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NHS GGC Outbreak Control Plan – version December 2009

OUTBREAK CONTROL PLAN

GASTROINTESTINAL ILLNESS (including FOOD- AND WATER-

BORNE GI INFECTION)

IN COLLABORATION WITH

Glasgow City Council East Renfrewshire Council

East Dunbartonshire Council West Dunbartonshire Council

Inverclyde Council Renfrewshire Council

Scottish Water

(August 2008) Updated December 2009


TABLE OF CONTENTS PAGESignatories to the Plan ………………………………………… 1

Forward ………………………………………… 2

Acronyms ………………………………………… 3

Definitions ………………………………………… 4

Summary A - Summary of Preliminary Investigation …………… 6

Summary B - Investigation of Possible Outbreak …………… 7

Summary C - Outbreak Response …………… 8

Outbreaks - Simply Classified …………… 10

1. Introduction ….… 112. What’s an Outbreak? What’s an Incident? ….… 123. Recognising an Outbreak ….… 144. Initial Response if there is suspicion of an Outbreak ……. 175. Declaration of an Outbreak ……. 266. The Role of the Outbreak Control Team ……. 277. ‘Incident’ Room ……. 288. Care of Patients ……. 299. Laboratory Resources and Sampling ……. 3010. Powers and Legislation ……. 3311. Following the Outbreak ……. 3512. Revision of the Plan ……. 37 Distribution List 38

APPENDICES Appendix A Model Agenda Appendix B Contact Details Appendix C Additional Guidance Appendix D Roles and Responsibilities Appendix E Testing for Norovirus Infection Appendix F Fax: Notification of Alleged Food Poisoning


SIGNATORIES TO THE PLAN

NAME TITLE AGENCY DATE SIGNATURE

Mr Tom Divers

Chief Executive

NHS Greater Glasgow & Clyde

19/08/2007

Mr George Black

Chief Executive

Glasgow City Council

28/08/2007

Mrs Lorraine McMillan

Chief Executive

East Renfrewshire Council

04/09/2007 (David Dippie)

Mr David McMillan

Chief Executive

West Dunbartonshire Council

12/08/2007

Mrs Sue Bruce

Chief Executive

East Dunbartonshire Council

04/10/2007

Mr Jon Hargreaves

Chief Executive

Scottish Water

27/08/2007

Mrs Sheilagh Brown

Divisional Veterinary Manager

Animal Health

11/09/2007

Mr David Martin

Chief Executive

Renfrewshire Council

12/09/2007

Mr John Mundell

Chief Executive

Inverclyde Council

22/10/2008

All signatures are held in PHPU

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FORWARD

This updated version of the NHS Greater Glasgow and Clyde Outbreak Control Plan for Food and Waterborne Gastro-intestinal illness (including GI infection) brings together the two outbreak control plans that operated in the former NHS Greater Glasgow and NHS Argyll and Clyde. It was developed in conjunction with the Public Health-Environmental Health-Med-Vet Working Group. It has been compiled by the Public Health Protection Unit and contributed to, and endorsed by, all six local authority departments of environmental health and by Scottish Water. It also has the approval of the Scottish Parasite Diagnostic Laboratory and our attending medical and food microbiologists. This plan should be read in conjunction with the national guidance on the subject (Guidance on the Investigation and Control of Outbreaks of Foodborne Disease in Scotland published jointly by the FSA(S) and the Scottish Government) and the NHS Greater Glasgow and Clyde Generic Incident Management/Outbreak Control Plan. The Appendix B includes a useful list of officers and agencies that one might need to get in touch with during an outbreak and their contact details. We would welcome feedback on the usefulness of this document at any point in the future in order to help us improve on it for future updated versions. Dr Syed Ahmed Clinical Director Public Health Protection Unit

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ACRONYMS AH - Animal Health (formerly known as the State Veterinary Service) CBRN - Chemical, biological, radiological and nuclear (usually refers to deliberate releases) CMO - Chief Medical Officer CPHM (CD/EH) - Consultant in Public Health Medicine (Communicable Diseases and Environmental Health) DPH - Director of Public Health DWQD - Drinking Water Quality Division (of the Scottish Government) DWQRS -Drinking Water Quality Regulator for Scotland (within the Scottish

Government) EDC - East Dunbartonshire Council EHO - Environmental Health Officer EPO - Emergency Planning Officer ERC - East Renfrewshire Council FSA(S) - Food Standards Agency (Scotland) GCC - Glasgow City Council GEMS - Glasgow Emergency Medical Services * (similar out of hours services operated in the Clyde area) HACCP - Hazard Analysis Critical Control Point HPS - Health Protection Scotland HSE - Health and Safety Executive IMT - Incident Management Team (defined overleaf) LA/EHS - Local Authority/Environmental Health Service NHSGGC- NHS Greater Glasgow and Clyde OCP - Outbreak Control Plan OCT - The Outbreak Control Team (defined overleaf) OCTSG - Outbreak Control Team Support Group OMST - Outbreak Management Support Team PAG - Problem Assessment Group (defined overleaf) PF - Procurator Fiscal PH EH Med Vet Working Group - The Working Group that holds quarterly meetings

and consists of public health doctors, health protection nurse specialists, EHOs, medical and non-medical microbiologists, Scottish Water and veterinarians with an interest in public health issues relevant in the NHSGGC area

PHPU - The Public Health Protection Unit, NHSGGC PRO - Public Relations Officer SAC - Scottish Agricultural College SEPA - Scottish Environment Protection Agency SOP - Standard Operating Procedure STAC - Scientific and Technical Advisory Cell SWHP - Scottish Waterborne Hazard Plan WDC - West Dunbartonshire Council

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DEFINITIONS CBRN - Used to refer to deliberate releases of chemical, biological, radiological and nuclear agents by what is inferred to be subversive and/or criminal forces. Cryptosporidiosis - the diarrhoeal infection caused by the Cryptosporidium parasite. Cryptosporidium - the plasmodium protozoan parasite, some species of which can cause Cryptosporidiosis. EHO - Environmental Health Officer, an officer trained in environmental health usually employed by local authority environmental health services (LA/EHS). The EHO shares statutory responsibility with the NHS Board for protecting and improving the public health within their geographical boundaries. HACCP - Hazard Analysis Critical Control Point, a food safety management system used by food businesses to identify vulnerable points (critical control points) and to document appropriate control measures. Incident Management Team (IMT) – An IMT is a team of professionals drawn from multiple agencies with the common goal of investigating and bringing under control a potential threat to the public health. It is convened comprising the relevant representatives from the stakeholder agencies with an interest in a public health incident. A public health incident involves a potential threat to the public health (a ‘scare’ involving food or water in this context, but that has yet to, and may never, cause illness). NHS24 - The response service provided by highly qualified nursing staff that is accessed by the public out of hours and that is used to perform a telephone-based triage including referral to medical services including A&E, domiciliary visit, etc. All areas across Greater Glasgow and Clyde are now included in NHS 24 and the appropriate GP out of hours service for each area is accessed through this mechanism. NHSGGC - The entire NHS within Greater Glasgow and Clyde including all Divisions and the Board. Covers all or part of the six councils named on the coversheet of this plan. NHS GEMS - Glasgow Emergency Medical Service, the GP-based and district nurse-based primary care service available out of hours in the Greater Glasgow and Clyde area, that is accessible via NHS24 after hours. Norovirus - Norwalk-like virus (a common cause of viral gastroenteritis) traditionally thought to cause illness in the winter months – hence the term 'winter vomiting disease' - but now found to be occurring at any time of the year. Outbreak - Two or more associated or linked cases of illness or infection; a greater than expected rate of illness or infection in a population; or a single case of certain serious, possibly contagious infections suggesting that there will be many more in the community (see major and minor outbreak definitions overleaf). Outbreak Control Team (OCT) – An OCT is convened when any representative from one of the three participating core agencies (NHS Board, Local Authority Environmental

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Health Department, or hospital microbiologist) feels there has been an outbreak of illness (related to food or water in this context). Problem Assessment Group (PAG) - A PAG is an informal group that can communicate either via the telephone, e-mail, fax or in person consisting of any representative from at least two of the three participating core agencies. Normally, a PAG would involve informal, initial communication about a possible incident or outbreak before it has been established that a formal IMT or OCT should be convened. The key members of a PAG would normally be the Consultant in Public Health Medicine (CPHM), an Environmental Health Officer (EHO) and a water authority scientific officer, if the event is suspected to be waterborne, or alternatively, the CPHM, EHO and microbiologist if a food source is suspected. It allows the representatives to discuss the basic known facts at an earlier stage and in the absence of the wider membership normally attending an OCT/IMT. Its key purpose is to establish whether a formal team needs to be convened. Scottish Water - The water authority providing water and sewerage services to most of Scotland.

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SUMMARY A Summary of Preliminary Investigation

Alert Public Health 0141 201 4917 (office hours) 0141 211 3600 (out of hours)

Section 4.1, Appendix B

Consultant in Public Health Medicine leads

Discuss features with informant, Environmental Health Officers,

Microbiologist, +/-”expert”

Problem Assessment Group? (PAG)

Section 4.2

See Section 2 Summary B

OUTBREAK? Requires Control

Team? Section 5

YES

NO

Monitor/Review (reassess OCT need) YES

Outbreak Control Team

(OCT) Section 4.2, 4.6

Membership Section 4.6 Standing Agenda

Appendix A

Outbreak over?

NO

YES NO or

NOT SURE

See Section 4

Summary C

Recovery phase: reporting, assessment and

recommendations Section 11

Outbreak of communicable disease suspected? Section 2.1

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SUMMARY B Investigation of Possible Outbreak

PUBLIC HEALTH ALERTED TO POSSIBLE OUTBREAK

Actions: OCP Section 4 (Initial Response) Collate outline information: who, what, when, how? Discuss information between PH, microbiologist and

environmental health (+/- “expert”) as informal Problem Assessment Group (PAG) Address “Key Questions”:

Features of PAG: (phone or meeting) CPHM “chairs” short meeting rapid decisions small number key players take notes (type up as record)

Key questions to inform decision to convene Outbreak Control Team

Large numbers of cases +/or possibility of further cases?

source or transmission route not yet identified? control measures required ? co-ordination necessary? unusually pathogenic or other unusual features? communications and media management required?

Public health decision informed by consideration of all these issues together

Convene Outbreak Control Team (OCT)

See: OUTBREAK RESPONSE: CONTROL PHASE Summary C

False alarm. Outbreak excluded. Minimal follow-up; reassess if new information/cases

More information required. No OCT yet. Reconvene PAG once additional assessment made and/or more information available. Section 4.2

Minor incident. No OCT. Continue liaison Well-defined cluster, small numbers affected, source identified/high suspicion; control measures implemented or not necessary; and/or not likely to extend further or warrant specific additional co-ordination. See Outbreaks Simply Classified

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SUMMARY C Outbreak Response Features of OCT: CPHM chairs Core members (CPHM, Senior EHO, Cons Microbiologist) + co-opted members - section 4.2, 4.6 Decide venue - section 4.4 Agenda - Appendix A and Minutes Objectives during investigation and control phase: section 6 Case finding and interviews, clinical and environmental sampling Consideration that waterborne disease may be implicated Inspection of premises Ensuring patient care Institution of control measures Communicate information (national and local agencies [Health Protection Scotland (HPS), Scottish Government (SG) and Food Standards Agency (FSA(S))], health professionals, public and media) - Appendix B and section 4.6.3, 4.7 Generate and test hypothesis Declare outbreak over, produce report, including lessons learned for involved parties Operational issues and allocation of functions As per normal function of each agency OCT assigns specific functions to agencies or individuals; In larger outbreaks may set up dual or multi-agency Joint Operational Team (JOTs) section 4.8.2 OCT Guiding Principles: section 6 OCT Considerations and Powers: section 10, 10.1, 10.2 Checklist / aide memoire especially for matters and practicalities sometimes overlooked Role of different OCT members: Appendix E CPHM, Chief EHO, cons microbiologist – section 4.6 and Appendix E Patient Care: section 8 Infection Control: section 8.1 Sampling and laboratories: section 9 Requires close liaison with NHS microbiology labs. Glasgow Scientific Services’ food lab processes all food samples from all areas in all outbreak situations. Direct lab EHO Links useful

Inspection of premises normally undertaken by EHOs: section 10 >1 NHS Board affected? - section 4.2 Hospital-based foodborne outbreak? CPHM should chair OCT – section 4.6.2

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Major Outbreaks Additional Resources: section 4.8.2 Rare situation – outbreak investigation/control impacts on normal functioning of any agency, resources need to be diverted or enhanced. “Major incident” (as per emergency planning Major Incident plans) can be declared

Outbreak Management Support Team (OMST) can be formed. OCT Chair request via the Director of Public Health (DPH). Executive officers from involved agencies; eg an NHS Clinical Director, DPH. Supports OCT: mobilises resources, considers financial issues, staff support, enhanced communications - section 4.8.3

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OUTBREAKS Simply Classified A MAJOR outbreak is defined as one in which one or more of the following applies: • large number of people are affected, perhaps including residents from beyond the

National Health Service Greater Glasgow and Clyde (NHSGGC) area • the organism involved is unusually pathogenic or virulent • there is potential for transmission to large numbers of people (widespread distribution

of food product or point source affecting large numbers) • there are unusual or exceptional features • there is likely to be heightened political, media and public interest • there is likely to be a need for additional resources including those that can be provided

by an Outbreak Control Team Support Group (OCTSG) Examples include small, medium or large outbreaks of E. coli O157; moderate to large waterborne outbreaks of cryptosporidiosis; large community-based foodborne outbreaks of salmonellosis, infection with Campylobacter, Clostridium perfringens, etc; health care associated outbreaks of salmonellosis, etc; outbreaks of typhoid or paratyphoid fever of any size; outbreaks of salmonellosis, etc based in pre-school settings; a single case of polio, botulism or cholera, etc. A MINOR outbreak is one which: • it can normally be investigated within the resources of the NHS Board Department of

Public Health, the relevant NHSGGC hospital, Local Authority’s Environmental Health Services and the appropriate clinical microbiology laboratories within NHSGGC

• and/or there is little or no intervention that can be advised by the statutory agencies in terms of food recall, diverting water supplies, infection control or exclusion of cases, etc and/or

• it would not normally be expected to attract media or political interest Examples include small outbreaks of cryptosporidiosis in the spring (less than 10 cases per week); outbreaks of norovirus in hospitals and other institutions; outbreaks of diarrhoea and vomiting in the community where no one has provided a stool specimen; small community-based outbreaks of Salmonella, Campylobacter, Clostridium perfringens, etc; two or more linked cases of giardiasis or pinworms in the same household, etc.


1. INTRODUCTION The purpose of this multi-agency Outbreak Control Plan (OCP) is to help ensure that outbreaks of gastrointestinal (GI) illness, including the communicable infection responsible for food-borne and water-borne outbreaks, are recognised, thoroughly investigated, and brought under control. Where possible, measures need to be taken to prevent similar outbreaks in the future. Finally, satisfactory communication, throughout, with appropriate external agencies and the general public, via the media, is a key characteristic of a successfully handled outbreak. The OCP should be read in conjunction with the Guidance on the Investigation and Control of Outbreaks of Foodborne Disease in Scotland, published by the Scottish Government and FSA(S) in the spring of 2002. In addition, there were key developments outlined in the Chief Medical Officer’s (CMO) generic guidance entitled Managing Incidents Presenting Actual or Potential Risks to the Public Health: Guidance on the Roles and Responsibilities of Incident Control Teams published in the summer of 2003. These include the recognition of the NHS Board as the lead agency with overall responsibility for co-ordinating the entire process, as well as ensuring that agencies charged with implementing the recommendations, agreed by the OCT, are followed up and their progress towards completing these tasks documented in writing. NHSGGC has responsibility for the identification, investigation, control and prevention of outbreaks throughout its geographical area, regardless of whether they occur in the community or within hospital settings. As such, the Public Health Protection Unit (PHPU) assumes responsibility for providing a CPHM to chair and convene appropriately constituted OCTs or for ensuring that an appropriately qualified Chair is found for this purpose. Hospital-based outbreaks

The latter is relevant in hospital outbreaks of gastrointestinal illness when this plan should be implemented in conjunction with the relevant hospital OCP. All hospital-based outbreaks should be reported to the PHPU inviting the CPHM to attend the OCT meetings and to agree who should chair the OCT. It is expected that for most hospital-based outbreaks, including Norovirus outbreaks involving significant degrees of ward closure, the Chair of the hospital Control of Infection Committee or consultant clinical microbiologist will chair an appropriately convened hospital-based OCT. If a hospital-based outbreak involves substantial life-threatening morbidity or loss of life, or is attracting undue media attention, a CPHM (CD/EH) from the PHPU (or a depute) at NHSGGC would be expected to lead the investigation, including chairing the meetings and overseeing the writing of the OCT Report. Historically, unless a foodborne outbreak is suspected, local authority EHOs are not generally involved with the investigation and control of hospital-based outbreaks. For hospital-based food or waterborne outbreaks the relevant local authority EHOs would lead the technical investigation in close co-operation with PHPU and hospital control of infection team staff. This plan should be put into action as soon as a significant outbreak of GI illness is identified, at which point, the time and date of the transition from Problem Assessment Group (PAG)¹ to a formal OCT should be noted and recorded.

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2. WHAT’S AN OUTBREAK? WHAT’S AN INCIDENT? 2.1 Outbreaks due to food, water and other sources An outbreak of gastrointestinal illness, including GI infection, regardless of its source (food, water, direct or indirect contact with animal faeces, secondary transmission, etc.) may be defined in one of the following ways: (a) Two or more associated ("linked") cases of illness or infection. Clearly, the higher the

numbers of cases and/or the more severe the infection, the more significance is attached to the outbreak.

(b) A greater than expected rate of illness or infection compared with the usual

background rate for the population, in that particular geographic area and over a specific period of time or season. This includes cryptosporidiosis where elevated rates commonly occur during the spring most years and the PHPU must make a judgement as to whether rates are sufficiently elevated to convene an OCT1.

(c) A single case of certain rare infections such as polio, botulism or cholera, etc. that

have clear implications in terms of a threat to the wider public health because of their serious nature and/or high communicability. A single case of paralytic polio constitutes an outbreak of polio, most of which will be sub-clinical, but is nevertheless very serious in a country like the UK where the disease is considered eradicated. Similarly, with botulism and cholera, a single known case strongly implies there will be others in the community because of high risk of secondary transmission (cholera) or point source transmission (cholera, botulism).

A significant outbreak that requires investigation (i.e. the cause is not immediately obvious), complex decision-making or control measures, requires a multi-agency OCT. If in doubt, convene an OCT; it can always be stepped down if ultimately deemed unnecessary. 2.2 Foodborne incidents A suspected, anticipated or actual incident involving microbial, chemical or radioactive contamination of food, even in the absence of confirmed illness, may lead to the convening of an IMT. This will be guided by the principles in the CMO Guidance published in 2003. In this case, the main effort will rest with food safety EHOs investigating the contamination of food and/or recalling distributed foods, in consultation with the FSA(S), and the NHS Board response will focus on enhanced surveillance of illness. 2.3 Waterborne incidents A suspected, anticipated or actual incident involving microbial, chemical or radioactive contamination of water will lead to the activation of the Scottish Waterborne Hazard Plan (SWHP), even in the absence of confirmed illness. Again, this will be dealt with by an

1 If, following investigation of such excess rates, no common source can be identified, the PHPU may relegate them to the status of 'an unexplained excess of cases' (e.g. spring-related excess of cryptosporidiosis) rather than 'an outbreak'.

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IMT. In this case, the main effort will rest with Scottish Water investigating the contamination of the water and advising their customers on the safe use of water. Nevertheless, the NHS Board retains leadership and overall responsibility for this investigation as per CMO Guidance referred to above. The NHS Board response will focus on enhanced surveillance of illness and reminding clinicians about how to advise vulnerable patient groups about the safe use water, as well as providing chairmanship of the IMT, and leadership of any communication sub-group that may be required, and the completion of a final IMT report. 2.4 Incidents and Outbreaks associated with deliberate releases of

CBRN2 In the early stages of such events, the deliberate nature of the cause may not be apparent. For this reason, all significant incidents and outbreaks necessitating the convening of an OCT/IMT, where the cause is not immediately apparent, should be reported to the police so that they can decide if there is a link with a deliberate act or whether they have any other role in controlling public disorder. In addition, the basic response by the CPHM and EHO should be the same, paying particular attention to the recording of significant events and responses, the quality of evidence-gathering, and the need to maintain confidentiality throughout, given the subsequent interest by the Procurator Fiscal (PF). Therefore, incidents and outbreaks associated with deliberate releases of chemical, biological, radiological or nuclear agents will be handled using the same plans and guidance documents described above as appropriate. In addition, specialised restricted guidance on chemical or biological agents will need to be accessed from the HPS website, the PHPU or the NHSGGC Emergency Planning Officer (EPO). The key difference is that the OCT/IMT will be accountable to the Scientific and Technical Advisory Cell (STAC) at the Strategic Coordinating Centre (SCC), usually through the DPH, who would normally be expected to attend the (STAC), having been briefed by the CPHM chairing the OCT/IMT meetings.

2 CBRN is an acronym for chemical, biological, radiological and nuclear. It is generally used to describe deliberate releases of a serious nature including those perpetrated by terrorists and other criminals.

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3. RECOGNISING AN OUTBREAK There is a myriad of ways that an outbreak can be suspected or identified. Information which draws attention to the possibility of an outbreak may come to the attention of any of the following agencies:

• Local Authority’s Environmental Health Service • consultant clinical microbiologists in NHS Division hospitals • hospital control of infection officers/nurses • local GPs • local clinicians (in hospitals or clinics) • Departments of Public Health (NHSGGC and others) • Scottish Water • HPS • FSA(S), Etc Any agency which suspects that an outbreak may be occurring should contact a CPHM (CD/EH)) or the on-call CPHM at the earliest opportunity (see Appendix B). 3.1 Notifying ‘alleged’ sporadic cases and outbreaks of unconfirmed

food poisoning Occasionally, members of the public contact the statutory agencies to report what they suspect is food-borne illness linked to a food premises, affecting a single case (sporadic) or more than one in a party of people who ate together (a possible cluster or outbreak). Some of these can be large and serious in nature, highlighting significant one-off or on-going problems with a possible food source that has gone undetected by routine surveillance methods. The key to successful investigation of foodborne outbreaks is timely case finding. The sooner the PHPU is notified of an alleged outbreak associated with a food premises the better in terms of improving the chances of accurately identifying the cause. The more cases of illness that can be brought to the attention of the PHPU, the more importance the outbreak is assigned and the better elucidated the spectrum of severity of illness in that outbreak. The PHPU depends on the environmental health departments maintaining proactive open communication, preferably by telephone, although fax will suffice for routine reporting of single cases. Delays of more than four hours are undesirable and delays until the next working day are unacceptable, particularly during outbreaks. A Standard Operating Procedure (SOP) for the way councils report alleged food poisoning to the PHPU is as follows: For a sporadic case: Fax completed ‘notification of alleged food poisoning’ form within that working day for each single case. Telephone if there is anything unusual or causing concern about the case (e.g. clinical botulism). For a cluster or outbreak: Phone the PHPU immediately and send ‘notification of alleged food poisoning’ form within that working day. It is critical that:

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• the initial informant to the statutory agency is advised in the first instance about the need for cases, that are ill with diarrhoea or vomiting, to provide a stool specimen as soon as possible. It should be made clear to the informant that it is difficult to investigate a suspected foodborne outbreak without confirmed microbiological results. In addition, this opportunity can be taken to advise the informant that they can obtain additional health advice from the PHPU at NHSGGC.

• all the relevant contact details for this initial informant (and/or the host organising the event) are obtained, including their name, address, work telephone number and mobile phone number (if available). If these are not available, the reason should be stipulated on the form.

• details such as date of consumption of the food, date(s) of onset of illness, etc. are very important and should refer to dates e.g. ‘was ill on 11/03 pm’, rather than days, e.g. ‘was ill on Saturday night’. Dates are less ambiguous and therefore preferred.

3.2 Investigating outbreaks is a key function of the Department of Public

Health at any NHS Board Key background information required to recognise an outbreak includes: • the normal background incidence in NHSGGC (consult the SIDDS database or an

information officer in the PHPU to assess what rates you would expect for a particular geographical area for that time of the year based on average figures for previous years)

• the number of suspected cases/the number confirmed microbiologically in a specific time period

• the epidemiological description of initial cases including an ‘outbreak curve’ plotting number of cases by onset against time (date of onset)

Once it has been determined that an outbreak is taking place, the OCT should try and answer the following questions: • Are there likely to be more cases? • Is the organism involved unusually pathogenic to humans or even likely to cause death? • Is there a potential for transmission to large numbers of people? • Are there any unusual or exceptional features? • What is the likely or potential medium of transmission, if relevant, including drinking

water (private or public), foodstuffs, swimming pool or bathing water, etc which are implicated?

• Is there likely to be media interest? There may be insufficient evidence to confirm an outbreak although suspicion may remain. It is then necessary to collect further evidence before the occurrence of an outbreak can be excluded. These investigations should include: • a case-finding exercise, using an appropriate case definition (this may involve

contacting all the GPs and hospital clinicians to point out the need to encourage everyone presenting with a specific constellation of signs or symptoms to provide a stool or other sample for testing)

• a microbiological investigation (this may involve reminding all hospital laboratories to test every stool specimen for the suspected pathogen, or ensuring that every specimen

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gets sent from the local laboratory to the Reference Laboratory for that pathogen to ensure that every specimen undertakes further testing to identify the species and sub-species/sub-types/genotypes, etc

• an environmental health investigation or an investigation of other environmental factors. The environmental health department may decide to pursue an investigation of a food premises even in the absence of epidemiological evidence of human illness

The first two bullet points constitute 'enhanced illness-surveillance'. The final decision as to whether an outbreak has occurred and whether it is MAJOR OR MINOR (see definitions, page 8) rests with the CPHM (CD/EH) after discussion with the relevant Local Authority’s Environmental Health Services Department and/or consultant clinical microbiologist/parasitologist/virologist.

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4. INITIAL RESPONSE IF THERE IS A SUSPICION OF AN OUTBREAK 4.1 Contacting Public Health Any person knowing of or suspecting any event that could be an outbreak or serious incident (including chemical contamination or single cases of highly unusual or virulent organisms or toxins) must urgently contact the PHPU, based at Dalian House, Glasgow. Early reporting by telephone is encouraged. Clinicians should follow up by formally notifying the DPH of all cases of food poisoning (or other diseases covered by the infectious disease regulations).

Within office hours: Telephone 0141 201 4917 and ask to speak to the public health consultant responsible for communicable diseases or, in their absence, another public health doctor or nurse. The caller must stress the importance of the call to the support staff. There are staff allocated at all times to ensure that public health emergencies are addressed. Outside office hours: Telephone Gartnavel Royal switchboard 0141 211 3600. Ask for the on-call public health doctor. This service is for health professionals and statutory agency personnel only, not members of the general public. The on-call rota is served by two doctors, at least one will be a consultant. The on-call rota detailing personal contact numbers is no longer distributed to other agencies.

The ‘out-of-hours’ numbers for critical agencies are included in Appendix B and must be updated by all partners as they occur and confirmed at the quarterly PH-EH-Med-Vet Working Group meeting. NHSGGC premises are accessible out-of-hours. It is critical that the various participants understand whom they will be contacting and how to do this in the event of an outbreak identified out of hours. It is also critical that all the various agencies have adequate out-of-hours on-call systems/communication cascades that work and are regularly tested3. It is essential that all participating agencies are able to offer adequate on-going support to the process, including providing appropriately qualified relief staff for prolonged outbreak investigations. 4.2 The Role of the CPHM (CD/EH) As soon as there is a suspicion that an outbreak might be developing, a lead CPHM (CD/EH) will be nominated from NHSGGC to co-ordinate the investigation. The CPHM (CD/EH) will contact the agencies described below as appropriate and discuss the evidence

3 The on-call system was thoroughly audited in the spring of 2005 when the local authorities contacted the Public Health Medicine out of hours service and vice versa. Contact the Public Health Protection Unit for the results.

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for an outbreak. This can be done either by telephone or by assembling the relevant representatives at a PAG or OCT, the choice of group depending on the availability and strength of the evidence and the potential or apparent threat to public health. In outbreaks affecting more than one local authority area, all relevant EHOs should be invited, although the EHO representing an area with few cases may opt to be kept informed by the chairman and their EHO counterparts rather than participate in the team’s meetings. In outbreaks affecting more than one NHS Board area, the Board with the largest number of cases should take the lead, unless the outbreak is extensive in which case leadership from HPS may be provided. In the latter case, the individual Boards will submit the results of their investigations to the chairman of HPS and HPS would be expected to coordinate this information-gathering exercise and provide the final report. However, responsibility for controlling the outbreak remains with the local authorities and NHS Boards. It may be necessary to call an informal preliminary meeting of relevant parties to ensure all evidence is considered; this will be referred to as the PAG. This may be conducted in person or by telephone (a teleconference of all parties is most preferable). Therefore officers attending the PAG will need to ensure they can either take on the role of a full member of the OCT or should be in a position to contact the appropriate person who should then attend the OCT. Circumstances may dictate that this OCT is held at very short notice. Any PAG meetings should be kept brief to ensure that, if required, an OCT is established without delay.

Key Questions for Problem Assessment Group

• Are there or could there be a large number of cases • Is there a possibility of further cases? • Has the source or transmission route been identified? • Are additional control measures required? • Is co-ordination necessary? • Is the suspected organism unusually pathogenic or has other unusual features? • Is communications and media management required?

If the answer is “yes” to any of these, an OCT may be warranted.

The three core members of any PAG or OCT are the: • CPHM (Chair) • EHO • clinical microbiologist/scientist Although inviting advisers from HPS is advisable, they are not a replacement for the relevant EHOs. All other members are contacted as appropriate and depending on the nature of the outbreak, either in advance of the first meeting or following discussion at subsequent meetings. The contact details of the key players can be found in Appendix B. In conjunction with these professional colleagues, the CPHM (CD/EH) will ascertain whether, using available epidemiological, microbiological and clinical evidence, an outbreak has occurred and what an appropriate response will be. 4.3 Convening an OCT

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It is critical that the OCT is fairly constituted and contains all the necessary expertise. It is therefore essential that all the partner organisations provide the backup required to operate an effective OCT, limiting the number representing any one agency to ideally two, and no more than three members. The chair of the OCT (who is usually a CPHM) should approach the DPH of NHSGGC if there is a problem in procuring such expertise. In addition, the OCT reserves the right to consult widely on all medical, scientific or public health matters. Where the usually constituted OCT lacks necessary expertise (e.g. breakdown of swimming pool treatment plant), a case for commissioning an expert report should be considered, the funding of which needs to be agreed on a case-by-case basis. 4.4 The location of OCT Meetings OCT meetings are best held at NHSGGC HQ in the case of community-based outbreaks and in the relevant hospital in the case of hospital-based outbreaks. 4.5 Guiding Principles 4.5.1 Seeking advice and accountability It is critical that the OCT, convened either within or outwith office hours, is appropriately constituted, ensuring adequate expertise to enable optimal decision-making. Advice from knowledgeable sources should be obtained by telephone, email or fax, if the relevant experts are unable to join the team. The source and nature of this advice should be documented in writing. Ultimately, however, the team is responsible for judging the advice it receives and the decisions it makes. 4.5.2 Declaration of conflict of interest and assigning status of participants on OCTs At the very first meeting the Chair should remind the IMT/OCT participants of their roles, responsibilities and status as members of the group. Attendees should be required to declare any possible conflicts of interest as individuals or on behalf of their organisations. Where a declaration of a possible conflict of interest is made, it should be recorded and a decision made by the Chair on that individual’s status. Individuals who are not full members may continue to attend the IMT/OCT by invitation, but should not expect to have equal rights in terms of determining the conduct of the investigation, the advice given to the public, the content of the press statements or the final report. 4.5.3 Confidentiality It is imperative that all members of OCTs, and their contacts within their respective agencies, understand that the information they receive at an OCT is strictly confidential and transmitted on a strictly ‘need to know’ basis. Any breach of confidentiality, particularly to the media, will be treated seriously and consideration by the chairman given to replacing the offending member on the team. 4.5.4 Handling disagreement within an OCT Should any member of the OCT be unhappy with the way the team is functioning, they are encouraged to raise this with the group or with the chairman in private. If their concerns cannot be resolved satisfactorily they are free to raise them with their senior manager who in turn can raise it with the chief executive of their agency. That chief executive has the option of raising it with the chief executive of the NHS Board leading the investigation who will ultimately bring it to the attention of the chair via their DPH, involving the relevant counterparts of any other agency involved in the dispute. The lead officer for the

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NHS Board (usually the DPH) is responsible for resolving these issues, preferably within the framework of the multi-agency OCT. 4.6 Members’ Roles 4.6.1 Local Authority’s Environmental Health Service Advice will be taken from a senior EHO of the appropriate local authority, or authorities. Support from EHOs might include assistance with interviewing cases of illness using the standard or disease-specific questionnaire agreed with the PHPU4; investigating food hygiene practices and taking samples from food premises; advising on and enforcing public health legislation including the Food Safety Act, etc. The active participation of an EHO is considered a critical component of any OCT, which should not be allowed to make crucial decisions without such local authority representation. In addition, it is important to ensure that at least one EHO representative is invited from each local authority affected by the outbreak. 4.6.2 Clinical Microbiology (bacteriology, virology, parasitology) The Board CPHM will chair community based outbreaks, and if the outbreak is localised in one sector of the NHSGGC area, the local hospital will provide microbiological support and nominate a consultant clinical microbiologist for the outbreak team. If the outbreak is area-wide, then one consultant clinical microbiologist from the most appropriate NHS hospital will be nominated to provide support to the PAG/OCT whilst maintaining liaison with the other hospital laboratories. The lead-laboratory, in conjunction with other laboratories, will provide microbiological support for analyses of specimens. Minor hospital-acquired outbreaks are normally chaired by the appropriate hospital Infection Control Doctor (ICD) with advice and support from a consultant clinical microbiologist. The CPHM should chair OCTs for major outbreaks as recommended in the Watt Report. A major outbreak includes situations where there is a death, serious life-threatening morbidity or exceptional media interest. A consultant clinical microbiologist will be a core member of any hospital OCT. 4.6.3 Press Officer/Director of Communications NHSGGC has agreed a Communications Strategy with all of its partner agencies that should be consulted via the NHS Board communications representative attached to the OCT. Attendance by the NHS Board Public Relations Officer (PRO) at the OCT meetings will be at his/her discretion, although this is generally considered essential in significant outbreaks. He or she may set up and chair a communications sub-group which will include the PROs from all the participating agencies.

4 Generally, it is assumed that EHOs will interview community-based cases of infection while the PHPU Infection Control/Health Protection Nurse Specialist at NHSGGC will interview hospital-based cases (whether hospital or community acquired). However, the PHPU reserves the right, following consultation with the relevant local authority, to interview community-based cases if necessary to quickly obtain information deemed vital to efforts to protect the wider public health. Whichever department of the two ultimately interviews cases, it is obliged to fax the surveillance form to its counterpart at the other statutory agency. Similarly, if the quality of information obtained is deemed unsatisfactory by either party, that party should contact the interviewer to clarify the details.

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All press releases must have prior approval of the OCT. It is a fundamental breach of OCT protocol for a participating agency to issue a separate press release or release information, formally or informally, which has been obtained from the confidential OCT meetings. Nevertheless, there are occasions when other agencies represented on the OCT, including one causally linked to an outbreak, require to issue information to the public regarding, for example, technical or financial aspects of the facility involved or the response to the outbreak. A key example is the water authority requiring to give advice on the safe use of the water during a waterborne outbreak. In this case, any such press statements require to be cleared with the OCT in advance of being released. 4.6.4 Seeking representatives from other Agencies or professional groups HPS should be informed of significant outbreaks (including CBRN incidents/ outbreaks) and may provide epidemiological assistance/support for the OCT, if appropriate, as a full member. However, HPS representatives are advisers to the OCT, and the CPHM in conjunction with the EHO, is ultimately responsible for decisions made by the OCT. The Scottish Government should be informed of major outbreaks. They may send a representative to attend the OCT, as an observer or ‘in attendance’. Similarly, Scottish Water representation (maximum of three members including a scientific officer and a senior manager with responsibility for operations) is essential during suspected waterborne outbreaks although these officers will be ‘in attendance’, providing information to the team as required (see paragraph 4.2 and appendix B). Scottish Water representatives will be expected to attend all meetings, except perhaps those of any sub-groups charged with discussing the clinical details of named ill patients. Animal Health (AH) should be contacted to send a veterinarian as a representative if salmonellosis associated with animals is suspected. Where other zoonoses are suspected, the Scottish Agricultural College (SAC) should be approached to supply a veterinarian to the OCT. The relevant expertise for cryptosporidiosis may not be available from the SAC and it is advisable to consider a HPS expert on the subject (if available) and a parasitologist with relevant expertise (see Appendix B). Other personnel who may be invited as appropriate to attend the OCT include representatives from:

• Glasgow Scientific Services • Scottish Environment Protection Agency (SEPA) • NHS Board and/or Hospital General Management (as necessary, observers only) • Other NHS Boards in incidents which cross boundaries • Relevant Reference Laboratory • West of Scotland Specialist Virology Centre • FSA(S) • The Care Commission • Strathclyde Police (if the outbreak is deemed to be the result of a criminal act, a

deliberate release of a CBRN agent or if there is a need to control public disorder or protect water bowsers, etc. See below)

Other potential members that should be considered include:

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• Appropriate physicians (specialist infectious disease consultants, general physicians, GPs or paediatricians)

• Infection control nurse from the hospital or primary care services • Infection control doctor (medical microbiologist) from the hospital or primary care

services • Infection Control Nurse and/or Health Protection Nurse Specialist (HPNS) from the

PHPU • Others, as dictated by the outbreak The Chair, in consultation with the OCT, reserves the right to invite other experts as required. 4.6.5 Civil Contingencies Planning/Emergency Planning Officers (EPOs) EPOs working for the local authority and the NHS Board provide an essential emergency planning contribution during non-outbreak periods and are instrumental in the regulation of large events and the response to major emergencies and catastrophes. During an outbreak, the council EPO, accessed via the EHO, offers an essential support to the OCT, for example, with evacuation of buildings and closure of local authority buildings and services, etc. The EPO for the council and the NHS Board would not normally be expected to attend the OCT meetings, which can be time-consuming and over-subscribed. Instead, it is essential that EPOs offer whatever support they are able to both within and outwith office hours at the request of the OCT, via the EHO and CPHM attending these meetings. 4.6.6 Strathclyde Police In outbreaks where criminal acts may be the underlying cause, the CPHM should ensure that appropriate discussion is undertaken, usually by the EHOs, with the Police and/or the PFs Office and at the earliest opportunity. In the early stages of an investigation, links with criminal activity may not be obvious to the OCT. For this reason, it is advisable to inform the police at the outset (immediately after the first PAG or OCT meeting) that a significant outbreak has been identified for which the cause is not immediately obvious. The Police will then decide if the outbreak has any significance for their work, if they need to attend the OCT meetings and if they have any other role to play (e.g. water bowser security). 4.7 Informing or consulting with other agencies Informing and regularly updating the relevant Scottish Government departments is critical, including the Department of Health, the Drinking Water Quality Division5 (DWQD), and the Department of Environment and Rural Affairs, etc. Normally, Scottish Government departments would not be expected to directly influence, or overturn, the decisions made by an OCT. Any advice provided by the Scottish Government that is in contradiction to that proposed by an OCT should be requested in writing (fax, email or letter). Foodborne outbreaks should also be reported to the FSA(S), including out of hours, although the amount of support the FSA(S) can provide out-of-hours may be limited.

5 This is the Division within the Scottish Government that accommodates and employs the Drinking Water Quality Regulator for Scotland (DWQRS).

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Other agencies may be accessed on an ad hoc basis, including academic university departments and specialist veterinary research institutes (e.g. The Moredun Institute, Edinburgh; Veterinary Laboratories Agency; Scottish Agricultural College (SAC) Veterinary Services, Auchencruive; Pool Water Treatment Advisory Group; etc). Useful expertise can also be sought from outwith Scotland, although it must be borne in mind that this should be validated (referenced) and qualified by the fact that any advice obtained may not officially apply in Scotland. In the event of fatalities arising during the outbreak it is appropriate for the relevant NHS clinician to report the death to the PF (if required by Health and Safety legislation or if otherwise suspicious) and for the Chairman of the OCT to consult the PF for advice. 4.8 OCT Support and Resources The PHPU at NHSGGC, Local Authority Environmental Health Services and NHS hospitals have personnel whose main tasks are communicable disease control and food safety. In terms of a large outbreak, NHSGGC and some of the larger council Environmental Health Service Departments have additional resources they are able to divert from other public health and environmental duties as well as the ability within NHS hospitals to reduce elective admissions to hospitals to free up hospital beds and channel staff to assist in dealing with such an outbreak. These additional resources include the Civil Contingencies Planning Unit of NHSGGC and these councils. However, it must be borne in mind that the scope available to some of the smaller Local Authorities for diverting staff resources may be more limited and appropriate contingency plans should be agreed by those authorities. 4.8.1 Administrative support The investigation of an outbreak can involve a large amount of work and under pressurised conditions. It is essential that adequate administrative and secretarial support be offered by the NHSGGC’s Corporate Services Department or the PHPU, or by the lead NHS Board if not NHSGGC. This should include an experienced minute taker who is accustomed to dealing with outbreaks in communicable disease and who can ensure that a preliminary draft of the minutes is available for the next OCT meeting. In addition, an administrative assistant should, ideally, be appointed from the relevant NHS Board to organise/oversee the entire process in terms of booking meeting rooms, arranging refreshments, circulating agendas and minutes, taking calls during meetings, etc. In exceptional circumstances, the Chair, in consultation with the OCT, may require to discuss the need to convene an OCTSG in conjunction with NHSGGC’s lead officer, normally the DPH (see paragraph 51 of the CMO Guidance Managing Incidents Presenting Actual or Potential Risks to the Public Health published in 2003). 4.8.2 Sub Groups of the Incident Management Team/Outbreak Control Team Sub-groups may be established by the IMT/OCT to manage specific aspects of the incident/outbreak, reporting back to the IMT/OCT for ratification of recommendations before implementation. The sub-groups may be required to ensure that control measures once ratified are implemented. The number and nature of sub-groups will depend upon the nature of the incident/outbreak but will generally include: - Communications: Multi-agency group of Public Relations Officers (PRO) and Press

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Officers - responsible for all aspects of communication with both the general public and the media. The NHSGGC PRO should normally lead this sub-group. Technical: Specialists responsible for all technical aspects of mitigating and ultimately resolving the incident/outbreak. Health: Responsible for advising all sections of the NHS of the potential health implications of the incident/outbreak, and, ensuring protocols are in place to rapidly identify any clinical cases which may have occurred as a result of the incident/outbreak, planning clinical care of patients and organising analytical epidemiology investigation. Local Authority: Responsible for advising all relevant Local Authority departments of the potential effects of the incident/outbreak and, to monitor as appropriate the effects and co-ordinating food and environmental investigation. Police: To investigate potential criminal aspects of the incident/outbreak whether negligent or deliberate. To assist the IMT/OCT in aspects of providing escorts to technical teams (if required) and public awareness/safety. Civil Contingencies Planning: Representatives from health and Local Authority (as required) Civil Contingencies Unit to provide support to the IMT/OCT. Admin Support Group: Minute taking, meeting preparation etc. 4.8.3 Outbreak Management Support Team (OMST) In exceptional circumstances, for example, large scale incidents, in particular those of national interest, it may be necessary to establish liaison between Executive Officers of the involved agencies through a separate OMST. In this case, the Chair of the OCT should discuss the need for an OMST, with the OCT, in conjunction with the Lead Officer for the Board, normally the DPH. The Guidance on the Investigation and Control of Outbreaks of Foodborne Disease in Scotland and CMO Guidance should be consulted on how such a group should be expected to function and how it relates to the OCT. Purpose of the OMST is to enable the OCT to fulfil its remit more effectively. Its members should address secondary issues raised by the outbreak, providing logistical, strategic and additional backup assistance, thus allowing the OCT to concentrate on the essential business of tackling and controlling the outbreak. It should be borne in mind that the OMST does not have a strategic role with respect to the decisions made by the OCT, but rather an operational, logistic and supportive role to enable the OCT to focus solely on its function. Thus, the OMST would not make independent decisions or take actions relating to the investigation or control of the outbreak, (that is solely the role of the OCT). The OMST has a flexible remit according to the circumstances. It should include:

• supporting the OCT by providing it with additional information and resources needed for its effective functioning

• supporting the OCT by providing an alternative contact point to deal with external factors e.g. media enquiries, whilst recognising that the OCT will have a named media spokesperson and are responsible for writing all press releases

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• making strategic decisions on the wider impact of the outbreak on services not directly implicated in the incident e.g. assessing impact on delivery of health care to other patients

• mobilising additional resources on request to aid the control of the outbreak and support the OCT (e.g. additional input from administrative, clerical, legal and information services outside normal working hours)

• considering financial issues, such as meeting costs of additional sampling, staff overtime etc

• ensuring staff support and rotation • assisting communications management and information distribution to other health

professionals and key national agencies, specifically the FSA(S)/Scottish Government who have the responsibility to brief ministers

• deal with enquiries from local and national politicians • respond to requests from the OCT where additional help is required to resolve

problems which may compromise the action of the OCT.

The OMST may not require to physically meet but potential members should be aware of their remit to liaise with each other and their respective OCT members during large outbreaks. Should the outbreak involve more than one of the NHS Boards within the Strathclyde Regional Co-ordination Group* the Directors of Public Health for those Boards will agree a lead NHS Board and appoint a chair for the Regional Group. This would act in the same way as an OMST in a single NHS Board area. This group could, for example, draw additional staff from the 3 NHS Boards to reflect the nature and geographical extent of the outbreak. *New nomenclature for Civil Contingencies Planning

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5. DECLARATION OF AN OUTBREAK The CPHM (CD/EH) on behalf of the DPH is responsible for declaring an outbreak after agreement with the core members of the OCT. The CMO Guidance on investigating incidents and outbreaks clearly emphasises the need to be open and frank about disclosure and to record in writing any reasons for not going public over ANY outbreak, particularly those of wider public health significance. Proactively released Press Statements/Holding Statements6 agreed by the OCT indicating that there has been an outbreak and summarising the nature and extent of the outbreak including clinical casualties is strongly advised if there has been at least one death or if there is likely to be significant public interest. If no proactive release is planned by the OCT, a Holding Statement for use by PR staff overnight should be retained. The contents of any Press/Holding statements are agreed by the OCT before being vetted by the NHS Board Press Officer who should then confirm the content with the OCT before issuing it. Under no circumstances should any agency represented at the OCT take it upon themselves to unilaterally issue a press release referring to information discussed in OCT meetings.

6 A Holding Statement is defined by the fact that it informs interested parties that a clear conclusion/statement is pending ongoing investigation and is expected within the next few hours. It can be retained for use if and when the media contact the Board or, alternatively, it can be proactively released.

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6. THE ROLE OF THE OUTBREAK CONTROL TEAM The following section has been copied from the paragraphs 2.16-2.18 of the Guidance on the Investigation and Control of Outbreaks of Foodborne Disease in Scotland:

The role of the OCT is to agree and co-ordinate the activities of the agencies involved in the control and investigation of the outbreak in order that the aetiology, vehicle and source of the outbreak are identified and control measures are implemented as soon as possible and if required, legal advice sought.

This may involve all or some of the following:

• case finding and interviews • clinical and environmental sampling • consideration that waterborne disease may be implicated • inspection of suspected premises • identifying the need for appropriate medical care facilities for patients and ensure that

local hospital plans are adequately addressed • agreeing action to control the outbreak and prevent further spread by means of

exclusions, withdrawal of foods thought to be hazardous (it may be necessary for members of the OCT formally to request information in terms of the relevant legislation), closure of premises, etc., always paying due attention to the need for effective risk assessment and management, and the primacy of public health over commercial considerations. In this instance the FSA(S) should be informed

• agreeing and co-ordinating the provision of advice to general practitioners and other professionals and to the public including the setting up of a help line if required

• generating a hypothesis for the potential cause(s) of the outbreak • to test hypotheses using analytical epidemiological studies • to agree arrangements for media liaison including press statements and the regular

release of information • to lead and co-ordinate all activities in the case of a multi-board OCT • to inform and liaise with HPS, Scottish Government and FSA(S) colleagues and

appropriate regulatory bodies • to produce a full report or reports, including lessons learned, for NHS Board, LA,

FSA(S), Scottish Government, HPS and other interested parties. A suggested template for an OCT report is available in Appendix XV of the Guidance on the Investigation and Control of Outbreaks of Foodborne Disease in Scotland

• to consider specific advice/guidance for patient support/voluntary groups in particular circumstances

Individual agencies should carry out investigations or take control action only after discussion with the team or, if that is not practical, with the Chair who will keep the team fully informed. It is imperative that members of the OCT share all the available information with the OCT even if it is still confidential in nature. A ‘checklist of matters’ to be considered by the team can be found in the Guidance on the Investigation and Control of Outbreaks of Foodborne Disease in Scotland.

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7. ‘INCIDENT’ ROOM NHSGGC’s Strategic Operations Room (Level 4 North) in Dalian House (HQ) could be used for this purpose. However, other larger rooms may be available at Dalian House including the Board Rooms for larger meetings (particularly out of hours). Alternatively, an incident room may be available within the Emergency Planning Control Room of Glasgow City Council (2nd Floor House 5 Charing Cross Complex) or in one of the other Local Authorities if required. Helplines A 10-landline helpline facility can be set up within the Strategic Operations Room at NHSGGC HQ by contacting the civil contingencies planning unit (see Appendix B for contact number). Alternatively, NHS24 can be used to provide information of a clinical nature by qualified nurses (see Appendix B for contact number). Finally, NHSGGC is part of the SECG Helpline system which will enable rapid connection to a tiered automatic Helpline, the third level of which will be manually operated. If it is likely that hundreds or thousands of callers are likely to inundate NHSGGC within a period of several hours or days, the bulk of routine inquiries can be satisfactorily dealt with rapidly while steering more complex calls to alternative messages and/or services. The SECG helpline can be accessed 24 hours a day via Force Control at Strathclyde Police (see Appendix B for contact phone number). Short stop-gap messages can be installed within minutes that can prevent NHS24 from being inundated with calls. In situations where NHSGGC activates the SECG helpline, NHSGGC will be responsible for the overall management of all messages placed on the system.

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8. CARE OF PATIENTS In most outbreaks the majority of patients will not be hospitalised, but remain in the community. This section covers care of patients in the community since once hospitalised, infection control procedures, sampling and treatment are undertaken in the same setting. The general clinical care needs including provision of appropriate medical care facilities should be discussed at OCT meetings, however regard for the confidential nature of individual patients’ conditions should be taken. Local hospital OCPs should include considerations about treating an excess of patients with an infectious disease. 8.1 Infection control One of the mainstays of outbreak management is adequate infection control. Timely infection control advice for infected patients is vital to prevent further cases. In the community, EHOs and health professionals play a crucial role. To avoid confusion the professionals performing this function should be assisted by the provision of information about the outbreak, the disease and details of specimen and request form requirements. NHSGGC’s PHPU have a number of leaflets available and others can be produced to augment this advice for specific circumstances if necessary. Production of suitable literature can be delegated to a sub group of the OCT. The content should be agreed by the OCT, or if that is not practical with the chairman of the OCT, prior to distribution. 8.2 Sampling and testing It should be made clear which agency is responsible for follow-up testing. In many circumstances faecal samples of contacts may be better co-ordinated by EHOs instead of by the general practitioner. To avoid confusion, decisions about who will sample should be discussed and recorded. • All parties should use the same outbreak code or reference on request forms • All sample request forms should state “copy results to PHPU, Dalian House” • It is good practice to leave written information about the sampling, its frequency and

advice on sample submission with the member(s) of the public involved • If a specific medium or technique is required for human samples, this should also be

stated 8.3 Treatment Unambiguous advice on the most important form of treatment should be devised by the consultant microbiologist (and hospital physician or general practitioner if involved) and distributed to health professionals. In major outbreaks additional primary care resources may need to be established. These might include triage clinics or treatment/vaccination centres. Such sites would also act as initial referral and patient information centres and specimen collection points.

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9. LABORATORY RESOURCES AND SAMPLING On suspicion of an outbreak, early decisions regarding appropriate sampling need to be taken between CPHM, Senior EHO and consultant microbiologist. Thereafter, whether an OCT is called together or not, close liaison between the CPHM or colleague and consultant microbiologist is paramount. Similarly, EHOs or other operational staff involved in sample collection should link closely with the receiving laboratory and public health and refer to the recommendations of the OCT (where established) regarding sampling strategy. In an outbreak, summary details should be distributed to all the NHSGGC laboratories and others as applicable, not just the one likely to receive the majority of specimens. 9.1 Laboratories Testing capabilities of the key laboratories change rapidly and it will be an important function of the OCT to ensure that the most appropriate laboratory testing is organised for the suspect organism, toxin or chemical. The OCT should appreciate that in large outbreaks the capabilities of single laboratories may be overwhelmed and additional laboratories may require to be contracted to undertake a share of the work. This has resource implications and decisions on cost allocations will need to be taken by the OMST with reference to the OCT. It has been agreed that in an outbreak the majority of foodborne or waterborne outbreaks, samples will be directed as follows: Human faecal and blood samples (e.g. for serology): To the closest Greater Glasgow and Clyde Microbiology Laboratory**. Where additional analysis is required (e.g. typing, or unusual pathogens) the samples will be forwarded to the appropriate reference laboratory from the local laboratory. Laboratory investigations of suspected chemical foodborne illness may require additional laboratory investigations such as biochemistry, haematology or specialist trace element or toxicological analysis. Food samples*: Food samples and kitchen surfaces/utensils specimens obtained by the Food Safety EHO should be sent to the food science laboratory at Glasgow Scientific Services. Unless otherwise notified by a clinical microbiologist or CPHM, examinations will be carried out for Salmonella species; E coli 0157 and Campylobacter. Specific enteric pathogens, other than those indicated above, will only be looked for after discussion with the relevant clinical microbiologist or CPHM. Animal samples: The SAC are responsible for the protection of public health through the diagnosis of zoonotic disease in animals, and can advise and provide laboratory support to NHS Boards and local authorities. In the case of outbreaks involving salmonellosis in animals or their surroundings, the Divisional Veterinary Manager is the responsible person under the Zoonoses Order and will arrange for appropriate sampling of animals. In the case of other zoonoses, the SAC has a remit from the Scottish Government Environment and Rural Affairs Department (SEERAD) to carry out advisory activity. Therefore, where (for example) rectal swabs from calves, lambs or other animals are to be tested, the samples should be obtained by a veterinarian from SAC. Veterinary samples will be dealt with by the appropriate SAC Veterinary Science Division laboratory (or where additional analysis

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is required to confirm the human-animal link, to the appropriate reference laboratory e.g. the Cryptosporidium Reference Laboratory in Swansea in the case of an outbreak of cryptosporidiosis where animals are a suspected source). Water samples: If public drinking water is to be tested, the samples should be obtained by an EHO and/or an officer from Scottish Water (SW) and tested either at the SW laboratory, Edinburgh and/or the Glasgow Scientific Services (GSS) laboratory respectively, as appropriate, and referred to an appropriate reference laboratory for speciation/genotyping if required. Samples from private water supplies would be collected by an EHO and analysis would depend on existing arrangements for routine samples. During an outbreak situation which had been declared an “incident” for the Scottish Water, 24 hour access to sampling, courier and laboratory analysis is available. Glasgow Scientific Services personnel may need to be involved in the OCT to facilitate laboratory links, provide additional environmental and/or food sampling and co-ordinate results. Familiarisation of local authority staff with laboratory access and personnel. Staff familiarisation is paramount. Some EH Sections already ensure officers are regularly updated on the practicalities of sample delivery. It would be good practice to ensure an annual visit by key EHOs/Food Enforcement Officers to each of the local NHS microbiology department (for faecal samples) to discuss these procedures, in particular what would happen during an outbreak or out-of-hours events. During the course of discussion it may be suggested that another laboratory receives environmental or food samples for onward transmission. Local EH sections should consider their options in advance. A local written protocol may be useful especially since in an outbreak situation staff from another section may be required to assist. 9.2 Sampling It should be noted that in large outbreaks, especially those affecting the hospitality industry, a combination of methods for sample collection and collation may be required. Some of the best co-ordinated outbreak investigations have resulted when samples were organised through EHOs rather than through several general practitioners. Laboratories in Greater Glasgow and Clyde should, when possible, use an outbreak code to link outbreak samples in the computer and enable subsequent data searches for results. The appropriate code would have to be agreed by the outbreak team, recorded on all request forms and notified to all laboratories that might receive samples. Specific “outbreak” labels have been provided to local authorities to reduce the time taken completing forms. Forms should specify the outbreak code, organism(s) suspected, and a request to copy results to both environmental health and public health. For faecal samples, full personal details are required including date of birth (not just age), full name and address. Investigators should ensure full details are included and that the chain of evidence is preserved. A sampling strategy should be agreed by the OCT to cover: • nature of samples (e.g. human or animal, food and/or water samples) • responsibility for sample collection and delivery

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• receiving laboratory or laboratories • timescale of testing and analysis • appropriate use of laboratory facilities (e.g. workload and diversion of other work) • the “outbreak code” to be used on request forms • the preparation and distribution of sampling information to be given to the public (see

paragraph 8.1) Early notification, by a designated person, to all laboratories that may receive specimens is essential. This should include anticipated numbers of samples and likely suspect organisms. Laboratories need time to ensure there are adequate numbers of staff and supplies of appropriate media to deal with outbreak specimens. Consequently there needs to be early intimation from the in situ investigators on the type and quantity of samples likely to be presented once the initial assessment of the situation has been made. The anticipated time and mode of delivery of samples should also be agreed to ensure samples are not mislaid and are dealt with appropriately, and the chain of evidence preserved. For food samples the designated person should almost always be a suitably authorised EHO or food enforcement officer. Operational staff (or where established, the Joint Operational Team) will discuss the details of the sampling strategy and determine, with reference to others: • Individuals who will undertake sampling • Sample volumes and characteristics • Use of and access to appropriate containers • Details on request forms • Labelling of samples (including designated outbreak name) • Mechanisms for sample collection, transport and storage 9.3 Mechanisms to update and record results The OCT will assign the responsibility for keeping a central computerised register detailing personal details of cases, samples taken with dates and results. This register should be updated regularly and shared with the receiving laboratory and CPHM, who will provide additional information. Notes: • * NB “Outbreak” food samples should only be directed to Glasgow Scientific Services

with the initial agreement of the CPHM and subsequent discussion with a microbiologist to alert them to the quantity and type of food, and discuss presenting symptoms and suspect organism. This does not apply to individual food complaints from consumers, family outbreaks or situations where initial faecal sampling of one or more complainants has not been undertaken.

• In outbreaks of suspected viral gastroenteritis the decision to sample food is made

after initial inquiries based on detail of cases and whether a point source is indicated or person-to-person spread more likely.

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10. POWERS AND LEGISLATION A wide raft of public health legislation exists that can be implemented by a variety of officials, as named by the relevant individual Act or Regulations, in different settings and in different agencies. Specific control measures required for individual outbreaks may vary and may be directed to infected persons or at the source of vehicle of the infection. In the majority of outbreaks the legislation will be used to: • exclude infected people from work, school and pre-school settings, • inspect, detain and seize suspect food, • close premises, however, a variety of other enforcement actions are available. The Water Quality Regulation Team at the Scottish Government is the main regulator of the quality of the public water supply and has at its disposal, as does the council EHO in the case of a food premises, the option of referring a case to the PF for court action. 10.1 Exclusion from work, school and pre-school settings Under the current legislation, Public Health etc. (Scotland) Act 2008 a competent person of the health board may make the following orders: • an exclusion order, prohibiting a person from entering or remaining in any specified

place (e.g. work, school, pre-school); • a restriction order, prohibiting a person from carrying on any activity specified in the

order (food handling); • a combined exclusion and restriction order. The Board is required to compensate a person (or carer) who has suffered loss of income as a result of complying with that request. 10.2 Inspection Of Premises As soon as there is reasonable suspicion that food premises are involved in an outbreak, whether small or large scale then an inspection of the implicated premises should be made as soon as possible. This may mean that inspection may precede the formation of an OCT in which situation the information gleaned at the inspection can add to the information considered during the assessment phase or at the first meeting of the OCT. Suitably authorised EHOs and/or food enforcement officers will normally undertake inspections. The purposes of the visit is to: • undertake a food hygiene inspection • collect food and environmental samples

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• assess the nature of food produced and its distribution pattern • glean further information of relevance to the investigation and control of the outbreak Information about the health status of food handlers and collection of relevant samples (including those from staff) may also be undertaken by the same inspectors, although in some local authorities this may be undertaken by different officers with a public health remit. Exclusion of food workers needs to be considered. Follow up visits are necessary to continue to assess the compliance with advice, institute control measures and gain further information or samples pertinent to the outbreak investigation. In situations where a larger team is required to undertake this work, this team should have a nominated leader who may or may not be the same person who is leading the Joint Operational Team. Use should be made of the aides memoire for food premises inspections and food sampling and the checklist for product recalls contained in the "Guidance on the Investigation and Control of Outbreaks of Foodborne Disease in Scotland", adapted for local use where necessary.

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11. FOLLOWING THE OUTBREAK 11.1 Declaring the outbreak over The OCT has to consider the available evidence and decide when an outbreak is over and that there is no longer a risk to the public health. A statement to this effect should then be made and communicated to the public and all appropriate agencies. 11.2 Audit, evaluation and reporting A formal debriefing meeting or meetings of the OCT should follow to consider the management of the incident, lessons learned and to recommend further preventive action if required. An assessment of OCT effectiveness in controlling the outbreak should be undertaken with HPS. Measures include: • Preventing further cases of ill health • Minimising morbidity and mortality through specific patient care measures • Communicating with the public about risks Thereafter each member of the OCT should contribute to an anonymised outbreak report. This report should, in addition to describing the outbreak, consider the effectiveness of the investigation and the control measures taken. It should also review the media management aspects and effectiveness of communications. A template for the production of a final report is in Appendix XV of the FSA(S) “Guidance on the Investigation and Control of Outbreaks of Foodborne Disease in Scotland.” A timetable for report completion should be set but the final report may be delayed or limited as a result of pending legal action. The report should be agreed by the OCT, signed by the core members and circulated to appropriate individuals and authorities. It should be formally tabled at a meeting of the Area Control of Infection Committee (or alternative with executive officers) where any recommendations should be noted and decisions on follow-up made. A copy should be kept in the PHPU files and full minutes of meetings and paperwork pertaining to the outbreak will be kept separately in view of the confidential patient information they contain. A copy of the report should be provided to the Chief Executive (or equivalent) of all agencies involved in the outbreak. The CPHM will complete a standard summary form and forward it to HPS. As well as feeding back to members of the OCT, the outbreak should be used as a focus for other participants in the outbreak investigation and colleagues in other areas to ensure that lessons learnt are disseminated and opportunities for improvement are taken forward.

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11.3 Performance assessment The DPH will oversee an assessment of the OCT performance. The aim is to demonstrate the use of essential good practice and structure processes employed in controlling the outbreak. It may be appropriate to ask external assessors to undertake this work to ensure transparency and answer concerns that may arise about conflict of interest. The “Indicators of Good Practice” will be used for this purpose. A draft of these indicators is included in “Guidance on the roles and Responsibilities of Incident Control Teams” (Section 4.6) 11.4 Following up recommendations The OCT and its chair has an important decision-making role during the outbreak to bring it under control, as well as an advisory role, making recommendations as it sees fit and leaving the responsibility for implementing/enforcing the recommendations to the targeted statutory agencies. As of 31 January 2003, the NHS Board now has responsibility for following up these targeted agencies responsible for implementing specific recommendations made in OCT reports and ensuring that any reasons put forward for failure of implementation are documented in writing.

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12. REVISION OF THE PLAN This plan should be reviewed annually, reviewing lessons learned from local and national incidents together with relevant changes in legislation, organisations and the current epidemiological picture. This will involve raising the need to review the plan at the preceding quarterly meeting of the PH-EH-Med-Vet Working Group and circulating an electronic copy to all interested parties including the six local authority departments of environmental health, Scottish Water, AH, and appropriate representatives with medical and food microbiology expertise. Suggested amendments will be collated and debated at the subsequent meeting and incorporated by the PHPU at NHSGGC. It will be necessary to regularly exercise this plan by a variety of methods agreed by PH-EH-Med-Vet Working Group, to both update and improve it and to provide necessary staff training. In addition, Appendix B should be updated at least quarterly at PH-EH-Med-Vet Working Group meetings by ensuring that the review of contact details are a regular quarterly agenda item.

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DISTRIBUTION LIST Chief Operating Officer of the Acute Services Division, NHSGGC Departments of Microbiology of the District General Hospital Laboratories in NHSGGC Directors of the Community Health Partnerships/Community Health and Social Care Partnerships within NHSGGC Land and Environmental Services (Commercial, Food Safety and Public Health Sections) of Glasgow City Council (GCC), East Renfrewshire Council (ERC), West Dunbartonshire Council (WDC), East Dunbartonshire Council (EDC), North Lanarkshire Council (NLC), South Lanarkshire Council (SLC) and Renfrewshire and Inverclyde Councils Civil Contingencies Planning Unit, NHSGGC Board HQ Food Standards Agency (Scotland), Aberdeen Health Protection Scotland, Glasgow Public Health Protection Office of NHS Lanarkshire, NHS Ayrshire and Arran, and NHS Highland respectively Public Health Protection Unit, NHSGGC West of Scotland Specialist Virology Centre, Gartnavel General Hospital Scottish Environment Protection Agency Scottish Water Scottish Agricultural College Scottish Parasite Diagnostic Laboratory Animal Health