The Scottish Government

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

Contents

Introduction
Education and communication
Research
Diagnosis, treatment, care and public health management
Surveillance
Organic waste on land
Private Water Supplies
Food
Review

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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. http://www.food.gov.uk/multimedia/pdfs/ecolitaskfinreport.pdf

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 to that report. (The SE/FSA Response, which can be viewed at http://www.scotland.gov.uk/library5/health/rrec-01.asp ). This response 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.

3.1 Updates were published in June 2003 http://www.scotland.gov.uk/Publications/2003/06/17411 and August 2004 http://www.scotland.gov.uk/Resource/Doc/17002/0012867.pdf . The Executive undertook to report further on actions, this paper 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.

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Education and communication

5. The FSA's Food Hygiene Campaign continues to provide information relevant to both commercial and domestic audiences.

6. Further to the information pack ( http://www.scotland.gov.uk/library5/health/ecsip-00.asp) which was distributed, in May 2003, to Local Authority Education Departments and all 2,600 primary schools in Scotland to emphasise the importance of good hygiene and hand-washing in the context of children visiting open farms, the Executive ran an advertising campaign earlier this year to raise awareness of E.coli O157 and the associated risk of direct contact with animals/animal pasture. It advised people of the simple steps that can be taken to reduce that risk.

6.1 This campaign which ran during the 2 weeks leading up to Easter 2005, the traditional start of picnic time and other outdoor activities, was aimed primarily, but not exclusively, at parents, educating them to ensure that children take simple steps such as hand washing to reduce risk, without discouraging families from enjoying the countryside, country parks, farms and petting zoos.

6.2 Radio adverts were aired on local stations, mainly at school run times, and newspaper advertisements placed in most of the national and local Scottish papers. The radio/press campaign directed listeners/readers to a website ( www.handsclean.info) providing simple advice on the risks and measures which can be taken to minimise those risks.

6.3 In addition, a leaflet was published which was distributed to a number of interested parties e.g. scouts, girl guiding associations, camping associations across Scotland. This leaflet is available on request by e-mailing: business.edinburgh@blackwell.co.uk or telephoning: 0131 622 8283. It may also be accessed at: http://www.scotland.gov.uk/Publications/2005/03/20839/54389 .

7. The Scottish Executive, recognising the importance of working with the voluntary sector to improve communication with patients, continues to provide financial support for HUSH (Haemolytic Uraemic Syndrome Help) to disseminate information on E.coli O157.

8. Health and Safety Executive (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 can be accessed via the HSE web site at www.hse.gov.uk/campaigns/farmsafe/ecoli.htm and is cross-referenced to other relevant HSE and other departmental guidance. HSE has also issued press notices on avoiding ill health during recreation on farmland.

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Research

9. The Scottish Executive Environment and Rural Affairs Department (SEERAD) has provided information on its E.coli research projects between 1999-2003 to the Microbial Safety of Food Funders Group (MSFFG). This information, along with data from other funders, has been used to compile a report for MSFFG 'UK Publicly Funded Research Relating To Verocytotoxin Producing Escherichia coli (VTEC)', that summarises research progress and identifies gaps in knowledge and related funding issues for funders to address. The updated report was published in October 2004 and is available at http://www.food.gov.uk/science/research/researchinfo/foodborneillness/microfunders/vtec .

10. SEERAD invested £115,000 in a research project, designed to provide high quality statistical inputs to the E.coli O157 epidemiological studies being conducted under the Wellcome Trust-funded International Partnership Research Award in Epidemiology (IPRAVE) programme, while also conducting original research into the mathematical modelling of E.coli O157 in cattle and the analysis of bioinformatic data.

11. SEERAD-funded scientists have collaborated with the Department for Environment, Food and Rural Affairs (DEFRA) funded Veterinary Research Fellow at the University of Edinburgh to identify for the first time the site of colonisation of E.coli O157 in the recto-anal junction in cattle. The identification of this site is an important step in developing our understanding of E.coli O157 biology and towards developing targeted methods of control in the ruminant host. Several new projects to follow up this discovery are in the process of being commissioned by DEFRA, FSA and SEERAD.

12. Two SEERAD-funded research projects that relate to organic waste and E.coli O157 contamination of water supplies have progressed. A successful project 'Survival and dispersal of E.coli O157 in Scottish agricultural soils, and potential for contamination of private water supplies' met all of its objectives and was completed in February 2004. The second project 'Environmental effects of woodchip corrals' was initiated in 2003. It investigated the microbial contamination (and pollution) potential of these structures which have recently become popular for outdoor overwintering cattle. The results of the project, suggesting that waste from these structures should be collected and contained to protect surface and groundwater, have fed into policy decision making on woodchip corrals by Scottish Environment Protection Agency and Environment Agency. The project was completed in Spring 2005. Copies of the final reports for these projects are available from SEERAD Science and Research Group.

13. Health Protection Scotland (HPS) continues to take forward a range of actions designed to enhance surveillance in Scotland. The extensive nature of the information gathered facilitates collaboration with several research groups investigating the epidemiology of E.coli O157.

14. HSE has recently produced research findings into the role of the wild rabbit population as a potential vector in the spread of E.coli O157. The full research report can be accessed via the HSE web site at www.hse.gov.uk/research/hsl/ochealth.htm . A brief summary of the report's findings, together with recommendations on suitable precautions to avert the health risk can be found on the HSE website at www.hse.gov.uk/campaigns/farmsafe/ecoli.htm .

15. Two FSA(S) funded research projects relating to non-O157 VTEC have been published. The first was a 30-month study looking at the prevalence of E.coli O26, O103, O111 and O145 in 300 Scottish beef herds, in conjunction with the International Partnership Research Award in Veterinary Epidemiology (IPRAVE) study on E.coli O157. The second project undertook to ascertain the relatedness of cattle and human E.coli O26 isolates to help identify if Scottish cattle are a reservoir for clinical infection of E.coli O26 and thus have the potential to contribute to human diarrhoeal disease as seen in many other European countries. Copies of the final reports of both projects can be obtained from Food Standards Agency publications Tel: 0845 606 0667 or e-mail: foodstandards@ecologistics.co.uk.

15.1 Following on from the previous research on E.coli O26, FSA(S) is funding a postgraduate studentship which aims to determine whether it is possible to identify factors linked to the potential for serotype O26 strains to cause human infections. This studentship is due to be completed in January 2008. FSA(S) is also funding a study to look at the prevalence of E.coli O157 and other non-O157 VTEC's in sheep presented for slaughter in Scotland.

15.2 A 3-year Postgraduate Studentship sponsored by FSA(S) has begun to examine the reasons for the urban and rural differences in E coli O157 human infection in Grampian. This study is due for completion in October 2007.

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Diagnosis, treatment, care and public health management

16. 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.

17. This was published in the Journal of the Royal College of Physicians of Edinburgh (J R Coll Physicians Edinb; 34;37-40) and SISS educational material is being published in parallel which will be circulated to all relevant health professionals in NHSScotland.

( http://www.rcpe.ac.uk/publications/articles/journal_34_1/E_coli_O157.pdf)

18. 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.

19. In the healthcare context there is of course a connection between improving hygiene, including hand decontamination, and effective infection control. Related benefits can therefore be expected to come from the work of the HAI Task Force, a major 3 year initiative launched in 2002 to control healthcare associated infection (HAI) in NHSScotland (and available for guidance in other sectors). The Ministerial HAI Action Plan specifies priority areas such as the development of a Code of Practice for local management of hygiene and HAI, and the setting of technical requirements for cleaning processes and frequencies: both of these were issued, following consultation, in May 2004. Work progressing in other areas includes mandatory induction training in hygiene and infection control for staff, HAI surveillance, development of risk-based methodologies for prioritisation of HAI risks, further implementation of the Antimicrobial Resistance Strategy, and guidance on management of outbreaks (including staff screening). On hand decontamination, the widespread introduction of alcohol hand gel (2005) and the production of a stand-alone hand hygiene training resource by NHS Education Scotland are expected to have a major impact.

20. The Scottish Executive publication Managing Incidents Presenting Actual or Potential Risks to the Public Health - Guidance on the Roles and Responsibilities of Incident Control Teams ( http://www.scotland.gov.uk/library5/health/mipa-00.asp) which details 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, will continue to be reviewed, and updated as required.

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Surveillance

21. The SE/FSA Response indicated that Health Protection Scotland (HPS) (formerly SCIEH) would take forward a range of actions designed to enhance surveillance:

• Scottish Infectious Disease Surveillance System 2 (SIDSS), a standard medical disease surveillance on all notified and reported cases of infection is currently being used by Health Boards in Scotland.
• An enhanced surveillance case register of laboratory confirmed E.coli O157 infection in Scotland has in the last two years provided HPS 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 HPS, 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. HPS 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. HPS 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, HPS, with SEHD funding, initiated a clinically based enhanced surveillance system (ENSHURE) of haemolytic uraemic syndrome (HUS). 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. Haemolytic Uraemic Syndrome Help (HUSH) is represented on the Steering Group of ENSHURE and has had input into the design of questionnaires and other study documents. Information from 2003 was published in the HPS Weekly Report of 10th May (volume 39 No.2005/18).

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Organic waste on land

22. The Executive accepted the broad thrust of the Task Force recommendations relating to organic waste on land, and has continued to tighten up legislation governing the use of organic wastes (including sewage sludge) on land. The latest amendments to the Waste Management Licensing Regulations came into force on 12 January 2005. Use of organic wastes in agricultural and non-agricultural crops (eg forestry), as well as in land restoration, is now tightly controlled. All farm wastes, including organic wastes, were brought fully within the control regime which applies to wastes from other sectors with effect from 21 January 2005. The Executive is also supporting work by the UK Government to revise the existing UK-wide Code of Practice on the agricultural use of sludge. Its publication is a matter for the UK Government.

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, was introduced on 1 October 2003 under the provisions of the Animal By-Products (Scotland) Regulations 2003. Day to day enforcement duties fall to the Meat Hygiene Service. The Executive issued guidance regarding this requirement to all Scottish abattoirs prior to the implementation of these controls and has also recently sanctioned the use of screening systems to cleanse the blood/waste water effluent generated by meat plants.

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Private Water Supplies

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. The consultation on draft Private Water Supplies regulations and proposals for a Grant Scheme concluded in June and the aim is to have these regulations in force early 2006.

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Food

25. The FSA's Food Hygiene Campaign continues to be on the annual programme. The current focus of the campaign is targeting consumers.

26. The FSA's Enforcement Codes of Practice have been published.

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 recommendations were reported to the Chairman of the Food Standards Agency and to the National Assembly for Wales. Following the Food Standards Agency Wales consultation in 2002, the Welsh Assembly Government decided that a voluntary change to raw milk labelling should 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 the evidence of the risk to health still supported a ban, it concluded from the consultation responses that the sales of raw drinking milk and cream should be allowed to continue in Wales. Although sales of raw drinking milk and cream will be allowed to continue, the FSA is now proposing, through a consultation on policy options for applying EC proposals to consolidate and simplify food hygiene legislation, to expand the labelling provisions in Wales for raw drinking milk and cream. This would provide a stronger warning to vulnerable groups of the potential risks to health associated with raw milk consumption. The proposal recognises that as risks are taken voluntarily by consumers the role of the FSA should be to ensure that consumers are informed of those risks. In addition, the FSA is proposing, in Scotland, to retain the current ban on the sale of raw cows' drinking milk and cream and to extend the ban to the sale of raw milk from all farmed animals.

28. An FSA (Scotland) review of the effectiveness and implementation of butchers' licensing was published in December 2002. A similar review of the butchers' licensing scheme in England is complete. Following a UK wide consultation and discussion at the open FSA Board meeting, the Board agreed that national butchers' licensing legislation should not be remade when new EC hygiene rules take effect. The new food hygiene legislation introduces food safety measures substantially equivalent to those in the current butchers' licensing regulations. 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. The proposed new EU Food Hygiene Regulations will replace the existing body of food hygiene legislation with more modern, risk-based requirements and will come into force early in 2006. This new legislation will require all food businesses (except those in primary production) to put in place food safety management systems based on Hazard Analysis Critical Control Point (HACCP) principles. Scottish Ministers provided additional funding of £2m for 2004/05 and a further £2m for 2005/06, to support Scottish catering businesses with the implementation of food safety management procedures based on the HACCP principles. FSA has developed a strategy for delivering this support and has produced guidance for businesses in printed and e-learning formats. The printed guidance has been translated into Urdu, Punjabi and Chinese and agreements are in place between the FSA and each Scottish local Authority to deliver support to businesses in a way that suits local circumstances. The FSA is providing trainers to Local Authorities to provide training in the languages covered by the translations in response to local demand.

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Review

30. Due to the long-term nature of the research projects it is proposed to produce a biennial report on implementation actions. This will be will be published in summer 2007.