The historical contamination of blood products in the UK with HIV and hepatitis C virus
From the 1970s to the early 1990s, tens of thousands of people were infected with hepatitis C and HIV as a result of receiving infected blood or infected clotting factor products in the United Kingdom. Many of the products were imported from the United States, and distributed to patients by the National Health Service. Most recipients had haemophilia or had received a blood transfusion following childbirth or surgery. It has been estimated that more than 30,000 patients received contaminated blood, resulting in the deaths of at least 3,000 people. In July 2017, Prime Minister Theresa May announced an independent public inquiry into the scandal, for which she was widely praised as successive governments going back to the 1980s had refused such an inquiry. May stated that "the victims and their families who have suffered so much pain and hardship deserve answers as to how this could possibly have happened." The final report was published in seven volumes on 20 May 2024, concluding that the scandal could have been largely avoided, patients were knowingly exposed to "unacceptable risks", and that doctors, the government and NHS tried to cover up what happened by "hiding the truth".
People with haemophilia were principally infected via the plasma-derived product known as factor VIII, a processed pharmaceutical product sourced from the United States and elsewhere. The creation of these products involved dangerous plasma donation pooling manufacturing processes that led to infected products. Large groups of paid donors were used, as many as 60,000 per batch, and included prisoners and drug addicts. It only required one infected donor to contaminate an entire batch, which would then infect all of the recipients.
This was at a time when the practice of paying donors for whole blood in the United States had effectively ceased. The UK did not import whole blood from abroad, but it did import large quantities of factor VIII given to those infected, as described in the documentary "". The UK imported these products because it did not produce enough of its own, and efforts to achieve self-sufficiency were inadequately funded. A study published in 1986 showed that 76% of those who received commercial clotting-factor products became infected with HIV, as opposed to none of those who only received the previous treatment – cryoprecipitate.
While then Prime Minister David Cameron apologised on behalf of the British government to those affected, no government, healthcare or pharmaceutical entity in the UK has formally admitted any liability in the scandal. As part of an ongoing public inquiry, 3,000 surviving victims were awarded interim compensation payments in August 2022, to be paid urgently due to the extremely high death rate of survivors.
On 20 May 2024, the six year long "Infected Blood Inquiry" was finally reported covering more than 2000 pages "the worst treatment disaster in the history of the NHS".
On the following day, 21 May 2024, the Minister for the Cabinet Office, John Glen, announced a new Infected Blood Compensation Authority to administer a new compensation scheme for victims.
Background.
Haemophilia is a mostly inherited genetic disorder that impairs the body's ability to clot, a process needed to stop bleeding. This results in people bleeding longer after an injury, easy bruising, and an increased risk of bleeding inside joints or other parts of the body.
Before the development of Factor VIII gene therapy, there was no long-term cure for haemophilia. Treatment and prevention of bleeding episodes is done primarily by replacing the missing blood clotting factors using "synthetic" or "non-human derived" factor products such as recombinant factor VIII. Factor products work by replacing the missing factor proteins, which can take place at home or in hospital. In the 1970s, haemophiliacs began to be treated with "factor concentrates", which were sold as a revolutionary treatment. In the 1980s, it was discovered that many of these concentrates were contaminated by hepatitis viruses and HIV. The concentrates were contaminated as a result of the way plasma was sourced and collected. The creation of these products involved dangerous manufacturing processes. Large groups of paid donors were used, as many as 60,000 per batch, and included prisoners and drug addicts.
Some of the most notorious examples of risky plasma harvesting are those of Luckner Cambronne, who became known as "The Vampire of the Caribbean" for his profiting from the sale of Haitian blood to the West for medical uses, and also Crysosan Ltd, a company based in Canada that was found guilty of harvesting plasma from the bodies of dead Russians and re-labelling it as originating from Swedish donors.
Products.
Plasma donations could be collected using a process called plasmapheresis. In addition to NHS-derived factors produced by Bio Products Laboratory (BPL), manufacturers that supplied clotting factor products to the UK during the mid-1970s and 1980s included Abbott (Profilate), Armour Pharmaceuticals (Factorate), Bayer-owned Cutter (Koate), Baxter International-owned Travenol/Hyland (Hemofil/Interhem), Immuno (Kryobulin) and Speywood (Humanate).
Hepatitis (1973-1986).
The dangers of factor concentrates had been raised since their inception. In 1974, American scientist Judith Graham Pool, who previously discovered the frozen blood product cryoprecipitate, a safer treatment, described the products as "dangerous" and "unethical", and warned against their use. The World Health Organization also warned the UK not to import blood from countries with a high prevalence of hepatitis, such as the United States.
In May 1975, the World Health Organization passed a widely circulated resolution urging all countries to aim at self-sufficiency in blood products.
In September 1975, an article was published detailing occurrences of a new kind of hepatitis.
In December 1975, an episode of the "World in Action" programme highlighted the danger of hepatitis from imported clotting-factor products.
By the end of 1978, more than 50% of the factor VIII used in England was being imported from overseas. This was because the UK had failed to become self-sufficient in its own supplies.
The BPL, which manufactured UK blood products, ran into continual trouble from under-funding. The Archer Report said, "In July 1979, the Medicines Inspectorate visited BPL. They reported that the buildings were never designed for the scale of production envisaged. They commented: 'If this were a commercial operation we would have no hesitation in recommending that manufacture should cease until the facility was upgraded to a minimum acceptable level'.
BPL was rescued by Crown Immunity. Among their recommendations the Inspectorate advised: 'Under no circumstances should production of any product be increased under the existing manufacturing conditions'. Meanwhile, the existing plant continued production, relying on Crown Immunity to dispense with all the requirements of the Medicines Act, but was able to meet only about 40% of the national requirements."
A study published in December 1983 showed conclusively that the risk to a haemophiliac of contracting hepatitis C by using untreated clotting-factor products was 100% upon first exposure.
HIV (1981-1990).
In July 1982, the American Centers for Disease Control and Prevention (CDC) reported that at least 3 haemophiliacs there had developed "Pneumocystis carinii" pneumonia. 2 had died, and all 3 had used untreated clotting-factor products. The CDC said that "the occurrence among the three haemophiliac cases suggests the possible transmission of an agent through blood products".
In March 1983, the CDC reported that "Blood products or blood appear responsible for AIDS among haemophilia patients".
In May 1983, Spence Galbraith, director of the Communicable Disease Surveillance Centre in England and Wales, sent a paper entitled "Action on AIDS", to Dr Ian Field at the Department of Health and Social Security in London, informing him of the death from AIDS of a haemophiliac who had received factor VIII concentrate imported from the United States. Galbraith stated: "I have reviewed the literature and come to the conclusion that all blood products made from blood donated in the USA after 1978 should be withdrawn from use until the risk of AIDS transmission by these products has been clarified ... I am most surprised that the USA manufacturers of the implicated blood products have not informed their customers of this new hazard. I assume no critical warning has been received in the United Kingdom?" Despite Galbraith's warning, the products were not withdrawn. A Department of Health letter considered that his suggestion was "premature".
In September 1983, a leaflet distributed to UK blood donors answered the question as to whether AIDS could be transmitted by blood-products, to be "Almost certainly yes".
In November 1983, Kenneth Clarke, Secretary of State for Health and Social Care, told Parliament that "There is no conclusive evidence that AIDS is transmitted by blood products", and the importation of infected products continued. When giving evidence to the Penrose Inquiry, Dr. Mark Winter said that, at the time Ken Clarke made this statement, "all haemophilia clinicians by this stage clearly believed that commercial blood products could and were transmitting AIDS".
In January 1984, Lord Glenarthur, Parliamentary Under Secretary of State at the DHSS, said that "It remains the case that there is no conclusive evidence of the transmission of AIDS through blood products, although the circumstantial evidence is strong". The use of untreated clotting-factor products and importation continued.
In April 1989, the HIV Haemophilia Litigation commenced, which culminated in December 1990 with an out-of-court settlement, following an investigation by ITV's "The Cook Report" in July 1990.
Destroyed-evidence investigation (2000).
In April 2000, the Department of Health published an internal audit to examine the loss of records relating to hepatitis C litigation. The report concluded that "an arbitrary and unjustified decision, most likely taken by an inexperienced member of staff, was responsible for the destruction of a series of files containing the minutes and background papers of the Advisory Committee on the Virological Safety of Blood (ACVSB)".
The Archer Report (2009).
In the early 2000s the former Solicitor General for England and Wales, Lord Archer, campaigned for an inquiry into the tainted blood scandal, alongside Lord Owen, who was the Health Minister from 1974 to 1976, Lord Jenkin, Health Secretary from 1979 to 1981, and others. They were unsuccessful.
In a 1990 episode of "The Cook Report", Owen said: "I can see why some people would be unhappy with having all the facts revealed because it will show negligence". In September 2016 Owen gave a speech in London during which he said the scandal had been covered up.
The late Lord Archer of Sandwell chaired a privately funded independent investigation set up in 2007. The Archer Report was published in 2009 and aimed to uncover the causes of the events that led to the thousands of infections and deaths. The report held no legal or official status and was unable to subpoena witnesses or demand the disclosure of documents.
It sought to address the issue of missing evidence and documents relating to the scandal. For example, the ministerial papers of Lord Owen had been destroyed. "We have been unable to ascertain who carried out the destruction of the papers, and who gave the instructions. But the conclusion appears inescapable that some official made a decision which he or she had no authority to make, or that someone was guilty of a serious error of judgement. The consequence is that Lord Owen has done his best to recollect details of events a quarter of a century ago, but both he, and we, have been deprived of the primary sources", Lord Archer reported.
Lord Jenkin voiced his difficulties obtaining documents for the inquiry. The report stated: "He subsequently received from the Department two bundles of documents. One of these was to be treated as confidential". Lord Jenkin felt that the destruction of records was deliberate, and done "in order to draw a line under the disaster".
Another handling error is described in the inquiry: "mishandling of documents arose in connection with a number of files relating to the Advisory Committee on the Virological Safety of Blood between May 1989 and February 1992 which were found to be missing". The report stated: "They were in fact destroyed over a period from July 1994 to March 1998". When summarising these events it is stated "some of those who gave evidence to us suspected that there was an exercise in suppressing evidence of negligence or misconduct."
Scottish Penrose Inquiry (2015).
In 2008, the Scottish government announced a public inquiry into the scandal covering Scotland only, to be chaired by Lord Penrose. The inquiry's terms of reference outlined five deaths that were to be examined. Only one of those victims was a haemophiliac and that person had been infected with hepatitis C in the 1960s as part