PAC Hearing 1 – Dr Henrietta Ewart
This summary should not be viewed as a verbatim transcript of the hearing, to hear the full sitting, click here.
Dr Ewart is giving evidence to the Public Accounts Committee’s inquiry into the use of genomics and the Steam Packet.
The committee comprises of:
Chairman Juan Watterson SHK (JW)
Julie Edge MHK (JE)
Chris Robertshaw MHK (CR)
Jane Poole-Wilson MLC (JPW)
Fellow member Clare Baber (CB) did not sit in on the first half of the committee hearing as she is a member of the DHSC. Lawrie Hooper was not able to attend this morning’s hearing.
Juan Watterson: Hi everyone, make sure your phones are on silent, we have two aspects to look at, genomics and the Steam Packet, so let’s get going.
I think it’s fair to say there’s been some pretty fundamental differences between yourself and Dr Glover…
Dr Ewart: No. I have absolutely no, well minimal, contact at all with Dr Glover. I need to make that very clear.
JW: That’s fine, I was going to say, in reference to the use of genomic testing and the utility of genomic testing which I think we’ve seen some quite different approaches.
Dr E: She has never been able to share how that would happen. I absolutely agree with the extraordinarily interesting nature of what is found and that genomics provides further evidence for the epidemiology that we get through contact tracing. What I have not demonstrated to me either through Dr Glover or published papers, or experts across, that it is immediately necessary in response to clusters or outbreaks and indeed it is not used in that way in the UK.
JW: I think that highlights the difference in the evidence we have had in the past that the public Health approach is very much one that takes a satellite view, looking at where the clusters are in the UK as opposed to Dr Glover’s approach which focuses on individual cases underneath the microscope and examining where that sits in the family tree?
Dr E: Yes and the issue there is, can she demonstrate that knowing that actually leads us to do something different in real time and the Public Health perspective is that it doesn’t.
JW: When we moved from the variant before the Kent one, whatever that was.
Dr E: (Explains genetic code of different variants). Can I assume that you’re familiar with the Genomics Consortium UK website, so you’ll be familiar with the wonderful graphic which shows the variants and spread? At that level it’s useful, but for a jobbing on the ground Public Health worker, that doesn’t change our response.
JW: Can we call it the original variant versus the Kent variant?
Dr E: We have to be careful because there is a huge difference. Kent came from nothing in September to accounting for over 99% of all cases countrywide, none of the others did that.
JW: So we had the “original” variant which we were told was more transmitted by droplets, the Kent variant was far more transmissible and it seems that when this comes up, it changed the approach and the risks?
Dr E: No, it changed the transmissibility but that does not change the control measures. SAGE looked into that and published a paper to that effect.
Chris Robertshaw: You referred to the level that the UK uses genomic sequencing, do you agree that the UK works to an intended level because it is working in such a huge environment with millions of people whereas it might be possible to delve down to the next level here where it may give more detail?
Dr E: No because communicable disease control is based at local level anyway.
CR: Sorry I maybe didn’t explain myself, it was a capacity issue in the UK because they had so much to do.
Dr E: I don’t accept that no. Nobody knew what was going to be needed, Prof Sharon Peacock at Cambridge created a collaboration when she realised how useful it could be, it’s all been step by step.
CR: For clarity, the UK system is going as far as it can?
Dr E: Yes. It can’t go any further, it is drilling right down as far as it can.
Jane Poole-Wilson: With the mitigation strategy and some of the changes coming in this week such as around high risk contacts, if we knew tomorrow that the next variant of concern had arrived on the island, how quickly would we want to change that approach?
Dr E: I’m not sure that it’s that which changes that approach. Obviously the variants of concern are important but with a lot of them we still don’t’ understand exactly what impact they have. Transmissibility is one thing but if they have no impact on severity of illness and it isn’t going to knock over our health services that could take you to the argument that if we aren’t so focussed on numbers anymore, so if people are just out there with it like people are out with flu it doesn’t matter so much. What interests us is whether it causes serious illness or evades the vaccine.
If you look at the Indian variant, we don’t know yet how concerned we should be. It’s suspicious because it looks like it has two mutations which affect the spike protein and that’s what drives immunity through the vaccine. So if it affects that then we could have a problem but we just don’t know yet.
JPW: When we look at the exit framework, we have the phrase ‘ready to react’ which includes rapid identification facilities so if we get to the point where there is a variant of concern, would it be important to know as quickly as possible whether that variant had arrived on the island to change our reaction and to get public recognition that it is important we know what we’re dealing with.
Dr E: So firstly, would it change our approach? Not necessarily, we have to have, for the foreseeable future, a capability to understand what is coming over the border. We aren’t able to generate new variants ourselves because we’re too small and it takes 90 days of uncontrolled transmission to drive a variant. We need to understand what we want to monitor at the border and whether that means some form of border testing even if it doesn’t include some form of isolation.
It troubles me greatly because there is no easy answer. Obviously we want to open up our borders but in the past when all variants were equal it wasn’t unreasonable to look at the UK and Ireland and calculating the risk and if it looks like one imported case in a long time then that’s kind of the argument behind the traffic light arrangements but the variants threw extra issue into that calculation.
It’s difficult to get a fully evidence based approach. We want to open the borders but if we don’t test then we won’t know and we won’t know until someone has brought it over or shared it to someone who becomes symptomatic.
Luckily the PCR testing is being adapted to look for variants of concern too. Which would largely take out the need for genome sequencing.
Julie Edge: How do you envisage rapid border testing could work? What will take place?
Dr E: That’s not my decision. Guernsey went for a test on point of disembarkation but it was expensive (cost about £4m). We went for the grandstand issue which had a capacity issue which we need to think about as we open up the borders.
Chris Robertshaw: You say PCR can do more detailed analysis do we have that now and if not how long until we get it?
Dr E: Currently going through fit for purpose testing. Our laboratory colleagues are talking to the manufacturer to get it lined up when it goes on sale and then we’d test it here against samples and people would be trained on using it but I wouldn’t like to say when.
CR: I got the impression and correct me if I’m wrong, that you were downgrading the risk of transmissibility a little bit?
Dr E: You misunderstood. It is of concern and we’ve seen on island how quickly Kent spread but one of the good things about what we’re learning about vaccines is that it dampens down transmissibility. That wasn’t known originally when they were launched.
CR: So very early doors we were clear that transmissibility was a key play in the Kent variant, what’s the ideal turnaround time between a variant of concern and knowing what it is from our perspective on the island? How fast would we want to turn it round?
Dr E: I wouldn’t really estimate to put it that way. As we’ve said, if you look at India, they have a perfect storm for driving the emergence of variants because it’s just spreading in a totally uncontrolled way. It’s already in the UK and we know that despite their border restrictions it’s got into Leicester and it’s transmitted between people there.
CR: If it arrives here and we don’t do border testing, could it be a week to 10 days before we knew it was here? And if it took us another few days before we knew what it was, that could be two weeks, would you be comfortable with that?
Dr E: We may not see it if it comes on island. That’s the whole problem with having no border testing and that’s where we get into the moorland fire. People could come here and not spread it or it could go on and creep along and come into contact with someone who was clinically vulnerable or gets ill and it’s only when they get sick and get to Nobles we know where it is. The new PCR tests should however help with that.
Juan Watterson: Doesn’t that mean we should be sequencing all positive tests until those new PCR tests are available?
Dr E: Yes which is what we are doing. From the Public Health perspective that doesn’t concern me because the measures will be the same.
JW: But people may react differently if they know it’s here.
Dr E: If it is felt that’s appropriate from a political perspective I’d support that but from a Public Health perspective it wouldn’t change our current protocols.
Julie Edge: So the current PCRs you’re saying needn’t be adapted to identify strains, but you’re also saying we don’t get the results back within 10 days, so we could have a highly transmissible variant on the island because we’re not doing rapid identification.
Dr E: We don’t need genomics instantly because the control of the person and their contacts is the same regardless. That’s what you do and continue to do. Across my colleagues in local authorities don’t get them at all unless, as happened at Leicester, Public Health England works with them.
Julie Edge: So we’ve seen the Kent variant and how that affected more than 1,000 of our population. So the Indian and Brazillian variant could come into our island, it could take 10 days you’re ok with that because you’re saying we could isolate people?
Dr E: I don’t know why you keep saying 10 days.
Julie Edge: You said 10 days but now you’re saying five working days.
Dr E: Yes which tends to work out at between five and seven days.
Julie Edge: Five to 10
Dr E: Five to Seven and I’m very comfortable with that.
Chris Robertshaw: So there is a difference between yourself and the medical director?
Dr E: Yes but as far as I’m aware the medical director doesn’t have any communicable disease training.
Juan Watterson: Let’s move onto the Steam Packet
Right back at the start, which feels like years ago, what was your role with border controls?
Dr E: I was an advisor. I have had no direct managerial input into that.
JW: In terms of those early days when border regs were established what advice were you giving to CoMin?
Dr E: None then and I wasn’t specifically asked anything by them.
JW: So you were involved in the gold, silver and bronze teams (which were set up to manage the pandemic response)?
Dr E: Yes.
JW: Did they discuss the Steam Packet and the border controls?
Dr E: Very little from a communicable diseases perspective. Companies were responsible for their own risk assessments etc. We have been open to providing advice but we don’t have capacity or powers to do risk assessments.
JW: When you moved to Cabinet Office, was that a continuation of your role?
Dr E: It was a continuation of my role and it is important to note that during the first wave, that move was almost ignored in that my relationship with DHSC didn’t change.
JW: In terms of gov ownership of the controls of the borders, who owned them? Who did you advise?
Dr E: I advised with anyone who asked. Mostly that was DoI asking for advice to feed back to the Steam Packet.
JW: In terms of expectation of what the company was doing, what was your understanding of that?
Dr E: Minimal, I had very little to do with it in the early days.
JW: As that went through 2020?
Dr E: It was only in the context of reacting to direct questions from the DoI and there wasn’t that much. I’ve had one meeting with the Steam Packet and that was this year, everything else was emails which you have.
Chris Robertshaw: Do you understand yourself as functioning as you would expect a Director of Public Health to function?
Dr E: What sort of Director of Public Health do you have in mind? I’ve had to function here as head cook and bottle washer, everything from Chief Medical Officer. The issue is a DPH in the UK has a totally different role from mine. Public Health England leads on most protection issues whether its Covid or not and supports the DPH in doing what is necessary in a local authority. That doesn’t happen here.
Julie Edge: Do you think we need a Chief Medical Officer?
Dr E: No.
Juan Watterson: Early 2021, Kent became the dominant strain and nothing changed in terms of response, to what extent were you talking to the Channel Islands?
Dr E: With Guernsey, loads, we call every week to 10 days. Jersey has only just appointed a Director of Public Health and it is a very different system there. But going forward we look at being able to work together more as a three. But as of now we haven’t had the same links.
JW: Have your discussions including ferries and what was the nature of those?
Dr E: That was around a supply ferry in Guernsey, different issue actually as the issue there was a resident crew which basically live on the ferry and the issue which resulted from a case there so it was really just peer review and sharing info. It wasn’t relevant to the Steam Packet at the time.
Over the summer I’d advised the Steam Packet that if they had crew mixing with colleagues and passengers from the UK, they had to be treated as potentially infectious and there were safeguards around that. That contact was via email.
Jane Poole-Wilson: Understanding the point you’ve made about organisations being responsible, as you were getting questions, at what point for overriding public health protection would you go further than just answering a question and be seeking more info about what was going on?
Dr E: Throughout most of last year, I and my one colleague have been working 10-15 hour days and fielding hundreds of emails and it’s simply not possible to take the in depth approach one might like.
JPW: Everyone recognises that and appreciates your work, we don’t suggest there’s been any slack but given that context, was there any thought that they should have made it very clear to any changes about their operation?
Dr E: That should happen through the borders and exemption process and they would bring them to us because if the situation changes then they should redo and resubmit their risk assessment. I’ve seen some risk assessments from some companies that aren’t worth the paper they’re written on but I can’t comment on them if I don’t see them.
Juan Watterson: When did you first see one for the Steam Packet?
Dr E: Recently, I don’t think I was involved in the early phase of their exemption granting.
JW: Would you have been expected to be asked?
Dr E: In so far as I would with others but remember the CEO of DHSC has also taken a role in signing off exemptions so they wouldn’t all come to me. If the Packet said we’d like our staff not to follow the exemptions for people coming to the island then that would require an exemption with a risk exemption.
CR: You wrote an email this month about improving working with the organisation or confusion would continue to occur, that’s the governmental side and the impression one gets is that the Steam Packet was seeking advice from where it can get it, in an ideal world what should be going on?
Dr E: There should be a very clear process and protocols with everything feeding through the same thing which should be capturable on a simple flow chart. I imagine that’s a matter for gov taking advice from appropriate departments.
Julie Edge: Do you know who was providing the exemptions team with clinical advice? And were health and safety advisors from gov involved?
Dr E: H&S were involved but they don’t do other people’s risk assessments, they have to be done by the organisations themselves. You don’t need clinical advice for exemptions.
Clare Baber: In regards to group exemptions, there should be a risk assessment but what you’re saying is there’s a clarity which didn’t exist and the info was being gathered by a selection of people, is that accurate?
Dr E: Not sure about info being gathered by different people as if they want an exemption then they have to go through the exemption team and if they want advice then it comes to me. But some organisations have perhaps tried to get into the systems at different points.
Juan Watterson: That would suggest we don’t have robust enough systems.
Dr E: Well in the case of the Steam Packet, I didn’t know what they were doing but they believed they were acting appropriately, as I understand it.
Clare Barber: Picking up from before, that it didn’t always come to you, where was the guarantee that it would be picked up? There seems to have been a number of mentions they weren’t isolating but it wasn’t the primary issue of the communications, where does responsibility lie for if those systems weren’t working?
Dr E: I don’t know those weren’t my responsibility.
Juan Watterson: You say about Steam Packet doing what they shouldn’t have been doing such as mixing in the community?
Dr E: Yes and some procedures on board too.
JW: So the risk assessment was deviating from practice, was anyone checking?
Dr E: I don’t think there has been capacity to do that. It emerged when we had cases and the contact tracing identified issues.
Jane Poole-Wilson: Building on the system around all of this, were you involved in giving input into the conditions for the exemptions which changed?
Dr E: Some but not all. DHSC CEO dealt with most of them, I picked them up when she wasn’t available.
Chris Robertshaw: What advice would you give us to help put all this into order?
Dr E: I think everybody has done the best job they could and retrospection is a wonderful thing but we do have a chance to try to coordinate things better. My input is limited to Public Health and I would look to work with colleagues in other areas and that process is starting. The plan to have a programme in place led by Mark Lewin to actually coordinate all of this. So Public Health is a strand in that, as is DHSC, Manx Care, the vaccine programme, the lab testing. Whether we need to deliver a genomics capability on island, which almost certainly we do, but that should be strategically not a knee jerk reaction.
Other strands are DoI, the borders, the exemption team and that’s being pulled together this week.
JW: January 25 meeting with the Steam Packet, what went down?
Dr E: It was at the Steam Packet offices and in my understanding, it was to look at mitigating the restrictions on the Steam Packet crew who had had a long and difficult year.
JW: And there was no explicit statement that said crews were going home and mixing in the community?
Dr E: No it was very much focussed on how we could use regular testing to allow this and was picking up on behaviours that were concerning the public. At that time we were getting a lot of calls from people saying they’d been on the ferry and they’d seen the crews doing things they shouldn’t like, not social distancing or wearing masks etc. So we spent quite a part of that meeting talking about that and also their risk assessment. They had repeatedly submitted one at that stage which was completely unacceptable. It was a risk assessment which was really an operational policy. I had thrown it back and said it wasn’t relevant and they need to make it relevant so we talked about that.
Julie Edge: So you didn’t go higher, so to CoMin?
Dr E: No, since September I’ve been attending CoMin and feeding in but this was an operational issue. I also help differentiate between public health advice and clinical advice.
JE: So this didn’t go up to CoMin?
Dr E: No. It was an operation issue but it led to the changes such as regularly swabbing of staff.
Juan Watterson: Was there a specific conversation about allowing resident crew to not isolate?
Dr E: Yes, providing we could agree on a testing regime which could support that.
Jane Poole-Wilson: You raised a concern about the rejected risk assessment not outlining how the UK and Manx crew were interacting with each other. Had that ever been covered?
Dr E: Not that I had seen but the first time I saw them was the start of the episode that we’ve just been talking about.
JPW: Do you know if anyone else had looked at it?
Dr E: Not to my knowledge.
Clare Barber: Why was there an understanding that the Steam Packet crew were required to isolate when others such as taxi drivers who were picking people up from the airport and sea terminal weren’t?
Dr E: There’s a difference in the risk assessment there. In the mitigation agreed with the taxi drivers, they wouldn’t class as high risk contacts. You can’t control behaviours which step outside those risk assessments, but there comes a point when you do have to believe people will follow the agreed risk assessments. The nature of the job on the Steam Packet is very different and when we later discovered we had cases, some of the mitigation we thought to be in place weren’t.
Juan Watterson: How do you balance that risk?
Dr E: It was mitigated by a number of measures which decreased the risk.
Chris Robertshaw: When did the Steam Packet first ask about vaccines?
Dr E: I don’t know I wasn’t involved, I imagine it came through DHSC though.
CR: Why was so long spent with taxi drivers but not the ferry operators?
Dr E: Taxi drivers wanted that engagement and the Steam Packet engagement was what they asked for. The RTLC directly asked for support but the Steam Packet was one removed through DoI. In an ideal world I may have been more proactive but simply we didn’t have the time.
Julie Edge: Did you ever ask for any extra resources?
Dr E: No our services are quite specialist so they wouldn’t have been much help but people could help for example by working in contact tracing. Overall this has worked incredibly well and I’ve seen some superb risk assessments. I suppose we have to ask why others weren’t as good and if more could be done to have brought those up to standard.
Juan Watterson: Have you ever been annoyed by people ignoring your advice?
Dr E: I provide the advice and people who are paid to make decisions make the decisions, if they don’t agree with my evidential advice then it is up to them but I do ask why.