Scottish Government

MANAGING INCIDENTS PRESENTING ACTUAL
OR POTENTIAL RISKS TO THE PUBLIC HEALTH:
Guidance on the Roles and Responsibilities of Incident Control Teams

KEY FUNCTIONS OF INCIDENT MANAGEMENT

1. Introduction

2. The key functions are outlined schematically in Figure 1. Local incident/outbreak plans should include reference to how these functions will be implemented in the relevant area.

3. Surveillance and reporting

4. An essential part of the control of outbreaks and incidents is the recognition of a change in the distribution of illness or of the occurrence of an illness of major public health significance. To this end surveillance, i.e. the collection and collation, analysis and dissemination of information is a vital tool. NHS Boards should ensure that surveillance systems are in operation locally and in particular that these include the notification of clinical illness and laboratory reporting of microbiological isolates. Such systems should feature the early reporting by telephone or electronic means of cases of significant illnesses, which may or may not be statutorily notifiable.

6. NHS Boards should have in place systems, which enable them to analyse and interpret information collected through surveillance and identify:

• an excess in the incidence of a communicable disease, or of an illness which may be due to an environmental hazard, over that expected for a specific time, person or place;

• the clustering of cases of communicable disease, or of an illness which may be due to an environmental hazard in person, place or time;

• the occurrence of a single case of a serious infection with significant public health implications;

• a clustering of cases of severe illness which have an unusual clinical presentation;

• a clustering of unexplained illnesses;

• the occurrence of an event which has led or has the potential to lead to a community or significant proportion of the population, being exposed to a hazardous agent.

2. NHS Boards should agree with their partners reporting mechanisms which include criteria ("triggers") for notification of potential incidents requiring further investigation and risk assessment. In particular they should agree with:

• clinicians in local healthcare services, a protocol for the notification of unusual illnesses;

• local microbiological laboratories, a protocol on the notification of infectious agents of known or potential public health significance;

• the statutory agencies responsible for monitoring air, food and water quality, the notification of data which indicate the development of a situation likely to present a risk to the public health;

• the emergency services, the reporting of incidents likely to lead to the public being exposed to harmful agents e.g. the fire service in respect to chemical spills.

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2. SCIEH is currently piloting a surveillance system known as CELSIUS (Clinical and Expanded Laboratory Surveillance of Illness of Unexplained or Unusual Severity). The study which aims to facilitate the early detection and reporting of severe illness, caused by deliberate release of chemical biological, radioactive or nuclear agents or by new re-emerging or unusual infections, will run for four months during the peak winter illness months prior to its evaluation in early April 2003.

3. Identification and initial response

4. The occurrence of one or more of the events indicated above should alert the NHS Board and in particular the Consultant in Public Health Medicine (Communicable Disease & Environmental Health) to the possibility of an outbreak/incident. Incidents, particularly those involving more than one NHS Board area, may be recognised through the national surveillance system operated by SCIEH. In certain circumstances e.g. an immediate response to a chemical incident, one or more agencies may have to take urgent action to protect the public before notifying the NHS Board. As soon as possible after control measures have been put in place, the Board should be informed.

6. On recognition of one or more of these events, the Board should ensure that:

• all relevant agencies with an interest in investigating and control of the outbreak/incident are notified;

• steps are taken to gather further information about the cases of illness and how they may have been exposed to the hazardous agent;

• an initial risk assessment is undertaken;

• if possible, a working hypothesis as to the cause of the outbreak/incident is formulated

• if necessary to protect public health, urgent control measures are put in place.

2. If the risk assessment indicates that there are cases of an illness which have major public health implications and/or there is a probability of the public continuing to be exposed to an infective or other hazardous agent, steps should be taken to convene an Incident Control Team. Based on an initial risk assessment, the NHS Board should reach a view in conjunction with the partners alerted about the need for specific control measures. These should be instituted as soon as possible and should not necessarily await the convening of an Outbreak/Incident Control Team if there is an urgent need to protect public health.

4. Some outbreaks/incidents may be over by the time they are reported or discovered. In this case the focus of the investigation will be on elucidating the cause and on the prevention of a future episode. An outbreak may be limited in terms or size and clinical significance, e.g. a mild infection affecting only one family unit. In such instances it may not be appropriate to convene an Incident Control Team.

6. Once the initial risk assessment has been carried out, a decision should be made on how the risk is likely to be perceived by the public; how and when it should be communicated and the best media for doing so. If there is a justified need for urgent preliminary communication, this should not await the meeting of an ICT.

8. The findings of an initial investigation; the timing and content of communications; the outcome of initial risk assessment; decisions on steps to be taken and all other relevant matters should be carefully recorded in an appropriate format.

9. Investigation

10. From the information gathered from the initial investigation, it may be possible to form a working hypothesis about the type of exposure to the infective agent or environmental hazard involved, the source and level of that exposure, the nature and size of the population exposed or likely to be exposed and the degree of risk to the public health. It will then be for the ICT to decide how to progress a fuller investigation to test that hypothesis.

12. The investigation should usually consist of three elements:

• an epidemiological investigation;

• a scientific investigation into the nature and characteristics of the implicated hazard (in communicable disease outbreaks, this would be a microbiological investigation);

• a specific investigation into how cases were exposed to the infective agent (e.g. food supply and hygiene, hygiene in healthcare settings).

2. Most outbreaks/incidents merit detailed description. Because of this, as full as possible a descriptive epidemiological study of cases should be carried out. The ICT should agree a simple definition of case for the purpose of the outbreak/incident and revise this definition as appropriate through the outbreak investigation. Specific draft data collection forms should be available prior to the outbreak/incident under investigation and should be modified for the purposes of the outbreak. Information from individual cases should be collated preferably using an appropriate computer software package. Standard epidemiological output, e.g. epidemic curve, incidence rates and exposed populations, should be presented to the ICT. The working hypothesis may then need to be reconsidered and alterations made as necessary. Based on the outcome of the descriptive epidemiological investigation, the ICT may decide to carry out an analytical epidemiological study. A decision to carry this out should be made in liaison with SCIEH and NHS Boards should normally expect support from that organisation in carrying out these studies.

4. It is essential to involve scientific especially microbiological laboratories as early as possible in the investigation of an outbreak/incident. The scientist on the ICT should advise on the taking of appropriate specimens and arrange for relevant investigations. This should include liaison with the relevant reference laboratory in Scotland or other specialist laboratories in the UK. It is essential that accurate consistent results of tests are available as rapidly as possible to the ICT. The ICT should therefore consider carefully the best use of laboratory resources available, taking into consideration turn-around times for testing and reporting. Guidance on the submission of clinical samples should be a high priority and should be communicated to all relevant clinicians. As part of the incident investigation such samples should be identified for the specific reference numbers or codes to distinguish them from other samples.

6. Specific investigations should be undertaken into the reasons for and circumstances in which cases were exposed to the infectious agent implicated in the incident. This will often involve the taking of appropriate samples for microbiological or other laboratory testing. It also may involve tracing the likely passage of the agent causing illness from the most probable source of contamination or infection to the specific circumstances in which the case was exposed to it. NHS Boards should liase with local authorities and other agencies in ensuring that relevant protocols for this type of investigation are developed.

8. Should a criminal investigation be likely to ensue, evidential procedures should be followed as far as possible.

10. The results of the epidemiological, scientific and exposure investigation must be considered together before reaching a conclusion as to their significance to the control of the outbreak. This should be linked to previous knowledge of the illness involved and local circumstances. Considering the findings from each investigation singly may be misleading. ICTs should take care to assess where the findings may be coincidental. In particular the ICT should review associations which may be considered causal and assess whether there is evidence of bias in the investigation and/or the strength of a specific association.

11. Risk Assessment

12. Based on the findings from the investigation and an assessment of the effectiveness of control measures taken, the ICT should assess the ongoing risk to the public from exposure to the hazardous agent involved in the outbreak/incident. The purpose of this assessment is two-fold:

• to estimate the probability of the public continuing to be exposed to the hazard, and

• to estimate the level of illness likely to arise in the population exposed.

2. Risk assessment essentially entails appraising the balance of evidence collected in the incident investigation and reaching a view as to whether it indicates that there is a significant threat to public health. It should involve:

• defining the impact on health associated with the agent identified as being the hazard to health;

• defining the probable or possible vehicle for the exposure of the agent and its distribution in the community exposed;

• identifying the population exposed or likely to exposed and their susceptibility to infection and

• estimating the overall probability of there continuing to be an ongoing exposure and the likely scale of ill health resulting from this exposure.

2. Conclusions derived from this process are principally a matter of professional judgement. However, for reasons of public accountability and understanding, it is essential that this process is as transparent as possible. The outcome of risk assessments must therefore be clearly recorded.

4. Once the risk has been assessed a decision should be made on how the risk is likely to be perceived by the public. This should inform the development of specific communications to the public about the risk and how it is being reduced.

5. Control Measures

   Measures to prevent further exposure

6. The principal objective of any control measure is to reduce the risk to public health by preventing further exposure to the hazardous agent involved in the outbreak/incident. Control measures may be directed at the source of the exposure and/or at affected persons to prevent secondary exposure to the agent of susceptible individuals.

8. Specific control measures will vary according to the type of outbreak/incident. In summary they will be one or more of the following:

• advising specific groups or the general public on how to avoid and minimise risks e.g. condom use, needle sharing, , safe food handling;

• delivering healthcare interventions to prevent the transmission or development of illnesses or their complications e.g. chemical antidotes, immunisation;

• implementing hygiene measures which reduce or eliminate contamination with hazards e.g. cleaning & disinfection; decontamination;

• auditing performance against standards and ensuring steps are taken to comply with these e.g. hand hygiene audits in hospitals

• curtailing normal daily activities or services e.g. prohibiting attendance at school or nursery, closure of food preparation or retail premises, either through voluntary agreement or enacting regulatory powers;

• providing alternative arrangements for normal services e.g. drinking water supplies.

2. A range of agencies may be involved in controlling an incident. Many of the measures taken have to be carried out within a legal or statutory framework. At times voluntary agreements will be sought with a range of parties implicated in the outbreak e.g. food retailers. Wherever possible these voluntary agreements should be recorded and if possible signed by both parties. It is important that professionals and the general public are provided with relevant information on the control measures being taken so that they can understand their relevance to their own practice.

4. Control measures taken by one agency will have implications for those taken in another. Because of this it is essential that the ICT maintains an overview and co-ordinates such measures. When controls involve or have the potential to involve legal proceedings, it is important that the local Procurator Fiscal's department is kept fully informed. The agency responsible for a specific control measure should check that the measure is being put in place in the time required and is having the desired impact (which should be defined by the ICT). It should report on this to the ICT.

5. Patient Care Measures

6. A major outbreak or other type of public health incident can lead to significant pressure being placed on primary care and hospital services. It is important that in such instances the Incident Control Team establishes effective liaison with the medical directors of appropriate NHS Trusts or hospitals.

8. In the case of a major outbreak or other type of public health incident, the ICT should decide as far as is practicable a plan of management for patients directly involved in the outbreak/incident. This plan should include details of guidance to GPs and hospital doctors on the clinical care of patients; the enhancement of specialist hospital based services if required; support arrangements for GPs and other primary care services; mechanisms to coordinate services between primary care and between and among different hospitals (if more than one is involved). The plan should also indicate arrangements for the admission of patients; the content of communications to professionals, patients and relatives; contact points for enquiries and infection control measures to prevent transmission in healthcare settings.

9. Communications

   Risk Communication

10. Risk communication is an essential part of the process of managing incidents and outbreaks. Because the main issues to be covered in communications about outbreaks and incidents generally concern hazards to the public health, NHS Boards should take the lead in decision making on risk communication. The report from the Department of Health (England) "Communicating about Risks to the Public Health - Pointers to Good Practice" provides guidance for action in this area. It states that:

• from evidence in the scientific literature and on purely tactical grounds, effective communication demands a presumption in favour of openness. Not being open puts at stake the perceived trustworthiness of the agencies involved in managing risks;

• when communicating about risks, health agencies should be clear about the objectives they are pursuing and identify any key issues which will influence the impact on the public of the communication (especially those identified in the Guidance as "fright factors " and "media triggers");

• plans for public health incidents should contain clear procedures for risk communication e.g. helplines, briefing for professionals, leaflet distribution, special arrangements for businesses and institutions (e.g. hospitals), media handling;

• the content of communications should acknowledge uncertainties and explain as far as possible the risk to the public in terms of probabilities and by comparing the current risk to others;

• mechanisms should be in place to monitor the impact of communication on public perception of risk and how this is reported e.g. monitoring the number and nature of calls to a helpline and the extent, content and tone of media coverage.

2. Decision-making on communication about public health risks should be based therefore on a presumption in favour of openness. As far as possible communications should be founded on factual evidence but if there is doubt as to the reliability of this, the public should be informed of this and uncertainties acknowledged. The particular need for specific communications aimed at high risk groups (e.g. immuno-compromised patients and babies) or at those with sensory deficits (hearing or vision) have to be kept in mind. Decisions on risk communication should be recorded. Decisions not to communicate about actual or potential risks to the public health even when these are uncertain should be justified and recorded.

3. Communications Plans

4. NHS Boards should have a communications plan which indicates how they will provide information about the outbreak/incident and its control to the following key groups:

• the key agencies involved in managing the outbreak;

• professionals involved in diagnosing, treating, or advising patients who are, or could be cases of infection or toxic exposure;

• the general public and in particular the community directly affected by the outbreak/incident.

1. Intra and inter agency communications

2. With regard to agencies involved in managing the outbreak, notification of the occurrence or likely occurrence of the outbreak/incident should be made to these key agencies prior to the first OCT meeting. Information should be regularly updated as appropriate. As part of their emergency plans, NHS Boards should maintain a contact list (including out of hours arrangements) for representatives for all key agencies.

4. During a major outbreak, a range of professionals working in laboratories or clinical services will require information about the nature of the infection, care arrangements, diagnostic testing, advice to the public and the scale of the outbreak and steps taken to control it. NHS Boards should have plans on how to disseminate and distribute such information.

6. NHS Boards should have in place mechanisms for the effective transmission of information within as short a time-scale as possible. This should involve faxes and/or e-mails. Communications should be recorded.

8. In respect of actual or suspected outbreaks or incidents, NHS Boards should ensure that there are procedures to ensure that on notification, information is passed to senior management and in particular the Board Press Officer. The relevant local authority and the Scottish Centre for Infection and Environmental Health (SCIEH) should be informed about suspected outbreaks or incidents

10. NHS Boards must notify all suspected outbreaks or incidents and especially those requiring the formation of a outbreak or incident control team to the Scottish Executive Health Department, if possible prior to the first meeting of the team. If the outbreak is one of foodborne disease, the Food Standards Agency should be notified also. SEHD should receive regular updates on progress.

12. Where deaths have or are suspected to have arisen as part of an outbreak or incident, the Procurator Fiscal should be informed and subsequently briefed if appropriate.

13. Communications with the public

14. To help allay any unnecessary anxiety, communications should be made as early as possible in the management of the incident. This requires tested systems capable of rapid deployment which are ready for use prior to any incident occurring. The following mechanisms should be considered:

• face to face communication with affected individuals or groups e.g. public meeting;

• the establishment of a helpline;

• letters or fact sheets provided directly to members of the public in an affected community;

• specially designed information leaflets to be distributed at appropriate points

• briefing key members of the public such as head teachers, MSPs, councillors, members of local health council

• information in the form of statements, press releases, interviews and briefings for the print and electronic media (see below).

2. Wherever possible standard templates for communicating with the general public and the media should form part of planning for more common or potentially dangerous types of incidents. They should include standard press releases and "question and answer" information sheets. These should require minimal customisation during incidents to facilitate speedy communication.

4. In some types of incident, private or public sector organisations implicated as probable sources of the exposure to a hazard will have existing lines of communication to their customers, clients or patients. . At times the organisation may form part of the ICT e.g. Scottish Water, NHS Trust. Use of these lines of communication can often facilitate advising the public on how to reduce risks and to implement control measures to prevent exposure e.g. not eating a product already purchased. In these circumstances the ICT should liase with the organisation in employing its knowledge and resources to communicate with public about risks. The ICT should co-ordinate the content and tone of any messages and how these should be disseminated.

6. NHS Boards should have in place mechanisms to establish help-lines promptly. In some incidents the public will look to contact a specific company or agency to obtain information about their services or products. In these instances, the ICT should liase closely with the organisation in the measures it establishes to deal with customer enquiries while recognising that the mechanisms for doing so are best left to the company involved. It should be made clear however that the central public health message is the responsibility of the ICT.

8. The ICT should maintain an overview of all communications to ensure that there are no contradictions in their content or tone.

9. Media handling

10. With regard to media liaison, the considerable extent of public, press and political interest in recent outbreaks and incidents highlights the importance of paying careful attention to this aspect of outbreak management. There is a need, in large-scale outbreak/incident situations, for a clear and proactive approach to media management and public relations especially by NHS Boards. In view of the crucial interface with the media, media management should form an essential part of outbreak/incident plans.

12. There are two important roles that require to be fulfilled, that of media liaison and that of acting as spokesman for the ICT. To fulfil the first role, an appropriate Press Officer agreed by the ICT should be identified to liase with the media to ensure that the information communicated to them is consistent and to organise arrangements for press briefings, interviews etc.. He/she should be the only press officer acting in this capacity on behalf of all organisations involved in the ICT. The Chair of the Incident Team should usually fulfil the second role i.e. be the "public face" of the ICT. There may be situations when the Press Officer fulfils both roles. If other professional opinions are sought from individual ICT members, these should not be given without the agreement of the Chair of the ICT and full liaison with the Press Officer. Whenever possible those from other organisations answering media enquiries should be members of the ICT.

14. In some instances it may be desirable for other organisations represented on the ICT to respond to press enquiries which specifically relate to their operations or legal responsibilities. Arrangements should ensure that such organisations can respond promptly to such enquiries without straying from the core message about public health risks and the measures being taken to reduce them. Again the Chair of the ICT should be informed and full liaison with the agreed Press Officer maintained.

16. To avoid confusion, a common data set (e.g. on number of cases and their clinical status) and a timetable for its compilation and issue to the media should be agreed by the ICT. Decisions about media briefing, and the issuing of press statements, should be made at each ICT meeting. In doing so, careful consideration should be given to:

• Background briefing material, such as the role of the ICT, the general nature of the hazard or threat, what is known, and important facts which may not be known;

• the implications of releasing the information;

• the implications of the timing of the release;

• the importance of presenting complex information in simple language

• and the different requirements of the print and broadcast media.

2. All Press Statements issued should be copied to the press offices of all organisations represented on the ICT, the Scottish Executive Health Department and other relevant and interested organisations. The Food Standards Agency must be informed about outbreaks of food-borne disease. Scottish Executive Departments will liase with ICT Press Officer and through him/her with the ICT Chair in handling media enquiries to the Executive and developing and releasing press statements.

3. Audit and evaluation

4. A recurrent theme with public health incidents is the need to learn from experience. This involves three key components:

• A formal ICT debriefing on the management of the incident with a view to including lessons learnt in the ICT report;

• Procedures to assess the performance of statutory agencies in managing public health incidents;

• An evaluation of the effectiveness of incident management arrangements in protecting the public health.

ICT debriefing

2. The OCT/ICT report should feature recommendations to prevent further outbreaks and incidents and improve the handling of further outbreaks and incidents. These may allude to research. Recommendations should be based on evidence collected during the outbreak and the OCT/ICT debriefing. Recommendations must be targeted at organisations with specific responsibility for taking action on the recommendation.

4. ICTs both during and in the debriefing following an incident should use criteria jointly agreed with their partners (see below) to assess and report on their own performance in managing the incident and the appropriateness of current plans. Recommendations on how these can be improved should be included in the ICT report (see also paragraphs 52 to 57).

5. Performance assessment

6. Public and media scrutiny of the performance of ICTs in dealing with public health problems is now common. NHS Boards work with their partners to jointly assess the performance of incident teams. In order to aid this process, SEHD is collaborating with the FSA(S), SCIEH and representatives of NHS Boards and Local Authorities in preparing indicators of good practice in outbreak/incident preparedness and management. The indicators listed provide evidence of "essential" good practice i.e. if not done they will significantly impede or constrain the efficiency and efficacy of managing an outbreak. They apply to the structure and process, not outcomes, of incident or outbreak control and investigations. Further work will be carried out to further develop a consensus about the validity and reliability of these indicators to public health practice.

7. Evaluating the effectiveness of incident management

8. For relevant outbreaks or incidents NHS Boards should submit promptly to SCIEH the appropriate standard summary form for outbreak/incident surveillance. SCIEH should work with NHS Boards, the Scottish Executive and other Scottish and UK partners to develop systems to assess the effectiveness of incident management in terms of preventing further cases of ill health; minimising morbidity and mortality through specific patient care measures and communicating with the public about risks.