2012 -2014

1 Foreword

The Public Health etc. () Act 20081 requires NHS Boards, in conjunction with Local Authorities, to produce a Joint Health Protection Plan (JHPP) providing an overview of health protection (communicable disease and environmental health) priorities, provision and preparedness for the NHS board area. Guidance on the content of joint health protection plans has been published by the Scottish Government.2

This second plan has been produced by the Joint Health Protection Planning Group (JHPPG) comprising representatives from NHS & Arran, the three Ayrshire local authorities (Environmental Health Services) and the Ayrshire Civil Contingencies Team.

This plan covers the period from 1 April 2012 to 31 March 2014. It will be reviewed regularly by the group throughout its duration to ensure the contents remain relevant and appropriate. Further plans will be published every two years.

The JHPP is a public document available on the websites of NHS Ayrshire & Arran and the three Local Authorities3 and on request from the Executive Director of Public Health or the Heads of Environmental Health at each of the local authorities4.

1 http://www.opsi.gov.uk/legislation/scotland/acts2008/pdf/asp_20080005_en.pdf 2 www.sehd.scot.nhs.uk/cmo/CMO(2007)02.pdf 3 www.nhsaaa.net; www.east-ayrshire.gov.uk; www.north-ayrshire.gov.uk; www.south-ayrshire.gov.uk 4Executive Director of Public Health, NHS Ayrshire & Arran, Afton House, Ailsa Hospital, Dalmellington Road, KA6 6AB Regulatory Services Manager, Council, Environmental Health and Trading Standards, Civic Centre South, 16 John Dickie Street, KA1 1HW Senior Environmental Health and Trading Standards Manager, Legal and Protective Services, Council, Cunninghame House, Irvine KA12 8EE Trading Standards and Environmental Health Manager, Council, Burns House, 16 Burns Statue Square, Ayr KA7 1UT

2 Signatories

NHS Ayrshire & Arran

Name: Carol Davidson

Designation: Executive Director of Public Health

Signature: ...... ……….

East Ayrshire Council

Name: Paul Todd

Designation: Regulatory Services Manager

Signature: ...... ……….

North Ayrshire Council

Name: Kevin McMunn

Designation: Senior Environmental Health and Trading Standards Manager

Signature: ………………………………………….

South Ayrshire Council

Name: Brian Lawrie

Designation: Trading Standards and Environmental Health Manager

Signature: ………………………………………….

3 Ayrshire and Arran Joint Health Protection Plan: 2012 - 2014

Version No: Version 2.0

Prepared by Dr James McHardy, Consultant in Public Health Medicine, NHS Ayrshire & Arran; Mr Kevin McMunn, North Ayrshire Council; Mr Paul Todd, East Ayrshire Council; Mr Brian Lawrie, South Ayrshire Council; Mrs Lorette Dunlop, Civil Protection Manager, NHS Ayrshire & Arran; Mr David Whyte, Ayrshire Civil Contingencies Team Effective from 01/04/2012 Review Date 31/03/2014 Lead reviewer Dr Carol Davidson (Executive Director of Public Health) Dissemination Arrangements Health & Performance Governance Committee (March 2012) NHS Board (March 2012) Committees of East, North and South Ayrshire Councils (March – April 2012)

Amendment record

Review date Comments Date of next review

4 Abbreviations ACCT Ayrshire Civil Contingencies Team CHEMET Chemical Meteorology CMO Chief Medical Officer COMAH Control of Major Accident Hazards CPH Consultant in Public Health CPHM Consultant in Public Health Medicine CPHM Consultant in Public Health Medicine (CD/EH) (Communicable Disease and Environmental Health) DWQR Drinking Water Quality Regulator EAC East Ayrshire Council EHO Environmental Health Officer EPH Environmental Public Health GP General Practitioner GSS Glasgow Scientific Services HAI Healthcare Associated Infection HPS Health Protection Scotland ISO International Organization for Standardisation JHPP Joint Health Protection Plan JHPPG Joint Health Protection Planning Group MACR Major Accident Control Regulations MIP Major Incident Plan MIST Major Incident Support Team NAC North Ayrshire Council PAG Problem Assessment Group REPPIR Radiation Emergency Preparedness and Public Information Regulations SAC South Ayrshire Council SECG Strathclyde Emergencies Coordination Group SEISS Scottish Environmental Incident Surveillance System STAC Scientific and Technical Advisory Cell SW Scottish Water

5 Contents Page number

1 Overview of Ayrshire and Arran 7 1.1 Demography and geography of the population 7 1.2 Minority ethnic population 9 1.3 Socio-economics of Ayrshire and Arran 10 2 Health protection planning infrastructure 11 2.1 Remit of agencies 11 NHS Ayrshire & Arran 11 North, South and East Ayrshire Councils 11 2.2 Multi-agency planning infrastructure 12 2.3 Civil contingency plans 12 3 Priorities for health protection, including emerging issues 13 3.1 National Priorities 13 3.2 Local Priorities 13 4 Civil protection risks 22 4.1 Ayrshire risk registers 22 4.2 Off site contingency plans 22 5 Significant events (1 January 2010 - 31 December 2011) 24 5.1 Communicable disease incidents 24 5.2 Environmental events 24 6 Health protection: resources and operational arrangements 25 6.1 Resources 25 6.2 Organisational arrangements to facilitate collaborative working 25 6.3 Arrangements to respond in office hours and out-of-hours 26 6.4 Arrangements for reviewing Health Protection Standard 27 Operating Procedures (SOPs) and guidance 6.5 Corporate arrangements for the maintenance of knowledge, 28 skills and competencies of staff with health protection duties 7 Health protection services: capacity and resilience 29 7.1 Assessment 29 7.2 Mutual aid arrangements 29 8 Public involvement in the planning and delivery of health 30 protection services 9 Summary and actions 31 Annex A Contingency plans for incidents within Ayrshire and Arran 32 Annex B Communicable disease incidents 36 Annex C Environmental events 40 Annex D Health protection: staffing levels 42 Annex E Information and communications technology resources 44 available in NHS Ayrshire & Arran and the three Local Authorities Annex F Policy guidance, template guidance and Standing 46 Operating Procedures (SOPs)

6

1 Overview of Ayrshire and Arran

1.1 Demography and geography of the population

Ayrshire and Arran is located in the south west of Scotland and is bordered by Inverclyde and East Renfrewshire to the north, by Lanarkshire to the east and Dumfries and Galloway to the south. Ayrshire and Arran covers an area of 3,377 square kilometres, from in the north, in the south and in the east.

The area covers a mix of rural and urban development, with an overall population density of 109 people per square km (/km2), which is slightly below the national

7 average. There are three Local Authority areas and one Health Board area in Ayrshire and Arran. The population density varies across the three co-terminous local authority areas in Ayrshire and Arran, and is 95 people/km2 in East Ayrshire, 153 people/km2 in North Ayrshire and 91 people/km2 in South Ayrshire respectively. Around 80% of the population of Ayrshire and Arran live in community settlements of over 500 people.

The 2010 mid-year population estimate for Ayrshire and Arran is of a total population of 368,770 people5. This is divided into: 120,240 in East Ayrshire, 135,180 in North Ayrshire and 111,440 in South Ayrshire. The size of the population in Ayrshire and Arran is very slowly decreasing. Compared to the population in the year 2000, there has been a reduction of 0.5% (1,910 people), which was the second highest loss of population in Scotland. There was a net loss of 300 people from Ayrshire and Arran in 2010 compared to 2009. Between 2009 and 2012, 692 people from overseas migrated into Ayrshire and Arran, with 1,068 people from overseas migrating out of the county at the same time, resulting in a net loss of overseas migrants. Whilst East and South Ayrshire have seen small net gains in migrants from within Scotland and the rest of the UK, North Ayrshire has seen a net loss of Scottish internal migrants.

The 2008 mid-year population estimates for the three key settlements within Ayrshire and Arran are6:

Local Authority Area Settlement / Town Estimated Population

South Ayrshire Settlement of Ayr & 60,880 people

East Ayrshire Kilmarnock 44,390 people

North Ayrshire Irvine 36,430 people

5http://www.gro-scotland.gov.uk/files2/stats/population-estimates/mid-2010/mid-year-pop-est-2010.pdf

6http://www.gro-scotland.gov.uk/statistics/theme/population/estimates/special-area/settlements- localities/mid-2008/settlements-tables.html

8 The next two largest settlements in South Ayrshire are (14,500) and (6,890). In East Ayrshire, the second and third largest settlements are (8,990) and Galston (7,710). In North Ayrshire, and comprise the settlement of Ardrossan with a population of 31,570, followed by (16,380) and then by (11,420).

Nearly nine out of every ten workers who live in Ayrshire and Arran also work in the area.

Ayrshire and Arran has good road, rail and ferry links as well as an international airport.

1.2 Minority ethnic population

Information collected in the 2011 Census about ethnic groups in the population will not be available until the second half of 2012. The General Register Office for Scotland also estimates the mid-year population resident in council areas in Scotland by nationality and country of birth. However, these data are not available for any of the local authority areas in Ayrshire and Arran due to the very small numbers of individuals involved7.

The 2001 Census8 indicated that the proportion of the population in ethnic minority groups in Scotland in 2001 was two per cent in comparison to 1.3 per cent in 1991. For Ayrshire and Arran, the corresponding figures were 0.68 per cent in 2001 in comparison to 0.49 per cent in 1991. Nevertheless NHS Ayrshire & Arran has the fifth lowest non-European population in Scotland, with East, South, and North Ayrshire Council areas having the fifth, sixth and seventh lowest rates among the 32 local authorities.

7http://www.gro-scotland.gov.uk/statistics/theme/population/estimates/special- populations/country-nationality.html

8 www.gro-scotland.gov.uk/files1/stats/key_stats_chareas.pdf

9 The largest ethnic groups in Ayrshire and Arran are similar throughout the county: Chinese (0.18 per cent) and Indian (0.16 per cent other than East Ayrshire, which has an Indian population of 0.07 per cent compared to a Pakistani cultural population of 0.14 per cent).

1.3 Socio-economics of Ayrshire and Arran

The Scottish Index of Multiple Deprivation (SIMD) indicates that there are significant differences in socio-economic status and deprivation levels throughout Ayrshire and Arran with areas of significantly high poverty close to areas of very low poverty. The employment and income domains of the SIMD were revised in October 2011 and reflect the impact of the economic downturn across the UK.

From the 2009 SIMD data9 updated in 2011, there are 480 data zones in Ayrshire and Arran. Of these, 96 (20%) are in the 15% most deprived data zones. The number of data zones in the 15% most deprived zones varies with local authority with 29 (19%) in East Ayrshire, 51 (28.5%) in North Ayrshire and 16 (11%) in South Ayrshire.

The SIMD data for income deprivation (October 2011) has shown that each of the Ayrshire local authorities has seen an increase in income deprivation of between 0.6-0.9 percentage points. This means that 20% of the population in East Ayrshire (24,000 people), 21% of the North Ayrshire population (28,000 people) and 16.2% of the population in South Ayrshire (18,090 people) are income-deprived. This compares to 16.3% of the population across Scotland as a whole who are deemed to be income-deprived10.

9Scottish Index of Multiple Deprivation: http://www.scotland.gov.uk/Topics/Statistics/SIMD/AnnualUpdates 10 SIMD: http://www.scotland.gov.uk/Topics/Statistics/SIMD/inc1revcount

10 2 Health protection planning infrastructure

2.1 Remit of agencies

NHS Ayrshire & Arran The health protection remit for NHS Boards is described in the letter of 2 February 2007 from the Chief Medical Officer11 and has been further clarified by the Public Health etc (Scotland) Act 2008. NHS Ayrshire & Arran delegates this responsibility to the Executive Director of Public Health with work carried out by the Health Protection Team comprising Consultants in Public Health Medicine (CPHM), Consultant in Public Health (CPH), Associate Specialist in Public Health Medicine, Health Protection Nurse Specialists (HPNS) and support staff. Their health protection remit relates to communicable diseases, environmental hazards and the deliberate release of biological, chemical, radiological and nuclear hazards. The remit is delivered through the key functions of:

• surveillance • investigation • risk assessment • risk management • communication • emergency response and management • audit, evaluation, education, training and research.

North, South & East Ayrshire Councils The Health Protection remit lies within the Environmental Health Services of North, South & East Ayrshire Councils and includes communicable disease, air quality, food safety and standards, occupational health and safety, pollution control, public health, private water supplies, pest control, tobacco control, the enforcement of the Smoking in Public Places legislation and the built environment, with Port Health included in the north and south of the area. In the main, this is statute-led and includes

11 www.sehd.scot.nhs.uk/cmo/CMO(2007)02.pdf)

11 monitoring, inspection, surveillance, sampling, investigation and resolution of enquiries and complaints.

2.2 Multi-agency planning infrastructure The NHS and the Local Authorities are an integral part of the Strathclyde Emergencies Coordination Group. It is through this forum that civil contingency (emergency planning) issues are addressed across the wider partner organisations, including the emergency services, military and the voluntary organisations.

2.3 Civil contingency plans There are a number of key plans within Ayrshire and Arran on which the NHS and the Local Authorities either individually or jointly lead. A full list of plans including review and exercise dates and access details are shown at Annex A.

12 3. Priorities for health protection, including emerging issues

3.1 National priorities

The Chief Medical Officer issued a letter on 31 January 2008 detailing the main priorities for health protection in Scotland. These were:

• Pandemic influenza planning • Healthcare associated infections and antimicrobial resistance • Vaccine preventable diseases and the impact on them of current and planned immunisation programmes • Environmental exposures which have an adverse impact on health • Gastro-intestinal and zoonotic infections.

These areas continue to form important aspects of health protection work locally, details of which are given in Section 3.2.

In autumn 2010, a national Health Protection Stocktake Working Group was established by the Scottish Government to conduct a multi-disciplinary stocktake of health protection in Scotland. The working group is due to report in 2012. This joint health protection plan will be reviewed in light of any national recommendations or priorities identified through this stocktake process.

3.2 Local priorities

3.2.1 Pandemic influenza New UK-wide pandemic influenza planning guidance was published in November 201112. Local pandemic influenza plans will be updated in line with the new national guidance and will be informed by lessons learned during the 2009 influenza A (H1N1) pandemic.

12 http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_130903

13 3.2.2 Healthcare associated infections (HAI) and antimicrobial resistance This area of work has received considerable national media attention recently and will continue to be a priority of work for 2012-14. The Executive Medical Director is the executive lead for the prevention and control of infection within NHS Ayrshire & Arran. The Infection Control Manager (ICM) is the “Designated Senior Manager” required under HDL (2001)10 to deliver the corporate accountabilities of the NHS Board, Chief Executive and Executive Medical Director. The Prevention & Control of Infection Committee (PCOIC) reports to the NHS Ayrshire & Arran Clinical Governance Committee which receives a HAI report at each meeting. The NHS Board also receives a HAI report at each of its meetings.

The Prevention & Control of Infection Team (PCIT) provides a service to all directly managed NHS Ayrshire & Arran services, including acute, continuing care and mental health services in the hospital and community settings. There is close liaison between the PCIT and Public Health Department’s Health Protection Team. A Consultant in Public Health Medicine (CPHM) and a Health Protection Nurse Specialist are members of the Prevention and Control of Infection Committee.

The Antimicrobial Management Team (AMT) is charged with ensuring a robust programme of antimicrobial stewardship in primary and secondary care. The AMT reports to the PCOIC on matters relating to antimicrobial audit, surveillance and education and to the Area Drugs & Therapeutics Committee (ADTC) on all matters relating to antimicrobial policy. The AMT, in conjunction with the Board’s Prescribing Advisers, has initiated a programme with General Practitioners to reduce the use of antibiotics considered to be the highest risk for triggering Clostridium difficile infection. Results to date indicate that there has been a significant reduction in the prescribing of these antibiotics.

3.2.3 Vaccine preventable diseases and their impact on current and planned immunisation programmes

i) The childhood immunisation programme: In Scotland, the routine childhood immunisation programme provides immunisation against diphtheria, tetanus, pertussis (whooping cough), polio, haemophilus

14 influenzae type b (Hib), pneumococcal, meningococcal group C (MenC), measles, mumps and rubella infections. In addition, there are targeted hepatitis B and BCG immunisation programmes for those infants and children identified as being at high risk.

The impact on vaccine preventable diseases covered by the routine childhood immunisation programme is highest when levels of uptake are 95 per cent or greater. In Ayrshire and Arran, the uptake of routine childhood immunisations at age 24 months has been consistently above the national target of 95 per cent. Uptake of Measles, Mumps and Rubella (MMR) vaccine has increased to 94 per cent at 24 months, the highest level for 10 years, and by the age of five years 97 per cent of children have received at least one dose of the vaccine, exceeding the national target of 95 per cent uptake at age five years.

Since 2006 there have been several changes to the schedule of childhood immunisations - booster doses of vaccine have been introduced at age 12 months and a new vaccine to protect against pneumococcal disease has been introduced. Uptake of these vaccines at 24 months is 94%.

ii) Human Papilloma Virus (HPV): This is the first vaccine programme to be introduced to prevent the occurrence of a cancer (cervical) and began in September 2008. The impact of this programme will not be seen for a number of years; its assessment is being undertaken at a national level.

The implementation of the HPV Immunisation programme required a great deal of joint working with exceptional effort shown by colleagues within the Public Health Department, Child Health Department, School Nursing Service, Vaccine Holding Centre (Crosshouse Hospital), Primary Care Department (including GPs) and Local Authority Partners, especially in the Education Services. Published uptake rates for all three doses of HPV vaccine for girls in Secondary 2 year are 88.5%, the highest in Scotland, and above the Scottish average of 81%13.

13 ISD 2011. HPV immunisation uptake 2010/11

15

iii) Seasonal Influenza vaccination: The national seasonal influenza vaccination programme runs from the 1st of October to the 31st of March each year. Seasonal influenza vaccination is offered to all those aged over 65 years, and to those aged under 65 years who are in an eligible ‘at risk’ category, including those with chronic medical conditions, pregnant women and carers.

In 2010/11, seasonal flu vaccine uptake in individuals over the age of 65 years in Ayrshire and Arran was 75.9%. This exceeded the national target of 75% and was higher than the uptake rate achieved in Ayrshire and Arran in 2009/10 (73%). The uptake rate in those under 65 years of age was 55.4%, which was lower than the national target of 60% but represented an increase from the 2009/10 uptake rate in Ayrshire and Arran of 49%.

The national target for uptake of influenza vaccine in the under 65s ‘at risk’ for 2011/12 season has risen to 75%, and the Health Protection Team will continue to work closely with colleagues in general practice and maternity services to promote and improve the uptake of this vaccine.

3.2.4 Environmental exposures which have an adverse impact on health

Environmental exposures currently recognised as impacting on health range from the beneficial impact of green space on mental wellbeing to the way in which environmental exposures determine the expression of genes.

Health Protection work in this area includes responses to acute incidents and chronic contamination resulting in human exposures to physical (e.g. ionising and non- ionising radiation, respirable particulates), and chemical hazards, whether by inhalation, ingestion, or direct exposure and contact.

A further aspect of Environmental Public Health (EPH) is the assessment of proposed policy changes and infrastructure developments in order to mitigate

16 adverse health impacts, and to promote beneficial influences on health such as assessments of developments involving hazardous emissions to air.

The three Local Authorities liaise closely with the NHS and work on a number of areas relating to environmental exposures which have an adverse impact on health. These include:

• Air quality monitoring - provision of automatic air sampling equipment which provides continuous monitoring at locations throughout the area • Opencast coal sites - particulate monitoring / investigation • Private water supplies - monitoring, advice and inspection of private water supplies including sampling • Health improvement measures - food hygiene and safety, food standards, infectious disease investigation, diet and nutrition advice, healthy eating campaigns (for example salt and fat content in food) • Smoking prohibition checks and checks on the sale of tobacco products to under 18s • Health and wellbeing campaigns, for example noise control and antisocial noise control relative to mental health and wellbeing • Healthy Working Lives - health and safety inspections and advice visits, accident investigations and participation in campaigns such as prevention of accidents from slips, trips and falls and working at heights • Improving the built environment, for example identifying houses below the tolerable standard and using statutory nuisance powers to seek resolution; identifying unlicensed houses in multiple occupation and houses rented by unregistered landlords in partnership with other council services to provide accommodation that is fit for purpose • Contaminated land use, identification and remediation • Regulation of the use of sunbeds • Regulation of skin piercers / tattooists given recent increases in popularity of tattoos

17 • General public health issues - pest control and dog warden, litter, fly tipping control and dog fouling campaigns / enforcement, nuisance control and abatement.

Emerging issues to be considered are:

• The surveillance and investigations of water quality failures in public buildings under the Water Quality (Scotland) Regulations 2010, and the Scottish Waterborne Hazard Plan • Implementation of the Food Standards Agency (FSA) Guidance on controlling the risk of cross-contamination from E. coli O157 • Gas safety in catering establishments, prioritising those located below flatted dwellings • Exposure to radon in the light of the recently published maps for affected areas in Scotland • Raising awareness of the duty to manage asbestos in buildings.

3.2.5 Gastro-intestinal and zoonotic infections

One of the most common health protection issues managed on a daily basis is gastro-intestinal infections. These are investigated and managed jointly by the Health Protection Team and the three Local Authorities to help prevent further spread. In addition, where there is any indication of an outbreak, a multi-disciplinary, multi-agency meeting convened by a CPH(M) will manage any incident.

A number of measures have been undertaken by the three Local Authorities targeting this area, including:

• Support to the annual FSA Food Hygiene Campaigns in 2010 and 2011 to prevent food poisoning in the home from campylobacter and promote good hygiene there to prevent the spread of harmful bacteria.

18 • Following the recommendations from the Independent Investigation Committee into the Godstone E. coli O157 outbreak, updated guidance was published on preventing or controlling ill health from animal contact at visitor attractions. Local businesses are visited to assess that suitable controls have been put in place to minimise the spread of zoonotic disease.

3.2.6 Other priority areas

3.2.6.1 Blood borne viruses:

The risks to health arising from infection from blood borne viruses are significant and pose major public health challenges. The Scottish Government recently published the Sexual Health and Blood Borne Virus Framework (2011-15)14 which brings together national policy on HIV, hepatitis B, hepatitis C and sexual health for the first time.

The framework includes a renewed focus on HIV and also establishes a context through the inclusion of hepatitis B. The outcomes to be delivered by the framework include:

• Fewer newly acquired BBV infections • Reduction in health inequalities associated with BBVs • People affected by BBVs leading longer, healthier lives • A society whereby the attitudes of individuals, the public, professionals and the media towards BBVs are positive, non-stigmatising and supportive.

An integrated and multi-agency approach is required to deliver these outcomes. Whilst the NHS has a critical role in preventing, diagnosing and treating infection, there is a vital role to be played by local authorities and the third sector (e.g. voluntary bodies). This is particularly important in relation to the links with other

14 The Scottish Government (2011). The Sexual Health and Blood Borne Virus Framework 2011- 15 Edinburgh

19 public health and health protection concerns such as drug misuse and excessive alcohol consumption.

The BBV Managed Care Network (MCN) is the local structure that has been established to support a multi-agency, collaborative approach, encouraging participation of all partners, including people living with BBVs.

3.2.6.2 Sexual health and sexually transmitted infections:

Sexual health is a major public health priority across Scotland, and the wider United Kingdom (UK), and there is strong national policy driving change in sexual health services.

Sexual health and wellbeing presents a number of public health and health protection challenges across Ayrshire and Arran and has been identified as a priority area for action.

NHS Ayrshire & Arran has agreed a local Sexual Health Strategy (2011-15) which presents a strategic vision and sets out the approach within Ayrshire and Arran to sexual health and wellbeing. This strategy dovetails with the Scottish Government Sexual Health and Blood Borne Virus Framework (2011-15) which recommends that multi-agency partners will contribute towards delivery of the Framework Outcomes, one of which is that there will be ‘fewer newly acquired sexually transmitted infections’. It also aims to promote and strengthen positive sexual health and wellbeing.

The key issues to be addressed in relation to sexual health are:

 Rising rates of diagnosis of sexually transmitted infections such as Chlamydia  Inequalities of access to sexual health screening services  Evidence of increasing levels of risk taking sexual behaviour (often linked to alcohol and drug misuse)

20 To achieve this, NHS Ayrshire & Arran leads a multi-agency and multi-disciplinary team, which builds on existing achievements, enhances sexual health service partnerships and embeds continuous quality improvement processes within the service delivery of all partner organisations and agencies.

21 4. Civil protection risks

4.1 Ayrshire risk registers The Ayrshire Local Working Group Community Risk Register15 has been compiled in accordance with the Civil Contingencies Act 2004 (CCA)16 and its associated Regulations and Guidance as outlined in the Scottish Executive document Preparing Scotland17(2006).

This register has been created to provide public information about the hazards that exist within the Ayrshire area and the control measures in place to mitigate their impact. These hazards do not represent forecast or predictions relating to particular incidents or sites but rather indicate the scale of potential problems relating to that type of hazard and for which relevant services and agencies may be expected to plan. The SECG Ayrshire Community Risk register can be found at www.strathclydefire.org/media/44868/SouthCRR2010.pdf.

4.2 Off site contingency plans

Within Ayrshire there are six top tier sites as defined by the Control of Major Accident Hazard Regulations 1999 (COMAH sites), two sites covered by the Radiation Emergency Preparedness and Public information Regulations 2001 (REPPIR sites) and one site covered by the Major Accident Control Regulations (MACR).

COMAH sites: • Chemring UK Ltd- processing, manufacturing and storage of explosives and chemicals, • Chivas Bros Ltd, Balgray Bonded Warehouse, • Chivas Bros Ltd, Willowyard Bonded Warehouse, Beith • Grants of Girvan – Distillery and Maturation Warehouse, Girvan. • DSM Nutritional Products Ltd – manufacture of vitamins , Dalry • Barony Universal PLC - manufacture of aerosol products, Irvine

15 www.strathclydefire.org/media/44868/SouthCRR2010.pdf 16 www.legislation.gov.uk/ukpga/2004/36/contents 17 www.scotland.gov.uk/publications/2006/02/27140215

22

REPPIR sites: Hunterston A, – decommissioning site Hunterston B, West Kilbride – civil nuclear power station used to generate electricity

MACR site: Ministry of Defence (MOD), Beith - maintenance and storage facility.

23

5. Significant events (1 January 2010 - 31 December 2011)

5.1 Communicable disease incidents The following are some examples of incidents dealt with jointly by the NHS and the Environmental Health Services which have been significant and / or where lessons have been learned together with improvements made over the period. Fuller details are contained in Annex B.

• Outbreak of measles in a travelling community • Norovirus outbreak in an Ayrshire hotel • Cryptosporidium investigation • Potted meat recall • Legionella investigation.

5.2 Environmental events

WATER • Raised lead levels in several different locations • Hydrocarbon contamination of domestic water supplies • Quality issues at a water treatment works • Bacteriological failures in private water supplies in several different locations.

AIR • Ammonia leaks.

Further details are contained in Annex C.

24 6. Health protection: resources and operational arrangements

6.1 Resources

Staffing information, including a note of designated competent persons, can be found at Annex D.

The availability of adequate information and communications technology is essential for the day-to-day work of health protection and is detailed at Annex E.

During a larger incident or outbreak there may be a decision taken to activate the NHS Control Centre. The control centre is resourced with telephones, computers, printers and a fax machine. The computers have internet access to allow access to specialist information, for example Health Protection Scotland, CHEMET and the Met Office. Facilities are also available for video / teleconferencing and although video / teleconferencing have limitations, they are beneficial aids for communication in fast moving incidents that involve several organisations.

While the NHS Control Centre is the central point for communications with all organisations involved in dealing with the incident, it is not used for dealing with public enquiries. This is provided by NHS24 (telephone number 08454 24 24 24).

6.2 Organisational arrangements to facilitate collaborative working

Organisational arrangements for collaborative working are in place between NHS Ayrshire & Arran, East Ayrshire Council, North Ayrshire Council, South Ayrshire Council and other health protection agencies.

The following currently meet:

• Joint Health Protection Planning Group • Ayrshire and Arran Water Liaison Group.

25 A number of other formal and informal arrangements are in place to facilitate good collaborative working including ad hoc meetings, phone calls and emails. There are also arrangements in place within East Ayrshire Council, North Ayrshire Council and South Ayrshire Council to ensure appropriate sharing of information and learning across teams and departments. In addition, Glasgow Scientific Services provide specialist assistance to each of the three Local Authorities.

Joint exercises also contribute to building and maintaining good working relationships. Recently tested exercise scenarios include a water incident, a radiation incident, a chemical incident and a nuclear weapons convoy involving establishing a Scientific and Technical Advisory Cell (STAC). Debriefs are held following every incident and are used to inform any changes in practice that are desirable.

6.3 Arrangements to respond in office hours and out-of-hours

In NHS Ayrshire & Arran, a Consultant in Public Health is always available out-of- hours through Crosshouse Hospital switchboard. There is a one in five consultant- led rota for health protection with support from specialist registrars during their training (usually two operating a one in five rota). The NHS also operates both a strategic and tactical directors’ rota to support both the duty managers and health protection rota.

The NHS Ayrshire & Arran Health Protection Team can be contacted by phoning 01292 885858 during office hours and by phoning Crosshouse Hospital (01563 521133) out-of-hours.

The three councils have staffing levels to deliver the full Environmental Health remit. Team Leaders have responsibility for either Food / Health and Safety enforcement or Public Health / Pollution.

26 Contact during office hours:-

North Ayrshire Council Office hours number is 01294 324300. Out of hours number is 07659183863

East Ayrshire Council Office hours number is 01563 554022/23. Out of hours number is 0845 7240000 (helpline number)

South Ayrshire Council Office number is 03001230900. Out of hours number is 01292 266289

Civil Contingency Team Single contact number is 07659183863

6.4 Arrangements for reviewing health protection Standard Operating Procedures (SOPs) and guidance

NHS Guidance and SOPs have been developed locally and are subject to regular review. Details are listed at Annex F. These documents are contained in the Health Protection Team shared drive available in the office and out of the office through remote access enabled laptops.

Other guidance and information documents can be accessed through relevant websites, for example Health Protection Scotland.

The three Local Authorities have Standard Operating Procedures (SOPs) and guidance covering food, occupational health and safety and public health enforcement activities. These have been developed based on national frameworks and adapted for local circumstances. They are subject to review and audit.

27

6.5 Corporate arrangements for the maintenance of knowledge, skills and competencies of staff with health protection duties

Within NHS Ayrshire & Arran there is an annual cycle of personal development planning and review and performance appraisal for all staff. Each year a set of objectives is agreed between the member of staff and their manager with a six month interim and annual performance appraisal. These appraisals and personal development reviews are used to identify training requirements to maintain and enhance knowledge, skills and competencies.

In addition to annual performance appraisal, medical staff are required to undertake annual consultant appraisal. All staff registered with the Faculty of Public Health are required to demonstrate their maintenance of Continuing Professional Development (CPD) records. These are checked at the annual appraisal. These measures accord with the current General Medical Council (GMC) Guidelines on revalidation and appraisal for doctors.

In each of the three Councils there is an annual professional development review process based on a competency framework for officers within Environmental Health. This ensures that technical and personal development objectives are agreed to maintain the necessary competencies. The process is recorded formally.

The Food Standards Agency (FSA) also carries out periodic audits of Food Safety / Food Standards Inspections and Enforcement carried out by this service. This provides feedback on the maintenance of standards by the Environmental Health services.

28 7 Health protection services: capacity and resilience

7.1 Assessment

There are no nationally set levels of staffing for health protection services in either the NHS or local authorities. Within NHS Ayrshire & Arran the capacity of the Health Protection Team to deal with service requirements is subject to ongoing assessment.

There has also been an ongoing focus on building resilience across the Department of Public Health with both formal and informal training. In exceptional circumstances, staff from across NHS Ayrshire & Arran will also assist in a variety of capacities, dependent on their skills.

7.2 Mutual aid arrangements

A memorandum of understanding exists between the West of Scotland NHS Boards (NHS Ayrshire & Arran, NHS Dumfries & Galloway, NHS Forth Valley, NHS Greater Glasgow & Clyde and NHS Lanarkshire) to provide mutual aid in public health emergency situations. In addition, NHS Ayrshire & Arran, NHS Greater Glasgow & Clyde and NHS Lanarkshire have agreed to work together to provide appropriate personnel to form a Scientific and Technical Advisory Cell (STAC) to advise the SECG in emergency situations within the Strathclyde area.

During a major incident the Local Authorities have a formal mutual aid arrangement with all neighbouring authorities to provide assistance when staffing levels and resources are fully stretched.

29

8 Public involvement in the planning and delivery of health protection services

There is public representation on the Prevention and on Control of Infection Committee and on the Blood Borne Virus Managed Care Network (BBV MCN), as well as on the Public Health Communications Group.

Day to day work involves contact with the public on a regular basis, and this in turn informs the planning process. There are also a number of informal mechanisms available to engage with the public including the NHS Ayrshire & Arran public website18.

During outbreaks or incidents any communication from the Health Protection Team to those affected contains contact details for people to get in touch. Informal feedback can be obtained in this way, though usually enquiries relate to the person’s own situation.

The three local authorities consult and engage with the public in a number of ways including by telephone or written questionnaire enquiry on various topics.

18 NHS Ayrshire & Arran website address: www.nhsaaa.net

30 9 Summary and actions

This plan gives an overview of health protection priorities, provision and preparedness within Ayrshire and Arran and describes how the Board and the Local Authorities deal with the range of health protection topics.

Working together, the Board and Local Authorities will:

• Review the joint health protection planning process and mechanisms required to support this work • Review organisational arrangements for collaborative working • Consolidate and continue to review joint priorities for 2012/3 and for 2013/4

Specific actions arising out of the contents of this JHPP include:

• A review and update of the pandemic influenza plan in line with newly issued national guidance. Lessons learned during the local response to the Influenza A (H1N1) pandemic will be incorporated • A review and update of the incident control plan in line with newly issued national guidance. Lessons learned from responses to local outbreaks and incidents will be incorporated

31 Annex A Contingency plans for incidents within Ayrshire and Arran

NHS Ayrshire & Arran Major Incident Plan (MIP)

(A) (B) (C) Plan Date of last review Scheduled date for next review NHS Ayrshire & Arran MIP Part 1 – Background March 2011 March 2013 Part 2 – NHS response April 2010 April 2012 Part 3 – Scene April 2011 April 2013 Part 4a - Crosshouse August 2010 August 2012 Part 4b - Ayr August 2010 August 2012 Part 5 – NHS Control Centre February 2011 February 2012 Part 6 - COMAH March 2011 March 2013 Part 7 – Emergency Services March 2011 March 2013 Part 8 - MIST February 2012 February 2013 Part 9 – Distribution of Countermeasures August 2011 March 2012 Part 10 – Incident Control Plan Currently under Currently under review review Pandemic Influenza Plan Currently under Currently under review review

These plans are available by writing to the Executive Director of Public Health, NHS Ayrshire & Arran, Afton House, Ailsa Hospital, Dalmellington Road, Ayr KA6 6AB or by emailing [email protected]

32

Ayrshire Civil Contingencies Team led Plans

Scheduled date for next Plan Date of last Review Date of last test review NAC Civil Contingencies Plan July 2011 July 2014 August 2011 SAC Civil Contingencies Plan November 2011 November 2014 September 2010 EAC Civil Contingencies Plan August 2011 August 2014 August 2011 Ayrshire Flood Plan 2007 Currently being reviewed During flood incidents

These plans are available by writing to Ayrshire Civil Contingencies Manager, ACCT, Building 372, Alpha Freight Area, Robertson Road, Glasgow Prestwick International Airport, Prestwick, KA9 2PL or by emailing [email protected]

33

Multi agency Contingency Plans:

(A) (B) (C) (D) (E) Plan Date of last Scheduled date Date of last Scheduled date Comments review for next review test for next test

COMAH Plans Chivas Bros, Willowyard, Beith December November 2013 30 November November 2014 2011 2011 COMAH plans Chivas Bros, Balgray, Beith December November 2013 30 November November 2014 are subject to a 2011 2011 review every three years DSM, Dalry November July 2012 27 May 2009 April 2012 2009

Chemring UK Ltd, Stevenston October 2010 October 2013 June 2010 June 2013

Grants, Girvan March 2011 March 2014 March 2011 March 2014

REPPIR Plans Hunterston Power Station March 2011 March 2014 Annual review (Offsite) Joint plan for A & B sites

Hunterston (A) January 2011 A and B Decommissioning Site exercised separately Hunterston B Power Station 29 September September 2013 (level 2) 2010

34

(A) (B) (C) (D) (E) Plan Date of last Scheduled date Date of last Scheduled date Comments review for next review test for next test MACR Plans MOD, Beith March 2010 March 2013 23 March March 2013 2010

Port Plans Prestwick Airport Plan 20 December December 2012 24 February February 2013 2011 2011

Girvan Harbour – LA June 2008 June 2013 31 August 2010 Ayr Harbour – British Port January 2010 December 2013 31 August August 2013 2010 Troon Harbour – British Port January 2010 December 2013 31 August August 2013 2010

35

Annex B Communicable disease incidents

Outbreak of measles in a travelling community In August 2010, a measles outbreak took place in Ayrshire and Arran associated with a group of families from the travelling community.

A range of professionals were involved with the assessment and management of the outbreak including the NHS Ayrshire & Arran Health Protection Team, the Local Authority Environmental Health Officers, clinicians, public health nursing staff, school nursing staff, microbiologists and Health Protection Scotland (HPS). Since this outbreak, there has been one unrelated case of measles confirmed in Ayrshire and Arran. Ongoing measles outbreaks within Europe and the UK indicate that there is a continuing risk of further measles cases occurring within Ayrshire and Arran.

Following this outbreak, a full report including key learning points and recommendations was presented to the Health and Performance Governance Committee of Ayrshire & Arran Health Board. Recommendations from the report are being actioned locally and include:

• The Health Protection Team should take every opportunity to improve clinicians’ awareness of: ° measles as a differential diagnosis and the increased risk amongst groups such as travellers ° the need to contact the Health Protection Team if measles is suspected.

• The development of a local Standard Operating Procedure (SOP) for the Health Protection Team for measles notifications to ensure registers are maintained, and appropriate action is taken.

• Improved communication between the Health Protection Team and the public health nurses with a remit for the travelling community.

• NHS Ayrshire & Arran should continue to maintain and improve high rates of MMR vaccination uptake within the childhood vaccination programme.

36 Lessons learned from this outbreak have been shared with relevant parties at both a local and national level.

Norovirus outbreak associated with hotel In December 2010, a problem assessment group (PAG) was convened to investigate this in an hotel in Ayrshire. A PAG was chaired by a Consultant in Public Health Medicine (CPHM) and included representatives from NHS Ayrshire & Arran, the Local Authority Environmental Health Service and Health Protection Scotland. The outbreak affected diners attending the hotel on a single evening during the Christmas party season, and was quickly brought under control.

Key learning points from this investigation included:

• The incident highlighted how easily norovirus infection can spread, particularly in large social gatherings, and the importance of prompt reporting and investigation of such outbreaks • Prompt investigation by the Environmental Health Service allowed the PAG to assess very quickly the situation and its likely cause and implement appropriate control measures. • The cooperation of the hotel owners was essential in ensuring that the investigation could be carried out and control measures implemented as requested.

Cryptosporidium investigation In June and July 2011 the number of reports of cases of cryptosporidiosis increased, with a concentration of cases in North Ayrshire. A problem assessment group (PAG) chaired by a Consultant in Public Health Medicine (CPHM) and with representation from Environmental Health, Microbiology, Scottish Water and Health Protection Scotland was convened to investigate this increase in cases. No identifiable ongoing source of infection was identified, despite thorough investigation.

Key learning points / actions resulting from this investigation included:

• The importance of maintaining good surveillance systems and reviewing these regularly.

37 • Investigations of such infections which can have multiple potential sources - e.g. farms, travel, water and people – can be extremely complex and require good working relationships across many agencies. • The cryptosporidium investigation form used by the Local Authorities and Health Protection Team was updated and expanded to include additional questions relating to potential food and water exposures.

E. coli O157 in potted meat In August 2011, two samples of potted meat from two separate butchers were reported to be positive for E. coli O157 by the food examiner. Investigations at the premises revealed potential cross contamination issues. Traditionally in this area potted meat is eaten by the elderly with Ayrshire new potatoes. As there was potentially a number of potted meats of the same batches sold, a product recall was initiated. This involved press releases in both local papers and radio.

Further analysis by the Reference Laboratory revealed the results to be false positives.

Key learning points from the incident included:

• Ensuring discussions between the EH, Glasgow Scientific Services (GSS) and the Reference Laboratory to clarify the priority for confirmation. This will be on a case by case basis dependent on the local risk assessment, resources available and nature of the issue. • Reviewing the ISO method that the food examiner uses to automate the manipulation stages and reduce the potential for cross contamination of the sample.

The false positives situation was a rare event and, although unfortunate, it was a valuable learning vehicle. It is clear that communication between the various agencies is essential. Should a similar situation arise in the future, consideration should be given to convening a Problem Assessment Group or Incident Control Team to ensure early coordination of effort and to agree priorities for action.

The multiagency collaboration in this incident showed that:

• Within a few hours of the initial notification, all potentially contaminated food had

38 • been removed from sale and samples taken • Within a few hours of the initial notification, possible routes of contamination had been identified and interventions taken to remediate these issues • GSS was able to receive and report on additional samples quickly.

Legionella investigation Between July and December 2011, three cases of Legionnaire’s disease were notified to the Health Protection Team. A thorough investigation of these cases conducted by the Health Protection Team and local Environmental Health services concluded that these were unrelated cases associated with travel outside of Ayrshire and Arran.

Key learning from this investigation included:

• The importance of mapping when investigating possible exposures of Legionella infection together with the importance of local knowledge and recorded cooling towers, condensers and air conditioning units. • The potential benefits and limitations of laboratory testing in relation to the investigation of Legionnaire’s disease • A greater understanding of the role of the Health and Safety Executive in the investigation of unrelated cases of Legionella infection.

39

ANNEX C Environmental events

WATER EVENTS

Lead Over a period of time, separate instances of raised lead levels occurred in some routine household water samples from both public and private water supplies, as well as in a local workplace. These have demonstrated ongoing risks due to persistence of lead piping in the supply pipes to, and within, properties, despite the replacement of all lead piping in pipes for which Scottish Water is responsible, and treatment and monitoring of all public supplies to ensure a pH which inhibits leaching of lead from pipework.

Key learning included:

• The importance of correct sampling to inform exposure assessment as well as remediation • The importance of, and scope to improve, inter-agency communication and coordination • The scope to improve public awareness.

Actions to date include:

• Contribution to development of a national protocol for the public health response to notification of lead in water samples • Using the experience to inform NHS Ayrshire & Arran’s response to a consultation on draft national guidance on the implementation of the Water Regulations 2010, which address chiefly supplies to public buildings.

Hydrocarbons Separate instances of hydrocarbon contamination of domestic water supplies due to leakage from domestic fuel tanks, and in a new housing development where construction activity was not complete, identified difficulties in retrospective exposure assessment, source identification and remediation.

40 Key learning included:

• The benefits of prompt recognition and inter-agency communication • The difficulty of risk communication in complex investigations with lines of responsibility complicated by other contractual relationships • The scope to raise awareness as to potential risks and design precautions in rural communities reliant on domestic fuel oil, and the potential to promote alternative energy sources

Water quality A series of quality issues at a Water Treatment Works, attributed to difficulties with raw water quality, resulted in extended communication with Scottish Water, and contributions to a Drinking Water Quality Inspectorate investigation.

Key learning included:

• The importance and benefits of strong working relationships with both SW and DWQR that allowed close monitoring of those few occasions where potential health risks were identified • Recognition that the professional arguments for substantive improvements and for consideration of resilience of overall supplies are informing ongoing evaluation of potential remedies.

AIR EVENTS

Local incidents resulting in releases to air included ammonia leaks at both industrial and health care premises, in line with a pattern of national incidents reported to SEISS. One industrial incident resulted in significant travel disruption and evacuation of residents, but demonstrated excellent liaison with the mobile analytical service of Glasgow Scientific Services working with Strathclyde Fire and Rescue, which allowed real time results to inform management.

Key learning included: • the scope to promote similarly prompt notification and good ongoing communications.

41

Annex D Health protection: staffing levels (as at 1st February 2012)

NHS Health Protection Team – During office hours

Consultant in Public Health Medicine 1.7 wte Associate specialist Public Health Medicine 0.4 wte Health Protection Nurse Specialist 2.0 wte Secretary 1.0 wte

In addition, at times of high demand, support from other staff in the Department of Public Health can be obtained by releasing them temporarily from non-essential duties. During the flu pandemic containment stage, staff from the wider NHS also provided a high level of input.

Ayrshire and Arran Designated Competent Persons

Designated competent persons NHS EAC NAC SAC Consultant in Public Health 5 Health Protection Nurse Specialist 1 Public Health Specialist 1 Environmental Health Officers (EHO) 5 8.6 Team Leaders 2 2 2 Environmental Health Manager 1 1

42

Local Authority staffing

Local Authority management, technical and professional staff EAC NAC SAC not included above Environmental Health Manager 0.5 EHOs (food, health, safety and pollution control) 9 Contaminated land officer 1 1 Food safety technician 1 2 4 Health and safety technical staff 1 1 Environmental Health Technical Staff 2 Pollution control technical staff 1 Out-of-hours Ayrshire noise unit staff 1 1 1 Corporate Enforcement Unit Staff 2 1 Pest control/dog warden staff 2 3 2 Enforcement Officer 1

43 Annex E Information and communications technology resources available in NHS Ayrshire and Arran and the three Local Authorities

NHS EAC NAC SAC

Hardware

Desktop and laptop computers    

Printers (black and white and colour)    

Photocopiers    

Fax machines   

Office and mobile telephones    

Blackberry / Smartphone available    

Single page scanner    

Document feed scanner    

Mobile broadband access – for Specialist  —  —

Registrars in Public Health

VPN token  — — —

Pagers (with text screen)  — — —

Audio-teleconferencing equipment  —  

Video-conferencing equipment    

On-call laptops with access to public health  — — — drive

44

NHS EAC NAC SAC Software MS Office (Word, Excel, PowerPoint,     Access) E-mail     Dictaphone  — — — SIDSS (Scottish Infectious Disease  — — — Surveillance System) Access to local computer networks and to     the internet Access to electronic information resources  — — and databases: – ECOSS (Electronic Communication of Surveillance in Scotland) SCI Store (to access laboratory results) SCI Gateway SHPIR (Scottish Health Protection Information Resource) TRAVAX (travel advice) Toxbase (toxicology database) SEISS (Scottish Environmental Incident Surveillance System) NHS Scotland e-library  NHS Education for Scotland Access to resources provided by NHS24  M3 Northgate system  FLARE system to record details of all food  businesses along with enforcement actions. IDOX UNI-form EH Management System — 

45 Annex F Policy guidance, template guidance and Standing Operating Procedures (SOPs) used by Health Protection Team NHS Ayrshire & Arran

Policy guidance documents Review date

Chemoprophylaxis and vaccination Completed 2010 September 2013 for Haemophilus Influenzae Type B (Hib)

Meningococcal infection Public Completed 2011 May 2014 Health Management for cases and clusters

NHS Ayrshire & Arran Control of Complete Rolling Infection Manual containing 28 Policy programme of documents review

Template guidance available (complete)

E. coli O157

Hepatitis A

Hepatitis B – new cases

Hepatitis B – Babies born to Hep B positive mothers

Legionnaires’ Disease

Management of diarrhoea and vomiting outbreaks in a care home

Management of contacts of Invasive Group A Streptococcal Infection

Meningococcal Meningitis

46 Standard operating procedures prepared

Telephone enquires and reporting of incidents

Mail / email communication

Notification a single case of Legionnaires’ Disease

Management of contacts of Invasive Group A Streptococcal Infection

Notification of Measles

Notification of Meningococcal Infection

Notification of Invasive Pneumococcal infection in under 5yr olds

Response to Suspect Packages

Notification of a single case of Tuberculosis

Over the next two years, all of these protocols will be reviewed and additional Standard Operating Procedures prepared according to needs identified.

47

48