Communication and cultural 'shortcomings' are highlighted in a review of the Auckland typhoid outbreak that hit a Pacific church congregation earlier this year.
The Ministry of Health requested the review of how the Auckland Regional Public Health Service (ARPHS) handled the outbreak that lead to 24 connected typhoid cases, one of which, a woman with multiple comorbidities, was only diagnosed as having typhoid around the time of her death (see timeline below).
The Health Minister found out about the outbreak through news reports ten days after the first case was notified and many of the church congregation were unaware that the deceased woman had had typhoid until a media release after her funeral service.
The review, prepared by the office of the chair of the three metropolitan Auckland district health boards, says 'shortcomings' in how the outbreak was managed served to create "undue concern among some members of the public and an impression of an organisation under pressure and struggling to cope".
It says the outbreak was contained quickly but in serious events like this it was necessary for health authorities "not only to be managing risks to public health expeditiously and effectively but being seen to do so".
In the past five years the majority (72%) of the country's 38-50 cases of typhoid a year have been in Auckland. Nearly all cases were of Asian and Pacific ethnicity with last year all locally acquired cases being from Samoan and Tongan communities.
The review shows that five days after the first outbreak case was notified it was apparent that the outbreak was potentially affecting a Samoan church group rather than a single family. But ARPHS's management of the outbreak was not escalated until day 13 of the outbreak, several days after a media release about the outbreak prompted both public concern and the Ministry and Minister to be in touch with the service.
The first media statement was released at 5pm on a Friday evening (March 31) with "no apparent plan" for how media enquiries would be handled over the weekend pointed to "inexperience" of those concerned who also did not send a copy of the statement to the Ministry of Health.
The review also highlights concerns about the communication and engagement with the Pacific community with various unsuccessful attempts after the patient's death to co-ordinate with the church's minister so congregation members could be contacted, tested and if necessary treated. The minister, busy with funeral arrangements for the deceased, indicated he would only be happy to assist the service once the funeral and burial service were completed, which was three days after the outbreak had been announced to the public.
In hindsight, says the review, ARPHS should have worked directly with senior members of the church group rather than the busy minister. It says once contact was made it proved difficult to arrange the faecal samples required for testing and communication in Samoan "further complicated matters". Also with the Pacific community being 'extremely broad' it was 'unrealistic' for ARPHS to rely on a single advisor to work across all groups and it should have reached to DHB-based Pacific health teams or senior community leaders to assist.
"While every effort needs to be made to work with the community and gain its trust and support, there will be occasions where progress cannot be made or cannot be made quickly enough to protect the wider public," says the review. "In such circumstances, ARPHS should be prepared to use its regulatory powers."
In a statement the ARPHS said it welcomed the review and said the recommendations (see below) had either already been implemented or were in process of being implemented.
It said steps were being taken before the outbreak to change and improve ARPHS's culture and strengthen it management capability and the review recommended these efforts 'be further strengthened and accelerated with external support".
The review says in response to the outbreak the ARPHS was taking steps to:
- Review the currency of its Enteric Disease and Acute Gastrointestinal Outbreak Investigation Protocols in the light of the experience of the recent typhoid outbreak
- Ensure that a process is in place to regularly review its other protocols so that they always kept up to date
- Ensure that, where relevant, cultural support is provided to the family of a person who unexpectedly dies during the course of an outbreak
- Consider the need for a media statement to be made when a Health Professional Advisory (HPA) is issued
- Provide increased support for its community advisors, including working proactively with community groups, for example by attending meetings of the Healthy Village Action Zone (HVAZ) funded by the ADHB/WDHB Pacific Health team
- Develop protocols for escalating work issues within ARPHS
- A case of typhoid notified to ARPHS
- A fourth case notified. Connection to a church group identified
- Fifth case notified
- Enteric disease meeting confirms five cases cluster linked to church group
- Later in day ARPHS notified by Auckland City Hospital that shortly before her death a patient had been diagnosed as having typhoid along with existing multiple co-morbidities.
- ARPHS attempts to contact family of deceased unsuccessfully
- ARPHS general manager emails CEOs of the region's three DHBs with an update on disease outbreaks including typhoid and the death
- ARPHS staff visit family of deceased, arrange for three children at home to be admitted to Starship
- Visit church Minister's house to request a list of congregation members (for contact tracing)
- ARPHS communications manager informed of outbreak and prepares a HPA (Health Professional Advisory) released at 2pm that day
- A media release follows at 5pm stating 10 people had been hospitalised with typhoid.
- Ministry of Health and Minister of Health not informed and find out through media reports
- ARPHS visits church minister, he's not at home but phones back at 8pm that evening
- ARPHS Pacific Advisor makes early visit to minister's home.
- Minister indicates funeral will be following day (Sun) and burial on Monday and that he would be happy to encourage congregation to support outbreak investigation once the services had concluded
- Media release says cases appear to be linked and contact tracing was continuing to limit spread within Pacific community
- Decision made to initiate ARPHS incident management structure on day 13 of outbreak.
- Additional support provided included senior communications staff, public health consultants and a registrar, health protection officers and cultural support from ADHB/WDHB Pacific Health team
- Media release to announce death previous week of patient who had contracted typhoid in outbreak.
- Also released that she was member of Mt Roskill Samoan Assembly of God church which was at centre of outbreak
- Announced that there were 16 confirmed cases and 2 probable cases with 12 people in hospital.
- 18 confirmed cases, six in hospital.
- Now day 16 of outbreak and ARPHS indicate outbreak had plateaued.
- Four asymptomatic cases confirmed bringing number of confirmed cases to 22.
- Two cases identified in Palmerston North linked to Auckland outbreak bringing confirmed cases due to outbreak to 24.
- Typhoid is spread by eating food or drinking water that is contaminated with faeces or urine from a person who has the illness, or who may be a carrier of the bacteria.
- Casual social contact, such as visiting a person in hospital and hugging and kissing them, is not a significant risk to people.
- The usual incubation period for typhoid is 8-14 days.