Near miss: Any infection only a plane ride away

Canadian clinicians roll out contingency plan

In the parlance of the aviation industry, call it a "near miss." A suspected case of viral hemorrhagic fever in an incoming airline passenger from the Republic of Congo recently prompted Canadian infection control professionals to implement a full gamut of precautions to prevent transmission of a deadly pathogen to patients and staff.

The word "Ebola" found its way into more than a few large-font headlines before the patient was diagnosed with malaria.

"The media focused on Ebola, but we had a broad differential," says Mark Loeb, MD, microbiologist and infectious disease consultant at Henderson General Hospital in Toronto. "Because [viral hemorrhagic fever] was one of the possibilities, we had to use the contingency plan. She did have malaria, but the malaria didn’t explain all of her symptoms and her signs. We were faced with a patient brought into our emergency room with a clinical picture that was compatible with a viral hemorrhagic fever."

The Health Canada contingency plan for such cases — similar to measures recommended by the Centers for Disease Control and Prevention in the United States — calls for rigorous infection control in all aspects of the patient’s care. (See recommendations, p. 70.)

Indeed, the CDC has been warning for years — particularly as the issue of emerging infections has climbed on the public health radar screen — that virtually any exotic pathogen on the globe is but a plane ride away from your emergency room doors.

"This could happen at any site," Loeb says. "I think the fact that we had a contingency plan in place emphasizes the importance of looking ahead and planning for these types of eventualities."

On Feb. 4, 2001, the female patient of undisclosed age was admitted through the emergency room to a negative-pressure room to minimize airborne spread of any pathogen into the rest of the hospital. Health care workers entering the room had to don gowns, masks, and face shields.

"We were very selective about any time we drew blood," Loeb says. "Blood was only drawn if it was felt to be critically important, and when we drew blood, we used dedicated instruments to process it."

Patient isolates were labeled and a special protocol was used to take them to the lab. According to the implemented plan, laboratory staff dealing with specimens from patients with suspected VHF must take, as a minimum, the same personal precautions as patient care staff. Disposable gloves, fluid-resistant surgical masks, impermeable gowns, and protective eyewear should be worn. Laboratory tests must be performed in biosafety cabinets. Blood cultures should be prepared in a closed system if at all possible, and when not possible, all manipulations must occur in a tested and certified biosafety cabinet. Centrifuges must have sealed carriers or heads, and every effort must be made to avoid splashing or creating an aerosol.

"Our ICP was on-site and going through the particular procedures we had to do, not only in terms of direct patient care, but what to do with anything leaving that room," Loeb says. "For example, some things went directly into an incinerator, and there was a protocol we followed to bring it there. Another issue was identifying contacts. We had to identify people who had direct patient care [contact] with this individual before she was identified as possibly having a viral hemorrhagic fever."

According to the Canadian plan, health care workers and other close contacts should be placed under surveillance. These individuals should record their temperature twice daily and report any temperature at or above 38.3 C. Those with close contact should also report any symptom of illness. Surveillance should be continued for three weeks after the individual’s last contact with the index patient. Surveillance is not indicated for routine occupational contact with patients in situations where the diagnosis has been considered and appropriate isolation precautions implemented.

"About 70 health care workers [were followed], but truly only a handful of those would have been at high risk of exposures," Loeb says.

There were no infections of any kind to the health care workers. The patient recovered and was discharged.

"The staff were extremely professional, particularly the people working in the [intensive care unit]," he says. "The overall effort of the hospital, in my opinion, was extraordinary. Because of the complexity of issues you have to deal with, you really need a multidisciplinary approach. People at all levels were pitching in: administration, infection control, public health. It was truly a team approach. When you are dealing with something like this, you have to have all the right people at the table."