The Scottish Government

Implementing the recommendations of the Task Force on E.coli O157

Introduction

1. The E.coli O157 Task Force was appointed by the Minister for Health and Community Care in September 2000, under the joint sponsorship of the Food Standards Agency (FSA) Scotland and the Scottish Executive (SE) Health Department, to:

• review the risk to health of the public in Scotland, and current activities to prevent human infection with E.coli O157;

• assess the effectiveness of the present arrangements for co-ordination of action at national and local level; and

• consider what future measures would help protect public health.

2. The report of the Task Force was published in June 2001.

3. In May 2002, the Scottish Executive and the Food Standards Agency, working with others including UK Government Departments and NHSScotland, published a formal response (the SE/FSA Response) to that report which listed the recommendations and the actions which had been, were being, or would be, taken as a consequence. That response acknowledged the importance of putting in place open and effective arrangements for monitoring implementation activity and confirmed that the Executive and the FSA would submit regular progress reports to public meetings of the Scottish Food Advisory Committee (SFAC) and to the UK Zoonoses Group. This paper, published approximately one year after the formal response, honours that commitment.

4. It is, however, important to stress that the following sections do not address recommendations which had already been implemented when the formal response was published, or other, ongoing tasks which will be included in subsequent implementation updates. The focus of this paper is largely on achievements or developments within the last year.

Education and communication

5. In both the Task Force report and the SE/FSA Response there was a consistent theme recognising the importance of risk education and communication to a range of key target groups, and to the public at large. As previously indicated that process is ongoing, and builds on the established activity of a range of organisations including the Executive, the FSA, NHS Health Scotland (formerly the Health Education Board for Scotland) and the Health and Safety Executive (HSE). These organisations have formed an E.coli O157 Awareness Group which meets regularly to plan and co-ordinate activity and share information.

6. Examples of specific actions in the last year include:

• The FSA's Food Hygiene Campaign which provides information relevant to both commercial and domestic audiences.

• NHS Health Scotland has produced and distributed hygiene and handwashing materials targeting young children, teenagers and the general public, and an A5 information sheet Health Tips for Teachers Leading School Visits; in addition the issues raised by the Task Force are being emphasised wherever appropriate in scheduled reviews of existing health promotion materials.

• These materials also feature in an information pack which was been distributed, in May 2003, to Local Authority Education Departments and all 2,600 primary schools in Scotland. Recognising the importance of good hygiene and hand-washing in the context of children visiting open farms, the pack was prepared collaboratively by the Scottish Executive, NHS Health Scotland, the Royal Highland Education Trust and the HSE. Local Authority Health and Safety Advisors, and others with policy and functional interests, attended a pre-publication seminar to raise awareness of the pack, discuss an associated evaluation programme, and promote ongoing dialogue and collaboration. The strategic aims are, of course, meeting the information needs of school communities and children, and thereby avoiding the spread of E.coli O157 infection.

• The SE/FSA response accepted the broad thrust of the Task Force recommendations relating to access and use of rural land, and confirmed that guidance on recreational use of animal pasture had been issued to relevant organisations, including, for example, the National Farmers Union, the National Scout Association and the Guide Association. The Scottish Executive re-issued that guidance in 2003.

• HSE has issued press notices on avoiding ill health during recreation on farmland. HSE also met with, and advised, a range of bodies including the National Trust (England & Wales), the National Farmers Union, the Royal Society for the Protection of Birds, local authorities and other organisations with interests in improving and encouraging access to the countryside.

• HSE has produced a video which highlights the risk of contamination from farm animals, buildings and equipment and emphasises the importance of thorough hand cleaning. HSE has also produced guidance for farmers on avoiding ill-health, reinforcing its existing guidance on occupational zoonoses. The video will be placed on (and accessed via) the HSE website, and cross-referenced to other relevant HSE and other departmental guidance.

• Recognising the importance of working with the voluntary sector to improve communication with patients, the Executive has provided grant support for HUSH (Haemolytic Uraemic Syndrome Help) for three years from 2002-03. The funding is being used to employ a co-ordinator to compile and disseminate information on E.coli O157 and to raise awareness of both E.coli O157 and the services provided by HUSH. Having targeted information on the young, HUSH is developing a campaign targeting older people.

Research

7. The SE/FSA Response endorsed, in principle, targeted, peer-reviewed research activity and noted the potential availability of funding through a range of established bodies and mechanisms.

8. The UK Biotechnology and Biological Sciences Research Council (BBSRC) has confirmed that relevant research activity is being supported through the Control of Foodborne Pathogens (CFP) programme. This aims to provide the fundamental scientific understanding of transmissible agents that contaminate food and water, to allow the development of more effective strategies for the control of food poisoning and spoilage microbes at all stages of the food chain. It includes investigations into the mechanisms of pathogenesis, survival and transmission of foodborne micro-organisms (including viruses) as well as studies on their inactivation and control. In the last year BBSRC has invested £0.7 million in research relating to E.coli O157.

9. The Scottish Executive Environment and Rural Affairs Department invested £115,000 in a research project designed to provide high quality statistical inputs to a variety of E.coli O157 epidemiological studies, while conducting original research in the mathematical modelling of E.coli O157 in cattle and the analysis of bioinformatic data.

10. The Scottish Centre for Infection and Environmental Health (SCIEH) has taken forward a range of actions designed to enhance surveillance in Scotland (see paragraph 18). The extensive nature of the information gathered facilitates collaboration with several research groups investigating the epidemiology of E.coli O157.

11. HSE is currently conducting research into the role of the wild rabbit population as a potential vector in the spread of E.coli O157. Initial work in the Yorkshire area was carried out last winter by the Health & Safety Laboratory at Sheffield and further faecal sampling and analysis is currently under way.

12. FSA(S) is funding a 30-month study on non-O157 VTEC which is due to finish at the end of June 2004. This study is looking at the prevalence of E.coli O26, O111, O145 and O103 in 300 Scottish beef herds, in conjunction with the International Partnership Research Award in Epidemiology (IPRAVE) study on E.coli O157.

Diagnosis, treatment, care and public health management

13. In 2002, the SE/FSA Response confirmed that SE funding had been provided to the Scottish Infection Standards and Strategy (SISS) Group to allow the development and dissemination of good practice guidance for health professionals, relating to:

• diagnostic awareness including indications for stool sampling;

• indications for referral for specialist advice;

• infection control measures to prevent person-to-person spread;

• clinical management of E.coli O157 infection; and

• public health management to prevent community spread.

14. This SISS educational material is being published in parallel with this paper and will be circulated to all relevant health professionals in NHSScotland.

15. Task Force recommendations emphasise the importance of excluding children from nursery schools on the grounds of health risk. The SISS guidance states that all pre-school children who have E.coli O157 infection, or who are household contacts of cases, should be excluded from pre-school care groups or nursery until two consecutive faecal samples taken 24 hours apart have tested negative for E.coli O157.

16. In the healthcare context there is of course a connection between improving hygiene, including hand-cleaning, and effective infection control. Some related benefits can therefore be expected to accrue from a major initiative launched in 2002 to control healthcare associated infection (HAI) in NHSScotland. The Ministerial Action Plan for Preventing HAI specifies priority areas such as the development of a Code of Practice for local management of hygiene, mandatory training and induction courses in hygiene and infection control for staff, and the setting of technical requirements for cleaning processes and frequencies. A Task Force chaired by the Chief Medical Officer has been set up to co-ordinate implementation, to monitor progress, to monitor levels of HAI, and to report on progress to the Minister for Health and Community Care.

17. In relation to incident management, following a request from the Ad-Hoc Group of Ministers on Health and Public Water Supply, the Scottish Executive published Managing Incidents Presenting Actual or Potential Risks to the Public Health - Guidance on the Roles and Responsibilities of Incident Control Teams (www.scotland.gov.uk) in January 2003, for consultation. Building on the Cairns Smith guidance published in April 2002, and other subject specific material, Managing Incidents deals with the generic organisational arrangements and main functions involved in handling incidents or outbreaks related to actual or potential exposures to a range of hazards, including E.coli O157. The consultation period ended on 30 ^th May 2003; the Executive is now considering comments received, and the need for any associated revision of the guidance.

Surveillance

18. The SE/FSA Response indicated that SCIEH would take forward a range of actions designed to enhance surveillance:

• A revised Scottish Infectious Disease Surveillance System (SIDSS) is being developed to allow information collected on cases and outbreaks of infection to be standardised. SIDSS is currently being user tested with three NHS Boards whose feedback will enable this tool to be offered to NHSScotland as a whole during 2003.

• An enhanced surveillance case register of laboratory confirmed E.coli O157 infection in Scotland has in the last two years provided SCIEH with detailed follow-up surveillance data on initial illness from 527 people previously infected with E.coli O157 and feedback on health 12 months after illness from 315 of these patients. These follow-up data are currently being analysed at SCIEH, but improved understanding of the epidemiology through enhanced surveillance has already allowed intermediate findings to be provided for appropriate agencies. For example, routine laboratory reporting indicated that 2% of these cases were imported; the more detailed surveillance identified that 14% of patients travelled outwith Scotland prior to illness. This information is relevant to the Food Standards Agency which has targets for reducing food poisoning figures. SCIEH annual outbreak surveillance reports included increased numbers of community-based general outbreaks of E.coli O157 (involving more than one household) due to linked cases identified by enhanced surveillance. SCIEH also found that 13% of cases were due to secondary or person-to-person spread of infection, a figure not available previously on a national scale. Only 36% of secondary cases were part of outbreaks and half the remaining sporadic secondary cases were under ten years old, reinforcing the importance of infection control within the community.

• In March 2003, SCIEH, with SEHD funding, initiated a clinically based enhanced surveillance system (ENSHURE) of haemolytic uraemic syndrome. This addition to laboratory-based surveillance will allow the number of cases of HUS to be more accurately estimated and facilitate joint working with clinicians to monitor long-term consequences. HUSH is represented on the Steering Group of ENSHURE and has had input into the design of questionnaires and other study documents.

• The Food Standards Agency (Scotland) has funded SCIEH to co-ordinate microbiological surveillance of food in Scotland to enable any food isolates of E.coli O157 to be compared with human and animal isolates.

As indicated earlier, the extensive nature of the information now being gathered allows SCIEH to collaborate with several research groups to investigate the epidemiology of E.coli O157.

Organic waste on land

19. The Executive accepted the broad thrust of the Task Force recommendations relating to organic waste on land and confirmed plans for early consultation about options for legislative change.

20. In the latter part of 2002 and the first weeks of 2003, the Executive consulted on amendments to both the Waste Management Licensing Regulations 1994 and the Sludge (Use in Agriculture) Scotland Regulations 1989. Amendments were proposed which would:

• make it a requirement to demonstrate, to the Scottish Environment Protection Agency (SEPA), the agricultural benefit of spreading organic wastes on land;

• provide an audit trail for SEPA to assess;

• restrict the usage of land on which sewage sludge or organic wastes had been spread;

• prohibit the spreading of septic tank waste or sludge on land;

• prohibit the spreading of untreated sewage sludge on agricultural land; and

• permit SEPA to develop charging schemes to cover the costs of rigorous regulation of the spreading of sewage sludge and organic wastes.

21. These proposals received strong public support.

22. Amendments to the Waste Management Licensing Regulations 1994 were laid in the Scottish Parliament on 11 ^th March 2003, becoming effective on 1 ^st April. Amendments to the Sludge (Use in Agriculture) Regulations 1989 will be laid later in 2003, with associated further amendments to the Waste Management Licensing Regulations. The new requirements will be taken into account in the updated PEPFAA (Prevention of Environmental Pollution from Agricultural Activity) Code, expected to be completed later in 2003.

23. A statutory requirement for blood from abattoirs to be treated prior to final disposal, arising from new European Union controls on animal by-products, will be introduced later in 2003.

Water Supply

24. The SE/FSA Response recognised the synergy between relevant Task Force recommendations and associated policy initiatives underlining the Executive's established commitment to maintaining and enhancing the quality of Scotland's water. The Executive is currently developing more robust regulatory standards which local authorities shall be required to enforce; a grant scheme providing assistance with the cost of upgrading private water supplies; and improved provision of information and guidance on risk management. The latter underpins proposals to introduce a regulatory requirement for microbiological risk assessment of private water supplies. Subject to consultation planned for later this year, new regulations will be introduced early in 2004.

Food

25. The FSA confirmed in 2002 that many of the Task Force recommendations were already being taken forward, for example, through the ongoing Food Hygiene Campaign which reinforces and reiterates seasonal food safety issues at regular intervals.

26. A public consultation on the revision of the Agency's Enforcement Codes of Practice was initiated. The consultation period ends on 10 ^th June 2003.

27. The Food Standards Agency Advisory Committee for Wales (ACW) recommended in December 2000 that the sale of raw drinking milk should be banned in Wales, and their recommendation has been reported to the Chairman of the Food Standards Agency and to the National Assembly for Wales. Following the Food Standards Agency Wales consultation, the Welsh Assembly Government has decided that a voluntary change to raw milk labelling is to be introduced. The results of the consultation showed that the very small minority of consumers who currently drink unpasteurised milk and cream should retain their right to do so. Though the ACW considered that evidence of the risk to health still supported a ban, it concluded from the consultation responses that sales of raw drinking milk and cream should be allowed to continue in Wales. Sales of raw drinking milk and cream will be allowed to continue, but the Agency will liaise with producers to encourage them to change the labelling on their product to give a stronger warning of the potential risks to health associated with raw milk consumption. This is consistent with established policy elsewhere which recognises that as risks are taken voluntarily by consumers the role of the Agency should be to ensure that consumers are informed of those risks. This is currently effected by legislation requiring raw milk to carry a health warning.

28. An FSA Scotland review of the effectiveness and implementation of butchers' licensing was published in December 2002. An action plan based on the report's recommendations and the views of consultees will be developed in the summer. A similar review of the butchers' licensing scheme in England is nearing completion and it is expected the results will be available in the latter half of 2003. The effectiveness of butchers' licensing and other developments in Europe will be taken fully into account before the Agency arrives at any decision about the wider potential for licensing of food premises.

29. Hazard Analysis and Critical Control Points (HACCP) principles have been fully incorporated into the current text of proposals to update and streamline EU food hygiene law. These proposals will consolidate 17 existing Directives into 5 new Directives. The element of the proposals that will require food businesses to operate procedures based on HACCP principles has achieved political agreement. The Agency has adopted a HACCP strategy to support the adoption of HACCP in food premises before it becomes law. FSA Scotland has secured an additional £2 million of funding (from 2004) to underpin its introduction. Funding bids in other parts of the UK have been less successful, but the strategy itself remains a key agency objective.

Review

30. A further report on implementation actions will be published in June 2004.