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Volume 25, Number 1—January 2019
Synopsis

Aeromedical Transfer of Patients with Viral Hemorrhagic Fever

Edward D. NicolComments to Author , Stephen Mepham, Jonathan Naylor, Ian Mollan, Matthew Adam, Joanna d’Arcy, Philip Gillen, Emma Vincent, Belinda Mollan, David Mulvaney, Andrew Green, and Michael Jacobs
Author affiliations: Royal Air Force Brize Norton, Oxfordshire, UK (E.D. Nicol, J. Naylor, I. Mollan, M. Adam, J. d’Arcy, P. Gillen, E. Vincent, B. Mollan, D. Mulvaney); Royal Air Force Henlow, Bedfordshire, UK (E.D. Nicol, J. Naylor, I. Mollan, J. d’Arcy); Royal Free London NHS Foundation Trust, London, UK (S. Mepham, M. Adam, M. Jacobs); Level 2 Queen Elizabeth Hospital Birmingham, Birmingham, UK (A. Green)

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Table 2

Limitations and challenges in Deployable Air Isolator Team missions and subsequent enhancements, United Kingdom*

Limitations and challenges Enhancements
Mission 1: Advanced CCHF in Glasgow—400-mile transfer to HLIU London (2)
UK cross-governmental communication and media interest: Identifying the correct persons within the relevant UK and Scottish government departments to authorize the substantial costs involved was challenging because the Department of Health had restructured and NHS England formed with a loss of critical contact details. The coordination of the clinical transfer, with limited clinical experience of VHF and lack of standard operating procedures, and concurrent management of the extensive media interest, was time consuming and, at times, risked distraction from patient care, particularly for the lead clinician.
 •Allocation of roles out with the front-line team for liaison with and arranging authorization by governmental departments.
•Addition of Liaison Officer to manage extensive media interest (3–5,8) and minimize intrusion on patient dignity.
•RAF anesthetic consultant for support of assessment, transfer and airway management such as in the event of neurologic compromise (2,6).
•Civilian infectious diseases expert to allow an independent critical eye to assess and modify DAIT procedures and equipment.
•Review of service level agreement between Department of Health and MOD for national air transfer (only international prior provision existed).
•Recognition that road transfer in standard VHF PPE (20) posed increased risk.
Mission 2: Decontamination
Before 2014, the T-ATI was decontaminated using formaldehyde before it was incinerated. This relatively slow and intensive process was potentially limited by lack of access to the whole T-ATI frame and by requiring physical cleaning by humans, increasing risk to staff.
 •A new vaporized hydrogen peroxide protocol has enabled much faster turnaround time and safer T-ATI decontamination (21).
Missions 2 and 3: Environmental effects on working in PPE
Heat and humidity while wearing chemical-resistant Tychem F PPE suits (Figure 6) posed challenges in Sierra Leone, while steamed-up goggles and sweat-filled gloves resulted in the loss of vision and dexterity. Gusting wind made decontamination and equipment containment difficult, compounding communication difficulties due to PPE and aircraft noise. Conversely, at Glasgow International Airport, Glasgow, Scotland, UK, near-freezing temperatures were experienced during the T-ATI transfer and decontamination procedures, and the hours of darkness presented visibility problems when working in PPE.
 •Subsequent mission staff numbers, previously kept low to minimize VHF exposure, were revised upward for confirmed cases, and the use of lighter Tychem B/C suits offered the same protection.
Missions 4 and 5: Needle-stick exposure
The DAIT were deployed to Sierra Leone to assess and transport HCWs who sustained a needle-stick injury while working in an Ebola treatment center (4,8,9). An in-country risk assessment permitted HCWs to return to the United Kingdom as standard aeromedical evacuations with DAIT as escorts, after initially being deemed too high risk to travel on a commercial airline. A T-ATI was kept on standby in case of clinical deterioration.
 •In-country risk assessment modified the role of the DAIT to provide standard aeromedical evacuation with T-ATI on stand-by for those with high-risk exposure rather than confirmed EVD.
•Civilian infectious diseases consultant enabled more rapid access to advanced EVD treatments for the injured HCWs.
Mission 6: Multiple patients on one platform, one confirmed in T-ATI and 2 exposed contacts with T-ATI on standby (Figure 5)
Three military HCW exposed to Ebola were returned from the Ebola Treatment Centre, Kerrytown, Sierra Leone, alongside a confirmed Ebola case-patient. After an in-country risk assessment, 3 T-ATIs were flown on a single C-17 airframe (Figure 5) to Sierra Leone (4). Two exposed HCWs joined the RAF flight to the HLIU, Royal Free Hospital; 2 were flown back 48 h later by commercial flight to the HLIU, Royal Victoria Hospital in Newcastle. •Team augmented to 22 personnel for 3 T-ATI. Marked out floating clean/dirty line through aircraft should all 3 T-ATI be used.

*CCHF, Crimean-Congo hemorrhagic fever; DAIT, Deployable Air Isolation Team; EVD, Ebola virus disease; HCW, healthcare worker; HLIU, high-level isolation units: MOD, Ministry of Defence; NHS, National Health Service; PPE, personal protective equipment; RAF, Royal Air Force; T-ATI, Trexler Air Transport Isolator; VHF, viral hemorrhagic fever.

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