DHB chief Kevin Snee says the joke in public health circles is that these things always happen on a Friday afternoon when the boss is away. That was the case here, with Caroline McElnay, Director of Population Health, on sabbatical and the first indications that something was seriously wrong coming into the DHB at 4pm on Friday 12 August.
Then 250 kids sent home from Havelock schools on Friday afternoon grew to 1,100 seen by GPs and then over 5,000 sick across the suburb by the end of that first week. It escalated faster than people could comprehend it let alone find answers to it.
The health response was three-tiered with vital glue – infrastructure, administration, logistics and support – coming from our two health organisations, the DHB and Health HB, our Primary Health Organisation. The three tiers were pharmacists at the coal face, GPs with district nurses supporting them, then the hospital. Of the 5,000 sick only
45 ended up there. Many in the sector are praising GPs for working so hard to keep patients away from secondary care. “I think the hospital would have struggled if it wasn’t 45 but 95 people being admitted,” says Snee.
What, when, how
There are roles for both the DHB and the water supplier, in this case Hastings District Council, in ensuring our water is safe to drink.
Drinking water standards from the Ministry of Health require the water supplier to submit safety plans every five years. The DHB reviews and signs off on those plans. Then annually the Council updates the plan, although the update doesn’t have to be approved by the DHB.
The last HDC plan was signed off in 2013. Caroline McElnay explains the process: “Testing is done by the water supplier. They get a result back, either an absence or presence test – and it’s E-coli we’re looking at – then inform DHB’s drinking water assessors. Council (as the water supplier) is responsible for testing and they are required to inform DHB of transgressions.”
Assessors are also trained as health protection officers and work within the DHB’s public health unit. Together the supplier and the assessor discuss the results, pulling together any other information that’s available, such as obvious explanations like works happening on the line or in the vicinity.
Once a problem is identified, the DHB recommend to the Council that a boil water notice be issued. It’s up to Council to action that. It is Council too who are charged with chlorinating the water source.
In a situation like this – although in many ways what happened here is unprecedented – the medical officer of health has the authority to require water treatment when there is a serious risk to public health.
“If you looked at every DHB in the country, I’d be surprised if they had this on the risk register, although it may have appeared in the last month!” Kevin Snee
“Initially it’s a recommendation – we get better results by working collaboratively,” says McElnay. “But there is the power to require it.”
Once those initial tests showed the presence of E.coli, Dr Nicholas Jones, DHB’s medical officer of health and chair of the Havelock North Primary School Board of Trustees, rang the school. His call confirmed something was seriously wrong in the suburb: an extraordinarily high number of absences due to gastroenteritis. The DHB’s health protection officers and district nurses then proactively contacted a number of schools in the area and found similar stories in many of them.
On Saturday morning, once the size of the problem began to become apparent, a Co-ordinated Incident Management System (CIMS) office was established at the DHB with senior leadership representatives from all the various parties. Incident plans set out roles and processes, but a situation of this type had not been planned for. A major water safety compromise was not listed on the DHB risk management plan.
Kevin Snee: “If you looked at every DHB in the country, I’d be surprised if they had this on the risk register, although it may have appeared in the last month!”
There is a major incident plan in place, however, and this dictates who does what and when. This kicked in to place on Saturday with the DHB taking the lead on communications, but the day before Council and DHB were working collaboratively and in some ways ‘making it up as they went along’.
“On Friday night there was a degree of uncertainty around how do we inform the public without creating unnecessary alarm,” explains Snee.
There has been some criticism that neither the Council nor the DHB raised public awareness soon enough or thoroughly enough, but they were only just coming to grips with the situation.
“There was still a fair degree of uncertainty on Friday afternoon about what exactly was going on. With the benefit of hindsight it’s probably obvious but at the time you’re dealing with a few phone calls and we’re not seeing much happening at the hospital yet,” says Snee. “We were sufficiently anxious to want to chlorinate the water and issue a boil water notice but actually we didn’t know if that might be a bit of an overreaction.”
McElnay agrees, “All we had was the lab test showing one presence test. We didn’t get the more detailed analysis until the next day.”
As the public health unit phoned schools to try and get a clear picture of what was going on, there were suspicions the issue was coming from water; it was probable but not definite. During the winter months mass illness in schools is not uncommon, and bugs like norovirus can sweep through a school with this much ferocity.
“Then we had GPs being knocked sideways on Saturday morning and at that point there was no doubt,” says Kevin Snee. The rates of people presenting to pharmacies and GPs with gastro symptoms climbed through the weekend, hitting a peak on Monday and Tuesday.
“GPs hadn’t been reporting people coming to see them the day before,” explains Snee. “There were people getting sick before, but they were managing it themselves (at home). Now we’re hearing that people were coming into the pharmacists for something to help with diarrhoea but they weren’t going to health care until later.”
It was as public awareness of the problems with Havelock water got out there that people began putting two and two together. “When we started putting out the media, that coincided with the peak of the cases, then people presenting to GPs started thinking, ‘That’s what the diarrhoea must have been’,” says Snee.
The 5,000 figure now available comes from four household surveys that were carried out from the early days of the incident until the beginning of October.
“The (initial) data we get comes from GPs and lab tests and it doesn’t pick up on those who don’t go to their GP,” explains McElnay. “So it was appreciated early on that this was the tip of the iceberg. The survey was done to ring 200 households in Havelock North, then you extrapolate out that information.” The figures are correct by 1% or 2%.
Holes
Many critics have said the main issue with how the water crisis played out was communications. Snee defends the use of Facebook as the main channel. “The use of social media was heavily criticised but it did get the message out there. While there were probably other things we could have done there was quite good coverage. It got out there quite quickly.”
Snee says one of the key lessons that has come out of the experience is how things are communicated, particularly as the incident didn’t just affect Havelock North, but surrounding areas as well. “The use of radio stations, and should the council have leafleted all the houses,” are some of the questions that will be asked in the aftermath, says Snee.
“We’re going through the process of looking at the lessons now, we’ve got the work that’s been done with scientists coming in and looking at a whole range of things, we’re also doing an internal look at how we responded,” Snee explains. The cost of the incident and the clean up is currently at $380,000 but Snee says he expects that to climb to half a million, including the costs of a specialist medical epidemiologist, and staff working on reviewing the DHB response and procedures.
Looking ahead
What happens next is still being discussed. The water continues to be chlorinated, even though the chlorination is happening in a water source that was not affected. It’s up to Hastings District Council to provide a water management plan that outlines how they will provide a safe, secure water source in the future. From there DHB water assessors would make a call on ongoing chlorination. Whether the public likes it or not, chlorine may be here to stay.
“You cannot be complacent, from a health point of view, when you have an untreated water supply. So you have to be very clear that there is protection of the source, that the source is not going to be contaminated and that the reticulation is also going to be protected so you don’t get bacteria into the water, because there is no safety net,” McElnay explains. Key to future decisions is determining whether this event was due to something systemic around the source or a one-off.
“They were amazing, they just got on with it. They were on weekend staff and they had one GP on; the volumes they saw were just incredible,” says Stockley.
“We would have to be assured that Council can supply safe water to the community,” says McElnay. “Council could put in a testing regime that is very frequent – everything’s got a cost and it’ll be a balance. We’re not going in as DHB and saying, ‘You must chlorinate, we’re not going to accept anything less than chlorination’. It’s about weighing up what that plan looks like.”
The ball is in HDC’s court and to keep permanent chlorination out of the water will take a commitment from the Council and a proactive call for that to happen from the community.
Kevin Snee: “It’s a balance of risk versus cost all the time and the less intrinsic safety there is in the water the more you have to put other measures in place and they all have a cost.”
Chlorination protects in the bore and the reticulation. UV protects only at the source. But UV does kill off things like cryptosporidium, that chlorination doesn’t.
“You have to have a conversation with the public about ‘Here are the pros and cons’,” says Snee. “Your water will taste a bit chlorine-y but it’ll be safe or you will have a risk that we will mitigate by charging you more on your rates.”
With only 15% of the country drinking non-chlorinated water, some feel the Hawke’s Bay source is worth protecting as an asset. Others feel it’s a luxury that has had its time.
“People can’t see what the issue is when they’ve drunk chlorinated water all their lives,” says McElnay.
Aftermath
The central government inquiry into the August 2016 gastro outbreak in Havelock will throw up a number of areas that were lacking, systems that need tightening up, processes that need changing, but at the centre is the source of water for Hastings District and its suburbs. Further testing of the aquifer and building up a collective understanding of how it works, how sustainable it is and how finite will be central to future decisions on how to manage it.
“There is a whole safety process around what’s known about the aquifer because that’s what we rely on: the age of the water, the past testing results, and the operation from the Council’s point of view, that all goes into the mix to give a grading on the water supply and for us to say, ‘Yes we are happy for that water to be delivered to the public’”, says McElnay.
“We have a vested interest in it because the aquifers and the bores are all about the security of the water,” she explains. “It is something we are interested in and so whatever information comes up in the inquiry will inform what we do going forward.”
First line of defence
Health HB, the region’s primary health care organisation, supported GPs, health centres and pharmacists through the gastro outbreak, and fed back on-the-ground intelligence to officials at the DHB.
Liz Stockley was chief executive at the time and says if there are any heroes of the incident it is the Havelock GPs, namely those at Te Mata Peak Practice as well as Dr Maurice Jolly and Dr Colin Wakefield.
“They were amazing, they just got on with it. They were on weekend staff and they had one GP on; the volumes they saw were just incredible,” says Stockley.
Working in their favour was the fact that Health HB had just taken a number of GPs on a field trip to Midlands Health Network, the PHO in Hamilton. There they’d heard about new ways of working for GPs, including the use of call-backs. A patient rings to make an appointment, they’re told to stay put then a GP then rings them back and does a consult over the phone. As soon as the numbers began to climb the GPs actioned this procedure and in that way ‘saw’ many more patients than they would otherwise have been able to.
“They changed their whole way of working. They dealt with hundreds and hundreds of people that first weekend.” Stockley says there were 1,100 additional GP consults over that time. “It was timely that they’d just recently seen a different way of working. They just got on and did it. They opened outside of normal hours, gave stuff away, didn’t ask how it was all going to be funded. They all worked well beyond their normal hours for at least 10 days. They weren’t questioning, they weren’t mudslinging, they were just getting on with it.”
Some of the GPs involved were sick at home and still doing call-backs.
Alongside call-backs, the PHO put staff into general practices in the area and they were proactively ringing patients over 80 years old and those with complex pre- existing conditions to give advice. Other PHO staff were helping with the bevy of administration tasks that needed to happen.
Working in this way Stockley believes primary health avoided large numbers going to hospital.
“The numbers kept away from hospital tells you how much was happening in primary care. They are the reason the hospital was able to continue operations normally,” she says.
Wayne Woolrich, business services manager at Health HB, confirms this: “At times the hospital was actually pretty quiet, because people were staying away; GPs were flat out.”
Further up the line pharmacists in the Village provided the advice and supplies many needed to keep them away from GP clinics.
“When there’s a big clinical thing going on you just jump in to get things done,” says Stockley. “I was immensely proud of my own team, how they came up with individual ideas of how to help clinicians.”
“We all need to look at how we communicate an urgent event in a timely manner, especially on a weekend.” Wayne Woolrich
As well as being ‘on the ground’ the PHO was part of the CIMS office (Co-ordinated Incident Management System, run by DHB) and checked in there twice a day. Wayne Woolrich does believe there were issues with communication across the whole operation, although he says overall, “I think we did a bloody good job.”
“We all need to look at how we communicate an urgent event in a timely manner, especially on a weekend,” Woolrich says. “(For example) some emails weren’t seen until Monday.”
Woolrich also feels there were gaps in the information passed on to those at the front line. “We could have shared figures around the volume of people, so they had a higher understanding of tracking.”
On the plus side, Woolrich believes the event provided an opportunity for the DHB and the PHO to work together and create a common understanding and some trust.
“The primary and secondary health sectors are not well linked and this began to build a better connection between the two,” he says.
As with all the organisations involved, the PHO is now going through a review process. Part of that is supporting and finding resource for a GP in the centre of the response, Dr Peter Culham, to prepare and share a paper on the incident and the lessons that came from it.