Journal of Public Health Advance Access originally published online on October 25, 2006
Journal of Public Health 2006 28(4):347-350; doi:10.1093/pubmed/fdl065
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Developing audit standards required for outbreaks of communicable diseases—lessons from a mumps outbreak
R. R. Kipping, Public Health Specialist Trainee1
S. Hamilton, Public Health Specialist Trainee1
M. Roderick, Specialist Registrar, Public Health2
K. Alexander, Specialist Registrar, Public Health3
1 South Gloucestershire PCT, No. 1 Monarch Court, Emerald Park, Emersons Green, South Gloucestershire BS16 7FH, UK
2 Avon Health Protection Team, King Square House, King Square, Bristol BS2 8EE, UK
3 North Somerset PCT, Waverly House, Old Church Street, Clevedon, North Somerset BS21 6NN, UK
Address correspondence to R. R. Kipping, E-mail: rrkipping{at}yahoo.co.uk
Background A mumps outbreak occurred in 2004–05 in England and Wales. The outbreak in the Avon area of England led to mass vaccination of 16- to 24-year-olds with the measles, mumps and rubella vaccine (MMR). The response to the outbreak was audited. Literature and web searches for audit standards were undertaken, and experts in the field were contacted. No comprehensive audit standards for outbreaks of communicable diseases were found. This article describes an approach to developing audit standards for outbreaks of communicable diseases.
Methods Audit standards were developed based on the memorandum of understanding between the National Health Service (NHS) and Health Protection Agency.The audit was undertaken involving 25 staff.
Results The audit standards developed identified many areas for improvement including training, strategic co-ordination, inter-organizational communication, consistency and timeliness of communication. Conducting the audit was problematic because there were not pre-defined audit standards.
Conclusions Audit standards should be developed, which include issues relating to the structure, process and outcome of responses to outbreaks. The development of audit standards for the management of outbreaks is crucial to evaluate outbreak control and make necessary improvements.
Keywords: audit, MMR, mumps, outbreak
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Introduction |
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The number of confirmed mumps cases rose across England and Wales in 2004 and 2005, with many reported outbreaks in universities.1 In 2002, there were 505 confirmed cases of mumps, and in 2005, there were 43 322 cases.2 The outbreaks predominantly affected older teenagers and young adults, who were too old to be offered measles, mumps and rubella (MMR) vaccination when it was introduced in 1988. The high uptake of the MMR vaccine in younger children reduced the circulation of mumps, which in turn prevented older unvaccinated children from being exposed to mumps and acquiring natural immunity.
In 2004, an outbreak of mumps in the Avon area led to mass vaccination of young people (aged 16–24 years) with the MMR vaccine. To identify areas for improving the response to outbreaks of communicable disease, the local National Health Service (NHS) and Health Protection Agency audited the response to the mumps outbreak.3 Audit is an improvement tool for reviewing services delivered against explicit standards, identifying where changes are necessary and implementing those changes.4
A literature and web search for audit standards for mass vaccination programmes in response to an outbreak was undertaken, including the assessment of any standards developed by the Health Protection Agency, Department of Health and Faculty of Public Health. Experts in the field were also contacted. No comprehensive audit standards for outbreaks of communicable diseases were found. The few examples of outbreak audits described in the literature focus on individual aspects of the outbreak, for example, notifications, helplines or the interventions (Table 1). Five Scottish health boards developed structure, process and outcome indicators including multi-sectoral collaboration in environmental services.10 However, outbreak control was not included. This article describes an approach to developing audit standards for outbreaks of communicable diseases.
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Methods |
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An audit of an outbreak that involves mass vaccination presents broader issues than auditing a routine immunization programme.11 For example, mass vaccination involves co-operation across organizations, rapid communication internally and with the public and administering large quantities of vaccine. The lack of objective criteria for measuring many of these tasks presents a considerable challenge when designing and measuring audit standards.
Owing to the lack of existing standards, relevant statements contained in the Memorandum of Understanding between the Health Protection Agency and Bristol South & West Primary Care Trust and the Faculty of Public Health’s media audit were turned into audit standards. The Donabedian approach of structure, process and outcome was used as the framework for constructing the audit12 (Table 2).
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An audit questionnaire was sent to 25 key staff involved in the strategic co-ordination of the outbreak, asking them to quantify the level of agreement with each audit statement. Staff included Directors of Public Health; Consultant in Communicable Disease Control (CCDC); leads for nursing, primary care and pharmacy; and communications managers.
It was apparent that valuable information could also be gained from staff involved at an operational level, including general practitioners (GPs), head teachers, prison health staff and nursing staff who administered the vaccine. As many of the audit standards were irrelevant to this group, a questionnaire was developed with five broad questions to find out what went well, problems encountered and suggestions for improvements. The results were then analysed thematically, and these qualitative results were presented alongside the main audit results. The results and subsequent recommendations were presented to those taking part in the audit.
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Results |
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This audit approach was useful in identifying many issues that need to be addressed during subsequent mass vaccination programmes, such as an influenza pandemic. These included issues related to training, strategic co-ordination, inter-organizational communication, consistency and timeliness of communication. Lessons from this audit are being incorporated into local preparations for pandemic influenza.
The process highlighted the inadequacy of the Memorandum of Understanding as a basis for audit standards and the problems created by a lack of specific standards—in particular, contradictory statements regarding which organization was responsible; no mention of the appropriateness, quality or speed of response; and no reference to expected outcomes. Statements contained in the guidance are broad, with no specific measures or standards against which it would be possible to identify whether roles and responsibilities had been suitably discharged.
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Discussion |
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Main findings
This study has found that there are no published standards for auditing outbreaks. It is surprising that no standards currently exist for auditing interventions following outbreaks of communicable diseases, given the inevitability of such events. The availability of a generic audit framework would enable organizations to audit and improve responses to outbreaks. The Health Protection Agency, Department of Health and Faculty of Public Health are all well placed to undertake this task. The Faculty of Public Health has developed an audit toolkit to ensure that the best available evidence is incorporated into practice and high standards are achieved.13 The toolkit could include audit standards for outbreaks under the heading ‘promoting and protecting the population’s health and well-being’.
What is already known
The literature review revealed that although audit standards exist for individual aspects of vaccination programmes, no comprehensive standards exist covering the range of issues pertinent to outbreaks.
What this study adds
Audit standards for outbreaks should cover the structural and process aspects of a mass vaccination likely to impact on outcomes, as well as specific outcome measures. Standards should address the timing, appropriateness and quality of the response. Based on the Avon experience of auditing responses to an outbreak, it would be useful to include the issues summarized in Table 3. The standards would be useful for a range of more common outbreaks of communicable diseases, e.g. Legionnaires’ disease, E Coli 0157 and meningococcal disease.
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Limitations
The audit was limited in scope because the audit standards were not developed at the outset. Therefore, the audit of the mumps outbreak relied on using standards within the Memorandum of Understanding. The study is limited by only applying audit standards to a mumps outbreak.
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Acknowledgements |
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We are grateful to our colleagues for their contribution to the audit: Keith Reid, Chris Payne, Chris Hine, Alison Frater, Max Kammerling, Kieran Morgan and Joyshri Sarangi. We are grateful for David Gunnell’s comments on a draft of the article.
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References |
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- Savage E, Ramsay M, White J et al. Mumps outbreaks across England and Wales in 2004: observational study. BMJ 2005;330:1119–20.
[Free Full Text] - Health Protection Agency. Confirmed Cases of Measles, Mumps & Rubella 1996–2005*. http://www.hpa.org.uk/infections/topics_az/measles/data_mmr_confirmed.htm (15 August 2006, date last accessed).
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[Abstract/Free Full Text] - Etuwewe O, Wood A, Lyon A. Delivering a selective neonatal BCG vaccination programme in a multi-ethnic community: an audit of the neonatal BCG immunisation programme in Birmingham and Solihull. Commun Dis Public Health 2004;7(3):172–6.[Medline]
- Donabedian A. Explorations in Quality Assessment and Monitoring, Vol. 1. The Definition of Quality and Approaches to its Assessment. Ann Abro, MI: Health Administration Press, 1980.
- Faculty of Public Health. Audit Toolkit. http://www.fph.org.uk/prof_standards/cpd/toolkit/default.asp (31 August 2005, date last accessed).
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