Tainted blood scandal (United Kingdom)

The "Tainted Blood Scandal" is the event of nearly 5,000 Haemophiliacs^[1] being infected with Hepatitis C and 1,200 also being infected with HIV, "co-infected", by using Contaminated Clotting Factor Products, supplied by the NHS in the 1970s and 1980s and the subsequent government reaction. Over 2,000 British Haemophiliacs have died due their infection and many others are terminally ill.^[2] The infections were principally due to plasma products such as Factor VIII that unlike regular Blood Donations were often sourced from the United States. Large groups of donors were used (as many as 60,000 per batch) and it would only take 1 infected donor to contaminate an entire batch and thus infecting all of the patients that received that material.^[3] In contrast this was at a time when the practice of paying donors for Whole Blood in the US had effectively ceased, the UK did not import Whole Blood from the US.(see Factor 8: The Arkansas Prison Blood Scandal). Plasma donations were collected using a process called Plasmapheresis. Manufacturers that supplied clotting factor products to the UK included Abbott (Profilate), Armour (Factorate), Bayer owned Cutter (Koate), Travenol / Hyland (Hemofil), Immuno (Kryobulin), Speywood (Humanate) and Baxter owned Hyland (Interhem).^[4]

A 1983 study showed that the risk to a Haemophiliac of contracting Hepatitis C by using these products was 100% upon the first use,^[5] although knowledge of the 100% risk and resulting chronic liver disease was also discussed during a symposium held jointly by the UK Haemophilia Centre Directors and the Royal College of Physicians and Surgeons of Glasgow in 1980.^[6] In fact the dangers of Factor Concentrates had been raised going back to the early 70's, for example in 1974 Dr. Judith Graham Pool (Credited for discovering Cryoprecipitate), described the products as "dangerous", "unethical" and warned against their use.

Between 1970 - 1985 hundreds of documented examples of warnings and/or knowledge of infection-risk communications were ignored or not taken seriously enough by James Callaghan or Margaret Thatcher's Government.^[7] For over 30 years Westminster has refused to investigate the scandal.^[8] The long list of those who have refused to commission an investigation now includes Theresa May who in October 2016 refused an investigation when responding to a call from Labour MP Diana Johnson.^[9]

To date no government, health or pharmaceutical entity in the UK has admitted liability for the scandal and no compensation has been paid to those infected or affected. Compensation has been paid in Ireland.^[10]

Despite continuous calls from campaigners, victims and MP's over the years, successive governments in Westminster have refused to hold a Public Inquiry or Investigation Panel.

In a 1990 episode of The Cook Report former British Health Minister Lord David Owen said "I can see why some people would be unhappy with having all the facts revealed because it will show negligence".^[11]

An Independent Inquiry into Contaminated Blood and Blood Products, chaired by Baron Archer of Sandwell, aimed to uncover the causes of the events that led to thousands of infections and deaths.^[12] Lord Robert Winston described it as "the worst treatment disaster in the history of the National Health Service".^[13]

Notable findings of the Archer Inquiry:

Missing Documents

The Inquiry sought to address the issue of missing evidence and documents relating to the scandal. For example, the ministerial papers of former Health Minister Lord David Owen had been destroyed "We have been unable to ascertain who carried out the destruction of the papers, and who gave the instructions. But the conclusion appears inescapable that some official made a decision which he or she had no authority to make, or that someone was guilty of a serious error of judgement. The consequence is that Lord Owen has done his best to recollect details of events a quarter of a century ago, but both he, and we, have been deprived of the primary sources". Lord Jenkin also voiced his difficulties obtaining documents to the Inquiry, although the Inquiry states "He subsequently received from the Department two bundles of documents. One of these was to be treated as confidential".

Another handling error is described in the inquiry "mishandling of documents arose in connection with a number of files relating to the Advisory Committee on the Virological Safety of Blood between May 1989 and February 1992 which were found to be missing". The inquiry goes onto state that "They were in fact destroyed over a period from July 1994 to March 1998". When summarising these events it is stated "some of those who gave evidence to us suspected that there was an exercise in suppressing evidence of negligence or misconduct."

Self Sufficiency

It is often highlighted by campaigners and critics that had the British government invested the money to make the UK Self-Sufficient in blood products, many lives could have been saved. Looking at this issue the Inquiry noted "it was known in the early 1970s that US commercial products carried an increased risk of infection. Indeed, some patients had become aware of this in various ways and were refusing treatment with those products, although the majority of patients had no idea of the danger". In May 1975, the World Health Organisation passed a widely circulated resolution, urging all countries to aim at self-sufficiency. Archer notes "it was not until 1978 that officials appreciated the concerns over infections from imported blood products. If that is so, it represents a serious oversight in the Department, or serious distortion of priorities. The destruction of the Departmental papers of Lord Owen and The Rt Hon Lord Jenkin of Roding has precluded us from investigating further the Departmental thinking and the extent to which ministers were made fully aware of the facts".

The BPL^[14] which manufactured UK Blood Products (which throughout the inquiry are described as being safer than US blood products) ran into continual trouble from under funding, the inquiry states "In July 1979, the Medicines Inspectorate visited BPL. They reported that the buildings were never designed for the scale of production envisaged. They commented: “If this were a commercial operation we would have no hesitation in recommending that manufacture should cease until the facility was upgraded to a minimum acceptable level". BPL was rescued by Crown Immunity. Among their recommendations the Inspectorate advised: “Under no circumstances should production of any product be increased under the existing manufacturing conditions". Meanwhile, the existing plant continued production, relying on Crown Immunity to dispense with all the requirements of the Medicines Act, but was able to meet only about 40% of the national requirements". Archer goes onto find that "In 1987 Lord Owen learned that the objective of self-sufficiency in blood products had not been achieved. He wrote on 17 November to the Rt Hon John Moore, then Secretary of State for Social Services. Mr Moore replied on 21 January. The fact that the reply required eight weeks of research suggests that self-sufficiency was not a priority theme in the Department". Lord Owen told the Archer Inquiry that "having told Parliament on 8 July 1975 that the target was to achieve self-sufficiency ‘within two to three years’; the fact that the target had not been achieved should have been made known to Parliament".

To present day the UK never achieved its goal of self-sufficiency for plasma products, "In the 1990s, a new blood-born infection had appeared. Variant Creutzfeldt–Jakob disease (vCJD) had been identified in blood donated within the United Kingdom, and therefore subsequently UK-donated plasma ceased to be used. In 2013 the UK Government sold its 80% stake in BPL to Bain Capital for £230 Million. In 2016, BPL was wholly acquired by Creat Group Corporation (China) for £820 Million. The Department of Health agreed to both sales and stand to receive a further £164 Million from the sale of its remaining 20% holding.

Chronology of Event

A chronology of events can be found at: http://www.taintedblood.info/timeline.php

See also

• Contaminated haemophilia blood products

References

External links

• The Archer Independent Public Inquiry
• Support Group for those affected and infected by Contaminated Blood & Blood Products
• The UK Haemophilia Society
• Video, News and Documentary Archive
• A group for those infected with Hepatitis C, through Contaminated Blood and Blood Products