Doctors Without Borders (MSF) Crisis Info COVID-19

Background on COVID-19

This is a new contagious virus and much remains to be understood. Unlike influenza, there is no known pre-immunity, no vaccine, no specific treatment and everyone is presumed to be susceptible.

This will be a mild or moderate respiratory illness for the vast majority (estimated 80% of confirmed cases) but it has a higher rate of quite severe complications for vulnerable people (elderly and people with comorbidities), than other viruses such as flu.

Based on current data (WHO joint mission report from China[1]) 20% of the confirmed cases will be severe and require hospitalisation for sustained monitoring and supportive treatment.  6% of total confirmed cases will require critical care provision (about 30% of those hospitalised).

The high level of supportive and intensive care required has placed a heavy burden on some of the world’s most advanced hospital systems. 

Public measures such as isolation, quarantine and social distancing are generally put in place to limit uncontrolled community transmission, slow down number of cases and severely ill patients and protect the most vulnerable and manage the collective health resources. However, these measures should not lead to an increase risk of transmission within a household and particularly for the more vulnerable family members.

Please note that this data is based on what is available so far and may vary somewhat in each scenario. (Countries have different policies for testing, so the proportion of confirmed cases with complications will also vary according to how much testing is done of non- complicated cases for example)  WHO’s interim guidance and other information on coronaviruses can be found here: https://www.who.int/health-topics/coronavirus

Background glossary– What is intensive care?

This is just for general background understanding, on what is meant by ICU and critical care, as this is one of the key issues in COVID-19. We will provide more detailed info on this if needed.  Any specific or technical questions on this are better answered by medical staff with ICU experience.

Intensive care for COVID-19 patients can be required for anywhere from 3 to 6 weeks, or even more, and requires very specialist medicine, which includes the capacity to intubate and ventilate and manage full organ support (such as dialysis). ICU care essentially takes over the functions of different organs in the body to allow for recovery. For example, for people suffering from respiratory failure, mechanical ventilation gives time for the lungs to recover, if the lung failure is reversible. The functioning of different organs of the body is closely linked, so if one organ starts to fail often others follow. Critically unwell patients might develop cardiac failure, or kidney dysfunction, which needs to be managed too.

Each patient should ideally have a dedicated nurse and all doctors working in the unit have long and highly specialised training. Care involves constantly adjusting the equipment used to take over the function of the organs, adjusting how much oxygen is delivered, ventilator pressure settings, the infusion of life-saving medicines. If you intubate and ventilate a patient you take over complete control of their airway and breathing, meaning that someone competent must remain at their side at all times because any problem could be quickly fatal.

The provision of intensive care requires extensive resources in terms of equipment and specialist staff. There are relatively few fully equipped and staffed Intensive Care Units throughout the world, particularly in low- and middle-income countries. Even in wealthy countries many intensive care units run at capacity, with little reserve to expand services in case of high demand. This is why events in countries like Italy have been so catastrophic - apart from the increased demand for ICU places because of critically unwell COVID-19 patients, ICUs have to also continue to care for other critically unwell people, suffering from sepsis, trauma or cardiac failure. Each new patient ties up not just the 'bed', but the equipment and most importantly the staff, and it can be assumed that each COVID-19 patient will stay for at least a month, if they survive. While more physical beds can be added to an ICU, it is not possible to train new staff quickly enough to expand services, so instead doctors are force to choose who is admitted when there is just not enough capacity.

Most MSF activities occur in low-income countries, where intensive care capacity is usually absent. MSF projects sometimes have the capacity to provide high dependency care, meaning that patients have access to oxygen, and there are more nurses and doctors available than in the standard hospital services to closely monitor patients. However, these services only rarely (in big hospital projects or trauma surgery programmes) exist in MSF projects and do not have the capacity to take over the functioning of vital organs, for example via mechanical ventilation.

Main messages:

A.         Preserving access to healthcare, both for COVID-19 patients as well as everyone else. This means ensuring that hospitals don’t become overwhelmed, and that health staff can cope with the number of patients requiring intensive care and continue providing treatment to other patients who need it too. Our projects are still able to continue medical activities, but ascertaining future supplies of certain key items, such as surgical masks, swabs, gloves and chemicals for diagnosis of COVID-19 is of concern. There is also a risk of supply shortages due to lack of production of generic drugs and difficulties to import essential drugs (such as antibiotics and antiretroviral drugs) due to lockdowns, reduced production of basic products, exportation stops or repurposing/stocking of drugs and material for COVID-19.

B.         Working in settings with fragile health systems: Generally, we are very concerned how COVID-19 outbreaks will affect people in countries with already fragile health systems, such as in CAR or Yemen.  In many areas where we work, there are few medical actors in a position to respond to an overload of patients. We want to make sure that we continue to ensure care for all patients where we work today, and that our medical teams are prepared to manage potential cases of COVID-19.   In places where there is a higher chance of cases, this means ensuring infection control measures are in place, setting up screening at triage, isolation areas, and health education. In most countries where MSF works, we are coordinating with the WHO and the Ministries of Health to see how MSF could help in case of a high load of COVID-19 patients and are providing training on infection control for health facilities.

C.         Populations in precarious settings at risk: MSF is extremely concerned how COVID-19 might affect populations living in precarious environments such as the homeless, those living in refugee camps in Greece or Bangladesh, or conflict affected populations in Yemen or Syria. These people are already living under harsh and often unhygienic conditions and their access to health care is already compromised. They may have more difficulty to implement the preventive measures and face obstacles to access healthcare. It is very important to inform people on what protective measures to take and that they have the means to protect themselves (washing hands and self-isolation in case of high-risk contact with COVID-19 patients). 

Key numbers

Epidemiologic Situation – as of 12 March

• Total cases since the declaration of the epidemic: 162.443 – 90% of which from China, Italy, Iran and South Korea
• Total number of deaths: 4641
• Countries and regions affected: more than 100
• These numbers change regularly – one website to check for the latest numbers is here: https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6

References for all UPDATED info:

• https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports
• https://www.chp.gov.hk/files/pdf/statistics_of_the_cases_novel_coronavirus_infection_en.pdf

MSF’s activities

A key priority for MSF is to keep our regular medical programmes running for the extremely vulnerable communities we are supporting around the world. We have tens of thousands of patients with other conditions. This is challenging, because these programmes are impacted by the current travel restrictions, which limits our ability to move staff between countries. We also have to deal with the consequences of global shortages of medical supplies, in particular personal protective equipment for healthcare staff, which can affect all programmes. These regular healthcare programmes are also preparing for having to deal with potential cases of Covid-19, especially making sure infection prevention measures are respected. We must be able to receive COVID-19 patients, and make sure that no one is consequently infected in our structures, patients nor staff.

MSF regular programmes: MSF supports extreme vulnerable communities with our medical programmes around the world. In any given day we are treating hundreds of thousands of patients for a variety of ailments. We need to ensure we can continue to provide adequate and life-saving medical care in our ongoing projects. This is challenging because current travel restrictions are limiting our ability to move staff between different countries. There is also global pressure on the production of some medical supplies, in particular specialised personal protective equipment for healthcare workers. Our projects are still able to continue medical activities, but ascertaining future supplies of certain key items, such as surgical masks, N-95 masks and gowns, is of concern. 

COVID-19 preparation: Protecting healthcare workers and patients is essential, so our medical teams are also preparing for potential cases of COVID-19 in our projects. In places where there is a higher chance of cases, this means ensuring infection control measures are in place, setting up screening at triage, isolation areas, and health education. In most countries where we have projects, MSF is coordinating with the WHO and the Ministries of Health to see how MSF could help in case of a high load of COVID-19 patients. In many countries, we are providing training on infection control for health facilities.

COVID-19 response: It is clear that healthcare workers need support and patients need care. Given the size of this pandemic, MSF’s ability to respond on the scale required will be limited. In Italy, which is now the second-most affected country (after China), this week MSF has begun supporting four hospitals in the epicentre of the outbreak with infection control, as well as patient care. In Hong Kong, our health education and mental health support continues for vulnerable groups. In Iran, MSF has submitted a proposal to the authorities to help caring for patients with COVID19. Whether we’ll be able to make similar offers to other countries will depend on the nature of the outbreak but also on our available resources.

All MSF interventions aim to prevent and to protect the staff, and to prepare projects and health systems to provide healthcare in case the virus overcomes all these barriers. With regards to international travel of MSF staff, there is no magic bullet to achieve zero risk, but we are determined to do all we can to minimise the risk of importing cases. Should this happen, we are working to ensure a proper response is in place to care for the staff and limit any further transmission.  Every individual, in MSF and worldwide, has also a key role to play - apply the universal precautions, report symptoms and follow MSF and health authorities’ recommendations.

OCB: In Italy, MSF is supporting 4 hospitals in the epicentre of the outbreak in Lombardia. MSF is running a health promotion project in Hong Kong, targeting vulnerable groups such as migrants, refugees, homeless people, etc. In Greece, MSF has prepared an emergency plan in case the refugee camp of Moria should the epidemic spread on the island. In Belgium, MSF is supporting organisations that work with vulnerable groups such as homeless people and undocumented migrants. In Afghanistan, MSF is supporting the authorities with technical advice.

OCP: MSF teams contacted health authorities in several of our countries of intervention, in order to assess their needs and propose support. In Iran, MSF has submitted a proposal to the authorities to help caring for patients with COVID19. In Afghanistan, teams are also assessing the situation in Herat where cases have been declared.

OCA: MSF is supporting the MoH in countries where we are already working in, with IPC improvements in some of the health facilities, and participating in Covid19 preparation meetings. In North East Syria MSF is preparing for COVID-19 patient care as the Ministry of Health (health governance) is hardly functioning in this part of the country due to the conflict.

OCG: Missions provided upon request support and guidance to countries we have regular activities in Asia (e.g. Kyrgyzstan). This includes pragmatic implementation of measures dealing with health promotion, infection prevention control, rational use of emergency equipment and triage in order to help prevent possible hospital overloads. MSF teams are in touch with MoH and WHO regional offices to provide support upon request.

OCBA: We are preparing our own staff and structures to deal with an outbreak of COVID-19. The teams are working on emergency preparedness scenarios and contingency plans for potential outbreaks in our health facilities. Some of this preparedness includes trainings, surveillance enhancement, infection prevention and control, medical supplies, case identification and management, contact tracing, community education and engagement.

[1] https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf