Chronology

1930s

It is recognised that a virus from a blood donor could be transmitted to a recipient of blood or blood products. (Archer Report)

1946

National Blood Transfusion Service established.

July 1948

NHS founded.

1950

The Haemophilia Society formed.

1950

Britain ’s BPL (Blood Products Laboratory) is established.

1957

Kekwick developed a method of fractionating out a fibrinogen, fraction rich in Factor VIII, the anti-haemophilic globulin. This led to the first clinical use of Factor VIII in treating haemophilia in 1957. (A Brief History of BPL and the Elstree Site by Tim Sandle)

1959

US Scientists, led by Judith Pool discovered that cryoprecipitate - the cold, insoluble globulin precipitate formed during the slow thawing of plasma - contained a five-fold higher concentration of Factor VIII compared to that of plasma. (A Brief History of BPL and the Elstree Site by Tim Sandle)

1964

Cryoprecipitate is introduced as an Haemophilia treatment. (A Brief History of BPL and the Elstree Site by Tim Sandle)

1967

Hepatitis B virus is identified. (Archer Report)

1967

Plasma Fractionation Laboratory (PFL) opened in Oxford (at the Churchill Hospital, Headington). (A Brief History of BPL and the Elstree Site by Tim Sandle)

1970

New York Times wrote of the "transfusion roulette" played by the blood industry. (Archer Report)

1970

Richard Titmuss publishes his book "The Gift Relationship" expanding on the dangers of taking blood from paid donors. It was widely read in the USA and the United Kingdom. (Archer Report)

1971

Scientist Judith Graham Pool discovers a simple method of creating Factor VIII Concentrate.

1973

By 1973, the desirability of national self-sufficiency in the supply of blood products was appreciated. (Archer Report)

1973

Factor VIII Concentrate first licensed for use in the UK.

1973

Hepatitis A virus is identified. (Archer Report)

Early 1970s

"It was known in the early 1970s that US commercial products carried an increased risk of infection. Indeed, some patients had become aware of this in various ways and were refusing treatment with those products, although the majority of patients had no idea of the danger" (Archer Report)

Mid 1970s

"Non-A, Non-B Hepatitis" is observed, it would eventually become known as Hepatitis C. (Archer Report)

Mid 1970s

"The danger of contamination from blood products was widely known in medical circles within the United Kingdom, and the particular dangers attendant on US commercial products were recognised". (Archer Report)

Jan 1975

Dr Allen wrote to Dr William Maycock, then Director of the UK Blood Transfusion Service, expressing anxiety about blood products from paid and prison donors. (Archer Report)

July 1975

Health Minister David Owen says "We can now say that we expect to be self-sufficient [in the supply of blood products] within 2 years". (Archer Report)

Late 1970s

By the end of the decade over half of all Factor Concentrate used was imported.

June 1977

Study reports on "Commercial Factor VIII-associated Hepatitis 1974-1975."¹

1978

The first Western cases of AIDS diagnosed in Port-au-Prince Haiti.²

Early 80s

Self-sufficiency in Factor Concentrates is achieved in Scotland

1981

The first diagnosis of AIDS in UK. ³

Nov 1981

New £1290,000 investment in Elstree laboratory and creation of Central Blood Laboratories Authority.⁴

Feb. 1982

The New Scientist reports that haemophilia sufferers are at risk of contracting AIDS. (Archer Report)

1982

First reported death from AIDS in the UK.⁵

July 1982

First reported case of AIDS in haemophiliacs in the US. ⁶

1982-3

Service guidelines drawn up for haemophilia treatment by 110 regional centres and 10 haemophilia centres in the UK, taking account of the impact of AIDS on the use of blood products and on patient counselling.⁷

Jan 1983

The HIV Virus was first isolated in France (then known as "LAV") and the findings published in May 1983. It was noted that the virus was found in people with AIDS and that there was a relationship between "LAV" and AIDS. The virus would later become known as "HTLV-III".

Early 1983

Possible transmission of AIDS through infected blood reported in UK medical press.

January 1983

New England Medical Journal concludes that haemophiliacs are at clear risk of AIDS and that cryoprecipitate should be used in preference to Factor concentrates.⁸

May 1983

A tabloid Sunday newspaper runs a story about two men, in hospital in London and Cardiff with suspected AIDS following routine treatment for haemophilia. The paper drew a link with the use of commercially produced, imported Factor VIII Concentrate. Also Dr N Galbraith, Director of Communicable Disease Surveillance Centre (CDSC) wrote to the Department of Health (DoH)to advise that the product be withdrawn from use due to the risk from AIDS.^{9 10}

Mid May 1983

6th Meeting Lisbon of European Committee of Experts on blood transfusion and immunohematology (SP-HM) prepared draft recommendations to be submitted to 361st European Committee off Ministers Meeting 13-22/6/1983.¹¹

June 1983

Council of Europe sent a letter dated 3rd June 1983 to the DoH) with recommendations from 6th Meeting to avoid the use of coagulation factor products prepared from large plasma pools except where such a product is specifically indicated for medical reasons, patients and clinicians be informed about the risk from AIDS.¹²

July 1983

Meeting on 13th July 1983 between Sub-Committee on Biological Products under the Committee on Safety of Medicines where it was established that the product carried a risk of AIDS.¹³

July 1983

Letter dated 27th July 1983 from JWG Smith to Professor Arthur Bloom asking "that the recommendations remain confidential, largely because of the Commercial implications."¹⁴

August 1983

First British haemophiliac died of AIDS at Bristol Royal Infirmary.¹⁷

Sept. 1983

The first DHSS leaflet ‘AIDS and How it concerns Blood Donors’ published (updated in December 1983)

Oct. 1983

Details published of the first known UK haemophiliac case of AIDS. Also Medical Research Council ’s Working Party on AIDS met for the first time: its discussion acknowledged use of Factors VIII and blood transfusion as risks for AIDS infection.¹⁵

Nov. 1983

Kenneth Clarke, Health Minister, states that there is no conclusive evidence that AIDS is transmitted through blood products.

Dec. 1983

Lord Glenarthur (Parliamentary Under Secretary of State) decides that Factor Concentrates, made from plasma (before US Regulations designed to exclude high-risk AIDS donors were introduced) will still be used. (Archer Report)

1983-86

Pamphlets for blood donors in UK – some people should not give blood.

Mid-late 1984

Prototype versions of HIV tests developed.

April 1984

HTLV-III is announced in the US as the causative agent of AIDS. It is the same virus as "LAV" which was isolated in France 14 months prior.

Autumn 1984

HIV antibodies found in sera taken from haemophilia patients in various parts of country who had been using Factor VIII. Also heat-treated Factor VIII first became available from a US commercial source.¹⁶

Nov.1984

Second British haemophiliac Terance McStay died on 18th November 1984 of AIDS after being treated with US Factor VIII at Victoria Infirmary Newcastle.

End 1984

Heat-treated NHS product first produced by Blood Products Laboratory.¹⁸

Early ‘85

DHSS recommended that only heat-treated Factor VIII be used in treatment of haemophilia.

Jan. 1985

Heat treatment of all imported Factor VIII. Also, further revised DHSS leaflet ‘AIDS and How it concerns Blood Donors ’.

Early 1985

Government campaign to encourage more blood donors, owing to the fall in numbers.¹⁹

Summer 1985

Heat treated NHS product became widely available.²⁰

Sept. 1985

Further revised DHSS leaflet ‘AIDS and how it concerns Blood Donors ’ – reflecting availability and introduction of HIV test, asked donors ’ consent for blood to be tested for HIV. Also, plans to dismantle the Public Health Laboratory Service (PHLS) were reversed.

Sept. 1985

Prime Minister Margaret Thatcher is requested to open the new BPL plant but her Private Secretary advises that the Prime Minister should "stay clear of AIDS."

Oct. 1985

After UK HIV test trials, two tests licensed for use in UK, one manufactured in UK (by Wellcome) and one in Netherlands (by Organon). HIV screening for all blood donated in the UK from 14th October, 1985 nationwide.²¹

Nov. 1985

906 Haemophiliacs and five of their spouses in the UK have tested HIV Positive.

April 1986

Minister John MacKay says that "AIDS is a totally self-inflicted illness"

Oct. 1986

Revlon subsidiary Armour ’s Factor VIII product "Factorate-HT" is withdrawn after two UK haemophiliacs who had used it seroconverted. This was due to an ineffective heat-treatment process used by the company.

Dec. 1986

At least 19 UK Haemophiliacs have died from AIDS.

1986

Bio Products Laboratory opened at Elstree - a new facility with capacity for national self-sufficiency.²²

End 1986

2/5 of reported HIV infections in UK attributable to blood transfusion &/or the use of blood products.²³

1986-7

General issues of HIV and AIDS prevention became intensely politicised.

Jan. 1987

Information leaflet on AIDS - ‘Don ’t Die of Ignorance ’ delivered to all households.

Feb. 1987

Co-ordinated broadcast media campaign marked ‘AIDS week ’.

March 1987

28 Haemophiliacs in the UK have AIDS, 22 have died.

Nov. 1987

The government made a £10 million ex gratia payment to a fund administered by the Haemophilia Society ’s MacFarlane Trust for haemophiliacs infected with HIV.²⁴

Nov. 1987

40% of all HIV cases in Northern Ireland are Haemophiliacs.

End June 88

1,469 cases of AIDS notified to PHLS.

1989

Hepatitis C virus is isolated and tests are available. (Archer Report)

1989

Haemophilia HIV litigation commences.

Nov. 1989

Additional £19 million payment to the MacFarlane Trust from the government.

Nov. 1989

1,200 Haemophiliacs in the UK have tested HIV Positive, 107 have died from AIDS.

Jul. 1990

35 spouses of Haemophiliacs in the UK have tested positive for HIV, 3 have AIDS.

Sept. 1990

Ognall J presiding in the Haemophilia HIV litigation urged an out-of-court settlement.

Sept. 1990

143 Haemophiliacs in the UK have died from AIDS.

Dec. 1990

Out-of-court settlement in Haemophilia HIV litigation approved in principle.

April 1991

£42 million ex-gratia payment is provided by the Government in order to bring about an end to the HIV Haemophilia Litigation to those who received contaminated Factor Concentrates.²⁵

Sept. 1991

UK introduces Hepatitis C testing.

1992

PFL (Oxford) closes, all operations and staff transferred to BPL.

Feb. 1992

Ex-gratia payment for non-haemophiliac recipients of infected blood was provided by the government on a basis similar to that for haemophiliacs (Small 1993, Garfield 1994).

March 1995

1,237 Haemophiliacs in the UK have tested HIV Positive, 596 have died.

1995

First Government "look-back" exercise to identify those exposed to Hepatitis C through blood / blood products begins.

End 1998

15,784 cases of AIDS in UK (13,844 in England & 937 Scotland) of which 783 from blood or tissue transfer or use of blood concentrates. 32,925 reported HIV infections, of which 1,573 from blood or tissue transfer or use of blood concentrates (of which 85% in blood factor recipients).

March 2002

800 of the 1,237 Haemophiliacs who have tested positive for HIV have now died. Furthermore 212 Haemophiliac deaths recorded from Liver Disease attributable to Hepatitis C. Total death toll surpasses 1,000.

Dec 2009

882 of the 1,243 Haemophiliacs who have tested positive for HIV have now died.

July. 2017

Collins Solicitors applies for a Group Litigation Order on behalf of their clients and fresh incriminating evidence hits the front page of the Daily Mail. Exactly one week to the day later Prime Minister Theresa May announces what will become the Infected Blood Inquiry.

27 Oct. 2017

Contaminated Blood Products Group Litigation Order granted on 27th October 2017.

Nov. 2017

The Cabinet Office takes over from the DoH as the sponsoring government department to the Infected Blood Inquiry.

Dec. 2017

Prime Minister Theresa May makes a written statement to parliament stating the Infected Blood Inquiry would be chaired by a Judge.

Feb. 2018

Mr Justice Langstaff announced as chair of the inquiry.

March 2018

Consultation began on the terms of reference of the Infected Blood Public Inquiry.

April 2018

The consultation into the terms of reference of the Infected Blood Public Inquiry closed on 26th April 2018.

May 2018

Mr Justice Langstaff took up his role as chair of the Contaminated Blood Inquiry from 1st May 2018.

July 2018

David Lidington, MP, Minister for the Cabinet Office, formally announced the opening of the Infected Blood Public Inquiry in the House of Commons on 2nd July 2018. The Terms of Reference are published (accessible here)

 

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1. J. Craske, Public Health Laboratory et al (1977) ‘Commercial Factor VIII associated hepatitis, 1974-5 in the United Kingdom: a retrospective survey’
2. A. Veitch “No Check on blood despite the fear” the Guardian, published 25th March 1985
3. Berridge and Strong (1992) 'AIDS policies in the United Kingdom: a preliminary analysis', in Fee, E and Fox, D (eds) AIDS: the making of a chronic disease, Berkeley: University of California Press
4. V Berridge (1997) 'AIDS and the gift relationship in the UK', in Titmuss, R M The Gift-Relationship from human blood to social policy, original edition with new chapters, edited by Oakley, A and Ashton,J, London: LSE Books
5. See endnote 3
6. N Small (1993) AIDS: The Challenge, Aldershot: Avebury
7. Bennett and Ferlie (1994) Managing Crisis and Change in Health Care. The organizational response to HIV/AIDS, Buckingham: Open UP
8. Irish Haemophilia Society, Tribunal News Issue 3 Proceedings dated June 22nd 2000
9. See endnote 4
10. Letter “Action on AIDS” from N.S Galbraith to I Field dated 9th May 1983
11. Minutes from 6th Meeting Lisbon of European Committee of Experts on blood transfusion and immunohematology
12. Letter from Public Health Division Council of Europe to Dept. of Health and Social Security
13. Minutes from the meeting of the committee on Safety of Medicines- sub-com on Biological products 13th July 1983
14. Letter from National Institute for Biological Standards and Control to Professor Bloom
15. See endnote 4
16. R Freeman ‘Success and failure in governance: a comparative analysis of European Studies. Crisis Management: HIV and the blood supply. Case Study: The United Kingdom’ in Bovens et al (eds.) Success and failure in Public Governance
17. S Boseley “Haemophilia’s death after transfusion” the Guardian published 19th November 1984
18. See endnote 3
19. See endnote 4
20. See endnote 3
21. V Martlew (1997) 'Transfusion medicine towards the millenium', in Titmuss, R M The Gift- Relationship from human blood to social policy, original edition with new chapters, edited by Oakley, A and Ashton, J, London: LSE Books
22. Ibid
23. See endnote 17
24. Minutes from 23rd Meeting of the Central Blood Laboratories Authority
25. See endnote 17