Report on the Lessons Learnt by organisations participating in the confirmed case

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					                                                                       AGENDA ITEM 20
                                                                        ENCLOSURE 16

Report on the Lessons Learnt by organisations
participating in the Redditch Legionnaires' Disease
outbreak, September 2004
These organisational findings were collated following a meeting held at
Crossgate House on 24 February 2005

Present at meeting:

Dr David Kirrage (chairman) HPA
Mrs Sue Hanbury Redditch Borough Council
Mr Carl Ridge Redditch Borough Council
Dr Mike Deakin West Midland South Strategic Health Authority
Dr Caron Grainger Redditch and Bromsgrove Primary Care Trust
Mrs Nicola Benge Redditch and Bromsgrove Primary Care Trust
Dr Alan Tweddell HPA
Mrs Joan Lewis HPA
Mrs Heather Gentry Alexandra Hospital, Redditch
Dr Jim Stone Alexandra Hospital, Redditch
Mr Tony Woodward, Health and Safety Executive

The lessons learnt exercise began with a presentation by the chairman of the
chronology of the outbreak and the actions taken. This presentation is
included as appendix 1 (available on request). He also presented some good
aspects of the management of the outbreak as well as some of the problems
encountered. A report prepared for the coroner was also provided to
participants as an aide memoire of the outbreak.

Participants were encouraged to discuss aspects of the outbreak from an
organisational perspective. Relevant learning points were agreed and noted
throughout the exercise. These are presented in italics below under various
headings appropriate to the stage of the outbreak investigation or specific
issue covered.

Early notification

Case 1 was in hospital 8 days before a urinary antigen test was taken. The
HPA had been informed on Friday 27 August but had not passed this onto the
PCT. Over the weekend (28 and 29 August) the family had informed the
press who contacted the PCT on 31 August for comment.

PCTs should always be promptly informed of a case of Legionnaires' to
enable them to prepare a media response and inform GPs who may be
contacted by relatives for information.

Much of the media handling in the case was undertaken by the HPA media
lead (due to compassionate leave within the PCT). This lead to some
confusion over record keeping and the feeling that good relationships with the

Report on the lessons learnt by organisations participating in the Redditch Legionnaires’
Disease outbreak, September 2004
PCT Board Meeting 26 April 2005                                                        Page 1 of 4
                                                                       AGENDA ITEM 20
                                                                        ENCLOSURE 16
local media were compromised at the expense of feeding the regional and
national outlets.

It was agreed that local media should be contacted by PCT media lead where
possible.

Communications within the team

It was agreed that the chairman of the Outbreak Control Team (OCT) should
ask members at the initial meeting to state their organisational responsibilities
and contribution to the OCT and gain agreement on this.

It was also agreed that there had been throughout the outbreak some
confusion over the terminology used. Different members had different
interpretations of the meaning of "inspection", "sampling", "cleaning",
"disinfection", and "shock dosing".

The group recommends that the terminologies and definitions used in
investigations of Legionnaires' Disease are agreed early on in the
investigation and minuted.

The decision to use the Chamber of Commerce as a means of warning all
companies with potential wet cooling system to consider shock dosing was
not 100% effective. There was evidence that some companies had not
complied and the Chamber of Commerce could not give any assurance to the
OCT that a warning had indeed been sent. Reliance on the media to back up
this message was also probably misplaced although it had seemed to be
effective in the Hereford Legionnaires' outbreak.

It is the responsibility of the Local Authority to issue advice in writing to all
companies with registered cooling towers if the OCT decide that shock dosing
is indicated as a general preventative measure. Other identified sites should
be offered advice which must be subsequently backed up in writing.

The hospital infection control team were very helpful in reviewing other
inpatients both currently and retrospectively to ascertain further cases of
Legionnaires'.     They felt that better definition of symptoms and
epidemiological data would have aided this process. It was stressed that it is
better to get a complete history at the initial interview with a confirmed case or
relative as this may guide case definitions and obviate the need for repeated
history taking.

A full history should be taken for all confirmed cases using the Legionnaires'
questionnaire already developed by CDSC. Epidemiological information from
these should be used where possible to develop a tighter case definition for
hospital teams ascertaining undiagnosed cases.




Report on the lessons learnt by organisations participating in the Redditch Legionnaires’
Disease outbreak, September 2004
PCT Board Meeting 26 April 2005                                                        Page 2 of 4
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                                                                        ENCLOSURE 16
Good aspects of this outbreak

   Prompt setting up of OCT by HPA
   Support of PCT in facilities and staff
   Commitment by organisations represented on OCT
   Support from neighbouring LAs (particularly Herefordshire)
   Support from Alexandra Hospital (microbiology and ICNs)
   Communication back to medical colleagues (PCC and GPs)
   Presence of laboratory liaison manager at OCT
   PCT well supported by HPA
   Media handling overall

Perceived problems with this outbreak

   Initial concern that situation not seen to have high priority by partners
   Clinical isolates only obtained for 50% of cases
   Lack of trained manpower and resources early in outbreak
   Lack of GIS expertise
   "Difficult" outbreak - prolonged, ?cluster rather than true outbreak
   Chairing meetings
   Difficulty in implementing decisions of OCT
   Difficulty in declaring outbreak over (Case 4 presented late in outbreak)

Outcomes since incident declared over

   Agreement nationally (West Mids to pilot) for HPA-LA memorandum of
    understanding to be developed
   Regional teleconference held on 9 November to review clusters of
    Legionnaires' disease occurring since Summer 2004
   Proposal for trained regional Legionnaires' cadre of EHOs and HPA staff is
    under active consideration
   New information officer appointed to Hereford & Worcs and Cov & Warks
    HPUs

Conclusions - Lessons learnt to be implemented

1. PCTs should always be promptly informed of a case of Legionnaires' to
   enable them to prepare a media response and inform GPs who may be
   contacted by relatives for information.

2. It was agreed that local media should be contacted by PCT media lead
   where possible.

3. It was agreed that the chairman of the Outbreak Control Team (OCT)
   should ask members at the initial meeting to state their organisational
   responsibilities and contribution to the OCT and gain agreement on this.




Report on the lessons learnt by organisations participating in the Redditch Legionnaires’
Disease outbreak, September 2004
PCT Board Meeting 26 April 2005                                                        Page 3 of 4
                                                                       AGENDA ITEM 20
                                                                        ENCLOSURE 16
4. The group recommends that the terminologies and definitions used in
   investigations of Legionnaires' Disease are agreed early on in the
   investigation and minuted.

5. It is the responsibility of the Local Authority to issue advice in writing to all
   companies with registered cooling towers if the OCT decide that shock
   dosing is indicated as a general preventative measure. Other identified
   sites should be offered advice which must be subsequently backed up in
   writing.

6. A full history should be taken for all confirmed cases using the
   Legionnaires' questionnaire already developed by CDSC. Epidemiological
   information from these should be used where possible to develop a tighter
   case definition for hospital teams ascertaining undiagnosed cases.


D Kirrage
February 2005




Report on the lessons learnt by organisations participating in the Redditch Legionnaires’
Disease outbreak, September 2004
PCT Board Meeting 26 April 2005                                                        Page 4 of 4

				
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