MSF update on COVID-19 coronavirus outbreak

Several factors make this virus particularly worrying. Being a new virus, there is no acquired immunity; as many as 35 candidate vaccines are currently in the study phase, but experts agree that no widely usable vaccine will be available for at least 12 to 18 months. The case-fatality rate, which by definition is calculated only on the basis of identified patients and is therefore difficult to estimate accurately currently, appears to be around 1%.

It is known that at least some of those affected can transmit the disease before developing symptoms - or even in the absence of any symptoms. In addition, a very high proportion - around 80% - of people develop very mild forms of the disease, which makes it difficult to identify and isolate cases quickly. Confirmation of the diagnosis requires laboratory and/or medical imaging capabilities that are only available in reference structures. It is therefore not surprising that it has proved impossible to contain the spread of the virus, which is now present in more than 100 countries around the world. This epidemic is therefore very different from those - such as measles, cholera, or Ebola - in which Médecins Sans Frontières has developed its expertise over the last few decades.

Furthermore, it is estimated today that approximately 15-20% of patients with Covid-19 require hospitalization and 6% require intensive care for a duration of between 3 and 6 weeks. This can, of course, quickly saturate the healthcare system - this was the case in China at the beginning of the epidemic, and is currently the case in Italy. There are currently more than 1,100 patients in intensive care units in the country and the hospital system in the North, although well developed, has been overwhelmed by the rapid increase in the number of patients.

As is often the case during this type of epidemic, medical staff members themselves are particularly exposed to infection. Between mid-January and mid-February in China more than 2,000 health care workers were infected with the coronavirus (3.7% of all patients). 

This epidemic is likely to lead to the disruption of basic medical services and emergency facilities, the de-prioritization of treatment for other life-threatening diseases and conditions and for other chronic infectious diseases everywhere... but especially in some developing countries, where the health system is already fragile.

Even though they cannot prevent the outbreak from spreading the measures currently being taken by many countries can slow it down by reducing the increase in cases and limiting the number of severe patients that health systems have to manage at the same time. The aim is not only to reduce the number of cases but also to spread them over time, avoiding congestion in emergency and intensive care units.

Priorities for intervention vary from one context to another.

In some areas that seem to be spared today, such as the Central African Republic, South Sudan and Yemen, where fragile or war-torn health systems are already struggling to meet the health needs of the population, it is necessary to protect healthcare personnel and to limit the risks of spreading the epidemic as much as possible. This is done by implementing prevention programmes - identifying areas or populations at risk; running health awareness and information activities; distributing soap and protective equipment for healthcare personnel; and reinforcing hygiene measures in medical structures - to prevent our hospitals and clinics from becoming places where the disease is transmitted. In these countries where MSF has a longstanding presence we want to contribute to these efforts against Covid-19 while ensuring continuity of care against malaria, measles, respiratory infections, etc. 

This continuity is now weakened by the restrictions (a ban on entering the country, preventive isolation for 14 days, etc.) imposed by governments on staff from certain countries, such as Italy, France and Japan,, where some of our international staff come from, as well as the closure of borders and the suspension of certain air links. Despite these constraints, our strength lies in the fact that we can rely on locally recruited staff in our countries of intervention. They represent 90% of our employees in the field.

In countries where health systems are more robust but where the epidemic is particularly active, such as Italy or Iran, the main challenge is to avoid overloading hospital care capacities. In these contexts we can contribute to the efforts of national medical teams by making MSF staff available to support or relieve them when needed. We can also help by sharing our experiences in triage and control procedures for infections acquired during epidemics. We have provided teams to support four hospitals in northern Italy and have also offered support to the Iranian authorities to support them in caring for severe patients. Depending on the evolution of the epidemic in France, we will make available to the response our experience, our logistics and the know-how of our staff, if they can be useful.

One of the keys of the fight against Covid-19 is the availability of protective equipment, in particular masks and gloves used for medical examinations. The anticipation of shortages leads to requisitions by many states, which can in turn become a reflex on the part of states to monopolise these precious resources. In the current context such equipment should on the contrary be considered as a common good to be used rationally and appropriately and therefore to be allocated as a priority to health workers exposed to the virus, wherever they are in the world.

Generally speaking, this pandemic requires solidarity not only between states but at all levels, based on mutual aid, cooperation, transparency, the sharing of resources, and, in the affected areas, towards the most vulnerable populations and towards caregivers.

More than 100 countries have now reported cases, and on 11 March, the WHO declared COVID-19 as a pandemic. Most countries still have only sporadic cases or defined clusters. 90% of the 118K cases are being reported from four countries: cases in China are now decreasing, but there are major outbreaks in Italy, Iran and South Korea. In other countries, including Europe, the numbers are growing exponentially.

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 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. 

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. 

This epidemic, in terms of scale and global spread and rapidity, has a huge effect on health care systems in the countries affected. Hospitalising so many people for such a long time at such a high level of care poses a real challenge to even the most advanced healthcare systems. We are very concerned about the consequences in countries with weaker healthcare systems, who will struggle even more if they have to deal with a large number of patients with COVID-19.

A) Ensuring continuity of medical care

MSF supports extremely 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 live 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, 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) Protecting our patients and healthcare workers

Protecting patients and healthcare workers 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 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) Our actions against the epidemic

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, we are providing health education and mental health support for vulnerable groups.

In Iran, MSF has submitted a proposal to the authorities to help caring for patients with COVID-19. Whether we’ll be able to make similar offers to other countries will depend on the nature of the outbreak but also on our capacity to deploy.

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 severely compromised. 

Generally, we are very concerned how COVID-19 outbreaks will affect countries with already fragile health systems, such as in Central African Republic (CAR) or Yemen.  

Infections of healthcare staff can happen easily in structures that are overwhelmed by large numbers of patients, and that have to deal with limited supplies of personal protective equipment for staff and probable reduced workforce. Infected healthcare staff will further reduce the capacity to admit and treat patients. Safety for healthcare workers should be a top priority in every healthcare facility.

In order to ensure that the medical tools urgently needed to respond to COVID-19 are accessible, affordable, and available; concerned stakeholders including governments, pharmaceutical corporations and other research organizations developing treatments, diagnostics, and vaccines should take the necessary measures to:

• prevent patents and monopolies from limiting production and affordable access;
• guarantee access to repurposed drugs for patients suffering from diseases that are the original indication for use to ensure continuation of care; 
• prioritise the availability of the medical tools for protection and treatment of front-line healthcare workers; and  
• Improve transparency and coordination, making sure an evidence-based approach is put in place to continuously monitor the risk of the potential supply chain vulnerability on essential medical tools, and to adapt mitigate measures when needed through international collaboration.

The disease is caused by a virus, currently called 2019-nCoV, which was discovered in early January in China and has been identified as a member of the family of coronaviruses. 2019-nCoV seems to be transmitted through droplets, spread by coughing.

The main symptoms include general weakness and fever; coughing and sometimes difficulty of breathing in a later stage. In 20 per cent of the reported cases, it has led to pneumonia. The early symptoms of some patients are mild and the disease ranges in severity.

Since it is new, much remains to be understood about the virus. Our understanding of the virus and the disease is still evolving. Some people that are infected with 2019-nCoV have become very sick, others were only mildly sick.

The disease is likely more dangerous for elderly people or people suffering from other infections or ailments, as often is the case with infectious diseases. Most cases reported to date have been mild or moderate, with around 20 per cent of those infected experiencing severe illness. At the end of January, around 2-3 per cent of the patients have died of the disease.

Our understanding of the virus and the disease is still evolving. It seems the virus can spread by sick people coughing. But how efficiently the virus is transmitted from one person another is not fully understood yet.

SARS (Severe Acute Respiratory Syndrome) and MERS (Middle Eastern Respiratory Syndrome) are both infections of the respiratory system. They are caused by types of coronavirus (SARS-CoV and MERS-CoV respectively) related to 2019-nCoV.

SARS was discovered in 2002 in mainland China and spread to a number of other countries. More than 8,000 people fell sick, and 774 of them died of the disease. Since 2004, no new cases of SARS have been recorded. MSF intervened in mainland China, Hong Kong, and Vietnam for the outbreak of SARS.

MERS was discovered in 2012, when an epidemic started in Saudi Arabia. More than 1,200 people fell sick, and 449 of them died. MERS still infects people every now then, primarily in Middle Eastern countries. MSF has not intervened during outbreaks of MERS.

For now, the health authorities are leading the response efforts including diagnosis of the virus, patient care, contact tracing, and investigations into a better understanding of the disease. Since it is a new virus, there is currently no vaccine or specific treatment (though supportive care is given to treat symptoms), and the understanding of the virus and the disease are still evolving.

We do know that in a respiratory disease outbreak, it is important to apply hand hygiene, coughing etiquette, avoid close contact with people showing symptoms of respiratory diseases, and inform a doctor when feeling sick. Public awareness of the virus and enhanced prevention measures such as these are key components for prevention.

During the outbreak of SARS, MSF supported the Bach Mai Hospital in Vietnam with an isolation ward. In mainland China, we gave support with training of healthcare staff in Infection Prevention and Control in the city of Guangzhou.

In Hong Kong we provided support with training of healthcare staff in infection prevention and control, healthcare education for people, and donated protection equipment.

MSF did not intervene for MERS outbreaks.

As with other coronaviruses, droplet infection seems to be the main mode of transmission, so infection prevention control measures such as hand-washing, and cough and sneeze etiquette are important for prevention.

Hand hygiene is paramount, so wash your hands often with soap and water. Use enough soap, and make sure all parts of both your hands are washed. Spend at least 20 seconds washing your hands. If there’s no visible dirt on your hands, an alcohol-based gel is also a good option.

If you cough or sneeze, cover your mouth and nose with a tissue, or with the inside of your elbow. Put used tissues in the bin immediately, just like used masks, and wash your hands.

A mask is a good preventive measure to protect from breathing in the virus or transmitting it if you are sick. Only touch the strings of the mask when you take it off. Put it directly in the bin and wash your hands.