BSE Outbreak Conclus

BSE Inquiry Report Volume 1 Findings and Conclusions Volume 1 Findings and Conclusions Terms of Reference, Committee Members and Report Volumes xiii A note on the footnotes xiv Executive Summary of the Report of the Inquiry xvii Introduction xvii 1. Key conclusions xvii 2. The identification of the emergence of BSE xviii 3. The cause of BSE xix 4. Assessment of risk posed by BSE to humans xx 5. Communication of the risk posed by BSE to humans xxi 6. Measures to eradicate the disease in cattle xxi 7. Measures to address the risks posed by BSE to humans xxii Slaughter and compensation xxii Food risks xxiii 8. Medicines xxiv 9. Cosmetics xxvi 10. Occupational risk xxvii 11. Other pathways of infection xxviii 12. Pollution and waste control xxviii 13. The identification of vCJD xxviii 14. Victims and their families xxix 15. Research xxx 16. Some general lessons xxxi 1 Introduction 1 Our task 3 The structure of the Report 7 Transmissible Spongiform Encephalopathies 10 Transmission to humans 11 The story in a nutshell 13 What happened? 13 Why did it happen? 20 2 Setting the context 23 The cattle industry 23 Slaughterhouses 24 Renderers 25 The animal feed industry 27 iii FINDINGS AND CONCLUSIONS The meat industry 27 The pharmaceutical industry 28 Other uses of bovine products 28 Government and BSE 29 Handling risk 31 Risk evaluation 31 Risk management 31 BSE and risk 32 3 The early years, 1986–88 33 Identification of a new disease in cattle 33 Restraints on information 34 What was the cause of BSE? 36 The scrapie theory 37 The ruminant feed ban 38 Exports 41 Human health implications 42 Mr MacGregor’s reaction 45 Sir Donald Acheson’s advice 46 4 The Southwood Working Party and other scientific advisory committees 48 The Southwood Working Party 48 Epidemiology 49 Risk to humans 50 Other scientific advisory committees 55 The Consultative Committee on Research into SEs (The Tyrrell Committee) 55 The Spongiform Encephalopathy Advisory Committee (SEAC) 57 5 The animal health story 58 Ruminant feed ban 59 The first BAB 61 UKASTA’s information about breaches of the ban 62 Cross-contamination in feedmills 63 What went wrong? 66 Introduction of the animal SBO ban 68 The voluntary animal SBO ban 69 The cat 70 The pig 71 The statutory animal SBO ban 72 iv CONTENTS The operation of the statutory animal SBO ban 73 Before the ban 74 The human SBO Regulations 75 Enforcement 75 The voluntary animal SBO ban 77 The statutory animal SBO ban 77 Reliance on the voluntary animal SBO ban 79 Reliance on the human SBO ban 79 Knacker’s yards and hunt kennels 80 SBO in transit 81 Responsibility 81 Monitoring 82 Renderers 84 Slaughterhouses 85 Knacker’s yards and hunt kennels 86 ‘Cradle to grave’ reviews 86 The truth emerges 86 The penny drops 87 The Meat Hygiene Service takes over and a new SBO stain is introduced 88 More shortcomings revealed 88 The new Order 90 Did the provisions of the animal SBO ban matter? 92 Why did it take so long? 93 Two fundamental issues 94 Conclusions 95 Cattle-tracking 96 Breeding 96 6 Protecting human health 98 Introduction 98 CJD surveillance 99 Surveillance recommended by the Southwood Working Party and the Tyrrell Committee 99 The CJD Surveillance Unit established 99 How the surveillance system worked 99 PHLS excluded from CJD surveillance 100 Slaughter and compensation 101 Was compensation too low? 104 Ante-mortem inspection 105 Compensation changed again 105 Unanticipated burdens 105 Introduction of the ban on Specified Bovine Offal (SBO) in human food 106 Government response to the Southwood Report 106 v FINDINGS AND CONCLUSIONS The decision to introduce the human SBO ban 110 Preparation of the Regulations 113 Brain, spinal cord, thymus, spleen and tonsils 115 Tripe and rennet 115 Mesenteric fat 115 Casings 115 Calves under 6 months of age 116 Mechanically recovered meat (MRM) 117 BSE and human health in 1990 121 Implementation, enforcement and monitoring of the human SBO ban 121 Bovine brains 122 Slaughterhouse practices and mechanically recovered meat 123 Europe and lymphoid tissue 126 Alarms and reassurances 127 The cat 128 The Agriculture Committee 130 SEAC considers the safety of beef 131 A look ahead 132 The false peace – 1 January 1991 to 31 March 1995 133 Slaughterhouse standards 134 History of the setting up of the Meat Hygiene Service 135 Monitoring compliance with the SBO Regulations 136 MRM on the agenda again 137 The distal ileum of calves 137 Advances in knowledge of BSE 139 Knowledge about dose 141 Two dairy farmers die from CJD 141 Vicky Rimmer 143 Chinks in the armour – April–December 1995 143 Action at last on MRM 146 Cause for concern 147 Public debate 148 A campaign of reassurance 150 The final months 151 Mr Hogg’s questions 152 SEAC’s meetings on 5 January and 1 February 1996 154 The storm clouds gather 156 Rumbles of thunder 156 The storm breaks 157 Postscript 160 Contingency planning 161 What would contingency planning have achieved? 164 vi CONTENTS 7 Medicines and cosmetics 166 Medicines 166 The medicines licensing system 167 Medical devices 168 Phase 1: the initial response on veterinary medicines 169 Phase 1: the initial response on human medicines 170 The period up to March 1988 170 March–December 1988 171 Initial action by the CMO and MD 171 The NIBSC discussion 171 Galvanising MD 172 The paper for the BSC 172 Sir Richard Southwood’s concerns about biologicals 173 Phase 2: preparing joint guidelines, January–March 1989 174 The final draft of the Southwood Report 174 The continuing concern on vaccines 176 CSM and VPC approval and the issue of the guidelines 176 Was the action taken adequate? 177 The Southwood message and how it was interpreted 178 Were non-binding guidelines appropriate? 178 Was the scope of the guidelines adequate? 178 Were existing stocks of injected products treated appropriately? 179 Phase 3: implementing the guidelines after March 1989 181 The context for handling matters 181 Collecting and analysing the information 181 The SBO ban and pharmaceuticals 182 How the BSEWG operated 183 First meeting of the BSEWG on 6 September 1989 183 The follow-up to the first meeting 184 Second meeting of the BSEWG on 10 January 1990 185 The follow-up to the second meeting 186 Third meeting of the BSEWG on 4 July 1990 186 Fourth meeting of the BSEWG on 31 October 1990 187 Veterinary products 187 Final meeting of the BSEWG in July 1992 187 Overview of the way the guidelines were implemented 188 Veterinary medicines 188 Human medicines 189 Research into pharmaceuticals 190 Cosmetics and toiletries 192 The main products 192 Regulation 192 vii FINDINGS AND CONCLUSIONS The Tyrrell recommendation on cosmetics 193 Was the initial action adequate? 193 Was DTI action adequate? 194 Action taken thereafter 194 The adequacy of the response 196 8 Occupational risk 198 Those at risk 198 Chronology of occupational safety advice 198 ACDP advice to laboratories, medical workers and undertakers 200 Chronology of drafting of ACDPWG advice 201 The issue of guidance to schools about dissecting bovine eyeballs 203 Chronology of guidance on bovine eyeball dissection 203 Overview of occupational health 205 9 Potential pathways of infection 207 Consideration of an audit of the uses of cattle tissues 207 The Tyrrell recommendation 207 Reasons for this outcome 210 Where responsibility lay 210 10 Pollution and waste control 212 11 Wales, Scotland and Northern Ireland 215 Wales 216 Scotland 216 Northern Ireland 217 Collective government and working relationships 218 12 Science and research 219 Scientific conclusions about BSE 219 Alternative theories 222 The organophosphate theory 222 The autoimmune theory 222 Research 222 13 What went right and what went wrong? 226 A recipe for disaster 226 The identification of the disease and its cause 227 The Government’s response 228 Eradication of BSE 228 Possible transmissibility to other animals 229 viii CONTENTS Possible transmissibility to humans 229 Shortcomings and possible reasons for them 231 Was there a conflict of interest in MAFF? 231 Other conflicts of interest 232 Perception of risk 232 Ignorance and failures of communication 235 Ignorance of views as to the minimum infective dose for cattle 236 Ignorance of views as to the minimum infective dose for humans 237 Ignorance of pathways of infection 237 Failures of communication 238 Between the Southwood Working Party, the Government and the public 238 Between SEAC, the Government and the public 238 Lack of rigorous consideration when giving effect to policy 239 The best being the enemy of the good 239 Inappropriate use of advisory committees 240 Administrative structures 242 Interdepartmental structures 242 DH role 243 Structure within MAFF 243 Chief Medical Officers and Chief Veterinary Officers 244 Central and local government 244 Central government and the Territorial Departments 246 Individual criticisms: redressing the balance 246 14 Lessons to be learned 249 Episodes in the BSE story 249 Lessons from the fact that BSE emerged 249 Commentary 249 Lessons 250 Lessons from the transmissions of BSE 250 Commentary 250 Lessons 250 Lessons from the spread of the BSE epidemic 250 Commentary 250 Lessons 251 Lessons from the identification of BSE 251 Commentary 251 Lessons 251 Lessons from the consideration of the nature and implications of BSE 252 Commentary 252 Lessons 252 Lessons from the investigation of the cause of BSE 252 ix FINDINGS AND CONCLUSIONS Commentary 252 Lessons 253 Lessons from the introduction of the ruminant feed ban 253 Commentary 253 Lessons 253 Lessons from the introduction of slaughter with compensation

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