Learning lessons from the recent Legionnaires’ outbreak in Edinburgh
Scotland’s Health Secretary Nicola Sturgeon has described the recent deadly outbreak of Legionnaires’ disease in Edinburgh as “the most significant in Scotland for a long, long time”. To date, is has claimed two lives and has seen around 90 confirmed or suspected cases. While the eye of the storm was in south-west Edinburgh, the outbreak prompted a national response. Sturgeon activated the Scottish Government Resilience Room and Sturgeon, together with NHS Lothian’s public health consultant, Dr Duncan McCormick, has become a familiar fixture on television news loops, outlining the latest developments and seeking to obviate alarm.
Now that the numbers of those contracting the disease appear to have peaked, the Scottish Parliament’s Health and Sport Committee has decided it is an “appropriate” time to ask questions about the handling of the outbreak and progress that has been made in identifying the source. The committee will hold a special evidence session tomorrow where it will hear from McCormick and other members of the Incident Management Team.
“The committee was keen to let those handling the outbreak to get on with their jobs and focus on dealing with this serious public health issue,” Deputy Convener Bob Doris MSP said.
“With the outbreak now under control, the committee is pleased that the incident management team is willing to appear in front of MSPs. The evidence session will allow the Health Committee to play a constructive role scrutinising the management of the outbreak. We are not calling into question any specific actions but rather assisting in promoting continuous improvement in how such incidents are managed.”
Early on in the outbreak, an NHS helpline was established by the special health board NHS 24.
The helpline provided a direct number for people to call with questions and concerns, and in the few weeks since it was set up it has already dealt with almost 1,000 calls.
“This dedicated line complemented the NHS 24 core service which dealt with patients who presented with symptoms suggesting that they may have contracted the illness.
“Working with Health Protection Scotland and clinical specialists NHS 24 we reviewed their assessment process to ensure that any patient with a risk of having the illness would be identified and appropriately managed,” a spokesperson said, adding that the board coped well with the increased demand and has been working closely with colleagues in the Scottish Government, NHS Lothian and other territorial boards to monitor the situation as it developed.” The board has prior experience in running a similar helpline that was set up in response to the 2009 swine flu pandemic, which it says helped inform its response to the current outbreak.
“As an organisation, we have learned from our experience in dealing with the H1N1 flu pandemic and were able to quickly and promptly put measures in place to ensure that we continued to deliver the best possible service for people in the affected area and beyond.
“We recognise that our role is part of a wider NHSScotland response to these type of situations and by working closely with our partners, we can appropriately and effectively respond to an evolving situation, securing an effective service for patients who are either unwell or are seeking further information and advice.”
Throughout this outbreak, managing the flow of information has been key. The first case was identified on 28 May and confirmed on 31 May, followed by a second case on 2 June that prompted the public announcement the following day. While some criticisms have been levelled at the public alert not being issued after the first case was diagnosed, Professor Hugh Pennington, Emeritus Professor of Bacteriology, says he has seen no evidence to suggest that the health board didn’t act as quickly as it could.
“There is always a problem at the beginning of an outbreak deciding if you have an outbreak or just a single case and you don’t want to cause mayhem. On the other hand, you want to act as quickly as you can. I see no evidence that they didn’t act as quickly as they could. Most of the cases that have happened were already infected by the time they worked out the problem, which is again very typical for outbreaks. By the time it is evident there is an outbreak, most of the damage has already been done.”
Nevertheless, Pennington states that the outbreak should never have happened in the first place as it is a preventable disease. From the outset, cooling towers in the south-west of the city, which have since been treated, were singled out as a likely source of the infection. During its investigations, the Health and Safety Executive issued improvement notices to the pharmaceuticals firm Macfarlan Smith and the North British Distillery, while a third was served on the National Museum of Scotland in relation to staff training. While this does not mean that these particular cooling towers have been identified as the source of the outbreak – indeed it is possible that the source may never be conclusively identified – Pennington says it raises questions for both the businesses and also the Health and Safety Executive.
“What you have to ask is why two sets of towers run by two completely different businesses required orders from the Health and Safety Executive to rectify the problems they’ve had. How long have there been these problems? Could they have been spotted earlier, and so on. Because at the end of the day, although it is the responsibility of the businesses to make sure that the cooling towers are working and being maintained and they don’t have slime building up in them, there is also a regulatory aspect from the Health and Safety Executive.”
Howard Dryden, of the marine biological company Dryden Aqua, which is based in the southside of Edinburgh, agrees with Pennington that in most cases, such an outbreak should be “entirely preventable.” Legionella is actually a very common bacteria, he explains, adding that 100 per cent aquatic features have legionella for a period of time during a year. However, of the around 70 different types of legionella, only one or two will cause legionella disease.
“There are lesser types of the infection causing, for example, Pontiac – which is not as bad as legionella but is still pretty nasty and you can go right down the spectrum to those that just cause a nasty cold. But legionella will be found, probably in most air-conditioning systems,” he says.
While it may be commonplace, however, this is still “no excuse” for industry, he says, adding that with proper control, precaution and routine monitoring then it is “very easy” to control legionella.
The latest updates from the Scottish Government indicate that the numbers are at last beginning to plateau and the infection has been brought under control. However, for many of those affected questions remain. Scottish Labour is among those seeking answers, with shadow health secretary Jackie Baillie calling for a public inquiry into the outbreak once it has been contained.
“I agree with the words of Professor Pennington and this should not have happened. A public inquiry will ensure we learn lessons and try to prevent this happening again,” said Baillie.
“Public inquiries are very expensive, that is the problem. A lot will depend on, really, how much data is going to be published by the incident control team. They will have done very detailed investigations, plus the Health and Safety Executive, plus Edinburgh council as well because they are all involved in this, and obviously the Scottish Government too because they have got themselves quite deeply involved with the Resilience Room too. So it is quite a complicated situation and what I would hope to see before we see whether there is a need for a public inquiry, would be all the data that has been accumulated published.”
He is not, however, ruling out the need for a public inquiry at this stage.
“It may need an independent look at it to make sure that everything was done, and that is where a public inquiry comes in. You may need to have a completely independent set of people looking at it. But I think one of the aims of a public inquiry is to learn lessons and make sure the lessons are learned and not forgotten in the future, and maybe that won’t be necessary if we get full disclosure of all the ins and outs.”
While there will undoubtedly be lessons for the businesses and authorities involved, Pennington argues there is also a wider lesson for the public about how their lifestyle choices might impact on their chances of fending off infections. While everyone is potentially at risk of developing Legionnaires’ a number of risk factors, such as a history of heavy smoking, make it more likely for certain individuals to experience a more severe form of the infection.
“That is where public information is important. Basically, if you can stop smoking, please do because if you do that you will reduce your chances of having a hard time with Legionnaires’ disease. If you are a heavy drinker as well, please reduce your drinking levels because that again seems to be a risk factor with Legionnaires’ disease.”
Pennington hopes the media attention surrounding the current outbreak can be harnessed to increase awareness of these lesser known risks.
“So it is not just that you might get lung cancer, you might get something like Legionnaires’ disease as well and of course there are a whole raft of other conditions that are associated with heavy smoking, which you might not think of at first of being related but they are. This is another one and this is a very high-profile one. It all hits the media in a dramatic sort of way when you have an outbreak like this. It has some resonance about it that could be used and should be used, actually, to remind people that lifestyle does play an important part in outcomes from disease, and when it is something like Legionnella, that is intrinsically nasty to start with, then it can improve your chances of survival if you do take the right lifestyle choices.”