Will Pooley, the 29 year old British nurse who has survived ebola is on his way back to Sierra Leone to help fight the disease. He also traveled to the USA to donate blood to treat Dr Kent Brantly and has been briefing British volunteers on his experience. Dr Brantly has himself donated plasma to treat further patients.
No staff treating Will Pooley have become infected. I have given some of the information in this diary in various comments in different diaries but think it may be appropriate to bring these together to give a comprehensive overview of the arrangements in place in the UK to deal with any patient or outbreak internally. In some details, these are different from the protocols in the USA.
The UK is also helping tackle the outbreak in Sierra Leone (an ex-colony of Britain set up for freed slaves) by sending military personnel, financial aid, a hospital/supply ship and volunteer staff from NHS hospitals. Those likely to be treating patients, rather than building facilities, are being given three day training in the use of PPE.
Some of the details may only be relevant to countries with a mature universal health care system but others can be directly applied or adapted. So for your information, I'll go through the arrangements that are in place.
First, and perhaps most importantly, patients with ebola are treated in specialist units set up to deal with exotic and highly infectious diseases. This approach appears to be now taken for patients in the USA where the second nurse infected in Texas has been transferred to a CDC facility in Atlanta. Currently there is only one unit open in the UK. This has two beds but that figure can be expanded. A second unit was being refurbished, which will be expedited and two further English hospitals will have units established. Any patients from Scotland, Wales or Northern Ireland will be treated by NHS England. This is how the Huffington Post explained the arrangements made for Will Pooley, prior to his arrival back in the UK for treatment.
The restricted site at the Royal Free Hospital in Hampstead, north London, is run by a dedicated team of doctors, nurses and laboratory staff, and is equipped with specialist equipment to help contain the infection.
The infected patient's bed will be surrounded by a specially-designed tent with its own controlled ventilation system. This helps to ensure that he gets the clinical care he needs, while also containing the infection.
Only specially-trained medical staff are allowed in to the ever-ready isolation unit, which is always "fully prepared to admit a patient with a highly infectious disease at very short notice", the hospital says on its website.
Security and safety measures are vital. The sick patient will be admitted through a specific hospital entrance. Waste is decontaminated and there is a dedicated laboratory to carry out tests.
All the air leaving the unit is cleaned to minimise risk to anyone at the hospital, the Royal Free said.
The unit was set up at the Royal Free Hospital in 2006.
The bold part is an important difference between the arrangements in the Royal Free and those employed in the CDC. Follow the link and you will see that effectively the patient is in a bed sized protective capsule. All items that need to be taken into or out of the tent are through an airlocked, separate tented trolley. The necessary face masks, sleeves and internal gloves are built into the tent as "half suits" so
the medical staff can safely wear just scrubs and light gloves. The blue device round Breda Athan's neck in the photos is an air cooled vest to keep the staff cool when using the half suits, you can see the tube for the air supply in the first picture.
The CDC appear to also use isolation tents but simple ones which require the staff to enter the tent to treat the patient. That off course requires that they wear full PPE and have to take this off properly, with all the risks we know that involves.
Any new patients from abroad would be taken directly to the Royal Free or one of the other special units if that is full. With the number of contacts the UK has with west Africa, you will be wondering about what happens if somebody falls ill after arrival, like Thomas Duncan in Dallas? The UK has a nationwide number like 911 in the USA for emergency responders (999 - or 112 which is the EU-wide number). NHS England also has a non-emergency advice line on 111 which is a relatively new arrangement. The other NHS organizations in the UK may not have this but it is likely that all callers to 999 will be transferred to suitably trained staff for advice whatever country they are in. This is how it should work and is the advice being given out:
Symptoms of Ebola include fever, headache, vomiting, diarrhoea, bleeding - but these are similar to more common infections like flu and some stomach bugs.
If you have these symptoms and have had contact with an Ebola patient then ring 111 first, do not go directly to A&E or a GP.
If there has been no contact with Ebola then seek help from 111, your GP or A&E if necessary.
The chances of developing Ebola in the UK remain low.
(A&E is "Accident and Emergency"; the British designation for emergency rooms. GPs are primary care doctors all NHS patients are registered with)
Last week, there were training exercises to practice response if somebody is, after the telephone consultation, suspected of having ebola. In that case, paramedics wearing PPE will be sent and the patient, if confirmed to be a high risk case, transferred to the nearest treatment center or the Royal Free Hospital if the units outside London have not been finished. Of course some will not have got the message about phoning 111 or used 999 so hospital ERs have been given advice. There have been at least two incidents of patients with suspected ebola presenting. One was at an NHS walk-in center, the other in my local hospital. Despite the rather hysterical reporting (the Daily Mail is a right wing rag that loves to diss the NHS), this report shows they were aware of the protocols and took appropriate action:
A spokesman for Lewisham and Greenwich NHS Trust said: 'It's important to stress that we did follow robust and established systems that are in place to manage and care for people with suspected infectious diseases.
'Following a clinical assessment and advice from the Imported Fever Service Unit, the patient was identified as "low risk" for Ebola. They were always treated in isolation and all staff wore appropriate protective clothing.
'As a low risk patient, they were allowed to see a visitor under controlled conditions, meaning the visitor was given protective clothing for the duration of the visit. Tests have confirmed that the patient does not have the Ebola virus.
'We understand that cases like this can be alarming for staff, and it's unfortunate someone has raised concerns publicly when the Trust did follow best practice guidelines.
'We will be speaking to staff to remind them of our protocols and procedures for infection control and to encourage them to let us know if they need any additional support.'
What about those entering the country who may have been exposed to an ebola victim?
Screening of arrivals is in place in one terminal at Heathrow Airport, London which is the most likely to be the place of entry. This is being rolled out to other terminals at Heathrow, Gatwick Airport and the Eurostar rail terminal.
Public Health England director Dr Paul Cosford said: "This is a set-up process. We will be learning from the experience today and over coming days as to how it is working.
"The principle benefit is about distributing information to people about how to contact, the symptoms to look out for, and who to contact in the event that they do get symptoms when they are in this country...
He said the information given out via leaflets, and protocol about who to call if affected, was as important as the screening.
No system was "100% certain" but it was about reducing the risk as much as possible, he added.
Public Health England has also issued guidelines for GP surgeries and A&E departments to manage suspected ebola cases and you will see that these were followed at Lewisham Hospital. In the UK, hospital A&E departments and walk-in centers have staff able to triage ambulant patients so somebody reporting they suspect they may have ebola would be isolated. Although not always met (
in 4.2% of cases go over the time limit) there is a target for all patients in A&E units to be seen within 4 hours. My own experience of the minor injuries unit attached to the A&E at Lewisham Hospital is that treatment was within 5 minutes of arrival, admittedly at a quiet time of day. It is also located in an area with a large West African and Turkish population, Texas Health Presbyterian has a similar catchment although I understand more Asian than Turkish as a second minority.
To get my injury treated I simply had to give my name, address and date of birth so these could used to start a medical record of my visit. No proof needed and treatment is free. Everybody has an "NHS number" from birth, used to coordinate medical records among other purposes, but unlike Social Security numbers in the USA; these do not have to be declared. Come to that, probably few people in the UK even know their's. Contrast that with the treatment Mr Thomas had when he first reported to the ER in Texas Health Presbyterian (bolds and italics mine):
So Ms. Troh took him to the ER at Texas Health Presbyterian Hospital Dallas, and asked for assistance. Eventually, a nurse asked Mr. Duncan what ailed him. When questioned if he had been around anyone who was ill, Mr. Duncan replied that he hadn’t, according to the hospital.
Medical staff requested Mr. Duncan provide proof of health insurance, a Social Security number and a driver’s license, and Ms. Troh responded in her thickly accented English that he had none of those things, that he was from Africa, according to a relative who spoke with her afterward. He was sent home that evening with a prescription for $40 in antibiotics, she said.
Also note that Mr Thomas and the first nurse were not transferred to a specialist unit but:
At Texas Presbyterian, an entire 24-bed intensive-care unit was cleared so that other patients and medical staff could be safe. The day that tests confirmed an Ebola diagnosis.
So potentially another 23 patients had to be treated in less than ideal conditions in order to allow the hospital to make hurried arrangements for one infected by ebola. In commercial terms, this is probably the best a system that has a miscellany of independently run hospitals could do (without the transfer). Having a special unit with highly trained staff is not cheap - the beds and tents used at the Royal Free are disposed after treatment is completed at a cost of about $45,000 alone, although the staff have other duties in normal times. Of course that is the sort of thing the CDC can do and probably should do in all cases - if the local politicians allow them to, "States' rights" and all that.
Thankfully, if somewhat belatedly, I believe the CDC has set up a hotline for worried potential ebola patients to call and is looking into setting up specialist centers. The USA of course does not already have the free non-emergency medical advice numbers nationally.
I hope I have picked up on some things that you might feel can be applied to the USA and you will know how they could be implemented so your comments, particularly from health professionals, would be valuable.
Finally, much has been said about the level of protection needed in the field in west Africa, including a US offer of $1 million for a new design of PPE. The UK government is on top of that and has already commissioned a high protection suit. In response to the continued outbreak in west Africa, the order for them has just been doubled to 100,000 units. The following video does not appear to embed properly so you may have to follow the link to http://www.itv.com/...
British company doubles order for Ebola...