will take time to gather sufficient evidence to assess the impacts of these changes.”

You go on to describe how, on a global level, negotiations are under way to draw up and agree a new pandemic treaty, and that pandemic treaty is designed, if it comes into force and is agreed, to replace the existing International Health Regulations to which you referred earlier.

Firstly, what did you mean by the global landscape of surveillance co-ordination being in flux? Are there significant changes underfoot? Do they matter?

Dr Hammer: So I think the exact thing here is that we do not fully know yet, that’s exactly what is in flux, indeed. The pandemic treaty, from what we know so far, is quite more substantial than the IHR were, so there’s now a first draft being discussed, that is with member states. But it is very, very early days. So it is very difficult to say anything yet, because it can be expected that there will still be changes made to that draft, that discussions will still go on for quite some time, but also very important to note even if the pandemic treaty was decided today, or even a week ago, it will take time for us to see what the impact of that will be. This is not something that is immediately self-evident, but rather something that we have to evaluate a little bit down the line.

Mr Keith: Are you able to say anything about the degree of change that any such pandemic treaty, if agreed, will bring about to the existing International Health Regulations? For example, will it provide for very real differences in terms of obligations on all member countries to report outbreaks within their borders, or obligations to close their borders, or obligations to close one’s borders to stop the influx of infection or an outbreak? I mean, how far beyond the current regulatory regime is the treaty likely to go, if agreed? Or can you not say?

Dr Hammer: That will entirely depend on what the member states of the assembly actually are able to agree on.

Mr Keith: So there’s no smoke that tells us yet what sort of changes they might be prepared to agree?

Dr Hammer: I think there is in the drafting an appetite for significant changes, but how much of that will survive is, at least to me, impossible to tell.

Mr Keith: Can you give us any assistance with the likely timeframe for any such treaty?

Dr Hammer: I do not know.

Mr Keith: All right.

Well, in light of all that, at page 31 of your report, you set out the learning points from the Independent Panel for Pandemic Preparedness and Response which I referred you to earlier, and we can see the main points set out there at 84:

“- stronger leadership and better co-ordination.

“- a more focused independent WHO.

“- investment in epidemic preparedness now.

“- stronger accountability mechanisms to spur action.

“- improved system for surveillance and alert.

“- a platform for vaccines, diagnostics, therapeutics and supplies with equitable delivery.

“- access to financial resources for preparedness and response.”

Those are all laudable aims, but pitched at, if I may respectfully suggest, quite a high level of generality. They’re very broad.

In terms of the United Kingdom, have you given thought to what sort of perhaps more precise recommendations have been suggested by the scientific community and what recommendations should, in your joint opinion, be made? And are they at paragraph 87, page 32?

Professor Whitworth: Yes, thank you.

So we’ve listed here a number of suggestions, some of which come from the scientific community, others are things that we feel ought to be considered.

One is that having sufficient reserve capacity within the health system is very important for resilience of the health system. We heard this morning from the representative from the Cabinet Office talking about resilience there, so maybe this is something that is in process, but we don’t know. And we feel this is important, particularly perhaps for laboratory capacity where, if there’s a need to develop new tests and then to run new diagnostic tests for diseases, that needs specific staff. And if that pulls them away from their important day jobs, then that has a knock-on effect on the health service in general to continue to deliver for other conditions that aren’t part of that outbreak that is there.

So in terms of resilience, we feel there does need to be thought about how you create that additional capacity, particularly in the laboratory.

Mr Keith: And just pausing there, resilience, as we’ve heard, is about, I suppose, a standing capacity of a country to be able to absorb a knock, to be able to respond, to roll with the blows, and to recover. So having extra capacity in terms of improving your resilience is something more than being able to put into place a surge capacity if a particular event requires it; it requires more of a standing capacity than a mere immediate response to an event. Is that right?

Professor Whitworth: That’s right. I think generally there are two approaches to resilience. One is that there’s a degree of redundancy in the system, so that there are sufficient staff who can be deployed to a specific area; and the other is that you have staff that are trained in different roles and are able to be re-deployed themselves, as required, according to the requirements of the system.

Mr Keith: All right. And you’ve referred there, obviously, to (a). At (b) you refer to:

“Better understanding of how to support minority ethnic groups and how healthcare providers and public health teams can work alongside community leaders …”

In the world of biosecurity and biosecurity threats, whilst that is again a self-evident and laudable aim, how will that bring about practical benefit?

Dr Hammer: I think we’ve seen during the Covid pandemic that the impacts were not felt the same across all groups –

Mr Keith: Yes.

Dr Hammer: – and this is a response to that, and I believe the Inquiry is hearing evidence on Friday on this matter as well, so clearly there is a recognition that this is an important issue, not so much in preventing a health emergency from happening, but in softening the blow, if you want to say.

Mr Keith: At (c) you refer to the need to ensure scientific advisers are not only independent but autonomous. That may be – well, perhaps I’ll allow you simply to develop that, although it’s a matter which we’ll be looking at in much greater detail in Module 2.

Why is independence and transparency of value in terms of having a system that brings about quantifiable benefit?

Professor Whitworth: I think in terms of the independence, that enhances transparency and to gain community trust and engagement with a clear understanding of who gave advice and so on, I think that’s very valuable to gain community trust, which I think is important in responding to any outbreak.

With autonomy, the issue there is that experts aren’t simply responding to questions put to them by government, but bring their own questions and dilemma for discussion as well, and that diversity of input guards against group-think, we believe, and we think that would be for the benefit of developing the recommendations for future epidemics.

Mr Keith: (e), you refer to the need for in-action and after-action reviews. You will know that there have been any number of reviews since the Covid pandemic, by Parliament, by parliamentary bodies, by the government itself, of course the international bodies to which you’ve made reference, and a number of commissions, but all in their own particular fields and, I might suggest, far narrower in significant part than this Inquiry.

Has the government in the field of biosecurity very recently issued a Biological Security Strategy? If you could say yes, rather than nodding, that would help the transcript.

Dr Hammer: I did not fully understand the question –

Professor Whitworth: Sorry, I wasn’t nodding so much as –

Dr Hammer: Yeah, I was – we were – I think I was looking for the document –

Professor Whitworth: I think by inference, we believe there must be, because there is now this new Biological Security Strategy that has come out and that does look to us that it has been developed with some after-action reviews.

Mr Keith: Could we have that, please, on the screen. It doesn’t have an INQ number, but it’s been fed into the system. It’s the Biological Security Strategy that I know was fed into the working parts earlier.

(Pause)

Mr Keith: Ah, there we are.

So I think on Monday the government issued – published this paper, “UK Biological Security Strategy”. Could we perhaps look at page 8.

There is the “Executive Summary”. It sets out the government’s:

“… renewed mission, vision, outcomes and plans to protect the United Kingdom and our interests from significant biological risks, no matter how these occur and no matter who or what they affect.”

They describe how the response, on the right-hand side of the page, sets out the strategic framework, the four pillars of the response – understanding, preventing, detecting responding – and what I think are described as cross-cutting enablers, which run through all four pillars: UK Leadership, Governance and Co-ordination – over the page, please – UK Science Base, Health and Life Science Sectors; International Leadership.

Then, please, page 10. Could you zoom in, so that we can read it. Thank you very much.

The government has set out a high level strategy implementation plan in the short, medium and long term in relation to those five doctrinal pillars, if a pillar can be doctrinal: Understand; Prevent; Detect; Respond; and Crosscutting.

There are a number of proposals set out, mainly by the way of continuing to do things, continuing to provide assistance, further developing other matters, delivering improvements, continuing to promote and develop practices, and continuing to develop capabilities.

Have you had a chance to look at this strategy? I appreciate it’s only very recently been published.

Dr Hammer: Briefly.

Professor Whitworth: Yes.

Mr Keith: Have you been able to take into account the high-level strategy implementation plan when reaching a final view in relation to the recommendations that you’ve just been talking about and which you’ll continue to set out?

Professor Whitworth: Yes, we have.

Dr Hammer: Yes.

Mr Keith: Does this implementation plan affect your opinions or the recommendations which you’ve made?

Dr Hammer: I don’t think it so much changes them as more that it takes on already quite a few of those that we’re making.

Mr Keith: All right.

So we needn’t trouble ourselves to try to put the two together and then see to what extent whatever you put in your report has been superseded by the passage of time in this plan?

Lady Hallett: Do you understand some of it? It seems like a fair bit of … I don’t know, what does “to effectively remediate” mean? I mean, it’s classic, I’m afraid. There seems to me to be rather a lot of jargon and not enough plain communication, but maybe I need to be a scientist like you two.

Dr Hammer: I think that is a very typical document of this type.

Lady Hallett: You’re obviously used to them. Thank goodness I’m not!

Professor Whitworth: I mean, I think there are some elements of what we recommend that we feel are covered here, and if it would be helpful we could explain some of those?

Mr Keith: Well, I think perhaps it might be easier if we look, go back to your report at INQ000196611 and – because we’ve already dealt with the first handful of points that you made on page 32, but we look at the recommendations you make on page 33 of INQ000196611, and as we go through them, where you believe that your initial view has been altered or requires alteration or where, in fact, it is indicative of what the government itself is saying, then you can say so as we go along.

So it was page 33, please, thank you.

Lady Hallett: That I understand.

Professor Whitworth: Right.

Mr Keith: That, I think, is not page 33, unless I’m mistaken.

Dr Hammer: No, that is not.

Professor Whitworth: Paragraph 88.

(Pause)

Mr Keith: Ah, yes, the pagination in the hard copy report is different from the electronic version. I apologise.

So paragraph 88:

“We also recommend that consideration is given to the following:

“a. Ensuring that action is taken from the learning points of regular simulation exercises for known and unknown epidemic threats.”

To what extent, Professor and Dr, is action not currently taken from learning points of regular simulation exercise? In what way is the historical simulation exercise process different?

Professor Whitworth: I think it can be difficult to know what the answer to that is, if one’s external to the process. There are regular simulation exercises that occur, certainly for known epidemic threats. What action is taken is not entirely clear to us, and I don’t think the new Biological Security Strategy really gives any further reassurance on that.

Mr Keith: Is the point, though, that in the past all exercises have been conducted on a premised basis? So, for example, the planners will say “In this exercise we’re dealing with an outbreak of MERS”, or “we’re dealing with an influenza pandemic”, or “we’re dealing with Ebola in Nottingham”, whatever it might be, and then they react accordingly. Your suggestion is that further and closer attention is given to exercises which are based on presumed unknown epidemic threats?

Professor Whitworth: I mean, sometimes with simulation exercises the participants don’t know at the start what it is that they are dealing with. The people who have set the exercise know, but the participants have to find out what it is that they’re dealing with, just like in the real world; and that is a valuable exercise to go through.

Mr Keith: All right, that’s very clear, thank you.

“b. Learning from the experiences in China and neighbouring Asian countries during the early stages of the … [pandemic] …”

Scaling up diagnostic testing, being able to scale up case detection and contact tracing early in an epidemic, flexible approach to risk assessment, ensuring hospitals and care homes are adequately resourced.

I mean, they, if I may suggest, are all again laudable and very sensible conclusions which might readily be drawn in a general sense from an understanding of Britain’s response to the pandemic.

To what extent are these grounded in your own biosecurity expertise?

Professor Whitworth: They are very much grounded in that, and the point here is that acting early and decisively is really important in an outbreak, to be able to keep on top of it and keep in control of it, and I think this recommendation of ours still stands.

Mr Keith: So is the heart of your recommendation in this regard that experience from other countries highlights the need for control, it highlights the need to ensure that whatever outbreak the disease amounts to is not allowed to run away from one’s own country, to run away from the control of the authorities, and the way to do that – to make sure control is not lost – is to have available mass diagnostic testing so that everybody can know whether or not they are infected, to have that capacity, to scale up case detection and tracing, so make sure that those people who are infected can be traced and made sure that they isolate, and then a flexible approach to risk assessment and to ensure hospitals and care homes are adequately resourced, to be able to deal with the consequences of infection?

So they’re all very sensible recommendations, but they all hang on the need to ensure that if you lose control you’ve got the wherewithal to get it back and to be able to care for your population.

Dr Hammer: Yes.

Professor Whitworth: That’s right, and the other point there is that there is information, there is learning, there is best practice from outside of this country, from previous experience that can be drawn upon.

Mr Keith: We’re going to pass over (c), because I think the issue of national security and political leadership is perhaps not one for biosecurity experts, although however eminent.

“d. [Strengthening] and [clarifying] scientific leadership by reinstating the National Expert Panel … (NEPNEI), or a similar body …”

That’s the panel, to which I made reference earlier, which had been disbanded.

I asked you earlier what the gain would be of reinstating that panel or a similar body, and in fact you said that whilst one could have a number of different bodies operating at different spheres and different levels, there was a need to bring all the information and learning together, perhaps at a level above it.

Do you think that there is a need for this sort of body, or is it a question of bringing the intelligence and learning together in an overarching structure?

Professor Whitworth: We note in the new Biological Security Strategy that they talk about developing a biothreats radar, which we believe does bring all those different elements of epidemic intelligence together in one place, and so we welcome that, seeing that, and I think that – well, it’s not entirely clear what independent expert advice would go into that biothreats radar but, that caveat aside, this new body does sound to us like it would fulfil the suggestion we make here.

Mr Keith: (e), you turn to surveillance and you say:

“Bringing together surveillance for influenza, and other respiratory viruses, with surveillance for other pathogens with epidemic potential. At present, these are treated separately by WHO and the [United Kingdom].”

You mean they’re not treated separately by the WHO from the United Kingdom, but both are treated separately in the United Kingdom as with the WHO?

Professor Whitworth: Indeed.

Mr Keith: Why would bringing together the different systems for surveillance, those for influenza and those for other pathogens, make a difference?

Professor Whitworth: Because if we’re thinking about the biosecurity risks that there are, then influenza is not separate from the other infectious agents that there could be, like Covid or whatever, and so to have that treated by a different body with a danger that there’s no cross-talking and no co-ordination, seems to us not – not a good plan, and to have a more cohesive review would be beneficial. It’s not clear from this document to what extent these would all be incorporated together, but it does sound like the biothreats radar at least would co-ordinate and synthesise influenza responses together with those for other new and emerging pathogens.

Mr Keith: All right. (f), the United Kingdom needs to be – in short, to have:

“… the ability to adequately respond to an epidemic with good epidemiological surveillance, including genomic sequencing, effective engagement and communication with society, rapid launch of clinical trials, development of diagnostic tests, vaccines and therapeutics …”

That is a very broad area indeed, Professor and Dr. I wonder whether the best way through that is to ask you to focus perhaps on the diagnostic test side.

In the Covid pandemic as it happened, the United Kingdom developed particularly a diagnostic test and very rapidly.

Why do you say that the United Kingdom, by implication, doesn’t currently have the ability to adequately respond with good development of diagnostic testing and rapid launch of clinical trials?

Professor Whitworth: The issue with diagnostic testing is that, while a test was developed very rapidly for Covid, it was, if you remember, inaccessible for most people in the early stages of the outbreak, that the scale of testing that was feasible was inadequate for the expanding epidemic.

Mr Keith: Ah, yes, you say here “development of diagnostic tests”, not dissemination, supply and general practice in the population, or use in the population of diagnostic tests. So is that what you’re referring to, you’re referring to the issue of mass testing of being able to get the diagnostic tests out on a mass scale?

Professor Whitworth: Yes, indeed, yes. Yes.

Mr Keith: All right.

You in fact say also that there’s a need to ensure that the United Kingdom adequately responds in relation to clinical trials. Were there not in fact a number of extremely efficient and very, very large-scale clinical trials conducted in the United Kingdom during the course of the pandemic?

Dr Hammer: Indeed there were.

Professor Whitworth: There were.

Mr Keith: VIVALDI, ZOE, and so on?

Professor Whitworth: Yes, and we need to make sure that that continues.

Dr Hammer: So this is less a recommendation of “This went wrong, we need to get this better”, and more, “We need to continue this, and we need to keep this”.

Mr Keith: Right, thank you.

“Engagement in this way with academic research groups is needed so that key unanswered questions … can be rapidly addressed.”

Is that a general appeal to make sure that there is always the requisite level of scientific expertise so that governments and decision-makers can draw on practical and research science in order to be able to make the right decisions?

Professor Whitworth: Yes, I think in general this worked pretty well within the Covid epidemic, and we’d like to see that continue.

Mr Keith: Finally, you refer on page 35 to something that you described as community based surveillance systems. You say in paragraph 95:

“… surveillance systems are good for delivering a pandemic response that is based on deaths and hospitalisations, and health care consultations but less good for identifying infections, illness or chronic disease …

“96. Consideration could be given to developing stronger community-based surveillance. This could be built on the model of the community-based surveillance system established by the … (ONS) …”

What did you mean by community-based surveillance, and what is the practical benefit of having a stronger community-based surveillance system?

Professor Whitworth: Currently most of the routine surveillance is based on hospital activity or people going to GP clinics, and that’s fine to an extent, but to know how widely a disease is circulating with a community, within the community, one needs to be sampling the community to be able to do that, and what our suggestion here is, is that we should build on these systems that we have at the moment to have routine surveillance going on in the community. And indeed, since we made that recommendation, we see that the Office for National Statistics has set up a new community-based respiratory illness surveillance programme called CRIS, which is Covid and Respiratory Infections Survey, and we welcome that, because we feel that while it might be sort of narrowly focused on respiratory infections, that’s exactly the area that we feel we should be moving into with surveillance. So that’s good.

Mr Keith: Were there to have been an extensive community-based surveillance system in January, February, March, April of 2020, of course the government would have been able to understand far better the extent of the spread, the nature of the transmission, of course, and the characteristics of the pathogen that would have assisted it to be able to respond as efficiently as possible?

Professor Whitworth: Yes, it would have given us a better, clearer picture rather than it being focused on hospitals entirely.

Mr Keith: That’s clear, thank you.

My Lady, those are all the questions that I intend to put to Professor Whitworth and Dr Hammer, thank you very much.

My Lady, you’ll know from the system in place before you in this Inquiry that the core participants have the opportunity of identifying areas that they wish the Inquiry to examine. There is then a secondary process whereby they may identify particular questions which they would wish either the Inquiry to put or which they would wish to put themselves.

You have provisionally indicated already the areas which Mr Weatherby, on behalf of Covid-19 Bereaved Families for Justice UK, wants to put himself. Of course that has to be revisited in light of the actual evidence given by the witnesses, but may I invite you – and I won’t perhaps seek formal permission in this way in the future, but on this occasion may I invite you to formally give permission to allow Mr Weatherby to put the questions he wishes to put in light, now, of the actual evidence which has been given.

Lady Hallett: Mr Weatherby.

Questions From Mr Weatherby KC

Mr Weatherby: Of course I’ll be brief.

There are just three points. My name is Pete Weatherby and I’m asking questions on behalf of bereaved families. Just three brief areas, two of which have been touched on, but I’ve got a couple of supplementary questions about.

Can I take you back to your paragraph 88(b) in your report, and you were asked some questions about this a few moments ago, so this is the point about learning from the experiences in China and neighbouring Asian countries.

Can I just check with you: which other countries did you have in mind? Korea?

Professor Whitworth: Yes, South Korea, Vietnam, Taiwan, Singapore.

Mr Weatherby: Yes. Thailand, perhaps?

Professor Whitworth: Yes.

Mr Weatherby: Thank you.

This is, of course, a recommendation looking forward, but these countries had measures to either slow the entry of the disease into their countries or to slow its infection within their countries once it had arrived; is that right?

Professor Whitworth: Indeed.

Mr Weatherby: So that’s what we’re talking about.

Then contact tracing to chase down the contacts to again limit the spread of the infection within the country, and that of course limited the infection and bought time until vaccines were available, yes?

Professor Whitworth: Yes.

Mr Weatherby: That led to better outcomes in those countries than might otherwise have been the case?

Professor Whitworth: Certainly in the initial wave, yes.

Mr Weatherby: Yes, thank you.

Now, am I right that those countries had developed those points, those policies, because of SARS and MERS, probably, but particularly SARS? So they’d learned from what had happened 20 years before, effectively.

Professor Whitworth: We ourselves don’t have any direct insights into the policy decisions that were made, but yes, we would believe that –

Mr Weatherby: Yes.

Professor Whitworth: – those would have been strongly influenced by their experience with SARS.

Mr Weatherby: Yes. Of course your experience is here. Can you help us as to why there wasn’t similar learning in the UK? Why is it that countries like South Korea or Thailand managed to do this and the UK didn’t?

Professor Whitworth: I think because of their direct experience of having had large serious outbreaks of coronavirus –

Mr Weatherby: Yes.

Professor Whitworth: – whereas in this country it was very small numbers.

Mr Weatherby: Yes.

Dr Hammer: Indeed.

Mr Weatherby: Okay, but the information was there.

Professor Whitworth: Yes.

Mr Weatherby: Yes..

Finally on this point, so that led in the initial stages, as you say, to a better outcome in those countries? Yes. Okay, that’s all I want to ask you about that point.

Can I go back to the prioritisation committee, Professor Whitworth: you were on this from 2015 to 2018, I think.

Professor Whitworth: Indeed.

Mr Weatherby: I think you then said that the committee didn’t meet after 2018.

Professor Whitworth: Thinking about that, I can remember meeting in the very early stages of the coronavirus outbreak –

Mr Weatherby: Right. Sure.

Professor Whitworth: – so I think 2020 –

Mr Weatherby: I see.

Professor Whitworth: – was probably the last time we met.

Mr Weatherby: Yes, okay. Am I right that Sir Peter Horby, the chair of NERVTAG, and Miles Carroll from PHE were also on that committee?

Professor Whitworth: I certainly remember Miles Carroll being on that committee, yes.

Mr Weatherby: All right, we can check that. But this was something that was taken very seriously by leading UK scientists in this area?

Professor Whitworth: What was?

Mr Weatherby: The committee, the prioritisation committee.

Professor Whitworth: The prioritisation committee, yes.

Mr Weatherby: So the point of it, to take these dangerous pathogens more seriously than had been in the past was a real priority for people like you in this field?

Professor Whitworth: Indeed.

Mr Weatherby: Yes, and was your role, and the role of the others from the UK, was it as independent scientists with expertise in this area, or was there an official element to it?

Professor Whitworth: I believe it’s an individual appointment. Certainly in my case I wasn’t representing an organisation as such.

Mr Weatherby: Yes. Do you think it would be preferable, with initiatives like this from the WHO, if there was a mechanism of reporting back to official bodies here so that that learning can fast-track, if you like, into the process?

Professor Whitworth: That sounds eminently sensible.

Mr Weatherby: Thank you.

Now, the initiative itself was to try to reduce the time between the emergence of a public health emergency from a pathogen and the time at which effective tests and mitigations could be developed; is that right?

Professor Whitworth: Correct, yes.

Mr Weatherby: So in the initiative itself, it was referred to as the urgent need for accelerated research and development.

Professor Whitworth: Yes.

Mr Weatherby: So that was the process.

Research and development by whom?

Professor Whitworth: By different groups. That would include academic groups but it would also include government scientists –

Mr Weatherby: Yes.

Professor Whitworth: – such as PHE, as it was at the time, and it would also include industry.

Mr Weatherby: Right. So was part of the initiative – was there any follow-through from the initiative in terms of the report being referred to member states so that they would take it forward in an organised way?

Professor Whitworth: As I recall, the process was that having identified priority diseases, then calls would go out for proposals for development of a MERS vaccine or SARS diagnostic test or whatever, and groups would be encouraged to develop those and to seek funding, and because that had priority from WHO, that would then give proposals for funding greater weighting.

Mr Weatherby: Okay, so would it be fair to describe it as an ad hoc follow-through process?

Professor Whitworth: Erm … well, the call would go out to all interested parties. Whether they responded to that would be their choice.

Mr Weatherby: Yes. Again, would it be better if the WHO system involved putting the call out to Member States –

Professor Whitworth: Erm –

Mr Weatherby: – so that the member states could ensure that there was research and development into these dangerous pathogens?

Professor Whitworth: I suppose in a way that would add another party into the chain of what was happening there. I mean, it might be that some countries really don’t have the capacity to develop such tests. You need to have a fairly specialist laboratory to be able to develop those and not all countries would be able to do it.

I would certainly agree with you that the national public health authorities in that country should be aware that these calls have gone out as well as individual laboratories. Certainly that would be sensible.

Mr Weatherby: Are you aware of any actual UK action that followed from the 2018 report, for example?

Professor Whitworth: Well, I believe the UK vaccine initiative that Miles Carroll led did address several of the issues that were brought up.

Mr Weatherby: I see. So the report would have fed into that?

Professor Whitworth: Yes.

Mr Weatherby: That’s very helpful.

Now, finally on this point, you mentioned the UK pandemic flu plan, which was based on the 2011 plan. Within that, there’s an acceptance with flu that measures to stop the transmission of flu once the dangerous pathogen had emerged would almost certainly fail. So there was a fatalistic approach to flu.

You’ve mentioned that having a plan is better than not having a plan for diseases such as Covid that emerge, unknown diseases that emerge. Isn’t that a problem where the plan is based on not having an approach to slowing the transmission of it?

Professor Whitworth: I think it is, and I think that in future it would be good to have not just a pandemic flu plan but one that is more generic for respiratory infections that takes into account different incubation periods.

The reason why there is that fatalistic attitude towards influenza is that when you’ve got an incubation period of just one to three days, by the time you’re aware that the disease is in your community, it’s everywhere and it’s too late to act. That isn’t the case if you’ve got a longer incubation period, as we did with Covid, which meant that it is possible to implement more of a plan to control transmission.

Mr Weatherby: So the plan going forward must have a recognition that you may be able to slow transmission?

Professor Whitworth: I think now we’ve had three experiences of Covid epidemics, we’ve got more information to develop a more generic Covid type of plan for the future. I think that was harder when we’d just got the two rather divergent approaches.

Mr Weatherby: Yes, although I think we’d agreed earlier that the Asian countries had kind of got the message about the transmission point.

Professor Whitworth: Yes, but I would imagine their plan was the SARS plan.

Mr Weatherby: Yes.

Professor Whitworth: It wasn’t the Covid plan, it would have been the SARS plan, at least initially, and then modified as more information came up.

Mr Weatherby: Thank you.

Finally, Mr Keith asked you about the Joint External Evaluation process, and you agreed that the UK had scored quite highly on that process, and also the Global Health Security Index.

Can I just take you back to the WHO Independent Panel for Pandemic Preparedness and Response on Covid in 2021. I’ll put it on the screen, if I may. INQ000183545, and it’s at page 18, please.

(Pause)

Mr Weatherby: Bottom of the – well, bottom of the text on page 18, at the bottom there should be a graph –

Lady Hallett: With lots of circles.

Professor Whitworth: Yes.

Mr Weatherby: With lots of circles, hoops rather than spaghetti today, I think. But the text just above that, if I can just read a few lines, it’s the last few sentences:

“Country preparedness was also assessed under the voluntary Joint External Evaluation process, undertaken to date by 98 countries. An independent academic exercise, the Global Health Security Index, also sought to score country pandemic preparedness.”

Then we have this rather interesting graph which I’m not going to go to, I’m just going to note. But then on the next page, if we could have the next page up, please, what all these measures have in common was that their ranking of countries did not predict the relative performance of countries in the Covid-19 response, and then it goes on to say why.

Then towards the end of the main first paragraph:

“The failure of these metrics to be predictive demonstrates the need for a fundamental reassessment which better aligns preparedness measurement with operational capacities in real-world stress situations~…” et cetera.

So simple point, we shouldn’t put too much store in these JEE scores; would that be a fair way of looking at it?

Professor Whitworth: I think it would. I think … I think the lack of any correlation there between the two was a surprise and not what we would have anticipated before the pandemic.

Mr Weatherby: Yes.

Professor Whitworth: But one thing that I think’s very important to get across is that the JEE is rather narrowly focused and it is looking at the public health capabilities and capacities within a country.

Mr Weatherby: Yes.

Professor Whitworth: It’s not looking at the wider picture, it’s not looking at the general health of the population, inequity, the state of the health service or care sector or policy or political decisions that are made about an epidemic. It is solely looking at the capabilities of the public health system.

Mr Weatherby: Yes. So the scores that we have been through may not take us very far, for those reasons?

Professor Whitworth: Indeed. So with retrospect, it’s perhaps not entirely surprising given the narrow nature of what is being scored in a JEE that that’s not reflected in the overall mortality.

Mr Weatherby: That’s very helpful. Thank you.

Dr Hammer: If I may add a sentence to that, I think there’s also one other aspect to consider here, that there is an inherent risk in scoring highly on such a tool, and that is a certain amount of complacency and of feeling that one is well prepared. I think that is certainly a lesson that almost everyone in the world can take to the future, from the scale of individuals to the scale of whole societies, that just because we’ve done good in the past or because we’ve done good on an exercise just should not lead us to say “Okay, we’re good, we can stop here”.

Mr Weatherby: Thank you very much. Those are all the questions I have.

Lady Hallett: Very good, Mr Weatherby, thank you very much .

Mr Keith, anything further?

Mr Keith: No, thank you, my Lady.

Lady Hallett: Professor Whitworth, Dr Hammer, thank you very much indeed. I did follow what you were saying, so thank you very much for helping us.

(The witnesses withdrew)

Lady Hallett: Right, good time to break?

Mr Keith: My Lady, that concludes the evidence for today.

Lady Hallett: Very well, and 10 o’clock tomorrow?

Mr Keith: Yes, please.

Lady Hallett: 10 o’clock tomorrow, please.

(4.08 pm)

(The hearing adjourned until 10 am on Thursday, 15 June 2023)