Air Evacuation under Biosafety Containment of Patients with Highly Contagious Infectious Diseases

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1 Air Evacuation under Biosafety Containment of Patients with Highly Contagious Infectious Diseases Maj.Marco LASTILLA, Col.Paolo TOSCO, Col.Roberto BISELLI Lt.Gen. Ottavio SARLO Italian Air Force - Health Department

2 Col. Paolo TOSCO

3 Every year... PANDEMIC AVIAN FLU? SARS new infectious diseases MARBURG

4 Air travels to exotic and isolated areas for turism or business are popular Armed Forces are deployed across the world Bioterrorism Exposure to the possible risk of contracting a Highly Infectious Disease 3

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6 DECISION MAKING GENERAL RULE: Do not fly during a communicable phase of illness Treat in place Low risk of trasmission No facilities available Window of non-communicability Dedicated flights unknown disease pending the identification of the pathogen; suspected of biological attack; VHF is NOT for AE movement of large numbers of BW casualties to referral treatment facilities Aeromedical Isolation Team 5

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8 DEDICATED FLIGHT Evacuation of close contact, high risk contact, low risk suspect case (B2, B3, C1) Flight with aeromedical crew PPE Patient in isolated area of the aircraft with bathroom Patient with mask Disinfection and decontamination procedures of the aircraft 7

9 The Aeromedical Isolation Team A rapid response team who can deploy to any area of the world to transport and provide medical care with isolators to a limited number of patients exposed to, or infected with, highly infectious, potentially lethal pathogens. 8

10 Air Evacuation under High-Level Biosafety Containment: The Aeromedical Isolation Team 1 George W. Christopher and Edward M. Eitzen, Jr. U.S. Army Medical Research Institute of Infectious Diseases, Fort Detrick, Maryland, USA Military contingency operations in tropical environments and potential use of biological weapons by adversaries may place troops at risk for potentially lethal contagious infections (e.g., viral hemorrhagic fevers, plague, and zoonotic poxvirus infections). Diagnosis and treatment of such infections would be expedited by evacuating a limited number of patients to a facility with containment laboratories. To safely evacuate such patients by military aircraft and minimize the risk for transmission to air crews, caregivers, and civilians, the U.S. Army Medical Research Institute of Infectious Diseases maintains an aeromedical isolation team. This rapid response team, which has worldwide airlift capability designed to evacuate and manage patients under high-level containment, also offers a portable containment laboratory, limited environmental decontamination, and specialized consultative expertise. 9

11 The Flight Environment: major and minor stressors of flight Major Hypoxya Barometric pressure changes (expansion of trapped gas, Decompression Sickness) Minor Dryness Noise Vibrations and turbolence Temperature changes Fatigue of flight 10

12 WHAT IS AN AIR TRANSIT ISOLATOR? The Air Transit Isolator (ATI) is a selfcontained isolation facility designed to transport safe a patient during air evacuation, protecting healthcare personnel, air crew and the aircraft from exposure to the infectious agents 11

13 ATI/STI systems Transport isolators have been designed specifically to provide a microbiologically secure environment for a patient requiring transportation For air transportation and in-flight care For transportation by ambulance or other means ATI: Aircraft Transit Isolator STI: Stretcher Transit Isolator 12

14 Isolation principles 1. PVC envelope 2. Negative pressure 4. Personal Protection Equipment 3. HEPA (High Efficiency Particulate Air) filters Multi-layer protection 13

15 ATI: Nursing facilities Two sleeves for intravenous drip bags Four pairs of gloved sleeves Two half suits for use if the freedom of movement within the sleeves is insufficient 14

16 ATI - Air Supply Unit NEGATIVE PRESSURE 1 inch of water pressure HEPA filter: filters out 99,97% of particles 0.3mm and larger Inlet HEPA filters (2 in parallel) Blower Outlet HEPA filter (double) Pre- filters 15

17 ATI - Electrical Supply System DOUBLE SYSTEM Control panel control beneath the isolator baseboard Four 12 volt BATTERIES with operating time of 6 hours each (24 hours independent time) Compatible electrical connections with C130J for emergency 16

18 PPE: different biosafety levels 1. Gown, facial mask, goggles, gloves 2. Suit (tyvek), full face mask with filters, gloves 3. Full body suit (tychem C) with positive pressure, gloves 17

19 Flight Certification Rapid decompression Test Vibration Test Electromagnetic Test Environmental Test According to Air Safety Certification the isolator must undergo stringent safety testing in extreme conditions Air Transit Isolator (ATI) Hercules C130-J 18

20 Located in Pratica di Mare Air Force Base Established in 2005 AIT Two teams, each comprised of: 1 Team leader, (Flight surgeon, Medical Corps) 2 Physicians (Medical Corps) (1 Infectious Diseases specialist; 1 Anaesthetist Specialist) 6 Health care specialists (Nurse Corps) + 1 Laboratory Technician (Mission dependent) 19

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22 Aeromedical Isolation Unit.training.training training..training. Every 15 days the team trains in Pratica di Mare Contaminated patient's recovery; Management of the patient in the stretcher both to the ground than in flight; Decontamination 21

23 Sacco - Milan/Spallanzani - Rome Hospital Teams and Air Force Team work together High Containment Ambulance of Spallanzani Team 22

24 Every year 3 unit components go for three weeks to attend the specific courses at USAMRIID to Fort Detrick

25 Aeromedical Isolation Team, USA Unità di Isolamento Aeromedico, ITALIA Joint Training Fort Detrick, Maryland 23 September

26 Teams of Aeromedical isolation unit in the world US UK ITALIA 25

27 Case Reports January 2006: patient with MDR TBC - from Alghero (Sardinia) to Milan; May 2007: patient with suspected Congo-Crimea hemorrhagic fever (after returning from Nepal) - from Turin to Rome; July 2007: patient with MDR TBC - from Alghero (Sardinia) to Bergamo. Aeromedical Isolation Unit Deployments First operating mission: January 24th,

28 Lung Tubercolosis MDR Milano Chest X-Ray after first cycle of chemotherapy Pratica di Mare Alghero January 24th 2006 January 2006: patient with MDR TBC - from Alghero (Sardinia) to Milan; May 2007: patient with suspected Congo-Crimea hemorrhagic fever (after returning from Nepal) - from Turin to Rome; July 2007: patient with MDR TBC - from Alghero (Sardinia) to Bergamo. 27

29 Torino Roma Spallanzani Hospital Pratica di Mare 3rd May 2007 January 2006: patient with MDR TBC - from Alghero (Sardinia) to Milan; May 2007: July 2007: patient with suspected Congo-Crimea hemorrhagic fever (after returning from Nepal) - from Turin to Rome; patient with MDR TBC - from Alghero (Sardinia) to Bergamo. 28

30 1 3 Aeromedical Isolation Unit Deployments 2 29

31 Tubercolosis MDR Bergamo Pratica di Mare Alghero July 19th 2007 January 2006: patient with MDR TBC - from Alghero (Sardinia) to Milan; patient with suspected Congo-Crimea hemorrhagic fever (after May 2007: returning from Nepal) - from Turin to Rome; July 2007: patient with MDR TBC - from Alghero (Sardinia) to Bergamo. 30

32 To fly with an infectious patient means to have the clearance of the countries we are flying over, because in case of emergency we could be constrained to land; for this reason the flight must be carefully planned We are not sure of arrival place, because for weather forecast, as fog for example, we could be constrained to land in another airport, but this problem can be easily get over, for example having also a STI as endowment during the deployment Resources in air are limited and therefore we have to know that limited medical interventions are possible 31

33 How long is it possible to manage the patient and the isolator in an acceptable way on C130J aircraft? Probably if the distance is very long, there will be an intermediate stop. At this regard, considering the possibility of a technical or meteorological stop, we are adding to its equipment also a portable negative pressure room, able to allow us to manage the patient in a situation of stop emergency for too many hours NEGATIVE PRESSURE ROOM (ISOARK ) FIELD ISOLATION Isometric view NEW CAPABILITIES

34 Movement of highly infectious patients is possible - Planning flight - Limited resources in air - Length of transfer BUT Maintaining well trained and equipped personnel to deal with such a situation is key. Without a trained staff care would be inadequate. BE PREPARED 33

35 Thanks for your attention 34 It's much difficult one that something can represent the terror of one not known what of the reaction of a population to manifesting itself of an epidemic, especially if the epidemic hits apparently inaccidental way E.Kass

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