Legionella Outbreak
Good morning. The first item of business is a statement by Nicola Sturgeon on the legionella outbreak. The cabinet secretary will take questions at the end of her statement, so there should be no interventions or interruptions.
09:15
I am grateful for the opportunity to update Parliament on the current outbreak of legionnaire’s disease in south-west Edinburgh. Members will be aware from the media coverage that a number of cases of legionnaire’s disease have been identified among individuals living or working in the south-west Edinburgh area.
I can advise Parliament that, as of last night, the total number of confirmed cases stood at 24, with a further 27 in the suspected category. It remains the case at this stage that there is no identified link between those cases other than an association with the affected areas in the south-west of Edinburgh.
Of the total 51 cases, 14 are being treated in the intensive treatment unit, two have been discharged from hospital and the remainder are being treated in general wards or in the community. Sadly, one person who had legionnaire’s disease died, and I convey my sincere condolences to the family of that individual.
Members will rightly be concerned to know what actions are being taken to investigate the outbreak, to identify and treat those who might be infected, and to minimise the risk of further infection. I will provide an update on each of those points.
First, I will say a word about legionnaire’s disease. It is an uncommon but serious form of pneumonia that is caused by bacteria that are distributed widely in natural and artificial water supplies. In most cases, the disease is caused by the inhalation of water containing the bacteria, and common sources can be showers, air conditioning, cooling towers or humidifiers. In Scotland, we would normally expect to see approximately 30 to 40 legionella cases each year. Typically about half of those cases are contracted abroad, but we also see indigenous cases, and it is not unusual to see single sporadic cases of community-acquired legionella. Across Europe, outbreaks are not uncommon, with dozens of outbreaks and thousands of cases every year. However, outbreaks of the size that we are seeing here in Edinburgh are rare in Scotland; the last time that we had an outbreak of this scale was, I understand, in the 1980s in Glasgow.
I turn to the action that has been and continues to be taken. NHS Lothian was first alerted to a confirmed case of legionnaire’s disease on Thursday 31 May and a second case was confirmed on Saturday 2 June. As is standard practice, the health board made arrangements to convene a group to assess those two cases on Sunday. During Sunday, two further cases were confirmed and NHS Lothian moved swiftly to set up a full multi-agency incident management team. The IMT is led by NHS Lothian and involves the environmental health service of the City of Edinburgh Council, the Health and Safety Executive and Health Protection Scotland. Other agencies are engaged as necessary in the work of the group. For example, the Met Office has been contributing regarding weather patterns that might be relevant.
During the group’s first meeting on Sunday, possible sources of infection were considered. On the basis of all the available evidence, it was judged that an indoor source, such as a swimming pool or spa, was unlikely and that the source was likely to be an outdoor community one. Most outdoor outbreaks of legionella are associated with cooling towers. Those cooling towers that are operating in the south-west of Edinburgh—the area with which all patients have an association—were therefore visited that same evening, samples were taken, and during Sunday night and Monday the cooling towers were shock-dosed with chemicals to treat bacterial growth. During the past two days, a further three towers on two sites that lie further from the site of the outbreak have also been tested and treated.
At this point, the team that is investigating the incident briefed the media to ensure that the public were aware and alert. Clinical services and general practitioners across NHS Lothian were also notified to ensure that the national health service was ready and able quickly to diagnose and treat potential cases.
Over the period from late Monday to late Tuesday, we saw a sharp rise in the numbers of confirmed and possible cases, with a parallel increase in the number of cases being treated in the high-dependency and intensive treatment unit. Accordingly, I took the decision on Tuesday evening to activate the Scottish Government resilience room. I chaired two meetings of the Scottish Government resilience committee yesterday, with all the key agencies in attendance. The committee will meet again later today.
In addition to the actions that have already been taken, and in the light of the growing number of cases, the decision was taken yesterday to establish a dedicated NHS 24 public advice line. That went live at 3 pm yesterday and the advice line can be contacted on 0800 0858 531. A public information leaflet has also been produced by NHS Lothian. That was issued electronically to key community contacts yesterday afternoon and is being delivered to all households in the affected areas. I advise Parliament that further testing of the treated towers has also been carried out. I was advised last night that additional treatment may be appropriate in some of the towers to increase the levels of chlorine present in them. However, discussions are taking place this morning between the City of Edinburgh Council and the Health and Safety Executive to determine what further treatment—if any—is considered appropriate.
The numbers of confirmed and possible cases continued to rise over the course of yesterday. That was not unexpected and we expect to see further cases over the next week. Members will be aware that the incubation period for legionnaire’s disease can be up to two weeks, although it will normally be in the region of five or six days. It is, therefore, vital that we ensure that the public are aware of the symptoms and that the NHS continues to be primed quickly to identify, diagnose and treat cases. I am satisfied that the appropriate steps have been taken to alert the public and to prepare our medical services, and it is encouraging that a number of the existing cases are reported to be responding well to treatment.
Of central priority both since Sunday and going forward is the investigation to confirm the source of the outbreak. I am advised that identifying the source of any outbreak of legionella is an extremely complex process. It involves epidemiological analysis, microbiology testing and a health and safety inspection process. All those different, though related, parts of the process are well under way and are making progress. We hope that they will begin to provide more specific answers about the source of the infection over the next few days. Members should be aware that it is not always possible to determine conclusively the precise source of an outbreak and that conclusions often require to be reached on the balance of probabilities in the light of all the available evidence. However, I am confident that the team that is managing the incident are deploying their full resources in resolving it. They certainly have—and will continue to have—the full support of the Scottish Government.
This is an anxious and concerning time for anybody who lives in the affected area or who has recently had reason to visit or pass through it, but the key message in south-west Edinburgh is that the risk to public health is low. The disease cannot be spread from person to person, and I am advised that for people who are generally fit and healthy the risk is very low. Nevertheless, we are seeing a significant number of cases. Some individuals are at greater risk of developing the disease, and those individuals should be alert for symptoms. Men are at more risk than women, and most cases are in people aged over 50 or who have a suppressed immune system, or who smoke or have lung problems. On a precautionary basis, however, other people who do not have those risk factors should not immediately rule themselves out, and anybody who thinks that they may be unwell should contact their GP or NHS 24. They will be quickly assessed and, if necessary, quickly treated.
As I have said, every effort is being made to investigate the potential source of the outbreak. The cooling towers that may be the potential source of the outbreak have been chemically treated and, as I said, the relevant agencies continue to monitor the situation to ensure that all appropriate action is being taken to minimise the risk of further infection.
Until the outbreak is over, the incident management team will continue to meet and all the relevant experts will continue to assess the information and data that emerge. The Scottish Government resilience room will continue to provide support to the investigation, and I will continue to ensure that all that can be done is being done.
Lastly, I take this opportunity to express my gratitude and thanks to all those who have worked and continue to work tirelessly to manage and respond to this serious outbreak. I will, of course, keep the Parliament fully updated on all developments.
The cabinet secretary will now take questions on the issues raised in her statement. I intend to allow about 20 minutes for questions.
I thank the cabinet secretary for an advance copy of her statement. I very much welcome what she has said to us. I, too, offer my condolences to the family of Mr Air, who died as a result of contracting legionnaire’s disease. I also offer our gratitude to the many staff of NHS Lothian who are involved in caring for the people who have been admitted to hospital and seeking to identify and treat the source of the problem.
With more than 50 cases of legionnaire’s disease reported so far, this is the biggest outbreak in a generation and, unfortunately, there is the prospect of more to come before the outbreak peaks. It represents a serious threat to public health, which in the words of Professor Hugh Pennington,
“shouldn’t be happening, it is preventable.”
The three questions on everybody’s minds are how the outbreak happened, what our response was and what lessons we can learn for the future. The immediate priority, of course, is to focus on how we respond. Other questions will, no doubt, exercise us in the future.
The NHS Lothian website identifies the first case of legionnaire’s disease as being on Thursday 28 May, not on 31 May as the cabinet secretary suggested. I therefore ask her how many people were suspected of having legionnaire’s disease on 28 May, and how many people were suspected of having it on 31 May.
Given that having more than one case is sufficient to trigger the incident management team, why was it not set up until Sunday 3 June? Why was it a full nine days later before the Scottish Government resilience committee met? I am sure that the cabinet secretary will agree that anything that shortens the time before our response is to be welcomed, and I wonder whether she will reflect on whether the response could have been swifter.
Finally, there is real concern in the local community about the lack of information. I welcome the helpline and the leaflet drop in the area, but again, that was a full nine days after the first case of legionnaire’s disease was identified by NHS Lothian. Does the cabinet secretary agree that it would have been much better to provide public information earlier?
I thank Jackie Baillie for her questions. First, I will deal with her specific point about the date on which NHS Lothian became aware of the first confirmed case. Jackie Baillie said that the website refers to Thursday 28 May. Indeed it does, and that is an error, because as she will know if she checks her calendar, Thursday 28 May is not a date that existed this year.
The timeline is as follows. The person who was identified and became known to NHS Lothian and was confirmed as a case on Thursday 31 May first experienced symptoms on Monday 28 May, but that was not known to NHS Lothian until the case came forward and was confirmed on Thursday 31 May. At that point, it was the only case that was known to or suspected by NHS Lothian. The next confirmed case was on Saturday 2 June, and at that time there was also a suspected case. At that time, as was entirely appropriate, NHS Lothian took the decision to set up a problem assessment group, as is standard practice in these situations, to look at the cases and see whether there were any linkages or not. As I said in my statement, individual, sporadic cases are not unknown.
On the Sunday, with two further cases being confirmed, the problem assessment group swiftly and properly became the fully fledged multi-agency incident management team. That was entirely the right action, and NHS Lothian took it timeously. I thank it for behaving in that way and responding as timeously as it did.
On the activation of the Scottish Government resilience room, it is not normal practice to activate the room for public health emergencies that exist within a single health board area. The normal practice is for an incident management team to be set up, which is what happened. I took the decision on Tuesday evening to activate the resilience room, which was a rather unusual step, because of the significant spike in cases that we saw over the course of Tuesday, and the concern that that had an implication for NHS Lothian’s capacity, as a single health board, to deal with the outbreak—most particularly, in the case of critical care capacity—and due to NHS Lothian’s potential requirement for aid from surrounding health boards. The scale of the impact and its potential to go across health board borders convinced me on Tuesday night that the correct course of action was to activate the resilience room. All agencies have acted timeously and the response has been swift—again, I thank agencies for that.
As I said in my statement, by Sunday evening NHS Lothian was dealing with four confirmed cases, the incident management team had been set up, all of the appropriate steps were being taken, and action was being taken to alert clinicians and GPs across the area, to ensure that they were alert to symptoms. The health board and the management team also took the decision—rightly, in my view—to proactively press release, so that the public became aware through that route. As the number of cases has grown, the action taken to further advise the public has been stepped up accordingly—I mentioned the NHS advice line and the public information leaflet that NHS Lothian has produced and is distributing.
These are difficult situations for any agency to deal with, but the agencies involved here thus far have acted timeously and appropriately, and they continue to do so. They continue to be under the pressure of dealing with the outbreak and I hope that all members will get behind them as they do that.
I thank the cabinet secretary for the advance sight of her statement and I associate myself with the condolences expressed by her and Jackie Baillie.
I welcome the cabinet secretary’s decision to set up the resilience room. She and Sir Harry Burns have a good track record on crisis management and people in Edinburgh will be pleased that they have become involved in the situation and taken charge of it. I very much welcomed the press conference that the cabinet secretary held yesterday and the authority that was conveyed to the public through it.
Information is the key. Therefore, in the absence of our knowing all the facts, will the cabinet secretary ensure that no false assurances are given and that the greatest integrity is placed on information? Given the vulnerability of elderly people, in particular, will the cabinet secretary ensure that anecdotal advice—which is often particularly unhelpful—is dismissed with a degree of authority, so that people know what they have to do and which things should concern them, and are not unnecessarily alarmed by things that they should not be concerned about, which, very often, only add to the worry?
I wish everybody involved in the incident, under the cabinet secretary’s direction, every success in dealing with it as expeditiously as possible.
I thank Jackson Carlaw for the content and tone of his questions. He is absolutely correct—information is key. On an on-going basis, we must assess and reassess the content, quality and all-pervasiveness of the information that we distribute. That will happen.
He is right about the importance of inadvertently—nobody would do it intentionally—giving false assurances. Colleagues and I have been doing what we can to reassure the public, so that there is not unnecessary anxiety, but while we do not know precisely the source, no absolute guarantees can be given. I indicated in my statement that the towers have been chemically treated, but there is an on-going process of testing, and further treatment to some towers may be required. It is important to reassure where we can, but also to be honest and open with the public about the risks and the fact that this is an on-going outbreak.
It is important not to allow anecdotal evidence to acquire an importance that it does not merit. However, some pieces of anecdotal evidence can be useful. I have been tweeted this morning by a few people with suggestions—specialists with information that they think might be helpful. It is my job to ensure that the experts look at that. If it is not appropriate, they will say so, but some of it may be appropriate. If anybody out there has expertise that they feel they can offer us, we will certainly listen. The experts engaged are working very hard and all of what we are saying and doing is driven by that expert advice.
I place on record my condolences for the individual who has lost his life and my very sincere appreciation of NHS Lothian staff, who have been working very hard and have responded very quickly to the incident.
After the incident has been resolved, what assessment of how the NHS, the Scottish Government and other key partners have responded will happen to inform future efforts?
As Marco Biagi will appreciate, the effort, focus and attention are currently on managing the outbreak, minimising the risk of further infection and, if we are able to, identifying the source. It is right that everybody’s attention, including my own, is focused on that. However, he is also right to say—Jackie Baillie made the same comment—that, as with all public health outbreaks, we need to ensure that after the event we look back and learn lessons about what went right and what it might be possible to do better.
I well remember, because I was centrally involved in it, such an exercise taking place after the pandemic flu outbreak. We learned some very useful lessons from an outbreak that was, in my view, nevertheless managed extremely well. I give Marco Biagi and other members the assurance that, when the outbreak is over, that exercise will take place. I will be happy to share any lessons and learning from the experience with the Parliament.
I welcome the cabinet secretary’s commitment that wider lessons will be learned from this experience.
I will ask about the long-term impact on NHS Lothian. I, too, offer our gratitude to the NHS staff in Lothian for pulling out all the stops to treat the patients who are currently experiencing legionnaire’s disease. Will the Scottish Government assist NHS Lothian, which has been under pressure on waiting times, to ensure that it can get up and running and respond after this event? Will there be support from the Scottish Government to enable it to do that?
We are working extremely closely with NHS Lothian and we will give it whatever support it requires to deal with the outbreak. NHS Lothian’s response so far has been absolutely superb. I mention in particular the leadership given by Dr Duncan McCormick, a consultant in public health, who has also, from the outset, been chairing the incident management team. NHS Lothian has already activated its emergency plan, which was put in place to deal with the pandemic flu outbreak, and has plans in place so that it can, if necessary, increase the number of critical care beds and bring in additional staff to support that provision.
NHS Lothian has also ensured that, should it be necessary, mutual aid from surrounding health boards can be made available to assist with critical care. Thus far, that has not been necessary, but it is available should it prove to be so. Three boards—I think that they are NHS Lanarkshire, NHS Forth Valley and NHS Fife—are already offering support to NHS Lothian with additional public health resource to help with the gathering of the case history of the patients affected and the analysis of that information. Both the Scottish Government and the wider NHS stand ready to give NHS Lothian whatever support and help it needs.
Given that the members of the public most at risk from legionnaire’s disease are people with an underlying health condition, will the cabinet secretary detail how she will ensure that information regarding the outbreak is communicated on an on-going basis to at-risk groups in the affected area, such as those with respiratory problems or older people?
I touched on some of that in my statement. Other members have mentioned the importance of information.
As I said, at the outset of the outbreak, NHS Lothian very quickly alerted clinicians, particularly GPs in the area, so that they were alert to the potential significance of certain symptoms. Members will have become familiar, as have the public over the past few days, with some of the symptoms that are associated with legionella. Members will also understand that many of the symptoms sound similar to those that someone would have with the flu or a cold, so it was really important that doctors were alert to the fact that at the moment those symptoms might signify something else.
As I said in my statement, as the numbers grew, we decided to set up a dedicated helpline, which is available to any member of the public who has any concerns or questions. NHS Lothian has prepared a general information leaflet about legionella, which also advertises the helpline number. That is being distributed and it will be distributed door to door in the affected areas in the coming period.
As I said in response to Jackson Carlaw, we will continue to look at the information that we need to communicate and how we need to communicate it, so that all the people who might be affected have the information and can respond accordingly. I will keep Parliament updated on that aspect, as on all other aspects.
Such outbreaks are not easy to manage and we should all congratulate NHS Lothian on how it has handled the outbreak so far. I will ask the cabinet secretary a specific question. How has NHS 24 been involved? NHS 24 is the one group that was not mentioned in her statement. She said that
“Clinical services and general practitioners across NHS Lothian were ... notified”,
which was entirely appropriate. However, as events happened out of hours at the weekend—the cases were confirmed on Sunday and the procedure swung into action then—was NHS 24 involved? Did it respond appropriately and give the right advice, of the sort that the cabinet secretary is now putting out?
I did not mention NHS 24 in my statement, but I understand that it was alerted, as were clinicians and as is appropriate. As would be expected, given that the media coverage kicked in on Sunday into Monday, NHS 24 did not receive a higher than expected number of calls over the weekend—in fact, demand was lower than forecast. The number of calls was higher into Monday and through to Tuesday. Because of the growing number of calls, NHS 24 decided—in consultation with the incident management team—that the appropriate course of action was to set up a dedicated helpline, to ensure quick access to information for the people who are concerned and to protect the core NHS 24 service. NHS 24 has been involved every step of the way and I will ensure that that continues.
I will follow up that point. Many GP surgeries were closed over the long weekend, so people would have relied on the out-of-hours service. Is the cabinet secretary confident that NHS 24 was properly alert to the issue from the outset and that people’s treatment was not delayed because they were advised that they had flu and that they should see their GP when their surgery opened on Wednesday?
I am confident, but if members want further information about the role that NHS 24 has played, I am more than happy to provide that. GP practices in Edinburgh—unlike those in my city of Glasgow—did not routinely close on Monday, which was not an Edinburgh holiday, although they were closed on Tuesday, so not all GP practices had a four-day closure. Nevertheless, the public holiday on Tuesday underlined the importance of NHS 24 providing the out-of-hours service. I am satisfied that NHS 24 has been appropriately involved, and it will continue to be so.
The cabinet secretary said that cooling towers on several sites were shock-dosed on Sunday and that some are being treated again today. If the tests on the cooling towers prove negative or inconclusive, while the number of cases continues to rise, what further steps will she take? What is plan B?
With apologies to the Presiding Officer for taking a bit of time over the following answer, I will go into more detail on the processes that relate to the cooling towers. The sample testing to which I referred, which may or may not—it depends on discussions that will take place this morning—result in further treatment of some towers, involves samples that were taken after the towers were treated. That testing will check that the chlorine levels and chemical levels in the towers are where we want them to be to minimise the risk of further infection.
Separate from that is the process of testing the samples that were taken before the towers were treated, to try to ascertain whether legionella could be detected in any of the towers. That process is under way. I am advised that legionella is a difficult bacterium to culture, so that process will take time. I understand that, even if those tests do not pinpoint the source, that will not necessarily mean that the bacteria were not there, because there are sometimes difficulties in finding a precise source, although everything possible is being done to find that.
In response to Kezia Dugdale’s broader question, on the balance of probabilities, all the available evidence points to the cooling towers, or one of them, being the source of the infection. None of the evidence points to another obvious source, and it is therefore right that we focus our attention on those cooling towers.
Nothing else is being ruled out: if the further epidemiological analysis reveals another link or another potential source, that will obviously be followed up very quickly. However, that is not the case at present, and we must act on the basis of what the evidence best tells us, which is what we are doing at the moment.
We have heard that the strain that the outbreak places on NHS Lothian may require other health boards to offer appropriate support, for example the use of ITU and high-dependency unit beds. Can the cabinet secretary give further details of that?
Are there likely to be any knock-on effects, such as the postponing of patient operations outwith NHS Lothian to free up HDU and ITU beds, which would be understandable in the circumstances? More importantly, we will need to inform any affected patients of why that has happened. Communication will be important.
There is not, at this stage, any need for that type of action in other health board areas. However, members will be familiar with the emergency plans that were put in place to deal with the flu pandemic and will be aware that those plans envisage—should the circumstances demand it—the cancellation, suspension or postponement of elective treatment in order to free up capacity for critical care.
That would happen first in Lothian and would happen only in extreme circumstances in other health board areas. There is very close dialogue on-going around all those issues just now, so that we are prepared. Right now, NHS Lothian is managing the impact of the outbreak within its own critical care resources.
I do not want members to read too much into this, but, at present, although we are seeing an increase in the number of cases overall, the number in critical care is more steady—there has not been a corresponding increase in those numbers. That may have changed by this afternoon, so we cannot read too much into it, but at present NHS Lothian is coping with that critical care demand.
As I said earlier, other health boards are offering other forms of assistance to NHS Lothian around its public health resource, so that the significant demand on that resource can be met quickly, as is appropriate given all the epidemiological analysis that requires to be done.
What provision has been made in each of the NHS Lothian hospitals to take in emergency cases? How will that impact on patients who were due to enter hospital this week?
My answer to Bob Doris probably covers Neil Findlay’s point. Not all the critical care cases are in the Royal Infirmary of Edinburgh—there are some cases in other Lothian hospitals. The outbreak is being dealt with within NHS Lothian resources, but the emergency plan has been activated, and NHS Lothian will require to ensure that it manages the demand for critical care as the outbreak continues.
Neil Findlay raises a reasonable point. As the situation develops, and if an impact on other services starts to be seen, NHS Lothian, with the support of the Government, will have to ensure that patients in the wider sense are properly informed and advised of why that might be the case. I assure members that we will ensure that that is kept very much at the forefront of our minds.