John Snow (the other one)

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No, not that one

IMG_3268

That one

I’m in lockdown. My Twitter feed has words filtered from it, my ears are tuned to the merest mention on the TV, and my eyes watch for posts to Facebook. You see, I am going off to Sierra Leone at a crucial time.

We are 3 weeks into a new season of Game of Thrones and I won’t get to see any of it til the end of July. I am acutely aware of the possibility of spoilers.

So in this post I’m going to recount the tale, told in epidemiology story-times across the world, of the other John Snow. I was in London last week and took the opportunity to make a pilgrimage to the place where it all began (said place is now, conveniently, a pub, and next door there is an equally convenient lovely coffee and chocolate cafe, but I can assure all my readers I went there purely for the epidemiological culture). Incredibly, it all began only 160 years ago when London still had the occasional outbreak of everybody’s favourite old-skool diarrhoeal illness, cholera.

160 years ago, the most popular theory for the spread of disease was that it was spread through ‘bad air’ or miasma. Essentially, it was thought that pollution and bad smells were the means by which disease was caught – germ theory was yet to be proposed. John Snow, a London physician (who, not content with fathering one branch of medicine – epidemiology – also made significant contributions to anaesthesia) was sceptical of the miasma theory and thought cholera might be transmitted through water. After publishing his theory to limited acceptance in 1849 (“You know nothing, John Snow,” the medical establishment said)….

[sorry]

….he investigated further when an outbreak of cholera hit Soho, London in 1854.

IMG_3269Snow, together with a local clergyman, did the first spatial mapping of disease. He found that people affected by cholera were far more likely to have collected their water from the pump on Broad Street than the other nearby pumps. Legend has it that he removed the handle from the pump and the cholera stopped, but as is so often the case the reality is more mundane. He convinced the council of his findings and they removed the pump handle. (And in fact the case numbers had started to drop quite substantially before the handle was removed anyway, but I think we should give him credit for convincing a council of something if nothing else.)

And so epidemiology was born. And then they put a pub where where there had previously been a cholera-dispensing water pump. It has a blue plaque and a picture of the man himself on the sign.

He might not be the most famous John Snow on the Internet (and from his pictures he looks like he might have actually been having less fun than the other one too), but he did something pretty cool nevertheless.

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A Peek Behind the Curtain

Apologies for the recent paucity of posts and blogs. You see, from a work perspective things went a little quiet after the end of January for me. I suppose it was to be expected, but arriving home after such a profound and intense experience as working in the Ebola Treatment Centre turned out to be a bit weird.

Once I had got my work boots back on I found little to post about that didn’t seem a bit of an anticlimax from the dizzy heights of the ETC.

Well ladies and gentlemen, dust off your Taylor Swift collection, because I have an announcement….

I’m going back. Are you really that surprised? I won’t be doing any clinical work, but will be helping with the backstage stuff – the coordination of medical teams and links with Sierra Leonean services.

So let the blogs recommence! I hope to have time to describe the back-stage operations, and explain the various cogs and gears in the huge machine that is a global public health response.

I’m in Geneva right now, then it’s back to Freetown mid next week.

Stay tuned!

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Quite Some Six Weeks

I’m now at the end of my 6 week deployment to Sierra Leone. I have worked with a wonderful group of people who I am completely in awe of, and I think we can be proud of what we have done and are continuing to do.

As you can imagine there have been some extremely sad and stressful times at the Ebola Treatment Centre. Work has been intense, tiring and emotionally draining. I’m disappointed to leave, but 6 weeks is the right amount of time for me.

However, as well as the distress, there have been some wonderful moments. There are some things that have caused a smile that is all the wider with the contrast of Ebola to compare to. So here, in no particular order, is a list of all that great stuff:

  • Watching a 15 year old girl who was paralysed and blinded for 2 weeks with her Ebola walk out cured whilst the nurses sang and danced.
  • The sense of appreciation and gratitude I felt having a day off by the beach with more laughter involved than any day for months after 2 weeks of intense ETC work.
  • 2 four year olds holding hands walking down the confirmed-case ward
  • The women who were recovering from their illnesses looking after the kids.
  • Every single time I walk past the hand wall.
  • 25. Count em

    25. Count em

    The support I’ve felt from everyone who has been reading my blog and FB posts

  • Mammi bringing out dinner when I got back from a late shift.
  • The camaraderie of that afternoon at the Radisson after a hard day at the ETC.
  • Feeling part of an incredible team doing amazing work.
  • The smiles and the drawings of the boy who was discharged later than his friends.
  • The buzz of a busy shift with a fantastic team

Now it’s time for a long journey with 21 days of monitoring at the end. I’ll keep writing and letting people know how the ETC is going.

Of course now I need to find me a new adventure. 😉

Thanks guys, its been incredible.

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Weird Bits

Sometimes the weird stuff is unexpected. For example, I often wonder before a major life event or trip, which piece of music will remind me of it after my return. Other than when I cocooned myself in my headphones at the beach a couple of times, there hasn’t been much music listened to on this trip, at least that was until I decided to do those videos. So now it looks like I will forever be reminded of 6 weeks working in an Ebola Treatment Centre by the dulcet tones of the great Taylor Swift encouraging me to Shake It Off. That tune is really catchy isn’t it? I have had it stuck in my head for days.

Even before I left for Sierra Leone, however, there was one thing I knew would be weird: the no touch rule. Because Ebola is spread by direct contact, a major public health intervention across the three countries affected has been to tell people not to touch each other. That means no holding hands, no kissing, and no hugging. It means no shaking hands, no high-fives, no fist-bumps and no tapping to get attention.

Minions

Minions

Meeting new people is a little odd as the natural urge to hold out your hand has to be suppressed and there is a brief moment when you fail to shake hands (knowing that the other person thought it appropriate were it not for Ebola) that feels a bit like the awkward moment when you fail to hold out your hand to be shaken and the other person starts to then realizes then stops.

Donned in PPE and ready for work

Donned in PPE and ready for work

Then there’s the no hugging bit. Hugs are natural and common. When dealing with stress and death all the time, hugs are necessary, but in the ETC hugs are all but non-existent. I did see a hug given over here once. For a few seconds one evening the rules were bent slightly and someone who really needed a hug got one, but most of the time there are no hugs.

One place where we can hug, though, is the donning area. In the minute or so we are fully clad in PPE but haven’t yet entered the red zone we are invincible, and can dole out and receive all the hugs we want. We look like big, happy Minions trotting off to work, and if you listen carefully one of us is probably humming Taylor Swift.

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Doff It Off

Follow the steps and dance along!

Follow the steps and dance along!

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My Most Epic Blog Title Yet

As most people who know me are well aware, although I have written pretty much exclusively about Ebola recently, vaccines are my first love.

And thus I think it is time to put the two words together to make the most epic blog post title possible and write about….

Ebola Vaccines!

Prior to last year Ebola was considered nasty but rare and reasonably easy to control. Only when it unexpectedly cropped up thousands of miles from where it was known to hang out, then made its way into a country with no health infrastructure and a culture that placed huge value on close care for recently deceased people did it kick off. So, with the exception of some military research, there was little effort put on developing prevention, and no vaccines were available. Because no vaccines (and therefore no vaccine photos) are available, I am just putting random photos from Sierra Leone into this post for you to enjoy.

Freetown

Freetown

The Ebola virus has very little of its surface covered with glycoproteins, most of it is lipids and sugars. Glycoproteins are relatively fixed structures whereas lipids and sugars are variable in shape and constantly changing, so it’s the glycoproteins that tend to get put in the vaccines. The trouble is, if there is little glycoprotein to bind to it is hard to create antibodies that will be effective. Of course being so dangerous Ebola is difficult to work with (I can attest to that!) so only the most specialized labs can work on it. There are several strains of Ebola virus and other similar haemorrhagic fevers, and ideally a vaccine would cover most if not all of them. Finally, of course, its rarity prior to last year made any clinical tests extremely difficult to perform: you could measure antibody levels, but could not know if that translated into a real clinical effect.

Sprayers drive behind the ambulances to spray with chlorine

Sprayers drive behind the ambulances to spray with chlorine

Then last year came along and changed everything. All of a sudden political will met clinical need and many labs around the world worked very hard to create a vaccine. That brought its own questions: years worth of work were being crammed into months, and processes needed shortening. Experts had to decide what if any of the safeguards and licensing regulations that would normally take many years to get through in development of a new drug could be shortened. There was great debate about whether or not to allow relatively untested interventions and who to test those interventions on, and whatever your opinion there is no doubt that Ebola, with its huge mortality, is a special case.

Now several vaccines have completed phase 1 and 2 trials (small trials on healthy people to assess safety and dosing) and are moving to phase 3 trials soon. In phase 2 studies both achieved reasonable (but not amazing) antibody responses with little in the way of side effects (1 vaccine caused joint pain, but this was temporary and worse with higher doses that didn’t change the effect of the vaccine). There was talk a few weeks ago of one of these companies looking for volunteers for their phase 3 trial in Sierra Leone. They were looking to test it on health care workers as we are at higher risk of the illness and thus easier to detect a vaccine effect in. These trials are scheduled to start in the next couple of months.

Ebola is an illness that has a very high mortality and also affects small pockets of people – families and small communities – due to its mechanism of spread. A vaccine would be a wonderful weapon to have against the virus to help snuff out the last of these pockets. Of course, now the epidemic is subsiding it will be harder to detect vaccine effect in the phase 3 trials. (Watch this space on the case decline – due to increased efforts in detection numbers could well increase again before they decline properly.) But that, I think, is a very good problem to have.

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Donning PPE

All eight minutes of it squished down.

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