Documents reveal what was happening behind the scenes

OVER 1,000 pages of documentation showing how publicity was handled by the Department of Health during the swine flu season have been released to The Detail under Freedom of Information legislation. The papers show the truth of the vaccine shortage, the pressure the department came under to announce information on swine flu deaths and how an attempt not to create public panic backfired. Extracts below show how the situation developed.

October 1st, 2010: Email from Alison Marley in the Private Office to Dr Liz Mitchell (Deputy Chief Medical Officer), Dr Michael McBride (Chief Medical Officer) and staff in the press office. Notes information from Australia which indicates an increased incidence of febrile convulsions in children who receive the vaccine marketed in the UK as Enzira vaccine. “This information only emerged after the central procurement process had been completed and in consequence 100,000 doses of Enzira vaccine have already been purchased for use in Northern Ireland.” GPs advised not to offer Enzira to children aged under five and are instead told to give them another product not associated with this complication.

October 20th: Memo from Health Protection Branch to Michael McGimpsey. Health Minister told of first lab-confirmed cases of H1N1 2009 (swine flu) in Northern Ireland in the 2010/11 flu season. Under ‘line to take’ it states: “This is a non-issue and there are no plans to make a news story of it.”

October 26th: 10.50pm. Email from Dr Liz Mitchell to Michael McGimpsey and others to inform him of second lab confirmed cases of H1N1 flu this season.

October 27th: Public Health Agency confirms that a case of influenza has been reported in a pupil attending Ceara Special School in Lurgan.

On the same day a “restricted” memo is sent from the Emergency Planning Branch to Dr Liz Reaney (Senior Medical Officer in Department of Health) and Michael McGimpsey. The document states that the child – who has underlying medical (neurological) conditions – has been admitted to intensive care. She had lab-confirmed swine flu. It stresses in bold “*this information is not yet in the public domain*” but warns that media interest is likely.

October 28th: Email from Dr Reaney includes: “There hasn’t been as much publicity around seasonal flu vaccination this year because of costs. We already achieve an excellent uptake in NI, so the benefits were thought to be marginal. However, the general messages are important.”

October 28th: Email from Dr Michael McBride to Dr Reaney and others: “We need to reinforce the message both in our response to media queries and our messaging that we are dealing with seasonal flu – not pandemic.”

November 2nd: Ministerial submission by Emergency Planning Branch to Private Office of the DHSSPS and copied to others. The ‘issue’ is that an eight-year-old girl recently admitted to intensive care with H1N1 passed away the day before. This is the first H1N1 death in Northern Ireland since the World Health Organisation announced the end of the pandemic in August 2010. The document states: “The department would not recommend issuing weekly updates, or reporting deaths. The Public Health Agency will continue to issue a weekly reporting bulletin.” Under the ‘lines to take section – “In line with seasonal flu reporting, the department will not be issuing notification of deaths from influenza.”

November 5th: Letter from Dr Kathryn Bell, clerk of the Health Committee, to the departmental assembly liaison officer requesting an update on swine flu following the child death.

November 24th: Letter from Dr McBride sent to all health staff. It states: “There are no supply problems for influenza vaccine and, indeed, the Seasonal Influenza Immunisation Programme should be nearing completion.”

November 30th: Paper from Dr Reaney to Health Minister informs him of two ICU patients confirmed with swine flu. A total of six confirmed cases of influenza A/H1N1 in Northern Ireland. She writes: “We expect to see further confirmed cases… over the coming weeks. Some of these may develop complications and require hospitalisation, critical care or may even die.”

December 13th: Email from Dr Reaney in response to an email from the Department of Finance and Personnel asking if any specific messages would be issued about swine flu following publicity about 10 swine flu deaths across the UK reported in the Daily Mirror. She says that key messages about managing patients have already been communicated and “we do not plan to issue any additional messages to the public at this stage.” And: “Unless something very unforeseen happens, there should be no need to invoke any contingency plans.” She adds: “It is important to strike the correct balance between creating undue public alarm and yet not becoming complacent in the face of a virus that is still relatively new. The situation will be kept under close review and further advice issued as required.”

Public Health Agency issues a press release calling on all pregnant women to get their flu vaccine.

5pm – Urgent submission sent from Dr Reaney to Michael McGimpsey about an increase in the number of confirmed swine flu cases in laboratory reports over past few days. In last 10 days, 10 confirmed cases reported. At least eight of the cases are known to be in hospital, including three maternity patients. One is in ICU.

5.26pm – Email sent by Dr Reaney to Michael McBride following a radio interview featuring Dr Lorraine Doherty (Assistant Director Public Health, Public Health Agency). Dr Reaney writes: “I have just listened to Lorraine’s radio interview. Nothing controversial. Just some variance in the numbers of cases reported. She said there were less than 15 and when pushed said that tests were taking place every day and that at the last count there were nine. I had said 17 in the sub to Minister, after speaking to the PHA. If there is any query about this, we say that ‘preliminary information is received from the labs but this then has to be validated to check for any duplicate reports, as patients may have had more than one test.’”

December 15th: Michael McBride, in an email to Dr Reaney and others, strongly criticises a decision by the Department of Health in London to give a media briefing to inform the press that it is dealing with seasonal flu, not a pandemic, and to encourage vaccination. Dr McBride writes: “My firm view which I am content is shared, is that any decision by DH to give a media briefing has not been well thought through, is ill-advised and likely to be counterproductive.” Dr Reaney had written to him: “If CMO England does give a briefing, this will generate media attention and possibly pressure here to respond likewise. My view is that while we look at what England are doing, we try very hard to keep the balance between providing professionals and the public with the information that they need and yet not end up creating unnecessary panic and alarm. We face seasonal flu every winter and can’t be in a situation of crisis every year.”

4.24pm – Email from Duty Room at Public Health Agency informing of another death. “We have just been informed of an adult who has died in Antrim ICU and was positive for H1N1. Patient had other severe problems and it is not clear that H1N1 2009 was direct cause of death, but may have been contributory.”

December 16th: An email from Dr Reaney said she is “very relieved” that the Chief Medical Officer in England is now not going to give a press briefing. She writes: “This is a good result, as it would have created public expectation that we should be doing the same.”

She also writes an email on the appropriate response to take when asked by media and others about the number of deaths. She stresses that there will be no cumulative total of deaths as this would be “incomplete and misleading”.

December 30th: Dr Reaney writes an email stressing that she does not want the ‘catch it, bin it, kill it’ catchphrase to be used to make the distinction between last year’s pandemic and this year’s seasonal flu. She says: “If we can just hold the line for another couple of weeks then we will have won the war and normalised the seasonal flu response. That means we won’t have to go through this again next year.”

January 1st, 2011: Dr Carolyn Harper (Director of Public Health at the Public Health Agency) writes in an email to Department of Health and health trust personnel: “For information: We have been notified that a 53-year-old man has died today in hospital from H1N1-related complications. He had extensive co-morbidities.” Dr Reaney forwards the email on to the department’s press office “for info only” and stresses: “As before, we are not reporting deaths.”

January 4th: Press office forwards copy of comments made by Sinn Fein’s John O’Dowd on Twitter criticising Michael McGimpsey. He wrote: “Fears heighten over swine flu and the apparent crisis in Antrim A&E but no sign of the Health Minister on media, he’s lucky he is not a Shinner!”

Email about a series of media interviews on radio and TV being done by Dr Lorraine Doherty. Dr Michael McBride says: “In response to these stories, in my view it would not be appropriate and indeed would be disproportionate to escalate to the department at this time. It is essential that consistent and fully informed messages continue to be communicated to the population in Northern Ireland and that a sense of balance and proportion is maintained in these reports.” He concludes: “It is disappointing that it would appear that the political dimension being played out in the media in England are now some weeks later being picked up here.”

And, in an email to staff in the press office, Dr McBride writes: “Today largely reflects a spill-over of the very political dimension in England and a confusion of situation there with that here. Clearly others may seek to misrepresent this for their own reasons.”

January 5th: Michael McGimpsey writes to Jim Wells (chair of Health Committee) to update him on work being done to manage seasonal flu in Northern Ireland.

January 5th: Paper from Dr Reaney to Michael McGimpsey and Michael McBride. She writes: “Management of seasonal flu in England has already become increasingly politicised. This is starting to happen in Northern Ireland also.” Within this, she states: “We are not aware of any GP practice running out of seasonal flu vaccine.” And “there are no supply issues for antivirals in NI.” She does say that the pressure on critical care capacity has increased and “escalation plans have been activated”. In relation to deaths, Dr Reaney writes: “Now that the pandemic has been declared over by WHO, we have returned to customary reporting of seasonal flu mortality. Although a death from H1N1 2009 may occasionally be reported in the media, there will be no cumulative total of deaths from any of the types of influenza viruses, as additional data is no longer collected and any figures would be incomplete and misleading.”

January 6th: Paper on input to Ministerial Briefing, Executive Committee meeting. It states: “There is no issue in Northern Ireland with the supply of vaccine.” It continues: "PHA has not run out of vaccines, but is carefully managing their distribution to ensure an equitable distribution. As vaccines are ordered and delivered on a daily basis GPs will always be able to obtain sufficient amounts of vaccines to meet the needs of their patients.” If pressed on that day’s news story about a lack of vaccine, the Minister was directed to say: “As of 4 January 2011, the PHA has taken the decision to query any order from GPs for more than 30 doses – this is to ensure that a practice has that number of people booked for vaccination rather than just ordering vaccine in anticipation. This is primarily because vaccine issued out to GPs cannot easily be taken back into central storage. I repeat there is no issue about sufficient supply of vaccine in Northern Ireland.”

Transcript of interview on Nolan Show with John Compton (chief executive of the Health and Social Care Board), following interview with health professional the previous day who alleged the serious swine flu outbreak was being played down. Mr Compton confirms that elective surgery has been suspended and that 42% of intensive care beds are occupied by people with flu. He also states that “fitter people” have been affected in a greater number this year. Dr Kieran Deeny is also interviewed and says that his own practice and others are running low on vaccines. In response, Mr Compton says: “There is no problem with vaccines in Northern Ireland.” Dr Deeny also says that urgent guidance is needed for GPs on what to do when healthy people request to be vaccinated.

January 7th: Dr Carolyn Harper is interviewed on BBC’s Stephen Nolan Show. Transcript shows how he pushes Dr Harper to state exactly how many of the 33 people currently in intensive care with flu have underlying health conditions. She said it would be around 40-50%. Stephen asks: “Why don’t we all have a right to access to this flu jab if half of those people with their life under threat have no underlying health condition?” And he continues: “It is surely responsible for you to either confirm or set the record straight as to how many people in Northern Ireland this year have died from swine flu.” Dr Harper said: “I am not going to give you a number because if I give you a number that is going to be misleading to the public.” Stephen said it was “incredibly patronising and condescending to suggest that the public are so stupid that they cannot deal with the information that you can deal with.” Jim Wells also interviewed and says “it is like pulling teeth to get the information out of those representatives of the PHA.” He said that people want clarity and statistics not a drip feeding of information. “If the PHA withhold the information or seem desperately reluctant to let it out into the public domain then that only feeds suspicion and causes panic.” He said it was a major change this year to have a substantial number of people in intensive care who had no underlying medical conditions.

January 9th: Press release issued by the Public Health Agency stating it is aware of 14 deaths since November 1 of people who had the swine flu virus. Ten had underlying health problems. It was “not yet known” whether the other four had underlying health problems.

January 10th: Email from Dr Richard Smithson (Consultant in Communicable Disease Control at the Public Health Agency). He writes: “The last two days have seen a significant increase in vaccine orders in spite of the cap which we have placed on them with a total of 6,670 doses being ordered in the last two working days. The total vaccine in stock is 3,350. It is therefore apparent that unless we get 10,000 doses which we have tried to acquire from Scotland, we will run out of vaccine by Wednesday. We are currently comparing the amount of vaccine delivered to each practice with the amount that they have reported as using and contacting those practices with the biggest discrepancy to see if they have any spare.” A question and answer sheet was prepared for patients to explain why they would be given the swine flu vaccine rather than the seasonal flu jab.

Transcript of Dr Carolyn Harper being interviewed by Mark Carruthers on Good Morning Ulster. In this interview he asks her did she get it wrong holding information back from the public? Dr Harper replied: “I think it is a fair comment that perception, that we were perhaps hiding something by not publishing the figures did lead to a level of public concern. It wasn’t unique to Northern Ireland. There was a similar debate going on last week in England and they also moved to publishing weekly swine flu deaths.” She also said that swine flu deaths were being under-reported in other parts of the UK.

January 12th: Line in media briefing paper states that it is estimated that there may be around 50-80,000 doses of seasonal flu vaccine currently with GPs and Trusts that has not been used yet.

Briefing paper for Minister says that weekly flu bulletin the following day will state there have been a total of 17 swine flu related deaths since November 1 – 14 had co-morbidities, two did not and information on the final case is awaited.

January 13th: Paper on lines to take for a media briefing. It stresses that “there is no shortage of safe, effective vaccine to provide protection against swine flu.” And it states that revised arrangements to reinstate weekly deaths reporting have now been put in place given the currently high levels of seasonal flu that are circulating.

And press release issued by PHA aiming to reassure the public after two deaths of people with no underlying health problems.

January 14th: Letter from Dr Michael McBride to Professor Andy Hall (Joint Committee on Vaccination and Immunisation) written at the request of Michael McGimpsey to ask if the committee recommends any change in the policy of vaccinating children aged under five given increased public concern about recent deaths of children in this age group across the UK. It also states that a total of 17 swine-flu related deaths have been announced, and: “Sadly we are aware of a further death this afternoon and expect a second one before the weekend is over.” Media briefing paper on January 18th states that JCVI advised that advice remains the same – vaccine should be offered to those in at risk groups and those over 65.

Seanin Graham (health correspondent at the Irish News) emails to ask for a comment after receiving a call from “a very concerned GP” who said his health centre can no longer get the seasonal flu vaccine. He has been told they will instead be getting the H1N1 vaccine. Seanin said that the doctor is concerned given the reassurances given by John Compton last week in relation to Northern Ireland having enough supplies.

January 15th: Press release from Michael McGimpsey offering his condolences to the family of a two-year-old boy from the Republic of Ireland who died from swine flu in intensive care in Northern Ireland. And, in the evening, the department also releases a statement about the death of a 10-month-old baby who had an underlying medical condition. He died from swine flu in intensive care.

January 16th: Mr McGimpsey’s private secretary emails Dr Elizabeth Mitchell to ask for additional material for the Minister prior to a briefing. As well as information on patients currently in intensive care, she said the Minister also wants to know how many vaccines have been received and the number of patients vaccinated at Dr Deeney’s practice.

January 18th: Professor Dame Sally C Davies (interim Chief Medical Officer at the Department of Health in London) asks for support to report deaths by nation – as well as the UK total. In an email to Dr Michael McBride and Dr Elizabeth Mitchell, Dr Reaney says that publishing Northern Ireland deaths alongside those in other parts of the UK would be a “lose-lose situation”. She says: “If we don’t report them then we are accused of hiding something, while if we do report them comparisons will be made.” And: “Any publication of deaths would have to be heavily caveated and even then it will look as if we are worse off than everywhere else.”

Vaccination figures from Martin Coleman at Department of Health among at risk groups. Email shows that 57% of pregnant woman were vaccinated, 48% of frontline health staff, 38% of healthy children (aged between six months and five years), 75% of 65 years and over ‘at risk’ and 87% of under 65s ‘at risk’.

January 19th: In an email to press office staff, Dr Reaney said that the number of swine flu deaths cannot be directly compared across the four UK countries as there are differences in the definition of what is being counted, the timeliness of obtaining that information and the completeness of the information. An agreement is reached to put out the figures with the caveat that the data is not directly comparable.

A paper on a media briefing to take place the following day stresses there is “no shortage of safe, effective vaccine to provide protection against swine flu”.

January 20th: PHA press release confirms 21 people from Northern Ireland have died from H1N1 flu during the current flu season. Of these, 18 had underlying medical conditions, two did not and one unconfirmed. In notes to the editor, death of child resident in Republic is mentioned as an additional case.

January 21st: Department response to press query from the Ulster Herald states that there are around 400,000 swine flu vaccines left in stock.

February 3rd: Email from Richard Smithson confirms that £145,000 was distributed to GPs to call in ‘at risk’ patients for vaccination – to be spent on envelopes and postage or phone calls.

February 9th: Weekly flu bulletin confirms four more deaths reported the week before. Total number of swine flu related deaths reported is 29. Of these, 26 had an underlying health problem, two did not and one is not yet known.

February 16th: Weekly flu bulletin. No flu deaths reported this week.