Section 1: The approach to outbreak management at local and national levels in Scotland
Scotland is now in a phase where continued, widespread transmission of the virus in the general population has reduced significantly indicating that the virus is progressively coming under better control. We cannot however afford to be complacent and the risk of an uncontrolled resurgence in viral spread will remain for the conceivable future.
Case numbers are generally low enough to be effectively managed using traditional and established public health approaches to communicable disease outbreak control, involving tried and tested, internationally recommended approaches. However, this can vary across the country at any time. These are embedded in the model described in existing Scottish guidance on the Management of Public Health Incidents (MPHI).
As we enter into the next phase of the national response to the COVID-19 pandemic we need collectively to be able to react to incidents involving individual cases, clusters and outbreaks of infection in order to limit further spread and protect public health especially of the most vulnerable groups.
The standard approach to communicable disease control in any situation including COVID-19 involves some basic elements.
This is the term used to describe a number of activities involving the collection, collation, analysis and sharing of information and intelligence on infection spread within the general population and defined communities. This includes collection of local, national or international intelligence. This helps us identify which groups of people, occupations or geographical areas have increased risk of infection. For the COVID-19 pandemic, population level surveillance is being developed using a variety of systems to inform proactive COVID-19 interventions to help try to prevent clusters of infection from developing. Such early warning systems will be used to guide pre-emptive investigations aimed at reducing risks and preventing the virus escaping from control.
Surveillance includes early identification of all COVID-19 cases to allow rapid contact tracing. This is the primary method used to try to prevent spread and stop outbreaks occurring. Active intervention by local health protection teams will be needed to prevent susceptible people from becoming exposed to COVID-19.
How are local public health incidents classified?
Five levels of incident are outlined with increasing severity and magnitude from:
- minimal response due to limited local level impact;
- more severe local level impacts requiring the co-ordinated efforts of local partner organisations to manage effectively;
- regional level, significantly wider impacts requiring cross boundary but still mainly local agency working;
- more severe local or wider regional impact requiring activation of a local resilience partnership for a high level of multi-agency coordinated response; and
- national level incident requiring local and central government co-ordination with population-wide national scale interventions.
The COVID-19 pandemic response is currently being managed in Scotland as a Level 5 incident, with local and national resilience functions co-ordinating a Scotland-wide, nationally coordinated response. Within this national level response framework, however, the response to local incidents must still be managed by the local NHS Board Directors of Public Health, their Health Protection Teams and their partners; they may need to react to multiple Level 1 and 2 incidents, and may also be involved in co-ordinating local responses and contributions to more widespread (Level 3 and 4) incidents.
A specific Scottish Government Directorate has been created to develop thinking about the systems and processes which support local incident management teams and Directors of Public Health, and to ensure essential, national strategic cross-Governmental inputs are achieved without interfering with necessary, local management actions or intruding on clinical decision making.
Strong local and national partnerships are already long established to ensure effective and coordinated public health incident management. This is based on many years of experience in dealing with a very wide range of public health incidents ranging from routine outbreaks of food poisoning, legionella, meningitis, measles and many other endemic infections, to complex problems such as HIV and Hepatitis C infection, as well as outbreaks of rarer diseases in recent years such as Anthrax and Ebola.
The Coronavirus Act 2020, provides the main legal framework under which the response to the COVID-19 pandemic is managed. A list of coronavirus legislation can be found here. Of particular interest in relation to health protection is the Coronavirus Act (2020) Schedule 21 Part 3, which outlines powers relating to potentially infectious persons in Scotland. The Act also gives Scottish Ministers powers to issue directions closing or restricting events, gatherings and premises and gives Ministers powers to make Regulations to respond to the incidence or spread of coronavirus in Scotland. Public Health Scotland has produced a summary of the Act.
Organisational responsibilities and procedures for the investigation of health protection incidents are set out in the Public Health etc. (Scotland) Act 2008. Salient points relating to incident management are set out in the guidance which accompanied the act.
What is Public Health Incident Management?
Public Health incidents are identified though surveillance (either via early warning intelligence of impending risks or via COVID-19 case identification) by the Health Protection Teams of NHS Boards. The NHS Board Director of Public Health has overall responsibility for this function but normally delegates this to the NHS Board’s Health Protection Team. The team undertake rapid information gathering and risk assessment to determine if other partner organisations need to be asked to contribute to an investigation. This initial assessment may be undertaken by a Problem Assessment Group (PAG).
Problem Assessment Group (PAG) – is formed in response to a potential incident or one of very limited complexity. This group usually only meets once to assess a situation and decide if it can be managed without an ongoing response or needs to be escalated to an active incident. Partners may be invited to participate though often this is an internal meeting only.
A simple incident may be dealt with by a single PAG meeting. If an incident has wider implications or is likely to require an ongoing response, the next step is formation of a formal group – an Incident Management Team (IMT) - to discuss the situation in more detail, to assess the situation and to coordinate action to control the incident.
Incident Management Team (IMT) – a multi-agency group chaired by a Consultant in Public Health. All relevant partner organisations are invited to participate as members. This group undertakes a structured investigation and will meet multiple times until the incident is brought under control.
An IMT is formed in response to a specific incident and is not a pre-formed group. Partner organisations who are relevant to the incident under investigation will be invited to join the IMT. Partner organisations act within their own area of expertise and under their own legislative frameworks to undertake investigation and enact interventions on behalf of the IMT. The potential membership of an IMT is detailed in Appendix 2. IMTs are usually chaired by a Consultant in Public Health (Medicine), delegated by the DPH on behalf of the NHS
Board Chief Executive and the NHS Board.
The IMT will undertake an established process of investigation to establish the “who”, “what”, “why”, “when”, “where” and “how” of the incident. This includes:
- an epidemiological investigation (the “who”, ”where”, and “when” of the incident);
- identification and investigation of the hazard, or laboratory investigation (the “what”);
- investigation of the method of exposure to the hazard, or environmental investigation for the source of the hazard (the “how” and “why”);
- risk assessment – if the hazard is still putting people at risk and the impact of the hazard;
- risk management – interventions or control measures to minimise the risk to the population; and
- risk communication – between and within agencies and with the public.
Effective communication about the incident will play an important role and an NHS Board communications officer will usually be a member of the IMT.
An IMT operates in confidence to enable the sort of open discussion needed to establish the facts, discuss hypotheses on causation of a problem, consider options for action and make decisions on appropriate action. One of the primary responsibilities of the IMT is to act quickly in order to protect public health.
A full IMT response may not be appropriate or necessary for all incidents, especially if there is local experience of managing similar incidents or the incident has minimum local impact. The health protection team in conjunction with the Director of Public Health will assess this on a case by case basis by using a risk assessment process.
At this stage of the COVID-19 pandemic response, especially during a period of proactive investigations to maintain low community infection prevalence, the potential for health protection teams having to manage multiple incidents (COVID-19 as well as non-COVID-19 situations), will increase. Consequently it may not be possible to follow all of the steps in the standard MPHI guidance especially in relation to the write up of all investigations via Incident Reports. Good internal communications aimed at rapid learning of lessons and sharing of practical experience (shared learning) and intelligence gained, with local and, potentially, regional or national health protection and formal resilience structures will be necessary instead.
How does the IMT interact with COVID-19 response mechanisms?
Local public health incident management will sit within the local, regional and national frameworks coordinating the response to COVID-19. Local Health Protection Teams are a finite resource that have to manage all the public health/health protection aspects of the local level COVID-19 response and incident management, in addition to investigating non-COVID-19 incidents.
An IMT may implement local control measures to bring an incident under control, but these need to be implemented in an environment of wider COVID-19 public health interventions. The interplay of local control measures and national interventions will be considered by the IMT. Local incidents of sufficient scale and significance will be managed either on a local basis or draw on other specialist resources (for example, PHS), as required. Any significant developments will be shared with national agencies and Scottish Government.
Figure 1 shows how an IMT will sit within COVID-19 response structures at the local level. It also shows the IMT levels based on the types of incident being managed (see Appendix 1). For more information about the organisational roles and responsibilities please see annex B of MPHI guidance.
For Level 1 incidents, the IMT membership will be local partner organisations and control measures implemented will affect a small proportion of the population. For these incidents, it is likely that decision-making will remain entirely within the IMT, with responsibility lying with the DPH.
For Level 2, 3 and 4 incidents the IMT membership will be more broadly based and the control measures implemented may have a significant interaction with the standing COVID-19 resilience structures. Whilst the IMT will recommend specific control measures in response to the incident, wider discussion with command groups within resilience structures may be needed to establish any interplay. In such situations, the DPH remains responsible for the implementation of control measures for the incident response and for discussing and agreeing actions in any wider groups as required.
For such incidents, there is a likelihood that there will be close interaction between the IMT and local or regional resilience partnerships, including health and social care partnerships (as appropriate), who are key to managing the wider consequences of outbreaks. Similarly at the national level there are links between Public Health Scotland and the Strategic Coordinating Group (SCG).
Reporting of local public health incidents
Local public health incidents are routinely reported by local health protection teams to Public Health Scotland (Health Protection Scotland) and the Scottish Government Health Protection Team via established routes.
Confirmed COVID-19 cases as well as outbreaks are currently and continue to be reported to Public Health Scotland (Health Protection Scotland). Laboratory reports of confirmed cases tested via NHS Scotland laboratories as well as via the UK Government sponsored testing services are monitored. The numbers of cases are recorded using existing computed database systems used by local health protection teams to track cases and to manage incidents and outbreaks. This data is collated daily by Health Protection Scotland and shared with the Scottish Government and with UK partners, as part of the national and UK surveillance system for COVID-19.
An overview of outbreaks and incidents is collated nationally through existing reporting mechanisms and this will continue into the next phase of the pandemic response and recovery period.