Hunterian Museum – draft transcript

Medical innovations: blood and bacteria, Tuesday 4 November 2014
 
This event will have live speech‑to‑text; please sit where you can view the text clearly. 

HAYLEY: Ladies and gentlemen, welcome here today to The Royal College of Surgeons.  We are very pleased to be working today with The Royal College of Pathologists who are currently celebrating their National Pathology Week.  This is the last of the series of lectures this year, following the theme of war artist surgery. We will have one more next year, if you are not already on the mailing list do please consider joining.  But now I will introduce our two speakers. First of all we have Dr Heidi Doughty; she is a consultant in transfusion medicine, working for both the MoD and the NHS Blood and Transplants.  She served for 33 years as a reservist and has a range of operational experiences.  Our other speaker is Dr Emma Hutley, who is a consultant in clinical microbiology; she is also serving the British Army and also working in the NHS.  She has served in Iraq and Afghanistan and is currently the Defence Consultant Adviser for pathology.  We are very lucky indeed to have the two speakers here today.

HEIDI: Good afternoon, ladies and gentlemen, welcome to Blood and Bugs.  This has been an amazing adventure with The Royal College of pathologists of public engagement and department who have ran a really successful roadshow with the BBC, reaching out largely to the youngsters and I had hoped there would be a group here today and more than 40,000 youngsters have actually come through this system during the summer.  What we would like to do is continue the theme and perhaps look a little more at some of the current and future challenges.  We will be comparing the last centuries and looking forward slightly.  One of the questions is, you know, what is pathology and we talk about the science behind the cure, and everyone thinks about white coats and if you look at some of the recent programmes they wear four‑inch heels, I couldn't do it myself!  We are doctors, and we are very much interested in the living.  Emma and I have been involved now very much with the care of our soldiers, not direct care, not just the direct care, but also an advisory service, working together with our technical colleagues, our medical scientists, these are the people really applying this on the field.  One of the challenges is do we bring people home or do we project medicine forward.  In particular here we see a mobile laboratory from the First World War.  But one of the things Emma has been working on is how can we miniaturise all our pathology equipment, reagents et cetera, can we actually get a pathology capability in a rucksack, we call it a Bergen, and actually be able to put that forward right where the troops are.  So this is one of the constant themes that we will see.  I think what we will do is we will take you back to the beginning and try to explore the reality of what it was like to be in the trenches in 1914.

EMMA: Clearly being in the trench there was the constant threat of injury from warfare.  But actually the real threat was from invisible, it was from Mike croaks rather than man.  There were many infections soldiers could succumb to, both from the horrendous conditions, and there was lots of soil, animal excrement, water, poor hygiene, they were living in very close confines and the ability just to wash themselves and their clothes was almost impossible.  However, the First World War was actually a turning point in some respects in terms of military medicine.  Up until the First World War the amount of death from disease in any military campaign had always far exceeded the deaths that had occurred as a result of trauma.  The First World War changed this, partly because of the type of warfare, but also because there was a golden age of microbiology before, where we had started to understand the cause of some of these infections and been able to take some basic steps to sort them.  You can see after that the number of deaths from deaths and disease falls and deaths in warfare are generally today due to trauma that is sustained on the battlefield.  That isn't to say that disease has gone away, it is still by far and away the highest cause of admission to field hospitals but it doesn't cause death, however it does cause a significant impact on our man power.  So you have heard about the roadshow over the summer.  We wanted to engage with the youngsters that came in some of the infections that may be acquired in the trenches.  There are clearly many of these but we picked three main infections to illustrate the risks both from your own bacteria, from organisms you might acquire from the environment and those you might get from other people.  So attendees were given a sticker at the start that looked very much like the pictures here, these are Grams stains, we use them to identify bacteria in the laboratory.  Back in the late 1800s as well as today.  If you were given one of these stickers with round blue organisms you had staphylococcus aureus, an organism acquired from person‑to‑person and also sharing common things, towels or razors then you have a risk of acquiring it.  If you had a blue rod with perhaps a spore on the end of it, it was clostridium tetani, an organism from the soil, and some attendees had pink dots which represent a difficult to grow organism called bartonella quintana, this was carried by lice and caused trench fever.  During the roadshow the youngsters would explore these organisms and perhaps some of the ways that in time we would come to understand the diseases and have treatments and how they were acquired.  Just to look at them in a little more detail, this is staphylococcus aureus, and 30% of us carry harmlessly this in our skins and in our throat.  And all of us I'm sure have had an infection due to staphylococcus aureus, perhaps a an inflammation by the nail bed, a spot, a sty, all commonly caused by staphylococcus aureus.  It is also the common cause of wound infections as you see down here.  And it can cause much more serious aggressive infections, it can cause pneumonia and infections of the heart and nasty bone infections, it is a really significant bug to find even in hospitals today.  Clostridium tetani lives in the soil, it doesn't like oxygen much, it will be pushed deep into the tissues of people injured, maybe in warfare, but it can also happen if you put your garden fork through your foot or sustain a significant injury while doing anything related to soil.  It isn't the organism itself that causes the problem, it is a toxin that the organism produces, it spreads and infects the nervous system and causes rigidity, it is opisthotonus, and this is a picture from The Royal College of Surgeons in Edinburgh demonstrating the opisthotonus.  This is a soldier who had been injured in warfare and who subsequently died.  I'm just going to mention here that the tetanus had come to be understood a little before the First World War, and we were already using some passive immunisation techniques to reduce the problems with this in the First World War.  So immunity to infection can either be acquired actively or passively.  If you have an infection and you recover, or if you receive vaccination for it then your immune system is subjected to that infection again and it will be able to respond and deal with the infection.  The other way is passive immunisation.  This is where you get some of the antibodies your immune system needs from somebody, another person, and it gives you rapid short‑term ability to fight the infection.  You will see the significance of this later on in the talk.  But this was already being used for diphtheria and tetanus in the First World War.  Finally bartonella quintana, this is an organism transmitted by lice, the lice would hide in the clothing of the soldiers in the trenches, it would bite them and cause itching, so they would scratch the skin and the organism is transmitted by the faeces and the excrement of the lice, when you were scratching your skin you would inoculate that into your body and cause a feverish illness, usually lasting about five days, hence the term quintana.  In order to deal with this, there was nothing you could do, other than try to get rid of the lice.  And it is actually the origin of the term "chatting" because the soldiers would sit around talking to each other and removing these lice which they termed "chat” that is where the term "chatting" today comes from.  As you have seen the threats from disease in the trenches were significant, but those in trauma were to as Heidi will detail further.
HEIDI: So trenches, we have already learnt a little bit about the conditions, and the fact that they give rise to the constant threat of disease.  But my interest is the immediate risk, the risk of shrapnel, the risk of direct wounding and the risk of bleeding to death.  That is still as pertinent now as it was then.  So first aid here was actually quite well organised.  There were first aid posts, run by the medical officers and stretcher bears, within the trench system.  They had really organised systems of being able to go in and extricate the men.  They knew about direct pressure on the wound, elevation of the leg, for instance.  Bandages, but actually it is all really, really very simple.  And the problem is, if you lose a lot of blood, then you haven't got enough circulating fluid, you are at risk of shock.  And there was very little in the way of fluids to treat shock.  The only thing they had was gummy fluid, which was a sort of gum extracted from the acacia tree, held in the body a little longer than water.  The problem is you lose whole blood you need whole blood replacement.  And we actually learned about blood groups at the turn of the century.  Here we have lance Steiner, he had begun to work out that not all blood was safe, and there were different blood groups and if you crossed the wrong blood into a patient what happened was, we can see it on the tiles here.  Here we can see that if the wrong blood and the wrong serum get together the cells all clump together, we call it glutination, when you want to transfuse someone you want transfusion not clumps of cells blocking up the blood vessels.  They had the science and one of the challenges we have in terms of science and innovation is taking science from the bench actually to the battlefield, that process of innovation is often stop‑start events and war paradoxically is a really powerful stimulus to innovation.  We see it time upon time, it is almost like you need war to get you all together to take scientific bits and pieces and make it into something useful.  Blood groups.  People then started exploring how do we get blood from one person to the other and you know going back in history we have seen various Popes having the blood of young boys, I can't possibly comment!  We had dogs, blood going into humans, really inadvisable.  Here we have direct blood transfusion going from one arm directly to another.  This system is actually used in Russia up to the 1950s.  By using a syringe you can draw it out of one, clamp it or use a three‑way tap and then push it.  Actually this is one of the things that Lucy and her team had mocked up during the roadshow.  So this is direct blood transfusion going from one person to the other, and you say well where are the blood donors, with the greatest of respect, if you have lots of soldiers in a field hospital, where they have been evacuated to, your donor is the person in the bed next to you who is less severely injured.  I'm not sure about his volunteer status, this could be questionable, and however, he was a volunteer....  Ah, our colleagues from the schools have arrived.  Hello everyone.  We're into the blood bit.  We are talking about blood transfusion, so come take a seat.  So direct blood transfusions going from one person to another.  But the difficulty there is you need to have the donors, or the volunteer, less injured person, next to you.  And you can see that doesn't allow you to plan, it doesn't allow you to have blood ready waiting to go.  What we needed was to be able to keep the blood out of the body to be able to store it so that when somebody needed it later it was good to go.  And so to do that we actually need to take the blood into a bottle, keep it liquid by using what we call citrate, a citrate is a chemical a little bit like vitamin C, the sort of things we get in oranges and lemons, and citrate binds the calcium in our blood and stops the clotting process, it keeps blood liquid.  So into the bottle, into the citrate, stir with the glass rod and then sometimes they would actually re-infuse it, put it through a piece of gauze to take out the froth and any clumps and then put it back into the patient.  This means that we have now disconnected our blood donor and our patient.  This is what we call indirect transfusion.  And it allows you to start banking blood.  When we talk about blood banking, that was a concept that came from the First World War, you know, there was work going on in the US and we saw some of the Canadian surgeries bringing it into the war.  But actually the Belgians had also started in 1914 doing the first indirect transfusions.  We saw different countries putting it together, sometimes in Civvy Street, sometimes in the trenches.  But really by the end of the war we had Robertson writing up in The Lancet, the key papers that talked about their experience of how transfusion was transforming the care of the most severely injured soldiers.  And that in turn then led to the advent of the first blood bank in the UK, in 1921, with Percy Oliver in London, and then from there the different cities, so spreading across the UK and then the next country that really went with it was Spain.  And again, here we have war stimulating innovation.  So the Spanish Civil War, again, led to a whole development in forward blood banks, where they were actually taking it on mules in panniers, blood, citrated, glass bottles up to the frontline.  First World War leading on to other wars was stimulating changes in science.  And again, we see the same thing the Second World War and actually what we really see then is the development of some microbiology.  Let's revisit our friend, the bugs.

EMMA: So after the First World War we had sort of the science behind some of these infections, we needed further work and investment from society as a whole to take this forward and produce some of the solutions to these infections we had seen.  And as the people who attended our roadshow moved through they learned about some of the treatments that they could receive for the infections on the sticker that they had received.  So by the time the Second World War came we had antibiotics and we understood the importance of hygiene and hand washing for things like staphylococcus, and we talked about tetanus before the First World War, this was built on further and we developed tetanus vaccinations so in the Second World War we didn't see that because most people had been vaccinated and clearly the importance of rapid effective surgery was key.  And with bartonella quintana the general measures for hygiene and cleanliness had been to some extent instigated and later on in the century we developed new antibiotics that could deal with this infection.  So this picture is of Sir Alexander Flemming, he worked extensively during the First World War on the infections that occurred in wounds.  He had a lucky discovery in his laboratory where he was looking at plates of organism that had been contaminated by mould, he realised the bacteria couldn't grow near the mould, that is how he started to develop the antibiotics.  Once the Second World War occurred penicillin was prioritised to be given to soldiers to such an extent and it was so precious that it would be administered to people and then their urine would be collected, so the antibiotic could be crystalised out and given to the next person.  Again as Heidi has demonstrated perhaps we have come a little further in our practices today.  But our antibiotics were really a key development in terms of combating infections.  This image I'm sure you will recognise is Edward Jenner, providing immunisation for small pox.  He was a student and he realised that those people who had could you pox didn't succumb to small pox in the same extent and inoculated this into individuals and protected them from small pox, this was really the start of developing a vaccination which has continued through history, today we have vaccination for many disease, measles and mumps and today the surgeon is on for a vaccine for Ebola.  An effective hygiene is very important; I wouldn't be doing my job if I didn't mention hand washing during the talk.  During the roadshow it was highlight today individuals they were able to use the Glo‑Germ gel to wash their hands and then put them under a UV light and it would highlight areas they may have missed in hand washing.  Just as many of you with the tablet for your teeth, it shows the areas you are missing.  Good hand washing is paramount to protecting against infection.  We see in the century following the First World War we had a whole load of discovery and innovation, and this really increased our confidence, particularly with infection that we had made massive progress and it was not going to be so much of an issue for us on the battlefield.  This led to an infamous quote by the General of the United States, William H Stewart, in 1967 he said it is time to close the book on infectious diseases and declare the war against pestilence won.  I think as we all moved to see this was perhaps a lack of insight into the future challenges that would evolve.

HEIDI: War is part of the commune condition, and far from over.  Whereas the College of Surgeons is focusing on how war has led to innovation, what we are going to do now is take a little look at what has been learned over the last decade.  Again we have people in trenches.  Living in close contact and in conditions where it can be hard, both for man and machine.  And the immediate threat to life is the risk of massive bleeding.  Catastrophic bleeding as it has been termed here.  And so there was a paradigm shift in the way that we you taught first aid.  Instead of ABC, airways, breathing, circulation, it then became CABC, catastrophic haemorrhage, and then ABC.  The soldiers were taught to stop the bleeding first before doing the procedures with the bleeding.  And how?  So all first aiders should be taught to be able to administer their own first aid as well as others.  Care under fire includes the use of a tourniquet to stop the bleeding.  Haemostatic dressings, a funny word that means haem‑blood, static‑stop.  It was to try to get the blood to stop bleeding, these dressings can be made out of a variety of things, but strangely enough they are normally made out of processed shellfish.  In fact sometimes, because the bandage has the same stuff, they are called "prawn dressings", it is strange but soldiers are strange.  Not only do we stop the clock but we include the pressure from the pressure bandages, as well as bandages impregnated with the ground shellfish that stimulates the clot, that stops the bleeding.  But the next thing to do now is to prevent the shock.  Because having lost blood either we make up with fluids, but sometimes that actually makes clotting worse, one of the things that has been really led by our surgeries, both the royal college here and the military surgeons is a better understanding of how shock itself affects our natural clotting and if people become shocked then they actually bleed more.  That has actually become so important that what we now do is instead of bringing people back on stretchers all the way back, what we now do is try to project the doctor, the nurse, the paramedic, together with treatment forward to the patient.  Since 2007 we have actually had blood on board, not just red cells, but also plasma and we will come back to that.  And you can see how this has been taken up by the London helicopter emergency and medical service, just before the Olympics, no accident there as part of Olympic planning.  And across the country we see blood on board coming on.  But why is it not just red cells, why is it plasma as well?  Because this is what we are trying to do. We have now learned that transfusion for trauma needs more than red cells for oxygen, what we need to do is to rebuild the blood clot.  We need to give plasma, the straw‑coloured fluid that contains our clotting factors and sometimes platelets which is a microscopic part of blood that does the end part of clotting.  When the blood vessels are damaged, once they are exposed, the platelets become sticky.  The sticky platelets together with the plasma then create a reaction and the reaction allows the blood to go from liquid to solid to clot.  And we get this strong fibrous network of clotting together with the platelets.  We build the clot, we provide the culls calcium that is sometimes missing, and we keep them warm and get them to a surgeon.  This is something that is really going in the last ten years.  The trouble is red cells only last for 35 days in the fridge.  Plasma is fine; it is frozen and lasts for three years in the freezer.  But platelet, that tiny fragment there, if any of are you platelet donors only last five‑to‑seven days.  If you are constantly trying to get that on aeroplane, from Birmingham where I work to the battlefield, that is really, really difficult.  So this is blood donation 2014.  If you contrast it with what we saw at the beginning, where you had direct transfusion, then you had indirect transfusion, giving whole blood.  This now just takes off the bit of blood we want.  You can see it is a straw‑coloured fluid containing the microscopic fragments called platelets.  This is using a cell separator be in a process called apheresis, these soldiers are proper volunteer donors, not injured people.  Often it is the doctors and nurses working in the hospital who are also acting as the blood donors for the patients.  Sometimes I refer to this as blood, sweat and tears, for obvious reasons.  This combination of pre‑hospital care, together with progressive resuscitation starting on the helicopter, the techniques used by the surgeries called damage control surgery as part of damage control resuscitation, has led to this extraordinary cohort that are sometimes described as the unexpected survivor.  But actually it is the beginning of a new battle; this is a quiet battle, a battle against inflammation and infection.

EMMA: So as we heard and there was significant advances after the First World War, with antibiotics and vaccine, but the development in the recent conflict, with this group of patients who are really severely injured and previously would never have survived have received massive amounts of blood products, created a whole new situation.  The war isn't over, it is never over.  With humans against microbes and they will constantly change as we produce changes and adapt to them and find new treatments they will change to overcome them.  And each conflict in history has had particular organisms which have been associated with it.  And for the recent conflicts in Iraq and Afghanistan these are the organisms which have been a particular problem, fungal infections which really we never see in human beings, perhaps some of them in immunosuppressed patients with chemotherapy and bone marrow transplants for cancer.  What happened in 2008 we found a group of patients who had all been very, very severely injured by IEDs in what we call the Green Zone, pictured in this photo here in Afghanistan, the area along the Helmand river full of lush vegetation, where there is farming and lots of animals and so soil full of all sorts of things.  These people would be blown up there and have this soil and dirt blown really deep inside their tissue, because of the fantastic care they were given they would survive these.  The key principle of war surgery is that you debride all of this dirty stuff and get back to clean tissue and prevent infection.  Often surgeries were unable to achieve that in these individuals because of their physiological state, their ability to withstand the surgery because they were so badly injured.  We often had to stop and after a couple of days go back when the patient was able to tolerate it.  And these individuals would be ten days after the injury still having mud and stuff taken out of the wounds that were really very, very deep inside the body.  And we had to respond to this with new strategies to try to prevent these infections.  But this is a new bug that has evolved; the bacteria were dealt with by antibiotics and allowed these infections to come to the fore.  Speaking about the bacteria they are not a problem because of broad spectrum antibiotics and we can treat those, this is not always the case.  What people attending the roadshow were able to do was look at the antibiotics to use for infections.  This is how we look for antibiotic sensitivity in the laboratory.  We have these discs impregnated by a small part of the antibiotics.  You put it in the incubator overnight and the bacteria grows.  If Flemming had done this when he was discovering penicillin, this plate would have had no bacterial growth at all, it would have been empty because it wasn't able to grow.  Now in the laboratory we increasingly see ‑‑ increasingly see this, it goes up to the paper discs so the antibiotic is ineffective.  This is staphylococcus, you are all familiar with MRSA, this is flucloxacillin the antibiotic we use for the skin and tissue infections and the organism is resistant.  And this obviously causes us significant problems.  It is not just the skin organisms that are developing, it is antibiotic resistance.  The ones that live in our gut, you have ten‑times more bacteria in your body than you have human cells; many of these are in your gut.  Very, very important for having normal healthy life.  But these bacteria getting into the wrong place, into euro Rhine or abdominal infection can cause infection.  These are increasingly resistant to antibiotics, to such an extent that Dame Sally Davies, the Chief Medical Officer has championed the cause of antibiotic resistance and has achieved the buy‑in from senior politician; this is the Prime Minister talking about antibiotic resistance.  It is actually one of the UK's national risk register, alongside terrorism as a risk.  Because antibiotics underpin modern medicine, if you have a routine operation, chemotherapy, antibiotics are crucial.  It is a reality today that there are infections for which we do not have effective antibiotics, and we have less and less being developed, so really the war is not won with respect to antibiotics and bacteria.  Finally infection prevention control, we learned about the importance of personal hygiene and hygiene perhaps in the camps, but we have learned some hard lessons in the last ten years in terms of our hospital infection control policies.  We are set up to save lives, to bring these soldiers home alive.  These are some of the headlines that occurred in 2007/08, where we imported a very resistant bacteria back into the UK hospitals which had been acquired by our soldiers who are serving in the Middle East.  This is partly because obviously we don't just treat our own soldiers we treat those soldiers on the other side, and also the local nationals, if you have a hospital of severely injured patients in field conditions it is more difficult than in the UK to achieve high standards of infection control.  But we have really learned from this, we now deploy infection control nurses into every hospital and pay particular attention to our healthcare system with infection prevention control rather than just that of the individual and the environment they live in.  So back to the future now, we have recently finished our operations in Helmand, in Afghanistan, just as we finished in the First World War with Spanish flu it occurred, which is pandemic of flu which killed more people than were killed as a result of the whole of the First World War.  And this is a picture of an American military facility set up to deal with influenza patients.  The news from Afghanistan the military has been straight out of that into the current global outbreak of Ebola.  This is a picture of our training facility in York we have developed, and some of our military personnel training to go and work in our Ebola treatment facility that will open in Sierra Leone this week.  Ebola really brings us full circle in the talk with respect to blood donors and bugs.  Ebola requires good infection control and hygiene measure, we desperately need to find a vaccine for it.  We need new diagnostics to diagnose patients near to them, quickly, and most importantly we need treatments, there are a few experimental ones you may have heard about.  The only current treatment is obtaining a blood transfusion or donation from an individual who has survived Ebola and giving that to a sufferer.  That brings blood and bugs back together working very closely in the current situations.  Heidi will conclude.

HEIDI: So the last few weeks I think it is no secret that we have been working with the nurse that came back from Sierra Leone and he has been giving his plasma, through the sort of machine that I showed you there and his plasma, which contains the antibodies to Ebola has now been deep frozen and made available to other people with the disease.  But clearly we need to scale this up, we need a combination of treatments, vaccines, diagnostics, as well as all of this for Ebola.  I hope we have given you a tiny taster of how military pathology contributes not just to military medicine but also leaves a wider legacy to wider healthcare.  We are very much partners in care, the royal colleges together, pathologists and the surgeons continue to work closely.  I would like to thank you all very much for spending this lunchtime with us today.  Thank you.  (APPLAUSE)

HAYLEY: Ladies and gentlemen we do have some time for questions if you have anything you would like to direct to our speakers today?
FLOOR: Now you have some donated plays plasma from this nurse, can you develop more from it with stem cell research with developed cells or does it have to be donated each time from a live sample?

HEIDI: You are right, what we need to be able to do is use monoclonal technology to industrialise and scale up.  That is one of the challenges with taking stuff from the bench to the bedside, it is more than just science, it is the industrial complex that allows us to then bring this, but you are probably aware that to develop drugs, to develop new vaccinations, orderly it would take at least five years.  We do not have five years for Ebola.  So at the moment the WHO is really putting together consortia from all sorts of countries and as we speak there are two groups working on convalescent plasma, certainly the blood service together with public health England is working on the screening and antibody tests where they can quantify it.  But there are also groups working on the monoclonals.  So sadly it won't be at least for a few months.  It will be broadcast on the news as soon as there is anything, because it is such an important global health issue.

FLOOR: Just a general question, with people travel abroad more and more and more, some with vaccinations and some without, what about having vaccinations and them being compulsory, with Malaria and things like that?

EMMA: Malaria there isn't at present a vaccine for it, it is a disease where there is a lot of I effort going in to find one, and taking the right anti‑Malaria drugs for the key region you are going to.  That is one part of it and taking those doesn't protect you, you need to employ the whole host of measures to avoid bites and things.  You are right, vaccination, prevention is always better an cure, I will always take my tablets but in the UK it is very difficult for us to make that compulsory.  And it is a way that we differ quite significantly in the military with the UK compared to the US.  Our vaccinations are all voluntary, we don't make our soldiers have anything, in the US you have to have it or you are out.  I think if you get your vaccinations and take those Malaria pills you are sensible and I wish everybody did that.

HEIDI: If you think about the basis of English law, people have the right to make decisions themselves, organ transplantation and opting in and out, even when it comes to the annual flu vaccination, you know, we still need to use public health messaging to say it is not just doctors and nurses but everyone public‑facing you benefit the whole community by having your vaccination, but we have to leave it as a discretionary measure.  What do you think?

FLOOR: I think in some ways, I don't I used to run a travel clinic, it was people going on exotic and expensive holidays but wouldn't spend another few pounds or more than that on vaccines.  It really didn't make a lot of sense.  Oh I don't need that; this holiday has always cost me that.

HEIDI: What do other people think, do you think that people should have compulsory injections if travelling abroad.  Can we have a hands up for yes?  Who thinks we should actually protect and who thinks no it should be up to people to make their own minds up.  There you go, it is interesting, we have a younger generation and an older generation and there is two views about public health.  That is why it is quite important to have these sort of discussions.

FLOOR: In some countries it is compulsory, yellow fever and so on and meningitis.

HEIDI: I have a feeling the gentleman was here first.

FLOOR: I was trying to read what was said, that's OK.  I have lived abroad and I have deliberately had these vaccinations and taken care about Malaria and things like that, because when you think about it the National Health Service doesn't want a big bill of people being sick because they haven't taken precautions, could we push that way, precaution is the key to it all.  My question is completely different if about haemophilia, and can blood transfusions be made between haemophiliacs at all?  In anyway

HEIDI: Are you asking whether haemophiliacs can donate blood?

FLOOR: Donate or receive?

HEIDI: To treat haemophilia we use a fraction of plasma where the plasma has been treated with special detergent‑type processes to make it safe, but also to distil the factor 8 and you need to have lots and lots of blood donations to treat that haemophiliac, so we do treat haemophiliacs with sometimes factor 8 from blood, but more often these days as my colleague pointed out it is made using modern technology, what we call recombinant technology, haemophiliacs can't give it.

FLOOR: Sorry I wanted to ask you, pneumonia vaccine exists and not used widely, how many people die from pneumonia every year?

EMMA: Pneumonia is difficult, it is, the vaccine is caused by a specific pneumonia, it has many different forms there are two current vaccines which have a combination of different, they provide protection for a different combination of the staph pneumonial, they are subject to risk benefit cost analysis and we know that step cock cuss pneumonia causes more infection in those who are older than younger people and people who perhaps have chronic medical conditions, particularly chronic chest infections.  So within the UK and the decision has been to immunise those patients who are particularly at risk from it, to prevent them from having the serious consequences in the infection.  The organism is around and some of us carry it harmlessly anyway, but clearly reducing infections and the ability for it to spread you would hope there would be some community effect from that as well.  That is why it is not compulsory, even if you have had the immunisation; it is still possible to have a streptococcus infection from a different train of the infection that is not included in the vaccine.  It is similar to flu, you have to have the injection year, because the virus changes from year‑to‑year and we have to try to predict a year in advance what is going to be the serious infection the following year, produce the vaccine, if there is some ready for the autumn in the Northern Hemisphere, in the autumn for us to give the immunisation.  For some organisms if you can provide a vaccine which would cover all of that organism for others it is more strain‑specific, depending on a particular variety of that organism.  I hope that makes sense.

HEIDI: Was there a particular angle for your question, is there?

FLOOR: No, so many people die in the UK from pneumonia and we have a vaccine and we don't use it?

HEIDI: But it doesn't cover all sorts of pneumonia, so we do use it selectively.  You are right we need to encourage people to have it if they are going to benefit from it.  Any questions from the back?

FLOOR: I was wondering where is formerly tropical climates, is there anything to (inaudible question)

HEIDI: We are talking about disease factors, changing the areas in which they live because of climate change, what do you think about that?

EMMA: That is a really good question; it is a significant issue, so there are diseases we traditionally associate with the Tropics, so dengue virus, and some viral infections that you have to go to a nice tropical country to get them.  We have had those infections in Europe in Italy, in Spain and even France.  And it is only a matter of time before we could potentially get that in the UK.  And so it is something that is being continually monitored and looked at.  And you have to remember that Malaria used to occur in Europe and we kind of eradicated it by using all the effective measures that we had available.  What we need to do really with any infection is get ahead of the curve, so much like the Ebola we hear on the news all the time that it is out of control, you know we are not up on the curve to where we need to be.  And what we have to be better at is preventing things by using vaccination but also surveillance so as soon as the first infection occurs we can start instigating appropriate measures to prevent t it is a significant threat for the future.

HEIDI: Have you heard of any things or had any ideas yourself about how to prevent it?

FLOOR: Just be a case of trying to keep an eye out and figure out which one is coming first for the vaccines.  Hide in blood transfusion we always take travel history, and every six months we are having to update travel history to take into account exactly what you have asked.  So we now ask about travel in Italy, because of some of the things.  So that would prevent transmission through blood.  But I think you are right, we need to not only understand the disease, but what carries the disease, and that's where you can all have interesting jobs in pathology and insect control later.

FLOOR: With climate change encourages bacteria, they probably like it better than we do?

HEIDI: I think that's his point.  We have time for a few more questions?

FLOOR: I'm a blood donor so I have these questions and it is very interesting how they change.  But one thing that has always puzzled me is how do they know whether I have got, I don't know, a cold or flu or just an ordinary disease that you get in the UK and I might pass that on to a trauma patient who is less able to cope with it than I am?

HEIDI: A really interesting question, you are referring to the fact that sometimes we can be incubating disease without showing any symptom, this is a big issue about Ebola, if you remember the story about the nurse who was asked to stay in quarantine for 21 days until she finished that period before coming out.  She had been out and about on her bicycle.  We don't, so we ask you are you well today.  Have you been in contact with anyone that's ill?  And then we have to ask a little bit about occupation and travel.  But then we have to take your word for it.  But do you recall what advice you are given if you are ill after donation.  Can you remember?  You are meant to be given a reminder or a little slip of pap their says if you are ill within the next two weeks please tell us.  And that's to recognise exactly what you are talking about, that you might be incubating something that hasn't yet made you ill, but might make somebody else ill.  And one of the jobs that the consultants do, as soon as somebody rings in to say, actually, I have come out in a rash and I gave blood five days ago, we then go through what is called a recall.  That is why every single bag of blood that is given as a separate barcode and we not only trace it going to the hospital, but we can track that for 30 years.  That is one of the consequences of variant CJD, that became a health concern a few years a less now, but law now requires us to track that unit of blood for 30 years.

FLOOR: I had a friend who had very, very successful major heart surgery about 30 years ago.  But was given a blood transfusion, and in giving the transfusion obviously unknown to the professionals was given Hepatitis C.  So presumably I mean it is discovered now because she was virtually needing a liver transplant but she has taken part in research and it has had a massive impact for her and hopefully for others.  But presumably with this 30‑year tracing, you can't know everything so in ten years' time there will be something that nobody has thought of today.  But for 30 years would be able to recall the patients who you knew got this blood and if there was anything that could be done to prevent an on‑going situation.

HEIDI: The whole point of traceability is you know from which vein to which vein the blood has gone in order to do that sort of recall.  Because as you say the battle against bugs is constantly evolving.  One way is to test but another way is to use techniques which are recall pathogen and activation, to try to blast plasma with chemicals or ultraviolet light to try to destroy bacterias and virus that is we don't know about.  That balance in transfusion between the good and the bad is always under discussion and we have a lot of steering group oversight to try to get that balance.

HAYLEY: Right, well I think I will call it quits on questions, thank you everyone for your questions.  I would like to thank our two speakers Dr Heidi Doughty and Dr Emma Hutley for their excellent presentation today and I do hope that you enjoyed it if you would like to show your appreciation one more time.  (APPLAUSE) As ever with these events on your seats you have our evaluation form and also for the Royal College of Pathologists, we very much appreciate it if you fill it out and hand it back to my colleague in the green top on your way out.  For those of you who are regular attendees that is pretty much it for this year, except we do have a big conference which is taking place on the 14th/15th of November where we are going to be evaluating 250 years of military medicine, so all the way from John Hunter's time in the 18th century to current procedures in Afghanistan and beyond, if you have had your appetite whetted do look on the website for more information about that.  My colleagues in the library would like to tell you that there are some examples of things that they have taken from the library and archives related to today's talk.  On your way out if you do pop into the library which is just on the left of the museum exit and see the objects that they have laid out there.  Thank you very much for coming today.