Q & A on MSF’s Ebola Response and Protocols

Julien Rey/MSF

The following information has been compiled to address questions about Doctors Without Borders/Médecins Sans Frontières (MSF) protocols and practices regarding the organization’s Ebola projects in West Africa and the people working in them. As noted earlier, MSF will not comment on the care and condition of Dr. Craig Spencer, our colleague who tested positive for Ebola on October 23, 2014, as he is now in the care of Bellevue Hospital in New York City, but MSF is committed to being transparent about its work, the precautions we take in these and other programs around the world, and the steps the organization is taking in response to this specific incident to reassure an understandably anxious public and insure the greatest possible safety for our staff and patients alike.

What do the recent New York and New Jersey orders, as well as those from other states, about quarantining returning medical workers mean for MSF?

MSF’s October 27 statement about these regulations is here. It reads, in part: “Forced quarantine of asymptomatic health workers returning from fighting the Ebola outbreak in West Africa is not grounded on scientific evidence and could undermine efforts to curb the epidemic at its source. Diligent health monitoring of returnees from Ebola-affected countries is preferable to coercive isolation of asymptomatic individuals.”

The regulations come with numerous concerns. They seem haphazard and not well thought out, and they have already had some troubling consequences for MSF field staff back from West Africa. What’s more, MSF is concerned that excessive strictures could deter would-be field staff from going to West Africa, for fear not of what they will encounter when they get there, but what they will encounter on their return. This will undermine the effort to combat and control the outbreak in West Africa, where it is doing the most damage, and thereby, as noted below, undermine the effort to keep people everywhere safe.

“There are other ways to adequately address both public anxiety and health imperatives, and the response to Ebola must not be guided primarily by panic in countries not overly affected by the epidemic,” Sophie Delaunay, executive director of MSF-USA, said in the October 27 press release. “Any regulation not based on scientific medical grounds, which would isolate healthy aid workers, will very likely serve as a disincentive to others to combat the epidemic at its source, in West Africa.”

Furthermore, the press release continues, “enhanced restrictions on returned aid workers in the United States could lead to similar measures being adopted in other countries, leading to an even greater impact on the ability to fight the outbreak in West Africa. ‘We need to be guided by science and not political agendas,’ said Dr. Joanne Liu, international president of MSF. ‘The best way to reduce the risk of Ebola spreading outside West Africa is to fight it there. Policies that undermine this course of action, or deter skilled personnel from offering their help, are short-sighted. We need to look beyond our own borders to stem this epidemic.’”

Why were returned field workers not quarantining themselves upon their return from West Africa?

This is an understandable question, one that MSF takes very seriously.

Ebola is a very dangerous disease, but it is also very hard to catch. In West Africa, the numbers are frighteningly high; this is the largest Ebola outbreak ever. But much of the spread is attributable to where it struck, in a cluster of countries that have extremely limited health care services.

The nature of the virus is such that it cannot be transmitted from one person to another until someone is displaying symptoms. Even after a patient begins showing symptoms, he or she is not very contagious. They become more infectious as the symptoms worsen, particularly after they develop gastrointestinal symptoms such as diarrhea and vomiting, and then, later, if they start bleeding. Even then, infection can only result from direct contact with bodily fluids such as vomit, blood, and feces.

MSF’s long-established protocols for returned field workers have been based on these and other facts drawn from prevailing medical science around Ebola. Our field workers, as detailed below, are given very strict protocols they must follow during and after their assignments. These ensure that in the event of possible infection they are immediately isolated and provided with the treatment they need, before they become contagious in any significant manner. That is what happened in the case of Dr. Craig Spencer, our colleague now in treatment in New York City. He immediately reported the onset of relevant symptoms and was swiftly moved into isolation in a facility prepared to handle such an eventuality.

To quarantine all health workers who return from working with Ebola patients in West Africa has been deemed by medical consensus an unnecessary and outsize response to the limited threat of contagion when proper protocols are in place. What has been declared absolutely necessary, and what MSF drills into its field workers, is vigilant monitoring of one’s own health, frequent communication with our offices, and immediate reporting of symptoms that suggest Ebola.

MSF’s protocols for returned field workers can be found here.

What preparations are made before staff leave for the field?

In general, MSF accepts only some 20 percent of the people who apply to work with us. For Ebola programs, the selection process is even more exacting. We only send out people who have had prior experience with viral hemorrhagic fevers and/or similar emergencies. Once approved, they must go through comprehensive training designed to prepare them for the rigorous and demanding work they will experience under difficult conditions in the field.

What precautions are implemented in the field?

All field workers take extreme precautions when working in MSF facilities. Our treatment centers are designed to ensure the safest possible working environment for staff and patients. Some staff members have no contact with patients, but they still follow all relevant safety protocols. Only essential staff are allowed to enter high-risk areas of MSF Ebola treatment facilities. They wear full personal protective equipment—PPE—that negates contact with the bodily fluids of patients. PPE use is governed by strict protocols that call for staff to observe a “buddy system” when putting on and taking off the suit, to make sure it is done properly, so they are protected from head to toe.

Before and after entering the high-risk patient wards, they spray themselves with a chlorine mixture to kill any traces of the virus. Because the suits are hot and cumbersome, staff limit the amount of time they spend inside the patient wards. When possible, they try to avoid using needles to administer medicine, to minimize the risk of puncturing protective gear. And whereas most MSF workers commit 9 to 12 months to a mission, field staff in Ebola programs spend four to six weeks at a time in country before rotating out, due to the demanding nature of the work.

National staff who frequently live in the communities where they work are likewise given extensive training on how to avoid contracting Ebola both at work and at home. This has proven a challenge (see below) due to the lack of infection controls, including water and sanitation measures, in many of the affected communities, and the slow response by the international community to contain the outbreak so far.

How many MSF staff members have been infected with Ebola in the field, and why were they infected given the precautions taken?

In these projects, as in many of the projects MSF runs, our staff assumes a certain amount of risk, as they must in order to deliver medical care to people most in need. This is the case in West Africa, as it is in Syria, the Democratic Republic of Congo, or Afghanistan. There is no other way, and we can fairly say that more than 1,100 people treated in our programs have survived Ebola in West Africa due to the willingness of our field workers to assume these risks.

As of October 30, 2014, there are more than 3,300 MSF staff working on Ebola in West Africa. The total number of people who have worked in Ebola projects since MSF began its intervention last March is significantly higher. To date, 23 MSF staff have contracted Ebola [note: this was previously reported as 24, but one staff member thought to have contracted Ebola was revealed to have had Lassa Fever] and 13 have died. Eight have survived, and one, our colleague now in New York, is in treatment. Twenty of the 23 have been national staff, people who live in the country in which they were working (national staff make up the vast majority of MSF staff around the world). Three were international staff, or “expats.”

After each and every case, MSF conducts an investigation to figure out how someone was infected (the same happens after security incidents in other projects as well) and protocols are enhanced to address identified vulnerabilities. In the case of the national staff members, it was determined that the vast majority became infected due to contact with people with Ebola outside of MSF facilities, in their home communities. The international staff members who contracted the disease and were later treated in France and Norway were deemed to have become infected due to chance encounters in a triage area where new patients are screened. MSF is still investigating how Dr. Spencer might have become infected.

Further investigations are being conducted and we are constantly reviewing the protocols, layouts, and functions at our facilities to make them as safe as they can be for staff and patients alike. As our knowledge of this disease and this particular outbreak evolves, our protocols are adapted

How many international field workers have begun showing symptoms after they returned home?

Of the more than 700 international staff who have worked in our Ebola projects, Dr. Spencer is the first and thus far the only. But MSF had for months been in contact with city and state authorities across the country, as well as the federal government and the CDC, to prepare for just this sort of contingency (just as the CDC and other state and federal health agencies had been in touch with MSF to learn about our safety and treatment protocols, which they used to adapt their own after the first Ebola patient in the US was diagnosed in Dallas). We know that it is impossible to remove the risk of infection completely, but that rigorous preparation can vastly reduce any risk to people in the communities to which field workers return. And we also know that MSF, as an organization that treated more than 9 million patients worldwide in nearly 70 countries in 2013, can only continue to do this work if we take every possible step to keep our field workers healthy before, during, and after their assignments.

What are returned field workers instructed to do when they return?

As noted here, upon returning to the US, each MSF staff member goes through a thorough debriefing process, during which they are told they must: check their temperature two times per day; finish their regular course of malaria prophylaxis, since malaria symptoms can mimic Ebola symptoms; be aware of relevant symptoms, such as fever; stay within four hours of a hospital with isolation facilities; and immediately contact the MSF-USA office if any relevant symptoms develop.

These guidelines are consistent with those provided to date by the CDC to people returning from one of the Ebola-affected countries in West Africa. MSF is also implementing new federal guidelines outlining reporting requirements for people returning from Ebola affected countries.

Given what happened, are you reviewing your protocols?

Our protocols were designed to minimize the risk to others in the event that one of our returned aid workers began showing signs of Ebola, whether in the field or when back home. MSF is also cognizant of the understandable anxiety around Ebola in the US and other countries and is therefore looking at steps that go beyond the established scientifically and medically recommended protocols in order to assuage public concern. We are in close contact with federal health agencies, as well as state health and executive offices, in order to discuss revised protocols for returned aid workers that strike a balance between the need to address public worries and to treat appropriately those who’ve spent weeks in West Africa trying to contain the outbreak at its origins—still the most widely acknowledged way of preserving public health the world over—and treating those unfortunate enough to be suffering through the disease.

In the case of Dr. Craig Spencer, when did he first report symptoms?

On the morning of October 23, when he first began to feel feverish. He called MSF’s office in New York and MSF called city health authorities.

What was his temperature when he reported it?

100.3 degrees (not 103, as was erroneously reported initially).

How contagious was he when he was moving around the city?

Given when his symptoms began, and the extent of his fever when he first reported it—after which he was entirely isolated in his apartment—he would have been an extremely low risk for contagion. This is not an MSF assessment. This is based on all available medical and scientific knowledge about Ebola and how it spreads. Numerous public health and government officials have said as much and have lauded Dr. Spencer for quickly reporting the onset of his fever and for his conduct once the symptoms began.

Why would he move around the city during the 21-day incubation period?

Like all returned staff members, our colleague was fully informed about and aware of the nature of the virus and when it is and is not transmissible. He knew to monitor himself rigorously, which he did, and he reported it immediately when he first felt feverish. Before then, when he was asymptomatic, he was at most a negligible threat to others, not unlike the innumerable medical professionals who treat patients with highly infectious diseases—some far more infectious than Ebola—at medical facilities throughout New York City and the United States.

When did nurse Kaci Hickox first report her symptoms?

She did not, because she did not and does not have any symptoms.

Have any other US-based field workers reported any symptoms after coming home?


Was Dr. Spencer’s case an example of the protocols working or not?

From our perspective as an emergency medical organization, yes, it was. This was an example of the protocols working wherein a health professional who immediately reported a change in his condition and has since cooperated with all agencies involved in his care, as recognized by the New York City Department of Health and the Mayor of New York City.

What is MSF doing in West Africa now?

MSF’s West Africa Ebola response began in March 2014 and now involves activities in three countries: Guinea, Liberia, and Sierra Leone. As of October 30, MSF was employing 263 international and around 3,084 locally hired staff in the region. The organization is operating six Ebola case management centers and providing some 600 beds in isolation, more than any other organization is providing at present.

Since the beginning of the outbreak, MSF has admitted more than 5,200 patients. A total of 3,211 were confirmed as having Ebola. Some 1,265 Ebola patients have survived. More than 877 tons of supplies have been shipped to the affected countries since March. The estimated 2014 budget for MSF’s activities on the West Africa Ebola outbreak is $64.26 million.

You can read more about MSF’s Ebola response here.

Despite promises of greater assistance from many quarters, MSF is still seeing critical gaps in all aspects of the response, including medical care, training of health staff, infection control, contact tracing, epidemiological surveillance, alert and referral systems, community education, and mobilization.

Will this affect MSF’s work in West Africa?

Absolutely not. The work MSF is doing in West Africa is not only crucial to the effort to slow the outbreak in the immediately affected countries, but it also plays a role in slowing the spread into the broader West African region and beyond, including into Europe and North America. While doing everything possible to address the concerns of people in the US and assist our colleague now being treated in New York, MSF will also continue to treat people suffering from Ebola in West Africa, in countries where there are still precious few other options for care, despite the clear urgency of the situation.

Furthermore, MSF will continue to work in its other projects in nearly 70 countries around the world, where staff have in recent years treated millions upon millions of patients who would otherwise have not had access to lifesaving, urgent medical care. MSF has, in fact, treated more than 17 million patients the world over in 2012 and 2013 alone.

MSF has been outspoken about the need for a more robust response in West Africa from other governments and organizations. Will this continue?

Yes, without question. The most important step in the battle against Ebola—and in the effort to keep people in other countries as safe as possible—is containing the outbreak where it began and where it is most virulent. That is why MSF has for months now been calling on other governments, organizations, and even militaries to dedicate the appropriate resources and personnel to the effort, and to get them on the ground and operational as soon as possible. MSF has likewise repeatedly urged member states and departments of the United Nations to step up their efforts and has advocated at numerous levels for a quicker, more efficient implementation of pledges and promises that have been made to erect treatment facilities and manage them with appropriate medical staff.

As noted, MSF understands and shares the concerns about Ebola in this country, but anyone who is concerned about the spread of Ebola, anywhere, to anyone, should have been, and should now be, advocating for a more robust, comprehensive, and active operational response to the outbreak where it began and where it has done the most damage, in West Africa.

There are many children in the Guéckédou Ebola case management centre. Some are orphans, which makes caring for them more complex. Staff easily become attached to these patients, whom they are the only ones to touch and comfort through two pairs of gloves and a mask.
Julien Rey/MSF