Ebola nurse Pauline Cafferkey became infected after using visor, report says

http://www.theguardian.com/world/2015/feb/04/ebola-nurse-pauline-cafferkey-infected-visor-report

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Pauline Cafferkey, the nurse diagnosed with Ebola on return from volunteering in Sierra Leone, was probably infected as a result of using a visor to protect her face rather than the goggles that were standard at the treatment centre where she was working.

Save the Children, which runs the Kerry Town treatment centre where Cafferkey worked, says in a report that it is most likely the nurse was infected there and not in the wider community when off duty. The non-governmental organisation says it has tightened up its procedures in light of the case.

Cafferkey returned from Sierra Leone to Heathrow on 28 December and complained that she thought she was developing a fever, but her temperature was in the normal range so she was allowed to fly on to Glasgow. Once home, her temperature rose, she was diagnosed and flown to the specialist Ebola unit of the Royal Free hospital in north London. She was in isolation for three weeks and was in a critical condition, but recovered.

The report of a panel convened by Save the Children and chaired by an independent expert from Public Health England says there is no conclusive evidence as to how Cafferkey was infected, but it points to the difference between her equipment and that of other volunteers.

Cafferkey was trained in the UK in the use of personal protective equipment, including a visor. She was first sent to the Lakka treatment centre, run by the Italian NGO Emergence, but she and the rest of her NHS colleagues transferred to the Kerry Town unit on 7 December. At Lakka, she had used a visor but Kerry Town was equipped with goggles.

“She was not able to use the standard protective goggles used there because she could not get them to fit properly,” the report says. “She acquired a visor that was the same as the one which she had used in her initial training, and similar to the one she had worn at Lakka, but that was not used by Save the Children. Both visors and goggles are equally safe but there are slight differences in the types of clothing worn with each, and in the protocols for putting the equipment on and taking it off.”

Taking off the protective suits, gloves and visors at the end of a shift inside the high-risk red zone of the centre is the most dangerous time. Cafferkey, using a visor, needed to follow different procedures from her colleagues who were wearing goggles.

“Although the procedures, equipment and protocols used at the ETC [Ebola treatment centre] are considered safe, they are only effective if applied as prescribed. Compliance (human factors) is a key factor,” the report says.

The panel said it was satisfied Cafferkey did not know she was infected when she left Sierra Leone. At the departure airport, her temperature was recorded as 36.7C (98F), which is normal.

Justin Forsyth, chief executive of Save the Children, said Cafferkey was “a dedicated humanitarian who worked tirelessly and selflessly in the fight against Ebola” and that they could never be 100% sure how she became infected. The panel had found that procedures and equipment at Kerry Town were safe, but “where STC-approved protocols may not have been followed, or where prescribed equipment was not used, they weren’t picked up immediately and therefore action might not have been taken quickly to correct them”.

“Lessons have already been learned and as a result of the findings we have further tightened our protocols and procedures,” he added.