Select Committee on Science and Technology Written Evidence

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 outbreaks1,2,3,4.

  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): 11-15.

  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 Devices.

  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.

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