Volume 1: Findings and Conclusions
13. What went right and what went wrong?
The Government's response
Eradication of BSE
Possible transmissibility to other animals
Possible transmissibility to humans

1152 In earlier chapters we have seen how the emergence of BSE confronted government with three challenges:

• how to eradicate BSE in cattle;
• how to address the possibility that BSE might be transmissible through animal feed or otherwise to other animals; and
• how to address the possibility that BSE might be transmissible through human food or otherwise to humans.

1153 Those chapters summarise our discussion in Volumes 3 to 9 and 11 of the adequacy of the response to those challenges, having regard to the state of knowledge at the time. In the remainder of this chapter we draw attention to the major policy decisions in relation to these matters, which we have concluded were appropriate. We have shown that shortcomings attended the introduction, implementation, enforcement and monitoring of the measures pursuant to these decisions, and we identify some underlying features which led to shortcomings.

Eradication of BSE

1154 Banning the incorporation of ruminant protein in ruminant feed was the correct policy to adopt in order to eradicate BSE. Had it been fully implemented it would probably, by today, have achieved its object. As it is, it brought about a massive reduction in the number of new cases of infection so that, by 1996, it was apparent that the epidemic had been brought under control.

1155 Precautionary measures could have been taken to address the possibility that BSE would prove to be maternally transmissible. Maternal transmission, of itself, might prolong but could not perpetuate the disease. It was reasonable to refrain from culling the offspring of BSE dams unless and until it was shown that maternal transmission was taking place on a scale that justified this. There was room for argument as to whether or not breeding from the offspring of BSE dams should be discouraged or forbidden, but this was not a major policy issue.

1156 The possibility that BSE might be horizontally transmissible was addressed by:

• guidance to farmers on preventing other cattle from coming into contact with the placenta of a calving dam; and
• a ban on the use of protein derived from Specified Bovine Offal (SBO) as fertiliser.

Possible transmissibility to other animals

1157 Although the primary motivation for the compulsory slaughter and destruction of cattle showing signs of BSE was the protection of human health, it had the added benefit that the carcasses of these animals could not be rendered for animal feed. Thus this measure was in part a response to the possibility that BSE would transmit to other animals.

1158 The measure specifically adopted to address this possibility was the animal SBO ban. The object of the ban was to prevent the inclusion in animal feed of protein derived from SBO. The leading pet food companies and the bulk of the animal feed industry had previously adopted this ban on a voluntary basis. MAFF made it compulsory after experimental transmission to a pig by inoculation had been achieved. This ban affected predominantly the content of pig and poultry feed. Although no express application of the ALARP principle was involved in this decision, we consider that, if effective, it would have reduced the risk of transmission of BSE to other animals through feed as low as was reasonably practicable, having regard to:

1. the reasonable belief that BSE was unlikely to be zoonotic;
2. the fact that there was no history of transmission of TSEs to, or experience of TSEs in, either pigs or poultry; and
3. the economics and waste disposal consequences of going further and imposing a total ban on including any animal protein in animal feed.

1159 Measures were also taken to reduce the risk of transmission of BSE to other animals through veterinary medicines. Guidelines were issued to manufacturers of both human (see below) and veterinary medicines, which advised that certain bovine products should not be used in the manufacture of certain medicines, suggested that action should be taken to reduce contamination in the collection and production processes, and advised on sterilisation or discarding of the equipment used.

Possible transmissibility to humans

1160 The principal policy decisions which addressed the possibility of transmission of BSE to humans through food were those to introduce:

1. compulsory slaughter and destruction of cattle with symptoms of BSE; and
2. the human SBO ban.

1161 These were two vital measures for the protection of human health. Each was introduced at a time when the possibility that BSE might be transmissible to humans in food was considered remote. On that basis we consider that they constituted a proportionate response that satisfied the ALARP principle, albeit that the policy decisions did not result from the application of that principle. It is necessary, however, to go on to consider the decisions about which tissues should be proscribed as SBO.

1162 For the reasons that we have set out earlier, we consider that the decisions about what should and what should not constitute SBO were reasonable, having regard to what was known at the time. It should be recognised that in drawing the line so as to exclude the abomasum, from which tripe and rennet were derived, and offal from calves aged less than 6 months, commercial considerations are likely to have weighed in the balance.

1163 The possibility that BSE might be transmissible to humans through non-food products was addressed by issuing guidance to a number of relevant industries about the potential risk, including occupational risk, from the use of bovine products. Perhaps the most important was that issued to manufacturers of medical products, which, as we have noted, applied equally to medicines for human use and veterinary medicines.

1164 The potential risk from occupational contact with bovine materials was also addressed by advice and guidance to many of those whose jobs brought them into contact with such materials. This advice was developed and issued over a period of time.

1165 The final policy decisions with which we are concerned were those reached on 20 March 1996:

1. a requirement that carcasses from cattle aged over 30 months be deboned in licensed plants supervised by the Meat Hygiene Service (MHS) and the trimmings classified as SBO; and
2. a prohibition on the use of mammalian MBM in feed for all farm animals.

1166 If there had been no need to consider practicality or public perception, a case could have been made for saying that the deboning scheme satisfied the ALARP principle. In the event it was not viable. On this occasion the wrong policy option was selected.

1167 The prohibition on the use of mammalian MBM in feed for all farm animals was we consider an appropriate response under the ALARP principle to the change in knowledge of the risk posed by BSE to humans, consequent upon the conclusion of the Spongiform Encephalopathy Advisory Commitee (SEAC) that the cases of vCJD were probably linked to exposure to BSE.