Return to an Address of the
Honourable the House of Commons dated
22 July 2002 for theFoot and Mouth Disease 2001:
Lessons to be Learned Inquiry Report

Chairman, Dr Iain Anderson CBEPresented to the Prime Minister and the Secretary of State for Environment,
Food and Rural Affairs, and the devolved administrations in Scotland and Wales

Ordered by the House of Commons to be printed
22 July 2002

LONDON: The Stationery Office
HC 888£10.00CONTENTS

1 FOREWORD BY IAIN ANDERSON

52 INTRODUCTION AND SUMMARY

83 LESSONS TO BE LEARNED
4 RECOMMENDATIONS
5 BACKGROUND TO THE 2001 EPIDEMIC
5.1

Introduction
History20

5.3

The Northumberland Report

22

5.4

Changes 1967-2001

25

5.5

Sheep in the 2001 epidemic

30

5.6

The run up to the 2001 epidemic

31

5.7

The eve of confirmation

31
32

108

18.1

Glossary of terms

167

Pressure builds

110

18.2

Key facts

169

12.3

Public health and environmental impact

111

18.3

Disease control statistics

172

12.4

Mass burial and landfill

112

18.4

Comparison with 1967-68

174

12.5

Role of the Environment Agency

115

18.5

Scotland

177

12.6

Cleansing and disinfection

115

18.6

Wales

182

12.7

The Livestock Welfare (Disposal) Scheme

115

18.7

The Inquiry Secretariat

187

120

ANNEXES on CD-ROM

The Abattoir

54

13.1

Vaccination

120

A

The ban on animal movements

58

13.2

International Animal Health Code120

B Meeting notes

8.3

The Longtown connection

61

13.3

EU Policy

123

C Regional visits

8.4

Access: Footpath closure and its effects

62

13.4

Contingency planning for vaccination

124

D Government publications

13.5

Proposed vaccination of cattle in Cumbria

125

E

126

9 THE DISEASE IN THE ASCENDENT

66

13.6

Lack of support for vaccination

9.1

The national perspective

66

13.7

Vaccination re-visited

127

9.2

The view from the ground

69

13.8

To vaccinate or not to vaccinate

128

9.3

Management information systems

71

9.4

The tasks on the ground73

14 THE ECONOMIC IMPACT OF FMD

130

9.5

Slaughter policy and practice

76

14.1

9.7

Under control?

79

9.8

The impact and timing of the involvementof FMD on the economy as a whole
14.2

Human and other costs

134

14.3

The benefits of FMD control strategies

137

9.9

Scotland83

14.4

Cost benefit analysis of FMD control strategies

139

9.10

Wales

83
84

9.11

Wider rural impact and its costs

The Drummond Working Group Report

34

9.12

The Regional Operations Director

6.3

Weaknesses in the plan

35

6.4

Risk analysis

38

system strengthened

86

Submissions

Media transcripts

130

81

6.2

15 COMMUNICATIONS

140

15.1

Introduction

140

15.2

The principles of good communications

140

15.3

The national response

142

10 PRE-EMPTIVE SLAUGHTER

88

15.4

Communications with stakeholders

143

10.1

Background

88

15.5

The role of new technology

144

7 SILENT SPREAD

40

10.2

The genesis of the FMD Science Group

90

7.1

FMD and its virus

40

15.6

Direct communications

144

10.3

The emergence of the contiguous cull

92

7.2

Global spread of the PanAsia O strain

42

15.7

The regional and local media

145

10.4

Slaughter on suspicion

95

15.8

The international media

147

10.5

The justification of the contiguous cull96
16 END OF THE OUTBREAK

148

16.1

Biosecurity

148

abbreviations and acronyms. Those we have used are

16.2

Autumn movements

152

as follows:

7.3

Entry of FMD into the UK

45

7.4

The legal import regime

45

7.5

Illegal imports

47

7.6

The spread of the disease prior to detection

49

7.7

Nature of the 2001 epidemic

51

7.8

Alternative theories

51

Foot and Mouth Disease 2001: Lessons to be Learned Inquiry

10.6

Implementing the culling policies

11 JOINING UP GOVERNMENT

97
100

167

The Government’s estimate of the impactof the military

32

39

Introduction

12.2

8.2

Contingency planning

Being better prepared

12.1

8.1

6.1

6.5

18 APPENDICES

13 VACCINATION

20
20

108

54

12

5.2

6 BEING PREPARED

2

11

8 THE IMMEDIATE RESPONSE

12 DISPOSALUSE OF ABBREVIATIONS
Throughout this report we have tried not to use too many

11.1

Opening of COBR

100

16.3

Exit strategy

154

COBR

11.2

Timing of COBR

102

16.4

UK declared FMD-free

155

DEFRA Department of the Environment, Food and

11.3

Management of information

103

11.4

Reinforcing the crisis response

104

11.5

Creation of Joint Co-ordination Centre

104

11.6

Handling of strategic and operational issues

106

Cabinet Office Briefing Room

Rural Affairs
17 LOOKING AHEAD

156

FMD

Foot and Mouth Disease

17.1

Keeping disease at bay

156

MAFF

Ministry of Agriculture, Fisheries and Food

17.2

Reducing vulnerability

161

NFU

National Farmers’ Union

17.3

Minimising the impact

163

OIE

Office International des Epizooties

Foot and Mouth Disease 2001: Lessons to be Learned Inquiry

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1 FOREWORD
BY IAIN ANDERSONIn August 2001 I was asked by the Prime Minister and theSecretary of State for Environment, Food and Rural Affairs
to conduct an Inquiry into the Government’s handling of theoutbreak of Foot and Mouth Disease (FMD) in Great Britain
during 2001 in order to draw out lessons and makerecommendations. I was asked to start when the epidemic
was judged to be over and then to report within six months.
I appointed a small secretariat (Appendix 18.7) toorganise the programme of work and assemble thefacts. This team was led by Alun Evans, a senior civil
servant with experience across government at thehighest levels.
The Inquiry gathered its facts in a variety of ways.
We asked for written submissions and received 576.
We travelled around the country, visiting many of theworst hit regions. In the course of these visits we held
public meetings, met over 200 representatives ofnational and local organisations in round-tablediscussions and talked, in their homes or places ofwork, to many people who had been directly affected.
Finally, we invited over 100 people to be interviewed.
Everyone has been willing to help. This is my chance
to place on record my thanks and appreciation to all
who contributed. I have special reasons to thank mysecretariat team who laboured so willingly, often intrying circumstances. I would also like to thank those
officials in The Netherlands, France and at theEuropean Commission in Brussels who gave up theirtime to meet us and answer our questions.
This Inquiry set out to address the major featuresthat characterised the handling of the epidemic.
Throughout the course of our work we were informed
4

Foot and Mouth Disease 2001: Lessons to be Learned Inquiryof many events specific to one location or even to
one individual’s experience. I particularly want to thankthe many hundreds of people who took the time toshare with us their first-hand accounts of what
happened, thereby contributing to our knowledge.
Because a particular story is not referred to in thereport does not mean it has not influenced ourthinking. Indeed, our understanding of what
happened has been built up layer by layer fromall the information we have collected.
My job was not to write a comprehensive history of
the epidemic. Nor was it to conduct research into themass of veterinary and epidemiological data that now
exists. That said, and precisely because I do not want
the rich vein of material we have assembled to be lost,I decided to publish (on CD-ROM and the Internet)
the submissions along with notes of interviews.
The only small exceptions to this are where membersof the public have written to us on condition that
we do not publish their statement or where we had
purely informal exchanges, for example, in farmhouse
kitchens. It is, I believe, very important that all the
relevant scientific data collected by DEFRA during theepidemic is published quickly. This will allow further
detailed research to be carried out.
Foot and Mouth Disease 2001: Lessons to be Learned Inquiry

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It is worth repeating here that I was asked to
conduct a completely independent inquiry into theGovernment’s handing of the epidemic. Those who
peruse the summary and then the detail of the Inquiry’s
findings will discover that a number of constructive
criticisms are made. Here, though, I should like to
air some personal observations which should beseen in the light of the overall analysis contained in
the report itself.

History repeats itself
We seem destined to repeat the mistakes of history.
In the Northumberland Report of 1968, and backthrough the decades, similar conclusions to ours
were drawn about the need for preparation, the rapid
deployment of resources and the central importanceof speed, above all speed-to-slaughter of infectedanimals. The epidemic of 2001 presented unprecedented
challenges which no-one in any country had anticipated.
But better preparation to support speedier deploymentof critical skills and faster action on the ground toslaughter infected animals and their close contacts
would have limited the scale of the damage.
Immediately prior to this outbreak, contingency plans
were in place. But maintaining and updating theseplans was not a priority at national level. If the best
preparatory work found in some locations had been
replicated nationally, the outcome for the country as
a whole would have been better.
Although Ministers and their veterinary experts andofficials recognised from the outset that they were
facing a serious situation, no-one in command
understood in sufficient detail what was happening
on the ground during these early days. We examinein the report both the reasons for this lack of detailed
intelligence and its consequences, as well as making
recommendations.
In government, departmental responsibilities areparamount. On day one MAFF recognised its
responsibility, as did all other departments. MAFF
was in charge. This meant that the wider resourcesof government were not mobilised early on. Ministers
who were dependent on complex veterinary and official
advice were expected to answer to Parliament withconfidence and clarity. At the same time they were
expected, via the media, to give reassurance to the
public that what needed to be done was indeed
being done.

6Foot and Mouth Disease 2001: Lessons to be Learned Inquiry

Confidence gives way to panic

Breakdown of trust

The truth started to emerge in early to mid-March.
Some relationships among those involved became
tense. A sense of panic appeared, communications
became erratic and orderly processes started to break
down. Decision making became haphazard and messy,
not least in the way in which the culling policy was tobe extended. The loss of public confidence and the
media’s need for a story started to drive the agenda.

Whatever central government does and however well,it cannot defeat a major outbreak of animal disease
on its own. It needs to co-ordinate the support andservices of many others, including those most directly
affected. This was the case throughout the epidemic
of 2001 and will be so in any future outbreak.
Wholehearted support for a common purpose
depends on mutual trust and confidence. One findingof this Inquiry has been the extent of the breakdownof trust between many of those affected directly or
indirectly and their Government. Many people havechosen to speak about this based on the experienceof their own eyes and ears.

For those of us outside the machinery of central
government, it may be hard to appreciate thedifficulties faced by Ministers and officials at suchtimes. They are constantly in the front line. Yet they aretightly constrained, their every word closely monitored
and analysed. This is an important aspect of ‘lessons
to be learned’. The normal processes of government
need to be adjusted to handle an emerging national
crisis effectively. Government has already recognised
this challenge and has put in place a procedural andstructural response system for dealing with it.

Management of the crisis
The process by which all the resources of government
are put at the disposal of the centre of government
is co-ordinated in the Cabinet Office Briefing Room
(COBR). This specifies a set of procedures andstructures designed to bring an orderly flow ofdecisions, resources and actions to bear on the
management of a crisis. COBR has flexible designprinciples and may be led, as was the case for sometime in this epidemic, by the Prime Minister, or by any
Minister appointed by the Prime Minister. When it takes
a decision, the government as a whole, with all its
departments, stands committed to deliver on it.
The role of COBR is examined in more detail later inthe report. It made a massive contribution to the way
the epidemic was eventually brought to an end. It wasconvened 31 days after the first case was notified, bywhich time 479 cases had been confirmed.

It is well beyond the remit of this Inquiry to speculate
on the wider implications of this lack of trust andconfidence. I simply say that success in the fightagainst any future major outbreak of animal disease
will depend on the co-operation of farmers and manyothers in the countryside. It will also depend on
farming and tourist interests recognising that they havea joint stake in the success of their rural communities.
Similarly, central government must regain theconfidence of, and work more in partnership with,local government.

Trust and confidence cannot be built by the
independent actions of one side alone. DEFRA
should take the lead, but others must follow. From theinsights obtained throughout the Inquiry I have formed
the opinion that a first step is for DEFRA simply toadmit that government made mistakes during its
handling of the crisis and that all involved aredetermined to learn from these mistakes.
Within MAFF, and now DEFRA, I detected a culture
predisposed to decision taking by committee withan associated fear of personal risk taking. Sucha climate does not encourage creative initiative.
It inhibits adaptive behaviour, and organisational
learning which, over time, lowers the quality ofdecisions taken. It seems to me that a reappraisalof prevailing attitudes and behaviours within the
Department would be beneficial.
This report describes our understanding of what
happened and why. It sets out the major lessons tobe learned, together with a set of recommendations
for action. I hope that not only the Government but
everyone with an interest in the future of farming andthe wider rural economy will look to learn theselessons, apply the recommendations and thereby
collectively ensure that the experience of 2001 is
never repeated.

The way ahead
During the course of the Inquiry we have been facedwith criticism of the Government’s policies and actions
throughout the epidemic. I recognise the frustration
and anger felt by so many. I understand the desire tosee someone blamed. I also understand that, farmers
in particular were subjected to stress and sometimes
to insensitive behaviour on the part of officials.
But, equally, I am satisfied that the officials I have met
in Whitehall and in the regions were trying to cope insometimes desperate, almost impossible,
circumstances.

Iain Anderson
July 2002

The nation will not be best served by seeking toblame individuals. Rather we should seek to apply thelessons to be learned in a manner that will contributeto changes in collective attitudes and approaches.
In that way we can, in future, approach the sharedtask of being better prepared and better able torespond with speed and certainty.

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2 INTRODUCTION
AND SUMMARY
Introduction

Summary

The Foot and Mouth Disease (FMD) epidemic of 2001
was one of the largest in history. Our Inquiry sets out
the lessons to be learned from it and makes
recommendations for action.

The last major epidemic of FMD in the UK wasin 1967-68. Following that outbreak, the 1968
Northumberland Report made a number ofrecommendations for action, some of whichwere still relevant in 2001.

This is the report of one of three independent inquiries
announced by the Government in August 2001.
The Policy Commission on the Future of Farming andFood published its report in January 2002. The Royal
Society published its report into infectious diseasein livestock in July 2002. We have not sought toduplicate their work. Nor have we gone into detail on
the financial aspects of the outbreak, which have been
covered by the National Audit Office in its reportpublished in June 2002.
It is worth making two points at the outset. First, given
the wide spread of the disease throughout the country
prior to detection, the impact of this outbreak wasbound to be very severe. Even had everything been
done perfectly by all those concerned to tackle thedisease, the country would have had a major epidemic
with massive consequences. Second, many farmers,
local people and government officials made heroic
efforts to fight the disease and limit its effects. Throughtheir efforts it was finally overcome and eradicated after
221 days, one day less than the epidemic of 1967-68.
This report covers England, Scotland and Wales but
not Northern Ireland. The following is a summary of
our findings.

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Foot and Mouth Disease 2001: Lessons to be Learned Inquiry

An outbreak of FMD was unexpected. Neither MAFF
nor the farming industry was prepared for an outbreakon a large scale. The Ministry could not cope with theunprecedented chain of events which allowed thedisease to go undetected for some weeks. However,in those areas where the number of cases remained
low, disease control was more effective. Ultimately,
the disease was contained and was prevented frombecoming endemic.
A contingency plan was in place, and agreed by theEuropean Union, but it had gaps and had not beenshared widely or vigorously rehearsed outside theState Veterinary Service. The scale of the outbreak,and the way in which it spread, could not have been
anticipated. The State Veterinary Service had, over theprevious two years, expressed internal concerns about
their readiness for an outbreak of FMD. These concerns
were not relayed to Ministers. Warning signs, from theexperience of classical swine fever in The Netherlands
in 1997 and in Britain in 2000, were not acted upon.
The country was not well prepared for what was
about to unfold.
The first responses to the early cases were not fastenough or effectively co-ordinated. The paramountimportance of speed, and especially the rapid slaughterof infected animals, was not given overriding priority
early on.

Knowledge within government of some changes infarming and farm practices was limited. In particular,
the nature and extent of sheep movements which
contributed to the wide dispersal of the disease
before its identification had not been fully recognised.
Information systems were incomplete and had to
be developed during the outbreak.
Initially the outbreak was treated as an agriculturalissue. MAFF took the lead within government inmanaging the outbreak. Almost immediately they cameunder severe resource pressures. The impact of thedisease, especially on tourism and the rural economy,
was not recognised early on. Although supported bymany at the time, with the benefit of hindsight, thewidespread closure of footpaths, with nostraightforward mechanism for reopening them,
was a mistake.
The scarcity of resources was not only confined tovets. There were important gaps in managerial andlogistical skills. The quality of communication was
mixed. Mechanisms for joining up government were
not brought into play from the start. As a result thisput enormous pressure on MAFF. The State Veterinary
Service tended to work in isolation. This may havecontributed to the fact that initially the depth of thecrisis was underestimated. People worked long andhard, under very difficult circumstances, to try tocontain the disease and limit the consequences.
Eventually the armed forces were deployed in supportand made an impressive contribution, providing
leadership, management and logistical skills.
In Scotland, with a different management structure andcloser relationships between central government, local
government and the farming industry, the outbreak
was better managed. Contingency planning had been
more systematic and the disease did not spread so far.
Key problems were identified early and dealt withquickly. In Wales, the lack of devolved powers foranimal disease control was a source of tension andresulted in blurred lines of communication,
responsibility and accountability between the National
Assembly for Wales and MAFF, now DEFRA.

Opening COBR towards the end of March and thepersonal intervention of the Prime Minister, were both
pivotal in managing the crisis. They brought to bear thefull weight of Government on tackling the disease.
A few days later and 35 days into the crisis, a scientificadvisory group gathered for the first time under thechairmanship of the Chief Scientific Adviser to theGovernment.
A network of Disease Control Centres was set up
in those areas where the infection was at its worst.
These Centres, each run by a senior Regional
Operations Director, made major contributions tocontrolling the disease.
Because disease control policy had not been debatedwidely before the outbreak, arguments took place as
the disease was raging. Changes, in particular toculling policy, were introduced at short notice. Often
they were poorly communicated. Large parts of the
farming and wider rural community became mistrustfulof government. The public and the media – which had
initially been broadly supportive of the Government’s
approach – turned against it. In particular, the policies
of culling apparently healthy animals, within 3km of
infected premises, or on contiguous premises, becamevery unpopular, despite their contribution to disease
control. Management of carcass disposal was a major
concern, particularly in the early days, but improved
significantly after the armed forces became involved.
However, the operation of the scheme for disposal
on welfare grounds was poorly managed and costly.
The issue of vaccination assumed a high profile, notleast in the media. However, by the time it was agreed
that vaccination should be used to help control thedisease in Cumbria, the disease had passed its peak.
In the event it was not used, largely as a result of
opposition by the farmers’ unions and parts of thefood industry.
As the disease declined, an exit strategy wasdeveloped. This included targeting resources to theareas of residual disease, coupled with a robust useof biosecurity and a programme of blood testing.
The introduction of the autumn licensing scheme foranimal movements caused considerable difficulties andhardship for farmers.

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The overall costs of the outbreak were enormous,
totalling over £8 billion. Millions of animals wereslaughtered. Different sectors of the economy wereaffected in very different ways. Farmers werecompensated for animals that were culled for disease
control purposes and for welfare reasons. Rural andtourist businesses however received very little
recompense. Farmers whose stock was not culled,
but who were subject to strict movement controls,received no compensation at all. Systems for valuation
had not been developed in advance of the outbreak.
Looking ahead, the processes of horizon scanning,
contingency planning, rehearsal and learning frommistakes should become part of government routine.
The creation of DEFRA which replaced MAFF after the
General Election in June 2001, and brought together
agricultural and rural issues, offers the opportunity forsuch developments to take place.
Good communications are vital to any organisation’s
business. For a Government in time of crisis they are
critical. This requires accurate, up-to-date, well targeted
and local communications systems, using the best
technology available.
Our report contains a series of recommendations which,if acted upon, will help ensure that: the chances of
exotic animal disease entering the country are reduced;
the farming industry itself is less vulnerable to outbreaksof infectious animal diseases; and that, if such a disease
does occur, the impact is minimised.
Our recommendations form an ambitious agenda.
But, taken in conjunction with the programme set out
by the Policy Commission on Farming and Food andunderpinned by the recommendations of the Royal
Society’s scientific report, we believe that they offer
the opportunity to transform and protect the rural andagricultural economies and communities of Britain.

3 LESSONSTO BE LEARNEDThe FMD outbreak of 2001 had a profound impact
on all those communities and individuals involved.
Collective learning from such a massive experiencecan have great value if it is carefully analysed andthen well used.
Perhaps the biggest lesson of all is that no amountof effort can eliminate the risk of damage from FMD.
To reduce the risk of economic damage as far as
possible, requires a range of co-ordinated actions by
Government, the farming industry and others in therural economy working together.
Drawing on the experiences of the 2001 outbreak wehave identified a number of themes which need
continuing attention. These are the major lessons tobe learned:• Have a legislative framework that gives
Government the powers needed to respondeffectively to the emerging needs of a crisis.
• Base policy decisions on best available scienceand ensure that the processes for providing scientificadvice are widely understood and trusted.
These lessons should be incorporated into a national
strategy designed to:• Keep out infectious agents of exotic disease.
• Reduce livestock vulnerability by reforms inindustry practice.
• Minimise the impact of any outbreak.

• Maintain vigilance through international, national
and local surveillance and reconnaissance.
• Be prepared with comprehensive contingency plans,building mutual trust and confidence through training
and practice.
• React with speed and certainty to an emergency
or escalating crisis by applying well-rehearsed crisis
management procedures.
• Explain policies, plans and practices
by communicating with all interested parties
comprehensively, clearly and consistently ina transparent and open way.
• Respect local knowledge and delegate decisions
wherever possible, without losing sight of thenational strategy.
• Apply risk assessment and cost benefit analysis
within an appropriate economic model.
• Use data and information management systems
that conform to recognised good practice in supportof intelligence gathering and decision making.

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4 RECOMMENDATIONS

Disease control policies should be developed inconsultation with those local authorities
responsible for implementing them.
(63, p.153)
Lessons learned should routinely be reviewed in
the light of changing circumstances. Policies, plansand preparations should be adapted accordingly.
(2, p.25)

Building on the lessons to be learned, our first andcentral recommendation is as follows:
We recommend that the Government, led by
DEFRA, should develop a national strategy foranimal health and disease control positioned
within the framework set out in the report of
the Policy Commission on the Future of Farmingand Food. This strategy should be developedin consultation and partnership with the farming
industry and with representatives of the wider
rural economy. The European Commission, thedevolved administrations in Scotland and Wales,
local authorities and other agencies ofgovernment should be involved in this process.
Throughout the report, we draw out a further 80
recommendations as they emerge from our analysis
in support of this over-arching recommendation.
This section pulls together those recommendationsgrouped thematically. Each recommendation is
numbered and has a page reference. They fall into
three broad areas:

Developing and maintaining a national
strategy for disease avoidance and control.

• Slaughter and disposal• Animal welfare• Human resources

Managing an outbreak of disease.

(50, p.137)• Crisis management

The Government should publish a biennial reportto the nation on the level of preparedness to tackle
animal disease emergencies. The first report
should be published in 2003 and include measuresof achievement against goals.

• Speed of response• Diagnosis• Role of the military• Communications

Developing and maintaining a national
strategy for disease avoidance and control.
Strategy
The following recommendations offer specificproposals in support of our central recommendation
on strategy:
Accepted best practice in risk analysis should be
used by DEFRA and others in developing livestock
health and disease control strategies.
(9, p.38)• Vaccination

Cost-benefit analyses of FMD control strategies
should be updated and maintained. These should
be undertaken at both the UK and EU level.

• Farming practices(52, p.139)• Veterinary matters• Biosecurity• Training• Import controls

Developing and maintaining appropriate
contingency plans and ensuring effective
preparedness.
• Contingency planning• Scientific advice• Information(11, p.39)• Management controls• Strategy• Legislation

The Government should make explicit the extent
to which the wider effects of disease control
strategies have been identified, measured andtaken into account in policy decisions.

Where the control of exotic animal diseases
has wider economic or other implications,
the Government should ensure that those
consequences for the country as a whole are
fully considered.
(32, p.86)
The interests of all sectors likely to bear the bruntof any costs should be properly represented andtaken into account when designing policy options
to control animal disease outbreaks.
(51, p.139)

The resources and research programmes of the
Pirbright Laboratory should be fully integrated into
the national strategy for animal disease control andbudget provisions made accordingly.
(65, p.159)
In developing the surveillance strategy, there shouldbe the widest possible involvement of those with arole to play in surveillance.
(67, p.160)

Vaccination
The country’s options for disease control should be
decided in advance of any future outbreak of infectious
animal disease.
Our Inquiry has not explored in detail the scientificissues concerning FMD vaccination, which werea central part of the remit of the scientific inquiry
conducted by the Royal Society. We have, however,formed a view that the option of vaccination should
be a part of any future strategy for the control of FMD.
There are hurdles to be overcome: the science is not
yet clear enough; many farmers and farming
organisations have expressed their opposition; there
are concerns about consumer reaction; there arecomplex EU and international issues. All these must
be tackled urgently. The UK Government should takethe lead in the international debate. We are not arguingfor routine preventative vaccination to be adopted but,in the event of an outbreak, emergency protective
vaccination must be an option available for use
whenever judged by the veterinary experts to beappropriate. All necessary work to prepare for sucha possibility should be put in hand. This means that:
The Government should ensure that the optionof vaccination forms part of any future strategy
for the control of FMD.
(48, p.129)
The Government should establish a consensus on
vaccination options for disease control in advanceof an outbreak.

Legislation(47, p.129)

The animal health legislative framework should berobust, unambiguous and fit for purpose. This was
not the case during the 2001 epidemic.

The State Veterinary Service should maintain thecapability to vaccinate in the event of a future
epidemic if the conditions are right.

The powers available in the Animal Health Act 1981
should be re-examined, possibly in the context ofa wider review of animal health legislation, toremove any ambiguity over the legal basis for
future disease control strategies.
(77, p.163)
Provision should be made for the possible
application of pre-emptive culling policies,
if justified by well-informed veterinary andscientific advice, and judged to be appropriate
to the circumstances.
(38, p.99)(49, p.129)

Farming practices
The livestock farming industry and government should
examine the opportunities to reduce the risk of disease
by influencing farming practices. Throughout our report
we have identified a number of specific proposals forgovernment that will contribute to this:
The Government should retain the 20-day
movement restrictions pending a detailed risk
assessment and wide ranging cost-benefit
analysis.
(78, p.164)• Public health12Foot and Mouth Disease 2001: Lessons to be Learned Inquiry

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4
The Government should develop a comprehensive
livestock tracing system using electronic tags tocover cattle, sheep and pigs, taking account ofdevelopments at EU level. The Government shouldseek to lead the debate in Europe on this issue.
(79, p.164)
The UK prohibition of swill feeding of catering waste
containing meat products should continue. The UK
should continue to support a ban at EU level.
(15, p.49)
The Government should build an up-to-date
database of livestock, farming and marketing
practices. This should include research to examine
the evolution of regional livestock stocking densities
and implications for disease risk and control.
(5, p.30)
However, the Government can only do so much toprevent a recurrence of disease. The farming industry
itself has a crucial role to play. We endorse therecommendations of the Policy Commission on the
Future of Farming and Food on assurance schemes
and recommend further that:
The livestock industry should work with
Government to undertake a thorough review of theassurance and licensing options to identify thosearrangements most likely to reward good practiceand take-up of training, and how such a new
system might be implemented.
(76, p.162)
Farm assurance schemes should take account ofanimal health and welfare, biosecurity, food safety
and environmental issues.
(75, p.162)
We also urge the livestock industry, and its
representative organisations, to do everything in theirpower to promote good practice, to tackle
shortcomings and poor standards of farming, and towork within the framework of recommendations wehave set out to reduce the risk posed by infectious
animal diseases.

Veterinary matters

Training

Imports

The State Veterinary Service provides the backbone fora national livestock health and disease control strategy.
Maintaining a strong State Veterinary Service, at thecentre of a surveillance and disease control strategy,
and involving many veterinary and other agencies,
should be a high priority.

During our Inquiry, gaps in people’s knowledge andunderstanding of the factors involved in preventing andmanaging infectious diseases of livestock were brought
to our attention. Filling these gaps is a long-term
challenge for the industry, the veterinary profession as
well as training centres, colleges and universities.

The national strategy for livestock disease control mustensure that proper steps are taken to minimise the riskof incursion from illegal imports of meat and meatproducts. We recommend that:

Notwithstanding some of the proposals made to us,
we do not support the devolution of State Veterinary
Service responsibilities to Scotland. There areadvantages in retaining an integrated organisation forGreat Britain, not least in terms of national disease
control strategies. However, we recommend thefollowing:

The Government should support a national actiongroup charged with the responsibility of producing
a plan to tackle the gaps in practitioners’
knowledge of preventing and managing infectious
diseases of livestock. To be effective this will needa timetable, milestones for achievement andincentives.

As many functions of the State Veterinary Service aspossible should be relocated from London toregional centres, particularly to Scotland and Wales.
(70, p.161)
There should be a reappraisal of Local Veterinary
Inspectors’ roles and conditions.
(3, p.28)
The Government should develop opportunities forincreased use of veterinary ‘paramedics’.
(69, p.160)

Biosecurity(71, p.161)(14, p.48)
The Government should ensure that best practicefrom import regimes elsewhere be incorporated
with domestic practices where appropriate.

Colleges, universities and training organisations
should provide courses to equip those working in
the food and livestock industries, and thoseowning susceptible animals, with the skills andknowledge to enable them to recognise the signsof animal disease early and take appropriate action
to prevent its spread.

(12, p.47)(72, p.161)(13, p.47)

Training for Local Veterinary Inspectors in exotic
diseases should be intensified, and consolidated
into ongoing training strategies.

The UK should urge the OIE to consider the
implications, for the detection and control of FMD,
of the removal of swine vesicular disease from the
List A of notifiable diseases.

(74, p.162)

The European Commission should lead a targetedrisk based approach designed to keep FMD out of
EU Member States. The UK should work alongsideother EU Member States to highlight areas ofgreatest risk.

(64, p.156)

Biosecurity measures must be a part of generally
recognised good practice for everyone involved in
producing and handling livestock. In the event of aserious disease outbreak good biosecurity becomes
critical and should be enforceable.

DEFRA should commission a handbook for farmers
on identifying and responding to animal disease,drawing on the experience of 2001.

Farmers, vets and others involved in the livestockindustry should have access to training inbiosecurity measures. Such training should form
an integral part of courses at agricultural colleges.

Training for those responsible for managing
disease control should include the relevant legal
frameworks and the structure and responsibilities
of local government.

(60, p.148)(43, p.112)

The livestock industry and government jointly
should develop codes of good practice onbiosecurity. They should explore ways tocommunicate effectively with all practitioners andhow incentives might be used to raise standards.

DEFRA and the Department for Education and
Skills jointly should explore with the veterinary
professional bodies and higher education
institutions the scope for increasing the capacityof undergraduate and postgraduate veterinary
provision. Equivalent work should be done in
Scotland and Wales.

(61, p.150)

DEFRA should be given responsibility forco-ordinating all the activities of Government tostep up efforts to keep illegal meat imports out of
the country. This should include better regulations
and improved surveillance on illegal imports ofmeat and meat products.

(73, p.162)

Developing and maintaining appropriate
contingency plans and ensuring effective
preparedness.
Contingency planning
DEFRA should develop further its interim plan,
published in March 2002, in full consultation withall interested parties. Its relevance should bemaintained through agreed programmes ofrehearsal, practice, review and reporting.
This work should be given priority for funding.
(81, p.165)(68, p.160)

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The following recommendations offer specificproposals in support:
As part of its contingency planning, DEFRA,
the Scottish Executive and the National Assemblyfor Wales, working with the Civil Contingencies
Secretariat, should examine the practicality of
establishing a national volunteer reserve trained
and informed to respond immediately to an
outbreak of infectious animal disease.

The National Assembly for Wales and DEFRA
should develop a comprehensive agreement forco-ordinating the management of outbreaks ofinfectious animal diseases in Wales. This should
cover all aspects of a disease outbreak, delegating
responsibility locally, where appropriate, andproviding clear lines of communication andaccountability.
(31, p.84)(30, p.82)

Scientific advice

Contingency plans should set out procedures to befollowed in the event that an emergency expands
beyond worst-case expectations.

The involvement of independent sources of scientificadvice early in the 2001 epidemic was due to thepersonal intervention of the Chairman of the FoodStandards Agency. The formal engagement of ascientific advisory group was not until 35 days after
the start of the epidemic. In order to ensure the fullest
access to best scientific and veterinary advice, we
recommend that:(6, p.36)
Government departments should ensure that theirown internal departmental arrangements properly
resource contingency planning work. This should
be monitored by the National Audit Office.
(10, p.39)
The contingency plans of DEFRA, the Scottish
Executive and the National Assembly for Wales
should specify the measures needed during an
epidemic to monitor progress and report to key
stakeholders.
(22, p.73)
The State Veterinary Service, together with the
Pirbright Laboratory, should increase their horizon
scanning and threat assessment capabilities for
major infectious animal diseases.
(66, p.160)
The Government should build into contingency
plans the capacity and processes to scale up
communications systems and resources rapidly atthe onset of any future outbreak of animal disease.
(53, p.142)(21, p.73)
Standard definitions of all important parameters of
information should be agreed in advance.

(19, p.72)
Use should be made of alternative sources of
information and intelligence during crises.
(18, p.71)

Slaughter and disposal(34, p.91)

DEFRA should revise its guidance and instructions
for slaughter.

FMD itself poses no risk to public health, but activities
involved in managing an epidemic may create issuesof public health concern. This was the case during theoutbreak of 2001. We recommend that:
All agencies with responsibility for public healthshould be actively involved in designing disease
control strategies and in contingency planning andcommunications.

Information(4, p.28)

Without access to timely, high quality information
decision-makers are handicapped. The FMD crisis
revealed shortcomings in the information gathering andprocessing infrastructure. We recommend that:

The Restricted Infected Area (‘Blue Box’
Biosecurity arrangements) procedures should bebuilt into contingency plans.

DEFRA should lay out milestones for investment
and achievement for improved management
information systems.

(62, p.151)(20, p.73)(80, p.165)

Human resources
DEFRA’s Geographical Information System and theIntegrated Administration and Control System(IACS) should be designed so that they can beused more effectively for disease control purposes.

Mass pyres and huge burial sites, used to dispose of
the remains of millions of slaughtered animals, remain
vivid images of the 2001 epidemic. We recommend
that:

Public health

The joint DEFRA Industry Working Group for
Animal Disease Insurance should ensure that its
scope and membership is set widely enough toaddress valuation and compensation issues
highlighted by the 2001 outbreak. Clear deadlines
should be set for reporting progress.

(23, p.73)

DEFRA’s Chief Scientist should maintain a properly
constituted standing committee ready to advise inan emergency on scientific aspects of disease
control. The role of this group should include
advising on horizon scanning and emerging risks.
Particular attention should be given to therecommendations on the use of scientific advisorycommittees in The BSE Inquiry report of 2000.

(44, p.112)
Where regional boundaries of Government Offices
do not match those of local authorities or otheragencies of government, special provision should
be made in contingency planning for management
and communications during a crisis.

Data capture and management information
systems should be kept up to date and reflect
best practice.

Burning animals on mass pyres should not be usedagain as a strategy for disposal.
(42, p.108)(28, p.78)
Local communities should be consulted on massdisposal according to best practice guidelines, andthe question of compensation for communities
accommodating emergency disposal sites be
researched. We recognise that this is a complex
legal area nationally and at EU level.
(45, p.114)

Animal welfare

One of the biggest challenges in crisis management isto ensure that the right people with the right resources
are in the right places at the right time. A strategy for
personnel management during a crisis should beworked out in advance and kept up-to-date incollaboration with stakeholders. We recommend that:
DEFRA should develop its human resources plansfor use in emergency. In particular they should
focus on how staff numbers and expertise can be
rapidly increased at a time of crisis. This should be
developed in England in consultation with the
Cabinet Office, the Regional Co-ordination Unit
and the network of Government Offices. Similararrangements should be developed in Scotland
and Wales.
(8, p.36)
Contingency plans at regional level should include
mechanisms for making effective use of local
voluntary resources.
(24, p.74)
Contingency plans should provide for early
appointment of Regional Operations Directors or
their equivalent to take on operational
management of a crisis. There should be a cadreof senior managers – not all of whom need comefrom central government – who can fulfil the role of
the Regional Operations Director in an emergency
and who should be trained in advance.
(33, p.87)

One lesson from the experience of 2001 was thatanimal welfare cases rise rapidly during the course ofan expanding epidemic. This may be the case in any
major outbreak. We recommend therefore that:
The Government should consider the welfare
implications of disease control policies, as part ofcontingency planning for FMD and other diseases,
and should seek to identify strategies thatminimise the need for slaughter and disposal on
welfare grounds.
(46, p.119)

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Managing an outbreak of disease

Speed of initial response

Crisis management

In an emergency, such as an outbreak of FMD, it isimportant to react with speed and certainty, taking
decisions and mobilising the required resources assoon as possible. A few hours gained or lost at theearly stages can make a big difference. Preparation for
rapid response is an important element of contingency
planning. We recommend therefore that:

With the benefit of hindsight, there were insufficiently
sensitive triggers in place to set off crisis warnings
early enough.
There should be a mechanism, put in place at thecentre of government, to assess potential
domestic civil threats and emergencies andprovide advice to the Prime Minister on when to
trigger the wider response of Government.
(39, p.102)
The practice of crisis management was supported by
the creation of the Joint Co-ordination Centre in Page
Street. This influential group of senior officials, vetsand military officers was joined by a representativeof the National Farmers’ Union and shared in thedecision making and subsequent communication
processes. This added value and we support thisapproach for the future. We recommend that:
A representative of the wider rural economy
should be invited to participate in the Joint
Co-ordination Centre.
(40, p.106)
At the height of the crisis the overall direction of policy
and operations benefited from the direct involvementof the Prime Minister as well as senior ministers andofficials. This meant that there was no senior groupwithin government offering informed, but detached,advice that could challenge prevailing thinking. We
recommend therefore that:
The concept of a ‘senatorial group’ should be
developed to provide independent advice to thePrime Minister and Cabinet during national crises.
(41, p.107)
Steps should always be taken to explain therationale of policies on the ground, particularly
where implementation is likely to be controversial.
Wherever possible, local circumstances should
be taken into account without undermining theoverall strategy.
(37, p.98)

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Foot and Mouth Disease 2001: Lessons to be Learned Inquiry

Provision should be made in contingency plans
for rapid prioritisation of a department’s work in
the face of a crisis, and for speedy reassignmentof resources.
(7, p.36)
In all suspected cases of FMD, the response
should reflect the experience of the emergency
services, where speed and urgency of action
govern decision making.
(16, p.61)
The State Veterinary Service should consider
forming a national network of ‘flying squad’ teams
capable of responding to an alert. The continuing
occurrence of false alarms can then be used
constructively to maintain readiness and topractice routines.
(17, p.61)

Diagnosis
All the evidence we have received supports the needfor more reliable and speedy diagnosis of disease.
Modern diagnostic technology should be harnessed tocontribute to the goal of acting with speed andcertainty. We recommend that:
The State Veterinary Service should be routinely
equipped with the most up-to-date diagnostic
tools for use in clinical practice, to contribute to
speed and certainty of action at critical times.
(36, p.95)

Role of the military
The contribution of the armed forces during the FMD
crisis received much praise. The military can bringprofessional expertise and advice in managing an
emergency. In particular, they have valuable logisticaland operational management skills. However, sinceno two crises will be the same and, since the armed
forces have their own priorities, it would not be
possible or wise to make specific recommendations
for the future based on their assumed availability.
We do, however, recommend that:

As part of the mechanisms to trigger the wider
Government response, the military should be
consulted at the earliest appropriate opportunity
to provide advice and consider the nature ofpossible support.

The State Veterinary Service should revise all its
disease control forms A-E and information about
exotic animal diseases in liaison with the Plain
English Campaign.
(58, p.145)(29, p.82)

Communications
To have any chance of communicating successfully toall stakeholders it is essential to plan in advance.
A government-wide crisis communication strategy
should be developed by the Civil Contingencies
Secretariat with specific plans being prepared at
departmental level; for example by DEFRA and thedevolved administrations in Scotland and Wales in
the context of animal disease control.
(54, p.142)
The Scottish Executive and the National Assembly for
Wales handle communications separately. The
following are recommendations to DEFRA. In Scotland
and Wales we urge that systems should be reviewed
as necessary to ensure equivalent standards are met.
We recommend that:
DEFRA should develop its regional communication
strategy and ensure that it has effective systems
for disseminating clear and concise information
quickly to all its regional offices. This should be
developed in the context of cross-government
crisis management planning, in consultation
with the Regional Co-ordination Unit andGovernment Offices.

Communications strategies during a crisis
should take special account of the needsof the international media.
(59, p.147)

Management controls
At the height of a crisis, the pressure to get things
done may mean that proper management controls
are overlooked. The National Audit Office examined
this issue in its report of the FMD outbreak of 2001.
We have a number of recommendations to add,from the perspective, of our own Inquiry, namely:
Dedicated control systems should be ready for use
in a sustained emergency, and regularly tested aspart of the contingency planning process.
(25, p.74)
The processes for procuring and delivering thenecessary goods and services from externalsources during a crisis should be reviewed.
Systems should be tested to ensure they cancope with unexpected increased demands.
(26, p.74)
Priority should be given to recruiting accounting
and procurement professionals to operate inemergency control centres during a crisis.
(27, p.74)(55, p.143)
DEFRA should resource its website to ensure it isa state-of-the-art operation. In any future outbreak,the website should be used extensively and acentral priority should be to ensure that it contains
timely and up-to-date information at national andlocal level.

From day one of an outbreak, provision should bemade to keep a record of all decisions made andany actions to be taken.
(35, p.93)(56, p.144)
DEFRA should commission research into theeffectiveness of its direct communications during
the Foot and Mouth Disease outbreak of 2001 sothat all the lessons may be learned, acted upon
and the results published.
(57, p.144)

Foot and Mouth Disease 2001: Lessons to be Learned Inquiry

195.2 History
FMD was not a new phenomenon. Nor were the techniques for controlling it.
On the face of it, an outbreak in 2001 should have been controllable using
conventional strategies. These include the slaughter of infected animals and‘dangerous contact’ animals (so-called ‘stamping out’). Such methods had
been used effectively in the isolated FMD outbreak on the Isle of Wight in
1981, and they worked in 2001 in those parts of the country where thenumber of cases was small and resources were not overwhelmed.

Different livestock diseases have different economic impacts which changeover time and vary from country to country. In Britain, throughout the earlypart of the 19th century, no attempt was made to eradicate FMD.
Compared with other animal diseases, such as cattle plague, its symptoms

LOOKING AHEAD
APPENDICESThe outbreak in 2001, however, was far from conventional. The way inwhich the disease had spread before its discovery and had disproportionately
affected sheep were both unprecedented. The failure to tackle the disease
quickly by traditional methods led to alternative culling approaches being
adopted. These are discussed in section 10.

VACCINATIONTHE ECONOMIC IMPACT OF FMDCOMMUNICATIONSEND OF THE OUTBREAK

On that Monday morning none of the vets involved guessed that the virus
was already incubating in more than 50 locations from Devon in the south
to Dumfries and Galloway in the north. A rare set of circumstances had
already determined that this would be one of the worst epidemics of FMD
the modern world has ever seen. Numbers alone cannot capture the senseof what unfolded. The great epidemic of 2001 left an indelible mark on
communities, businesses and people from all walks of life.

THE DISEASE IN THE ASCENDENT
PRE-EMPTIVE SLAUGHTER

This encounter, within sight of London’s eastern skyline, signalled the startof the FMD epidemic that spread across Britain. By the end of September
over 2000 premises had been declared infected, millions of animals
destroyed and many rural lives and livelihoods affected in a manner
unknown for a generation.

BACKGROUND TO THE 2001 EPIDEMIC
BEING PREPARED

Around mid-morning on Monday 19 February 2001, Donald Vidgeon, adrover of long experience, alerted Craig Kirby, the resident vet at Cheale’s
Abattoir in Brentwood, Essex to a problem with a batch of sows held overfrom Friday’s shift. Mr Kirby examined the animals and saw how serious
the problem was. Clinical signs alone can not distinguish swine vesiculardisease from FMD. Both are notifiable diseases. He assumed, even hoped
it was swine vesicular disease. First he stopped the production line.
Then he telephoned the local office of the State Veterinary Service.
About an hour later, after inspection by two government vets, one of whom
had experience of FMD in Greece, there was no doubt. This was eitherswine vesicular disease or FMD. Only laboratory work could tell which.

SILENT SPREAD TO THE 2001 EPIDEMIC JOINING UP GOVERNMENTBACKGROUND
THE IMMEDIATERESPONSEDISPOSAL
BEINGPREPARED
SILENT SPREAD
THE IMMEDIATE RESPONSE
THE DISEASE IN THE ASCENDENT
PRE-EMPTIVE SLAUGHTER
JOINING UP GOVERNMENTDISPOSAL ISSUESVACCINATIONTHE ECONOMIC IMPACTS OF FMD 2001
COMMUNICATIONSEND OF THE OUTBREAKLOOKING AHEAD
APPENDICESBACKGROUND TO
2001 EPIDEMIC
5 THE

5.1 Introduction

5

5“The question I think youneed to be asking is why
was it possible to haveorders to slaughter andbury in 24 hours in 1747
[Order in Council,
22 March 1747] when it
wasn’t possible to achievethat in 2001.”
Public Meeting,regional visit to the North East

were relatively mild and mortality rates low. Yet, by the end of the
19th century, perceptions of the importance of FMD had changed.
It became a notifiable disease, despite farmers opposition.
Legislation originally passed in the 1880s allowed for slaughter, withcompensation, of FMD-infected animals and their contacts. However,this was rarely invoked until the major epidemics of the early 1920s when
all diseased and contact animals were slaughtered except for valuablepedigree herds. Since then, stamping out has been the preferred approachfor controlling FMD in Britain.
The desire for a better understanding of FMD in order to improve control
policy led to the creation of the Pirbright research facility in 1924. The
Pirbright Laboratory, now part of the Institute for Animal Health, is theUK’s centre of excellence in FMD research and is the World Reference
Laboratory for FMD. We refer to it throughout this report as the
Pirbright Laboratory.
On the continent, immunisation techniques were developed in the inter-war
years but not used in Great Britain. A Government report after the major
FMD outbreak in 1952-4 contained extensive discussion of vaccination.
It concluded that stamping out remained the right policy for Great Britain
in general, adding that “in the case of a severe epidemic” vaccination
might be a valuable or even indispensable weapon.

5.2.1 History repeats itself“[The initial outbreaks] were followed by an unprecedented numberof outbreaks which were reported at such a rate as to overwhelm theexisting staff of the Ministry, and to necessitate the immediate
recruitment of an emergency staff whose time was fully occupied
in dealing with the cases as they arose.”Foot and Mouth Report, 1922

“During the whole of this time the movements of animals in the district
had been proceeding unhindered – in fact with unusual expedition.
Rumour – as has so often been the case – preceded action by
responsible authorities; … there was a rush to move animals out of the
district before the standstill restrictions normally imposed by the Ministry
could become effective. Crewe market was carried on as usual and theanimals exposed there were dispersed.”
Foot and Mouth Report, 1924

“A single outbreak that was not reported early enough was responsible
for half the outbreaks during the epidemic.”
Foot and Mouth Report, 1954

By contrast, in other parts of Europe, vaccination was used both asa control mechanism to throw a ring around specific outbreaks and,routinely, along land frontiers.
Between 1922 and 1967 there were only two FMD-free years in the wholeof Great Britain. Four epidemics were so severe that they prompted official
Government reports in 1922, 1924, 1954 and 1968, the last conductedby Lord Northumberland and known as ‘the Northumberland Report’.
There is a high degree of continuity in the central themes of these reports.
Recurring issues include: the importance of contingency planning; the roleand supply of vets; speed of response; the impact of animal movements;
the use of swill as a source of infection; restrictions after markets;
tagging of animals to aid identification; and liaison between central andlocal government.
All these issues featured in the 2001 outbreak. That is why we say that
it is perhaps easier to identify lessons than to learn and act upon them.

5.3 The Northumberland Report“There is difficulty in recruiting veterinarians to the Veterinary Field
Service of the Ministry of Agriculture and it is essential that the Ministry
should attract a reasonable number of good veterinary graduates whowill later be available for promotion to the important posts which carry
responsibility for controlling animal diseases like foot-and-mouthdisease. Satisfactory disease control depends on a strong State
Veterinary Service.”“We have studied carefully the control procedures laid down by the
Ministry of Agriculture and which have been put into operation in thepast when outbreaks of the disease have occurred. We consider thatthese procedures in general have been satisfactory but were notadequate during this unprecedented epidemic. Our main
recommendations and suggestions therefore relate to the need for moredetailed pre-outbreak planning for the mobilisation of manpower andequipment to deal with an outbreak wherever it may occur.”Northumberland Report, 1968

One of the constant refrains surrounding the 2001 outbreak is that thelessons of the Northumberland Report were not learned. The CD-ROM
annexes contain a full list of the Northumberland Report’s recommendations
and a summary from DEFRA of the extent of implementation of each ofthem. Frequently, the recommendations relating to disposal of carcasses
and the role of the military have triggered critical comment.

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On disposal, the Northumberland Report concluded that: “burial of
carcasses is preferable to burning”. Off-farm and mass disposal were
not discussed as they did not arise. In 2001, 48% of the 600,000 tonnesof carcasses generated by the outbreak, including welfare cases, were
disposed of by on-farm burial and burning. A further 14% went to mass
burial and 16% to commercial landfill. Scope for burial was constrainedby an increased awareness of the potential contamination of groundwater.
This was aggravated by very high groundwater levels during the wet winterand spring of 2001. Disposal issues are discussed further in section 12.
On the role of the military, the Northumberland Report stated: “it appears
that assistance from the Armed Services is normally available toGovernment Departments when all other suitable labour resources havebeen exhausted. …There was no delay in or difficulty in obtaining Service
assistance when the 1967/68 epidemic became widespread. …speed
and efficiency in slaughter of infected and in-contact animals, disposalof carcass and disinfection of premises are the most vital elements incontrolling an outbreak and these will not be achieved without disciplined
workers under experienced and trained supervisors. …. After the epidemic… agreement was reached that, in FMD outbreaks, any of the Ministry’s[of Agriculture] regional controllers could approach Army Commands
for assistance as soon as they considered that all suitable civilian labour
resources had been committed. We recommend that the approachshould not be delayed; liaison should be established forthwith …
and be maintained”.
The role of the military is discussed further in section 9. However, the links
established with the armed forces after 1968 were not maintained. This
was, in part at least, a result of the reduced size and changing nature androle of the armed forces since the mid sixties.

5.3.1 Military personnel 1967-2001
1967

Military servicemen and women:
Civilian support:
Total:

445,050
353,850
798,900

2001

Military servicemen and women:
Civilian support:
Total:

211,200
111,700
322,900

The criticism that the Northumberland Report was not implemented is,inevitably, simplistic and generally not well-founded. Many of theNorthumberland Inquiry’s specific recommendations were, by 2001, simply
overtaken by developments. For example, “Exempting animals carriedby rail through Infected Areas from restrictions provided they are not
untrucked” has limited relevance today. Equally, constitutional
developments, most notably the UK’s membership of the European Union
have profoundly changed the legislative and trading framework.
Nevertheless, some of Northumberland’s recommendations have stood thetest of time and would have helped in the fight against the 2001 outbreak.
The Northumberland Report attached great importance to “the early

24

Foot and Mouth Disease 2001: Lessons to be Learned Inquiry

recognition of the disease and immediate action in stamping it out”
and to “measures designed to limit the spread by controlling movements”.
It also emphasised that “control procedures should be based on veterinary
considerations only and should give rise to as little disturbance of normal
commercial and public activities as such considerations would allow”.
And its main recommendations and suggestions related: “to the need formore detailed pre-outbreak planning for the mobilisation of manpower andequipment to deal with an outbreak wherever it may occur.”
Despite the similarities, comparing 1967 with 2001 is not always fruitful.
Ministry and veterinary structures have changed considerably over the
past thirty years, as has the social, economic and political landscape.
Contingency plans had not kept pace with changes in society.
2. We recommend that lessons learned routinely be reviewed in thelight of changing circumstances. Policies, plans and preparations
should be adapted accordingly.

5.4 Changes 1967-2001
Since the last significant FMD epidemic occurred in 1967, we have chosenthat as a useful reference year for comparison with the present day.
The most fundamental differences between 1967 and 2001 are the UK’s
membership of the EU, coupled with structural change in livestock farming
and a reduction in its relative economic importance and profitability (5.4.2).
In parallel with these changes there has been a growth of rural leisureand tourism.
Agriculture has become increasingly regionalised over the period withlivestock concentrated in the North and West and arable farming in theEast. Land tenure arrangements have led to far greater fragmentation offarm holdings, with farmers often keeping livestock on land widely scatteredfrom the farmstead itself.
Similarly, the State Veterinary Service has changed since 1967 (5.4.3).

5.4.1 Local and Temporary Veterinary Inspectors
Local Veterinary Inspectors are mainly private practice veterinarians who
are appointed by Ministers as agents to carry out certain areas of work
on behalf of the Department. Local Veterinary Inspectors are appointed
to specific panels, eg. TB, brucellosis, anthrax, export of horses etc.
They can only carry out work for the panel to which they are appointed
and for which they are trained. In 2001 there were approximately 7,000
Local Veterinary Inspectors.
Temporary Veterinary Inspectors are registered veterinary surgeons who
are appointed on a temporary basis to the State Veterinary Service.
There were 117 Temporary Veterinary Inspectors routinely employed by
the State Veterinary Service prior to the outbreak.

Foot and Mouth Disease 2001: Lessons to be Learned Inquiry

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5
The impact of change on veterinary surveillance
and response
The number of vets employed by the State and its agencies in 2001 wasroughly two thirds that in 1967. The most sizeable reduction in the State
Veterinary Service was in the number of vets in middle management roles.
Reliable data are difficult to obtain. DEFRA’s own figures show that front line
veterinary officer numbers fell from around 270 in 1967 to 220 in 2001.
Moreover, problems of veterinary recruitment in the South East, mean that
the State Veterinary Service headquarters is currently operating with 10 ofits 27 posts vacant.
The changes to the State Veterinary Service stemmed in part from a
reduction in the volume of work required as farming and animal healthpractices evolved, although recent events, including BSE and the pet
passport scheme for rabies, have driven the workload back up without
a matching increase in resources.

5.4.2 Changes in the farming economy 1967-2001

26

Immediately prior to 1967/68 outbreak

Immediately prior to 2001 outbreak

Policy Context

Pre Common Agricultural Policy;
UK market still open to significant
imports of food.

Period of Common Agricultural Policy
reform and re-opening of EU markets tosignificant imports of food.

Economic performance (livestock and dairy)
England
Output per £100 input£114–117 depending on sector.

£75-94 depending on sector.

Average size of dairy herd England & Wales(Proportion over 100 )

30
(12%)

76
(55%)

Average size of flock of breeding ewes
England & Wales(Proportion over 500)

131

267

(25%)

(56%)

Annual UK slaughter of prime cattle

2.5-3.0 million

2.2 million

Annual UK slaughter of sheep

12-12.5 million

18 million

Annual UK slaughter of pigs

12.1-13.4 million

12.6 million

Proportion of meat retailed by independentbutchers (GB)

83%

12.5%

UK self-sufficiency in beef

72%

100% plus

UK self-sufficiency in sheepmeat

36%

95%

UK self-sufficiency in bacon and ham

42%

50%

UK self-sufficiency in pork

96%

100% plus

Number of auction markets
in England and Wales

380

180

Number of abattoirs in Great Britain

2,200

360

Approximate number of farm holdings
in England

260,000

146,000

Foot and Mouth Disease 2001: Lessons to be Learned Inquiry

The changes also reflect a shift away from direct government delivery ofservices to greater use of agencies and privately contracted work. A 1995
review of the State Veterinary Service recognised the need for a balance
to be struck between these elements. Although much of the State
Veterinary Service work could, in theory, be removed from central
Government control, there was a need to retain the capacity to respondto an animal health emergency.
We conclude, from the data above and from the views submitted to us byvets with many years experience, that insufficient attention was given to
the relationship between the core State Veterinary Service and other partsof the veterinary surveillance and response network, including the private
practice veterinary sector. The economics of farming mean that vets are

5.4.3 The State Veterinary Service 1967-2001
Year

State Veterinary Service

Agencies

SVS numbers

Notes

1967

Included Central Veterinary Laboratory,a laboratory in Scotland, Cattle
Breeding Station, and Veterinary
Inspection Service.

n/a

not known –approx 600

Animal Health Divisional Offices
26 in England
5 in Wales
19 in Scotland

1971

Agricultural Development & Advisory
Service created, incorporating State
Veterinary Service.

–

–

–

–

597

Review of MAFF structures.

just over 500–

1979 –1980
1986

Agricultural Development & Advisory–
Service became a charging organisation,
State Veterinary Service reintegrated
into the Ministry.

1987

–

–

Animal Health Divisional Offices
reduced to 44.

1990

Veterinary Inspection Service reviewed –reduced to 5 Veterinary Investigation
Centres England/Wales, 8 in Scotland.

Central Veterinary
Laboratory and Veterinary
Medicine Directorate
became agencies.

430–

1993-1995

Moratorium on recruitment to State
Veterinary Service.

–

–

–

1995

Review of MAFF Animal Health andVeterinary Group implemented.

Veterinary Inspection
just over 300
Service merged with theCentral Veterinary
Laboratory to become
the Veterinary
Laboratories Agency.
Meat Hygiene Service
created – 12 vets transferred.

Animal Health Divisional Offices
15 in England
3 in Wales
5 in Scotland

Veterinary Laboratories
Agency employed 99 vets
Meat Hygiene Service
employed 40 permanent
vets and 5 casuals, with
462 contract vets also on
the books.

Approx 100 Temporary
Veterinary Inspectors employed
in normal times.
Some 7,000 Local Veterinary
Inspectors also formed partof the veterinary network.

2001

286 (220 in thefield service)

Foot and Mouth Disease 2001: Lessons to be Learned Inquiry

27

5

5
less likely to be called out to animals today than they were in 1967. At thepresent time there is less extensive routine surveillance and fewer large
animal veterinary practices from which to draw vets in a crisis.

5.4.4 The European Union and disease control

The Local Veterinary Inspector arrangements, which the British Veterinary
Association reported to us as dating back to 1937, had not been reviewed
and updated to meet changed circumstances. The Department had planned
discussions with the Association on Local Veterinary Inspector appointment
and training in February 2001. The first meeting had to be cancelled becauseof FMD. Discussions have now recommenced. The question of veterinary
capacity and surveillance is addressed in section 17.

In contrast to 1967, Community legislation now covers many areas ofdisease control and trade in animals and products of animal origin in
Member States. These include: animal identification; health rules
applicable to intra-community trade of most species of animals and theirproducts; health rules applicable to imports from third countries ofanimals and their products; procedures for control of the list A diseases
specified by the International Animal Health Organisation, the OIE(17.1.1); veterinary checks on animals and animal products which aretraded; and notification of outbreaks of relevant diseases.

3. We recommend that there be a reappraisal of Local Veterinary
Inspectors’ roles and conditions.

Regional and central government
The structure of UK regional and local government in 2001 is very different
from that of 1967. In Scotland and Wales, devolved administrations now
take many executive decisions. The Scottish Executive has sole policy
responsibility for all, and the Welsh Assembly for many animal healthmatters within the context of the UK’s EU obligations. In both Scotland
and Wales, ministers are locally accountable for aspects of rural policy.
In England the county structure and the two- and three-tier systems of
local government are, in many parts of the country, far removed from thestructure of the mid 1960s.
Central Government too has evolved. In 2001 the network of Government
Offices for the Regions in England had an important role in co-ordinating
the operation of Government policy in the regions. However, only some
Departments were under their umbrella. MAFF only became part of theGovernment offices on 1 April 2001 and DEFRA remains part of thatstructure. In many parts of Great Britain, the regional boundaries of someof the many Government agencies responsible for responding to FMD did
not match. This made management and communication more difficult.

Foot and Mouth Disease 2001: Lessons to be Learned Inquiry

In addition, where disease is confirmed, all animals of susceptible
species are to be slaughtered under official supervision. Carcasses ofslaughtered animals must be destroyed in such a way as to prevent the
spread of FMD virus. Meat, milk and milk products from the infected
premises must be traced and destroyed, as must all substances likely
to carry the virus. All farm buildings and equipment must be cleansedand disinfected.
At the same time that infection is confirmed, a Protection Zone of atleast 3km radius and a Surveillance Zone of at least 10km radius fromthe infected premises is to be established.
Fifteen days after completing preliminary cleansing and disinfection of
the infected holding, the rules in the Protection Zone are relaxed and therules in the Surveillance Zone are applied instead. The Surveillance Zone
restrictions may not be lifted for at least 30 days after cleansing anddisinfection of the infected holding.

4. We recommend that where regional boundaries of Government
Offices do not match those of local authorities or other agenciesof government, special provision be made in contingency planningfor management and communications during a crisis.

The Directive requires an inquiry to be carried out to establish the lengthof time the virus may have existed, the possible origin of the disease andits likely means of spread.

Public opinion

Disinfectants have to be approved by the competent authority and animals
moved from their holding have to be identified.

Animal welfare issues have assumed a far greater importance in the public
mind since 1967. Public confidence in farming, science and government
was damaged by the BSE crisis. Contingency planning had not kept pacewith these developments. There had been no recent public debate on
slaughter and vaccination so key components of the disease control
strategy lacked the backing of public consensus.

28

Directive 85/511/EEC, which came into force on 18 November 1985,
provides for compulsory notification of suspicion of FMD in Member
States. As soon as notification is made to the Commission, the holding
is to be placed under official surveillance.

Routine vaccination against FMD is prohibited but limited emergency
vaccination is permitted under certain conditions.
The Commission is reviewing the existing Directive to take account of
the 2001 FMD outbreak. Detailed proposals are expected later this year.
The Commission is also working up new proposals on identification andtraceability of sheep, including electronic tagging, as well as reviewing
the import controls in place to protect the Community.

Foot and Mouth Disease 2001: Lessons to be Learned Inquiry

29

5

5
5.5 Sheep in the 2001 epidemic

5.6 The run up to the 2001 epidemic

A significant difference between the 1967 and 2001 outbreaks was the fact
that, in 2001, sheep played a critical role. The 1967 outbreak was largely
restricted to cattle and pigs. There were over 2,300 cases, confined mainly
to cattle farming areas, in particular the North West Midlands and North
Wales. The disease lasted 222 days and 434,000 cattle, pigs and sheep
were slaughtered. The total number of animals slaughtered for disease
control purposes in 2001 was more than ten times this, yet the 2001
outbreak comprised 2,026 cases. The reasons for this increased slaughter
rate are discussed in section 10. A comparison of the 1967 and 2001
outbreaks is in the Appendix at 18.4.

Before 2001, the continuing threat of BSE and the possibility of its
appearance in sheep had been a major focus of activity for MAFF. It was
unable to divert its scarce veterinary resources from this and other highprofile investigations such as TB in cattle. For three months in the autumn
of 2000, 80% of the State Veterinary Service resources had been absorbed
dealing with the East Anglia outbreak of classical swine fever which
comprised only 16 cases.

In other outbreaks around the world, the predominant pattern has beenfor pigs, not sheep, to play a key role in spreading infection to cattle.
There were almost 60% more sheep in England in 2001 than in 1967,
concentrated in the northern parts of the country. The symptoms of FMD
are not highly visible in sheep which is why the disease became widely
disseminated before detection.
5. We recommend that the Government build an up-to-date databaseof livestock, farming and marketing practices. This should include
research to examine the evolution of regional livestock stocking
densities and implications for disease risk and control.
The wide dissemination of FMD in 2001 was exacerbated by the nationwide
pattern of sheep movements throughout February 2001. This was dueto the nature of sheep farming and, in part, to the agricultural changes
referred to in section 5.4 above. Seasonal movement of sheep for fattening,in response to grass growth and climatic differences around the country,
is long-standing practice. The distances involved have been great eversince the advent of transport by railway in the 19th century. The movementof sheep purchased by a dealer from Devon at the livestock market inLongtown, Cumbria, was a feature of the 2001 outbreak, but this was nota new phenomenon. Dealers have played a significant role in livestock
markets for decades. There has been no collection of data on the extent ofdealing activity over the years, so the significance of this part of the market
is not well understood. Changes in the supply chain arising from the growthof supermarkets and the reduction in abattoirs may have increased the roleof dealers in putting together batches of animals to meet demands.

In 1997 in The Netherlands there had been a major epidemic of classicalswine fever culminating in the slaughter of 9 million pigs. We have foundno evidence of MAFF actively learning lessons from the Dutch experience,
but we know that State Veterinary Service vets in the regions had
acknowledged that they were poorly prepared for an exotic disease
outbreak. Their concerns triggered an internal report into State Veterinary
Service preparedness, the Drummond Report1, written in 1999 (6.2).

5.7 The eve of confirmation
On the morning of 19 February 2001, when vets were called to look atsome distressed pigs awaiting slaughter in Cheale’s Abattoir in Essex,
MAFF and the State Veterinary Service nationally had a number of top level
priorities. Most prominent was the alarming possibility that BSE might infectsheep. There was also concern that classical swine fever might return andthat scrapie in sheep could become extensive. The pet passport schemeand the control of rabies were high profile, as were problems with TB in
cattle. There was concern too at the general level of resourcing of theservice. Given these preoccupations among senior managers in the State
Veterinary Service, the possible return of FMD, one of the most infectious
animal diseases, was low on their list of priorities.

Other developments that may have contributed to the scale of sheep
movements in February 2001 include the Common Agricultural Policy
annual premium which encourages farmers to ensure they have their fullquota of sheep for the inspection period in February/March. MAFF was
certainly aware of sheep movements but was taken by surprise by thevolume of animals moving during February 2001. MAFF’s initial estimate
to Number 10 in the early days of the outbreak of one million movements
was soon revised upwards to two million.

1 Report of a Study of Notifiable Disease Preparedness Within the State Veterinary Service(Jan 1999)

30

Foot and Mouth Disease 2001: Lessons to be Learned Inquiry

Foot and Mouth Disease 2001: Lessons to be Learned Inquiry

31

The Government’s Memorandum to our Inquiry stated that “comprehensive
contingency plans were in place”. We did not find this to be so. Papers
laying out FMD contingency plans had been prepared and accepted by
the European Commission and approved by the Standing Veterinary
Committee. But we found the contingency plan limited in scope, out ofdate in some respects and not integrated into a national programme ofrehearsal and testing. Some local government representatives and otherstakeholders claimed they were not aware of these plans. One stakeholder
referred to them as the “best kept national secret”.

LOOKING AHEAD
APPENDICESIn March 1991, the European Commission published ‘Recommendations
or Guidelines for Contingency Plans against Foot and Mouth Disease
DGVI/1324/9’. One of these recommendations was that each Member
State should ensure that it had, immediately available, sufficient trained
staff to deal with, at any one time, up to 10 cases and to maintainsurveillance of premises in the 3km protection zone required aroundeach. This was based on the scale of outbreaks previously experienced
in Europe. A calculation made for the whole of the European Union during
the preparation of Directive 90/423/EC estimated, in a worst-case scenario,
13 primary outbreaks, each with about 150 cases, throughout theCommunity over 10 years.

VACCINATIONTHE ECONOMIC IMPACT OF FMDCOMMUNICATIONSEND OF THE OUTBREAK

The contingency plans within MAFF consisted of three main parts: theplans submitted to the EU in accordance with Article 5 of Directive 90/423;
the instructions issued to the State Veterinary Service for dealing with an
FMD outbreak and contained in Chapter 3 of the State Veterinary Service’s
Veterinary Instructions, Procedures, and Emergency Routines (referred toin this report as the Veterinary Instructions); and the local Divisional plans
drawn up by each Animal Health Divisional Office.

THE DISEASE IN THE ASCENDENT
PRE-EMPTIVE SLAUGHTER
JOINING UP GOVERNMENTDISPOSAL

Contingency planning is the process by which organisations plan for
uncertain events. Effective contingency planning covers all aspects of
preparation for such eventualities, including: recruitment and training of staff;
deployment of systems for administration and information management;
installation of structures for management and decision making; sourcingof goods and services; and procedures for communicating internally andexternally. A cornerstone of good contingency preparation is open
communication among key partners to address strategies for response,
including escalation, according to circumstances. Some organisations,notably the emergency services, have well-honed systems to respondto emergencies, and they rehearse and update them regularly.

BACKGROUND TO THE 2001 EPIDEMIC
BEING PREPARED
SILENT SPREAD
THE IMMEDIATE RESPONSE

BEING
6 PREPARED

6.1 Contingency planning6

6
The contingency plan for Great Britain was approved by the Commission
in 1993. This plan included the detailed veterinary instructions and guidance
set out in Chapter 3 of the Veterinary Instructions. It described the legislative
framework, financial provisions, national and local disease control centres,
personnel resources, availability of diagnostic laboratories, epidemiologists
and training exercises. Prior to the 2001 outbreak, the plan had last been
updated in July 2000. It was not, at the time of the outbreak, available on
the DEFRA website. It was placed there in August 2001.

In response to its own internal report, the State Veterinary Service agreed totarget available resources to five priority areas. These were: making a genericemergency plan for FMD available for each Divisional Veterinary Manager to
use if desired; formulating regional and Divisional training plans; preparing
national guidance on overcoming the problems of supply of services andmaterials for dealing with outbreaks; ensuring up-to-date instructions wereavailable for staff on-line; and discussing with the veterinary profession how
to improve relations with Local Veterinary Inspectors.

The State Veterinary Service’s Veterinary Instructions provide, in over 100
chapters, guidance and procedures for dealing with diseases and all theother tasks that the Veterinary Field Service performs. Chapter 3 which
deals with FMD, is based on the EU agreed slaughter policy and disposal
arrangements. This chapter provided the basis for managing the outbreak.
Over 200 Emergency Instructions were issued during the outbreak.
These reflected changes as policy developed and experience was gainedin the field.

In June 1999, the Chief Veterinary Officer emphasised the importanceof emergency planning to deal with outbreaks of notifiable diseases.
He acknowledged that resources had been concentrated on BSE, rather
than on implementing the recommendations of the Drummond Report.

Each of the 23 Animal Health Divisional Offices is required to havecontingency plans for FMD and other diseases. These plans were lastchecked and updated during 2000. They focused on ensuring that all the
local information that might be needed in the event of an outbreak was
readily available and that Animal Health Divisional Office staff knew how
to implement the Veterinary Instructions.

6.2 The Drummond Working Group Report
In July 1998 the State Veterinary Service had been considering the stateof its contingency planning. It set up a working group to study how well
prepared it was for dealing with outbreaks of notifiable disease and to
make recommendations for any necessary improvements. Richard
Drummond, Head of the Veterinary Service in Harrogate, the lead region
with responsibility for notifiable disease, chaired the working group.
His report, published in the CD-ROM annexes, was submitted in February
1999. It concluded that there was considerable variability throughout theState Veterinary Service in its readiness to deal with outbreaks of exotic,
notifiable diseases. In particular, it was concerned about resources andidentified five broad areas requiring action: training; contingency planning;
infected premises work; use of information technology in outbreak control;and staffing and direction.
On contingency planning, it recommended that objectives and targets relevant
to planning be included as work objectives within annual staff reporting.
It urged that a template contingency plan be available on the MAFF Intranet,
and that there should be increased awareness amongst the veterinary
profession to the threat of notifiable disease. It also urged consideration to begiven to the risks posed by the gathering of animals at markets, shows andlarge livestock units, and called for discussion of the ways in which contacts
with local authorities could be established and best maintained.

34

Foot and Mouth Disease 2001: Lessons to be Learned Inquiry

In July 2000 the Chief Veterinary Officer remained aware of the lack ofprogress on contingency planning. On 18 July 2000, the Assistant Chief
Veterinary Officer in Wales wrote to the Chief Veterinary Officer expressing
his concerns about lack of progress on implementing the Drummond
Report recommendations, in particular those concerning the slaughterand disposal of carcasses and the training of staff.
The Chief Veterinary Officer was not only aware of the lack of contingency
planning but had also visited the Pirbright Laboratory on 12 July 2000,
where he was shown the deteriorating FMD situation in the Middle and
Far East.

“Any contingency planningmust be put in place which
will identify the animals thatare at risk of getting thedisease and slaughter
those animals only and not
generate huge masses ofcarcasses which just puts
intolerable pressure on any
disposal system, whether
it is rendering, incinerationor whatever, because
these animals shouldn’t bein that processing systemanyway.”Public Meeting,regional visit to the South West

The Chief Veterinary Officer on 18 July 2000 wrote to colleagues within theState Veterinary Service expressing his concerns (in the CD-ROM annexes).
However, his concerns were not exposed to Ministers or to the
Department’s Permanent Secretary. No action outside the State Veterinary
Service was taken to tackle the significant shortcomings. We believe thiscontributed to a false sense of security within MAFF on 20 February 2001,
when FMD was confirmed.

6.3 Weaknesses in the plan
It has been suggested to us that the level of preparation by MAFF was
adequate for the generally accepted level of risk and that the extraordinary
nature of this epidemic could not have been anticipated or prepared for.
There is some truth in this argument. As noted above, the plan was basedon EU guidelines suggesting that Member States should have the resources
to deal with up to 10 simultaneously infected premises.
In developing its contingency plans, the State Veterinary Service used
two scenarios – moderate and severe – each comprising 10 simultaneous
outbreaks. The severe case scenario envisaged there being more premises
at risk in the 3km protection zone around each outbreak. This would leadto a need for more tracings, including livestock movements through amarket, than in the moderate case scenario. The severe case scenario

Foot and Mouth Disease 2001: Lessons to be Learned Inquiry

35

6

6
“May I pay tribute to
the lay staff at MAFF
Gloucester who playeda large part in getting theright people to the rightplace at the right time.
The veterinary teamof three who planned
action played their part
magnificently, often
working long hours.
As a Temporary Veterinary
Inspector I felt that I was
most of the time being
sensibly deployed.
There seem to have beenadequate staff for the jobs
in hand. We were perhaps
fortunate to have an influxof students at peak times
and they worked hard
and well.”Temporary Veterinary Inspector
employed in Gloucester“The whole organisation
was sound asleep, they
were asleep on their feet.”
Public Meeting,regional visit to the North Westdemonstrated that the UK would need 235 veterinary officers.
The Commission judged the UK’s readiness for disease outbreak as thebest in the Community.
MAFF estimated that, in a more extensive outbreak, the number of staff
needed might rise to 300. In such circumstances, it was expected that
resources would be drawn from elsewhere within the service, the private
sector and certain foreign countries with which agreements had beenreached. “…The State Veterinary Service did not often have to deal withcrises on the scale of this FMD outbreak, and it had to come down to what
was a reasonable insurance premium to pay in terms of maintaining highstaff numbers…” (Senior MAFF Official).
In the event, when FMD broke out, at least 57 premises were infected
before the initial diagnosis was made. All State Veterinary Service resourceswere fully utilised almost immediately. During the course of the outbreak,over 2,500 Temporary Veterinary Inspectors were appointed, with nearly 70
from abroad. A further 700 foreign government vets and other secondees
assisted on a temporary basis. There had been no assessment of theeffects that a large-scale outbreak might have, or of how plans might beescalated. Better scenario planning would have left the State Veterinary
Service more able to cope with the severity of the outbreak that it eventually
faced. Planning should be comprehensive enough to deal explicitly with thechallenges of scale-up. “…The classical swine fever outbreak had stretched
State Veterinary Service resources to their absolute limit so that when FMD
struck it had, from the outset, rung alarm bells within the State Veterinary
Service…” (Senior MAFF Official).
6. We recommend that contingency plans set out procedures to befollowed in the event that an emergency expands beyond worstcase expectations.
7. We recommend that provision be made in contingency plans for
rapid prioritisation of a department’s work in the face of a crisis,
and for speedy reassignment of resources.
8. We recommend that DEFRA develop its human resources plansfor use in emergency. In particular they should focus on how staff
numbers and expertise can be rapidly increased at a time of crisis.
This should be developed in England, in consultation with the
Cabinet Office, the Regional Co-ordination Unit and the network of
Government Offices. Similar arrangements should be developed in
Scotland and Wales.

Contingency planning is not just producing a written document. Rather,
it is about putting in place the systems, processes and culture to respondeffectively to crises. Above all, it is about a shared sense of ownership andpurpose across the relevant stakeholder community. We believe that theplans at national level would not have stood up to critical stakeholder
scrutiny in advance of the outbreak. Deficiencies in critical resources could
have been identified with prior communication and consultation.

6.3.1 Preparedness in Dumfries and Galloway
Dumfries and Galloway has a highly developed emergency planningapproach – the Major Emergency Scheme – that has grown from its
experience of the Lockerbie air disaster. This Scheme is based ona multi-agency partnership, co-ordinated by the Dumfries andGalloway Council.
Following activation of the Scheme on 28 February, the emergency
planning group met daily throughout the outbreak and co-ordinated awide range of support activities. These included: the establishment of theEmergency Room – known locally as ‘the bunker’; local work to prevent
spread of disease; setting up a logistics and transport operations centre;
providing fully equipped accommodation centres for vets and military
personnel; and establishing catering and welfare services.
As one submission commented, “Contingency plans for the managementof FMD are only as good as the working relationships between theorganisations that are involved in the disease control campaign.”
Co-ordination between the centre and local operations ensured that thepolicies determined by the Scottish Executive Environment and Rural
Affairs Department, based in Edinburgh, were implemented effectively.
The Scottish Executive Environment and Rural Affairs Department
seconded staff to work with the Council and the Council was
represented at relevant Scottish Executive committees. By contrast,
MAFF did not fully exploit local authorities’ expertise for managementof emergencies in England.
The Council’s Chief Executive and Emergency Planning Officer worked
closely with the Regional Operations Director, the Divisional Veterinary
Manager and Army Commander who jointly managed culling operations,once they were established in Dumfries. They met and updated eachother at regular meetings, often two or three times a day.
Early and close involvement of the farming community contributed to the
management effort. Unlike some areas in England, where the NFU felt
marginalised, the NFU Scotland President was allocated space in the
Scottish Executive Environment and Rural Affairs Department’s
Edinburgh offices.
The arrangements worked well. FMD was eradicated from the region
within three months.

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37

6

6
“There were bright spots –the Divisional Veterinary
Manager in Stafford ...
is one of the few people
who had sat down andthought. He had planned.
He was ready. It paid
off…the local outbreak
was soon under control…
I say congratulations
Divisional Veterinary
Manager Stafford whoever
you are… We needmore of you.”
Temporary Veterinary Inspector

Time and again as we visited different parts of the country, at public
meetings and in meetings with officials, we were given evidence of thelimitations of the contingency plans that existed and of the wider
community’s lack of knowledge of these plans.
Coupled with this lack of consultation and awareness, the Inquiry also
found that there had been little emphasis on training and simulation
exercises. “…In recent years there had been insufficient resources devoted
to training, the rehearsing of contingency plans, and particularly I.T. systems
because of competing priorities such as BSE…” (Senior MAFF Official).

6.5 Being better prepared
The contingency plans available in MAFF on 19 February 2001 to fight FMD
met EU requirements but lacked scope. The plans that did exist were notwidely exposed or rehearsed and, as a result, there was a limited sharedsense of ownership by stakeholders. In addition, plans had failed to keep
up with changing farming practices. Contingency planning was low downon the Department’s list of priorities. It was not seen as part of a wider
process of disease prevention and risk management.

We found that some parts of the country were more prepared than others.
In a number of regions rehearsals had taken place and internal lessons
learned by the State Veterinary Service.

10. We recommend that Government departments ensure that theirown internal departmental arrangements properly resource
contingency planning work. This should be monitored by the
National Audit Office.

Staffordshire, for example, had been able to put its procedures andpreparations to the test during the classical swine fever outbreak. Those
involved believe that good communication at all levels and appropriate useof local knowledge were central to their ability to cope with the disease.

The eventual scale of the FMD outbreak could not have been foreseen.
Nevertheless, better preparation, including better contingency plans, whichwere understood and well rehearsed would have done much to limit thescale of the crisis.

In Scotland, Dumfries and Galloway was also better prepared than most.
The Scottish Executive in its submission acknowledged the impact that theexperience of the Lockerbie air disaster in 1989 made on its contingency
planning in that region. The local authority played a central role in managing
the outbreak north of the border (6.3.1).

11. We recommend that the Government publish a biennial report tothe nation on the level of preparedness to tackle animal disease
emergencies. The first report should be published in 2003 andinclude measures of achievement against goals.

“Contingency planning, thisshould have been present
already in view of the 1967
outbreak, the lesson shouldhave been learnt then.”Public Meeting, regional visit to Wales

The best example of contingency planning that we identified was in The
Netherlands. Prompted by the experience of a large outbreak of classicalswine fever in 1997, the Dutch contingency plans had been thoroughly
reviewed, tested, agreed with all key stakeholders and approved by
Parliament before FMD appeared in Britain in February 2001.

6.4 Risk analysis
Contingency planning should not be seen in isolation. It is a dynamic
process, not a static document. It must be linked into a wider processof risk analysis and disease prevention.
Risks should be managed so that the country can better respond to
threats at an early stage. This can help to ensure that future animal
disease emergencies are less likely to become crises, and that crises
do not become disasters.
9. We recommend that accepted best practice in risk analysis be usedby DEFRA and others in developing livestock health and disease
control strategies.

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39

FMD is a highly infectious animal disease, caused by a virus. Its symptoms
include lameness and lesions (blisters) on hooves and in or aroundthe mouth. Signs of FMD are easily recognised in cattle and pigs.
However, infected sheep often do not display symptoms and the diseasecan go unnoticed.

FMD spreads most effectively when susceptible animals are closely
confined. Virus is present in the excretions, mostly faeces, and secretions
such as milk, saliva and breath of infected animals. Animals become
infected through inhalation or contact of the virus with mucosal
membranes, especially in the mouth and nostrils.

Airborne FMD virus can be carried great distances on wind plumes
depending on weather conditions. For example, the 1981 FMD outbreakon the Isle of Wight was caused by a virus plume from Brittany, France.
However, animals infected with the PanAsia strain of UK 2001 produced
less airborne virus than other strains, so the potential for distant windborne
spread was reduced.

There are seven different forms, or serotypes, of FMD virus: types O, A, C,
Asia 1, SAT 1, SAT 2 and SAT 3. Each serotype produces a distinct
response in an animal’s immune system, triggering a different set of
antibodies. This means that, if an animal has immunity to a type A FMD
virus, it may still be susceptible to FMD caused by a type O virus.

LOOKING AHEAD
APPENDICES

Other susceptible species include goats, camels, llamas, deer andhedgehogs. Some, who attended the Inquiry public meetings, reported
seeing wild deer display classical FMD symptoms and were concernedthat they were spreading the disease. Although infected deer may transmit
the disease, their living habits suggest that they are unlikely to have directcontact with livestock. Four hundred samples from deer were tested andall gave negative results. We believe that deer were unlikely to have spread
FMD in this epidemic.

VACCINATIONTHE ECONOMIC IMPACT OF FMDCOMMUNICATIONSEND OF THE OUTBREAK

Cattle and sheep are very susceptible to airborne virus, the former moreso than the latter. Pigs are relatively resistant to airborne virus but very
susceptible to contact infection, such as by eating infected feed. Infected
pigs excrete large amounts of airborne virus – hundreds of times more thancattle – but cattle excrete the most virus in total, because they produce
large amounts of infectious faeces and milk.

THE DISEASE IN THE ASCENDENT
PRE-EMPTIVE SLAUGHTER
JOINING UP GOVERNMENTDISPOSALFMD does not usually cause death in livestock, except for young animals.
However, contrary to the views of some it is not simply an equivalent of
the common cold. Infected animals may suffer acute stress and pain.
On recovery, their long-term health and condition may be affected, withserious economic impacts.

BACKGROUND TO THE 2001 EPIDEMIC
BEING PREPARED
SILENT SPREAD
THE IMMEDIATE RESPONSE

SILENT
7 SPREAD

7.1 FMD and its virus

77.2.1 Likely spread of the PanAsia O strain of FMD virus 1990-May 2000

77.1.1 Relationship of FMD virus strains
Virus

FMD virus

Serotype

Type O

StrainPanAsiastrainIsolateUK 2001

Type A

Type C

Asia 1

SAT 1

SAT 2

South Africa 2000

SAT 3

Japan 2000

FMD viruses evolve, so that for each serotype, there are several different
strains. Within those strains there are different sub-strains called ‘isolates’,
which derive from individual outbreaks (7.1.1). The 2001 UK epidemic wascaused by the PanAsia strain of FMD type O virus.

2000
2000
96
96

7.2 Global spread of the PanAsia O strain
The PanAsia strain has spread widely since its first appearance in India in
1990 (7.2.1). During the 1990s, it moved across the Middle East towards
Europe reaching Greece in 1996. It also spread across Asia, causing
several outbreaks in 1999 and 2000 in the Far East.

96-99
98-99
95-99
98-99

97
96
2000
99-2000

97-99
2000

99
95-98
97-99
97-99
94-99

93-96

98
99

96

99
99

90-99

The PanAsia strain has never been identified in South America (7.2.2).
Other FMD type O viruses have caused outbreaks there, but none wasrelated to the PanAsia strain. Suggestions that FMD in the UK may havecome from South America are therefore not valid.

2000

99
95-98

99-2000
99-2000

2000
95

In 2000, the PanAsia O strain took a major continental leap to South Africa.
The incident was attributed to feeding pigs with untreated, infected meatfrom waste food. With hindsight, this should have been a warning that FMD
remained a serious risk to any country, not just neighbours of those
infected, especially through feeding swill to pigs.
The movements of the PanAsia strain and other variants of the virus before
the UK outbreak were already well known to FMD experts. Predictions had
been made that an epidemic of FMD was likely to hit Europe in the next few
years. The European Commission for the Control of Foot and Mouth
Disease convened an Expert Elicitation Workshop on the Risk ofIntroduction of FMD to Europe in September 20001. The experts predicted
that, within the next five years, one introduction of FMD was likely in eachof the ‘Islands’ (UK and Scandinavian countries) and Western Europe
groupings of countries.

1 Estimating the risk of importation of foot-and-mouth disease into Europe.

Gallagher et al. Veterinary Record (2002) 150, 769-772.

42

Foot and Mouth Disease 2001: Lessons to be Learned InquiryFirst recorded occurrences• India• Nepal• Saudi Arabia• Malaysia• Yemen• Lebanon• Israel• Kuwait• Turkey• Bulgaria• Greece• Armenia• Georgia• Bahrain• United Arab Emirates• Iran• Bhutan

1990
1993
1994
1995
1995
1995
1995
1996
1996
1996
1996
1996
1997
1997
1997
1997
1998

• Jordan• Syria• People's Republicof China• Taiwan• Qatar• Thailand• Iraq• Vietnam• Cambodia• Laos• Malaysia• Japan• South Korea• Russia• Mongolia

1998
1998
1999
1999
1999
1999
1999
1999
1999
2000
2000
2000
2000
2000
2000

Source: N.J. Knowles & A.R. Samuel, July 1999-May 2000 Institute for Animal Health
Pirbright Laboratory

Foot and Mouth Disease 2001: Lessons to be Learned Inquiry

43

7

7

7.2.2 Worldwide occurrence of FMD virus type O and the PanAsia O strain
when first UK case confirmed
PanAsia O strain
FMD type O present

Furthermore, the British Chief Veterinary Officer, Jim Scudamore, wrote tohis deputies on 18 July 2000, saying, “Having been at Pirbright for a day
last week and seen the various maps of the deteriorating FMD situation in
the Middle and Far East, there appears to be an increasing risk of
incursions from exotic viruses.”

7.3 Entry of FMD into the UK
The exact source of the FMD virus implicated in the UK outbreak will never
be known. Genetic analysis of the UK isolate showed that it bore thegreatest similarity to the virus that caused the outbreak in South Africa in
2000. This information suggested that the two outbreaks were connected,
either directly or by means of a common source. All the viruses which aremost similar to these are from the Far East – the isolate from Japan 2000
being the most closely related. The UK and South African outbreaks both
started through swill feeding of waste food. Although the possibility that
FMD entered via imports from South Africa cannot be excluded, it is most
likely that the source of FMD was a virus imported into the EU from theFar East1.

7.4 The legal import regime
It is possible, but very unlikely, that the contaminated meat was legallyimported. Legal imports have to be certified as originating in FMD-freecountries or regions (7.4.1). Only de-boned matured beef is permitted to
be imported from countries or regions that use routine FMD vaccinations.
At certain temperatures, the FMD virus can live for at least five months inbone marrow and lymph nodes. Meat that has been de-boned and either
heated to the centre to a temperature of at least 70ºC or matured for ninemonths is considered to present negligible risks.
All meat consignments must be presented on arrival to a Border Inspection
Post where they are subject to documentary and identity checks. At least
20% of consignments also undergo physical checks.
Legal imports have not taken place from any country where the PanAsia O
strain of FMD occurs, apart from South Africa. On the basis of information
available on imports, it is highly improbable that the disease could havebeen imported legally from South Africa.
Infected meat or meat products brought into the country as ‘personal
imports’ are a possible source, but it is unlikely that these would enter the
animal food chain. They are more likely to be consumed or discarded as
domestic waste, rather than as catering waste that could be fed to livestock.

Source: Institute for Animal Health Pirbright Laboratory

44

Foot and Mouth Disease 2001: Lessons to be Learned Inquiry

1 Origin of the UK Foot and Mouth Disease Epidemic in 2001, J M Scudamore, June
2002 in the CD-ROM annexes.

Foot and Mouth Disease 2001: Lessons to be Learned Inquiry

45

7

7
7.4.1 Current import controls

7.4.1 Current import controls continued

EU legislation

Personal imports

Under the terms of the single European market in the veterinary sector,
there are controls on the movements of animals and animal products
into and within the European Community. The UK, along with all
Member States, is subject to a system of veterinary inspection
and certification.

Personal imports of meat and meat products from countries outside theEuropean Community are prohibited, except for an allowance of 1kg offully-cooked meat products that have been prepared in hermeticallysealed containers.

Intra-community trade conditions
Animals and animal products imported into the UK from other Member
States are not routinely inspected at the port or airport of arrival, but they
are required to be checked at their premises of origin. Routine borderchecks on goods traded between EU Member States are not permitted.
Random spot checks at the premises of destination are, however,
permitted and determined by risk. The competent Authority in theexporting Member State is legally required to notify the receiving
Member State of all consignments of live animals and some consignments
of products (for example, raw material for processing) despatched.
All imported live animals must have appropriate health certificates.

Personal imports from EU countries

12. We recommend that the Government ensure that best practicefrom import regimes elsewhere be incorporated with domestic
practices where appropriate.
13. We recommend that the European Commission lead a targetedrisk based approach designed to keep FMD out of EU Member
States. The UK should work alongside other EU Member States
to highlight areas of greatest risk.

Imports from countries outside the EU

Illegal shipments on a commercial scale are usually intended for wholesale
outlets or for sale to restaurants or canteens. They are most likely to beillegally described or presented as non-food imports. This increases the
chance of the virus getting into catering waste. If not properly cooked
before feeding to livestock as swill, this material could reach pigs in
sufficient quantities to cause disease.

Commercial imports of livestock and animal products are only permitted
into the EU through approved Border Inspection Posts. In Great Britain
the State Veterinary Service and Port Health Authorities at seaports, andlocal authorities at airports are responsible for conducting veterinary anddocumentary checks on live animals and animal products imported fromcountries outside the EU through Border Inspection Posts.

Foot and Mouth Disease 2001: Lessons to be Learned Inquiry

Waste food from ships or airlines could have been responsible for theoutbreak. This material, which presents a high risk if fed to animals, wasthought to be responsible for the outbreak of FMD PanAsia O strain inSouth Africa. EU and UK law prohibits the feeding of this waste food toanimals. Food from ports and airports is collected under licence from
DEFRA and destroyed by incineration or supervised landfill.

Individuals are allowed to import meat, meat products, milk and milk
products, other than raw, unpasteurised milk. Any individual attempting
to import more than 10kg may be required to provide evidence that thecommodities are solely for personal use. From time to time, further
restrictions are introduced because of an outbreak of a specific disease
in a certain country or countries.

As a rule, live animals or animal products imported into the Community
may only originate from a country approved by the Community. The
approval process takes into account such factors as the level of animal
health in the country, with particular attention being paid to exotic animal
diseases. Meat and meat products must originate from premises
approved by the Community.

46

The European Commission has recently come forward with a draft
Regulation tightening rules on personal imports.

7.5 Illegal imports

The products that present the highest risk are those from regions where
FMD is endemic. Meat, especially pork, still on the bone or with lymph
glands attached, presents a serious risk as does de-boned frozen meat,
especially pork. However, the likelihood of a significant quantity of frozen
or chilled meat avoiding detection by Customs is low as it would tend to
be transported using refrigerated containers and therefore easier to target.
Between 1 November 2000 and 9 April 2001, 1,321 Customs Declarations
were selected as a control sample to test overall compliance with Customs
requirements. All consignments selected were physically examined. None
was found to have failed to declare meat imports.

Foot and Mouth Disease 2001: Lessons to be Learned Inquiry

47

7

7
7.5.1 Import controls more strict in New Zealandthan in the UK?
Many people have drawn comparisons between the import control
regimes in the UK and several other countries. Perhaps the mostcommon example brought to our attention was that of New Zealand.
New Zealand has a number of positive measures in place on personal
imports, including a single biosecurity agency with a large presence at
ports, supported by effective publicity, a system of signed declarations,amnesty bins for personal imports that break the rules, andon-the-spot fines.
Some of these measures may be suitable for the UK. However, it isimportant to take account of the practical circumstances that prevailin particular countries. New Zealand has 3.5m air passengers per year
compared to 71m passengers arriving from outside the UK annually,of which 28m are from outside the EU. And New Zealand is a net
exporter – 60% of its trade relies on agricultural exports. Maintaining
low production costs is therefore economically critical given the
distances to their markets.
Examining the policies adopted by other countries is a useful element indeveloping best practice at home. However, what is right for one country
may not automatically be right for another. Even so, this caveat must not
be put forward to justify any failure to adopt particular measures where
they are both practical and effective.

It is difficult to assess the quantity of illegal meat that may be entering
the country. However, the 2001 outbreak underlines the importance ofcontinued vigilance by all authorities with border responsibilities in orderto keep out the agents that can cause exotic infectious diseases.
DEFRA is leading interdepartmental consideration of the problem of illegallyimported animal products (17.1). They may learn also from the control
measures of other countries, such as New Zealand (7.5.1).
14. We recommend that DEFRA be given responsibility forco-ordinating all the activities of Government to step up efforts tokeep illegal meat imports out of the country. This should include
better regulations and improved surveillance on illegal imports ofmeat and meat products.

7.6 The spread of the disease prior
to detection
Once the FMD virus had infected animals in the UK, the disease spread forweeks without detection. The probable timing of infection and transmission
was judged by the age of the lesions on the animals inspected. Information
about farms and movements of animals was used to trace the spread of thedisease (7.6.1) (see CD-ROM annexes and Gibbens et al. paper 1).
All the available evidence suggests that, sometime between mid-January
and early February 2001, but most likely around 7 February 2001, pigs on
Burnside Farm, Heddon-on-the-Wall became infected with FMD. Catering
waste, containing illegally imported meat infected with the virus, is believed
to have been fed to pigs as swill. By law, the swill should have been heat
treated before use.
A ban on swill feeding was introduced on 24 May 2001. At that time, only
1.4% of the pig population in Great Britain were fed swill. Most domestic
and catering waste was disposed of in licensed landfill. The additional
volume generated by the ban was not considered to be significant.
15. We recommend that the UK prohibition of swill feeding of catering
waste containing meat products continue. The UK should continue
to support a ban at EU level.
The disease could have been present at Burnside Farm for weeks, but itwent unreported, despite the requirement of farmers to report suspectedcases of notifiable diseases.
Sheep and cattle on the nearby Prestwick Hall Farm, Ponteland, were
the next victims of the disease. The farm is five kilometres north east ofBurnside Farm and lies under the potential virus plume generated by theinfected pigs. Weather conditions had been suitable for airborne spreadthroughout the likely period of infection. The most likely date of infection
was 12 February 2001, although inspection of the animals suggested it
might have occurred earlier.
FMD in sheep is difficult to diagnose. Farmers and vets can miss the signs.
Infected sheep often display mild symptoms, if any, and suffer from otherconditions that may be confused with FMD. Because cattle are more
susceptible and show obvious signs of infection, they can act as sentinels
for the disease, an ‘early warning system’. The sheep on Prestwick Hall
Farm were only diagnosed after the vet had been called out to inspect
the cattle.

1 Descriptive Epidemiology of the 2001 foot-and-mouth disease epidemic in Great Britain:

the first five months. Gibbens et al. Veterinary Record (2001) 149, 720-743.

48

Foot and Mouth Disease 2001: Lessons to be Learned Inquiry

Foot and Mouth Disease 2001: Lessons to be Learned Inquiry

49

7

7
Sixteen of these sheep went to market. On 13 February, together withthree other sheep, they were sold at Hexham Market in Northumberland.
Of the 19 sheep, three went to a butcher, six to a farm in Lancashire (which
subsequently became an infected premises) and 10 to a dealer. The dealer
took them to Longtown Market in Hexham on 15 February along with 174
other sheep. Potentially at least 24,500 sheep had passed through themarket and been exposed to the disease between that date and
23 February when the movement standstill was introduced.

7.6.1 Probable initial spread of FMD

Far East (or South Africa)

Illegally
imported meatin untreated
pig swill

So, before anyone realised its existence, FMD had been seeded in many
areas around the country. At least 57 farms in 16 counties were infectedby the time the first case was confirmed.

Burnside Farm, Heddon-on-the Wall, Northumberland
Pigs most likely infected on 7 February,confirmed 23 February

Meanwhile, as FMD was spreading via sheep, infection had continued torage on Burnside Farm. Infected pigs were sent to Cheale’s Abattoir in
Essex on 15 February and slaughtered on 16 February. Pigs that arrived at
the abattoir on 16-18 February from the Isle of Wight, Buckinghamshire andYorkshire, subsequently succumbed to the disease carried from Burnside
Farm. Those animals were the first to be identified as suffering from FMD
on 19 February.

Virus plume
5km north east

Prestwick Hall Farm, Ponteland,
Northumberland
Sheep (and cattle) most likely infected
on 12 February, confirmed 23 February“Had these sheep [fromLongtown Market] been
followed up and destroyed,
and any other sheep they
were in contact with had
been destroyed
immediately, those cluster
bombs would not havebeen left there to manifest
and go off and spread live
virus all over the place.”
Public Meeting,regional visit to Scotland

7.7 Nature of the 2001 epidemic
Several conditions contributed to the introduction and widespreaddissemination of FMD:

Pigs
15 Feb

16 Sheep

3 Sheep

Hexham Market, Northumberland
13 February
Isle of Wight
Pigs
16 Feb
6 Sheep

3 Sheep

Farm,
Lancashire
Confirmed on
27 February

Butcher

Buckinghamshire
Pigs
16 Feb• The inclusion of infected meat in swill.
• The feeding of untreated swill to pigs.
• A delay in diagnosis of infected pigs.
• The infection of sheep by a virus plume.
• The undetected disease in sheep for weeks.
• Large number of sheep movements.
The nature of the 2001 epidemic was significantly different from theoutbreak of 1967. In the latter, the disease affected mostly cattle,
so diagnosis had been more straightforward. Most of the infection had
been by airborne spread, though also through milk and animal movements.
However, in 2001 the PanAsia strain was excreted in significantly lower
amounts. So, airborne spread was not a major mechanism of transmission.

7.8 Alternative theories

10 Sheep

174 Sheep

Yorkshire
Pigs
18 FebLongtown Market, Cumbria
15 February

During the outbreak, a large number of alternative explanations of theorigin and mechanism of spread of the disease were put forward (7.8.1).
Journalists who met the Inquiry told us that they investigated more than thirtysuch theories. Some of these ideas gained widespread popular support.
We have investigated a selection of these theories. In no case has thesuspicion stood up to scrutiny.

Possibly
24,500 sheep
exposedbetween 14
and 23 Feb

Cheale’s Abattoir, Brentwood,Essex
Pigs infected from 16 February,confirmed 20 February

181 formal purchasers
Source: Gibbens et al.

50

Foot and Mouth Disease 2001: Lessons to be Learned Inquiry

Foot and Mouth Disease 2001: Lessons to be Learned Inquiry

51

7

7
7.8.1 Alternative theories for the origin of the disease

7.8.1 Alternative theories for the origin of the disease
continued

Railway sleepers
One claim was that the Government knew that FMD was present in the
UK long before February 2001 because MAFF had asked railway sleeper
suppliers about their levels of stock shortly before the outbreak. DEFRA
says that the enquiries were part of a routine exercise to update the listsof contractors identified in local contingency plans.
The enquiries in question were indeed standard practice. Lists ofcontractors from across the country, and details of the dates andlocations of similar exercises, confirm this (see CD-ROM annexes).

Porton Down
In April 2001, a newspaper article claimed that live FMD virus had gone
missing from the Government research facility at Porton Down and wasused to start the outbreak deliberately.

Experimental farm
It is claimed that lambs infected with FMD were sold inadvertently froma Government experimental farm on the military range at Otterburn inNorthumberland. The farm attempted to buy large number of lambs ina failed attempt to put the lid back on the disease.
The premises in question is the Redesdale experimental farm, run by
ADAS Consulting Ltd. It has had no FMD-related activities. No FMD virus
or vaccine has ever been kept there. And no livestock infected with, or
vaccinated against, FMD has ever knowingly been kept on the farm.
Inspection of the farm’s livestock movement records since December
1999 revealed that no unusual movements of livestock either on or off
the farm took place during the relevant period (see CD-ROM annexes).

None of the laboratories at Porton Down have either held live FMD
virus before May 2001 or experienced any theft of microbiologicalmaterial (see CD-ROM annexes). They could not have been the sourceof the outbreak.

Sheep exported to France
Positive test samples from sheep, exported from Wales on 31 January
2001 and arriving in France on 8 February, suggested that FMD had
been in Wales in January 2001. When FMD broke out in the UK, theFrench authorities as a precaution culled all sheep imported from the UKfrom 1 February and took blood samples. In an initial virus neutralisation
test carried out on this particular group of animals, seven out of thirtyone samples appeared positive.
We visited France and met the officials involved in these tests. They wereabsolutely clear that the first tests they carried out were false positives.
When further tests were performed using protocols applied by otherlaboratories around the world, all samples gave negative results(see CD-ROM annexes).

CanadaIn October 2001, a Sunday newspaper printed claims that the Canadianauthorities knew that FMD was present in the UK in December 2000 andthat travellers entering the country before Christmas 2000 had to wadethrough disinfectant baths.
A letter from the Canadian Chief Veterinary Officer states that these andother claims made in the article were “absolutely not true and without
foundation” (see CD-ROM annexes).

52

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Foot and Mouth Disease 2001: Lessons to be Learned Inquiry53

A form A was issued declaring the abattoir an infected area. This meantthat all movements in and out of the abattoir were stopped and tracing of
all contacts was started.
An enormous amount of work was then needed at the abattoir to do a fullclinical survey of all the animals. Advice on cleansing and disinfecting had
to be given to all the people working there. Lorry loads of animals arrivingin the afternoon had to be turned backAn email was sent from MAFF Head Office to the Pirbright Laboratory
saying that the samples were on their way. In the event that email wasnever read, so the samples waited overnight at the Pirbright Laboratory
before being collected the next morning. So, 12 hours of testing time hadalready been lost.

VACCINATIONTHE ECONOMIC IMPACT OF FMDCOMMUNICATIONSEND OF THE OUTBREAK

In accordance with their standing instructions, the vets took blood andtissue samples at around midday to send to the Pirbright Laboratory for
immediate analysis. The vet from the State Veterinary Service phoned MAFF
Head Office to explain her initial views. One of the Animal Health Officers
from the MAFF local office drove the samples to Pirbright, around 70 miles
away across London. The Animal Health Officer left Brentwood at around1700 and arrived at the Pirbright Laboratory at 1900.

THE DISEASE IN THE ASCENDENT
PRE-EMPTIVE SLAUGHTER
JOINING UP GOVERNMENTDISPOSAL

It was around 1030 on the morning of Monday 19 February, when Craig Kirby,
the resident vet at Cheale’s Abattoir, made his critical phone call to the local
State Veterinary Service office in Chelmsford. Things at first moved quickly.
Two state vets were despatched immediately to Cheale’s, arriving shortly
before noon. They both confirmed Kirby’s initial suspicions. This was aclassic case of either swine vesicular disease or FMD. Both are exotic viraldiseases which may show indistinguishable clinical signs and symptoms.
There was no doubt in any of the three vets’ minds that this was definitely
one of the two. Whichever it was, speed was of the essence.

BACKGROUND TO THE 2001 EPIDEMIC
BEING PREPARED
SILENT SPREAD
THE IMMEDIATE RESPONSE

THE IMMEDIATE
8 RESPONSE

8.1 The Abattoir

The first ELISA test to detect FMD (8.1.1) was started at 0900 on Tuesday
20 February. It was completed by 1330 and confirmed as a positive.
MAFF was informed at 1350.

By Tuesday morning, things had deteriorated. Many of the pigs werebeginning to suffer extreme distress. Kirby himself authorised killing severalof them on welfare grounds. Nothing further could be permitted until
Pirbright scientists had completed their tests. After the first of these proved

LOOKING AHEAD
APPENDICES

Back at the abattoir routine activity had ground to a halt. Work on
slaughtering the pigs had been stopped as soon as the alarm was firstraised on Monday. The process of culling infected animals under thesupervision of the State Veterinary Service could not start without formal
authority from Page Street.

88positive MAFF requested that a second be performed. That was completed
later on Tuesday afternoon and it removed any remaining doubts. This wascertainly FMD.

8.1.1 Confirmation and diagnosis
FMD is confirmed primarily on clinical grounds. A vet needs to beconvinced by the visible signs of the disease. Other than to confirm
the first case of a new outbreak, laboratory diagnosis is only used forequivocal cases.
During the epidemic, there was significant confusion about whether
laboratory confirmation was needed. Early on, MAFF Headquarters’
staff at Page Street were not convinced by the telephone reports andinstructed field vets to take samples. Lack of veterinary experience of
FMD and the difficulty of diagnosing sheep which did not show obvious
disease signs, led to a huge volume of testing.
Serious delays arose from waiting. Transport of the samples to thePirbright Laboratory could take up to one day. Infected animals were to
be slaughtered immediately after confirmation, but laboratory results could
take four days.
Samples from animals suspected of FMD were tested for the presenceof the FMD virus or specific antibodies which animals produce as partof their immune response to infection. Generally these antibodies can bedetected from around five days after animals show signs of FMD.
The ELISA tests take about four hours, but the OIE ‘gold standard’ tests
take longer. Virus isolation takes up to four days to confirm a negative,
although positive results can be confirmed sooner. Virus neutralisation
tests take at least two days.
Tissues likely to be infected, such as epithelium from lesions, are tested
for virus by the direct sandwich (DS) ELISA and by the virus isolation
test. The DS ELISA is also used to check that virus isolation positives
are indeed FMD virus.
The liquid phase blocking (LPB) ELISA is used to screen blood samples
for the presence of antibodies that recognise FMD virus. Positive or
inconclusive samples are put through the virus neutralisation test.

SampleTest

DS ELISA
positives

56

Foot and Mouth Disease 2001: Lessons to be Learned Inquiry

for detecting
ANTIBODIESInfected tissues,
fluid or blood

Blood

Virus
isolation

LPB
ELISA

positives orinconclusives

By that time a farm next door to Cheale’s Abattoir, had also been affected.
This too was declared an infected premises, and slaughtering began there.
There are important lessons to be learned from the experience of thosecritical hours, from noon on 19 February until around 2000 on 20 February.
That is why we have recorded in some detail what happened over that
period of 30 hours. It is a time when speed can make such a precious
difference. Standing Veterinary Instructions declare that, until laboratory
tests are complete, a suspected case of swine vesicular disease shouldbe treated as a case of FMD.

8.1.2 Slaughter of suspect pigs
The pigs at Cheale's abattoir were still alive several hours after FMD was
first reported. Dr Donaldson of the Pirbright Laboratory has advised us
that, in future, pigs with lesions should be slaughtered without delays
and the carcasses kept for inspection, if necessary. The priority ofslaughter should reflect those highest to lowest virus producers:• pigs with generalised unruptured lesions;• those with early developing lesions;• those with ruptured lesions;• the apparently healthy pigs.

With hindsight many things could have been done more quickly. Even
without it, though, there are lessons that can be learned. During theseprecious 30 hours, the source of the infection could have been identified
more quickly. Urgent phone calls could have been made to alert the
Pirbright Laboratory to the samples on the way for analysis. The knowledgeof Cheale’s staff about the quality of the pigs received could have beensought. The expertise of their key staff would have offered at least a shortlist of possible sources. The Chief Veterinary Officer has told us that therecords at the abattoir were hand-written and not easy to use. It took
48 hours to work through them all. Nevertheless, efficient record keeping,coupled with interviewing of the staff at Cheale’s might well have indicatedthe index case more quickly.

Suspected
FMD casefor detecting
VIRUS

Even then the slaughter of all the affected pigs was not authorised. First,
Dr Alex Donaldson, Head of the Pirbright Laboratory, needed to observe
the clinical signs at first hand and collect samples. He arrived at the abattoir
at about 1830 and confirmed classical symptoms of FMD in the pigs.
He left at around 2000. The slaughter of the pigs began and wascompleted around 0100 on the following, Wednesday, morning.

Virus
neutralisation
test

Foot and Mouth Disease 2001: Lessons to be Learned Inquiry

57

8

8.2.1 Map of animal
movements before
23 February 2001

Infected abattoir

Implicated market

First case discovered

Movements on or before 20 February 2001

Infected farm or livestock dealer

Movements on 21 to 23 February 2001

8

Index case

By the evening of Tuesday 20 February, when the animals on the farmnext to the abattoir showed clinical signs of FMD, there were at least threeoutbreaks of FMD in the country: one at the abattoir; one at the farm next
door; and one or more other cases at a place or places then unknown,
which had been the source of the virus reaching the abattoir.
At 0545 on the BBC’s ‘Farming Today’ the next morning, Mr Ian Campbellof the National Pig Association said, “The probability is that the infection…
has actually occurred on contact in the abattoir and therefore it hasn’tinterfered with the vehicles that brought the pigs into that abattoir andinfected these other pigs, but that is only a guess.” He also said,“It’s very serious and it requires every single pig producer in the UK to getstraight out there and look at their stock and assess whether they have aproblem... They should look very hard at their stock. They should identify
anything which is out of the ordinary and showing lameness andimmediately notify their vet for a double check to be made.”
The confirmation of FMD on 20 February led swiftly to a ban on exports
on 21 February of live cattle, sheep, pigs and goats, and also of meat,
meat products, milk and milk products and certain other products suchas hides from these animals. But, apart from the strict controls around theplaces of infection, no animal movement restrictions were introduced
across the country.

LONGTOWN
MARKET

HEXHAM
MARKET

8.2 The ban on animal movements
Three days later, at 1700 on Friday 23 February, national movement
restrictions were introduced. That morning an order was agreed by the
Minister of Agriculture, after discussion with the Prime Minister, to comeinto force late in the afternoon. Animals in transit were allowed to complete
their journeys. We were told by a number of people that the level of animal
movements that evening was unprecedented.
The decision not to impose immediate movement restrictions was criticised
time and again during our Inquiry. Are these criticisms justified? Once again
hindsight can distort judgement. Even today the State Veterinary Service
believes it would not have had the justification or the support to introduce
widespread restrictions. Given the prevailing conditions we have sympathy
for this view. Movement restrictions would probably have been seen as
a disproportionate response. They would certainly have been very
controversial. But it is an inescapable fact that the following could havebeen deduced by the evening of 20 February. Somewhere around thecountry, a pig farm was pumping out FMD virus and putting other farms
and livestock at risk. Considering what is known about the infectious natureof this disease, we conclude that earlier movement restrictions would havebeen justified, and should have been ready to be put in place more quickly
than they were.

WELSHPOOL
MARKET

HEREFORD
MARKETNORTHAMPTONMARKET

ROSS
MARKET

Between 20 and 23 February the number of animal movements was
substantial. The map of the animal movements (8.2.1) that did take place
during those critical days shows just how great was the traffic.

Source: Descriptive Epidemiology of the 2001 foot-and-mouth disease epidemic in Great Britain: the first five months. Gibbens et al. Veterinary Record (2001) 149, 720-743

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Professor Woolhouse of Edinburgh University observed in evidence to theHouse of Commons Environment, Food and Rural Affairs Select Committee
that:

There is an overriding lesson to emerge from comparing the UK and Dutch
experiences. It recurs throughout the story of the FMD crisis. The key toeffective disease control is speed, speed and more speed.

“If we had imposed a national movement ban on 20 February, three days
earlier, our estimation is that the epidemic would have been between one
third and one half that it actually was.”

16. We recommend that in all suspected cases of FMD, the responsereflect the experience of the emergency services, where speed andurgency of action govern decision making.

Hours mattered. DEFRA epidemiologists have estimated that in the sevenhours between the order having been signed and it coming into effect,
19 additional farms would have been infected – about three each hour.

Samples should be moved to the competent laboratory by the fastestmeans available. A senior member of the State Veterinary Service withappropriate clinical experience should be taken to the suspect site todetermine and control the response, based on a risk assessment.
Decisions should be communicated quickly at all times.

In contrast, prompted by the knowledge of the outbreak in Essex,
The Netherlands introduced restrictions on the transport of susceptible
animals on 21 February. Precautionary action in Britain, similar to thatcarried out in The Netherlands would, without doubt, have reduced thesize of the epidemic.

8.2.2 Tough decisions early on: the Dutch experience
A devastating outbreak of classical swine fever in 1997 had led
The Netherlands to review thoroughly its contingency planning arrangements
for dealing with major infectious animal diseases. The importance of
speed of response had been one of the key lessons learnt from theDutch experience and was a feature of their reaction to FMD in 2001.
After the first case of FMD had been confirmed in Essex on the eveningof Tuesday 20 February 2001, The Netherlands imposed a transport ban
the following day on all susceptible animals imported from the UK since
24 January 2001.
On the same day, a decision was taken to ban the collection of sheep
within The Netherlands except for direct movements between farms or
to slaughterhouses. Sheep movements to markets, collection centres,
auctions and exhibitions were prohibited. This was extended to allsusceptible animals on 22 February.

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Foot and Mouth Disease 2001: Lessons to be Learned Inquiry

There are many unconfirmed cases every year and these should not
generate a disproportionate response. Action taken should be in proportion
to the level of risk. There should be a mechanism whereby, if experienced
vets have no doubts about the presence of exotic disease, as happened
with three vets on the morning of 19 February, a fast track procedure canbe developed.
17. We recommend that the State Veterinary Service consider forminga national network of ‘flying squad’ teams capable of responding
to an alert. The continuing occurrence of false alarms can then be
used constructively to maintain readiness and to practise routines.

8.3 The Longtown connection
On Saturday 24 February, four days after the first case was confirmed in
Essex, the first case occurred in Devon. The disease was identified ona sheep farm belonging to a sheep trader. He had bought sheep from
Longtown market in Cumbria earlier that month. This batch had then been
distributed to a number of different locations, especially in the South Westof the country, many of which were eventually to succumb to the disease.
From this weekend onward the extent of the disease spread from
Longtown became clear.

On 26 February, the transport of all sheep and goats in The Netherlands
was banned, even to slaughterhouses. This was extended to allsusceptible animals, following confirmation of the virus in France on
13 March.

Some 25,000 sheep had passed through the market between
14 and 23 February, all of which could potentially have been exposed to
FMD. They had then been dispersed widely spreading the disease silently
before detection.

Despite the swift imposition of these precautionary measures, The
Netherlands recorded its first confirmed case of FMD on 21 March 2001.
The source of the outbreak is thought to have been calves imported
from Ireland that had come into contact with infected British sheep ata welfare staging point in Mayenne, France. This deduction was madeonly after confirmation of the first cases of FMD in The Netherlands, as
the system for tracking animal movements between EU Member States
did not record stops at staging points in third countries. The European
Commission is reviewing the use of such staging points with a viewto proposing further controls.

From 25 February, the MAFF epidemiological team began the work of
tracing the sheep from Longtown. This was a slow task. With the headstart that the disease already had, coupled with the enormity of the job inhand, MAFF was not well equipped to do it quickly. To complicate matters,
there was the possibility that some dealing had taken place outside themarket and there would be no record of those movements.
MAFF officials worked hard to trace all the contacts, but the process
was slow. As late as 8 March they were still writing to farmers who
had potentially bought sheep at Longtown. By then, the disease waswidespread throughout the country.

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8.4 Access: Footpath closure and its effects
In the early days of the epidemic there were understandable concernsthat everything possible should be done to prevent the disease spreading.
By the end of the first week and over that first weekend as the extent of thedisease spread was becoming clearer, many people were urging more
draconian measures, especially with regard to footpath closures.

8.4.1 Footpaths
There are over 150,000 miles of Rights of Way in Great Britain. Local
authorities are responsible for their management.
The powers to close footpaths in the context of an FMD outbreak stemfrom a Foot and Mouth Disease Order (1983) which reflected the viewsof the Northumberland Report. Under that order areas can be declared
either ‘infected’ (areas of about 10km radius around infected premises)or ‘controlled’. Controlled Areas were conceived originally as areas
where temporary restrictions would apply pending the tracing of
in-contact animals.
In Infected Areas the Order gives local authorities powers to close
footpaths. A wide range of outdoor activities such as hunting, shooting
and certain equestrian events are also prohibited. In Controlled Areas
outdoor activities would normally be allowed with only deer hunting andstalking being prohibited.
In an unprecedented step the whole of Great Britain was declared aControlled Area on 23 February 2001, and the associated restrictions
lasted around nine months.
An amendment to the 1983 Order was made on 27 February with theintention of extending local authorities’ powers to restrict access outside
Infected Areas and to enable ‘blanket closure’. Having been hurriedly
introduced, the amendment did not provide the powers intended, so
a second amendment was introduced on 2 March. Under this order,
local authorities could close all paths within their boundaries without theneed to place closure notices on individual footpaths. In areas where
there were no cases of FMD, exercise of the powers was officiallysubject to clearance by the Minister. In practice local MAFF officials
gave this clearance.
The power to impose new blanket closures was repealed on 16 Marchbut existing closures were unaffected.
Some consideration was given to ministerial revocation of closure.
In the context of impending local elections and expected opposition fromfarmers and some local councillors ministerial powers were not used.

8.4.2 Closure of footpaths: different interpretationsof the same thing
Official advice from MAFF was qualified. The first formal guidance tolocal authorities, in a circular dated 6 March, stated:“[Power to restrict
access outside Infected Areas] should only be used where there isevidence ... that to allow such unrestricted access would pose apotential risk of spreading the disease.”
The Prime Minister in his Internet broadcast on 27 February had said:“...though we are not at direct risk from this disease, we can playa part, unknowingly, in spreading it. FMD is a highly infectious virus
which can be picked up by us on our boots, clothes and cars andcarried many miles. By staying away from farmland, by keeping off any
footpaths through or next to farms or open land with livestock, we canhelp the efforts to eradicate this disease. We are giving local authorities
today the power to enforce the temporary closure of footpaths andrights of way, but we hope people will voluntarily stay away in any case.”
In the House of Commons on 28 February, Nick Brown, Minister for
Agriculture, said “I deliberately left the issue to the discretion of local
authorities, on the understanding that they would know best the local
circumstances. It is for them to make an assessment of risk. ...
Incidentally, if they want advice from me, I suggest that they act ona precautionary basis.” (Official Report col. 921) Later in the same
debate, he said “I urge local authorities to prosecute people who insist
on arguing about those measures [to close paths].”(Official Report col. 931)
NFU President Ben Gill on 27 February said: “It is imperative that every
local council which has rural footpaths and rights of way within
its boundaries closes them immediately. There must be a blanket ban
across the country. This could be crucial in helping us to stamp out thishighly virulent disease. With new outbreaks being confirmed all the time,
we are sure every responsible member of the public will support us.
Remember the disease could be anywhere – not just in the restrictedzones. I implore everyone once again: please, please stay away fromthe countryside.”

The NFU was calling for widespread closure. Other organisations supported
the call for caution or took their own steps to close footpaths. On 22
February the Ramblers Association advised against taking rural walks.
On 23 February the Royal Society for the Protection of Birds closed its
nature reserves for a week. The National Trust announced the closureof all its parks containing livestock, and the British Mountaineering Council
called on mountaineers and climbers to respect restrictions and stay out of
the countryside.

In July 2001 the Minister revoked remaining blanket closures by declaration.

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No one knew where the disease might crop up next. By 26 February there
were FMD cases in Essex, Northumbria, Devon, Wiltshire and Wales(Anglesey); by 27 February there were also cases in Northamptonshire,
Durham and Lancashire.

The decision on footpath closure contributed to the costs on the economy
as a whole. Once this was recognised, the decision proved very difficult toundo since the reopening process had not been thought through at thetime of closure. The role of local authorities was critical.

The Government came under pressure from many quarters to extend theclosure of footpaths and restrict access to the countryside beyond theofficial Infected Areas. MPs from all parties argued for temporary closureof rights of way in a debate on 26 February. The Welsh Assembly wasconcerned that the public were ignoring pleas to stay away from
Snowdonia in particular. Officials in the Department of the Environment,
Transport and the Regions were aware on 26 February that widespreadclosure would have implications for the whole rural economy, given that
tourism is a larger rural business than agriculture. But they were sensitive
to the wider mood of support for closures.

If future disease control measures necessitate the closure of footpaths local
authorities, the National Parks and major landowners such as the National
Trust should be consulted fully. The possibility of keeping livestock awayfrom key heritage sites should at least be considered. This was suggested
to us in the context of keeping open sites such as Hadrian’s Wall to
encourage continued tourism.

The Countryside Agency reported to us that, when they issued a press
release on 2 March saying that costs to the rural economy could run to£2 billion, they experienced opposition from MAFF.
The audit trail for how the decision on footpath closures was finalised
is unfortunately unclear (see recommendation 35 on page 93). What isapparent, is that following a series of meetings with the NFU and otherstakeholders, and dialogue between MAFF and Number 10, Ministers
sought powers to close rights of way beyond Infected Areas.
It is easy to understand the pressure Ministers were under to allow closure
beyond just the Infected Areas. Many stakeholders were urging theGovernment to take action. They did so but not as far as we have beenable to determine on the basis of explicit veterinary and scientific advice.
Many submissions stated that, with hindsight, this blanket closure offootpaths was mistaken. The National Trust described it as “the most costly
decision of the entire outbreak”, even though the Trust itself had initially
supported closure.
Many tourist and leisure organisations realised quickly that the impact
would be significant. As the realisation grew that the outbreak was unlikely
to be short lived, many people began to recognise its potential impact.
The frequent changes in guidance, the lack of clarity in communication, theloss of confidence in the Government’s scientific understanding and controlof the outbreak, all hindered those seeking to get consensus on reopening.
Farmers under tight biosecurity restrictions found it difficult to accept thatwalkers would not pose a risk. The public began to wonder why a disease
that reportedly did not have much of an impact on animals and for which a
vaccination was said to exist should be causing so much disruption. Only
with the establishment of the Rural Task Force in mid March did a strategy
begin to emerge for reopening footpaths based on a process of veterinary
risk assessment. There was greater appreciation of the need to get thebalance right between rural access and disease control. But, in terms of thewider economic impact on tourism and the rural economy, the damage had
been done.

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This policy was in line with the pre-existing contingency plans, based asthey were on the presumption of a relatively small, contained outbreak, theassociated tracings of which could be completed reasonably quickly.
What the policy did not, indeed could not, take into account was that thedisease had remained undetected for three weeks during which it had
spread throughout the country.
The advice that the State Veterinary Service gave to Ministers was that thepolicy would work. It was only a matter of time. This message was passed
to Number 10 and the media.

The media’s response to the disease in the first two weeks was broadly
sympathetic. The view was that MAFF recognised the nature of theinfection and the way it was spreading, as well as how to control and theneliminate it.

The Cabinet Office carried out its traditional role of co-ordinating discussion
across government. Over the following three weeks, official meetings were
held to inform other departments of the impact of the disease and themeasures being taking to control it. With the benefit of hindsight, there wasmuch more that could have been done at this stage if information on the

LOOKING AHEAD
APPENDICES

Other government departments were not greatly involved at this stage,largely because MAFF was not asking for help. However, on the first dayof the outbreak, officials from the office of Baroness Hayman, a Minister
at MAFF, contacted that of John Spellar, a Defence Minister, to raise thepossibility that some form of military assistance might be needed if thedisease could not be confined to one area.

VACCINATIONTHE ECONOMIC IMPACT OF FMDCOMMUNICATIONSEND OF THE OUTBREAK

On 21 February, Nick Brown, the Minister for Agriculture and Jim
Scudamore, the Chief Veterinary Officer held the first of a series of dailypress briefings on the state of the disease and the progress of the
response, a development that was welcomed by the media. These briefings
continued until 25 March.

THE DISEASE IN THE ASCENDENT
PRE-EMPTIVE SLAUGHTER
JOINING UP GOVERNMENTDISPOSAL

By 27 February, one week after the disease had been confirmed, a control
strategy at a national level was in place. The initial policy response,of slaughtering all susceptible animals on infected premises and tracing andslaughtering dangerous contacts, had been put in hand, managed by
the State Veterinary Service. These measures were supplemented by thenationwide ban on animal movements. On Tuesday 27 February, footpaths
in all infected areas were closed and the Government empowered local
authorities to close any footpath within their boundaries if they chose to do so.

BACKGROUND TO THE 2001 EPIDEMIC
BEING PREPARED
SILENT SPREAD
THE IMMEDIATE RESPONSE

THE DISEASE IN
ASCENDENT
9 THE

9.1 The national perspective

9

9
actual state of the disease in the country had been available. For example,
the Cabinet Office Briefing Room, known as COBR, which was to prove
so effective in marshalling the full resources of Government to bear on the
disease, might have been opened at this stage rather than 31 days into
the crisis.
The outbreak was first discussed in Cabinet on 1 March. The minutes of thatmeeting indicate that the Minister of Agriculture gave a factual account of thedisease control measures in place, which it was hoped would contain the
spread of the disease. There was no discussion of the outbreak at thefollowing week’s Cabinet, due to the imminent budget. The next opportunity
was the Cabinet of 14 March. By this stage, the impact on the tourist
industry was becoming more apparent and was raised for the first time.
On-site disposal was also discussed. The Minister reported that thepriority remained to control and eliminate the disease. As yet he had not
asked for any assistance from the Ministry of Defence other than to borrowveterinary officers.
At a national level, the shortage of qualified vets was the one real area ofconcern outside MAFF. The Chief Veterinary Officer wrote to his counterpartsin Australia, New Zealand, Canada, USA and the Republic of Ireland on 23
February to request help. He followed this up on 25 February with lettersto his opposite numbers in EU Member States.
Access to financial resources did not limit MAFF’s response. The Treasury,
in evidence to our Inquiry, told us that they had recognised at an earlystage that disease control would cost more than MAFF’s budget would
allow. Aside from the need to ensure financial propriety and value formoney, the Treasury placed no constraint on the resources available totackle the outbreak.
MAFF experienced difficulty in converting offers of help from othergovernment departments into practical reality. Promises of extra staff weresometimes not translated into action by those making them. And, whereextra staff were made available, for example, additional press officers, theorganisation was not in place to use them effectively. The Prime Ministerhelped address these difficulties by stating clearly that, whatever resourceswere needed to tackle the disease, should be made available. This wasimportant, as it is extremely difficult to mobilise cross-government resources
without such a clear statement of will from the highest level.

9.2 The view from the ground
However, at ground level, things were deteriorating.
On the weekend of 24-25 February the disease reached Devon. A vet there
told us that he had been taking a walk on the beach with his family when
he received confirmation of the first outbreak in the county. When herealised its location – at a farm belonging to a sheep trader – he said hisheart sank. He decided to continue with the walk but told his family thatthey would not be seeing much of him for many weeks to come. Similarly,
from a different perspective, the Head of Personnel within the State
Veterinary Service told us that she recognised, during the same weekendof 24-25 February, that there was likely to be an “exponential” increase in
the demand for vets and support staff.
Demands for manpower were indeed to grow exponentially. A single
infected premises requires, as a minimum, a vet supported by a two-person
team. After working at the infected farm, the team is classed as ‘dirty’ andhas to be stood down for a period of time. The original infected premises
generates a further set of farms to be traced and checked, each requiring
yet another veterinary team. Meanwhile, in the early weeks of the outbreak,two or three other infected premises might be added each day. This typicalscenario could increase the demand for field operatives very quickly
indeed (9.2.1).
On Monday 26 February, once the first implications of the Longtown spread
were becoming known and the first cases had been confirmed in the North
East, leave for all State Veterinary Service vets was cancelled. The Prime
Minister echoed the Chief Veterinary Officer’s appeal for vets to volunteer.
Discussions took place about how to reduce vets’ workloads to enable
them to concentrate on core veterinary tasks and about how to allocate
non-veterinary tasks to other staff. Some MAFF regional personnel weredirected to support the immediate response. However, there were still too
many non-veterinary tasks that, at this stage, had to be carried out by themost precious resource of all – the vets themselves.
By the beginning of March, there was a fast growing need for nonveterinary staff with a wide range of skills to which MAFF senior
management was not sufficiently alert. The State Veterinary Service,
particularly during the early stages, had tended to assert that it was“coping with the outbreak”, and this was not challenged from the centre.
As a result, no systematic effort was made early on to acquire additional,
non-veterinary resources.
Part of the reason for this was cultural. The State Veterinary Service valued
its independence and reflected this in its approach. There had been tension
for many years within MAFF between administrators and vets, in generalterms, no group would willingly choose to admit that it was not coping.
Indeed, the State Veterinary Service may have felt that its successful
handling of the classical swine fever outbreak of 2000 demonstrated thatit could cope.

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Later in the crisis, the NFU played an important role in the Joint
Co-ordination Centre by providing an additional source of information about
what was happening on the ground.

9.2.1 Build up of field staff
70

18. We recommend that use be made of alternative sources of
information and intelligence during crises.

60

Number50

Local police forces offered support, although there were differing views on
what their role should be. For example, the police forces of Devon and
Cornwall provided farm gate security at infected premises, viewing their role
as one of reassuring and communicating with the local community. Avonand Somerset police, on the other hand, decided that a local security firm
would handle this job better.

40
30
20
10
0

1

2

3

4

Day

Other activities expanding rapidly:

The situation was not helped by the difficulty in obtaining robust and reliable
management data. It is impossible to tackle a crisis effectively without
information about the developing situation and the performance of theemergency response measures. The management information systems
available to MAFF at the start of the outbreak were not adequate.

Slaughtermen
Vets/Animal Health Officers for surveillance
Foot patrols
Cleansing and disinfecting
Disposals
Licensing
Mapping
Epidemiology and tracings
Finance and contracting

The root of the problems can be traced back several years. The needfor better use of information technology in disease control had been
identified in the 1999 Drummond Report. Following the implementation ofa major network solution in the early 1990s, staff had become increasingly
comfortable with new technology. There was enthusiasm within theState Veterinary Service for applying new technology to disease control
and planning.

Number of
infected premises

Numbers of contiguous premises
and dangerous contacts

Numbers ofstaff

Yet the warning signs of the fragility of the State Veterinary Service
resources were there in 2000 and not picked up soon enough in 2001.
The Service was exhausted by the classical swine fever experience.
Around 80% of its vets had been drawn on to tackle an outbreak that had
consisted of just 16 cases. During the FMD outbreak that total was reachednationally on 27 February. By the end of the second week of the crisis,
there were five times as many cases. The system was rapidly becoming
overwhelmed. Clear messages about the severity of the worsening crisis
were not getting through to senior management or Ministers.
At the same time, communications from senior management downwards
also appeared to have difficulty reaching their target recipients. The
message that FMD was an overriding priority did not filter througheffectively to the rest of the Department. A human resources manager at
DEFRA told us that the Department had a ‘silo mentality’ and individual
groups and managers not directly involved with the outbreak remained
focused on their own targets. There was no incentive for them to releasestaff to help in the fight against FMD.
It is a shortcoming that there was no inbuilt process for providing analternative means of reconnaissance for MAFF’s senior management.

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Foot and Mouth Disease 2001: Lessons to be Learned Inquiry

9.3 Management information systems

However, in 1998, MAFF was set a budget that was seen as very tight.
This came on top of a series of difficult spending settlements over anumber of years. As a result, by the beginning of 2001, MAFF’s computer
systems had suffered protracted under-investment.
The earlier experience of dealing with classical swine fever had highlighted
the importance of management information systems. However,development work had to compete for a limited pool of resources andmade slow progress. When FMD broke out, MAFF’s ability to record andanalyse data about the spread and management of the disease was stillbased largely on a patchwork of unconnected systems operated byindividual regions, some of which used only paper records.
To its credit, MAFF then moved quickly. On 23 February, talks were held
between MAFF’s Information Technology Directorate and senior vets ondeveloping a database for recording information about FMD cases,
including visits and restrictions. This system later became known as the
Disease Control System. The principle behind it was the replacement ofexisting systems with a single, national database.
Building a new computer system, particularly one as large and complex
as the Disease Control System, during a national crisis was exceptionallydifficult. Months of work was compressed into two weeks. We commend
the work of those involved in achieving this.

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9
Geographical information systems

Central data entry

Accurate and up to date geographical information, including data on thelimits of infected areas, the location and boundaries of infected premises
and the spread and control of the disease, was vital to the effective
management of the outbreak. MAFF set up a dedicated team at the Page
Street Departmental Emergency Control Centre early on to handle theprovision of this information.

The Government’s Memorandum to this Inquiry (paragraph 2.8.14) statedthat the Disease Control System “…was rolled out on 6 March 2001
and…was available both locally and to the Departmental Emergency
Control Centre in Page Street”. This was an overstatement.

MAFF’s Geographical Information System was fed from two sources.
The Disease Control System, which provided information on the addressesof infected premises and the Integrated Administration and Control System,or IACS, a business system used for payment of Common Agricultural
Policy subsidies. IACS generated grid references for every field belonging
to a particular farm, but it was not designed specifically for disease
control purposes.
The main output of the Geographical Information System was a set ofdetailed maps made available centrally and to all the regions.
The Geographical Information System, and many of the decisions thatwere based on the data generated, particularly in relation to the 3km andcontiguous culls, were the subject of often fierce criticism on the ground.
As one farmer in Yorkshire told the Inquiry, “what seems to be extraordinary
is that there doesn’t seem to be any link-up with all the work that thefarmers have put in over the years doing their IACS registrations and all
the field numbers and grid references”.
Information was frequently out of date, on occasion by several years. It was
sometimes difficult to pinpoint the location of livestock accommodation
within an individual holding, or to identify the operator of the land.
There were particular difficulties with holdings covering more than one site.
MAFF’s recent attempts to rationalise the holding number system, gave riseto problems in identifying land ownership.
Many of the problems experienced by the Geographical Information Systemarose from the fact that one of the main elements had been designed for
purposes other than that of controlling a major outbreak of a highly
infectious animal disease. Many elements central to disease management,
were not critical for payment of agricultural subsidies. Getting ahead ofa disease as virulent as FMD permits little opportunity for challenging thedata. It must be right first time.
If databases constructed for other purposes are to be used to support
disease control they must be fit for that purpose in terms of design,accuracy and currency of data. However, it is preferable to design a system
for the specific purpose of disease control.
19. We recommend that DEFRA’s Geographical Information Systemand the Integrated Administration and Control System (IACS) be
designed so that they can be used more effectively for disease
control purposes.

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On 6 March, the ability of regional Disease Control Centres to enter data on
the system locally was limited. Information on how the outbreak was being
handled on the ground had to be sent to Page Street from the regions by
fax, phone or email and entered centrally.
However, by this stage, the regions were becoming increasingly
beleaguered. Information gathering slipped down the list of priorities for theteams on the ground. As a result, the information fed into Page Street waspatchy. To make matters worse, because of the relatively small number ofstaff at the centre, backlogs in data entry built up.
Central data entry was not going to be up to the task. Although MAFF again
moved quickly to enable information to be entered locally, it was not until theend of April that the last local systems in the regions could be turned off.
Even then, it took some effort to persuade certain Disease Control Centres
to abandon the local systems in favour of one national system.
For at least three critical weeks in March, despite the effort that went into
their development, systems for collecting key management information on
the handling of the disease were ineffective. They remained only partiallyeffective until the end of April 2001.
20. We recommend that DEFRA lay out milestones for investment andachievement for improved management information systems.
21. We recommend that data capture and management information
systems be kept up to date and reflect best practice.
22. We recommend that the contingency plans of DEFRA, the Scottish
Executive and the National Assembly for Wales specify themeasures needed during an epidemic to monitor progress andreport to key stakeholders.
23. We recommend that standard definitions of all importantparameters of information be agreed in advance.

9.4 The tasks on the groundOn the ground, heroic efforts were made to tackle the infection and containits spread.
In every area with significant presence of the virus a Disease Control Centre
was established. The logistical effort involved was enormous, let alone theoperational challenges facing the staff once the centres were set up. It isa tribute to everyone that so much was achieved in the face of the odds
against them.

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“If you have a guy ina uniform who looks likehe can go into the jungle
and take people out;
that’s a really positive
communication tool.”
Senior Government Official[of Brigadier Birtwhistle]

The outbreak was traumatic for everyone it touched. Many people sustained
extreme working patterns, often 12 or more hours a day, seven days a week
for long periods. They absorbed a great deal of emotion from farmers andothers who were in considerable distress. Many staff, often at quite juniorlevels, endured abuse and intimidation.

Training on how to cope with stress was patchy. As the outbreakprogressed, counselling and welfare provision was made increasingly
available. However, it was not until April that some managers began tounderstand the need for staff to take a break from their duties.

Regional Centres received many offers of help from the local community.
However, there was no mechanism in place to manage this response,
so many of them were unable to take up these offers. This gave rise to
frustration and some resentment among local people.
24. We recommend that contingency plans at regional level include
mechanisms for making effective use of local voluntary resources.
Efforts were focused, particularly in the early stages, on obtaining the large
numbers of veterinary and administrative staff, and the goods and services
necessary to mount an effective response to the disease.
Financial control systems were not up to the task. MAFF frequently had
to pay over the odds in exchange for speed of delivery. The Department
strayed from strict observance of its normal guidelines when awarding
contracts.
The National Audit Office report contains a more detailed account of this
aspect of the outbreak.
25. We recommend that dedicated control systems be ready for use
in a sustained emergency, and regularly tested as part of thecontingency planning process.
26. We recommend that the processes for procuring and delivering
the necessary goods and services from external sources during
a crisis be reviewed. Systems should be tested to ensure they cancope with unexpected increased demands.
27. We recommend that priority be given to recruiting accounting andprocurement professionals to operate in emergency control
centres during a crisis.

Foot and Mouth Disease 2001: Lessons to be Learned Inquiry

Setting up a Disease Control Centre was a complex operation.
Considerable human, financial and material resources needed to bebrought together very quickly.

Some suffered breakdowns. Some are still suffering.

Disease Control Centre staff were trained mainly on the job. At the startof the outbreak, there was a lack of clarity over roles. This was largely
resolved by mid-April. However, it proved difficult in practice to disseminate
lessons learned or best practice developed, because human resource
management was focused principally on staff recruitment. Some goodpractice was developed, such as regular telephone conferences for
Regional Operations Directors.

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9.4.1 Setting up a Disease Control Centre

For example, during the outbreak, the veterinary staff available to theCarlisle Centre increased from six to 200. Administrative staff rose from31 to 250. At the peak there were 400 technical staff, compared to five
before the outbreak. An entirely new force of 200 military personnel was
brought in.
By the time the effort was at its peak, in April 2001, the Carlisle Disease
Control Centre had acquired the following assets:
• 156
• 217
• 60
• 60
•8
•7
• 102
• 22
• 300
•6
•8
•5
• 689
• 114

Portacabins & toilet blocks
Articulated wagons
Eight-wheeler skip wagons
Eight-wheeler rigid wagons
Six-wheeler wagons
Four-wheeler wagons
Telescopic handlers
Low loaders
Hire cars
Drinks machines
Microwaves
Main servers
Computers
Printers

• 720
• 838
• 254
• 316
• 114
• 67
• 31
• 16
• 15
•2
• 62
• 52
• 42

Desks
ChairsCabinets
Pedestals
Fans
Drawers
Air conditioning units
Refrigerators
Book cases
Boilers for coffee etc
Fax machines
Server hubs
Photocopiers

It was not just a question of getting hold of people and equipment, butalso building the infrastructure. It needed telephone lines. It needed
services such as electricity, water, gas and waste handling. Financial
and personnel systems had to be put in place, including support
mechanisms for staff many of whom were working under intensepressure. It needed effective channels of communication with the media
and the local community. New staff needed basic training. The managers
had to bring the whole thing together to make it work. Many staff were
strangers to each other.
Setting up a Disease Control Centre represented a major achievement.
Many people told us of their admiration and respect for the effort madeby local staff. Nevertheless, the magnitude of the task reinforces several
themes of our findings, including: the importance of thoroughcontingency planning involving everyone with an interest; the need for
Government to mobilise its wider resources in a joined-up manner;
the imperative for first-class communications with people in the local
community affected by a crisis.

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“I worked at one time oranother with six slaughter
teams. All were at least
adequate and several ofthem were absolutely firstclass. .... Slaughter
seemed to have processedvery smoothly, and many
owners commented on thesmoothness and humanityof the operation.”
Temporary Veterinary Inspector
employed in Gloucester,
19 March – 19 April 2001

Data supplied by DEFRA indicate that mean report-to-slaughter times werein the order of three days in the first weeks of the outbreak. The growing
shortage of ‘clean’ veterinary resources limited the ability to maintainsurveillance and tracing activity. In Cumbria, in an attempt to manage
the scarcity of vets, a ‘triage system’ was introduced. This meant that,
if a reported case with classic symptoms was within 3km of an existing
case, then a less than fully-quarantined vet would be allowed to attend.
On 10 March the Chief Veterinary Officer reduced the stand-down time fordirty vets from five to three days, stating that this was an ‘informed’decision not simply a response to shortage of vets.

9.5.1 Slaughter and disposal of animals
600,000

400,000

200,000

0

25/3

The evidence presented to us did not confirm that valuation contributed
significantly to delay. FMD status reports to the Joint Co-ordination Centre
and COBR do not mention valuers as a problem whereas they do mention,for example, shortage of vets and slaughter equipment.

Before the introduction of slaughter on suspicion in late March there were
delays of up to 96 hours while test results were awaited in around 12% ofcases where diagnosis was uncertain.

18/3

But there were problems of delay. In the first few weeks of the outbreak, theideal, only later made explicit, of slaughtering within 24 hours of report wasvery far from being met. In the first four weeks, one quarter to one third of
infected premises were culled within 48 hours of owner report and only one
in 10 was culled within 24 hours. Sometimes reports came in after dark:
animals that were farmed extensively had to be gathered up; stockades had
to be built; health and safety assessments had to be undertaken. Stock had
to be valued and valuations were often disputed even though Veterinary
Instructions limited the permissible delay to at most 12 hours.

The valuation process and the financial implications for compensation are
discussed in greater detail in the National Audit Office report. We return tocompensation and insurance in section 17.

11/3

Many of the circumstances during the 2001 epidemic were distressing for
all concerned, including the farmers and their families whose animals werebeing destroyed, the vets supervising the destruction, the slaughtermen
operating in conditions far removed from the automation of the abattoir.
We heard harrowing accounts from many individuals during our regional
visits. In some instances, many of which were reported in the media,
slaughter was poorly carried out. The RSCPA expressed particular concernthat piece rate payments to slaughtermen encouraged them to cut corners.
The RSPCA received 130 complaints and investigated 83. While the aim
must be to eliminate any cause for complaint, we believe these relatively
low numbers show that in the majority of cases an unpleasant task was
conducted effectively, often in very difficult conditions. Many farmers praised
the manner in which the slaughtermen did their job. One submission said
‘there were Government inadequacies in every area bar slaughter’.

The standard valuation system was introduced to address a problem that
may not have existed to any significant degree. It generated a new problem
in its own right.

04/3

The basis of the control strategy was stamping out. This involved culling
infected animals ‘as soon as possible’ coupled with the tracing andslaughtering of dangerous contacts, that is, animals thought to have been
exposed to the disease. Other animals within a surveillance zone aroundthe infected premises were then monitored closely. The Veterinary
Instructions refer to ‘slaughter with all practical speed’ and ‘immediateslaughter’ following confirmation. There was perhaps an unstatedassumption that confirmation itself would be speedy. In the early weeks,nothing was explicitly said to emphasise the importance of quick report-toslaughter times. We discuss in section 10 the consequences of this.

25/2

Unprecedented numbers of animals were slaughtered during the outbreak,not only as a direct result of the disease control culling strategies but also
because of the welfare problems caused by movement restrictions. The
Livestock Welfare (Disposal) Scheme is discussed separately in section 12.7.

Nonetheless, it was suggested during March 2001 that valuation wascausing delay. As a result, a system of standard values was introduced.
Legislation did not allow compulsory standard values. The standard values
were pitched generously to encourage farmers to take up the new system.
In the event, only 4% of farmers made use of the standards. We heard
evidence that the most significant effect of the standard valuation system
was to inflate the value of culled animals, increasing the amount ofcompensation that had to be paid.

Number of animals

9.5 Slaughter policy and practice

Week ending
Slaughtered76

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Awaiting slaughter

Disposed

Awaiting disposal

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The RSPCA and the Humane Slaughter Association were present atsome culls. A suggestion that slaughter should be open to independent
observation by such organisations also warrants consideration provided
that, in practice, this would not create additional potential for delay.
28. We recommend that DEFRA revise its guidance and instructions
for slaughter.

500,000

5000

400,000

4000

300,000

3000

200,000

2000

100,000

1000

0

01/4

6000

25/3

600,000

18/3

7000

11/3

700,000

Number of vets

9.7.1 The growing demands of slaughter, 20 February to 1 April

04/3

Although relatively few submissions to the Inquiry raised the practicalitiesof the slaughter processes, some made proposals to enhance the efficiency
and effectiveness of any future slaughter scenario. These include:
conducting an audit of slaughter capacity, including those licensed to killlarge animals, with a view to maintaining up-to-date records to draw on inan emergency; developing further a strategy for killing in the field where thisproves necessary; considering an ‘ID’ or ‘green card’ system for licensed
slaughterers; and banning the use of shotguns.

By Sunday 11 March, three weeks after the disease had broken out,
164 cases had been confirmed. A number of disease clusters had begun
to emerge across the country (9.7.2). Disposal problems were mounting,particularly in Cumbria, where over 40,000 carcasses lay rotting on the
ground. The rate of increase of animals awaiting slaughter was vastly
outstripping the growing number of vets being deployed (9.7.1). The logisticalmachinery for dealing with the epidemic was inadequate for the task.

25/2

As the realisation grew that delays were occurring and contributing to
spread, the pressure for further slaughter intensified. Slaughter on suspicion
removed both the need to tie up a vet in surveillance of uncertain cases
and the wait for test results. In mid May some 90% of slaughter on
suspicion cases in sheep had been tested. Of these, between 5-10%
tested positive. Slaughtering of stock on contiguous premises only
occurred if the slaughter on suspicion case tested positive. The slaughteron suspicion policy put vets under pressure. We heard from many whowere concerned at the number of animals culled on suspicion that
subsequently tested negative.

9.7 Under control?

Number of animals

Other parts of the Veterinary Instructions, relating to the presence ofveterinary officers at slaughter, were compromised in some areas by scarce
resources. The Royal College of Veterinary Surgeons submission to theInquiry says that it was instrumental in reversing an attempt to reduce
supervision of slaughter to as little as one Temporary Veterinary Inspector
per 10 farms. A submission from a Temporary Veterinary Inspector madeclear that the Royal College of Veterinary Surgeons accepted that somecompromise of best practice was necessary given the other pressures ofthe outbreak. We also accept that there had to be some compromise given
the unprecedented nature of events. But we believe that better contingency
planning and speed of response could have limited the scale of the culling
required and the associated need to compromise on good practice.

0

Week ending
Slaughtered

Awaiting slaughter

Number of vets

The process of tracing movements from Longtown market had been slow.
MAFF had issued a news release the previous Thursday, 8 March, asking
farmers for help in tracing sheep movements from Longtown as it believedthat there was a substantial number of sales which took place ‘out of thering’ by private transaction and which may not have been recorded. In aninternal minute to officials on Friday 9 March, the Chief Veterinary Officer
said it was difficult to ascertain the extent of the FMD outbreak and pointed
to the following two weeks as being crucial in determining whether it would
continue to escalate or level off.
On Sunday 11 March, the Minister of Agriculture, Nick Brown, during aninterview on the BBC’s Breakfast with Frost programme, made a numberof comments to the effect that the disease was under control. Indeed hestressed that he was “absolutely certain” that the disease was undercontrol. A transcript of the interview is published in the CD-ROM annexes.
The remarks were widely reported in the media on Monday 12 Marchand subsequently.
It is understandable that the Minister should have sought to reassure thepublic about control measures already in place. However, his comments did
not reflect the situation on the ground. The disease was, at this stage, outof control by any reasonable measure (9.7.2). Thirty-four cases of FMD had

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9.7.2 Map of the disease as at 0800 11 March 2001
Confirmed Cases

been confirmed in the two days leading up to the interview. A further 24
would be confirmed on 11 March. On 12 March, the day after the interview
MAFF scientists, reporting internally the findings from their predictive
computer models running in the previous week, made a tentative
assessment that there might be 1,000-2,000 cases in total.
The Minister’s comments contributed to the loss of trust on the part of ruralcommunities. Many people, including some of those directly involved inmanaging the outbreak, still find it difficult to reconcile their experiences
during this period with the notion of the disease being under control. The
following extract comes from the transcript of one of the Inquiry’s public
meetings: “…night after night on television news we had Jim Scudamore or
Mr Brown, sometimes the Prime Minister, Professor King, it is under control,
it is completely under control, it is definitely under control and we felt
absolutely insulted and patronised by these lies that we were told.
And furthermore it did a great deal of lasting damage because it meant that
we are all now so completely cynical about anything the Government says.
It has destroyed trust, trust takes years and years to build up and it can be
destroyed overnight, and that is one thing that happened.”
The Minister’s comments also sent a message to Government as awhole that the outbreak was being comprehensively managed by MAFF.
It was another 11 days before COBR was opened (section 11).

74 Cases
1 Case

9.8 The impact and timing of the involvementof the military
3 Cases

Of the many questions that were posed up and down the country at
our public and round-table meetings, few were asked more often than:“Why, given the state of the disease, and the failure of the existing
administrative structures to cope, were the armed forces not brought insooner?” It is a compelling question to which there is no obvious answer.

1 Case3 Cases

9 Cases

1 CaseWe received many views. The delays may have been due to a desire to
avoid sending negative political messages about the gravity of the crisis.
They may have been caused by MAFF’s reluctance to ask for help. Or they
may have occurred simply because central government did not appreciate
the sheer size of the task.

4 Cases
7 Cases

1 Case1 Case7 Cases

1 Case23 Cases

3 Cases

Whatever the reason, the arrival of the military heralded a positive stepchange in the management of the disease.
In fact, the Ministry of Defence had been alerted on 20 February to thepossibility that the armed forces might be called upon to help. In response
to a request from MAFF, the Ministry of Defence deployed a limited numberof military vets on 14 March. By this time, however, the perception among
the public and in the media was that the disease was running wild. Large
numbers of decomposing carcasses were awaiting disposal, giving rise toboth a general risk to public health and great distress for those directly
affected. Calls for full-scale military deployment were growing.
Over the weekend of 17-18 March, two officers with expertise in logistics
were despatched to MAFF headquarters to scope out the contribution thearmed forces might make. Although the need to inform local military80

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commanders to ensure that training manoeuvres did not aggravate thespread of the disease was set out clearly in the existing contingency plans,
references to the role the armed forces might play in disease control werelimited to the following: “If any emergency should arise where assistancefrom HM Forces is required, Head Office should be consulted immediately”– Veterinary Instructions chapter 3, paragraph 9.
The civilian authorities may have held the view that what the armed forces
could best provide was large scale manpower to assist with slaughter,burial pits and disposal. In fact, that was not the case. There were readysources of access to those. Brigadier Birtwhistle who eventually led theefforts to tackle the disease in Cumbria told the Inquiry, “that is what the
Yellow Pages is for”. What was really lacking was logistical expertise and,more generally, the leadership and management skills needed to handle
a crisis. As one farmer told the Inquiry, “…one of the first things the army
did when they moved in here was to find knowledgeable local people, theyused local contractors, local hauliers and they used their knowledge to run
their operation as efficiently as possible.”
The two officers’ work over that weekend resulted in the deployment ofmilitary personnel in Devon on 19 March and Cumbria on 21 March, to befollowed by further deployments in other regions. Critically, a Headquarters
element of 101st Logistical Brigade was despatched to MAFF HQ on
23 March to assist with logistic co-ordination and planning. The Commanderof the Brigade was subsequently appointed Deputy Director of Operationsin the Joint Co-ordination Centre on 26 March.
The armed forces in the regions worked alongside the Regional Operations
Directors and the existing Divisional Veterinary Managers. This approach
was, in the worst affected areas, finally to bring the disease under control.
This could and should have been done earlier.
However, we have been told by several senior officers that there may becircumstances under which the military is unable to provide support on thesame scale as during this FMD outbreak. Military duties may mean that theavailability of the armed forces to assist with the management of domestic
crises is restricted.
29. We recommend that as part of the mechanisms to trigger thewider Government response, the military be consulted at theearliest appropriate opportunity to provide advice and consider
the nature of possible support.
30. We recommend that as part of its contingency planning, DEFRA,
the Scottish Executive and the National Assembly for Wales,
working with the Civil Contingencies Secretariat, examine thepracticality of establishing a national volunteer reserve trained
and informed to respond immediately to an outbreak of infectious
animal disease.

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Foot and Mouth Disease 2001: Lessons to be Learned Inquiry

9.9 Scotland
In Scotland, action was more rapid. The first outbreak was confirmed in
Lockerbie on 1 March. Immediately, an operation swung into action to
manage the emergency. This was, in our view, an example ofthe disease outbreak being handled as effectively as possible given thecircumstances. Without doubt, the experience of the Lockerbie air disastersome 12 years earlier facilitated cross-agency working. This was not,however, the critical factor. Other areas of Britain without such experienceswere effective – Staffordshire and Lancashire being good examples. The
components of the effective response shown in Scotland were as follows:
proper planning and rehearsals; access to all the senior people in therelevant agencies; short chains of command up to and down from thecentre; decision making devolved as far as possible to local level; goodmanagement information systems; effective computer systems and links;
effective communications internally, and externally both with the media andwith key stakeholders.
In section 10, we set out the role that the Scottish Executive played in thedevelopment of the 3km sheep cull north of the border. Some people haveargued that, given the devolution on policy on animal health matters to
Scotland, there should also be devolution of the role of the State Veterinary
Service. On the face of it, it is an unusual arrangement whereby policy on
animal health is devolved to Edinburgh, whereas field operations work is still
governed from London. However, infectious diseases do not recogniseinternal boundaries and borders. We believe therefore that the existingarrangements and a national State Veterinary Service should be maintainedand do not recommend any further devolution of the Service in Scotland.
Sensible local delegated responsibilities are already in place and worked
well during the 2001 epidemic.

9.10 WalesThe National Assembly for Wales has published its own assessment of theoutbreak and lessons to be learned (in the CD-ROM annexes). The National
Audit Office’s summary has also been reproduced, in the appendices to theInquiry Report. In contrast to Scotland, the National Assembly for Wales
lacked full legal powers to take decisions alone on disease control. It wasable to make legislation separately on imports and exports but had no roleto play in the declaratory orders designating infected areas in Wales. It had
no power to make decisions on animal movement restrictions. In
accordance with the Animal Health Act 1981 and the Transfer of Functions
Order 1999 (SI999/672), the National Assembly for Wales legislated jointlywith the Department, nationally, to enable a consistent and uniform
approach to be undertaken by the enforcement bodies.

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“When agriculture suffers
disease or other shocks
the knock on effect to therest of the rural economy
is sharp and severe.”Country Land and Business
Association

This was a significant source of tension. The then Minister of Rural Affairs,
Carwyn Jones, told us that he was seen as politically responsible for the
management of the crisis in Wales even though, constitutionally, he wasnot. He had held daily press conferences for the first month and regularly
thereafter. The National Assembly for Wales had also set up telephone
helplines about the outbreak. The fact that information was being imparted
in this way reinforced assumptions that the National Assembly for Wales
was taking decisions and had legal powers to act alone.
The National Assembly for Wales has identified several occasions, particularly
with regards to changes to the licensed movement regime, when it failed tofind out about significant policy decisions or developments until the last
moment, leaving little time to prepare staff on the ground or brief Assembly
Ministers. Despite the presence of Assembly staff in London acting as a linkwith departments in London and COBR, the pace of developments meantthat communications were sometimes confused. The Minister told us that heneeded the same legal powers as his Scottish counterpart, although this was
not a call for a separate State Veterinary Service.
Political responsibility without power is uncomfortable. We understand
why the National Assembly for Wales believes that it should be given
constitutional powers, and the appropriate resources for animal healthissues related to disease control in Wales. We are not convinced, however,that further fragmenting disease control policy is the best way forward. As
we have said in relation to Scotland, exotic animal diseases, such as FMD,
do not respect borders and so there is a strong argument in favour ofretaining a uniform policy of disease control in England and Wales, which
can be directed from the centre but adapted to local circumstances.
The relationship between the National Assembly for Wales and DEFRA
needs to revisited, however, in the context of contingency planning for
future outbreaks to ensure that there are clear lines of responsibility,
accountability and communication.
31. We recommend that the National Assembly for Wales and DEFRA
develop a comprehensive agreement for co-ordinating themanagement of outbreaks of infectious animal diseases in Wales.
This should cover all aspects of a disease outbreak, delegating
responsibility locally, where appropriate, and providing clear lines
of communication and accountability.

9.11 Wider rural impact and its costs
Alongside developments in disease control there was a growing recognitionof the wider impact that the disease and the control measures were having.
In particular, the closure of footpaths was having a considerable impact on
tourism and the wider rural economy. “About two weeks in to the outbreak,the closure of footpaths outside the Infected Areas had provoked regional
colleagues to contact the Department of Environment, Transport and theRegions expressing worries about the potential impact of this policy. At thisstage, there had still been the expectation that the outbreak would be overby the early summer so discussion with concerned parties such as the
National Trust had focused on how to encourage visitors to return once theoutbreak was over.” Senior Official, Department of Environment, Transport
and the Regions.
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Farming and tourism are interdependent and interlinked with the wider rural
economy. Rural tourism and other businesses are often dependent onaccess to a landscape heavily influenced by farming. Many rural areas havea narrow economic base, dominated by farming and tourism; and manyrural businesses are vulnerable, for example where they depend on
passing trade.
In addition to the direct impact on hotels, holiday lettings and visitor
attractions, other examples of rural activity were affected by FMD control
measures. Village services such as pubs, shops and post offices; voluntaryorganisations dependent on countryside recreation, leisure activities andoutdoor sporting events all suffered.
Section 14 discusses estimates of the overall economic costs of theoutbreak.
Some of the hardest hit regions have below average incomes. Devon andCumbria were hit particularly hard, both because of the extent of theoutbreak and the relative importance of tourism compared to livestock inthese regions. Tourism contributes 6% to the GDP of both Cumbria andDevon compared to agriculture, arable and livestock, which contributes 4%.
In early April 2001, the Department of Environment, Transport and theRegions asked the Government Offices in England to commission surveys
to assess the economic impact in their regions. Some impact assessment
work was also done by the Department for Culture, Media and Sport,
based on tourism surveys. Over 40% of businesses in Cumbria, Devon and
Cornwall surveyed in April/May 2001 reported that they had been adversely
affected, compared to just over 30% in the South West and North West asa whole. The GDP loss to the whole of the South West in March and April
was estimated at just over 3%, while lost turnover was around £760m.

The Rural Task ForceAs the disease spread, an appreciation grew of the wider implications forthe rural economy. In response, the Government established the Rural Task
Force which met first on 14 March. The Rural Task Force included
representatives of a range of Government departments and agencies, andof stakeholders from farming, tourism, local government, small business,conservation and community interests. Its remit was to consider theconsequences of FMD for the rural economy, both immediately and in thelonger term, and to report to the Prime Minister on appropriate measures.
The final report of the Rural Task Force ‘Tackling the Impact of Foot andMouth Disease on the Rural Economy’ was published on 18 October.
Throughout our Inquiry many people have commented that the Rural Task
Force played a significant role in increasing wider awareness of the impactof FMD beyond just the farming community. In particular the Rural Task
Force played an important role in introducing a risk based approach to
the re-opening of footpaths and tourist attractions closed as a result of
the disease.

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Both the Department of Environment, Transport and the Regions andstakeholders welcomed the Rural Task Force forum and felt that it had
made a valuable contribution. However, it was not seen as the wholeanswer. “There should have been some mechanism to enable a wider
consideration of the policy issues. Discussion of policy issues elsewhere
had usually been firmly focused on fighting a war against FMD, without
full consideration of the potential impact on the rural economy.”
Senior Official, Department of Environment, Transport and the Regions.
32. We recommend that, where the control of exotic animal diseases
has wider economic or other implications, the Government ensurethat those consequences for the country as a whole are fully
considered.

9.12 The Regional Operations Director systemstrengthened
As the disease progressed, it became increasingly clear that the policy ofplacing overall responsibility for regional management of the disease in thehands of the local Divisional Veterinary Manager was not working. This was
not due to any inherent lack of capability on the part of the individuals
concerned. Rather, the failure to cope with an outbreak of this scale meantthat it was important to avoid wasting vital veterinary resources on workthat could be done by other, non-specialist, staff or contractors.
Remedying this situation became pressing.

Preparations should be made, through the contingency planning process,to appoint Regional Operations Directors very much earlier, ideally assoon as an outbreak is identified. The Permanent Secretary of DEFRA
told the Inquiry that, in future, Regional Operations Directors would be
employed immediately.
33. We recommend that contingency plans provide for early
appointment of Regional Operations Directors or their equivalent
to take on operational management of a crisis. There should bea cadre of senior managers – not all of whom need come from
central government – who can fulfil the role of the Regional
Operations Director in an emergency and who should be trainedin advance.
In addition, although Regional Operations Directors made a positive
contribution in every case, their effectiveness depended on the individual
calibre of those appointed. As the Permanent Secretary of DEFRA, put it,“outstanding individuals could achieve outstanding results”. We believethat proper training and sharing of expertise would allow individual calibre,
and hence effectiveness, to flourish. This should include training incommunication with the media and local communities. The role of theRegional Operations Director is focused very tightly on local delivery. He or
she represents the sharp end of the Government response in the regions.

The desirability of identifying an individual to manage regional stakeholders
and external relationships was recognised by MAFF senior management
early on. Given the need to release veterinary resources, this role developed
to encompass the management of all non-veterinary work in the regions,
including administration and media relations.
The first Regional Operations Directors, both MAFF senior civil servants,
were appointed to head the Disease Control Centres in Cumbria and Devonon 19 March. Further appointments were made to a number of other
Disease Control Centres over the following days. The introduction of theRegional Operations Directors made a big contribution to the fight against
the disease.
Relationships within the Disease Control Centre were often tense. There
were multiple lines of control, with administrative, veterinary and militaryelements. Finding a way through and managing these tensions successfully,
depended very heavily on the personal abilities of senior management,
particularly the Regional Operations Directors.
Regional Operations Directors often held their posts for relatively shortperiods. For example, the first director at the Carlisle Disease Control
Centre remained in post for just six weeks. We commend this practice,on the basis that the demands of the job were such that individuals needed
to be rested in order to remain effective.

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