On Tuesday 1st of November 2016 The Royal College of Pathologists held a symposium on the role of pathology and laboratory medicine in humanitarian disasters and public health emergencies, which was hosted at The Royal Society of Medicine, London. AAPT Council member Debbie James FAAPT reports on this broad meeting and includes abstracts for the lecturers.
The symposium was opened by Dr. Suzy Lishman, President of The Royal College of Pathologists and Dr. Ian Hosein, President of the Royal Society of Medicine’s Pathology Council, who welcomed attendees to the day.
The day was broken down in to 3 sessions and 2 keynote addresses:
Session I – Facing the Facts about Humanitarian Disasters and Public Health Emergencies
Session II – Voices from the Field
Session III – Getting Involved
Keynote Address I – The Politics of Public Health Emergencies: When do they Become International Concerns?
Keynote address II – Disaster Victim Identification
The day was engaging and brought together many sectors of humanitarian and healthcare providers to understand the roles that services play in a humanitarian disaster or public health emergency. The speakers covered the impacts these services have on such situations and provided information and advice to all attendees to better understand the works that have been done, and are continuing to be done, globally by international, multidiscipline workers.
Above all the day brought an awareness of the importance of pathology and laboratory services that are required and used around the world amongst the humanitarian non-government organisation (NGO) community.
DR ALEXANDER VAN TULLEKEN
Trustee, Doctors of the World
Doctors of the World provide healthcare to vulnerable people wherever and whoever they may be globally. Internationally Doctors of the World are assisting the refugee crises in Calais and Dunkirk, The Balkans, Greece, Jordan and Lebanon. In the UK Doctors of the World run clinics for vulnerable people to be able to access the healthcare they need. There are clinics in Bethnall Green, Hackney and Brighton.
Looking back over the years from the concentration camps during WWII to the present day refugee camps, they are all designed in a typical fashion and supply basic human needs. Refugee camps are an area where displaced people are temporarily accommodated after fleeing from their home country or displaced from within the same country. Most refugee camps are built and run by a government; however there are some unofficial refugee camps which do not have the support of the government. Camps run by governments are controlled and allow the refugees access to clinics, hospitals and immunisation centres, refugees that choose not to live inside the government camps or do not gain admittance to the camp do not have access to any healthcare, clean water or food provided by that government. Doctors of the World assist these vulnerable people to be able to access basic needs.
Post emergencies the vulnerable people, (including those in the government refugee camps) still need to have access to healthcare and Doctors of the World stay on to provide not just this service, but to teach and train local people and to help rebuild a better healthcare system that is functional and sustainable once all the aid has been removed, this provides a better future for the communities. Doctors of the World are presently helping to attain this functional healthcare system in Sierra Leone post Ebola crisis.
DR KWEKU ACKOM
Senior Health Advisor, International Medical Corps (UK)
The International Medical Corps assist in emergencies to help provide health, water, medical treatment, mental health, food, nutrition, security and support people through any gender based violence. The medical corps provides aid but, aid in itself has severe problems and limitations however aid managed correctly can be a solution and not a problem.
The International Medical Corps sent teams to Nepal after the earthquake to assist in people with many broken limbs and to see through the recovery and rehabilitation process of the survivors. In 2010 the international medical corps was deployed to Haiti’s earthquake to assist survivors and also in 2016 to assist after Hurricane Matthew. In 2010 Cholera was introduced to Haiti due to the international agencies assistance of which the medical corps dealt with alongside maintaining the original criteria of aiding the survivors post-earthquake. When in 2016 after Hurricane Matthew the potential for a Cholera outbreak to arise again was high, and knowing that an outbreak would have devastating effects the decision to deploy vaccines for a vaccination programme to commence was underpinned and the programme is to start mid-November. In Haiti there is a survivor’s wall where those who have survived the disasters can leave their painted hand print on the wall.
The medical corps was also deployed to Greece to assist people fleeing from the war in the Middle East, Afghanistan. The people fleeing from Afghanistan were refugees and not migrants but using the correct terminology helps the world to understand the gravity of the emergency at hand. None the less, terminology aside, both refugees and migrants can be in need of aid and should be treated as the human beings that they.
Post emergency recommendations are made to be able to move forwards and be able to learn lessons for the future. It is also the responsibility of all to be able to maintain systems in place; teams are required to stay longer to help rebuild communities. The teams in South Sudan trained and built health capacity by training 22 locals as midwives and nurses; this aids in the sustaining of the community needs.
DR RAFIL YAQO
Director, Dhhok Specialised Laboratory Centre (Iraq)
70% of refugees from Iraq & Syria are outside the city camps awaiting healthcare. There are over 40 medical teams working 24/7 against the potential outbreak of communicable diseases; polio, measles and cholera, and aiding in mental health.
Healthcare is provided to 265,000 people and all children under the age of 15 years have had all vaccinations given under the vaccination programme.
Outside of the camps there is an increase in cancer with 206 cases more for specimen diagnosis.
The centre helps women and girls that have survived the trauma of ISIS, specialising in their health and mental health.
Peshmerga forces (military forces of the autonomous region of Iraqi Kurdistan) have medical teams embedded throughout the area and training has been given to assist these staff.
Health centres are being established however resources are stretched due to a drop in oil and the war against ISIS.
Sustaining the health services is not viable as there is no more help available and more areas are being liberated, putting more pressures on the health service.
The camps are congested which means that there is a high possibility of an outbreak of a communicable disease.
Senior Technical Advisor, UK International Rescue Committee
This committee was founded in 1883 by Albert Einstein. The IRC is present in 40 countries worldwide and responds to the world’s worst crisis’s, helping people survive, recover and reclaim control of their futures.
Over the last 20 years there have been 6873 natural disasters. In 2014 59 million people were displaced by war, in 2016 this number had risen to 65.3 million. In 2015 there was a Cholera outbreak and there was no preparation for this emergency. Ebola crisis struck in 2014 when the health system was weak and reported non communicable diseases (NCD) have doubled / tripled since the 1980’s in human emergencies; this requires better testing or a different approach.
The Global Health Security Agenda is to prevent, detect and respond, so community surveillances and case confirmations for measles have been in progress and assistance is requested if positive test results are found or confirmed cases rise significantly.
EWARN; early warning and response network, pre-empt late confirmations of outbreaks through community surveillances. This led to IRC recruiting and training local community members to become community health workers, who in turn can test for rapid level malaria and these tests can be processed and results obtained due to the rising number of mobile laboratories being available.
Genoexpert provided a test for Ebola that reduced the result waiting time down from 1-7 days (depending on location to testing laboratory) to 1 ½ hours which gives a far better response time for treatments.
PROFESSOR AMY PATTERSON
Professor of Politics, University of the South (USA)
Health issues – How do they get prioritised?
World Health Organisation (WHO) have declared 4 Public Health Emergencies – H1N1, Wildtype Polio, Ebola & Zika virus, of which it has taken WHO 8 months to declare a global emergency from the first case. However because the Zika virus has few symptoms and few deaths it took longer to recognise this event as a possible emergency.
In 2005 the International Health Regulations (IHR) were revised as only notifiable diseases were allocated as worthy of note and only 3 remained on the list that were applicable; yellow fever, plague and cholera. This list did not apply to resurgence of diseases like Tuberculosis, new diseases or non-disclosing diseases. The revised regulations are not based on notifiable diseases; however notifiable diseases such as smallpox, SARS, influenza and wildtype polio are automatically taken up by Public Health Emergency (PHE).
For a Public Health Emergency of International Concern (PHEIC) to be declared states investigate reports and events and if 2 or more of the 4 questions answered are ‘yes’ then this is notified to WHO.
(* reference – Governing Emergencies https://governingemergencies.org/2016/02/02/public-health-emergency/)
They will investigate and declare a PHEIC once confirmation and clarification has been obtained. If a PHEIC is declared, this impacts on resources, media attention, co-ordination, unusual and exceptional events.
Global Health governances of a PHEIC involve multiple sectors and a variety of disciplines. Once any issue becomes multidisciplinary, politics is involved. WHO have 50 states, all of which have priorities and want control of the situation. Budgets get earmarked due to wants of specific programmes required in that area and eventually the donor states take control over the agent, in this case WHO, so there are 6 autonomous regional offices to maintain governance.
When a PHE is declared media attention becomes an essential part of communicating with the public important and relevant information about the event. Framing the message that is to be broadcast globally, needs to resonate with the audience whilst being truthful and salient. Experts framing the message are more likely to gain a following especially as the framing of the object of the message is highly important also.
Zika Virus was run by the Centres for Disease Control and Prevention (CDC) who are experts in their field and the Zika virus was about infants; more effective politically to gain an agenda
Ebola Virus was run by the media who are non-experts in the field of diseases and the Ebola Virus affected all ages which doesn’t pull on an emotional level; less effective and yet the Ebola Virus is far more dangerous.
Messages should be framed so that they are presented & perceived correctly and politically. Information is essential for messages to be framed so as to gain a better political decision.
PROFESSOR GUY RUTTY
Chief Forensic Pathologist, East Midlands Forensic Pathology Unit (UK)
Disaster Victim Identification (DVI) is a multidiscipline, multinational team who work together at disasters of mass fatalities and bring together the data from ante mortem (AM) and post mortem (PM) records and prove a positive identification by scientific means.
At a disaster the police collect data and record on the Interpol AM (yellow) form. The Pathologist and DVI team record data on the Interpol PM (pink) form. These paper systems are used and reviewed every 5 years, the electronic system used is Plass data. A new database, FAST ID, is a picture matching database for items of clothing, shoes, accessories etc. To enable identity (ID) of a deceased the AM form and the PM form data is compared and matched.
To be able to identify victims in a disaster there is an ID criteria that is recommended;
PRIMARY ID – fingerprints, ondontology, DNA, any unique identifiers such as medical implant serial numbers.
SECONDARY ID – jewellery, personal effects, marks, scars, x-rays/ computer tomography imaging, physical data, blood grouping, tissue ID
ASSISTANCE – visual aids like photos, location of deceased, clothing, descriptions
The process of receiving and identifying deceased in a disaster scenario;
The deceased is transferred to the mortuary where the staff receive the deceased, unique identifiers that have been allocated to the deceased are checked and the deceased is signed for and brought into the mortuary facility. X-rays (fluoroscopy) are taken of the deceased and the deceased is then placed into primary storage. When the pathologist is ready to proceed, the deceased is removed from storage, stripped, searched, fingerprinted and is ready for a pathologists/anthropologists examination. Secondary x-rays are taken (plain film) and odontology is completed. When all examinations have been completed the deceased can be reconstructed to a condition fit for the relatives to view and embalmed to preserve the deceased. The AM and PM data is then shared and the evidence is put to the coroner. Once the coroner is satisfied that sufficient proof has been recorded for the identification the deceased can be released to the family for a funeral.
Being part of a DVI team it is essential to be well prepared and ready to be deployed to disasters at short notice and for this purpose there are some pointers which make this practical and more organised i.e. know where you are travelling to, where you are staying, look up local culture and ethics, ensure vaccinations are up to date and recorded, passports are in date, VISA’s are valid, have the correct travel insurance in place, take any PPE which is personal / fitted to you, know the rulings around customs and excise and have an escape plan should you require it.
On arrival at the disaster there will be no infrastructure and the bare minimums will be available so the work environment will be challenging. There could possibly be chemical or biological issues to contend with, the mortuaries can be unpleasant, in some instances due to health and safety it has been required that post mortems are conducted in view of the public to contain spread of contamination and the volume of deceased can be quite overwhelming.
Recently post mortem computer tomography (PMCT) has been used. There is a mobile system which scans all deceased at the disaster and the deceased can be scanned whilst being contained in a body bag which assists in containing any chemical or biological hazard. The images can provide enough information to identify what’s inside the body bag, determine a Cause of Death and gain a positive Identification. From an Anthropologists perspective this can assist on identifying any morphological features of the deceased. Any of the scanned images can then be sent electronically to be able to confirm an identity. Computer tomography is as good as plain film x-rays for odontology, this method has been used successfully since August 2016, and it can also depict natural and unnatural diseases.
PROFESSOR SAHR GEVAO
Chairman of Laboratory Technical Working Committee, Ministry of Health & Sanitation (Sierra Leone)
The Ebola Virus in Sierra Leone was the worst spread in history. The Ebola Virus started in May 2014 in Gueckedou in Guinea, just outside the borders of Sierra Leone and Liberia. By sept 2014 the Ebola Virus had spread to nearly all of the regions of Guinea, Sierra Leone and Liberia. The causes of the spread were population mobility; traveling to cities and traveling to get away from the virus and due to cultural practices on a deceased. Culturally the family wash and dress the deceased after death and a bury the deceased which spread the virus. Spread of the Ebola virus continued due to poor health infrastructure and limited laboratory capacities and capabilities.
Initial diagnosis was diagnosed in France as prior to the outbreak the cities were unequipped to deal with the request. Nigeria was sent samples to diagnose but as the virus spread their capacity was outstretched and this took 24hrs for a result. In response to this problem mobile laboratories were deployed from 10 countries providing 16 international mobile laboratories.
The role of the mobile laboratories was to diagnose suspected cases, test all deceased during the epidemic and to test patients prior to discharge back into the community. Testing was essential for treating patients with Ebola instead of treating a patient with suspected Ebola who turned out to have another disease which mimics Ebola i.e. Malaria, Lassa Fever & Cholera.
If a patient is suspected of having the virus they were sent for triage and a specimen taken for testing. The specimen management was poor due to tubes having wrong labels or wrong forms. The laboratory would reject the specimen and a retest would be required.
The specimen transportation was a problem due to the rough track roads that meant that the specimens would break in transit which in turn meant obtaining another specimen.
Testing of the specimen resulted in a lot of false –ve/+ve results, there were also a high number of errors from the laboratory giving a false result so the patient was sent back to the community to spread the virus.
There was a delay in the communication of results due to no mobile signal, no network signal which has an impact on the results and processing of the patient.
Due to the specimen testing problems a committee was formed by representatives from all of the laboratories and mechanisms were put in place, protocols and training were provided and competencies assessed. Initially the laboratory staffs were being infected so they were retrained in the use of personal protective equipment (PPE). Transportation of the specimens was undertaken by the armed forces. Quality assurance and audits were completed to ensure that all staff in all laboratories was singing off the same song sheet and weekly reports were done to enhance this process. Training of community healthcare providers for the purpose of swabbing patients correctly and training was provided for ‘doffing’ and disposal of PPE.
Using Polymerase Chain Reaction (PCR) kits, testing was complete within 72 hours and this prevented false results. Rapid diagnosis was available late into the epidemic however it can be used in the future.
Genetic sequencing was done from the test results and this enabled laboratory staff to track back to the first case of Ebola and the fact that the patient had travelled to see a traditional healer in Gueckedou and this is how the virus initially spread.
Now working on Biobanking and Biosecurity to enable to learn from the specimens collected and swabs from the deceased by collaboration to retain specimens. Biobanking will allow for the samples to be stored safely for cultural research.
Recommendations from the Ebola outbreak; use mobile laboratories, Biosecurity in Guinea and Liberia as in Sierra Leone, training in Biosecurity, collaboration building and robust surveillance systems.
Head of logistics, Emergency Health Unit, Save the Children (UK)
Essentially STC assist in the development of Frontline health in areas of crisis. In the past the types of emergencies that STC have attended were mainly rapid onset. Now the emergencies are trending more towards the displacement of children away from their homes due to war.
STC have 10 sectors where their efforts are utilised and these include emergencies, child refugee crisis, education, health & nutrition, HIV, protection & shelter, wateraid, livelihoods, child poverty and children’s rights.
STC are involved in procurements which requires a certain skill set; languages, VISA’s, passports, travel arrangements, equipment – these can be local, regional or international partnerships. Over the years it is becoming harder to mobilise funds and maintain support for long term programmes. There has been a rising trend of recipients of aid over the last 7 years which make the aid a consistent requirement therefore partnerships are needed to fund and sustain post emergencies.
In July 2013 STC joined with Merlin, becoming a global enterprise with the key objectives of building global pharmacy teams and emergency responses.
Out of the partnership with Merlin an emergency health unit has been formed, this consists of 4 teams with full time contracts. There are 3 primary health teams consisting of 6 staff and these teams are placed in regional focus areas and these are global.
Post conflict the teams can be deployed and on site within 48 hours ready to treat key primary health, vaccination programmes and disease control.
This partnership is currently developing inpatient response teams to cover emergency hospital care and major outbreak responses.
Ebola crisis, Kerry Town, Sierra Leone
STC responded to the Ebola crisis and deployed a team to Sierra Leone. From the experience in Sierra Leone key factors were learnt whilst building the Ebola unit. Initially there were no plans in place to give direction for the build and this led to heated debates which with hindsight could have been averted and an unnecessary waste of time management. However, working together with the multiple aid workers and charities involved the unit opened the doors to the first patient within 5 weeks.
Outcome reviews of the Ebola crisis in Sierra Leone have led to having more confidence in directing what is required to handle given situations; relationships have been formed through this crisis which can now provide a quicker service for the future.
Procedures and protocols have been developed however practically what is on paper in an emergency or crisis is not always viable or best practice in the given circumstance, an element of constant adaptation is required to navigate obstacles that need to be overcome to give aid to the best of everyone’s abilities.