A European Centre for Disease Prevention and Control project has recognized the important role of the community in public health emergency preparedness and response.
The report presents findings of a case study into outbreaks of Shiga toxin-producing E. coli (STEC) at childcare facilities in Ireland.
It found affected communities are key in public health emergencies with concerns and experiences of the public being an important part of the response.
It is part of a wider ECDC project to investigate synergies between communities affected by public health threats and institutions mandated to prepare for and respond to them. The aim is to collect evidence and share good practices on inter-sectoral collaboration and community preparedness for health emergencies, by seeing what has worked in different contexts.
Across the EU there were 6,647 cases of STEC reported in 2017, 37 percent of which were hospitalized due to hemolytic uremic syndrome (HUS), a type of kidney failure. Twenty of the patients died. In the same year, Ireland had the highest notification rate of confirmed STEC in the EU. The incidence has increased substantially in recent years, with 839 cases reported in 2016.
There was a large number of STEC infections in summer 2018, with 91 patients linked to a possible foodborne outbreak. The Health Protection Surveillance Centre (HPSC) is Ireland’s agency for the surveillance of communicable diseases and is part of the Health Service Executive (HSE).
The team visited Ireland for a week in late November 2018. Phone interviews were done the week after. Information was sought about community engagement during STEC outbreaks in general, but also in a specific outbreak at a childcare facility, or crèche, earlier in 2018. The source of infection was never identified with less than 10 children ill and no-one developed HUS.
Data sources included a document review; interviews with technical experts, and community members affected by STEC; focus group discussions with technical experts and community representatives and stakeholder mapping.
Stakeholder mapping indicated that institutional parties dominate response, with the community having a significantly smaller role to play than the authorities.
A set of suggested good practices for promoting community engagement during STEC outbreaks were identified and include knowledge of STEC prevention and control needing to be enhanced, for the wider community, health workers, and crèche owners and staff as well as challenges faced by parents of children with extended STEC infection.
Essential supplies, such as sample pots, were not always available when and where needed. Challenges were also noted with perceived delays in receiving laboratory results.
Closing a crèche, also referred to as childcare centers, because of an STEC outbreak is standard practice but can have financial consequences for the crèche and parents, who sometimes need to take time off work to care for their children until it is re-opened. Calls were made for some form of compensation from authorities. The crèche also lost income after enforced closure and costs incurred through deep cleaning the premises.
In the 2018 outbreak, the relatively low risk of a serious health outcome for their child was outweighed in the minds of parents by the moderate-to-high risk of a heavy hit to the family budget. A recent STEC outbreak in a nearby crèche provided an opportunity for peer-support during the main period of uncertainty at the start of the outbreak for the crèche owner.
Early Childhood Ireland is working with the Food Safety Authority of Ireland on a hand hygiene program to give small children an understanding of how and when to wash their hands.
The ECDC team heard from national and regional level respondents about instances where parents were publicly blamed and shamed for their children being infected with STEC, and where owners were hostile toward public health officials, actively obstructing infection control activities. There have also been cases of crèche owners being obstructive and modifying information produced by authorities for parents, making it incorrect or misleading.
Some parents were unable or unwilling to ensure their children – infected or not – were kept apart from others, so they could continue work. They provided informal cover for each other on a rotating basis, so one parent would care for a small group of children one day and another the next day. Staff members said children who had tested positive and negative continued to play and share food together at homes and at playgrounds during the closure of the daycare center.
Those in the community want their voices to be heard in the outbreak preparedness and response process, and want to be seen by authorities as genuine partners but a feeling of disconnection was reported by some in the community.
Irish authorities were very experienced in dealing with STEC but the sense from community respondents was that it is not generally a well-known or understood disease. One challenge is parental understanding of the need to maintain strict STEC control measures if children are excluded from a crèche because they are infected, even though they continue to look and feel well.
After the outbreak, the regional public health authorities held training for staff at the affected crèche and left them with materials about infection control.
During a review of several STEC outbreak reports, the nature and extent of community engagement activities conducted by health protection nurses in affected crèches was not given much focus. Neither is there any mention of post-outbreak training that may have been given to staff.
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