The September 2005, E.coli O157 Outbreak in South Wales.ppt

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1、The September 2005, E.coli O157 Outbreak in South Wales,Paul J Mee, Service Director for Public Health & Protection & Julie Barratt, Director CIEH Wales,Wrexham Outbreak August 2009,Surrey Outbreaks-September 2009,Introduction,Outbreak Control Plan Declaration of the Outbreak Initial Investigation &

2、 Control J Tudor & Son, Bridgend Control Measures Detailed Investigations & Results Communications, Politics & the Media Chief Medical Officers Review Police Investigation The Local Authority Prosecution What have we learned? Response to Public Inquiry Recommendations,E.coli O157,Highly virulent low

3、 infective dose 1-14 days incubation period Can cause complications such as HUS and is sometimes fatal Young and elderly particularly vulnerable Prolonged asymptomatic excretion High risk of secondary spread,Outbreak Control Plan,Devolved administration Welsh Assembly Government 22 Unitary Local Aut

4、horities Local Health Boards National Public Health Service for Wales Consultant in Communicable Disease Control NPHS laboratory services Regional Epidemiologists & CD Surveillance Centre Model Outbreak Control Plan Lead Officer for Communicable Disease,The Outbreak Control Team (OCT),Chaired by CCD

5、C, supported by regional epidemiologists, consultant microbiologist EH representatives of all LAs Local Health Board Local Public Health Director Food Standards Agency Also from Rhondda Cynon Taf: Local Education Authority Catering Direct Communications,Outbreak Declaration,Friday 16th September 200

6、5 first 8 cases notified to NPHS following hospital admissions Further 2 cases confirmed by NPHS laboratory via +ve stool specimens Incident meeting convened that afternoon 2 further cases added to list Outbreak declared and OCT formed,Initial Investigation & Control Measures,Fast Food Outlet Swimmi

7、ng Pool School Meals Menus Milk Water coolers Fruit tuck shops Cooked sliced meats Meat supplier School kitchens/School Inspections,Initial Investigations & Control,Sunday 18th September decision to remove all cold cooked unsanitary condition of premises,Tudor & Son Butchers, Bridgend,Vacuum packer

8、& weighing scales used for raw & cooked meats No sanitizer on the premises so equipment could not have been cleaned between use Cooked meat brought into raw meat preparation area to be weighed and packed Cooked meats stored in boxes previously containing raw meat Vacuum packer located immediately ad

9、jacent to mincing machine Failure to follow HACCP document stipulating separation of raw and cooked meat,Numerous food hygiene offences,Vacuum packer dirty & greasy Fly killer positioned directly above vacuum packer Floor covering in poor condition Walls dirty and marked with blood splashes Grills t

10、o floor drains had gaps allowing past access Band saw unit dirty with food debris,Walk in freezer iced up & stocked haphazardly Wash hand basin leaking causing water to pool on floor Meat slicer dirty Table dirty Walls of walk in chiller were dirty Drain blocked with food debris Light covers were di

11、rty with flies & insects,Control Measures,Removal of cold & cooked sliced meats from school meals FSA - Food Alert for Action 21st September removing all cooked meat supplied by Tudors Butchers from the food chain,Control Measures Spread of Infection,Verbal advise and advisory leaflets to all cases

12、Exclusion of cases & case contacts from school & work Risk groups identified in accordance with national guidelines Suspected cases & contacts until screened Children under 6 years of age within affected families 2 ve samples at least 48 hours apart obtained,Control Measures Spread of Infection,Cont

13、rol measures within schools Withdrawal of cooking activities No plasticine, sand or water play Advice on cleaning measures Advice on good hand washing No food brought into schools other than for own consumption Harvest festivals, Christmas parties etc.,Detailed Investigations,Epidemiological Investi

14、gations Case definition Case ascertainment Descriptive epidemiology Analytical epidemiology Microbiological Investigations Faecal specimens Food stuffs Environmental samples Environmental Investigations Inspections,Results of Investigations,Widespread contamination no single school Pattern of cases

15、reflected distribution of meat All cases had consumed school meals Samples of meat removed from schools contained the same strain of E.coli O157 as many of the cases E.coli O157 genotype unique to this outbreak Inspection revealed significant shortcomings at meat supplier Primary cases ceased to pre

16、sent within one incubation period of withdrawal of meats OCT confirmed source as cooked sliced meats supplied by J Tudor & Son Butchers,Communications,Proactive release of information Parents given priority Direct contact Letters to head teachers & schools Letters to parents E.coli O157 Helpline Sch

17、ool meetings Daily press updates All releases agreed by OCT Single speaker to ensure consistent message Web sites Communication with health professional Communication with public officials & elected members,Summary & Statistics,Declared over on 20th December 2005 157 cases meeting case definition, 1

18、18 microbiologically confirmed 44 schools affected across 4 local authorities 109 cases strain of E.coli O157 unique to the outbreak 31 cases hospitalised, 1 death Largest outbreak in Wales, 2nd in UK,Politics & Media,Very high profile Constant & insatiable media attention Intrusive and distractingR

19、ole of media & public figures in a public health crisis social responsibility,Communications and Media,Sub judice nature of much of the information to hand General public concern regarding E. coli Need for information and informed comment Need for professional response to political comments Need for

20、 the profession to be seen by the public and by the profession,Chief Medical Officers Review,Commissioned by Minister for Health & Social Services Fettered by the ongoing criminal investigation and requirements of confidentiality Evidence gathered was anecdotal and from parties outside the investiga

21、tion Recommendations of little value,The death of Mason Jones 4th October 2005,“ the sad news today about the death of young Mason Jones from Bargoed, is devastating to us all. Please can I express my personal gratitude for everything you, and your team, are doing to arrest the E.coli outbreak. I ha

22、ve heard nothing but complimentary remarks about the professional way in which you have conducted yourselves and can reassure you that you have my complete confidence”Keith Griffiths, Chief Executive of Rhondda Cynon Taf County Borough Council (4th October 2005),Police Investigation,Statements from

23、employees of J Tudor & Son Poor practices revealed: Only ever been one vacuum packer at premises used for raw & cooked meats continually Weighing scales, vacuum packer never cleaned In 3 years a member of staff had never seen any sanitizer at the premises Staff had never seen any temperature reading

24、s being taken No stock rotation, staff instructed to reuse decomposing meat High risk equipment only cleaned with a cloth Meat returned by customers would be reused in between slices of good meat,Police Investigation,“There is a large amount of evidence, in the form of witness statements, to indicat

25、e that cross contamination from raw to cooked meat was an almost certainty” Prof. C Griffiths“It ismy opinion that W Tudor misled and/or gave false information to enforcement officers during visits to the premises. In particularhe had no intention to provide a separate vacuum packing for cooked meat

26、s to minimise the risks of cross contamination” - Colin Houston,Dual Investigation,Evidence necessary to make out local authority case available very early Police evidence gathering very complicated, lengthy and expensive Decision on manslaughter charge made by CPS Prosecution took place 2 years aft

27、er outbreak Much information sub judice for 2 years Public and media frustration at delay Public and media failure to understand charge and sentence,The Local Authority Prosecution,Jointly brought by Rhondda Cynon Taf, Caerphilly & Bridgend County Borough Councils 5 charges for placing on the market

28、 unsafe food relating to 5 positive meat samples 1 charge for placing on the market unsafe food relating to Deri Primary school and Mason Jones 1 charge relating to the operation of the food business failing to ensure that raw & cooked meat was protected against contamination,Guilty Plea 7th Septemb

29、er 2007,William J Tudor admitted to offences Sentenced to 12 months imprisonment Prohibition from managing a food business No costs awarded Actually served 12 weeks of sentence before release Cost to LAs - 596,000,What have we learned?,The Outbreak The Prosecution The Public Inquiry,The Outbreak,Key

30、 characteristics of E.coli O157 Low infective dose/severe symptoms High risk of secondary spread at home Asymptomatic cases/excretion Decision to keep schools open vindicated Communications internal & external Staff welfare during the outbreak Impact on service delivery Role of Environmental Health

31、a job well done!,The Prosecution,Difficult to reconcile two investigations Frustrating - confidentiality Public Health vs. Criminal Significant resource implications Valuable evidence gathered which supported LA prosecution Could we have brought our prosecution without the Police evidence?,The Publi

32、c Inquiry,Response to recommendations Food Law Enforcement & Inspections Procurement School Toilet Facilities,Food Law Enforcement & Inspection,Food businesses & HACCP Separation of raw & cooked meat “Light touch” enforcement Audit based inspection of HACCP plans Training, experience & competency of

33、 EHOs HACCP Management “Red flagging” issues/concerns Evidence based decisions on management confidence Discussions with employees Quality vs. Quantity, Outcomes vs. ProcessBetter quality regulation not less!,Procurement of Food,Costs vs. quality & safety Third party audit of suppliers EHO involveme

34、nt Scrutiny of inspection reports Tendering process Contract monitoring & evaluation Complaints systems Where is the real risk? supplier assurance What about commissioned services & non approved suppliers? residential care homes, independent schools,School Toilet Facilities,Provision of hot water, s

35、oap, hand drying facilities Audit/inspection of facilities Capital programme of improvements What about management? About infection control in schools per se, not this outbreak!,“Dodgy business people are going to be around forever and a day. And the only thing protecting the public against them is

36、EHPs. But there arent enough of them to do this essential job” Prof. H. Pennington Sept 2009I am very worried about this continued decline in the esteem EHOs are held in when it comes to their role in protecting public health” Prof. H. Pennington May 2009“Over the years Ive worked with a lot of EHOs

37、 and Ive got enormous respect for their practical intelligence and common sense and the way they try and apply themselves. I think it would be very regrettable if the conclusions about any deficiencies that may or may not have occurred in inspection focus on what individuals may or may not have done

38、, because it seems to me that there are a number of institutional issues here that are highly relevant” - Dr Roland Salmon,Lessons for EHPs,Check everything and evidence the response Record everything (including reasons for recording nothing) Verify what you are told Check practice, not process Iden

39、tify trends and follow them up Flag up and follow up concerns Believe nothing, trust no one, check everything, record everything,Issues,Pennington -v- LBRO Competencies of managers Dealing with criminals Red flagging - how suspicious is suspicious? FOI implications Restrictive inspection protocols data collection etc Procurement,Contacts,Paul J Mee Paul.J.Meerhondda-cynon-taff.gov.uk 01443 425514Julie Barratt j.barrattcieh.org 01633 865533,