Something in the water

October 2016 Vol. 16 (5)

Hawke’s Bay nurses were recently tested when Havelock North was hit by what’s believed to be the country’s worst ever waterborne disease outbreak – more than 5,000 people brought down with gastric illness. FIONA CASSIE shares the stories of some of the nurses involved and some of the lessons they learned.

The gastro outbreak that slugged Havelock North so hard was slow to sneak up on the community at first.

The first residents began being hit by vomiting and diarrhoea around Monday 8 August – just small numbers at first but gradually increasing.

Carolyn Dale, the nurse team leader at Te Mata Peak Practice, recalls as the week went on that the practice, Havelock North’s largest, was starting to think, “Gosh, there’s a nasty tummy bug going round”.

THURSDAY 11 AUGUST: Drink lots of fluids…

It was a text message that Thursday – her day off – that was the first hint to Jo Miller that something might be awry. Miller is the infection prevention and control officer at Mary Doyle Lifecare, a very large retirement village and care centre complex in Havelock North that is home to about 410 residents.

The nurse was told that three residents at one of Mary Doyle’s five care centres (Miller manages one of them) had come down with vomiting and diarrhoea overnight.

Miller came into work worried she may be facing a norovirus outbreak and was on the phone notifying the Public Health Unit in Napier when more reports of ill residents arrived, consolidating her fears. Then yet more reports arrived – this time from a dementia unit in a separate building.

“I thought, ‘Oh my God, it’s everywhere’,” recalls Miller.

In outbreak mode, the complex ‘locked down’ the affected units, restricted visiting and sent specimens for lab testing to confirm whether or not it was norovirus. Meanwhile, they gave the usual advice for treating vomiting and diarrhoea – to drink lots of fluids…

FRIDAY 12 AUGUST: An increase in ‘d’s and v’s’ overnight

The Friday began for infection control nurse Margaret Drury with an email from the Hawke’s Bay Hospital’s duty manager giving a heads-up of a slight increase in ‘d’s and v’s’ overnight.

Drury, the Hawke’s Bay District Health Board’s infection prevention and control advisor, already knew that Mary Doyle and one other aged care facility in Havelock North had reported a suspected norovirus outbreak. She scanned and duly noted the email.

By the time Jo Miller arrived back at work Friday morning, there was a handful of reports of residents in Mary Doyle’s 135 independent villas becoming ill. Then one of the specimen results came back positive, not for norovirus but for campylobacter. Miller scratched her head trying to find a foodborne link between cases as she reported the results to public health and continued on with her infection control protocols.

Meanwhile, over in Napier, Liz Read, nurse manager for public health and Susan Stewart, public health nursing team leader, started to get reports rolling into the public health nursing team of large numbers of children becoming unwell at Havelock North schools and early childhood centres. “They had big numbers – 30, 40 to 50 children who had become unwell during the morning,” recalls Read.

The first wind that Drury got that they were dealing with much more than an ‘increase in d’s and v’s’ was the public health team calling a teleconference early that afternoon followed by a larger meeting early that evening with DHB and Hastings District Council leaders and staff. (It was later released that Hastings District Council received “suspicious” water results about 10.30am on Friday with confirmation on Saturday that two of Havelock North’s water bore supplies were contaminated – likely by animal faeces.)

By the end of the day the water was chlorinated and a media release was out that night urging all Havelock North residents to boil their water because of a still to be confirmed, water-linked vomiting and diarrhoea outbreak.

It was a ‘boil your water’ post shared on Miller’s Facebook page around 8pm that night that solved the puzzle of her outbreak. She immediately rang all the care centres telling them not to drink any water straight from the taps or water purifiers.

Likewise, Carolyn Dale was alerted via Facebook that night that it was possibly bugs in the water causing the “nasty tummy bug”. Dale says she carried on with scheduled plans to head away for the weekend early the next morning as “nobody really realised the enormity of what was about to pan out”.

SATURDAY 13 AUGUST:  Cases begin pouring in

At 9am Te Mata Peak Practice opened it doors with its usual single doctor and a receptionist for business as usual.

But as the phone started incessantly ringing, they called in an extra doctor, nurse and reception staff to try and cope with the gastric onslaught. It was to be nearly a week before any semblance of ‘business as usual’ was to return. Dale says the called-in doctor was put to work phoning back patients and triaging those who needed to be seen in person and those who could be given advice and assurance over the phone.

Margaret Drury’s day started early by meeting the emergency response advisor (also a nurse) to put together an email to send out to Havelock North’s five aged care facilities. She then got on the phone to the managers or acting managers of all the facilities (two of which manage somehow to escape the outbreak).

Miller, concerned about Mary Doyle’s independent villa residents missing out on the boil water alert came in to work to make up a flyer and started door knocking. Residents of about 16 villas were ill and a third were unaware of the boiling water alert. (By the time the outbreak was over, 128 of Mary Doyle residents became ill, two seriously, and sadly one, with underlying health issues, died that first weekend. In addition, 25 of its 250 staff became ill.)

After the 10am public health team meeting in Napier, Drury headed over to Hastings-based Hawke’s Bay Hospital “to do what an IPC (infection prevention and control) nurse should do” and talk to hospital staff, including its ED acute assessment unit, and ensure that personal protection equipment (PPE) was being worn. Drury says a fortunate circumstance was that, despite being mid-winter, the hospital was not at full occupancy so was better able to cope with the increasing numbers presenting over the weekend and beyond.

Confident the hospital was managing the IPC requirements, Drury says she spent much of that first weekend liaising with aged care facilities and working with DHB logistics team to ensure extra PPE, hand sanitiser and IV supplies got out to those who needed them. She didn’t know it then but she was about to work 12 long days in a row.

The scale of the outbreak quickly saw the DHB sending district nurses out to check independent residents in the town’s retirement villages and offer advice and support to the ill over the weekend. The district nurses provided subcutaneous fluids for dehydrated residents. Miller says the district nurses were “fantastic” and were a constant presence in Mary Doyle’s villas for the next week and a half, for which she was more than grateful as she was continuously getting called out as residents fell ill.

SUNDAY 14 August: Dehydration cases escalate

At 8am neighbouring Hastings Health Centre opened its Accident & Medical Centre.

By 8.20am a call went out to Marie Beattie, the centre’s clinical services manager.

“They rang saying, ‘The first four people through the door are really sick and need IV fluids – we need to do something’ and I said, ‘Well, I’m on my way’,” recalls Beattie.

Beattie, with 14 years’ public health nursing behind her, says the centre implemented its pandemic plan and opened up one of its GP suites as a mini-hospital ward for patients needing IV fluids.

She spent the rest of Sunday offering phone triage – largely assuring people with gastro symptoms they were doing the right thing. The key messages that the centre’s clinical director told her to share was that if anyone had blood in their stools or experienced increasing lethargy (a sign of worsening dehydration) then he wanted to see them.

Meanwhile as the posts built up on school social media sites it became ever clearer that more and more children were becoming unwell. Liz Read says she and other public health unit staff were called in for an urgent meeting with the Ministry of Education on the Sunday with the focus on how schools would operate under the boiled water order and would ensure that unwell children stayed at home. Water tankers were arranged for all the schools and additional hand washing instructions put in place ready for the next day.

Back at Mary Doyle, Jo Miller was in her fourth day in outbreak mode and says staff kept on keeping on as more and more residents became ill. “The staff worked over and above … they were just amazing. It was hard work as they were cleaning up residents in hospital wings who couldn’t toilet themselves.”

MONDAY 15 AUGUST: Schools open half empty

When nurses arrived to start the day at Te Mata Peak Practice on Monday morning, there were already 50 answerphone messages stacked up for them to answer.

Carolyn Dale says she assigned two nurses permanently to dealing with the outbreak – one taking incoming calls and others making callbacks. The doctors were also doing phone consultations and the practice cancelled all non-urgent appointments.

“We freed up all our available resources to deal with the phone consultations [most consultations were over the phone] and the acutely ill patients who came in.”

The ones they did get to come in were mostly older patients, people living alone or those just not managing to keep any fluids down.

“So we did a lot of IV fluids here … we’ve always done IV fluids but certainly never to the extent where you are wondering where you will hang up the next
IV bag,” says Dale.

The two public health nurses who usually worked with the Havelock North schools were on deck that Monday morning, working behind the scenes as schools opened their doors. But soon the town’s eight schools – including three boarding schools – were reporting half the school or more were unwell or absent – teachers included. And the about 23 early childhood centres were hit very hard too.

Back at the Public Health Unit the notifications of campylobacter started to flood in, so six to eight of the 16-strong public health nursing team were redeployed from their normal school work to concentrate on the outbreak – largely following up campylobacter notifications of people living or working outside Havelock North.

The local primary health organisation (PHO) also stepped up early that
week to support primary health care in Havelock North by setting two PHO nurses the task of ringing every enrolled patient in Havelock North 80 years and older living independently – which is a very large population in the popular retirement centre.

The pair went on to ring all insulin-dependent diabetics and all patients on warfarin, advising them to get their blood tested. The mobilising of district nurses from Manawatū helped to free-up local district nurses to go into the homes of people triaged as needing assistance with rehydration and other cares.

Miller began the huge task of case logging all the cases in the complex (a job that didn’t end until 29 August) with the support of the DHB’s gerontology nurse specialist Lorraine Price. Mary Doyle staff and residents also had to face media hanging over their fence line with cameras after news got out that a resident had died.

Overall, the numbers hospitalised during the outbreak peaked on the Monday at 19, including several needing intensive care. Drury says the less serious cases that met the campylobacter case definition were ‘cohorted’, when necessary, into three- or four-bedded rooms.

Meanwhile, by the end of the day schools, under public health and education ministry advice, made the decision to close because of the large number of staff and children affected and – although it was a waterborne illness – to limit the possibility of secondary infection, says Liz Read. So all schools and most early childhood centres closed on the Tuesday and Wednesday  – extended to Thursday for the primary schools – but with the secondary schools reopening as they were more confident that the older students would meet the extra hand hygiene vigilance needed.

“The impact on the community was massive – economically and emotionally, I think,” says Read.

Water bugsLOOKING BACK and LESSONS LEARNED

In retrospect, the worst of the outbreak was over on Monday 15 August,  but the long incubation period, recurrences and those hit by severe dehydration meant it took many days before health providers could step back from crisis mode.

Even then the alert was out for the complications that can arise after campylobacter infection, such as Reactive Arthritis and the much rarer Guillain-Barré Syndrome (as at early October one person had been hospitalised due to Guillain-Barré Syndrome linked to the Havelock North outbreak).

On 26 August – two weeks after the water was chlorinated and a week before the boil water notice was lifted on 3 September – the DHB also announced that an elderly patient hospitalised during the campylobacter outbreak had died of an unrelated medical condition, bringing deaths linked to the outbreak to two. Apart from personal losses great and small, the DHB alone estimates the outbreak cost it $380,000, about half due to staff sick leave. This includes $24,000 spent on ongoing household telephone surveys that indicated that nearly 5,200 people – more than a third of Havelock North’s 14,000 population – has been struck by gastro illness due to the waterborne outbreak.

Apart from social media alerts, the telephone was the technology that
nurses spoke of most often, with telephone triage being seen as invaluable in
the outbreak.

Dale says that prior to the outbreak the practice had only just started implementing a phone callback system but the crisis required “a lot of thinking on their feet” and it was decided to use it in earnest to deal with the hundreds of phone calls flooding in. “The phone call demand was huge but it was also our lifesaver,” says Dale. “We couldn’t have managed it otherwise.”

Beattie agrees that telephone triage was one of the key ways her centre managed the crisis by stemming the flow of people who didn’t need to be seen but did want advice and reassurance. The Hastings centre had 64 people present with gastro symptoms on Monday 15 August and 66 telephone consultations; this dropped to 50 presentations and 42 telephone consultations by the Tuesday and by the Wednesday the numbers finally started to wane.

Read and Stewart say that apart from tracing notifications another major
role for public health nurses was supporting reopened schools and early childhood centres to reinforce hand hygiene education. This involved also grabbing the moment to once again highlight to schools how good it would be if someday they could find money in their budget to bring hot water to all school toilet blocks.

The vital importance of critical incident management (CIM) training exercises was also brought home to the pair. “When you have CIM training it can sometimes be hard to see the relevance,” says Read. “However, when there is an massive outbreak the value of preparing for a CIM is obvious.” The outbreak also highlighted the big-picture lesson of the importance of public health fundamentals such as clean water and clean air, says Read.

The nurses report that staff illness was an issue for all health providers – including staff who needed to look after sick children or elderly parents or children off school – but relieving staff and staff coming in on their days off stepped up and filled the gaps.

Gratitude for the support given by the DHB, local pharmacies, suppliers, neighbouring city nurses and the community was warmly expressed by the Havelock North nurses for everything from the district nurse support, the
quick supplies of extra PPE, to IV lines, to the gifts of hydrolytes and hand sanitiser, as well as morale boosting cakes and gift baskets. Plus there was pride and gratitude for how their staff worked as teams to get through the
challenging times.

There was also acknowledgement of the ‘lucky break’: a mild winter had meant that flu and winter ailments hadn’t reached their peak when the outbreak hit.

“If it had happened at the same time last year, it would have been a different story,” says Beattie. “So someone was looking out for us.” 

 

Jo Miller

Liz Read

Margeret Drury
Jo Miller Liz Read Margaret Drury

MESSAGES AND LESSONS TO SHARE

  • Ensure a good consistent communication plan is in place and the right information gets to the right people in a timely manner.
  • Hand and general hygiene messages should be sent out early and reinforced throughout.
  • Telephone triage in primary health care is very important to both advise and assure those who do not need to be seen in general practice and screen for those that do need to be seen or supported by outreach services.
  • District nursing services, including back-up from other regions, are vital in providing outreach services, particularly to the elderly living independently.
  • The value of surge capacity in the public health service across all district health boards being available to support other DHBs in need.
  • Ongoing education on outbreak management in residential aged care facilities and having good infection control practices and policies in place is important.
  • Adopt standard precautions and wear personal protection equipment when working with patients with vomiting and diarrhoea, including a mask if they have explosive vomiting.
  • Check what medications patients or residents are on, or conditions they have,  such as diabetes, that could be affected by ongoing diarrhoea and vomiting.
  • Advise people on regular diuretics or laxatives to stop taking them while ill because they could further dehydrate them.
  • Ensure campylobacter-affected patients or residents on warfarin have their blood tested to monitor their INR (international normalised ratio) levels.
  • The waterborne outbreak highlighted that most schools don’t supply warm water to children for hand washing.
  • The importance of the relationship of public health nurses with their schools and health promotion in schools about hand hygiene and preventing communicable diseases.
  • The relevance of critical incident management (CIM) training exercises is made clear when put into practice in a real crisis.

 

 

CAMPYLOBACTERIOSIS

Campylobacteriosis is New Zealand’s most frequently notified foodborne disease and causes gastro illness of variable severity:

  • Incubation period: usually 2–5 days but can range from 1–10 days.
  • Most often transmitted by eating contaminated food.
  • In New Zealand, consumption of faecally contaminated water is another common transmission route.
  • Person-to-person transmission is uncommon but possible with poor hand hygiene causing contamination of food that is ingested.
  • Fluid replacement is the main treatment.

 

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