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 & 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

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 Authorities• 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 CCDC, supported by regional epidemiologists, consultant microbiologist

• EH representatives of all LA’s• 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 2005 – 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• Swimming 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 & sliced meat from school meals

• Catering staff urgently contacted so that meat removed and stored separately for collection by EHOs

• Inspections of meat supplier on 19th & 20th September

• Emergency prohibition notices – risk of cross contamination from vac packing process; unsanitary condition of premises

Tudor & Son Butchers, Bridgend

• Vacuum packer & 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 adjacent 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 to 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 dirty

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

• 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

• Control 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 Investigations– 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 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 present 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– School 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

E-Coli Epidemic Curve

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Date of onset of symptoms

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Primary case in school Primary case in community Secondary case in community

first cases reported to NPHS

population control measures instigated

No further cases after the 08/11/2005

Summary & Statistics

• Declared over on 20th December 2005• 157 cases meeting case definition, 118

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 distracting

• Role 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 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 investigation

• Recommendations of little value

The death of Mason Jones4th 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 have 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 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 readings

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 indicate that

cross contamination from raw to cooked meat was an almost certainty” – Prof. C

Griffiths

“It is…my opinion that W Tudor misled and/or gave false information to enforcement officers during visits to the premises. In

particular…he had no intention to provide a separate vacuum packing for cooked meats

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 after 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 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 September 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 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 – 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 Public 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 EHOs

– HACCP– Management

• “Red flagging” issues/concerns• Evidence based decisions on management confidence• Discussions with employees• Quality vs. Quantity, Outcomes vs. Process

• Better quality regulation not less!

Procurement of Food

• Costs vs. quality & safety• Third party audit of suppliers• EHO involvement

– 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, soap, 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 EHPs. But there aren’t enough of them to do this

essential job” – Prof. H. Pennington Sept 2009

I 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 I’ve worked with a lot of EHOs and I’ve 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, 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

• Identify 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 MeePaul.J.Mee@rhondda-cynon-

taff.gov.uk01443 425514

Julie Barrattj.barratt@cieh.org

01633 865533