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Swine Flu

Volume 491: debated on Monday 27 April 2009

With permission, Mr. Speaker, I should like to make a statement on the reports of human cases of swine influenza, known as the A(H1Nl) infection, in some parts of the world, notably Mexico and the United States of America.

The outbreak began in Mexico on 18 March, and as at 9 pm last night, there have been over 800 cases and 89 deaths in that country. However, to date, only 18 cases in Mexico have been confirmed as being caused by the H1Nl virus, and it is highly possible that other, more routine causes of infection are also currently circulating in that country.

On Tuesday last week, under the terms of the international health regulations, the United States reported seven cases of the H1N1 infection. On Friday 24 April, the United States Centres for Disease Control and Prevention confirmed that samples from Mexico contained the same virus as those in the United States. Twenty cases have now been confirmed in five different states of the USA, four have been confirmed in Canada and one in Spain. Suspected cases have also been reported in New Zealand, France and Israel, although it is important to note that these are suspected cases and have not yet been confirmed as the H1N1 infection.

In the UK, 25 cases under investigation have been reported. Eight of these have proved to be negative, and three are currently undergoing further specialist tests. These three patients are in isolation wards in hospital, after recently travelling in Mexico. People who have been in close contact with them are being contacted. The remaining 14 suspected cases are undergoing initial investigation and the people involved are sufficiently well to be managed in the community.

It is too early to say whether the cases in Mexico and the US will lead to a pandemic. Scientists do not yet understand the extent to which cases in Mexico and the US are linked and are not yet able to make a complete assessment of the health implications of this new virus.

A pandemic is declared when the World Health Organisation raises the pandemic alert to phase 6. That means that there is widespread person-to-person transmission of a virus in the general population. At the moment we are at phase 3.

The director general of the WHO, Dr. Margaret Chan, has declared that this is a public health emergency of international concern. The WHO is convening a committee of experts from around the world that is meeting this afternoon to review the situation and to determine what further action is required at a global level.

In deciding the state of the pandemic alert, the WHO bases its decision on expert scientific advice based on the available epidemiological and scientific evidence. The range of symptoms in the people affected is similar to those of regular human seasonal influenza. It is important to note that, apart from in Mexico, all those infected with the virus have experienced mild symptoms and made a full recovery. The swine flu that has been isolated in Mexico and the United States is sensitive to the antiviral drugs Tamiflu and Relenza. Those drugs are effective in treating the illness, provided they are taken quickly enough. They can also reduce the length of symptoms and usually their severity.

I would like to outline the measures that we are taking in response to this significant health threat. The UK has been preparing for a flu pandemic for the past five years. We have established a stockpile of enough antivirals to treat more than 33 million people—half the UK population. All NHS organisations have pandemic flu plans in place and the Department of Health is now working closely with the NHS to ensure that those plans can be put into action so that antivirals can be made available to the public very rapidly should we reach that stage.

Over the weekend, the Government have been putting in place precautionary measures to implement the plans that we have been developing in case of more widespread infections in the UK. I have spoken to ministerial colleagues and my Opposition shadows this morning, and I will be convening a meeting of the Civil Contingencies Committee immediately following this statement.

We have enhanced our port health checks so that passengers arriving in the UK with symptoms of illness are identified and assessed. Information is being made available to passengers arriving at ports and we have provided urgent advice to doctors. Should the virus start spreading widely in the UK, we propose to use our antiviral stockpile for treatment of symptomatic patients. We already have advance agreements in place with manufacturers, should a vaccine be developed, although it is important to note that it will be some time before scientists can develop a vaccine, as the virus is not yet sufficiently understood. Experts are currently examining whether vaccination with the regular, seasonal flu vaccine can in any way boost immunity to the H1N1 strain, and we are considering how best we can use the limited stocks that are currently available within the UK.

Many people will wish to know whether they should wear face masks. Although we are aware that face masks are being given out to the public in Mexico, the available scientific evidence does not support the general wearing of face masks by those who are not ill while going about their normal activities. We are, however, urgently looking into how we can increase our stockpiles of face masks for health care workers who are treating sick patients. We have also established infection control guidance to support staff when treating or caring for people who have symptoms.

We already have well-advanced plans for providing information to the public in the event of a pandemic, in particular about what people can do to help themselves in the event of swine influenza being confirmed in the UK. Updated information is available on the NHS Choices and the Health Protection Agency websites. Further information is also available for health and social care staff on the Department of Health website. We are putting in place an information line containing recorded, up-to-date information for those who want to know more about this type of flu. In addition, NHS Direct is providing information to people who have recently travelled overseas and are worried that they may have symptoms.

There are three key messages that I would like to stress at this stage. First, it is important to emphasise that in all cases outside Mexico the symptoms of this illness are mild and all patients have made a full recovery. Secondly, we can all take simple measures to prevent infection, in particular, covering one’s nose and mouth when coughing or sneezing, and washing hands regularly. Anyone who develops flu-like symptoms should go home and contact their general practitioner. Thirdly, anyone who has recently travelled to the affected areas and is experiencing influenza-like illness should stay at home in order to limit contact with others and seek medical advice by phone from a local health professional or NHS Direct. In line with advice from the World Health Organisation, there are currently no travel restrictions on those who are planning to visit affected areas. Anyone who is planning to do so is advised to ensure that they take the measures I have outlined to prevent infection and consult a doctor immediately if they show signs of flu-like symptoms. To enable local health services to respond to the pressure that the possibility of a pandemic may put on services, we are working with primary care trusts to ensure that arrangements are in place to support that distribution arrangement for antivirals, should it become necessary.

There is understandable trepidation and concern across the world. Here in the UK, we are monitoring the situation very closely, alongside the WHO and our international partners. The UK has been preparing for such an occurrence for a number of years, and the WHO has recognised that the UK and France are the two best-prepared countries in the world. I wanted to use this opportunity to update the House on what we know so far, but I shall, of course, keep Parliament fully updated on what is obviously a rapidly developing situation.

I am sure that the House is grateful to the Secretary of State for making a statement at the first opportunity, and I was grateful for the opportunity to see it beforehand and for the conversation that we had about this matter this morning, to which he referred.

May I express—I hope on behalf of the whole House—our sympathy with, and support for, all those in Mexico who have suffered as a consequence of this outbreak? I hope that, through the WHO, we will be able to continue to give the greatest possible support to that country. However, the current situation illustrates a point that we have discussed before in relation to pandemic preparedness: that an influenza pandemic would expose dramatic differences in the ability to respond in different parts of the world between the most developed countries and the least developed countries. The national reporting systems in Mexico are clearly not as good as they should be. For a month, several hundred cases had emerged in Mexico before the point last week when the CDC in Atlanta—the Americans’ responsible authority in this area—on behalf of the WHO, became aware of the new strain and was able to trigger the necessary alerts. Clearly, the UK and developing countries are interdependent, and we should be supporting them and trying to ensure that we have not only better alerts, but the resources available to support such countries in responding more rapidly and more effectively to flu outbreaks.

As the Secretary of State said, the United Kingdom is among the better prepared countries, and we have been discussing such preparations for nearly five years for that to be the case. If the WHO, which is meeting this afternoon, moves the alert status from phase 3 to phase 5, as is possible, given the nature of what we know, that will trigger a response in this country. As the Secretary of State implied, it is important for us not to assume that what is in the UK pandemic plan and its underlying assumptions about the likely profile of an influenza pandemic is what we will experience in this case. That plan is much more geared to more severe symptoms than we have seen in the cases that have emerged in America and elsewhere; this is, in a sense, more like the Russian flu of 1977, which was an H1N1 flu virus for which the vaccine was available within three months and the clinical attack rates and mortality rates were much lower than were assumed in the pandemic plan. We do have reasons to be optimistic, including the mild nature of the flu that has been experienced in other countries. However, we do not know whether there is a much greater prevalence in Mexico, with only the most severe cases going to hospital.

It is important that we review our preparations, and I have several points to make in that respect. We have a stockpile of treatments, although in an answer on 12 January the Minister of State, Department of Health, the right hon. Member for Bristol, South (Dawn Primarolo) said that Department modelling had shown that prophylactic or preventive use of antivirals in a flu pandemic would be effective. That would require a stockpile of 75 per cent. equivalent of the population, rather than the 50 per cent. that we have at the moment. Perhaps the Government could tell us what further steps they have taken following that reply in January.

The Secretary of State will also know that for four years we have told the Government that other countries, including France and Australia, have a strategic stockpile of face masks and gloves. It is not for distribution to the whole population, but it is to ensure that everybody in frontline care would be able to wear face masks and gloves. The Government say that they are urgently looking for face masks, but when SARS—severe acute respiratory syndrome—emerged the international supply of face masks disappeared almost overnight. It is therefore unlikely that the Government will be able to procure face masks very readily.

The Secretary of State may be able to tell us something about vaccine research and our support for it. In November 2005, President Bush devoted $2.8 billion to improvement of vaccine technologies, and I hope that we can say that we are doing our bit, especially as we have some of the leading scientists in the area.

If there is a change in the WHO alert status, it will trigger a communication exercise with the public about our pandemic preparations, under the pandemic plan. On 22 January, my hon. Friend the Member for Rutland and Melton (Alan Duncan) asked for a debate in Government time on pandemic preparedness, but the Government have not given us that. I wish that they had, as it is better to discuss the issues raised by a pandemic before it happens rather than when we face the immediate prospect of it happening. None the less, will the Government now accept that request?

The flu contingency plan states that if a WHO phase 5 alert is declared, UK Health Departments will run a national door-drop and advertising campaign. Are the Government ready and willing to do that, were it to be triggered today? Why is the EU Commission offering travel advice while the WHO and the UK Government are not? Will those who are travelling to Mexico or the south-west states of the US have access to antiviral treatments for prophylactic purposes on the NHS, rather than just through private prescriptions, to reduce the risk of transmission?

I welcome what the Secretary of State had to say about updating the House regularly and I heartily endorse what he said about the general importance of hand hygiene. I look forward to further updates in due course.

I agree with the general points that the hon. Gentleman made. It is important that we deal with this across parties and across all the devolved Administrations. That is how I intend to proceed. He is also right to draw attention to causes for optimism, and it is important to get the balance right. We do not want to frighten the lives out of individuals unnecessarily, but we do want people to be properly alert to the dangers. The media yesterday were fairly well balanced, but some hyperbole crept into some reports this morning.

It is important to stress that there is no pandemic at this stage. The scientists are working hard on the issue, and we will know from the WHO meetings later whether we move to a phase 5 alert. I agree with the hon. Gentleman that that is still not phase 6, but it is important to recognise also the mild nature of the symptoms outside Mexico.

The hon. Gentleman mentioned the dramatic differences in countries’ preparedness. I am not prepared at this stage to say what happened in Mexico, but what I do know is that Mexico has been a very active member of the WHO and it is always present at the G7-plus and is always keen to talk about this issue. I want to know more about what happened before I say anything that is even mildly critical of the Mexican authorities.

The House has discussed pandemic preparedness. I know that we have not discussed it on numerous occasions, but we have probably discussed it more than many other Parliaments. There is a broad measure of agreement between us and, as the hon. Gentleman knows, the matter has been discussed between Ministers and shadow Ministers and with officials, so I think that we have given sufficient time to it.

The hon. Gentleman says that that was Opposition time, but I am talking about parliamentary time as if we all owned that time.

The hon. Gentleman asked whether we are ready for a national door-drop. Yes, we are. He mentioned face masks. I wish we were further ahead with face masks, but we have nearly enough face masks for staff, and it is important to note that they are not just ordinary face masks. The face masks that we would give to NHS staff have much better filters and are much more sophisticated, as they need to be. We need to ensure that we address that situation quickly.

The hon. Gentleman mentioned advice that came from the Commission. My understanding is that the advice came not from the Commission but from the commissioner, and it probably was not that helpful.

The UK and the US are working closely together on vaccine research, in which GlaxoSmithKline, in particular, is an important player. The partnership between the US and the UK will lead the way in vaccine research. If this turns into a pandemic, the key issue will be to identify the strain of H1N1 and to produce a vaccine. It is likely to take between six months and a year to identify the strain and to produce and manufacture the vaccine.

The hon. Gentleman’s final point was about prophylactic drugs. The last time we debated this subject, we were prepared for an H5N1 virus—an avian type of flu. As the hon. Gentleman mentioned, this is a human type—H1N1—which gives us some cause for optimism that we can tackle it. We do not know yet, but the general flu injections that people take might help. However, the H5N1 prophylactic that we had available is not applicable in this case.

The hon. Gentleman says from a sedentary position that he was talking about antibiotics—I am sorry, I misunderstood him. We have sufficient stocks of antibiotics. They are very important, because most of these cases will lead to complications, which antibiotics will deal with. If he was talking about using antivirals as a prophylactic, we have sufficient quantities. The hon. Gentleman’s point was whether we should give prophylactics to people who go to the affected countries. My view at the moment—we will discuss this further—is that we should not, because we need to ensure that we have sufficient stocks for 50 per cent. of the population if an outbreak occurs. We will obviously keep that under examination, but at this stage I do not think that that would be wise.

I, too, want to thank the Secretary of State for coming to the House at the earliest opportunity to give this statement on what must be a busy day for him as he assesses the advice that he is getting. My hon. Friend the Member for North Norfolk (Norman Lamb) wants to apologise for his absence.

Does the Secretary of State agree that the difficulty in understanding the nature of the threat is caused by some of the mysterious aspects of this outbreak? Why do the cases appear so much more severe in Mexico than elsewhere in the world? Will the outbreak always be this virulent? Did it actually start in Mexico? The Secretary of State said he was convinced it did, although one cannot be certain that there were not sub-clinical strains elsewhere before the first Mexican report? Has the antigen drift made it less pathogenic as it has spread from Mexico? That is one cause for hope, and it is why we are seeing different pathogenicity elsewhere.

How easily is the disease spread from human to human? That is not yet known, but how easily the disease is spread from human to human and whether that transmissibility is sustained as the virus changes, as such viruses do, will determine as much as anything else the extent to which the disease is likely to become a pandemic. Of course, we do not know what protection, if any, is available from the H1N1 seasonal flu vaccines.

It is important to note that only one published paper on the two isolates from California has been available on the CDC—US Centres for Disease and Control Prevention—website. It is not yet possible to compare those isolates with the Mexican isolates to see whether the genetic changes—the genetic assortment that appears to have taken place, according to that paper, between the 1918 north American strain and the 1979 Europe and Asian strain—are replicated in all such cases. There are simply too many unknowns, so I share the Secretary of State’s caution, but it is wise to assume that the worst may happen and to plan for it, which the Government appear to be doing.

I have a number of questions. First, may I pursue the issue of preparedness in other countries? We are in a world of global travel, so the weakest link in surveillance and reporting will be the one that causes delay in bringing the virus to scientists to study so that public health experts can give advice. Will the Secretary of State say more about what we can do to improve surveillance and public health in areas such as central America—not just in Mexico—as we needed to do, and still need to do, in the far east in relation to the threat of bird flu?

Is the Secretary of State certain that we have right the proportions of the antivirals, Relenza and Tamiflu? If there is a differential, and it is possible for the virus to become resistant to one but not the other, which would be unusual but possible, it might be good to have a balance of both. As I understand it, we have a preponderance of the oral form but not a huge amount of the inhaled version—for obvious reasons in terms of ease of delivery—and that might become a factor.

Has the Secretary of State given any thought to what might happen if the worse comes to worst and the buying of antivirals by asymptomatic people, privately or over the internet, causes problems for public confidence in the distribution system? I share his scepticism about the appropriateness of providing prophylactics to travellers, as that might be an inappropriate way, outside a country’s plans, of introducing antivirals that could lead to resistance.

Order. Perhaps the hon. Gentleman could draw his remarks to a conclusion, as a number of Back Benchers are hoping to contribute.

Finally, can the Secretary of State reassure us that there will be full international co-operation between scientists and countries? That scientific effort will give us the information we need, and the hope of a vaccine sooner rather than later.

I think the hon. Gentleman was musing aloud during the first part of his contribution. I do not know the answers, and the WHO does not yet know the answers to the issues he raised about the strain and how we can deal with it.

The hon. Gentleman asked what we can do on the weakest link argument. What we can do is support the WHO. Although the WHO is keen to ensure that all countries co-operate, he knows that one country in particular—Indonesia—is refusing to provide certain information about avian flu that could help us. It is very important that every country gives information to the WHO so that it can co-ordinate activity. Supporting Margaret Chan and her colleagues at the WHO is the greatest contribution we can make.

The hon. Gentleman says that there is a preponderance of Tamiflu, which is quite true. I understand that Relenza can be used by women who are pregnant or breastfeeding, for whom Tamiflu is inappropriate, so I think that we have the right balance. There is a preponderance of Tamiflu because it can be taken by most of the population, except pregnant and breastfeeding women and some other groups. We are fortunate to have Relenza for them because many countries have only Tamiflu.

It is important that hon. Members do not get into the issue of buying antivirals yet—there is not a phase 6 alert. We have talked about all the things that we need to do at this stage, and the hon. Gentleman is right that full international co-operation is absolutely essential, which is why the WHO deserves all our support.

Order. I ask Back Benchers to limit their supplementaries to one brief question, and for similar responses, because many hon. Members wish to catch my eye and we have important business on the Budget to follow.

There is absolutely no complacency on such issues, but we are all reassured that the Secretary of State has made a statement in the House immediately and that the UK has been singled out as one of the better prepared countries.

The Secretary of State will know that I have a particular interest as one who initiated some of the preparations and as the MP for Monklands hospital. The situation at Monklands is being dealt with by the Scottish Government. I have been in touch with the local MSP, Karen Whitefield, and the Minister, Nicola Sturgeon, who has acted with commendable speed. Will the Secretary of State reassure the House that there will be maximum co-operation, liaison and exchange of information between the devolved Governments and central Government, because something such as this is no great respecter of borders inside or outside the United Kingdom?

I can give my right hon. Friend that assurance. Two of the three cases under examination involve people from Scotland. I spoke to Nicola Sturgeon yesterday and again today. She has acted with admirable promptness and has been extremely co-operative. We will work together on this, because it is otherwise no good talking about international co-operation—[Interruption.] Of course, this is international co-operation. This is a UK-wide issue, so we will deal with it as such through Cobra. We will ensure that there is absolute solidarity and close working between all the devolved Administrations.

The Secretary of State said that if the virus starts spreading widely in the UK, the Government propose to use their antiviral stockpile to treat symptomatic patients. What would he say to elderly and vulnerable constituents in Kettering and elsewhere, and to the parents of young children, who might not have the symptoms, but want to ensure that they do not pick up swine flu if it spreads widely in this country?

If people do not have the symptoms, the advice at this stage is that which I gave in my statement: catch it, bin it, kill it. People should ensure that they use a handkerchief or tissue when they cough or blow their nose, ensure that that is thrown in the bin, and then ensure that they wash their hands. That advice is very simple, but it is the most profound that can be given in such circumstances.

If people do not feel unwell at all—if they feel fine—I would not want them to be concerned, whether they are elderly constituents in Kettering, Hull, Cambridgeshire or anywhere else. If they start feeling sickly but have not been anywhere near Mexico or the US, they will, in all probability, have a cough or cold—adults get between five to eight doses of that each year—and they should deal with it in the normal way. If, however, they have had contact with anyone who has been in those affected countries, they should go home and contact the Health Protection Agency or a health professional. That is the advice that we should give, rather than giving anyone the feeling that we have moved to a phase 6 alert when we have not.

I thank the Secretary of State for his statement and the information that he gave. May I take him back to a point made by the hon. Member for Oxford, West and Abingdon (Dr. Harris)? There is a marked difference between the death rate reported in Mexico and that reported outside it, apparently due to the same strain of flu. Does the Secretary of State think that more than one type of flu might be going around, which would make the dangers more complicated than have been realised, and is he in close touch with the Mexican authorities, especially those in Mexico City, about the public health warnings and advice they are giving, especially regarding people cleaning their noses and wearing face masks to try to reduce the spread of the virus?

My hon. Friend is right: the situation in Mexico is complex. I mentioned 800 cases and a large number of deaths, but at the moment only 18 of those cases are linked to H1N1, which is why there is the suspicion that there are other illnesses involved in Mexico. We are in close touch with the authorities there through the WHO, but I can assure my hon. Friend that no one is in closer touch with them than the US authorities, because of course this is a cross-border issue for the US. We want to help the Mexican authorities to deal with the matter, and we want to help them to help us understand what is going on there, because until we do we will not have the key to whether this is the kind of pandemic that we all hope it is not, but that we fear it may be. The key is finding out what happened in Mexico.

I appreciate that the Secretary of State has given thought to prioritising to whom to give vaccines should the need arise, but, following on from the question put by my hon. Friend the Member for Kettering (Mr. Hollobone), does the Secretary of State feel that there is an argument that some priority ought to be given to certain groups of people—for example, to those on the front line of health services, who may well be dealing with people who come in with the relevant symptoms, or those working in airports and port authorities?

It is important to be clear—I am not saying that the hon. Gentleman is not—that we do not have a vaccine. We do not have something that can be injected or taken to prevent anyone from getting this flu. We have an antiviral; if people develop the symptoms—if they are symptomatic—and take it, all the evidence is that they will recover very quickly. We cannot take that action until they are symptomatic. There is a view that one could use those antivirals as a preventive measure, but no one is absolutely sure of that. As for using up that precious stock of antivirals, it should be borne in mind that we were catering for 25 per cent. of the population; we have now expanded provision to cater for 50 per cent. of the population. We do not want to diminish and dilute that by using the antiviral in a way that we are not sure will have a beneficial effect. There is not a vaccine, a pill or tablet, or medication that anyone can take to prevent the illness—yet. There may well be, once the scientists have had a chance to examine the strain and produce a vaccine, but that will take some time.

Order. May I reiterate my earlier comments? The time left for this statement is very limited, so I re-emphasise the importance of brief questions and answers.

My right hon. Friend the Secretary of State will know that modelling the spread of such illnesses is incredibly difficult. As by the hon. Member for Oxford, West and Abingdon (Dr. Harris) indicated, that is partly because of the way in which we travel today and because such a virus can mutate and change, hopefully becoming less harmful. Perhaps that is where we are. It requires a hugely challenging laboratory exercise to maintain a full understanding of what is happening. Is my right hon. Friend satisfied that he and his colleagues in the Department for Environment, Food and Rural Affairs have at their disposal the resources for that, so that we can not only follow the path of the illness, but ensure that we learn lessons from what has happened?

I am entirely satisfied that that is the case, and entirely satisfied with regard to the NHS. The matter has been a tier 1 priority in the operating framework for the past three years. However, I am not complacent about the issue. The hon. Member for South Cambridgeshire (Mr. Lansley) raised an important point: we are talking about something that is actually happening, as opposed to preparing for something that we were worried about, so we have a chance now to modify our approach, depending on what we find. However, I think that we are in a better state of preparedness than most other countries.

Will the Secretary of State assure us that just as there are good relations between England and Scotland at ministerial level, there are good relations between officials?

Yes, I can. At the officials’ Cobra meeting yesterday, Scottish officials were involved and made an important contribution. There must be good relations, and that is the case at ministerial level and at official level.

We know already that flu is the largest vaccine-preventable disease in the UK and the viral load is much higher in children under two, so as we look to the future beyond any immediate danger, will my right hon. Friend consult the Joint Committee on Vaccination and Immunisation and consider an annual flu vaccination programme for children under two, who are more likely to pass the virus on to their families, carers and friends? Such a programme would have the added benefit of scaling up the public health response, which would enable us to respond to the threat in any future pandemic.

My hon. Friend raises a more general point about flu inoculation. We give children the flu jab if they are asthmatic and particularly vulnerable to flu. I will talk to my colleagues about how far we can move to a vaccine for those under two years of age. That is an important general point. With reference to swine flu, the antivirals work for children as well. That is very important.

The British pig industry has been having a particularly hard time of it recently, so the chief veterinary officer’s remarks this morning reassuring people about the safety of eating pork were most welcome; only the New Zealand farming industry to date has issued a statement saying, “Don’t stop eating pork.” Has the Secretary of State met his colleague, the Secretary of State for Environment, Food and Rural Affairs, to discuss reassuring the public about the safety of eating pork and, if necessary, diverting funding to promote a safety in eating British pork campaign?

I have just spoken to my right hon. Friend, and I will speak to him again at the Cobra meeting immediately following this statement, at which we will discuss that. My right hon. Friend tells me what the hon. Gentleman already knows: we do not have any pigs or pig products from Mexico in the UK.

The idea of phoning NHS Direct is very good. NHS Direct would fax the chemist, and the person affected would get a friend to pick up the pills. My concern is that people will be very scared and NHS Direct might be overwhelmed with calls. What preparations have been made for escalating the number of staff responding?

That is the next phase. We are not at that phase yet. The hon. Lady rightly points to our plans, if we are at a stage 6 alert and are dealing with a pandemic, in which case we would want everyone, especially those who are elderly and living alone, to have a friend who can go and collect their drugs for them, to avoid people travelling around. We have good plans to ensure that, at that stage, people can access such a distribution system and that it would work. It is important to emphasise that we are not at that level at present, and I hope we never get to that level.