Outbreaks of cholera, measles and yellow fever can spread rapidly and be fatal, and are a particular risk in poor living conditions. Malaria is endemic in more than 100 countries. Millions of people are living with HIV/AIDS and tuberculosis and are in need of proper treatment. Viral haemorrhagic diseases such as Ebola or Marburg are rarer, but are potentially fatal, with no treatment or vaccine currently available.

In the last couple of years alone, we have responded to outbreaks of yellow fever in Angola and Democratic Republic of Congo (DRC), plague in Madagascar, large-scale cholera and measles epidemics in several countries across Central and West Africa, and outbreaks of the long-forgotten disease diphtheria in Yemen and among Rohingya refugees in Bangladesh.

The ongoing COVID-19 pandemic has seen nearly every country around the world record cases, with more than a million people dying of the disease. MSF teams have responded, including providing treatment for the new coronavirus and assisting with infection prevention and control measures, in over 75 countries.

Who is at risk?

Epidemics and pandemics can place the strongest health systems under strain – but the people at highest risk are mainly those living in poverty or in areas of great instability. In these situations living conditions are precarious, access to healthcare is far from being granted to all of those in need, and routine vaccinations are often interrupted or have reduced coverage.

The resurgence of diphtheria in the refugee camps in Bangladesh in late 2017 is a testimony to the Rohingya’s exclusion from healthcare while in Myanmar. The majority of Rohingya were not vaccinated against any diseases, as they had very limited access to routine healthcare, including vaccinations.

In armed conflict, the destruction or damage of health infrastructure, disruption of disease-prevention programmes, and weakened surveillance systems, all heighten the risk of a serious outbreak.

War-torn Yemen, where the health system has collapsed and many hospitals have been bombed, was plunged into one of the most severe and largest-ever cholera epidemics in 2017. Our teams treated 101,475 cases. In late 2017, an outbreak of diphtheria - a long-forgotten, vaccine-preventable disease - also emerged.

In Central Africa Republic, routine vaccination coverage plummeted after instability and violence hit the country in 2013. The vaccination coverage rate for measles and pneumococcal infections fell from 64% to 25% and 51% to 20%, respectively. In response, in 2016 we organised a mass vaccination campaign with the Ministry of Health, vaccinating 220,000 children under 5 years old.

People living in camp settings can also be extremely vulnerable to outbreaks, particularly if there is overcrowding and water and sanitation services are poor.

Meanwhile, the COVID-19 pandemic has shown that people who are socially excluded, such as those who are homeless and the elderly – even in the world’s wealthiest countries – are vulnerable to disease, if they live close together with no proper outbreak prevention and control measures in place.

People living in homeless and refugee shelters in France and Belgium have been particularly at risk, with MSF teams setting up alternative accommodation for these groups of people with the coronavirus. Our teams have also responded in nursing homes, which have been badly hard-hit, in Spain, Belgium, France, the Czech Republic, the United States and other countries, where a lack of government response and measures have left elderly people – already at high risk – exposed and extremely vulnerable.

How to respond to outbreaks?

The needs of affected patients and communities need to be at the heart of any outbreak response for it to be effective. Reacting swiftly can significantly impact the number of people falling ill and those dying of disease.

An epidemic outbreak often requires a rapid and large logistics deployment, which depending on the situation, can range from setting up temporary facilities to treat patients, implementing infection prevention and control measures, or improving water and sanitation to help prevent the spread of a disease.

During outbreaks of highly contagious diseases like measles and meningitis, prevention often means vaccination. In addition to organising mass vaccination campaigns in response to epidemics, our teams also reinforce routine vaccination coverage in the health centres we work in.

For other diseases - such as some strains of meningitis, and viral haemorrhagic diseases - diagnosis and treatment is difficult with a lack of the right tools to fight the disease.

Awareness-raising is also important so that people know about the risks of the disease and how to help prevent its spread.

Pandemics

The current worldwide outbreak of COVID-19 is the world’s biggest pandemic in 100 years. Nearly every country on earth has recorded cases of the new coronavirus, which is similar to the virus that caused the SARS epidemic in 2003 and is believed to have originated in China in late 2019.

Healthcare systems around the world, including those of some of the wealthiest countries, have buckled under the strain under a staggering number of cases; as of mid-November 2020, over 55 million people had been recorded as having the disease – with one million new cases having been recorded every two or three days at some points – resulting in well over one million deaths.

MSF teams have responded to the pandemic in over 75 countries; some – such as the United Kingdom, Switzerland, Norway, the Czech Republic – for the very first time. Our teams have been responding to COVID-19 – including to provide treatment and advice on infection prevention and control – while trying to maintain existing services and access to medical care for people in countries we already work in.

Over the past two decades, MSF has treated people living with HIV/AIDS and tuberculosis (TB). In 2020, we started treatment for nearly 13,800 TB patients and antiretroviral treatment to over 77,000 people living with HIV. In addition to providing treatment, our advocacy teams also push for more affordable access to diagnostic and treatment tools.

Despite unprecedented international mobilisation in recent decades which has led to significant progress in the fight against HIV, the disease continues to kill massively, and is responsible for a million deaths per year.

In 2015 TB became the world’s deadliest infectious disease. Today it’s responsible for 1.4 million deaths per year, nearly all in developing countries. It’s estimated that over 10 million people develop the active form of the disease each year, and that over one-third are not diagnosed nor treated, due to a lack of adapted tools and financing. MSF is the world's largest non-governmental provider of TB care.

Ebola epidemic in West Africa 2014- 2016

The Ebola epidemic in Guinea, Liberia and Sierra Leone claimed over 11,000 lives including almost 500 health workers across the region.

At the forefront of the response, MSF responded to the Ebola epidemic in the three worst affected countries – Guinea, Sierra Leone and Liberia – and also responded to cases in Nigeria, Senegal and Mali.

We deployed up to 4,000 staff members and admitted more than 10,000 patients in Ebola management centres . We also provided psychological support, health promotion, surveillance, contact tracing, and ran activities to improve non-Ebola healthcare. Post-outbreak, we provided medical care for survivors of the disease in dedicated survivors' clinic.

Although we had over 20 years' experience working on Ebola outbreaks, the enormity of the West Africa epidemic tested our limits. At the peak of the outbreak, facing an exceptionally aggressive epidemic and a weak international response, our teams focused on damage control. This included making difficult choices in the absence of available treatment and sufficient resources, and making compromises between competing priorities of patient care, surveillance, safe burials and outreach activities, amongst others.

Global failures were brutally exposed in this epidemic. A lack of political will paralysed the initial global response and subsequent fear hindered it. To protect their own, governments effectively closed their borders and implemented tight quarantine measures to anyone from the Ebola-epidemic countries or to anyone - including aid workers and our staff - who had been there.

Ultimately, the needs of affected patients and communities need to be at the heart of any future response - to ensure that the tragic records set by this Ebola outbreak are never matched again.