E.coli O157 Outbreak - August / September 2009

Summary

1 This circular provides information on outbreaks of E.coli O157 reported by the Health Protection Agency (HPA) at open farms (i.e. farms which invite members of the public to visit and which facilitate direct contact with animals) in Surrey and elsewhere during August/September 2009.

2 It also provides guidance on the action to be taken by Health and Safety Executive (HSE) Inspectors and Environmental Health Officers (EHOs) in local authorities (LAs) in carrying out the programme of visits to open farms as requested by the HPA.

Issue

3 Open farms are commercial operations the primary purpose of which is leisure/entertainment and at which visitors are encouraged to have hands-on contact with animals. Responsibility for enforcing health and safety legislation at open farms falls to the LAs by virtue of the Health & Safety (Enforcing Authority) Regulations 1998. It is, however, possible that there are a small number of equivalent 'farm attractions' on premises, the main activity of which is as an 'agricultural undertaking' and for which enforcement falls to HSE.

4 Following the E.coli O157 outbreak in Surrey, the HPA recommended LAs should inspect all open farms for compliance with HSE guidance currently set out in Agriculture Information Sheet No. 23 "Avoiding ill health at open farms - Advice to farmers (with teachers' supplement)" [AIS239rev)]. LACORS advised councils of this recommendation on 17 September 2009 and this programme of work is underway.

5 In addition, HSE has agreed to adopt the following strategy:

• A Health alert on the HSE website providing the farming community with a precautionary reminder of the current guidance; and
• Visits to the equivalent (if any) of LA-enforced open farms operated within larger HSE-enforced agricultural undertakings where information about these premises can be identified centrally, supplemented by local intelligence.

Background

6 The guidance in AIS23 is predicated on the assumption that microbiological hazards, including that of E.coli O157, are always liable to be present on farms i.e. that it is not possible to prevent exposure. Thus the guidance focuses on adequately controlling the risk.

7 Different types of visitor farm attraction present different levels of risk of exposure to or infection with E.coli O157.

The degree of microbiological risk is difficult to quantify but influencing factors include the:

• number and types of animals;
• degree of contact between people and animals;
• number of visitors;
• presence or absence of eating facilities;
• adequacy of control measures, particularly hand washing.

Open farms

8 Open farms are commercial operations whose primary purpose is entertainment and which can be distinguished from conventional working farms (commercial agricultural undertakings) by a number of factors.

The following features in isolation or combination are relevant:

• the farm attraction is open to the public by direct access
• the farm attraction is visited on a daily/throughout the year basis
• provision of fixed facilities for visitors including hand washing
• provision of animal petting areas; and
• provision of rides and play amusements/facilities.

9 Assessment of the risk from contact with animals using the criteria set out in the previous section, may suggest that open farms are likely to present the most significant risk of exposure to and the greatest potential for infection from, zoonoses.

10 Almost all open farms fall to the LAs for enforcement and it is this category that HPA has recommended should receive a thorough inspection. However it is possible that that there are a number of equivalent attractions located within farms which fall to HSE for enforcement. The Agriculture and Food Sector (the Sector) believe the number of these to be very small.

HSE-Enforced farms

11 Farms subject to HSE enforcement are working farms (commercial agricultural undertakings) whose primary purpose is agricultural activity and for which visitor access is educational or incidental. The attraction will not be a separate business nor will it have been dissociated from the management of the main farm.

12 It is difficult to identify those visitor farm attractions that fall to HSE for enforcement. Whilst a voluntary registration scheme, the National Farms Attraction Network (NFAN), has more than 400 members, not all visitor farm attractions are registered with it.

13 Working farms visited by school parties where the visits are planned but occasional activities, that participate in various educational schemes for educational purposes that open for specific seasonal events e.g. during lambing or as part of the national Open Farm Sunday scheme are not visitor farm attractions. The visits by members of the public (including children) are incidental to the main farm business.

14 Approximately 1000 working farms in England and Wales that fall to HSE for enforcement have undertaken training to be badged under the Learning outside the classroom (Lotc) scheme, administered by Farming and Countryside Education (FACE) through the Countryside Education Visits Accreditation Scheme (CEVAS). CEVAS has identified a further 700 farms that receive children and other visitors as part of the Government programme to ensure learning outside the classroom.

15 Farm visits are a priority under the programme. The visits involve education rather than leisure and are not primarily intended to promote contact between people and animals; though this may take place on some farms and at certain times of the year, e.g. during lambing. The Lotc farms have been through a formalised process to be part of the scheme and are likely to be well aware of the controls required. To indicate the scale of these activities, it is estimated that approximately 1 million children visited a farm under one or other of these schemes during the Year of Food and Farming (2007/08).

16 Many other farms in England and Wales that fall to HSE for enforcement allow access to visitors for various activities, though not necessarily involving direct contact with animals. By way of example, 425 farms received 140,000 visitors in a single day as part of the Open Farms Sunday scheme in June 2009.

17 Similar schemes operate in Scotland and are administered by the Royal Highland Education Trust (RHET).

Current guidance

18 AIS23 (rev) was first published in 1998 and most recently revised in June 2009.

19 HSE's Biological Agents Unit (BAU) is satisfied that the guidance in AIS 23(rev) is proportionate and fit-for-purpose providing sensible, practical advice, consistent with that provided in other countries, e.g. USA. It is aimed at farmers and through the supplement at teachers or others in charge of visits as a work activity, not at members of the public generally.

20 The Advisory Committee on Dangerous Pathogens (ACDP) has been asked to review AIS 23(rev). The Sector working with BAU will give evidence to the ACDP and respond to the outcomes of its review and any recommendations from the Outbreak Control Committee arising out of the investigation. In the meantime, we believe the guidance is relevant and that the basic hygiene advice - the key to avoiding infection from animals - is, and is likely to remain, sound.

21 It is important to remember that members of the public have a personal responsibility for following the good hygiene advice provided to them when visiting visitor farm attractions, as well as working farms. Though it is not directly the responsibility of HSE, there does not appear to be any authoritative, widely available guidance targeted at members of the public for farmers to handout/make available during visits e.g. highlighting some of the practical issues such as nail biting, use of dummies, sucking thumbs etc.

Evidence base for the assessment of risk

22 E.coli O157 is not a notifiable disease under regulation 5 and Schedule 3 of the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 1995. Notwithstanding, BAU advises there have been 6 or 7 reports of E.coli O157 infections at HSE regulated premises in the last 3.5 years; out of ~1 million RIDDOR reports. None of these were connected with farms or farming activity.

23 The HPA publishes annual figures of E.coli O157 infection in the UK which, in the five-year period 2004-2008, averaged approximately 900 cases a year; but these include cases of transmission from contaminated food products.

24 There is, therefore, no clear indication as to the number of cases connected with farms or contact with farm animals. This means there is no evidence to date to suggest a widespread problem that would necessitate a change in HSE's advice or enforcement strategy for working farms.

Action by LAs

25 LAs are already carrying out visits to visitor farm attractions.  Feedback from these visits is being collated by LACORS.

26 HSE is aware that in at least one case, an LA has taken steps beyond those recommended by HPA in visiting all farms where they believe 'petting' takes place; apparently using public health rather than health and safety provisions. Such action will take LAs onto HSE-enforced farms and may, in turn, result in EHOs identifying issues that they report to HSE and which might draw on HSE operational resource.

Action by HSE

27 HSE has issued a health alert to the farming community on its website, directing them to the guidance in AIS23 (rev) and is proposing to carry out a programme of visits to those HSE-enforced agricultural undertakings that contain within them the equivalent of LA-enforced open farm attractions, where these can be identified.

28 The aim of this programme of visits is to provide reassurance to the HSE Board, to the HPA and to the public, that the controls in place at open farm attractions on HSE enforced premises are satisfactory and in line with the guidance set out in AIS 23(rev).

29 The objectives are to ensure that appropriate control measures are in place with respect to the:

• layout of the farm and the segregation of animal handling from other areas;
• identification, segregation and cleanliness of animal contact areas;
• designation, location and management of eating/picnic areas;
• provision and management of washing facilities;
• provision of appropriate information and signage for visitors;
• training and supervision of staff;
• livestock management arrangements; and
• arrangements for liaison with schools and other organisations which intend bringing parties of children to site for educational or leisure purposes.

30 HSE is currently in discussion with the NFAN and is seeking access to its membership database. If or when this information is made available, HSE Field Operations Division (FOD) HQ has agreed to carry out necessary evaluation of the intelligence to identify which, if any, premises fall within HSE's jurisdiction. This information will be provided to Divisions and, together with any local intelligence should, be used as the basis for divisional visit programmes.

31 HSE's approach is consistent with the HPA's request for site visits. It will ensure that premises equivalent to those subject to LA enforcement will be visited and that other HSE enforced premises, where the risk is likely to be lower (i.e. where the scope for exposure or the numbers exposed to contact is substantially lower), receive a precautionary reminder of the current guidance.

Health and Safety arrangements

32 Subject to any normal risk assessment of staff with underlying health problems, the following points should be noted and relevant precautions observed before visiting farms under this programme:

• the HPA advises that there is little risk to those in the age range 18-60 years.
• no additional or special precautions need be taken over and above those required for normal visits.
• no additional personal protective equipment is required. 
• staff should thoroughly wash and dry their hands as appropriate and necessary during and at the completion of site visits. Further advice on good handwashing practice is set out in AIS 23 and on the NHS poster on the Agriculture Community website.
• HSE's biosecurity advice should be followed at all visits. For further information Biosecurity: Guidance for FOD inspectors who visit farm premises

Enforcement Guidance

33 Guidance on enforcement that may be taken by HSE and by EHOs is set out at Annex 1 which is subject to the application of the HSE Board's Enforcement Policy Statement and HSE's Enforcement Management Model (EMM).

34 Guidance on applying the EMM principles to health risks is set out in LAC 61/1 'General guidance on application to health risks' and is intended to help inspectors reach a proportionate enforcement decision. It contains advice on use of the EMM, determining the Risk Gap, risk-based decisions and compliance issues and refers to the Initial Enforcement expectation (IEE).

35 The guidance in AIS23 comprises a package of measures some of which are risk based, some of which are not. Failure to comply with a number of the key risk control measures may result in a 'Serious Health Effect' including specifically:

• Where there are no washing facilities or the washing facilities provided fall short of the guidance set out AIS23 or the facilities are not properly maintained and members of the public (in particular children) have close contact with E.coli O157 secreting animals or are exposed to  potentially contaminated animal faeces;  
• Where the dutyholder has failed to take steps to discourage members of the public from eating in animal contact areas and there is evidence that they are doing so; and
• Where catering facilities and designated eating areas are not properly segregated from those areas where the public are encouraged to have close/ intimate contact with animals or are exposed to potentially contaminated animal faeces.

36 Some control measures such as:

• farm layout and routes
• the provision of information and signage; and
• the provision of training and supervision
• livestock management procedures; and
• the management of manure and compost are essentially risk control systems subject to risk gap analysis and for which the EMM Risk Gap Table for multiple casualties is appropriate.

37 Other measures such as the failure to carry out a risk assessment are not of themselves risk based, but rather are 'administrative failures' for which the level of non-compliance needs to be considered against the authority of the benchmark standard in determining the Initial Enforcement Expectation.

38 These considerations are reflected in Annex 1 which aims to provide guidance to inspectors in exercising their discretion when making enforcement decisions.

It does not seek to direct enforcement in any particular case but rather to:

• promote enforcement consistency;
• promote proportionality and targeting by confirming the risk based criteria against which decisions are made; and
• provide a framework for making decisions on enforcement more transparent and a guide for inspectors in making enforcement decisions.

Annex 1

The following scenarios are designed to aid application of the Enforcement Management Model (EMM) when considering the health hazards associated with E Coli O157. They are not all encompassing, rather guidance on application. In every case the established standard is AIS23. Duty holder and strategic factors must also be considered when applying the EMM.

Scenario	Application of EMM	Standard	Initial Enforcement Expectation/Action
Farm business
Establish the enforcing authority.	n/a	Defined	Advise duty holder and where necessary transfer premises to relevant enforcing authority.
Farm layout
Failure to segregate public access areas from main farm work.	Areas of the farm to which members of the public have access need to be defined and segregated in order to implement the control measures in AIS23. The Risk Gap will depend on the circumstances and may range from Nominal-Extreme.	Established	Advice/inspection form/letter/ Improvement Notice.
Failure to clearly define visitor routes around the attraction	AIS23 outlines why it is important to clearly define visitor routes around the attraction. The Risk Gap will depend on the circumstances and range from Nominal- Substantial.	Established	Advice/inspection form/letter/ Improvement Notice.
Failure to keep visitor routes reasonably clean and free from build-up of animal faeces	Sensible hygiene practices indicate that traffic routes should be clear to minimise risks of contamination of hands and footwear and reduce transfer of faecal matter to non-animal areas. The Risk Gap is likely to be Nominal.	Established	Advice
Animal contact
Failure to provide adequate washing facilities adjacent to areas of animal contact.	The primary control measure is good hygiene. Failure to provide or maintain adequate washing facilities gives rise to a Health Risk Gap of Serious Health Risk.	Established	Improvement Notice/ Prohibition Notice consider Prosecution.
Failure to segregate non-contact animals from the public.	Access to animals that have been designated as non-contact should be managed in accordance with AIS23. The Risk Gap will depend on the circumstances and range from Nominal-Extreme.	Established	Advice/inspection form/letter/ Improvement Notice.
Livestock management
Are there procedures for managing the health of the livestock?	New animals introduced to the farm, newly born and newly birthed animals and sick animals may present a broad range of zoonotic illnesses but are no more likely to have E.coli O157 than any other animal. AIS23 provides guidance on good livestock management practice and subject to the issue of cleanliness (see below) should be assessed as a Compliance and Administrative arrangement. The level of non-compliance may vary from Minor-Absent.	Established	Advice/inspection form/letter/ Improvement Notice Refer to local Defra Animal Health Offices for further advice/guidance and enforcement. For contact details see: Animal Health Offices
Are animals excessively dirty and do pens have a build-up of detritus?	Cross contamination risks increase where animals are dirty. The Health Risk Gap is that of a Serious Health Risk.	Established	Advice/inspection form/letter/ Improvement Notice or Prohibition Notice Refer to local Defra Animal Health Offices for further advice/guidance and enforcement. For contact details see: Animal Health Offices
Visitor facilities
No washing facilities provided?	Thorough hand washing is a primary control measure. The Health Risk Gap is that of a Serious Health Risk.	Established	Prohibition Notice and consider Prosecution.
Washing facilities not immediately adjacent to petting areas, eating areas, or areas where contact with animals or their faeces likely, includes exits.	Thorough hand washing is a primary control measure. The Health Risk Gap is that of a Serious Health Risk.	Established	Prohibition Notice and consider Prosecution.
Insufficient number of washing facilities provided?	Thorough hand washing is a primary control measure. The Health Risk Gap is that of a Serious Health Risk.	Established	Prohibition Notice and consider Prosecution.
No clean running water provided?	Thorough hand washing is a primary control measure. The Health Risk Gap is that of a Serious Health Risk.	Established	Prohibition Notice Consider Prosecution.
No soap provided?	Thorough hand washing is a primary control measure. The Health Risk Gap is that of a Serious Health Risk.	Established	Improvement Notice to achieve compliance If soap cannot be provided - Prohibition Notice and consider Prosecution.
No liquid soap provided?	Depending on type and method in which they are used bars of soap may not be effective and may present additional microbiological risks. Thorough hand washing is a primary control measure. The Health Risk Gap is that of a Significant Health Risk.	Established/Interpretive	Letter/inspection form/advice.
No personal means of drying hands thoroughly provided?	Drying by paper or roller towel that will not be contaminated forms part of the thorough hand washing as a primary control measure. The Health Risk Gap is that of a Serious Health Risk.	Established	Prohibition Notice and consider Prosecution.
Does the water used in hand washing accumulate or fail to drain away quickly?	Re-using used hand washing water must not be possible to ensure thorough hand washing is a primary control measure. The Health Risk Gap is that of a Serious Health Risk.	Established	Prohibition Notice and consider Prosecution.
Failure to provide segregated/clean picnic and eating areas with co-located washing facilities.	Permitting eating in areas with recent faecal contamination is unacceptable and in all cases thorough hand washing prior to eating is a primary control measure. The Health Risk Gap is that of a Serious Health Risk.	Established	Prohibition Notice and consider Prosecution.
Are visitors discouraged from eating and drinking in the animal contact areas?	Permitting eating in areas with recent faecal contamination is unacceptable and in all cases thorough hand washing is a primary control measure. The Health Risk Gap is that of a Serious Health Risk.	Established	Prohibition Notice and consider Prosecution.
Information and signs
Is information available for visitors on need for good hygiene?	Should be assessed as a Compliance and Administrative arrangement. The level of non-compliance may vary from Minor-Absent. .	Established	Advice/inspection form/letter/ Improvement Notice.
Are washing stations clearly signposted on the route around premises?	Should be assessed as a Compliance and Administrative arrangement. The level of non-compliance may vary from Minor-Absent.	Established	Advice/inspection form/letter/ Improvement Notice.
Are there signs to instruct on hand washing techniques?	Should be assessed as a Compliance and Administrative arrangement. The level of non-compliance may vary from Minor-Absent.	Established	Advice/inspection form/letter/ Improvement Notice.
Training and supervision
Employees/staff unsure what visitors can and cannot do?	The concern is that of staff neither appreciating the risk and thus not preventing members of the public from eating in animal handling areas. The Health Risk Gap is that of a Serious Health Risk.	Established	Advice/inspection form/letter/ Improvement Notice or Prohibition Notice.
Employees/staff unsure of how to explain the hygiene message to visitors?	Should be assessed as a Compliance and Administrative arrangement. The level of non-compliance may vary from Minor-Absent.	Established	Advice/inspection form/letter/ Improvement Notice.
Employees/staff unsure how to manage difficult and uncooperative visitors	Should be assessed as a Compliance and Administrative arrangement. The level of non-compliance may vary from Minor-Absent.	Established	Advice/inspection form/letter/ Improvement Notice.
Manure & compost heaps
Manure and compost heaps and their liquid run-off are not fenced to prevent avoidable spread of faecal matter?	Sensible hygiene practices indicate that traffic routes should be clear and fences or channels set to minimise risks of contamination of hands and footwear and reduce transfer of faecal matter to non-animal areas. The expected Risk Gap will be Nominal.	Established	Advice
Public are allowed to bag own compost?	If hand contamination risks exist to public then hand washing facility will be required. The Risk Gap will be Nominal-Extreme.	Established	Advice/inspection form/letter/ Improvement Notice.