Guidance

Communicable disease outbreak management: operational guidance

Updated 21 December 2023

Introduction

There have been significant organisational changes to the management of outbreaks of communicable diseases since the publication of this document in 2014. To ensure the guidance reflects current organisational structures, the document has been updated as interim guidance with a more detailed review to be undertaken during 2024.

This interim document provides operational guidance for the management of outbreaks of communicable disease in England for staff at all levels of the UK Health Security Agency (UKHSA). It is also used by organisations with responsibility for health protection and delivery of health protection responses.

This UKHSA guidance was first developed by Public Health England (PHE) in collaboration with partner agencies in 2011 and revised in 2014. This guidance provides a framework for working across public health structures in local authorities, integrated care systems, NHS England and other relevant bodies and is for use in outbreak management both locally and nationally. It has been developed in association with the Association of Directors of Public Health, the Chartered Institute of Environmental Health and the Food Standards Agency, along with many individuals sharing their expertise.

This guidance can also support integrated care systems, NHS England regional teams and local authorities by ensuring that commissioned services have robust plans in place to respond to an outbreak. It may also inform local health resilience partnership (LHRP) and emergency preparedness resilience and response (EPRR) plans.

It is expected this guidance will be made operational through local adaptation. The appendices provide a comprehensive set of documents that can be used to guide this process.

Where disease or situation-specific guidance is separately available this should also be considered. Links to examples of relevant documents are provided in Appendix 1.

Policy and legal context

UK Health Security Agency

The UKHSA strategic plan sets out UKHSA’s vision and goals to prepare for and respond to health threats and build the capabilities and technologies to protect the country in the future. The 6 strategic priorities for UKHSA laid out in the strategy are to:

1. Be ready to respond to all hazards to health.

2. Improve health outcomes through vaccines.

3. Reduce the impact of infectious diseases and antimicrobial resistance.

4. Protect health from threats in the environment.

5. Improve action on health security through data and insight.

6. Develop UKHSA as a high-performing agency.

As an executive agency of the Department of Health and Social Care (DHSC), UKHSA:

• provides strong national leadership on public health security and health protection
• ensures a cohesive response across England and the UK’s public health functions
• embeds effective clinical, scientific and operational functions in the public health system

UKHSA also has a duty as a Category 1 responder under the Civil Contingencies Act 2004 (CCA) in respect of emergency preparedness and the response and resilience functions for public health. For the avoidance of doubt, these duties under the CCA shall be delegated from the Secretary of State to officials in UKHSA who are responsible for emergency preparedness, resilience and response, such that those officers operate as if UKHSA itself were a category 1 responder under the CCA.

In fulfilling this, UKHSA provides public health EPRR leadership and scientific and technical advice, including health protection services and expertise. The UKHSA incident response plan (IRP) provides a tactical overview of EPRR arrangements and details the response to significant public health incidents at a local, regional and national level. The IRP details the 3 UKHSA incident response levels, as described in Appendix 3. This guidance is intended to complement and be used in conjunction with these documents.

Local authorities

Under section 6 of the Health and Social Care Act 2012, directors of public health (DsPH) in upper tier and unitary local authorities have a duty to prepare for and lead the local authority public health response to incidents that present a threat to the health of the population. In practice, this means that the director of public health (DPH) will provide information, advice, challenge and advocacy on behalf of their local authority, to promote preparation of health protection arrangements by relevant organisations, operating in their local authority area.

Under the amended Public Health (Control of Disease) Act 1984 and associated regulations, the majority of statutory responsibilities, duties and powers significant in the handling of an outbreak lie with the local authority, including appointment of a proper officer whose powers include the receipt of notifications. In the majority of local authorities this responsibility is delegated to UKHSA.

Under the Civil Contingencies Act 2004, local authorities are identified as Category 1 responders. The specific local authority (including district councils) statutory responsibilities, duties and powers which are significant in handling a communicable disease outbreak are described in Appendices 4 and 5.

NHS and ICBs

Integrated care boards (ICBs) are the local commissioners of NHS-funded community and secondary care services and sit on their LHRP as part of the NHS system to prepare and plan for emergencies. Integrated care systems (ICSs) have 2 statutory components: ICBs and integrated care partnerships (ICPs). ICBs are responsible for developing integration and collaboration, and for improving population health across the system. Under the Civil Contingencies Act 2004, NHS England and ICBs are identified as Category 1 responders.

Coordination

The roles of UKHSA, the Food Standards Agency (FSA), local government and the NHS in the public health system are complementary. In practice these organisations work closely as part of a single public health system to deliver effective protection for the population from health threats.

UKHSA regional deputy directors for health protection will agree alerting criteria for incidents with their local DsPH and ensure mechanisms are in place for the timely passage of information. Local arrangements for mobilising resources to respond to incidents and outbreaks should be agreed.

More detailed information about the roles and responsibilities of partners can be found in Appendix 4.

Aim of this guidance

This guidance aims to ensure an effective and coordinated approach is taken to outbreak management, from initial detection to formal closure and review of lessons identified. It promotes a consistent approach across all levels of UKHSA and across organisations with responsibility for health protection and delivery of health protection response. It includes a set of standards for outbreak response.

The appendices contain additional guidance to support outbreak management and investigation, including:

• roles and responsibilities of main organisations and individuals
• convening an outbreak control team (OCT)
• communications strategy, including media relations

Definition of an outbreak and outbreak control team

An outbreak or incident may be defined as:

• an incident in which 2 or more people experiencing a similar illness are linked in time or place
• a greater than expected rate of infection compared with the usual background rate for the place and time where the outbreak has occurred
• a single case for certain rare or high-consequence diseases such as diphtheria, botulism, rabies, viral haemorrhagic fever or polio
• a suspected, anticipated or actual event involving microbial contamination of food or water

It is recognised that many cases and clusters of communicable disease are handled within routine health protection team (HPT) business without the need to formally convene an OCT. It is important that such cases are appropriately recorded and managed for audit purposes and to support surveillance and any future outbreak management. In some instances, more routine or low-risk outbreaks may be managed through standard operating procedures, with the option to escalate should the risk assessment change.

An OCT may be a formal meeting of all partners to address the control, investigation and management of an outbreak, or a discussion between stakeholders following the identification of a case or exposure of concern. All such discussions should be appropriately recorded. The principles outlined in this guidance apply at any level.

NHS and local authority funded healthcare providers should involve both the commissioners of the service and the UKHSA HPT region to obtain appropriate advice and assure staff and patients of a robust response if an outbreak is detected. As above this advice may take the form of a formal OCT or a one-off web teleconference call but should be appropriately recorded so that there is an audit trail of advice sought and control measures taken.

It should be noted that the terms ‘incident management team’ and ‘outbreak control team’ are often used synonymously; both have very similar aims, membership and procedures.

Management arrangements for outbreaks

The protection of the health of the population takes priority over all other considerations.

Primary objective

The primary objective in outbreak management is to protect public health by identifying the source and cause of infection and transmission dynamics, to implement control measures to prevent further spread or recurrence.

The OCT must always give due consideration to their responsibilities in supporting investigations which may result in legal proceedings, for example, under the:

• Corporate Manslaughter and Corporate Homicide Act 2007 (as guided by the Work Related Death Protocol)
• Food Safety Act 1990 and associated regulations
• Health and Safety at Work Act 1974 and associated regulations

These responsibilities include obtaining and ensuring the continuity, or chain, of evidence for presentation in concurrent or subsequent legal proceedings as well as civil proceedings or a Coroner’s Inquest. Evidence may include information relating to patients and contacts obtained in the course of the investigation of an outbreak. The OCT should if required seek guidance regarding the chain of evidence for a potential prosecution.

Secondary objective

Secondary objectives include refining outbreak management, adding to the evidence base about sources and transmission of infectious agents and control measures, training and lessons identified for improving communicable disease control.

Responsibility for managing outbreaks is shared by all organisations who are members of the OCT. This responsibility includes the provision of sufficient financial and other resources necessary to bring the outbreak to a successful conclusion. NHS and local authority commissioned health and care providers should have a requirement in their contract to provide what is needed to rapidly respond to outbreaks. The suggested membership of an OCT, main roles and responsibilities are described in Appendix 4.

Many incidents and outbreaks are dealt with as part of normal acute service provision, also known as business as usual (BAU). Occasionally outbreaks are of such magnitude that there may be significant implications for routine services and additional resources may be required. The surge, escalation and major incident plans of organisations affected will be invoked as appropriate.

The UKHSA IRP should be used to determine the appropriate incident level, response and triggers for escalation within UKHSA (Appendix 3). If it is anticipated that an incident may compromise UKHSA services, the relevant UKHSA director must be alerted and a contingency plan implemented to ensure a satisfactory service can be maintained, using mutual aid arrangements if necessary. Other organisations may refer to their own escalation plans.

Outbreaks confined to NHS trust premises, whether acute, community or mental health, will usually be led by the relevant trust in accordance with their operational plans and with the advice and input of UKHSA HPT region. Where this involves food, the NHS will engage the relevant local authority.

If any party is concerned with another organisation’s response to an outbreak the consultant in health protection (CHP) should initially discuss the issue with the responsible commissioner. If the issue cannot be resolved by discussion between parties, they should seek advice from the UKHSA regional deputy director and local DPH.

Risk assessments

All activities should be underpinned by a comprehensive risk assessment agreed by the OCT and regularly reviewed throughout. An example of the risk assessment framework used by UKHSA is provided in Appendix 6. However, it is acknowledged other organisations may use different frameworks for their own risk assessments. The OCT should agree on a standard format for risk assessment.

Cross boundary outbreaks

If the outbreak crosses UKHSA HPT region or local authority boundaries, there will need to be close liaison with neighbouring UKHSA HPT regions and local authorities, and a decision made as to who will lead the investigation. The UKHSA regional deputy director for health protection together with the respective DPHs should make this decision as soon as possible in consultation with field services (FS) and national UKHSA disease experts if necessary. The lead area will most likely be where the outbreak is first identified or where the majority of cases reside. Where the outbreak crosses local authority boundaries, the relevant DPHs will need to establish and maintain good communication with the neighbouring authority. If the outbreak is food-related, the FSA national incident team needs to be informed and will have a coordination role across multiple local authorities.

Cross-border and international outbreaks

National incidents

UKHSA is responsible for providing information and services to support a coordinated and consistent UK public health response to national incidents involving devolved administrations. Liaison will be conducted via daily or weekly web teleconferences as agreed by the OCT.

FSA is responsible for providing information, advice, guidance and coordination to local authorities for outbreaks that are serious and/or widespread (affecting multiple local authorities), as outlined in the Food Law Code of Practice.

International incidents

UKHSA is responsible for reporting incidents of potential international significance to the World Health Organization (WHO) under International Health Regulations (IHR 2005). Events that meet the definition for a serious cross-border threat to health will also be reported to the European Commission (EC).

(A serious cross-border threat to health is defined as a life-threatening or otherwise serious hazard to health of biological, chemical, environmental or unknown origin which “(a) spreads or entails a significant risk of spreading across the borders of at least one EU member state and the United Kingdom; or (b) may necessitate a coordinated response by the UK authorities in order to ensure a high level of human health protection.”)

The FSA is responsible for notifying the International Food Safety Authority Network, (INFOSAN), Emergency Contact Point (ECP). The FSA will also inform the European Commission and European Food Safety Authority (EFSA) when a European country is involved.

Recognition of an outbreak and initial response

Outbreaks may be recognised by UKHSA, local authorities, NHS or public health microbiologists, FSA or service providers. Each organisation has its own procedures for surveillance, detection and control. Immediate contact between these parties is essential as soon as it becomes apparent that an outbreak may exist, so that the parties can share situational awareness, undertake a risk assessment, and agree lead responsibilities, timelines and level of response required.

Immediate control measures should be implemented as per relevant guidance, and investigation to clarify the nature of the outbreak should begin within 24 hours of receiving the initial report. The following steps should be undertaken to establish significant facts and inform the decision to declare an outbreak:

• confirm the validity of the initial information (for example, ascertainment bias, laboratory false positives)
• consider the tentative diagnosis and whether all cases have the same diagnosis
• conduct preliminary interviews with cases to gather basic information including any common factors
• collect relevant clinical and/or environmental specimens
• form preliminary hypotheses
• consider the likelihood of a continuing risk to public health
• carry out an initial risk assessment (see Appendix 6)
• manage initial communication issues

Declaration of an outbreak

Locally confined outbreaks will usually be recognised and declared by the CHP or senior health protection practitioner. Where appropriate this will be following consultation with a consultant microbiologist or relevant environmental health officer (EHO) and occasionally the DPH.

For more widespread outbreaks, such as those that are national or regional, the outbreak may be recognised by FS, a consultant or senior epidemiologist, national UKHSA disease expert or the FSA. It is possible that a widespread outbreak may be initially recognised as sentinel ‘local’ outbreaks.

For local incidents the UKHSA HPT region should inform the DPH and, if required, ICBs. For standard and enhanced incidents (Appendix 3) relevant external bodies such as NHS England should be notified. NHS England will provide oversight and support to ensure that alerts from UKHSA are actioned.

Convening an outbreak control team

Following the recognition and declaration of an outbreak, a decision regarding the need and urgency to convene an OCT is required. This decision should be guided by a risk assessment. The rapid establishment of an OCT is particularly appropriate if an outbreak is characterised by:

• immediate or continuing significant risk to the health of the population
• one or more cases of serious communicable disease
• a large number of cases
• cases identified over a large geographical area suggesting a dispersed source
• significant public, political or reputational interest

If no formal OCT is convened, it is likely it will still be necessary to take public health actions and liaise with partners and stakeholders.

When a decision has been made not to declare an outbreak, the responsible CHP should review the situation at appropriate intervals and be prepared to declare an outbreak if required. This may involve consulting with the other parties to assist with ongoing surveillance.

Role of the outbreak control team

The purpose of the OCT is to agree and coordinate the activities involved in the investigation, management, and control of the outbreak. The OCT will:

• gather, analyse and share information relevant to the outbreak
• assess the ongoing risk to the health of the population
• ensure that that the cause, vehicle and source of the outbreak are investigated, and suitable control measures implemented as soon as possible
• seek legal advice where required

Details regarding the organisation and functioning of the OCT are contained in Appendix 4, but main points include:

• the chair of the OCT should be appointed at the first meeting; this will usually be the CHP, consultant epidemiologist (CE) or DPH, although it may be another OCT member if appropriate
• membership of the OCT should be in accordance with Appendix 4 – the chair and members should ensure that all important individuals are invited and kept under review
• members must have the appropriate delegated authority to agree and implement decisions and allocate resources
• at the first meeting terms of reference should be agreed and a preliminary risk assessment conducted
• a communications strategy should be agreed early and reviewed as necessary

Investigation and control of the outbreak

Outbreak investigations will vary depending on circumstances, but an outline of actions that should be undertaken is provided in Appendices 4 and 7. Main points are summarised below.

Definitions of a case, contact and exposed persons, including descriptions of time, place, person and clinical features should be agreed early on in the investigation and reviewed throughout.

Control measures should be documented with clear responsibilities and timescales for implementation.

Descriptive epidemiology

Basic descriptive epidemiology is essential and should be reviewed at each OCT meeting. Sometimes descriptive epidemiology might be sufficient to take action. It is also crucial for generating a hypothesis as to the source of the infection.

The types of information that should be gathered are summarised here:

1. Review initial information and establish the number of probable and confirmed cases based on the agreed case definition.
2. Describe the outbreak in terms of person (for example age, sex, ethnicity or other relevant factors), time (preferably onset date) and place (geographical distribution of cases).
3. Conduct in-depth interviews with initial cases to establish any common factors such as places visited, foods consumed, lifestyle habits such as pet exposure.
4. Form preliminary hypotheses based on descriptive epidemiology and interviews with cases.

Analytical studies

An analytical study should only be undertaken if there is a hypothesis to test. The need to conduct an analytical study should be considered early in the investigation. Criteria and further information on conducting analytical studies are contained in Appendix 8.

The purpose of conducting an analytical study is to confirm a hypothesis regarding the source of infection or mechanism of spread in order to confidently take and/or target action to protect public health. Robust evidence may be needed to provide support for and to justify interventions and control. In addition, it is good practice to conduct an analytical study where possible and practicable.

A written protocol for any analytical study should be drawn up at the earliest possible point, with level of detail appropriate to the nature of the outbreak. An example template is provided in Appendix 8.

Microbiological and environmental investigations

The role of reference microbiology tests should be considered in helping define the cluster and links to potential sources, as should other sources of evidence such as food chain investigations.

Communications

It is essential that effective communication is established between all members of the OCT, partners, industry affected, the public and the media, and that this is maintained throughout the outbreak.

A communications lead should be part of the management of an outbreak from the outset. A strategy for informing the public and important stakeholders should be discussed and agreed by the OCT. Communications teams of organisations involved should be in contact with each other to ensure that messages are consistent.

The chair should ensure that minutes are taken at all OCT meetings and circulated to participating agencies as soon as possible afterwards. All important decisions should be recorded. It is recommended that administrative support be provided to the OCT as standard.

Standard communications protocols should be followed for dissemination of critical information within UKHSA and with OCT members as necessary, including regular briefing notes (standard and enhanced incidents) or situational reports (SITREPs) as described in the UKHSA IRP, epidemiological summaries, phylogenetic trees, information about case exposure, for example, food, where the OCT determines this relevant and necessary.

Communication between all partners involved in the outbreak investigation will be according to locally agreed arrangements for responding to health protection incidents.

The UKHSA regional team will keep the DsPH informed about health protection issues and of the actions being taken to resolve them.

Use of communication through the media may be a valuable part of the control strategy of an outbreak and the OCT should consider the risks and benefits of proactive versus reactive media engagement in any outbreak. A suggested media strategy is included in Appendix 9.

End of the outbreak

The OCT will decide when the outbreak is over and will make a statement to this effect. The decision to declare the outbreak over should be informed by ongoing risk assessment and when:

• there is no longer a risk to the public health that requires further investigation or management of control measures by an OCT
• there is a decline in the number of new cases
• the probable source has been identified and addressed

Constructive debrief and lessons identified

UKHSA recommends that debriefs using the constructive debrief and lessons identified process should be undertaken following an incident.

The lessons identified (LI) process should be followed in line with the UKHSA IRP.

A debrief facilitator who was not directly involved with the incident should support this process. For routine or standard incidents this could be a local emergency planner. For enhanced incidents this should be someone from UKHSA EPRR directorate.

Following a constructive debrief for routine or standard incidents the OCT chair and debrief facilitator should meet to determine the important lessons identified. These lessons will then be reported to the appropriate senior management team (SMT) to decide actions to be taken and who will lead on them.

A ‘lessons identified’ action table should be completed to report the results of the constructive debrief. This highlights issues that need to be resolved, how this will be achieved, who will take responsibility and timeframe for implementation.

The results of this process should be presented in the outbreak control report and disseminated locally for routine and standard incidents. For enhanced incidents, reports are sent to the UKHSA EPRR directorate.

Further information on constructive debrief is provided in Appendix 10.

Outbreak report

At the conclusion of the outbreak the OCT will prepare a written report. Final outbreak reports are primarily for dissemination to a distribution list agreed by OCT members and should be completed within 12 weeks of the formal closure of the outbreak response. Appendix 11 contains a standard format for the final outbreak report and guidance regarding legal issues that need to be taken into consideration.

Lessons identified and recommendations from the outbreak report and constructive debrief process should be disseminated as widely as possible to partner agencies and main stakeholders. Consideration will be given by the OCT members whether there is benefit in publishing outbreak reports. Lessons identified should be reviewed within 12 months of the formal closure of the outbreak. Learning should be reviewed against local plans and plans updated in light of this where required.

Audit

Audit is essential for improving quality. A set of standards for managing outbreaks was created during the development of these guidelines and an audit tool for measuring against them is provided in Appendices 12 and 13.

The communicable disease outbreak management plan should be evaluated at regular intervals and at least annually, preferably through the audit of outbreaks that have occurred at both local and national levels. UKHSA has lead responsibility for ensuring this takes place and will ensure this guidance is tested at every level of the organisation.

Main organisations and individuals should arrange regular and appropriate training or exercises to ensure that all staff that are likely to be involved in outbreak investigation and control are familiar with this guidance and the management of outbreaks of communicable disease.