Niger 2007 © Alain Fredaigue/MSF
In 1988, MSF created Epicentre, an epidemiological research center based in Paris and tasked with establishing surveillance, monitoring, and evaluation systems in refugee crises and epidemic outbreaks. Today, Epicentre’s 50 staff members work in MSF offices in Paris, Geneva, Barcelona, Brussels and New York, and also in field offices in Uganda and Niger. Overall, Epicentre typically supports 20 to 30 MSF projects at any given time, often in partnership with leading academic and research centers.
Epicentre’s activities often help shape MSF’s emergency responses. Epicentre studies have also spurred changes in MSF’s approaches to a disease or crisis and revisions in World Health Organization (WHO) guidelines. What’s more, the team regularly publishes its finding in scientific journals, sharing important data and perspectives on humanitarian medicine with the medical and scientific communities.
Here, Emmanuel Baron—the executive director of Epicentre, the former head of MSF’s Medical Department in Paris, and a doctor who has worked with MSF in Sri Lanka, Afghanistan, and in other MSF settings in Africa—talks about Epicentre’s support of MSF operations and the challenges of conducting epidemiological studies in highly complex environments.
Can you define for us what epidemiology does?
Epidemiology uses a set of tools to measure a situation— even the most chaotic—with data gathered from scouring medical records in health structures, interviewing people to understand health behaviors, measuring findings against known and expected trends for a disease, and so on. It is a science that helps us understand what is happening on a larger scale, ascertain when a particular epidemic threshold has been reached, assess efficacy of a care strategy, and decide when a particular intervention may need to take place.
In a crisis, you have the qualitative, lived experience of the practitioner, and then you have epidemiology to back this up and create a bigger picture with quantitative data. It can play an important role through establishing surveillance systems, like we’ve done recently through our outposts in Somalia and Kenya to monitor the medical needs of people fleeing war and drought.
It can help with clinical trials or similar methods of comparing and assessing the relevance of new approaches to diagnose or treat a disease or carrying out a vaccination campaign; and ultimately to introduce better protocols or treatments that can lead to global policy changes, as we’ve seen with our work on sleeping sickness and other diseases. Also, retrospective morbidity and mortality surveys can help us piece together what happened in a particular region and help us better understand what the population has gone through.
How did Epicentre come about?
In the early and mid-1980s, MSF was running extensive medical programs in refugee camps in Thailand and Malawi. Tens of thousands of people were crammed into unsanitary and makeshift shelters, suffering from malaria, malnutrition, and other life-threatening conditions. MSF came up with a list of ten priorities to address in an emergency, which we would apply to crisis situations from then on—including shelter, water and sanitation, rapid health assessments of the population, mass vaccination campaigns against measles, surveillance, control and prevention of communicable diseases, and so on.
This was the first step toward recognizing the need for systematic surveillance and evaluation systems to better serve our patients. A group of MSF doctors then came to the US to study epidemiology at the Centers for Disease Control (CDC) and in universities (primarily Tulane in New Orleans), with the aim of creating an organization dedicated to helping MSF improve its data collection and create surveillance systems— and to have a sound scientific base using quantitative data from which to make operational decisions. Then they had to adapt what they learned and apply it to populations on the move in incredibly precarious settings, where data collection can be quite tricky.
Can you give us some examples of Epicentre’s impact?
In 2003, we conducted a clinical trial in Niger that compared a single shot of ceftriaxone to treat meningitis in an outbreak situation against the standard treatment of oily chloramphenicol, a treatment that was about to go out of production.
The results showed that ceftriaxone was efficient and could represent a valid alternative for the future. Our studies showed clearly that this cheaper, shorter course of treatment was just as effective, making life easier for patients, doctors, and local health authorities during mass epidemics, which occur regularly in Africa’s meningitis belt.
Following the findings of this study, WHO recommended in 2007 that a single dose of ceftriaxone would be the reference treatment in epidemic situations. We also contributed to a change in WHO recommendations for the way tuberculosis (TB) is diagnosed.
Until 2007, international recommendations required three collections of sputum samples from patients over two days. This is incredibly difficult for patients, health workers, and laboratories in the settings where MSF works. In partnership with the University of Liverpool and the Kenyan Medical Research Institute, Epicentre evaluated the effectiveness of a simplified strategy, and as a result, two-thirds of patients can now be diagnosed on their first visit, and the workload in health centers has been significantly reduced.
And right now, we are on the verge of releasing some exciting data related to rotavirus [the most common cause of diarrhea in young children], which the WHO said was killing around 450,000 children under the age of five every year. Two vaccines are currently recommended by WHO, but they came out of studies done in developed countries. Our research center in Niger is close to getting results that we believe will show that the strain of the disease in Niger is different than those covered by the two vaccines—data that will help us advocate for new, effective vaccines to be developed. The question is whether this data can be extrapolated to other parts of Africa, and if it would necessitate the kind of radical health policy changes we’ve seen with malaria treatment.
How much time do you spend on a particular study?
Hemorrhagic diseases like Marburg or Ebola are short-lived; they last just a few weeks. Measles vaccinations in refugee camps is another pretty brief intervention. But in Haiti, for example, where our teams are tracking the cholera epidemic, we expect to be present for a very long time.
We’re also involved in an 18-month study in Niger at the moment, in partnership with the World Food Program and MSF, to find the best protocols for preventing severe malnutrition in children. And sometimes we are asked to do retrospective mortality surveys; we’ve done several hundred to date, most recently in Niger, Democratic Republic of Congo, and Somalia.
What are Epicentre’s current and future priorities?
Whatever MSF’s priorities are, those are our priorities. We are driven by operational needs. And as MSF enters new territory, so do we—advanced surgical techniques, for example, or mental health, and we are just now starting to look at environmental health issues, antibiotic resistance, and cost-effectiveness studies.
We’ve seen the benefits of our two research centers in Niger and Uganda in so many ways. It is really important that we have more experts from affected countries involved in studies and decision-making. Whether that means more centers like these, or small satellite offices, I don’t know. I just know I’d like to see us evolve in that direction.