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Safeguarding access to healthcare during COVID-19

A nurse wears a protective mask at Zugdidi regional TB hospital. Samegrelo region, Georgia, July 2016. © Daro Sulakauri/MSF
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    COVID-19 is a disease caused by a contagious new coronavirus, SARS-CoV-2, 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.   
    MSF is very concerned how the COVID-19 pandemic will affect people in countries with already fragile health systems. On any given day, our staff treats tens of thousands of patients for a variety of illnesses in our medical programmes around the world. In many areas where we work, there are few medical organisations in a position to respond to an overload of patients.

    Of particular concern is how coronavirus 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 and overcrowded conditions and their access to health care is already compromised.

    In particular, people living in large settlements, in overcrowded conditions with little sanitation and access to healthcare, can be at huge risk. People in these areas may have more difficulty to implement the recommended preventive measures and face obstacles to access healthcare.

    How can we ask people to protect themselves when they don’t have easy access to water? Or to stay at home and self-isolate if they rely on daily jobs to make ends meet or share a room with 10 other people?

    Nonetheless, it is very important to inform people on what protective measures to take (such as often washing their hands) and that they have the means to protect themselves (including self-isolation in case of contact with a person infected with COVID-19).

    If COVID-19 starts to be openly transmitted in fragile settings like these it will be practically impossible to contain. Basic health screening and ideally decentralised testing for high-risk settings such as refugee camps (Cox’s Bazaar in Bangladesh/Greek islands) or high-density slum dwellings (Kibera in Kenya or Khayelitsha in South Africa) needs to be implemented immediately.

    As soon as a single case is identified, isolation of these cases and increased measures to protect healthcare workers will be paramount. We must prevent widespread transmission in these areas by breaking transmission chains as quickly as possible, otherwise it will be impossible to control. People living in camps or slums are already very neglected – if an outbreak of coronavirus COVID-19 were to propagate in these settings, the impact will be more severe than that experienced elsewhere.

    Challenges in ensuring continuous care in MSF projects

    We want to ensure continuous care for all patients where we work today, and that our medical teams are prepared to manage potential cases of COVID-19. Protecting patients and healthcare workers is essential, so our medical teams are also preparing for potential cases of coronavirus disease COVID-19 in our projects.

    More research and information is needed on COVID-19 in patients co-infected with other diseases such as malaria, dengue, tuberculosis or measles. that are hugely prevalent in many areas where we work.

    In places where there is a high chance of seeing a number of cases, this means ensuring infection prevention and control measures are in place, including setting up screening at triage zones, creating isolation areas, and providing health education.

    In most countries where MSF works, we are coordinating with the World Health Organization (WHO) and local ministries of health to see how MSF could help in a situation with a high number of COVID-19 patients. We are also providing training on infection prevention and control for health facilities in a number of countries.
    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 for other diseases due to a lack of production of generic drugs and difficulties to import essential drugs (such as antibiotics, antimalarial and antiretroviral drugs), caused by community lockdowns, reduced production of active pharmaceutical ingredients, and reduction in export movements.

    We face additional challenges because current travel restrictions linked to COVID-19 are limiting our ability to move staff between different countries. Currently, much of our international staff are unable to travel to project sites; 50 per cent of our international staff come from Europe, and are no longer able to go to projects. We are trying to find ways to manage this, as it can have a heavy impact some projects needing specialist profiles, such as surgeons. However, international staff represent just eight per cent of our total global workforce, so most MSF projects are run by locally hired team members. 

    MSF response to coronavirus disease COVID-19

    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), we are supporting three hospitals in the epicentre of the outbreak, in the country’s north, with infection prevention and control measures, as well as providing care to patients. Outside the hospitals we are starting activities to support family doctors and healthcare workers assisting people under isolation at home, and the staff of a nursing home for the elderly where cases have been detected.

    In Belgium, MSF is supporting organisations that work with vulnerable groups such as homeless people and undocumented migrants, with triage and infection prevention and control (IPC) measures.

    In France, we are setting up activities to help detect and manage coronavirus COVID-19 cases among the most vulnerable populations in Paris and the surrounding region. Activities will include mobile consultations and screening to be able to the most vulnerable, and support with diagnosis, isolation and case management in both existing and prospective shelters.

    In Spain, MSF is advising the Spanish Ministry on developing models to expand the capacity of hospitals as well as identifying venues where hospitals can be set-up but there is no direct case management at this stage due to lack of PPE. We are also participating in the MOH crisis communication to advise on strategies based on our expertise in managing epidemics.

    In Hong Kong, we are providing health education and mental health support for vulnerable groups. Staff in health facilities in Cambodia and Papua New Guinea have received training.

    In Iran, MSF has submitted a proposal to the authorities to help care for patients with COVID-19.

    In Libya we have delivered trainings on infection control & case management to nurses & doctors in hospitals in Tripoli.

    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 send staff.

    About coronavirus disease COVID-19

    COVID-19 will be a mild respiratory illness for the vast majority of people (estimated 80 per cent 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.

    More than 160 countries have now reported cases, and on 11 March, the WHO declared COVID-19 as a pandemic. The number of confirmed cases is near 250,000. While it took more than three months to reach 100,000 cases, it took only 12 days to reach the next 100,000. Four countries in Europe are reporting the highest number of cases: Italy (now with more deaths than China), Spain, Germany, and France.

    The number of cases in Africa has remained comparatively low – around 650, with the highest numbers in South Africa - but the health system in many African countries could be quickly overwhelmed should the virus take hold. Containment measures must to be in place and strengthened to avoid this worst-case scenario.

    Based on current data from WHO, 20 per cent of people confirmed to have COVID-19 will be severe and those people will require hospitalisation for sustained monitoring and supportive treatment. Six per cent of total confirmed cases will require critical care provision (about 30 per cent 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 the number of cases and severely ill patients, 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 more vulnerable family members. They should also not hinder or delay medical care for patients suffering from any other disease.

    As the research and development is underway for effective treatment for coronavirus COVID-19, we are closely tracking the trials and evidences concerning the potential medicines in the pipeline.

    For comprehensive information, including how to protect yourself against the disease, please visit the World Health Organization's (WHO) COVID-19 webpage. For updated technical information and details on the evolution of the pandemic please see WHO's COVID-19 situational report page.

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