Variant CJD and Surgery

Debate between Jim Shannon and Paul Beresford

Tuesday 29th November 2016 Commons Chamber

[Sir Paul Beresford (Mole Valley) (Con)]

I am delighted to see the Minister in her place, and I am sure that she is delighted to be here—or at least she is trying to smile under the circumstances. She has probably been made aware of my long-term interest in, and deep concern about, this subject. I am sorry to inflict it on her this evening, but she is bearing up. I also declare a potential interest, as a very part-time dentist.

Variant CJD is a fatal neurodegenerative disease originating from exposure to bovine spongiform encephalopathy-like prions, prions being small particles of protein. Variant CJD prion infections are associated with a very long and clinically silent incubation, but when the disease strikes, it causes a fast, spongy degeneration of the brain, followed by a horrible and untimely death. It is probable, but not certain, that carriers might not produce the disease themselves, but it appears to have a potentially decades-long incubation. The long incubation period means that some will die of other causes first, but, as we live longer, we cannot be certain that in time —after decades—the disease might not strike all carriers, if they survive long enough. Carriers might also unwittingly pass on the prion through blood transfusion and via surgical instruments.

Variant CJD is an appalling disease with no cure. The number of asymptomatic individuals with variant CJD prion infection is unknown, but recent research estimates that the carriers number about one in 2,000 adults, which is a staggering number. The disease poses a risk to others, via blood transfusions, blood products, organ or tissue grafts and contaminated medical or dental instruments. The response of this and previous Governments has been bipolar. To give an exaggerated simplification, the first position of this bipolar response is that as we have not had many recent cases, there is no problem—but considering the long incubation period and some recent changes, this is a dangerous assumption. The second position is that there might be a problem so we should apply the precautionary principle in some areas. We cannot have both. I believe that waiting and an occasional application of the precautionary principle really do not hit the problem. If the Minister takes no action, I hope she will recognise that the absence of evidence is not evidence of absence.

As I have said, research says that one person in 2,000 is a carrier. The incubation period may well be decades, and some individuals appear to be more susceptible and some less so, although in time this could be proven wrong. A death from variant CJD in Edinburgh in January this year showed a potentially deeply worrying change. People are of various genotypes: they can be VV homozygotic, or MM homozygotic or MV homozygotic—and for the sake of Mr Deputy Speaker, I will not explain that. Until this case of the Edinburgh patient, all cases of variant CJD had been MM. The Edinburgh patient was the first MV patient that we have seen. It was thought that being MV or VV might offer some resistance, but this does not seem to be the case. We should bear it in mind that about 45% of the population are MV.

There is still no conclusive evidence, but there is a possibility that patients with the MV genotype may have a longer incubation period, which could lead to a second wave of variant CJD. The real point is that until recently it was hoped that MV patients might not show clinical signs, but in these early days this appears to have been put in deep doubt.

Research also shows that prions are transmissible by blood products and contaminated surgical instruments, and as the prions resist decontamination from stainless steel, we have a problem. Over the years, a precautionary principle has been applied—it is still being applied, but only partially. Much has been done slowly over many years. Leucodepletion was introduced, and synthesised clotting factors have been provided for haemophiliacs. A prion unit was set up at Queen Square. Single-patient use of stainless steel endodontic reamers was made mandatory, which I find quite interesting and will return to in a few moments. Non-UK blood supplies were sourced for those born after 1 January 1996.

What I found curious about the endodontic reamers is that if a patient requires endodontics, it is possible to use the stainless steel reamer but singly; but if the patient for some reason does not have endodontics, the tooth will have to be extracted using a stainless steel instrument that is used repeatedly, called a pair of forceps.

Very early on the Government established, through Medical Research Council funding, a prion unit at Queen Square under Professor Collinge. This unit was tasked with finding a test, finding ways of stopping or reducing transmission and hopefully even finding a cure. The prion unit with DuPont has produced a RelyOn soak, which deactivates the prion on stainless steel surgical instruments. Following the soak, there is then decontamination and a washing machine—a dishwasher-type machine—and then a full-blown steriliser, particularly a vacuum-based one. These instruments will bring about total sterilisation, from which the prion will be lost.

DuPont is no longer producing the soak, because there is no market. And there is no market simply because hospitals, clinics and surgeries in this country are not required to use it; if they were, there would be a market. That is quite extraordinary considering that this country has the greatest deposit, if I may use that term, of people carrying the prion.

In a surgery washer, the disinfectant would do the job. Recently, Professor Collinge became aware that the Department of Health had announced funds for research into prion-disinfecting stainless steel instruments. I believe the prion unit has applied and will hopefully get a grant. The problem with the wash was that it meant an extra stage, which slowed everything down in the hospital, but if DuPont or another manufacturer could produce it in the form of a tablet, a powder or a liquid that would go into the dishwasher without frothing, that step would be taken away, we would get rid of the prion and there would be no time wasted. Those instruments would be prion-free.

Incidentally, the Minister may be aware that there is some evidence that a protein may—and I stress the word “may”—be responsible for the occasional transmission of Alzheimer’s disease. If she wants a little bit of help on moving with RelyOn, I can tell her that RelyOn would disinfect instruments with this protein as well.

Another major failure relates to the sourcing of blood products. People born after 1 January 1996 who needed blood products—for instance, a transfusion—could get non-UK-sourced plasma that was almost certainly prion-free. Those born before that date would get UK plasma, and would have to pray earnestly that the donor was not the one in 2,000. As a parent, I can imagine having two children born on either side of that date. If for some horrible reason they both needed blood transfusions, one child would get the prion-free plasma and the other would take the risk, as would elderly people like us.

With a test, we could be fairly sure of excluding that one in 2,000. Professor Collinge and his prion unit team have developed such a test. They tried it out in this country and subsequently went to the United States, where they checked it with an extensive research programme to make sure that it produced no false positives. They were successful. They then returned to this country. The final stage of the research needs to be tested on a large batch of anonymised UK blood samples, but the Medical Research Council will not fund it. At least, that is the case so far.

If we had that test, blood donors who were carriers would be sorted out and their blood not used, and special measures could be taken for surgery patients who proved to be carriers. In respect of the latter line, the Minister’s Department introduced new guidance in July this year. I understand that it requires separate instruments to be used on high-risk tissues in the case of patients born before and after 1 January 1997 respectively. That is sensible reasoning, because it is thought that people born since 1 January 1997—I thought that it was 1996—have had less exposure to prions via the food chain. Those people form a group who are at lower risk of prion diseases, and thus less likely to contaminate surgical instruments with prions.

The instruction from the National Institute for Health and Clinical Excellence on a risk-reduction strategy requires every hospital and clinic to have separate pools of instruments to be used for high-risk surgery. It distinguishes between patients who were born before 1 January 1997 and those who were born on or after that date. The instruments must be kept separately, and notated. Although I consider that instruction to be eminently sensible, it will add greatly to the costs to hospitals of instrument provision, storage, and the required regular re-sterilisation. Tracing and tracking of instruments has also proved costly, and some hospitals are etching all instruments with identification numbers to ensure that they can carry out the process properly.

I have only been able to obtain one figure, but I understand that since, I think, July, observing the new guidance has cost the National Hospital for Neurology and Neurosurgery in Queen Square an extra £120,000. A little further down the road, the cost to a hospital specialising in children will be considerably higher. If RelyOn were developed so that it could be used, that difficulty would be removed.

I have three small asks of the Minister. First, we must recognise that all patients need to be treated equally in respect of blood products. As one person in 2,000 is thought to be a carrier, until we have a variant CJD test everyone should receive non-UK plasma. Secondly, rather than chasing a new product for sterilisation, the Department of Health, through whatever means, should fund the manufacturer of RelyOn to produce it in a more user-friendly form. If NICE or the Care Quality Commission made the use of such a product mandatory, there would be a market potential, which might be sufficient to persuade DuPont or some other manufacturer to produce such a user-friendly product without the need for funding, because it would be sold and used every time sterilisation pouches went through the dishwasher. Thirdly, funding the last stage of the testing of the prion unit system for prion detection would enable carriers to be taken out of the blood transfusion pool, and would also ensure a more sensible separation of surgical instruments. The cost savings would be vast.

[Jim Shannon (Strangford) (DUP)]

I congratulate the hon. Gentleman on making such a compelling case for those with CJD. In 2001, the Government set some money aside for a compensation scheme for UK victims of variant CJD. A trust fund was set up in April 2001 and compensation payments of £25,000 were made to the most affected families. Does the hon. Gentleman feel the Government should reconsider the compensation scheme and upgrade it for 2016 for those who, clearly from what he says, will probably fall into that category—although I hope not—in years to come?

[Sir Paul Beresford]

The hon. Gentleman makes a good point, but what I would really like to do is get the Government to take some action that is sitting, waiting, readily available to prevent it; otherwise, in time to come I believe we are going to have a chance of a considerable flood of variant CJD disease, but we do not know, and if this test was there we would know if the figure of one in 2,000 is right or wrong, or if we can separate patients out, so that those who have it have special instruments and the rest of us are all right, and we can also start using blood products in this country, because we will only be using products that do not have the prion on board.

In effect, the Minister needs to think about this: I do not want my grandchildren to be the generation that sees the re-emergence of variant CJD and for them to turn to me, if I am still around, and say, “Why didn’t we do something about it?” That is not a very big ask.

Child Dental Health

Debate between Jim Shannon and Paul Beresford

Wednesday 3rd February 2016 Commons Chamber

[Sir Paul Beresford (Mole Valley) (Con)]

I have a well-known interest to declare as a very part-time, or occasional, dentist. I am a member of a number of dental organisations that have applied considerable pressure on me to seek this debate.

On 27 May, the Minister will give the opening address and take questions at the British Dental Association’s annual conference in Manchester. There are 39,000 dentists and 63,000 dental care professionals in the United Kingdom, spread over the four nations, with the majority of them in England. They will wish to hear about the national health service and contracts, but as professionals their biggest concern will probably be child dental health. Perhaps the Minister’s reply could be secret practice for opening the meeting, bearing in mind that, I suspect, very few dentists will be watching us.

Dentists feel that their small branch of general health is seen as a “Cinderella” service and a sideline within the national health service. Increasingly, the biggest problem they face is child dental health in the form of caries. This disease is almost entirely preventable, but it is not being prevented. As the Minister is aware, the biggest single factor in dental caries is sugar. The raw statistics on child dental health are pitiful. Deciduous teeth, or baby teeth, are particularly susceptible to decay as they have thinner enamel compared with permanent dentition, and this obviously contributes to children having dental decay. Dental decay is the No. 1 reason for children aged five to nine being admitted to hospital in the United Kingdom.

[Jim Shannon (Strangford) (DUP)]

In Northern Ireland, tooth decay among under-15s has fallen consistently since 2000, and specific education has been done by our health and education Departments to make that happen. The hon. Gentleman referred to those aged between five and 10 consuming sugar. Every child will eat their weight in sugar in a year. Does he agree that we need a tax on sugar, because if we address this at the early stages, we will go a long way towards addressing the problem of tooth decay?

[Sir Paul Beresford]

I wish it were that simple. I personally believe that that would not make one iota of difference after a few months. One need only stand in the supermarket watching the kids pushing the mothers for sweets and the mothers feeding them to realise that, as I say, it will not make one iota of difference unless it is prohibited, in which case we would have other difficulties that I will not go into.

As I have said, the No. 1 reason for children aged five to nine being admitted to hospital in the United Kingdom is dental decay. The NHS spent £30 million on hospital-based extractions for children aged 18 and under in the year 2012-13. That is 900 children a week, who are being admitted primarily for tooth extraction—often under a general anaesthetic, which carries a slight risk in itself.

I am sure that the Minister is aware of the results of the 2013 child dental health survey. For the sake of those who have not read the statistics and who may glance tomorrow at the debate, I will touch on some of the figures. For example, 31% of five-year-olds had obvious decay in their primary teeth. That figure was higher in more deprived areas, where 41% of those eligible for free school meals had decayed primary teeth, in comparison with 29% of other children of the same age. Of five-year-olds who were eligible for free school meals, 21% had severe or extensive tooth decay, compared with only 11% of those who were not eligible.

By the age of 15, 46% of our children have tooth decay. Of the 15 year-olds, 59% of those eligible for free school meals had decay, compared with 43% of other children of the same age; 45% reported that their daily life had been affected by problems with their teeth and their mouth in the previous three months; and 28% reported being embarrassed to smile or laugh because of the condition of their teeth. Those are 15-year-olds, who are suddenly taking notice of the world and hoping to be taken notice of themselves.