Continuing professional development

Outbreaks of infection in communitysettings: the nursing implicationsPHC750 Gould D (2013) Outbreaks of infection in community settings: the nursing implications.

Primary Health Care. 23, 3, 32-40. Date of submission: February 1 2013. Date of acceptance: February 4 2013.

Dinah Gould, director ofresearch, School of Nursingand Midwifery Studies,Cardiff University

Correspondence

Gouldd@card¡ff,ac.uk

Conflict of interestNone declared

KeywordsOutbreak, epidemic,

infection prevention and

control, infection

These keywords are based onthe subject headings fromthe British Nursing Index.This article has beensubject to double-blindreview and checked usingantiplagiarism software.For related articles visit ouronline archive and searchusing the keywords

Abstract

Outbreaks of infection are managed by specialist practitioners in public health and infection control. However, the

occurrence of an outbreak impinges on the work of other nurses employed in the affected service. In most cases

the effects will be self-limiting and although inconvenient at the time, are not far-reaching. However, media reports

have fuelled concerns about outbreaks of infection among health workers as well as the public. The aim of this

article is to provide an understanding of outbreaks of infection and the implications of outbreak situations for nurses

employed in community settings, drawing on the lessons learned from a wide range of outbreaks past and present.

Aims and learning outcomesTHE AIM of this article is to provide an understanding

of outbreaks of infection in community settings for

nurses in clinical roles. After reading this article you

should be able to:

Explain the meaning of the following

terms: epidemic, pandemic, endemic

disease, and give examples of each.

Discuss factors that affect the occurrence

of infectious diseases and outbreaks

of infection in a population.

State how epidemics are detected.

• Explain the principles underlying the

investigation of an epidemic.

• Discuss the implications of outbreaks

for members of the pubiic.

IntroductionOutbreaks of infection are frequently reported in

hospitals and the community in western countries

and the developing world (Lashley and Durham

2007). They often attract media attention and are

a source of anxiety to patients and the public as

well as to health professionals (Lynn ei al 2004).

Outbreaks are managed by specialists in public

health, and when they take place in hospital by

infection control teams. In community settings the

expertise of the infection control team may also be

drawn on, for example in the case of an outbreak

in a nursing home. Senior managers are involved.

especially when dealing with the media and when

additional resources such as extra staff are deployed

(Lynn ei al 2004). When an outbreak occurs it will

inevitably impinge on the work of nurses employed

in the affected service, either directly or indirectly.

Nurses are well placed to notice early symptoms

of infection and can play an important part helping to

recognise and report outbreak situations. Contact with

infected patients can place nurses at risk of developing

infection. Some infectious conditions that give rise to

outbreaks are mild and self-limiting (Lynn ei al 2004).

Others can pose a serious threat to heaith (Loeb ei al

2004). Some of the nurses who had contact with

patients infected by the sudden acute respiratory

syndrome (SARS) in 2003 became very ill and there

were a number of fatalities (Loeb ei al 2004).

Epidemiological termsEpidemiology is the study of diseases and patterns

of the distribution of disease in populations,

either in hospital or the community (Last 2000).

Traditionally, the term was used only when referring

to communicable disease, but epidemiologists now

study the rate and risk of all diseases, whether they

are transmissible or not (Lashley and Durham 2007).

The work of the epidemiologist in relation to

communicable disease entails surveillance (Box 1)

to identify incipient outbreaks and assess the impact

of strategies for control (Last 2000). The discipline

of epidemiology has its own terminology.

April 2013 I Volume 23 | Number 3 PRIMARY HEALTH CARE

Surveillance

Surveillance is a process of monitoring infection

to identify changes in the baseline rate that will

identify epidemiological trends so that rapid action

can be undertaken to control outbreaks (Thacker

and Berkelman 1988). Infection prevention and

control teams in hospital monitor the number

of cases of meticillin-resistant Staphyiococcus

aureus bloodstream infections and infections

caused by Clostridium difficiie and report them

to the relevant statutory bodies in England

and Wales, Scotland and Northern Ireland.

Terminology

Go online or use a standard textbook tocheck your understanding of the followingterms: epidemic, pandemic, endemic disease,prevalence, incidence.

Epidemic Epidemics are not precisely defined.

Much depends on the type of infection, the

population in which the epidemic has occurred

and the last time the infection was detected in

the population (Hawker ef a/ 2005). According

to one of the most widely accepted definitions, an

epidemic is considered to have occurred if there is

an increase in the expected number of infections in

a population, locality or institution (Last 2000).

A single case of a communicable disease long

absent from a population or of a condition not

previously recognised would require investigation,

as would two cases related in time and place

(Last 2000). Epidemics have been reported in

schools, nurseries, hospitals, hotels and on cruise

ships. Cases can emerge over a long period or

explosively over a very short time, sometimes

within a few days (Curran and Wilson 2008).

Example

Give an example of an epidemic. What wasthe source of your information? What wasthe causative organism and how many peoplewere involved?

Epidemics provide excellent human interest material

for journalists (Boyce ef ai 2009). It is therefore

likely that you will have obtained your information by

reading a newspaper or from the radio or television.

Examples of organisms that have caused outbreaks

of infection in recent years and which have attracted

considerable media attention are listed in Box 2.

The list is not exhaustive and it is possible that you

may have suggested an example that took place

locally and which has not been widely reported.

When an epidemic is reported the reaction of

the public is usually one of fear and sometimes

outrage, especially if there is a perception that

the situation could have been prevented. The

outbreaks of dostridium difficiie reported from

Stoke Mandeville Hospital in Buckinghamshire

between 2003 and 2005, and Maidstone and

Tunbridge Wells NHS Trust between 2005 and

2006 received wide media coverage for months,

prompting public outcry regarding the state

of hygiene, environmental cleanliness and the

quality of patient care in British hospitals. Both

incidents were followed by public enquiries.

Lessons from the past

Use the internet to locate information aboutthe epidemics reported in Stoke MandevilleHospital in Buckinghamshire between 2003and 2005 and Maidstone and TunbridgeWells NHS Trust between 2005 and 2006.Information on both epidemics can be foundat the Care Quality Commission website:www.cqc.org.uk. The executive summeiriescover the main points well.What appears to have contributed to theseepidemics? Are there any similaritiesbetween the circumstances under which theyoccurred? What lessons can be learned?

There were striking similarities between the two

hospitals. In both it was concluded that the epidemics

constituted untoward incidents waiting to happen,

with failure to implement guidance from the resident

infection control teams. Both organisations had

recently undergone difficult mergers and the reports

suggested that managers were preoccupied with

financial issues and imperatives to meet government-

imposed targets at the expense of responding to

important clinical issues. The patient care environment

Some organisms that have given rise to

outbreaks on infection in the community

Norovirus

Influenza viruses

Escherichia coi i 0157

Legioneiia pneumophiiia

Saimoneila

nber 3 ^ HPRIMARY HEALTH CARE April 2013 I Volume 23 | Number 3

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> Notifiable infections (England and Wales)

Public Health Control of Diseases Act 1984

Cholera

Plague

Smallpox

Public Health (Infectious Diseases)

Acute encephalitis

Acute poliomyelitis

Anthrax

Diphtheria

Dysentery (bacillary and amoebic)

Leprosy

Leptospirosis

Malaria

Measles

Meningitis

Meningococcal septicaemia

Mumps

Food poisoning

Relapsing fever

Typhus

Regulations 1988

Ophthalmia neonatorum

Paratyphoid fever

Rubella

Scarlet fever

Tetanus

Tuberculosis

Typhoid

Viral haemorrhagic fever

Viral hepatitis

Whooping cough

Yellow fever

was poor in both cases including old buildings that

were difficult to clean, dormitory-style wards, lack of

single rooms and nursing shortages. Unacceptable

standards were reported, including high levels of

environmental contamination and poor hygiene.

Coupled with an increase in the number of cases of

C. difficile reported nationally, these two epidemics

helped to increase the profile of infection prevention

in the UK and led to the introduction of mandatory

reporting of C. difficiie from April 2007. Reported

cases in the UK have since declined (Gould 2010).

There are other examples of large hospital

outbreaks of infection affecting public health policy

and changes in legislation. The Stanley Royd incident

is still widely quoted as an example. In 1984 an

outbreak of Salmonella food-poisoning at the Stanley

Royd Hospital in Wakefield, Yorkshire affected

355 patients, mostly those who were frail and old,

resulting in 19 deaths (Department of Health and

Social Security (DHSS) 1986). The subsequent

Classic epidemiological

Gradual increase

in the number of

new infections

Sharp decline as all

susceptible people

have been infected

Time (months)

(Adapted from Gould and Brooker 2008)

enquiry revealed poor practices in the hospital

kitchen highlighting the risk of foodborne infection

to vulnerable older people. The incident eventually

resulted in the removal of Crown Immunity which

until 1987 had protected hospitals from prosecution

by environmental health officers (DHSS 1986).

Pandemic A pandemic is defined as the simultaneous

occurrence of the same infection among large

numbers of people, usually on a scale involving

several countries or entire continents (Hawker ef al

2005). History is full of examples (Boxes 4 and 5

page 37). Such accounts continue to attract attention

because they contain messages about the past

behaviour of communicable disease that can offer

valuable contemporary information (Last 2000).

The influenza pandemic that killed 20 million

people throughout the world in 1918 is of particular

interest because it contains information about the

behaviour of the influenza virus and important

messages for modern approaches to prevention,

especially in the light of the H l N l (swine 'flu)

pandemic in 2009 (Phillips and Killingray 2003).

H l N l infection proved not to be as serious as originally

feared: the virus caused a relatively mild infection.

Most people are reported to have recovered

uneventfully without healthcare intervention or

medication (Health Protection Agency (HPA) 2009).

However, when a pandemic occurs, concern is

inevitable as the infection moves from one country

to another. The more serious the infection is,

the greater the need for forward planning.

Health officials charted the progress of SARS

in detail, including its emergence in Hong Kong in

February 2003, its rapid appearance in other parts

of Asia, North America, Canada and Europe and its

effect on the populations and healthcare systems

in affected countries (Fung and Cairncross 2006).

Throughout 2003 there were 8,098 probable cases

with a mortality rate of 9.6 per cent (Parashar

and Anderson 2004). The modern management

of a pandemic demands collaboration between

the public health agencies in affected countries

(MacLehose ei al 2001). In addition, these agencies

receive advice and support from the World Health

Organization (WHO), which produces guidelines

for the control of communicable disease.

Endemic disease An endemic disease is one that

is always present at low levels in a population

(Hawker ei al 2005). The number of cases depends

on factors that allow the organism responsible to

multiply and the susceptibility of people in the

population. Malaria is endemic in many parts of

the world where mosquitoes carrying the infective

April 2013 I Volume 23 | Number 3 PRIMARY HEALTH CARE

organisms (plasmodia) are able to breed because

economic conditions are poor and there is a

lack of resources and infrastructure to drain the

stagnant water which harbour them. Malaria is a

huge global problem. According to WHO (2013)

it causes over a million deaths every year, mostly

in Africa. Infants, small children and pregnant

women are at greatest risk (WHO 2013).

The infection is responsible for enormous suffering

and economic loss. Most cases reported in the UK

are contracted abroad, although travellers incubating

infection may not experience symptoms until they

return home. Failure to take prophylaxis is the main

cause of malaria contracted in this way (Hill 2006).

Infections can also become endemic in

hospitals and nursing homes. In the 1980s,

meticillin-resistant Staphyiococcus aureus (MRSA)

was continually present in many hospitals in the UK

(Duerden 2007). Legislation introducing improved

surveillance, coupled with more strictly enforced

infection prevention and control precautions in

NHS trusts, has since resulted in a decrease in

the number of MRSA bloodstream infections.

Identifying epidemiological trendsSurveillance plays an important role in identifying

unexpected occurrences and upsurges of infection. In

NHS trusts, local infection prevention and control teams

undertake this activity for key healthcare-associated

infections (Box 1, page 33). Surs/eillance in the

community is undertaken by the HPA in England,

Public Health Wales and Health Protection Scotland.

They monitor the number of cases of notifiable

infections reported to them by clinicians (Table 1). A

similar system is in place in Northern Ireland. These

bodies suggest where and how preventative action

should be taken or the need for health promotion.

For example, upsurge in measles, mumps or rubella

would indicate the need for a renewed campaign

to encourage uptake of the immunisation.

Responsibility for notification falls to local

authorities, which have a statutory responsibility

to control communicable disease reported within

their boundaries. They are also permitted to follow

up other infectious conditions not listed in Table 1.

For example, human immunodeficiency virus is not

notifiable, but there is a confidential voluntary referral

scheme. Sexually transmitted infections are reported

anonymously to the Department of Health.

Investigating epidemicsWhen an epidemic is detected, the pattern of its

distribution throughout the affected population

can be illustrated on a graph by plotting the

number of new cases against their date of onset.

Figure 2 Lpoint epidemiological curve

Time (days)

(Adapted from Gould and Brooker 2008)

Graphical presentation of the data can:

• Suggest the source of the epidemic.

• Indicate a possible cause.

• Illustrate the extent of the problem, helping to

convince managers that extra resources are

necessary. Feedback can also be used to motivate

clinical staff to prioritise infection control precautions

(Curran ei ai 2002).

When the number of new cases of infection is plotted

against time, one of several possible epidemiological

patterns will emerge.

Classic epidemiological curve

Look at the classic epidemiological curveshown on Figure 1. What does it tell youabout the rate at which new cases of infectionare being reported and about the decline innew cases as the epidemic wanes?

Classic epidemiological curve The left hand side

of the graph shows that the number of new cases

of infection increases slowly at the beginning of

the epidemic, eventually reaching a peak at the

midpoint when the maximum number of people

have been infected. The right hand side of the

classic epidemiological cur̂ /e shows that as the

epidemic wanes recovery proceeds faster than new

cases emerge. The classic epidemiological curve

is the typical pattern assumed when a population

is exposed to an infectious agent for the first time.

A number of deviations have been described:

• The single point curve.

• Propagated outbreak.

• Cyclical infection.

Single point epidemiological curve A single point cwn/e

is created when the victims have been simultaneously

exposed to the same source of infection (Hawker ef al

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Figure 3

Primary and

secondary peaks

Time (months)

(Adapted from Gould and Brooker 2008)

;lical epidemiological cur

Time (years)

(Adapted from Gould and Brooker 2008)

CDJD

E

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15Time (days)

The (first) index case appeared on day 1. Two more cases appeared sporadically

on day 5 and day 7. On day 10 three new cases were detected. Therefore it can

be inferred that the incubation period is around 3-7 days and the first patient

must have been exposed to the infectious agent 3-7 days before symptoms were

detected. No new cases were detected after Day 10, indicating that infection

control precautions have been effective.

(Adapted trom Curran and Wilson 2008)

2005). It usually occurs when the incubation period is

short (hours or days) and recovery is rapid (Figure 2,

page 35). This is the pattern often seen with foodborne

illnesses, when contaminated produce has been

consumed at a party or in the same restaurant.

Propagated outbreak In a propagated outbreak

the epidemiological curve is shallow because

the causative organism has a longer incubation

period (weeks or months) and new cases appear

gradually (Figure 3). Successive waves on the

graph represent secondary spread from one person

to another. A propagated outbreak might occur

with an enteric pathogen such as Salmonella

enteritidis, which causes nausea, vomiting and

diarrhoea. The incubation period is 12-72 hours

but symptoms take up to seven days to appear.

Person-to-person spread can occur in the same

household or ward, resulting in the secondary peak

illustrated in Figure 3. Secondary spread indicates

that any infection control measures implemented

up to that point have not been successful, either

because they were not the right ones or, despite being

appropriate, have not been properly implemented.

Further investigation is required to provide more

information (Curran and Wilson 2008). For example,

in the case of an outbreak of food poisoning,

food storage, handling and preparation would be

investigated by the environmental officer of health.

Cyclical epidemiological curve Some infectious

agents give rise to epidemics that occur cyclically

every few years. This was common for the classic

childhood infections such as pertussis (whooping

cough), measles and mumps before immunisation

programmes were introduced. Outbreaks were

reported when cohorts of children lacking immunity

had developed in the community, peaking when the

maximum number of cases occurred and waning

as the availability of potential victims declined

(Figure 4). Between outbreaks, cases of infection

became sporadic until a new cohort of children

lacking immunity had developed once more.

Time-line graphs To illustrate which patients have

become infected and when, time-line graphs can be

used (Figure 5). Looking at Figure 5 it is possible

to infer when exposure to the source of infection

happened as initial contact with the infectious agent

must have taken place before the appearance of the

first (index) case. However, time-line graphs cannot

reveal what has happened to trigger the infection

without additional information. Nursing insights can

be important. They can alert the infection prevention

and control team to a new clinical practice or failure

April 2013 I Volume 23 | Number 3 PRIMARY HEALTH CARE

Factors influenci

of outbrea

Demography

• Social and behavioural factors

• Advances in healthcare technology

• Climate change

• Wars

• Natural disasters

(Lashley and Durham 2007)

to implement an existing practice or the presence in

the community of a possible source of infection.

Communicable disease cind thedevelopment of epidemicsEpidemics develop when substantial numbers

of people in a population are susceptible to the

infectious agent, suitable environmental conditions

prevail and the pathogen is able to cause disease

readily in the available hosts. Factors that can

influence the occurrence of epidemics are shown

in Box 3 (Lashley and Durham 2007).

Risk is increased when a large cohort of susceptible

people exist together, explaining why outbreaks so

commonly occur in closed or semi-closed environments

such as schools, hospitals and nurseries (Lashley

and Durham 2007). Demography is important. The

rapid growth of a population, changes in its profile,

such as increased birth-rate or aging, migration,

housing conditions and the way that a population is

distributed within a country, all influence the pattern

of communicable disease. For example, increased

life expectancy in developing countries has fuelled

the need for nursing home accommodation where

frail, older residents undergo frequent transfers

between the home to hospital. They may acquire

MRSA during admission and still be carriers on

discharge: the incidence of MRSA carriage in nursing

homes in the UK is 20 to 30 per cent (Barr ei al

2007). Other infections commonly repohied from

the nursing home sector and which may cause

outbreaks include norovirus (Wu ei a! 2005) and

infestations of scabies (Johnston and Sladden 2005).

Overcrowding and poor living conditions have

traditionally been associated with increased risk of

infectious disease and outbreaks. The Black Death

in the 14th century (Box 4) was possible because

human habitations were frequently infested with rats

carrying the fleas that acted as the vectors of disease.

Although cases of bubonic plague are still sometimes

reported, the possibility of a major outbreak in a

western country is highly unlikely. A vaccine has been

developed to protect travellers who venture to the

regions, mainly in China and Russia, where cases

The Black Death (bubonic plague) which swept across Europe in the 14th century

is a much-quoted example of a pandemic of historical significance (Hays 2005).

Bubonic plague is caused by the bacterium Yersinia pestis, which is carried by

fleas infesting rats. The nature of the infection is indicated by descriptions of the

typical, florid symptoms that victims developed: blackened skin and enlarged,

discoloured lymph nodes ('buboes'). When the symptoms are less distinctive it is

harder to deduce the cause of a pandemic occurring long ago and impossible to be

certain about the numbers of people affected because records, often obtained from

sources such as parish registers, do not provide accurate or complete information.

are occasionally still reported. Members of the public

can be reassured that person-to-person transmission

is not a feature of this infection (Hays 2005).

Social and behavioural factors are important

contributors to the changing patterns of communicable

disease in populations and influence the occurrence

of epidemics. For example, more liberal attitudes and

behaviour have resulted in an upsurge in sexually

transmitted disease for people of all ages in England

and Wales (HPA 2010a). The rise has been greatest

for people aged between 18 and 24 years, but there

has also been an increase among middle-aged people

who become single again after marital breakdown.

The Family Planning Association has responded

by launching the Middle-age Spread campaign

(tiny.cc/middleagespread). Generally, these individuals

are less confident than younger people about

.eeionnaires' disease

Legionnaires' disease is a modern phenomenon that has arisen because

Legionella pneumophilia thrives and multiplies in the modern built environment,

in complex water systems where water is allowed to stagnate. The first

recorded outbreak was reported among delegates attending a convention of the

American Legion in Philadelphia in 1976. Two hundred and twenty one mainly

middle-aged and older men developed pneumonia and 34 died (Newsom 2008).

Legionella pneumophilia lives harmlessly in the environment but at

the time little was known about it because the bacteria are difficult to

grow in the laboratory and their pathogenic potential was unsuspected.

They survive in the still water of cooling towers and ventilation systems

in tali buildings, especially in sections that are unused, and are

disseminated in aerosols, including those created by showers.

The outbreak in Philadelphia was possible because of a unique

combination of factors. The hotel was an old building with an antiquated

water system and the delegates were predominantly middle-aged and older

men, who are especially susceptible to Legionnaires' disease. The outbreak

attracted intense media interest because of the mysterious nature of the

infection and the emergence of a large number of cases in a luxury hotel.

Over the years a number of outbreaks have been reported in the

UK. Overhaul and replacement of old heating and water systems

and maintaining water at temperatures able to destroy the bacteria

have proved effective control measures (Newsom 2008).

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Continuing professional development

accessing sexual health services and are at particular

risk if there is no need to use barrier methods of

contraception to prevent pregnancy. They may be

more receptive to information and advice from nurses

they meet during other routine health consultations,

for instance in the general practice setting. The

campaign website provides health promotion resources

designed for use by nurses in non-specialist roles.

Air transport is another important factor adding

to the risk of introducing communicable disease

previously rare or unknown in a given population.

Individuals can incubate SARS or malaria without

showing signs of infection until after arrival (Hill

2006). The risks of respiratory infection are

increased on aircraft because air is recycled.

Advances in health technology enable some

pathogens to infect human hosts for the first time,

or help to increase existing risks (Box 5, page 37).

Antibiotic-resistance among bacteria emerged as

an adaptive response that enables them to survive

and multiply at the expense of antibiotic-sensitive

strains, giving them selective advantage (Ayliffe ei al

1998). The higher susceptibility of older and very

sick people coupled with increasing use of invasive

devices has placed large numbers of patients at

risk of infection by the bacteria (Gould 2009).

Advances in technology have also reduced the

incidence of some communicable diseases and the

risk of outbreaks. The introduction of vaccines that

provide protection against Haemophilous influenzae

and Neisseria meningitidis have dramatically reduced

the incidence of meningitis. Climate change, wars

and natural disasters have all been associated with

increased risk of communicable disease and the

occurrence of epidemics (Lashley and Durham 2007).

Susceptible hostsInfectious agents depend for their survival on a supply

of new hosts. Public health measures to reduce the

number of people affected focus on immunisation

programmes, especially those aimed at children and

young people. The purpose of immunisation is to

create a state of herd immunity in the community.

Herd immunity

Herd immunity depends on ensuringthat levels of susceptibility to a particularinfection are low. What is the publichealth challenge of maintaining herdimmunity and the nursing implications?

A state of herd immunity will only persist in a

community if everyone or nearly everyone who is

potentially susceptible has been immunised and the

vaccine is effective. It is generally accepted that more

than 90 per cent of a population must be immune

for this state to exist. An important part of the role of

health visitors, practice nurses and school nurses is

to ensure that high levels of uptake of immunisation

are attained to promote the health of the individual

child and of all children in the population. However,

immunisation will never be able to offer every

individual or all populations complete protection.

There are many infections, for example malaria

and most sexually transmitted diseases, for which

vaccines are not yet available, compliance may be

poor and in developing countries governments may be

unable to bear the cost of immunisation programmes

or lack the infrastructure to administer them. Some

vaccines must be administered annually because

antigens on the surface of the causative organism are

capable of undergoing mutation so that the existing

vaccine becomes ineffective (antigenic drift).

In the UK, people in the groups eligible to receive

immunisation for influenza (people over 65 years

and those with chronic conditions) are invited to

receive the vaccine every autumn because the virus

undergoes antigenic drift (Mayon-White 2005). For a

small minority of people, immunisation is considered

unsafe. Some vaccines are prepared from attenuated

organisms (ones that have been weakened but are

still alive). These are not suitable for individuals

whose immune response is impaired through ill

health or treatment such as cancer chemotherapy.

'New' infectionsOver the years 'new' infections have emerged as

changing conditions in populations have placed

individuals at risk for the first time and advances

in technology have made it possible to detect the

organisms responsible (Box 4 page 37). Box 6

provides some examples of 'new' infections detected

for the first time throughout the second part of

the 20th century. Sometimes existing pathogens

are found to be responsible for new, serious

infections. Escherichia coli is a normal inhabitant

of the human gastrointestinal tract able to cause

healthcare-associated infection. Outside hospital

it is most frequently responsible for urinary tract

infections and diarrhoea in overseas travellers.

In recent years a strain called E.coli 0157 has

gained notoriety for causing foodborne infection which

can have severe health consequences, especially in

young children. An outbreak reported in 1996 in

Lanarkshire, Central Scotland resulted in 20 deaths.

The source was a butcher's shop that supplied meat

and meat products to other business outlets (Williams

and Ellison 1998). Numerous recommendations for

food handling, training, minimising contamination.

April 2013 I Volume 23 | Number 3 PRIMARY HEALTH CARE

Hepatitis B

Hepatitis C

Human immunodeficiency virus disease

Legionnaires' disease

Bovine spongiform encelopathy

regulations and enforcement, and managing outbreaks

were published by the Pennington Group, which was

established by the government to investigate all aspects

of the Lanarkshire outbreak (Pennington Group 1997).

Other outbreaks and sporadic cases of E.coli 0157

have been reported since 1996. Most have been

attributed to the consumption of contaminated food,

but in 2009 an outbreak was traced to a 'petting'

farm in Surrey resulting in hospital admission for 12

children, some of whom required renal dialysis. It is

likely that new recommendations for such recreational

visits involving contact with animals will be made

in the wake of this widely publicised event.

Managing outbreaks of infectionThe HPA has drawn up standards and an action plan

for managing outbreaks of infectious diseases (HPA

2012). These are meant to provide a blueprint for

best practice, but they must be adopted according

to local need and are meant to be used flexibly. The

primary objective is to protect the public and prevent

further spread. The guidelines suggest that once an

outbreak has been recognised, investigations should

begin within 24 hours with immediate risk assessment

and formally convening an outbreak control team.

The next step is descriptive epidemiology to

document the number of cases, type of epidemic

curve, description of the key characteristics of

the people affected (such as age and gender),

geographical spread and risk factors. This information

is used to generate a hypothesis concerning the

likely source of the infection and how spread

should be controlled to protect the public.

Risk assessment will need to be repeated

throughout the course of the outbreak and it may

be necessary for the outbreak control team to seek

legal advice. The outbreak is declared over when the

number of new cases has declined, there is no longer

a threat to public health and the probable source of

the outbreak has been identified and withdrawn.

The public health bodies in the UK also play a major

role drawing up and implementing guidelines to help

prevent outbreaks of infectious disease. For example,

the HPA has issued guidance on the management

and control of norovirus outbreaks (Norovirus Working

Party 2011) and plans in the event of an influenza

pandemic (HPA 2010b). Nurses with special expertise

in the relevant area may be invited to contribute to the

working groups responsible for compiling such guidance,

usually through their membership of a professional

body such as the Infection Prevention Society.

Outbreaks and tbe mediaEpidemics and pandemics attract intense media

attention because they capture the 'human interest'

angle so well (Boyce et al 2009). Stories are

especially newsworthy if they affect frail older people,

such as the C. difficile outbreaks reported in Stoke

Mandeville Hospital and Maidstone and Tunbridge

Wells NHS Trust, children, as in the 2009 £ coli

outbreak described above, or affect people in luxury

surroundings such as hotels that are assumed to

offer high standards of cleanliness and hygiene

(Box 5, page 37). Senior managers, public health

nurses and members of the infection prevention and

control team work together in outbreak situations

to prepare statements for the press containing

material that is accurate, factual and honest.

To avoid confusion other members of staff are

usually requested not to speak to the press. The

HPA provides information on its website specifically

designed to help the media report cases of infection

and outbreaks in an accurate, non-alarmist fashion.

Nevertheless media reports are frequently inaccurate

and sensational. This is a major cause for concern as

lay people appear to obtain most of their information

about infections, especially healthcare-associated

infections, from the media and are thus at risk of

being misinformed (Washer and Joffe 2006).

Implications for the publicMembers of the public are deeply concerned about

the risks of infectious conditions, including health

care-associated infections (Gould et al 2009).

Local effect

What effect could an outbreak of infectionhave in your locality and on your work?

In the community, outbreaks can result in the closure of

schools and nurseries, disrupting education, childcare

arrangements and parents' work. The workload of

community nurses may increase, for example following

up contacts of infected people requiring investigation,

treatment or immunisation.

During outbreaks members of the pubiic can be

directed to seek information from the HPA website.

PRIMARY HEALTH CARE April 2013 I Volume 23 Number 3

which contains regularly updated information written to

meet the needs of a lay audience and is free of charge.

Communication is also part of the work outbreak control

teams. The website provides an excellent resource for

lay people and health workers concerning all matters

related to infection.

ConclusionIn the UK and other developed countries sophisticated

surveillance systems are in place to monitor the rates

of communicable disease in the population, enabling

prompt action to be taken if an unusual infection is

detected or if the number of cases of a given infection

increases. However, communicable diseases still offer a

threat to people in this country and globally, especially

throughout the developing world. Outbreaks of infection

are a source of anxiety to members of the public and

disrupt patient care and service delivery in modern

healthcare systems. They affect the work of nurses by

increasing workload and the need to cope with the

questions and concerns of people who are affected and

members of the public who are anxious.

Practice profile

Now that you have completed the article,

I you might like to write a practice profile

of between 750 and 1,000 words. Go to

the Primary Health Care website:

I wwv\\primaryhealthc£ire.net and follow the

I link to the Learning Zone for information on

how to make a submission.

Find out more

Health Protection Agency www.hpa.ac.uk

ReferencesAyliffe G, Buckles A, CaseweU M et alii998)Working Parl> Report. Revised guidelinesfor the control oí methicillin-resistantStaphylococcus aureus infection in hospitals.Journal of Hospital Infection. 39, 4, 253-290.

Ban- B, Wilcox MH, Brady A et al (2007)Prevalence of methicillin-resistantStaphylococcus aureus colonization amongolder residents of care homes in the UnitedKingdom. Infection Control and HospitalEpidemiology. 28, 7, 853-859.

Boyce T, Murray E, Holmes A (2009) Whatare the drivers of the IIK media coverage ofmeticillin-resistant Staphylococcus aureus, theinter-relationships and relative influences?Journal of Hospital Infection. 73, 4, 400-407.

Curran ET, Benneyon JC, Hood J (2002)Conn"olling methiciliin-resistant Staphylococcusaureus. a feedback approach using annotatedstatistical process control charts. InfectionControl and Hospital Epidemiology. 23, 1, 13-18.

Curran E, Wilson J (2008) Using data effectivelyto prevent and control infection. Journal ofInfection Prevention. 9. 3, 26-33.

Department of Health and Social Security(1986) Report of the Committee of Inauiry intoan outbreak of food poisoning at Stanley RoydHospital HMSO. London.

Duerden B (2007) Bloodstream infections andtheir controL Nursing Times. 103, SuppI 46, 6-7.

Fung IC, Caimcross S (2006) Effectiveness ofhandwashing in preventing SARS: a review.Tropical Medicine and International Health.U, 11, 1749-1758.

Gould D (2009) Effective strategies for theprevention and control of Gram-negativeinfecUons. Nursing Standard. 23, 48, 42-46.

Gould D (2010) Prevention and control ofclostridium difficile infection. Nursing OlderPeople. 22, 3, 29-34.

Gould D, Brooker C (2008) Infection preventionand control. Applied Microbiology forHealthcare. Second edition. Palgrave, London.

Gould D, Drey NS, Millar M et al (2009)Patients and the public: knowledge, sources ofinformation and perceptions about healthcare-associated infection. Journal of HospitalInfection. Tl, 1, 1-8.

Hawker J, Begg N, Blair I et a/ (2005)Communicable Disease Control Handbook.Second edition. Black\veU Piiblishing. Oxford.

Hays JN (2005) Epidemics and Pandemics: Theirimpacts on Human History. ABC-CUO, SantaBarbara CA.

Health Protection Agency (2009) Reports ofSwine Influenza in Mexico and US - An Update.HP.A. London. \\w\v.hpa.org.uk/NewsCentre/NationalPressReleases/2009PressReleases/090425Swinefiu (Last accessed: Februan 26 2013.)

Health Protection Agency (2010a) SexualHealth Week. HPA, London, www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C71284131302022 (Ust accessed:February 26 2013.)

Health Protection Agency (2010b) InfluenzaPandemic Preparedness Update, www.hpa.org.uk/Publications/lnfectiousDiseases/Influenza/061 OlnfluenzaPandemicPreparednessUpdate(Last accessed: February 26 2013.)

Health Protection Agency (2012) TheCommunicable Disease Outbreak Plan:Operational Guidance, w^w.hpa.org.uk/webc/HPAwebFile/HPAweb_C/131713.';i66228(Lastaccessed: February' 26 2013.)

Hill DR (2006) The burden of illness ininternational n-avelers. New England Journal ofMedicine. 354, 2. 115-117.

Johnston G, Sladden M (2005) Scabies:diagnosis and treatment. British Medical .loumal.331,7517,619-622.

Lashley F, Durham J (2007) Emerging InfectiousDiseases: Trends and Issues. Second edition.Springer Publishing Company, New York NY.

Last JM (2000) A Dictionary of Epidemiology.Fourth edition. Oxford University' Press, Oxford.

Loeb M, McGeer A, Henry B et al (2004) SARSamong critical care niu-ses, Toronto. EmergingInfectious Diseases. 10. 2, 251-255.

Lynn S, Toop J, Hanger C et al (2004)Norovirus outbreaks in a hospital setting: therole of infection control. New Zealand MedicalJournal. 117, 1189, U771.

MacLehose L, Brand H, Camaroni I et al (2001)Commimicable disease outbreaks involvingmore than one country: systems approach toevaluating the response. British Medical Journal.323,7317,861-863.

Mayon-White R (2005) Re-emerging infections.Part 4: respiratory infections. Journal ofInfection Prevention. 6, 2, 13-16.

Nevvsom SWB (2008) Legionnaire's disease.The Philadelphia outbreak. Journal of InfectionPrevention. 9 3,18-21.

Norovinis Working Party (2011) Guidelinesfor the Management of Norovirus Outbreaks inAcute and Community' Health and Social CareSettings. HPA, London. wAvw.hpa.org.uk/webc/HPAwebFUe/HPAweb_C/1317131639453(Ustaccessed: Febiüary 26 2013.)

Parashar UD, Anderson U (2004) Severe acuterespiratory .syndrome: review and lessons ofthe 2003 outbreak. Intemational Journal ofEpidemiology. 33, 4, 628-634.

PMUlps H, Killingray D (Eds) (2003) TbeSpanish Influenza Pandemic of ¡918-1919.Routiedgc, Abingdon.

Pennington Group (1997) Report on theCircumstances Leading to the 1996 Outbreak ofInfection with Escherichia coli 0157 in CentralScotland, The Implications for Food Safety andthe Lessons to be Learned. The Stationery Office.Edinburgh.

Thacker SB, Berkelman RL (1988) PubUc healthsun'eillance in the United States. EpidemioiogicReviews. 10, 1, 164-190.

Washer P, Joffe H (2006) The 'hospitalsuperbug': social representations of MRSASocial Science and Medicine 63, 8, 2141-2152.

Williams P, Ellison J (1998) Food fears.Nursing Times. 94. 28, 72-75.

World Health Organization (2013) Malaria.Fact sheet No. 94. www.who.int/mcdiacentre/factsheets/fsO94/en (Last accessed: February26 2013.)

Wu AW (2000) Medical error. The second victim.British Medical .loumal. 320. 7237, 726-727.

Wu FDH, Fomek M, Schwab KJ et al (2005)A Norovirus outbreak at a long-term-carefacility: the role of environmental surfacecontamination. Infection Control and HospitalEpidemiology. 26, 10, 802-810.

April 2013 I Volume 23 | Number 3 PRIMARY HEALTH CARE

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