Memorandum by Dr H A Thurston, Consultant
in Communicable Disease Control, Ms K Gunn, Public Health Nurse
in Communicable Disease and Infection Control, and Dr M Afza,
Specialist Registrar in Public Health Medicine
What policy interventions would have the greatest
impact on preventing outbreaks of and damage caused by infectious
disease in the United Kingdom?
High standards of infection control need to
be maintained and monitored in elderly care settings.
The Care Standards Commission has a key role
to play to ensure this occurs within nursing and residential homes.
Without the high standards of infection control,
outbreaks will continue to occur as described below.
An outbreak of E. coli O157 in a private nursing
and residential home in North Staffordshire
In July 2001 an outbreak of E coli O157
infection was identified amongst staff and residents of a private
nursing home in North Staffordshire. Although the source of the
infection was not ascertained, there was potential for cross contamination
in the main kitchen and person to person spread within the home.
Between 1 July and 29 August, there were 75
clinical cases, amounting to an attack rate of 35/181 (19.3 per
cent) staff and 40/139 (28.8 per cent) residents, fitting the
case definition of gastroenteritis. There were 20 confirmed cases
of E coli O157 infection, twelve (6.6 per cent) staff and
eight (5.8 per cent) residents. The index case was the most severely
affected, and was hospitalised with bloody diarrhoea and Haemolytic
Uraemic Syndrome (HUS). Thirteen cases had symptoms consistent
with gastroenteritis and six cases remained asymptomatic. The
disease seemed to be milder then usual (low hospitalisation rates
and no fatal outcomes) with only the index case developing bloody
diarrhoea and HUS. This is in contrast to the previously observed
serious outcomes and relatively high fatality rates in similar
The infection control audits undertaken at the
onset of the outbreak highlighted significant lapses in the infection
control practice and procedures in the Nursing Home. A particular
management problem for the Outbreak Control Team (OCT) was the
implementation of infection control measures. The CCDC and Outbreak
Control Team had limited power over the administration of the
Home in expediting environmental cleaning and essential training
for the staff in observing enteric precautions.
The outbreak provided insight into the inadequacy
of the routine nursing and residential home inspections in identifying
infection control issues. It was disappointing to see that although
this Nursing Home was owned by a national chain of nursing and
residential homes, it was struggling to implement and maintain
infection control standards.
Many nursing home patients require the intensity
of care usually offered in a hospital setting, such as feeding
via Percuteneous Enteroscopic Gastrostomy (PEG), care of indwelling
urinary catheters etc. Therefore nursing homes should be expected
to observe a similar level of infection control standards as deemed
appropriate for a hospital setting.
Shortly before this outbreak this Nursing Home
had been a subject to a routine inspection by the Nursing Home
Inspectorate. The inspection did raise some issues about the adequacy
of staffing. However the poor standards of infection control practices
and lack of infection control policies and procedures were not
identified by this inspection. Since then, due to the reorganisation
of social and health services, the Nursing Home Inspectorates'
functions have been passed to the Care Standards Commission (CSC).
The Outbreak Control Team report on this outbreak was submitted
to the Health Authority, and included specific recommendations
for the CSC.
Recommendations to the two key agencies, the
Nursing Home management and the Care Standards Commission responsible
for maintaining the standards of patient care, were as follows:
Infection control strategy, policy
and guidance should be reviewed at a corporate level, to ensure
robust infection control procedures and practices within the Home.
Monitoring of the application of
infection control policy should be instigated (infection control
audit) both from a corporate level and locally in the Home.
Infection control training and education
at induction and at least annually should be instigated in the
Home and should be given a high priority.
A surveillance system needs to be
maintained by the Home to identify infections and report them
to appropriate agencies promptly.
High standards of infection control
need to be maintained and monitored in elderly care settings.
Consideration should be given to
the review of regulatory inspection documentation, so that it
may assist with the identification of infection control issues
in registered nursing home premises.
Infection control standards in nursing homes
need to be monitored and high standards maintained to prevent
similar outbreaks. The organisation of infection control in the
private sector should be on a par with NHS systems. An example
of this might be the application of the Control Assurance Standards
for infection control5 within the private sector.
This case study illustrates the need for and
importance of effective infection control policies and procedures
in the health care facilities outwith the National Health Service.
Over half of all beds allocated for health care in the United
Kingdom are in independent nursing homes for older people6. These
patients have complex health care needs, not dissimilar to those
patients in the NHS hospitals. Good infection control practices
are crucial for the prevention of similar outbreaks affecting
a vulnerable section of the population.
1. Pennington Group: Report on the circumstances
leading to the 1996 outbreak of infection with E. coli
O157 in Central Scotland, The implications for food safety and
the lessons to be learned. Stationery Office, Edinburgh ISBN-0-11-495851-3
2. Cowden J M, Ahmed S, Donaghy M, Riley
A. Epidemiological investigation of the Central Scotland outbreak
of Escherichia coli O157 infection, November to December
1996. Epidemiol Infect. 2001Jun; 126 (3): 335-41.
3. Kohli H S, Chaudhuri A K, Todd W T, Mitchell
A A, Liddell K G. A severe outbreak of E. coli O157 in
two psychogeriatric wards. J Public Health Med. 1994 Mar;6 (1):
4. Carter A O, Borczyk A A, Carlson J A,
Harvey B, Hocckin J C, Karmali M A et al. A severe outbreak
of Escherichia coli O157: H7-associated hemorrhagic colitis
in a nursing home. N Engl J Med 1987 Dec 10; 317(24): 1496-500.
5. Health Service Circular 1999/179, Control
Assurance Standards in Infection Control; Decontamination of Medical
6. Kerrison H S, Pollock A M. Regulating
nursing homes: Caring for older people in the private sector in
England. BMJ 2001; 325:566-9.