Volume 3: The Early Years, 1986-88
2.
Dissemination of information
Dissemination of information - a chronology
June 1986
December 1986
January 1987
February/March 1987
May 1987
Spongiform encephalopathy in a nyala
2.15 Before BSE in cattle was identified, a single case of a TSE was identified in an animal of the same family at a zoo. In late June 1986, several months prior to the CVL's examination of the cattle brain samples forwarded to them by the Wye and Langford (Bristol) VICs in November and December, Dr Jeffrey at the CVL's Pathology Department received tissue sections from the brain and cervical spinal cord of a nyala. 1 A post-mortem examination of the nyala had been carried out by Mr Geoff Holmes of the Winchester VIC. The nyala had exhibited unusual nervous symptoms for two weeks prior to being 'euthanased' at Marwell Zoological Park. 2
2.16 Dr Jeffrey's diagnosis was that he had detected a spongiform encephalopathy, 3 so-called because under a microscope, the affected areas of the brain have a 'spongy' appearance owing to the presence of numerous small holes, or vacuoles. Dr Jeffrey told the Inquiry that the similarity of the nyala brain section to natural sheep scrapie was 'striking', with the lesions being particularly florid. As far as he was aware, this was the first recognised case of a TSE-like disease in a bovine species. 4
2.17 Following this discovery, Dr Jeffrey drafted a scientific paper intended for journal publication in the Veterinary Record. He believed that his paper, entitled 'Scrapie-like Disorder in a Nyala', was submitted for publication in autumn 1986, although he could not be sure of the date. 5 Dr Jeffrey told us that all manuscripts for publication were customarily reviewed by line managers and also by other colleagues in the Department. Finalised manuscripts were submitted to the Head of Department, in this case Mr Bradley, before being forwarded to the CVL Directorate, who would in turn submit the article to the MAFF Animal Health Group at Tolworth (see paragraphs 2.12-2.14 above). Dr Jeffrey said that prolonged intervals could elapse before permission was received to submit a paper to a scientific journal. 6
2.18 Dr Jeffrey sent sections of the nyala brain, and later a copy of his paper, to Dr Hugh Fraser of the Neuropathogenesis Unit (NPU) in Edinburgh for his comments. 7 Similarly, slides of the nyala brain were sent to Dr Richard Kimberlin, also of the NPU. Dr Jeffrey could neither recall the exact dates the material was sent, nor find any supporting documentary evidence, but said he recalls sending at least the brain sections in 1986. 8 Dr Kimberlin was certain that he did receive the slides, which he then passed on to Dr Fraser, probably during the last quarter of 1986.Dr Kimberlin vividly recollected seeing the slides because the pathology was so striking. 9 The fate of Dr Jeffrey's paper is considered further below.
Communication about BSE within MAFF
10
2.19 The initial communication between the Pathology Department and other staff in the CVL regarding a possible TSE in cattle is largely undocumented. We think news of the disease probably spread within the CVL at about the time of Mr Bradley's confidential minute to Drs Shreeve and Watson on 19 December 1986. That minute enclosed a report which diagnosed a spongiform change in a bovine brain. 11
2.20 After Mr Rees (the CVO) was told of the disease in December 1986, he informed Mr Jack Hepburn, the Under Secretary in charge of the Animal Health Group. 12 The latter was succeeded in the course of that month by Mr Alistair Cruickshank and passed the information on to him. Mr Cruickshank's recollection was that the disease was yet to be given a name and that very little was known about it. Only a very few animals had contracted it. The vets were trying to establish the nature of the disease, but it was clear nothing could be done until more had been learned about it. 13
A confidential communication
2.21 During a brief private conversation with Mr Wells at a meeting of the British Neuropathological Society in January 1987, Dr Fraser of the NPU recalls he was told in confidence that the CVL was beginning to see 'scrapie in cattle'. This appears to have made little impact on Dr Fraser, who was perhaps somewhat sceptical, for he gave no further thought to the conversation over the next six months. 14 Mr Wells, who could not recall the conversation but did not doubt that it took place, said that he was not, at that time, considering involving the NPU in work on BSE. 15 Dr Fraser could not recall whether he and Mr Wells had discussed the possibility of conducting transmissibility studies at that time. 16
2.22 At a meeting in Paris in December 1986, Dr James Hope of the NPU had described, for the first time, a fast method for detecting scrapie-associated protein, which enabled confirmation of a TSE within four hours. 17 Dr Fraser did not mention that method, known as the western blotting technique, to Mr Wells during their brief conversation. Although aware of the technique, Dr Fraser was not familiar with it and had not performed it himself. 18
2.23 It is not clear to what extent Dr Fraser discussed Mr Wells's information with his colleagues at the NPU. 19 It seems that it was passed on to at least Dr Alan Dickinson. Dr Dickinson, Head of the NPU, told us that the news had a considerable effect on him in terms of what it could mean for the NPU, a unit specialising in research on spongiform encephalopathies. 20
2.24 However, Dr Hope did not become aware of the new disease until almost a year later, in the autumn of 1987, when Dr Watson, Director of the CVL, made a visit to the NPU in September to meet with Drs Fraser and Kimberlin. 21
2.25 At the beginning of the year both Mr Bradley and Dr Watson gave some thought to consulting the NPU regarding their findings. Dr Watson was familiar with the work undertaken by the NPU and the expertise available to it, having been a member of a visiting group in 1985 charged with reviewing the facility. 22 Similarly, Mr Bradley was acquainted with Dr Fraser and his work through attendance at veterinary meetings. 23 However, the two ultimately thought that the NPU's involvement would be premature given the small number of cases involved at the time. 24
Publication in Vision considered but not pursued
2.26 During February the CVL Virology Department examined homogenised brain tissue from one of the affected cows for scrapie-associated fibrils (SAFs). 26 These are small, abnormal fibres, the presence of which in treated brain extracts was recognised to be one of the identifying features of a spongiform encephalopathy. Investigations into possible genetic causes of the disease were also under way. 27 In a note to Mr Wells on 4 February, Mr Bradley commented on the view that BSE was a scrapie-like disease: 'Your view and mine is to keep an open mind.' 28
2.27 By 18 February neuronal vacuolation had been found in a case received by the Truro VIC. Meanwhile, study of the earlier brain extract by electron microscopy showed fibrils that resembled SAFs. Mr Bradley raised with Dr Watson the issue of whether MAFF should play the matter 'close to the chest' or inform the VI Service of the new disease through an article in Vision, the scientific newsletter which circulated to all VICs. Mr Bradley referred to the conflict between not wanting MAFF to miss suspected cases, yet not wanting the 'ultra-smart' to release prematurely information of 'dubious value' to the public, before enough was known about the disease to answer some of the vital questions that would be posed. 29
2.28 A few days later, Mr Bradley asked Mr Wells to begin work on a draft article for publication in Vision. The article was to detail the clinical signs and the gross post-mortem findings only. 30 Because Mr Wells did not agree with that course of action, he spoke to Mr Mike Dawson (a CVL Research Officer) about it and made his position known to Mr Bradley. His subsequent minute said that he and Mr Dawson were agreed that there was little to be gained, and perhaps something to be lost, by the publicity Mr Bradley was proposing. He commented 'we do not need to know the prevalence of the disorder at present' and questioned the confidentiality of Vision. By drawing attention to the new disease, Mr Wells thought it was likely to encourage referral of cases to veterinary schools rather than to the CVL. He recommended postponing the article and reconsidering publication at a later date when more information was available. 31
2.29 Mr Bradley acknowledged Mr Wells's concerns, but having made these known to Dr Watson, still saw preparation of the article as being valuable. He asked Mr Wells to prepare the draft article promptly. A decision could then be taken on whether or not to publish the article in Vision. 32
2.30 Mr Wells duly wrote the article by early March, though on the covering minute he noted his continuing reservations:
A statement about the potentially novel disease for distribution to SVS outside of CVL is at present premature, uninformative by virtue of necessary omissions and predictably damaging to scientific achievement at this Laboratory. 33
2.31 Following further discussions between Mr Bradley and Dr Watson, the decision was made not to publish the article at that point. Both Dr Watson and Mr Bradley were asked about this decision when they gave oral evidence. Dr Watson said that he was in favour of publication at the time. It would have assisted in getting more of the materials and specimens that they needed for the case study. He could not remember why the publication did not proceed. 34 Mr Bradley told us that account was taken of the views of Mr Wells and Mr Mike Dawson. 35
2.32 We have seen no further contemporary documents dealing with dissemination of information about BSE prior to May.
Decisions on dissemination
2.33 The minutes of the meeting of the UKASTA/BVA/ADAS Liaison Committee for the South West Region on 6 May record that the BVA representative, Mr M Vivian stated:
Scrapie seems to be on the increase and there is some thought that cases may be occurring in cattle. 36
2.34 On 14 May Mr Bradley circulated to his CVL colleagues Dr Watson, Dr Shreeve, Dr Roberts, Mr Wells and Mr Mike Dawson a detailed 'Summary of Decisions made on Dissemination of Information' about the new disease. The first two paragraphs dealt with publications which would have a limited circulation. The next three paragraphs dealt with publication in a journal, such as the Veterinary Record, with a wider circulation:
1. GAHW [Wells] and MD [Mike Dawson] will prepare a 2 paragraph summary for the CVO. This will be a résumé for presentation at the Joint Vet/Med Research Club Meeting 37 on 29 May to be attended by both authors. Dr Watson will field questions of a non-scientific nature. The paper will only be given if the abstract is agreed by the CVO. At this meeting acknowledgement will be made to those contributing to the scientific information including VIOs, Messrs Dawson and Scott and Messrs Wells and Jeffrey. If presented the contributors (ie those listed above) should be informed of the gist of the subsequent discussion bearing in mind still the caution we must exercise. The respective HODs [Heads of Department] should also be kept in the picture. Dr Watson will keep the CVO and Head of VIS informed and any written communication should be sent to him via the HOD.
2. GAHW and MD will prepare an updated article for Vision to be cleared with HOD, Directorate CVL and Mr Williams before his departure on 25 May. This would include information on specimen submission (fresh and fixed) and a direction to send it to the CPU/Virology Dept CVL. We should consider what to do re the Scottish VICs who normally send neuro tissue to the Moredun. Some direction as to the restrictions and intentions as to future publication should be given. Direction on this point could only be given by the CVO or by the Director CVL and Head of VIS jointly.
3. Mr Williams has withdrawn authority for Mr Hancock to publish his 170 word article in the Record. I have spoken with him and informed him of the proposed Research Club paper and that he amongst others will be given recognition there.
4. GAHW and MD recommend restraint on publication until more tissues are examined (especially by Virology Dept). These are being sought and the Vision article would accelerate the progress. We should continually be taking stock of the situation re timing of publication. On the one hand there is enthusiasm to publish in some quarters now albeit with incomplete data and to ensure 'A First Report' both personally and for the SVS. On the other a more complete account would (apart from delaying publication) perhaps give the UK even more of a head start over others and also remove many of the uncertainties we now have.
5. When a publication is made it should, apart from giving an authoritative scientific account, give acknowledgement to those contributing to the knowledge in an agreed fashion and indicate to the reader the teamwork necessary to identify, recognise and describe such new conditions ie the importance of surveillance in the SVS which is conducted jointly by the VIS and CVL in the context of the current investigation. 38
2.35 In accordance with paragraph 1 of the 'Summary of Discussions', Mr Wells sought permission from Mr Rees to present a short paper on the new disease at the closed joint meeting of the Veterinary and Medical Research Clubs on 29 May 1987. 39 The request was dealt with by Dr Roy Moss, acting CVO in Mr Rees's absence. Dr Moss's note of his discussion with Mr Wells granting permission included the comment: 'Dr Wells is fully aware of the problem of association of this condition with scrapie of sheep without reference to the differences.' 40 The paper Mr Wells proposed to give included the following sentence: 'Histopathological examinations of brains from four cases has revealed a spongiform encephalopathy, indistinguishable by light microscopy from that of scrapie of sheep . . .' 41
2.36 In accordance with paragraph 2, Mr Wells and Mr Mike Dawson prepared for publication in Vision an updated version of Mr Wells's previously unpublished article. 42 The article was to be cleared by the Head of Department, the CVL Directorate and Dr Williams, before his retirement on 25 May 1987.
2.37 With regard to paragraph 3, Dr Bernard Williams, Assistant Chief Veterinary Officer (ACVO) and Head of the VI Service, explained to us that Mr Roger Hancock was one of two veterinary staff in the South West of England, each anxious to publish his findings of a single case of BSE. Dr Williams said that he had no recollection of Mr Hancock's paper but believed that he had decided that this paper was uninformative and incomplete and that publication of the joint CVL/VI Service investigation into the Kent herd should have priority, as this would contain more complete information. 43 Mr Rees has stated that he did not know anything about the article by Mr Hancock at the time and is unaware why approval for publication was withdrawn. 44
2.38 We subsequently obtained a copy both of Mr Hancock's letter, of which fellow veterinarian Miss N J Paull was co-author, and of the letter that Dr Williams wrote to him withdrawing permission for its publication.
2.39 Mr Hancock's and Miss Paull's letter described a cow which had died suddenly seven weeks after displaying behavioural changes, including mild ataxia. The letter continued:
A full post-mortem examination was not undertaken but the head was submitted for laboratory examination. The brain appeared normal on gross examination but histopathological examination revealed spongiform changes in the brain stem with vacuolation of the neurones. A diagnosis of spongiform encephalopathy of unknown aetiology was made. The lesions were similar to those seen in sheep with scrapie. 45
2.40 Dr Williams's letter to Mr Hancock read:
Further to our telephone conversation this morning, I am now confirming that the letter to the Veterinary Record which I cleared earlier in the week should not be published. I explained to you that this condition had been discussed by the CVO and the Director of CVL, and because of possible effects on exports and the political implications it had been decided that, at this stage, no account should be published. No doubt there will be an opportunity for your case to be published in due course. 46
This matter is considered further in the discussion section (see paragraphs 2.167-2.176).
Information to Veterinary Investigation Officers
2.41 Dr Williams told us that he did not agree with the CVL's suggestion of using Vision to advise VIOs of the existence of BSE. He believed that Vision articles did not receive immediate attention because of their routine nature and because they often related to matters of little interest to particular centres. He believed it prudent to circulate BSE information either as a circular letter or as a stand-alone article to all VI Service veterinary staff. Dr Williams told us, however, that he did not press that view, preferring to defer the decision until the article had been drafted. 47
2.42 On 15 May Mr Bradley sent a minute to Dr Watson, Dr Shreeve, Dr Roberts, Mr Wells and Mr Mike Dawson noting that, 'by agreement with the Director', the proposed Vision article would now be circulated as a separate Directive to VICs in England and Wales only. 48
2.43 A draft was submitted to Dr Williams for his approval. He suggested that the final paragraph should be amended to read:
It has been agreed that a joint/co-ordinated CVL-VIS publication will be produced in due course. Meanwhile, because of the nature of the disorder, its political implications and possible effects on exports it is essential that VIS staff must not, at this stage, discuss it with or consult workers at Research Institutes and University Departments. Furthermore, any statements for publication or discussions at meetings must be cleared by the respective Directors of the Services. 49
2.44 On 27 May Dr Peter Dawson succeeded Dr Williams as the ACVO and Head of the VI Service, and Dr Richard Cawthorne succeeded Dr Peter Dawson as Head of the Veterinary Investigation Section (VI Section) at Tolworth.
2.45 The final version of Mr Wells's article, entitled 'A Novel Bovine Neurological Disorder?', was eventually circulated on 8 June 1987 to Superintending Veterinary Investigation Officers in England and Wales. The document was headed 'urgent' and 'in confidence'. It described the nature, symptoms and pathology of the new disease and gave instructions for the submission of pathological material to the CVL. It included the following directions:
Similar clinical cases are of interest to VI Section, Tolworth, and the Pathology and Virology Departments at CVL. Such cases must be notified initially only to SVO(HQ), VI Section, Tolworth and Neuropathology Section, Pathology Department, CVO. At this stage VI staff should not consult workers at Research Institutes or University Departments . . .
A co-ordinated VIS/CVL publication on this subject is proposed. All statements for publication, or discussion at meetings MUST BE CLEARED by respective Directors of Services. 50
A watershed presentation
2.46 Meanwhile, Mr Wells made his agreed presentation at the tail-end of the closed joint meeting of the Medical and Veterinary Research Clubs on 29 May 1987. This was referred to in the meeting minutes as 'an impromptu 10 minute presentation on a neurological scrapie-like illness in Friesian cows.' 51 The established rule for such meetings was that no one could subsequently make any communication or statement in public about the proceedings without the permission of the speaker. Mr Wells told us, however, that it was recognised that one would speak about the meeting to colleagues within the same institute. 52
2.47 Both clubs were private with meetings open only to members and invited guests. 53 Mr Rees told us that he was aware of the clubs' rules relating to confidentiality. 54 However, both Mr Wells and Dr Watson referred to the meeting as a 'watershed' in relation to the dissemination of information to a wider audience. 55
2.48 Dr Kimberlin, of the NPU, was present at the meeting. Following Mr Wells's presentation, there was discussion between Dr Watson and Dr Kimberlin about the NPU's potential involvement. Dr Watson told us that he had tremendous regard for Dr Kimberlin's international reputation in the field. He said Dr Kimberlin was particularly experienced in pathogenesis and transmission, 'an area I felt we needed input in quickly'. 56
2.49 Nonetheless, five days after the meeting, Mr Bradley, who had by then been designated the CVL's BSE coordinator, issued a confidential minute to members of the CVL asking that no discussions with the NPU 57 be initiated until after a meeting with Mr Rees on 5 June. 58 Dr Watson had agreed to this request. In his oral evidence, Dr Watson said: 'I felt there should not be, shall we say, open communication before the Minister had been informed.' 59
1 A nyala (Tragelaphus angasi) is a deer-like African animal belonging to the same species group as cattle
2 YB86/6.23/1.1
3 YB86/7.8/1.1
4 S64 Jeffrey para. 9
5 S64 Jeffrey para. 10
6 S64 Jeffrey para. 11
7 S64 Jeffrey para. 24
8 S64 Jeffrey para. 24; T25 p.18
9 YB98/11.18/1.1
10 The term 'Bovine Spongiform Encephalopathy' or 'BSE' appears to have first been used in a minute from Mr Bradley to Mr Wells on 31 January 1987 (YB87/1.31/2.1)
11 YB86/12.19/1.1 (see Chapter 1, paragraph 1.37)
12 T54 p. 19
13 S75 Cruickshank para. 2
14 T23 p. 82
15 T26 pp. 84 and 96
16 T23 p. 85
17 S57 Hope para. 17; T23 pp. 79-80. Methods previously used involved time-consuming purification and electron microscopy steps. The western blotting technique is a standard method for detecting individual proteins present in a mixture. Its use therefore enabled more rapid identification of scrapie-associated protein. See vol. 2: Science for a further description of the western blotting technique
18 T23 pp. 86-7
19 T23 pp. 87-8
20 T31 p. 106
21 S57 Hope para. 22; T40 p. 81
22 S70 Watson para. 32; YB85/3.4/1.1(Visiting Group Report)
23 T29 p. 79
24 T29 pp. 82-3
25 YB87/1.29/1.1; YB87/1.31/1.1; YB 86/12.18/2.1
26 T26 p. 83; YB 87/2.4/1.1; Wells et al (1987) Veterinary Record 121, 419-20
27 S71 Bradley para. 18
28 YB87/2.4/2.1
29 YB87/02.18/1.1
30 YB87/02.23/1.1
31 YB87/02.25/2.1
32 T29 p. 103
33 YB87/03.02/1.1
34 T29 p. 105
35 T29 pp. 99-103
36 YB87/07.14/6.2. UKASTA is the UK Agricultural Supply Trade Association; BVA, the British Veterinary Association; and ADAS, the Agricultural Development and Advisory Service
37 This was a private meeting of the Veterinary Research Club with the Medical Research Club
38 YB87/05.14/1.1
39 YB87/05.14/2.1
40 YB87/05.14/2.1
41 YB87/05.14/2.1; this memo was a précis of the intended statement
42 YB87/05.14/1.1
43 S328A Williams paras 13 and 28
44 S126D Rees para. 22
45 YB87/5.00/2.1
46 YB87/05.13/1.1
47 S328A Williams para. 7
48 YB87/5.15/1.1; 'the Director' refers to Dr Watson
49 YB87/5.22/2.1
50 YB87/6.8/1.1
51 YB87/05.29/3.1
52 T26 p. 98
53 T39 pp. 41-2
54 T54 p. 24
55 T29 pp. 84-5; T26 p. 107
56 T29 p. 85
57 Erroneously referred to in the minute as the neurobiology unit
58 YB87/6.3/1.1
59 T29 p. 87
60 YB87/5.27/2.1
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