The following information has been compiled to address questions about Médecins Sans Frontières/Doctors Without Borders (MSF) protocols and practices regarding the organization’s Ebola projects in West Africa and the people working there.

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 to ensure the greatest possible safety for our staff and patients alike.

  • 1. What do the recent New York and New Jersey orders about putting returning medical workers under quarantine mean for MSF?

    MSF’s October 27 statement 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 new regulations imposed in New York and New Jersey regarding health workers returning from an Ebola context come with numerous concerns. They seem haphazard and not well thought out, and they have already had some troubling consequences for MSF field staff returning 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 home. This will undermine the effort to combat and control the outbreak in West Africa, where Ebola is doing the most damage, and thereby, as noted below, undermine the effort to keep people everywhere safe.

    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, explains 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.

     

  • 2. 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 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 virus 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. Patients become more infectious as the symptoms worsen, particularly after they develop gastrointestinal symptoms such as diarrhea and vomiting, and 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 isolate themselves and are 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.

  • 3. What preparations are made before staff leave for the field?

    In general, MSF accepts only some 20 per cent 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.

  • 4. What precautions are implemented in the field?

    All field workers take extreme precautions when working in MSF facilities. Our treatment centres 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 prevents 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 their suits, to make sure it is done properly, so they are protected from head to toe.

    Before and after entering the high-risk patient wards, staff spray themselves with a chlorine mixture to kill any traces of the virus. Because the suits are hot and cumbersome, staff will 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 nine to 12 months to their overseas missions, field staff members in Ebola programs spend four to six weeks at a time in country before rotating out, due to the demanding nature of the work.

    Locally hired employees (known as “national staff”), who frequently live in the communities near 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.

  • 5. 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, Afghanistan or any of the other nearly 70 countries around the world where MSF works. 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.

    At present, there are more than 3,200 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, 24 MSF staff have contracted Ebola and 13 have died. Ten have survived, and one, our colleague now in New York, is in treatment.  Twenty-one of the 24 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 they became infected due to contact with Ebola-infected people 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 in order 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.

  • 6. 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 one who has shown symptoms only after returning home. 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 nine 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.

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

    Upon returning to the Canada, 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 office if any relevant symptoms develop. 

  • 8. 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 Canada and other countries, and is therefore looking at steps that go beyond the established scientifically and medically recommended protocols in order to calm public concern. We communicate regularly with the federal health agency, as well as provincial health authorities in order to discuss best practices in managing Ebola cases as well as supporting returned aid workers in a way that reassures public worries. Containing the outbreak at its origins is still the most widely acknowledged way of preserving public health in this outbreak —and treating patients who are suffering through the disease.

  • 9. 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 23, MSF employed 270 international staff and more than 3,000 locally hired staff in the region.

    The organization is operating six Ebola case management centres 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 4,900 patients. Around 3,200 were confirmed as having Ebola. Some 1,140 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 $58.5 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.

  • 10. Will the public’s concerns about MSF protocols affect MSF’s work in West Africa?

    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 Canada, 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 of patients who would otherwise have not had access to lifesaving, urgent medical care. MSF has treated more than 17 million patients the world over in 2012 and 2013 alone.

  • 11. 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 medical military personnel 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.