Last updated: 27 November 2020
Highlights of our COVID-19 response activities can be found in the interactive map below; click on a country to read brief information.
To read detailed information on our activities per country, scroll down to the list below, or click on the regions on the menu to the left.
(Note: neither map nor detailed activities list below are exhaustive of all of our COVID-19 response.)
MSF response to coronavirus disease COVID-19
We started our first activities in our response to the COVID-19 pandemic in January 2020. As the new coronavirus spread, touching virtually every country in the world, MSF adapted or scaled up our ongoing activities and started new activities in many countries over the course of the first six months of 2020.
We committed substantial resources to developing dedicated COVID-19 projects, maintaining essential healthcare in our existing programmes, and accompanying ministries of health in preparing and/or facing the pandemic. This support was often in the form of training in infection prevention and control, health promotion and organisation of healthcare services.
In the second half of 2020, most of this training has concluded, and the greater part of our COVID-19-specific activities have been handed over or closed. Most COVID-19-related activities have been integrated in our regular projects, although we are maintaining some COVID-19-focused projects and, with the second wave of infections in some areas, some activities are re-opening, especially in Europe. Where we are doing so is very much dependent on the context: the local epidemiological situation, the local health needs, and our own resources.
It is still difficult to provide a global narrative on our operations, as the pandemic is affecting every country in the world, with different consequences, in different places. Therefore, our approach can also be very different from country to country or even from project to project.
In São Paulo, Brazil, MSF staff are working in collaboration with MoH staff in providing palliative care to patients at the Tide Setubal hospital.
In the state of Mato Grosso do Sul, our team in Amambaí has been conducting IPC training while waiting for an authorisation from federal authorities to work in indigenous territories.
In Rio de Janeiro, we undertook screening and health promotion activities with the homeless and vulnerable people.
In Manaus, in the country’s north, an MSF team trained local health professionals on infection and prevention control. We worked at the public hospital 28 de Agosto, and provided treatment to people in ICU beds and in a ward for moderate and severe cases of COVID-19. We also ran an isolation centre for migrant Venezuelan indigenous people with suspected COVID-19.
In São Paulo, MSF teams ran medical activities at two isolation centres with a total of 140 beds, for vulnerable patients (homeless people, drug users and the elderly) with mild COVID-19. Teams worked with homeless people – in shelters and on the streets – youth in adolescent detention centres, and with heavy drug users, providing health promotion and IPC education, and ran a mobile triage clinic in the downtown area. At Tide Setubal hospital, in the city’s east, we opened an eight-bed intensive care unit and provided care to people from the neighbourhood and those from outside São Paulo; we closed these activities on 8 October.
In the same São Paulo neighbourhood as Tide Setubal, our teams undertook outreach for active case finding and contact tracing of people who were admitted to the ICU. MSF teams also ran health promotion activities in the neighbourhood’s slum districts, and developed health promotion activities, in addition to having installed handwashing points and distributed hygiene kits to residents, in partnership with local leaders. We ended these activities at the end of September.
In Amazonias state, teams worked in the remote towns of São Gabriel da Cachoeira and Tefé, several hours by plane from Manaus. In Tefe, we provided training at the town’s main hospital and undertook epidemiological surveillance in rural villages. In São Gabriel da Cachoeira, we ran a 10-bed ward where we treated people with moderate cases of COVID-19.
In the state of Mato Grosso do Sul, in Brazil’s south west, we ran mobile clinics in indigenous areas near the towns of Aquidauana and Anastacio, and in the Aquidauana urban area; we also supported the activities at the local hospital in Aquidauana. All activities in the region had ended by 12 October.
In Boa Vista, in Roraima state, MSF staff worked in a COVID-dedicated field hospital, providing medical care in an ICU ward treating people with moderate and severe cases. Our team also visited informal shelters where migrants and refugees from Venezuela gathered, and provided hygiene and physical distancing guidance to residents. We assisted in expanding access to water in formal and informal shelter and distributed hygiene kits.
In mid-September, we started providing medical care to prison detainees in Corumbá. Our staff monitored for COVID-19, but teams treated COVID-19 comorbidities such as TB and hypertension to men in the men’s prison, and we provided medical consultations at the women’s prison. These activities closed at the end of October.
In Guerrero state, on Mexico’s lower Pacific coast, MSF teams have coordinated with the state health authorities to provide technical IPC support in several state hospitals. We are also providing training for health staff and support in setting up patient and staff flow.
MSF teams are also working in migrant shelters. The objective is to help shelters and migrant centres to adapt their structures to the pandemic response, including IPC measures.
MSF teams established an auxiliary hospital unit in a basketball stadium in Tijuana, in the far northwestern corner of Mexico. MSF medical staff provided treatment to non-critical COVID-19 patients, which relieved the burden on local hospitals.
In Matamoros and Reynosa, on the eastern Mexican/US border, our team provided medical care to mild and suspected patients, and severe patients that needed oxygen, in two adapted centres for COVID-19 patients.
We are currently triaging and supporting patients with respiratory symptoms at Tibú hospital, in Colombia’s north. In Buenaventura, we have adapted and expanded our psychological care Line #335 for the early identification of potential patients with symptoms of COVID-19.
In Arauca, we are providing technical advice to hospitals and mental health support to medical staff. MSF teams are also engaging people on health promotion and IPC activities in towns, villages and neighbourhoods throughout the northeast, through different community strategies and the media.
MSF is working closely with health authorities in Norte de Santander and Tumaco to support the local response. We are currently participating in outpatient triage and supporting the area for patients with respiratory symptoms at the Tibú hospital. In Tumaco, we are carrying out medical and mental health activities in the two public hospitals in the city. In each of these places we are also focusing a large part of our efforts on promotion and prevention activities in towns, villages and neighbourhoods through different community strategies and the media.
We have deployed a small technical team, the Flying COVID Team, which has been supporting local hospitals in Atlantico, one of the regions most affected by COVID-19. The team’s work, which is now supporting Erasmo Meoz Hospital in Cúcuta, has focused on rapid assessment, technical training, mental health care for health staff, and donations of medicines and supplies to help health facilities keep COVID-19 services safe at the peak of the outbreak.
In Caracas, Venezuela’s capital, MSF teams are working in Pérez de León II hospital in the Petare neighbourhood, where teams rehabilitated the infrastructure, adapted the patient flow, established IPC measures and trained staff to receive COVID-19 patients for hospitalisation and ICU care. Teams are providing medical care and logistic support.
MSF is also supporting with staff recruitment, treatment and hospital support system services in Vargas hospital in Caracas.
Activities closed. In Canada, we used our expertise in emergency outbreak response to provide valuable guidance to medical organisations, government agencies and remote Indigenous communities on how to prevent and manage COVID-19 outbreaks. Teams created and shared two e-briefings related to COVID-19; one on infection prevention and control (IPC) and another on adapting and developing medical facilities.
MSF facilitated experienced field staff in Canada to join other front-line organisations. MSF teams conducted several IPC assessments in shelters in Toronto for people experiencing homelessness and long-term care facilities in Montreal, providing recommendations to improve staff and residents’ overall safety. After three months of activities, all MSF COVID-19 projects in Canada had closed by 15 July.
Activities closed. In the United States, MSF worked in key sites around the country with local authorities and partner organisations serving vulnerable communities who often lack access to healthcare. Our teams also helped residents and staff at long-term healthcare facilities reduce and stop the spread of the coronavirus. The last of our activities in the US ended on 15 October.
Our response in the US started in New York in March. During our activities, we donated over 160 handwashing stations to key locations, including soup kitchens and supportive housing facilities in the city. We also distributed 1,000 mobile phones to vulnerable New Yorkers who lack the essential technology needed to contact emergency and support services, including telemedicine providers. MSF teams opened a shower trailer in Manhattan to give people who are homeless or housing insecure a place to bathe while public restrooms and facilities are closed due to COVID-19. We also supported New York City authorities with webinar training on IPC practices.
MSF teams worked in nursing homes across the country, including in Michigan and in Texas. In Michigan, in the country’s northeast, our team worked in nursing homes which needed assistance, including general guidance to improve infection prevention and control practices; technical on-site support and training; and mental health workshops to address the high level of stress and grief that the frontline staff face every day. Our activities in Michigan came to a close at the end of July. Starting in August, two MSF teams, comprised of nurses and a wellness specialist, worked in nursing homes across Texas. Each team conducted in-person IPC trainings and created tailored IPC action plans for both medical and non-medical staff. They also provided technical support and wellness sessions to staff and residents. Our support to facilities in Texas ended in mid-October.
On the island of Puerto Rico, MSF teams worked across the island, in and around San Juan, or travelled to remote areas in the east, west, south and the third-largest island, Vieques. Teams distributed essential supplies, such as masks, face shields and hygiene kits to healthcare facilities and vulnerable groups of people on the island. We also provided training on IPC measures. We collaborated with local partners on the island and provided primary care consultations in homes and at ‘pop-up’ clinics to people suffering from chronic health conditions who had been unable to or fearful of going to health care facilities due to COVID-19. The team also monitored the symptoms of COVID-19 patients or people who tested positive, but were asymptomatic.
In Immokalee, Florida, where approximately 15,000-20,0000 migrant farmworkers have been working during the pandemic with minimal access to healthcare and testing, we worked closely with Coalition of Immokalee Workers (CIW), the Department of Health and local organisations and healthcare providers. MSF ran a public health education campaign and mobile ‘virtual’ clinics, which provided COVID-19 testing and remote medical consultations for COVID-19 and other health issues. The clinics have been handed over to the Department of Health who will continue this work.
In southwestern USA, especially in the states of New Mexico and Arizona, an MSF team worked with local officials, healthcare workers from the Navajo Nation and Pueblo peoples, and organisations that directly address needs related to COVID-19 in Native American communities. We provided infection prevention and control technical guidance to healthcare facilities and communities, including to prisons and communal living facilities, such as nursing homes.
Activities closed. In Port-au-Prince, Haiti's capital, MSF reorganised our Emergency Centre in the Martissant neighbourhood of Port-au-Prince to isolate and refer COVID-19 suspect cases. In city’s Drouillard area, we had converted our burns hospital to a field hospital to treat COVID-19 patients; we screened over 330 people and treated nearly 200 for COVID-19 before the centre closed at the beginning of August, and reconverted back to our burns hospital. Our teams also visited the Chancrelles hospital in Port-au-Prince’s Cité Soleil district, and supported them in implementing IPC measures, including triage and isolation.
MSF teams carried out health promotion activities in communities all over the country, via mass media such as radio and social networks but also through training health workers and community leaders, and in health institutions.
In Haiti’s south, MSF supported several public health facilities across Port-à-Piment and Port Salut for the set-up of triage systems, isolation beds, referral systems and training of medical staff.
In Les Cayes, also in the country’s south, our team set up a triage and an isolation unit in the departmental referral hospital. Medical staff were trained on early detection of suspected cases and IPC standards. Support staff, such as hygienists and health officers, were trained in IPC standards and in the maintenance of the water and sanitation infrastructure installed by MSF. Our activities in Haiti ended in August.
Activities closed. In Tegucigalpa, the capital of Honduras, MSF provided medical care in an adapted centre for severe COVID-19 patients, to help the metropolitan health system to keep the hospitals from overcrowding. We also provided mental health, social work and health promotion activities; all activities had come to an end by mid-October.
Activities closed. In Ecuador’s capital, Quito, MSF supported health centres, in the wake of a launch of a testing campaign, in the follow-up on positive tests. We also provided training and support for IPC, health promotion and mental health to mobile teams and to health posts.
In the city’s Temporary Attention Centre, we provided palliative care and trained staff in this field; the initiative was a pioneering project for the country.
MSF teams also provided on-site support and training on IPC, mental health and health promotion in nursing homes and shelters for homeless people across the country.
In the Guayaquil region, which was the first area in Ecuador to be hit hard by COVID-19, a small team assisted health centres and nursing/care homes with infection prevention and control measures. An MSF team worked in the coastal Esmeraldas Province in the northwest. All projects in Ecuador had been handed over or ended by October.
Activities closed. A team assessed needs in the Beni region, a rural Amazonia-basin area in the northeast of Bolivia. Our activities focused on training on IPC measures and medical training in six COVID-19 centres covering five municipalities. MSF also donated PPE and medicines.
Activities closed. In Peru, MSF started supporting the Ministry of Health’s COVID-19 activities in the Amazon region in June. In cooperation with a team of the Basque health authorities in Spain, we treated severely ill patients in the hospitals of Tarapoto, Huánuco and Tingo María, and also provided support to health centres in the provinces of Datem de Marañón and Condorcanqui through donations and training. Our activities in Peru closed at the end of September.
Activities closed. In Argentina, MSF offered technical support and advice to health authorities in the provinces of Buenos Aires and Córdoba. We helped to design protocols, circuits and infection prevention and control measures in health structures, alternative treatment structures, and nursing homes. In Córdoba, we provided technical support to the province’s Emergency Operations Committee working group for enclosed structures (which includes nursing homes, haemodialysis units and prisons), and participated in training the staff.
In Buenos Aires, we collaborated with the secretariats in charge of the response to COVID-19 in the city’s vulnerable neighbourhoods on possible intervention strategies, definition of priorities, and in the trainings. Overall, MSF teams provided direct training (in person and online) to more than 550 people who work with some of the most at-risk groups: staff from nursing homes, organisations for people with disabilities, homes for children and adolescents, and community representatives from vulnerable neighbourhoods. MSF also worked with the National Penitentiary Office, providing advice on general aspects of the disease, prevention measures in detention centres, psychosocial aspects and promotion of mental health. Activities in Argentina ended in July.
Activities closed. MSF developed the PAEC-LAT (‘Proyecto de Asesoramiento Estratégico ante el COVID-19 en Latinoamérica’, or Strategic Advisory Project for COVID-19 in Latin America) project, as a way to overcome the restrictions for face-to-face work and staff movements. We created a free online strategic and technical support service aimed at institutions and staff that are at the frontline of the pandemic in Latin America. This innovative digital solution took advantage of the possibilities of virtual visits and online trainings to reach multiple countries, regions and different audiences, including health professionals, administrative staff, cleaning staff, community agents and indigenous health teams, mainly in remote communities and areas with limited access to healthcare services.
Between May and November, PAEC-LAT responded to more than 1,500 requests from health personnel working against COVID-19 in 14 countries in the region (Mexico, Guatemala, Honduras, Nicaragua, Costa Rica, Colombia, Venezuela, Peru, Uruguay, Argentina, Chile, Ecuador, Bolivia and Puerto Rico), and conducted 130 trainings and 35 virtual visits followed by recommendations reports.
As of end of November, over 32,000 deaths linked to COVID-19 had been recorded in Africa, when, in comparison, the continent recorded 380,000 deaths due to malaria in 2018. In the Sahel, it has been confirmed that the peak of malaria season struck more intensely and for longer this year, in particular because the rains started earlier and were heavier compared to previous years. In many countries of the sub-region, national prevention programmes have been impacted by the restriction measures put in place to deal with the COVID-19 pandemic. Mass activities such as mosquito net distributions or seasonal prevention campaigns have often been slowed down.
In eastern Burkina Faso, we are supporting community awareness activities and triage at the health centre in Fada. We are also training MoH staff and undertaking disease surveillance and health promotion activities. With the high number of displaced people in the northern, north-central and eastern parts of the country, our teams are monitoring the epidemiological situation throughout the country.
MSF worked in Bobo-Dioulasso, in the country’s west, where the second-biggest outbreak in the country had been located. We provided care for COVID-19 patients in a dedicated facility, in collaboration with the national health authorities. We installed an oxygen production unit, which provided oxygen to dozens of people, direct to their beds, at once. Teams reinforced other facilities’ capacities in terms of triage, isolation, protection equipment and infection prevention and control measures at the University Hospital Centre, and at the Medical Centres with Surgical Annexe of Do and Dafra. Following a sharp drop in cases in the area, we ended our activities in the city and surrounds on 15 July.
Following a better than expected evolution of the pandemic in the country, MSF teams, who had finished the construction of a 50-bed hospital centre for the care of COVID-19 patients in Ouagadougou,, handed over all activities to the Ministry of Health at the end of July.
Teams had been providing patient support in Fada health centre, in the country’s east, where we had also rehabilitated a 20-bed treatment site at the regional health centre. These activities were handed over to the regional health authorities on 28 July.
In Dakar, the capital of Senegal, we are supporting the treatment of people with moderate and severe cases of COVID-19 in the Hopital Dalal Jamm. Here we are also providing training as well as support for water and sanitation activities, and simplified triage protocols.
We are providing support in Guediawaye district, in Dakar’s northern suburbs. Our teams are supporting the MoH on community engagement, case surveillance, testing mechanisms and improving IPC measures and continuity of care.
Other MSF response activities in Africa:
In Sierra Leone, MSF is part of the national emergency preparedness task force and MSF epidemiologists are providing support with contact tracing and surveillance. We are providing health promotion to local people and supporting improved IPC in MoH basic healthcare units.
In slum areas of Freetown, Sierra Leone’s capital, we are working with community health workers to identify the poorest families in the slum and provide them with a small hygiene kit of soap and buckets with a tap, and masks for the adults. Community health workers have distributed large COVID-19 banners and also have put up COVID-19 posters we have donated about social distancing, how to wear a mask, and proper hand hygiene to distribute in other slum areas and key areas within Freetown.
In Kenema district, we adapted and rehabilitated a Lassa Fever isolation unit at Kenema government hospital to become a 25-bed COVID-19 treatment centre.
In Freetown, MSF water and sanitation and construction specialists repurposed a government facility into a 120-bed COVID-19 treatment centre, and carried out PPE training for around 140 workers. In Makeni Regional hospital, Magburaka hospital and Hinistas Community health centre, our teams set up isolation wards.
In Liberia, our teams are undertaking health promotion activities on prevention measures in and around Monrovia, the capital.
MSF provided support to the MoH COVID-19 treatment centre, by improving patient flow and the quality of care for patients. Our teams completed a month-long COVID-19 hygiene awareness and soap distribution campaign in April, reaching more than 78,000 households in four of Monrovia’s most vulnerable neighbourhoods.
We also provided technical support at the city’s Military hospital, run by the Ministry of Health, where COVID-19 patients are being treated.
In Niger, MSF is supporting epidemiological surveillance and community awareness in the towns of Niamey, Zinder, Diffa, Tillabéry and Agadez.
In Niamey, our teams constructed a 50-bed COVID-19 treatment centre, close to the Hôpital National Lamordé, and trained the staff on COVID-19 treatment. We handed this centre over to the Ministry of Health. A response team composed of MSF and MoH staff were monitoring people with simple COVID-19 cases at home. We also supported a COVID-19 call centre in the city.
In Zinder, the second-most affected city by the virus, sensitisation and IPC activities in support to the health structures are handed over to the district. By the end of July, we had closed our COVID-19 project in the area of Maradi, where our teams supported logistics and IPC training in 50 health centres in the districts of Maradi and Madarounfa, as well as awareness raising activities.
Our teams also organised the transport of COVID-19 samples from Zinder to the laboratories in Maradi and Niamey.
MSF teams in Nigeria are establishing isolation facilities and improving staff and patient flow. Teams are also setting up handwashing points and isolation areas, plus providing health promotion information, in local communities and IDP camps.
In Ngala, MSF teams are focusing efforts on reinforcing infection prevention and control. In Ebonyi state, we are supporting the Ministry of Health and Nigeria Centre for Disease Control’s COVID-19 testing centre and are supporting a 25-bed MoH facility with treatment for COVID-19. In Sokoto, we have supported the MoH to renovate a 32-bed isolation and treatment centre.
In Borno state, we support the Ministry of Health COVID-19 isolation centre in the state capital, Maiduguri, with training and implementing IPC measures, including managing the laundry.
With local authorities we helped to conduct a large community awareness campaign on COVID-19, reaching 370 settlements. In Benue and Zamfara, we have supported communities with health promotion and installed water points and distributed soap and hygiene products to displaced communities in those areas.
Democratic Republic of Congo
In Kinshasa, DRC, we are working in four structures in the capital’s Limete health zone where we support COVID-19 prevention measures and treatment.
In Mweso and Walikale, in North Kivu province, we are supporting a number of health facilities that treat COVID-19, but there are currently have no patients in these structures.
In South Kivu province, in Baraka, we are remotely supporting a 20-bed treatment facility (equipped with oxygen) and remain ready to support the Ministry of Health in Bukavu, as well as continuing to support the COVID-19 committee with technical and surveillance support.
In Kinshasa’s Saint-Joseph hospital, an MSF team had installed a 40-bed isolation ward. Our teams also supported the hospital’s medical staff and Ministry of Health staff with the treatment of people with COVID-19. Between the end of April and when we handed the project over to authorities at the end of September, the COVID-19 treatment centre had provided care for 220 patients, including 102 placed on oxygen.
At the Kabinda hospital centre in Kinshasa, where MSF supports people living with HIV/AIDS, we set up a 20-bed isolation/stabilisation unit, which was used before transferring patients to health facilities identified by the MoH.
In Ituri province, with the commitment of the indigenous and displaced communities, MSF built isolation rooms for the handling of COVID-19 cases in structures where we are already present. We also implemented infection prevention and control measures in the community health sites, health centres and hospitals we support. The teams trained health workers in the region about COVID-19 and strengthened the hospitals in Nizi, Drodro and Angumu with medical equipment, human resources, and prepared the isolation and treatment structures within these hospitals.
In North Kivu province, we set up a 20-bed isolation ward, and a 12-bed ward for the care of seriously ill patients who needed oxygen support at the General Reference hospital in Masisi. We also established a patient flow route at Nyabiondo Reference Health Centre. In Goma and Lubumbashi, MSF handed over to MoH the management of the two COVID-19 treatment centres which we built and equipped. We also supported COVID-19 testing in these two cities by donating GenXpert rapid testing cartridges to MoH laboratories. In Mweso, we set up isolation centres for the treatment of moderate COVID-19 patients in six health structures.
In South Kivu, we have a COVID isolation centre in Kimbi; however, a series of security incidents in the Kimbi area has forced the teams to suspend all operations. We established isolation centres in Baraka hospital and Nyange heath centre for suspected COVID-19 patients, with 80 beds total capacity, and mental health support for patients. MSF teams treated COVID-19 patients in Bukavu general hospital, and at the treatment centre in Bwindi in the province.
In Kinshasa and Goma, MSF produced tens of thousands of reusable masks. These masks were manufactured to protect patients and their carers in the structures that we support, as well as our non-medical staff.
MSF teams across Sudan are conducting health promotion and awareness sessions with the local community. We are also providing mentoring and training on a daily basis to health workers in the health facilities we support. We also run a mobile COVID-19 unit that supports other facilities, working on early detection and prevention of the disease.
At the Omdurman Teaching hospital, the largest hospital in the country, where MSF has a team of more than 60 staff, we are working closely with the MoH in the emergency department and to prepare to cope with COVID-19. We are also supporting the MoH to set up and manage isolation centres in two towns in East Darfur and South Kordofan states (Ed Daein and Dilling).
We are supporting three main public hospitals in Khartoum to strengthen their screening and triage system, expanding the isolation area in one of the hospitals. The objective is to protect or reopen lifesaving services and to reinstate confidence among health workers. MSF teams are supporting with trainings, reinforcement of infection prevention and control (IPC) measures, weekly donations of PPE. We also trained staff from 10 primary healthcare centres, donated IPC items and provided technical on-site support, which continues in different facilities in Khartoum.
In August our teams opened a temporary COVID-19 treatment centre in Omdurman teaching hospital in Khartoum, in partnership with the hospital and the Ministry of Health. The 18-bed centre has the capacity to expand to 40 beds, if needed, and provides medical care to patients with moderate to severe COVID-19 symptoms.
We are also supporting the MoH to manage isolation centres in East Darfur and South Kordofan states.
In South Sudan, our teams are working on health promotion activities, to explain how hygiene and sanitation affects health and relates to COVID-19, as well as preventive measures such as setting up washing points and establishing isolation areas or pre-screening areas for suspected COVID-19 patients.
In the capital city, Juba, MSF teams are reducing the number of handwashing points we’ve installed, as other organisations and businesses install others. We continue to provide technical support to the MoH, the National Public Health Laboratory with a laboratory supervisor, and Juba Teaching hospital, with water and sanitation measures, donations and IPC training.
Outside of Juba, three MSF facilities in Bentiu and Malakal Protection of Civilian sites run COVID-19 testing.
MSF assisted the Ministry of Health with the training of healthcare workers in infection prevention and control measures and triage for symptoms compatible with COVID-19. In addition, 117 community leaders enrolled in a SMS-based community mortality surveillance system we established, which covers 52 neighbourhoods in Juba.
In Yei, MSF supported the management of the COVID-19 isolation facility, at the request from the Ministry of Health, given constraints in staffing and supply. With people in the town afraid of visiting health facilities, we ran mobile clinics in three different locations within Yei town where about 140 consultations were conducted on a daily basis, with referrals to MSF’s clinic.
In Agok, we prepared an in-patient department for COVID-19 patients, and in Old Fangak, we set up a 10-bed COVID-19 centre.
In Lankien, our teams renovated a COVID-19 isolation area tent and constructed a mortuary and a maternity delivery room in the COVID-19 isolation areas. In Doro refugee camp in Maban, the MSF team, along community leaders, undertook door to door health promotion and awareness raising. The teams also conducted sessions with women’s groups and youth groups in the camp.
In Gambella region, Ethiopia, MSF has set up a 20-bed COVID-19 isolation centre and another one with a capacity of 10 beds in two camps for South Sudanese refugees (Kule and Tierkidi). In Gambella town, a team provides support to the COVID-19 triage and temporary isolation centre in Gambella hospital.
Since May, a team in Addis Ababa has been providing mental health support in to more than 5,000 migrants who returned mainly from Saudi Arabia, Kuwait and Lebanon, and are placed in three COVID-19 quarantine centres in the capital. MSF is supporting the MoH’s medical and non-medical staff who work in the quarantine centres by training them on migrants’ mental health needs.
Our teams support the regional health authorities in our different project locations in Amhara and Somali Region in their isolation and treatment centres and with health education.
Somalia and Somaliland
We are providing health promotion to communities and technical advice or logistic support to set up isolation structures in some places; teams are screening people at the entrances to hospitals. In Somaliland, we are training members of the MoH rapid response teams on prevention of COVID-19.
In Hargeisa, we have trained emergency room staff and ambulance drivers in assisting the Ministry of Health to set up a COVID-19 centre. Due to a lack of patients, our teams have stopped their support to treatment centres in Galcayo, Las Anod and Baidoa.
MSF is part of Kenya’s National Taskforce on COVID-19. MSF is supporting several health facilities in Nairobi, Kiambu, Dadaab and Mombasa counties. At Kibera South Health Centre, in the slums of Nairobi, the team is boosting infection prevention and control, triage, screening and managing referral of people suspected of having COVID-19 to a nearby hospital.
In Dagahaley camp, in Dadaab, Kenya’s largest refugee camp, MSF has set up a 10-bed isolation unit for COVID-19 patients.
In Mombasa, we have set up isolation rooms at the Mrima health centre in Likoni subcounty, which will allow women who have COVID-19 to give birth safely.
In the city of Homa Bay, the county isolation centres are either closed or insufficiently equipped to treat symptoms and underlying conditions in the increasing number of patients. MSF is setting up a COVID-19 high dependency unit (HDU) within the county’s referral hospital, to manage moderate to severe cases of COVID-19. Some of these patients come from the adult inpatient wards we already support as part of our regular activities. The HDU is in addition to our ongoing support of COVID-19 screening and suspect case management at the referral hospital.
We are also supporting smaller facilities that are now burdened by the increasing number of patients after some health facilities were turned into COVID-19 isolation centres.
In Embu county, MSF is providing IPC support to 11 MoH health facilities, as well as the provincial level hospital.
Uganda has reported a low number of confirmed cases and no COVID-19 deaths so far. MSF teams have helped with logistics and hygiene measures in three MoH isolation units in Arua and Kasese. We are raising awareness among the communities where we and distribute masks to patients and staff in MSF-supported health structures, as well as protective equipment to medical staff working with COVID-19 patients.
In Tanzania, our health promotion team in Nduta refugee camp, is undertaking health promotion activities, raising awareness among the community on hygiene and best health practices. MSF has built four triage/isolation areas at each of our health clinics at Nduta refugee camp, and a main isolation centre at our hospital, with a 100-bed capacity, where people suspected of having COVID-19 are referred.
In Harare, the capital of Zimbabwe, we are supporting COVID-19 patient care and IPC measures at the city’s Wilkins and BRIDH isolation centres. Our water and sanitation team is providing additional support in communities, including providing masks, soap and access to water. MSF has trained over 400 healthcare workers on COVID-19 treatment, laboratory surveillance, IPC measures, water and sanitation measures in facilities, epidemic surveillance, contact tracing, data management, as well as the safe transport of people testing positive for COVID-19.
Teams are also providing support for COVID-19 screening, sample collection for testing, and providing non-COVID-19 healthcare services and health promotion to people recently returned to the country.
In areas where we already worked, MSF is providing support to the MoH. In Maputo, the capital of Mozambique, we are supporting the main COVID-19 referral hospital, Polana Caniço with logistic and technical support. In Pemba, we helped local health authorities to install two isolation centres, 18 de Outubro (30 beds) and Decimo Congresso (100 beds) and we are providing health promotion in two IDP centres in Metuge. In Beira, we assisted in the installation of two isolation centres, 24 de Julho (100 beds) and Marazul (33 beds) and provide support for the follow up of HIV patients with COVID-19 at the emergency isolation unit of the main hospital. We are also providing help in patient flow and triage of suspected COVID-19 patients in four health centres.
In Malawi, MSF is working at the Nsanje District hospital, where we are reorganising and adapting the patient flow, set-up a (pre-) screening and triage tent, waiting areas, and consultation zone. We’ve also undertaken health promotion and training frontline medical staff at the hospital, providing technical support. Around Nsanje district, we’re installing handwashing stations at health care centres, and are running health promotion activities.
In Neno, Dedza and Nsanje districts, we provide COVID-19 information and measures to prevent COVID-19 transmission among female sex workers (FSW) and in the community. Our Zalewa health centre continues to screen patients for COVID-19 symptoms.
We are providing support to the ministry of health in Eswatini by assisting with infection prevention and control and triage at health facilities. We are also part of technical advisory groups to the ministry of health. MSF teams are conducting health education and promotion in the community. A mobile team is providing home-based care for COVID-19 patients.
Activities closed. In Bissau, the capital of Guinea-Bissau, we provided different training at the National hospital Siamo Mendes including on the treatment of people with COVID-19, on IPC measures, water and sanitation improvement, and provided support with hygienists on waste management.
Activities closed. In Guinea, MSF teams provided care for 350 COVID-19 patients with mild symptoms of the disease but who need hospitalization in the Nongo Epidemic Treatment Centre, in the capital, Conakry. We had set up this structure in 2015 as part of our response to the Ebola epidemic, before handing it over to the authorities, and in April 2020, we had rehabilitated the structure, so it is now a 75-bed COVID-19 isolation and treatment unit with the capacity to provide oxygen therapy. Both the structure and our treatment activities were handed over in August.
Our teams also disinfected the homes of patients admitted to hospital, provided psychosocial support, and traced and followed up on patients’ contacts. In Kouroussa, Guinea, we established an 8-bed isolation ward at the Hopital Préfectoral de Kouroussa.
Activities closed. In Bamako, Mali’s capital, MSF supported the Hôpital du Mali, improving triage, patient and staff flows and the isolation of the COVID-19 treatment centre. We also helped with IPC, staff training, and revised patient flow in two other hospitals in Bamako with COVID-19 patients. We reinforced the MoH’s outreach and contact tracing activities in communities in the city, and in connection with these activities, MSF set up handwashing stations and provided locally-produced cloth masks and soaps. More than 800 community health workers were trained, 50 handwashing facilities were installed, and 20,000 soap and 40,000 masks were distributed.
Also in Bamako, MSF supported the management of a 100-bed COVID-19 unit within the grounds of Point G hospital, where we run our oncology programme. The unit included a triage and isolation area, and a ward. We renovated and improved the hospital’s oxygen distribution network. MSF provided the COVID unit with medical, nursing and hygiene control staff, some coming from our regular project in Koutiala, as well as logistical and technical support. By the time we handed over the unit exclusively to the MoH at the end of August, 436 patients had been admitted, with 270 people cured. We also engaged on COVID-19 related health promotion/awareness with local organisations, health workers and members of civil society organisations.
In the centre (Ségou, Niono, Tenenkou, Ansongo, Douentza, Koro), south (Koutiala) and north (Kidal and Ansongo) of the country, our teams strengthened hygiene and IPC measures and set up isolation areas in the supported hospitals and health centres, and trained local staff. We also supported MoH activities such as treatment, raising awareness among people, improving prevention and setting up isolation structures for patients. We conducted health promotion activities with local people, and established handwashing points at the referral hospital in Niono and surrounding health centres.
In Timbuktu, MSF teams conducted home-based care, traced contacts, tested patients and promoted IPC measures within the community.
In Tominian, near the border with Burkina Faso, we installed a tent for isolating people suspected of having COVID-19, and a handwashing point.
In Mopti, MSF implemented patient flow and provided training to staff where a case was confirmed. Training was also done for 45 medical staff from the Gao region.
Activities closed. In Côte d’Ivoire, at Yopougon treatment centre, MSF partnered with a local NGO and the Ministry of Health on a pilot telemedicine project. Two MSF teams composed of doctors, nurses and care-givers provided consultations to COVID-19 patients at the Yopougon site to detect co-morbidities (diabetes, hypertension, respiratory failure and cardiovascular diseases), using an electronic platform to connect to specialists such as an internal medicine doctor and a cardiologist in order to confirm diagnoses. The consultation stage of the pilot, in which MSF teams provided 148 tele-consultations, ended in August; teams are now assessing the results.
In Abidjan, MSF teams were working with the Ministry of Health treating people with moderate COVID-19 in a treatment centre at Grand Bassam, just outside the city. In Bouaké, we trained health workers and provided screening at the different entry points to the city. Both activities have been handed over to the Ministry of Health.
MSF also produced 1 million cloth masks in partnership with UNIWAX and other civil society organisations. They were distributed to vulnerable people in Abidjan and other sites. Our teams, through local associations, also distributed cloth masks to patients suffering from kidney failure, as well as to diabetics and people with high blood pressure.
Activities closed. In Chad, MSF teams worked in Farcha hospital, in the capital, N’Djamena, where people with severe cases of COVID-19 are being cared for. We provided clinical training to the staff, reinforced lab and testing capacity, and installed an oxygen generator. With the low number of severe cases, our support was no longer needed. Also in N’Djamena, our teams supported laboratory activities at central level to draw up biosecurity procedures.
Elsewhere in N’Djamena, we provided support for surveillance, contact tracing, and home-based care for people with mild forms of the disease. We are also undertook health promotion and community engagement, including with marginalised groups who have less access to health information such as nomadic people on the outskirts of the city. We strengthened IPC measures across communities, including having installed handwashing stations.
Activities closed. In Yaoundé, the capital of Cameroon, our teams treated patients with moderate COVID-19 in Djoungolo hospital; MSF teams had worked to increase the hospital’s capacity in building four rooms with 20 beds each, for a total capacity of 110 beds. Between late April and the end of August, 328 people had received treatment. Also in Yaoundé, our teams improved IPC measures, triage, and staff and patient flow in the General hospital, and we set up a systematic triage service at Jamot hospital.
MSF teams ran community information sessions in Cité Verte, as well as follow-up home visits for moderate cases and referrals to a dedicated hospital for the most severe cases. We also supported patient tracing and epidemiological surveillance in this district.
MSF’s research and epidemiologic branch, Epicentre, carried out operational research activities on the effectiveness of screening tests, in partnership with the national emergency operations centre.
In the southwest, MSF teams set up a 20-bed isolation ward in Buea regional hospital to treat people with the new coronavirus. Our staff provided training for IPC measures and treated people with suspected or confirmed COVID-19 disease; we also supported the hospital with oxygen supplies and other logistics equipment. In the local community, we provided health promotion to people on hygiene measures. In the same region, our teams constructed a 38-bed isolation unit at Tiko District hospital and a 16-bed isolation unit was constructed at the Presbyterian General hospital in Kumba.
MSF teams trained hospital staff at Bamenda Regional hospital on IPC measures and installed a pre-screening tent at the entrance. We also trained staff at the general hospital in Douala, Cameroon’s second-most affected city, and at two other hospitals in the area.
Teams provided psychosocial support in Vitib, with the presence of two psychologists recruited by MSF. Two other psychologists were recruited to support Ivorian citizens repatriated from neighbouring countries and contact cases who were followed by the medical authorities.
In both Northwest and Southwest regions, we strengthened health promotion measures at community level, especially targeting people affected and displaced by violence, using community health workers and nurses, as well as radio messages. Community health workers informed their communities on COVID-19 using communication materials and tools our teams equipped them with.
In the Far North, we had set up triage and isolation circuits in nine health centres in the city of Maroua and constructed an 8-bed isolation ward in the district hospital of Mora.
Central African Republic
Activities closed. In Central African Republic, teams worked with people living with HIV in four outpatient treatment centres across Bangui, benefiting 9,000 people, on the practice of shielding.* A similar strategy, which included the distribution of soap and masks, providing food support and awareness raising sessions, was implemented in Paoua and Carnot, and targeted around 4,000 patients and their families.
Also in Bangui, our teams supported the MoH with surveillance activities, including contact tracing and sample collection. We engaged with the communities to explain what COVID-19 is and work together to promote and adapt prevention measures to their daily realities.
MSF built a COVID-19 treatment centre in Bangui, with a capacity of 24 beds, but given the low number of severe cases, the centre did not open; it remains ready to be used.
*Shielding consists of creating ‘green zones’, or safe zones, where individuals more susceptible to COVID-19 are kept protected from any potential source of infection. The areas where they stay can either be inside the household or in separate locations, in the neighbourhood. During the shielding phase, these people should have minimal physical interactions with their relatives and other community members.
Activities closed. In South Africa, we sent staff from all four of our existing projects to COVID-19 responses in Gauteng, KwaZulu-Natal and Western Cape provinces. MSF staff assisted with physical and telephonic contact tracing, the development and dissemination of health promotion materials, and by implementing various strategies for decongesting healthcare facilities.
In Johannesburg, a mobile team conducted primary healthcare consultations and screening for COVID-19 cases in four homeless shelters, as well as links to an MSF testing and tracing team.
We supported secondary care interventions in two hospitals in uMlalazi district, KwaZulu-Natal. Teams developed additional COVID-19 treatment capacity for healthcare facilities in Eshowe and Mbongolwane; in rural Mbongolwane district hospital, we established a patient flow system, including a “flu clinic”, in which all patients presenting or claiming COVID-19 symptoms were screened by an MSF nurse and were seen by an MSF doctor for triage and testing.
In Eshowe district hospital, an MSF doctor supported care for patients under investigation awaiting test results. Approximately 1,500 asymptomatic patients with chronic conditions in this project area were enrolled in a programme that sees their medication delivered to pick up points in communities, saving a trip to the clinic.
In Khayelitsha, the health promotion team provided neighbourhood groups with COVID-19 training, with over 170 groups trained to date.
In Eshowe and in Rustenburg, MSF installed triage tents and handwashing points at several hospitals and community health centres. In Khayelitsha, a 60-bed MSF field hospital where teams were providing treatment starting from June was reduced to 30 beds, and then finally closed in August, following a drop in cases.
Middle East and North Africa
In Hajjah Governorate, Yemen, teams have been working in Abs and Al-Jamhouri hospitals, including setting-up screening points in both hospitals and establishing a 11-bed capacity isolation unit in Abs hospital. We have also improved IPC measures and provided training to MoH staff on COVID-19 symptoms and case definition, treatment, and IPC measures. MSF teams are also supporting referrals of patients from Al-Jamhouri hospital to an isolation centre at Al-Rahadi, as well as the triage area of the centre.
In Aden, MSF is supporting the 22 May hospital with donations of PPE, and training for medical staff on how to manage triage for COVID-19 suspect cases and on IPC measures.
In Khamer (Amran Governorate), our COVID-19 treatment unit, in which we treat patients with respiratory infections and suspected moderate cases of COVID-19, is still receiving some patients.
In Haydan (Saada Governate), we downsized the capacity of COVID-19 treatment unit to two beds, due the decreased number of admissions.
In Abyan governorate, MSF has provided training for the COVID-19 centre health staff, including triage, diagnosis, medico-therapy, physiotherapy and ICU care of critical cases.
MSF ran the COVID-19 treatment centre at Aden’s Al-Ghanouria hospital; our treatment activities at Al-Amal hospital had been transferred to Al-Ghanouria in light of the reduction of cases and admissions. Both projects have now closed.
In Sana’a, MSF has handed over our activities at Sheikh Zayyed and Al-Kuwait hospitals, where we treated people with severe cases of COVID-19, to the local health authorities.
In Hodeidah, MSF teams conducted training in various districts across the governorate. In addition, our teams also assisted to set up an isolation unit in Al-Salakhana hospital and supported the isolation centre with supplies of drugs and PPE. MSF teams put in place IPC measures, set up screening and triage, and identification for potential cases in Al-Salakhana hospital and Ad Dahi rural hospital.
In Taiz governorate, we conducted training on, and implemented, IPC measures, in hospitals across Taiz Houban and Taiz city. Our teams undertook triage, screening and identification for potential cases at the hospital in Taiz city.
In Lahj governorate, MSF teams provided training to medical teams in Yafa'a district, on how to manage triage, isolation and referrals of COVID-19 patients. Referrals were either to treatment centres in Lahj or Aden (for severe cases) or home (with observation) for mild cases.
In Ibb governorate, we supported local authorities to run the Al-Sahul COVID-19 centre. The centre had 18 intensive care unit beds and 70 inpatient beds, and MSF provided medication and medical supplies, including PPE. Our staff coached the centre’s staff, and we put in place IPC measures, assisting with technical support, triage and screening, facility management including workforce planning, and waste management. Teams also provided training on health promotion for MoH staff and private carers.
In Iraq, our teams have been supporting Al-Kindi hospital in Baghdad, which is the epicentre of the pandemic in the country. MSF teams were working in the hospital’s respiratory care unit by providing training for hospital staff on treatment for COVID-19, administering ventilation and conducting disinfection procedures, but we have now expanded our support and are operating a 24-bed COVID-19 ward for severe and critical patients.
In Mosul, we temporarily transformed our post-operative care centre into a COVID-19 facility; in early September, we scaled the centre down to 20 beds. Our teams work in collaboration with local health authorities to provide treatment to people with mild and moderate COVID-19 cases.
In Laylan camp, Kirkuk governorate, our teams are triaging people for suspected cases of the new coronavirus. We have mobilised a 20-bed isolation and treatment facility, and are providing health promotion messages to communities on IPC measures.
In Erbil and Dohuk, MSF helped local health facilities in both cities by providing technical support, logistics support and trained their staff on infection prevention and control.
Our teams did a distribution of reusable cloth masks to Laylan camp residents and raised awareness about prevention measures there. To promote health awareness around COVID-19, MSF also carried out a digital health awareness campaign targeting the city of Mosul.
Other MSF activities in Middle East and North Africa:
In Zahle, central Lebanon, where MSF runs a paediatric ward in the Elias Hraoui Governmental hospital, our teams are supporting the hospital staff by triaging children for COVIID-19 in tents outside the premises. Those who test positive are referred to hospitals managing COVID-19 treatment.
We have trained hospital staff in Hermel, Saida and Tripoli including on IPC measures, and have provided hospitals in these areas with logistical support.
In South Beirut, in Baalbek-Hermel and in the Bekaa Valley, MSF teams are training and assisting families with the practice of shielding. Shielding is a voluntary process that can provide additional protection to people at higher risk of contracting COVID-19, such as the elderly or people living with chronic diseases.
MSF health promotion teams are also raising awareness on COVID, targeting people who are in daily contact with the community (such as taxi drivers, internal security forces, food distributors and waiters) on IPC measures, to avoid potential transmission of the virus when they do their work.
Since late May, we have sent Medical Response Teams (MRT) to support the Ministry of Public Health in its COVID-19 testing strategy across Lebanon, taking samples for testing from people who have been contact traced or are within active clusters of infection. In addition, the teams provide guidance and support to medical teams and people with COVID-19 in isolation sites. Our project-based Rapid Response Teams have also been part of the testing campaign in their project areas, notably in Tripoli and in the Bekaa Valley.
In Siblin (south Lebanon), the training centre of the United Nations Relief and Works Agency for Palestine Refugees (UNRWA) that had been turned into an isolation site in partnership with MSF, is taking in patients who test positive for COVID-19. The centre admits vulnerable people of all nationalities, who cannot home isolate due to overcrowded living conditions.
At the end of May, we launched a quick response unit in the Ras Al-Nabaa and Basta neighbourhoods in Beirut to support vulnerable people, where 70 people confirmed to have COVID-19 had been previously identified. MSF provided information to suspected and confirmed COVID-19 patients on their health condition, and also general health awareness sessions and mental health support. Over the course of 10 days, our teams took more than 200 swab samples of suspected cases in the Basta area for testing.
In northwest Syria, MSF continues to provide care for patients with moderate and severe symptoms in Idlib National Hospital’s 30-bed COVID-19 treatment centre. We are in the final stages of opening an additional isolation and treatment centre in the region. In the camps where we work in northwest Syria, our teams are still spreading awareness messages about COVID-19 and distributing hygiene kits to the families.
In Syria’s northeast, MSF teams are working with the Kurdish Red Crescent in supporting the only dedicated COVID-19 hospital in northeast Syria, on the outskirts of Hassakeh city, which also has some intensive care capacity. People who are discharged from care, as well as people who are able to self-isolate at home with mild illness, are supported with hygiene materials, health education, and with identifying vulnerable people within their household. Patients are also offered self-protection advice, and their health status is reviewed at regular intervals over a one-month period; we also follow up on their household contacts. We have increased our support in Raqqa city with a focus on protecting healthcare workers, improving IPC in primary and secondary healthcare facilities, improving triage, providing and care for suspect patients requiring inpatient care while they await test results.
In Al-Hol camp, our teams have identified 1,900 people who are particularly vulnerable to COVID-19, (due to having conditions such as diabetes, hypertension, or asthma). MSF teams are supporting them as per their individual needs. WHO’s COVID-19 treatment facility in the camp continues to provide concerning levels of quality of care, and each patient referred by MSF is followed up on regularly by MSF staff. However, there have not been significant numbers of positive COVID-19 cases in the camp to date.
In northeast Syria, we provided training and preparedness measures in Al-Hassakeh National hospital. This included creating a 48-bed isolation ward, introducing surveillance measures, identifying and treating people with COVID-19, and patient flow and triage processes. We provided training on infection prevention and control measures and personal protective equipment usage training.
In northwest Syria, an MSF team also delivered a COVID-19 training to staff from other NGOs and the Department of Health.
MSF, in collaboration with the MoH of health in Jordan, and other organisations, has opened a dedicated 30-bed COVID-19 treatment centre in Zaatari refugee camp. We treat confirmed and suspect COVID-19 patients in the treatment centre; our care includes providing psychosocial support. We also undertake health promotion activities. In a dedicated ‘transition area’ of the camp, MSF teams also carry out daily screenings for asymptomatic COVID-19 patients (confirmed cases and/or people who were close contacts of cases), transferring patients in need of medical attention to our COVID- 19 treatment centre.
In our reconstructive surgery project in Amman, we have opened a 40-bed dedicated COVID-19 treatment centre, following a request from the MoH. The centre provides care for people with moderate COVID-19.
In Hebron, Palestine, the MSF team launched a hotline service to provide remote counselling in support to some of the people most affected by the COVID-19 outbreak, such as patients and their families, medical personnel and other first responders, and families of detainees.Our team is also distributing hygiene kits and carrying out COVID-19 health promotion and mental health promotion activities to affected households.
We’re also supporting the local health system in Hebron by providing technical advice and hands-on training on PPE, infectious waste, cleaning processes, oxygen therapy and bedside training to staff in Dura, Alia and Al-Muhtaseb hospitals.
In Gaza, MSF teams are supporting MoH teams in patient management and oxygen therapy at European Hospital. Our teams are providing training on oxygen management, patient support, and intensive care. We also helped with the definition of COVID-19 treatment protocols as well as hygiene management. We are providing IPC support in Indonesian hospital and in some healthcare centres in the north of the Gaza strip. We also conduct similar activities in Al-Awda hospital.
In Libya, our COVID-19 focused activities centred on providing training on infection control and treatment to nurses and doctors in hospitals in Tripoli. In the city, we are also supporting the Ministry of Health in one COVID-19 testing site.
Teams are providing training to medical staff and are reinforcing IPC measures in detention centres in Tripoli, Zliten and Zintan, including having installed handwashing points, distributed soap and cloth masks, and undertook health promotion with migrants and refugees, and detention centre guards.
Activities closed. In Iran, MSF had reached an agreement with authorities to provide care for patients with COVID-19 in the city of Isfahan. We had flown over cargo, including an inflatable hospital, and staff, and were preparing to start activities, before authorities unexpectedly revoked permission.
After the Iranian Ministry of Health rescinded the approval for our intervention in Isfahan, MSF was asked to participate in the response dedicated to foreign nationals in the northeast of the country. A team went to assess the possibility of setting up our inflatable medical unit in places located between Mashhad and the Afghan border, but after discussion with local authorities, it appeared there was no location in this area where our medical unit could be sent in support of an existing medical facility, as planned in the original design of our intervention.
In early April, when it became clear that we would not launch activities to respond to the COVID-19 outbreak in Iran, the international team who had arrived to start activities left the country. In mid-June, the inflatable medical unit and the medical supplies which we had sent to Tehran for the response were shipped to Afghanistan. They are being used in Herat, in the COVID-19 treatment hospital which MSF has opened.
Regular MSF activities in Iran are continuing in South Tehran and Mashhad.
In Penang, in Malaysia’s northwest, we are providing health education in different languages for vulnerable people, including Rohingya and Burmese, and translations in hospitals. We have started a COVID-19 health promotion campaign for Rohingya refugees via an online Rohingya news network. We’re also providing health kits and hygiene items, such as soap, to people in immigration detention centres.
In Indonesia, MSF teams are conducting workshops and training for doctors and community health workers in Jakarta and Banten provinces, who treat suspected COVID-19 cases and those observing home-isolation. Training sessions are on topics including IPC measures, contact tracing and health education. Health promotion sessions are still ongoing – with over 68,000 people reached so far – with MSF teams now also conducting training-of-trainers targeting specific community members to ensure increased coverage and sustainability.
Closed projects. In West Java, health promotion activities, including leaflets on disease prevention measures, and setting up hand-washing points, have been carried out.
Other MSF response activities in Asia:
In Manila, capital of the Philippines, the MSF team is supporting our partner organisation Likhaan with health promotion activities. Teams are also supporting with contact tracing and COVID-19 prevention activities at community level, plus helping to implement IPC measures in the health facilities that are caring for COVID-19 patients.
In Marawi, a “mobile information drive” to passes health promotion messages to vulnerable people and the team has so far trained the local health teams in 60 of the 72 communities in charge of COVID-19 surveillance and contact tracing.
In Manila between early July and mid-August, MSF teams distributed ‘quarantine kits’ – including hygiene materials - to 726 COVID-19 patients and contacts.
In June, we started supporting the COVID-19 ward and the hospital laboratory at San Lazaro hospital, in Manila, with human resources, PPE, biomed equipment and pharmacy. Following a decrease in the number of cases, we ended our activities at the hospital at the end of October.
Teams in the Rohingya refugee camp in Cox’s Bazar, southeastern Bangladesh, are treating a number of patients who are COVID-19 positive, as well as monitoring others with suspected COVID-19, in isolation wards in our facilities in Cox’s Bazar. We are also undertaking health promotion activities among those in the camp and building two dedicated COVID-19 treatment centres.
In Kamrangirchar urban slum, in Dhaka, the country’s capital, MSF is focusing on providing health promotion about COVID-19 to residents. We are also supporting the local health facilities with IPC training.
In Nepal, MSF staff are running 24/7 mental health telephone hotline in Nepali, an extension of the same service our teams are running in India.
Our teams in Patna, Bihar state, eastern India, have converted a sports hall to set up a 100-bed field hospital for mild to moderate COVID-19 patients, to support the Nalanda Medical College hospital. MSF teams are now providing treatment to patients in the field hospital, however given the low numbers of people arriving at the facility, and across the state of Bihar in general, the project is transitioning to providing health promotion, mental health, and psychological first aid activities to healthcare workers in government hospitals across the state. Community health promotion and education activities are also taking place in the area.
In Mumbai, teams are providing training on screening, triage, IPC measures, and testing. We are also establishing an appropriate referral mechanism for suspect cases for treatment and isolation in 28 informal settlements in the city. MSF is supporting an existing fever clinic and treating people with moderate cases of COVID-19 in a newly-built, 1,100-bed, MoH-run hospital. Our teams are also carrying out health promotion, mask and soap distribution to high-risk people, and water and sanitation activities in hotspots in the city’s in M-east ward district.
We have opened a 24/7 mental health phone hotline in English and Hindi, with five counsellors, who have been recruited and trained by MSF.
In Balochistan province, northern Pakistan, MSF staff are working in the 32-bed isolation ward at Killa Abdullah District hospital, hiring support staff, providing water and sanitation and logistics advice, and training to health staff. A screening and triage setup has also been installed by MSF at the main entrance of the hospital, where the team is screening about 250 people daily who come for the MoH outpatient services. We also refer critically ill patients and facilitate COVID-19 sample delivery to Quetta.
In Karachi, we have started new digital health promotion activities within Machar Colony Community to debunk myths and raise awareness. We also made donations of PPE to district health authorities in Karachi and Timergara to support them with the second wave of COVID-19.
We are also conducting extensive awareness-raising activities on ways for people to protect themselves and prevent spreading the virus, and we have added protective COVID-19 measures and isolation areas in most of the facilities we support across Pakistan.
In Timergara, northern Pakistan, the MSF team ran an isolation ward for people with mild and moderate cases of COVID-19, and referred serious patients to university hospitals. Our teams also screened nearly 208,000 people for symptoms of the virus and provided over 3,300 consultations to those who have suspected cases of the new coronavirus. MSF also collected COVID-positive patients in Lower Dir district to bring them to the isolation ward by ambulance.
In Herat, in northwestern Afghanistan, MSF’s activities in our 32-bed COVID-19 centre in Gazer Gah has been reactivated, after being suspended for several weeks, due to a resurgence in the number of severe COVID-19 cases in the city and the inability for the Ministry of Public Health’s facility in Shaydayee to respond to increasing needs. Our screening and triage activities in Herat regional hospital continue and patients are being referred to other COVID-19 centres in case they show symptoms.
In Lashkar Gah, the team is providing technical support for the management of the COVID-19 facility set up in Malika Suraya hospital. In the city’s Boost hospital, screening and stabilisation areas and a referral mechanism have been established for suspected COVID-19 patients; the 44-bed ward for COVID patients with comorbidities is being reduced to 30 beds, given the low numbers of people with COVID-19 in Helmand province.
In Kandahar, a refresher COVID-19 training was given to Kandahar’s Ministry of Health medical staff following a resurgence of the numbers of people with the new coronavirus.
In Kabul, Afghanistan's capital, MSF provided infection prevention and control training, and improved patient flow and triage at the Afghanistan-Japan hospital, which is the referral hospital for COVID cases in the country. However, after the attack on our maternity hospital in the city’s Dasht-e-Barchi district in mid-May, our support to the Afghanistan-Japanese COVID-19 referral centre in Kabul has been stopped.
In Karakalpakstan, in Uzbekistan’s west, we have started a health promotion campaign aimed at TB patients on how to prevent contracting COVID-19.
In Tajikistan, we have developed a tuberculosis+COVID health education leaflet and shared the document with the health ministry to ensure accurate information is disseminated. In Dushanbe, we are working with TB patients, their families and their communities to explain how to prevent the transmission and infection of COVID-19.
At the Republican Centre TB dispensary, we are developing improved triage protocols and patient flow, and offering health promotion for people awaiting their consultation. Additionally, a separate outdoor, open space waiting area with shade protection is being constructed for people with suspected COVID-19.
In Kyrgyzstan, we are working closely with the MoH, with a specific focus on Chuy and Batken oblasts (provinces). MSF teams are providing home-based care for moderate and mild COVID-19 patients to prevent hospitals from being overwhelmed. mobile teams are supporting with contact tracing and community surveillance. Our teams are providing training in infection prevention and control measures.
We are working to improve IPC measures in four hospitals in Kadamjay raion (district), through training, managing logistics, and by providing disinfectants and PPE. MSF teams are also supporting health promotion initiatives and assisting epidemiological surveillance through data collection. We are managing the logistics of all four mobile teams, providing them with vehicles and fuel, and equipping medical teams with PPE. Teams have distributed over 4,500 masks to protect patients with NCDs and existing complications in the region; MSF recently distributed 10,000 locally-sourced, reusable masks to 5,000 school-age children in 87 schools across the raion.
Still in schools, MSF teams also organised a webinar for primary school teachers to raise awareness about COVID-19. With this training, teachers can now ensure adequate infection prevention measures are put in place in schools, ventilation is assured in class rooms and students are briefed on the proper usage of masks and appropriate physical distancing measures.
We have also provided the Ministry of Health with PPE, including N-95 masks and gloves, thermometers, chlorine tablets and alcohol pads.
Activities closed. One of the first activities in MSF’s global COVID-19 response was in Hong Kong, when at the end of January, we started providing face-to-face, and later virtual, health promotion sessions with vulnerable people less likely to be able to access information, such as refugees, and those on the front line, such as street cleaners.
Given the prolonged crisis and exposure to uncertainty in the city-state, which can cause stress and anxiety, our teams focused on managing people’s mental health and conducted workshops on how to manage stress and anxiety for vulnerable people. We also created a website for the general public which offers tips and tools to cope with stress and worry; https://howareyou.msf.hk/en/.
Our emergency team had been working with Impact HK, a local NGO, that has been supporting the homeless for some years. Our teams visited homeless people twice a week in various streets of Hong Kong, and distributed food, drinking water and hygiene kits; our caseworkers also followed up on individuals’ needs. Between June and when the project was handed over in mid-September, the team conducted 51 free medical consultations and arranged temporary shelter for 35 vulnerable individuals.
Our activities in Hong Kong had ended by November.
Papua New Guinea
Activities closed. In Papua New Guinea, staff in health facilities received training on infection prevention control, and screening and triage of people with potential cases of COVID-19 in 22 provinces. Our teams also set up a large facility for treating COVID-19 patients in the capital, Port Moresby.
Activities closed. MSF provided staff in health facilities in three provinces in Cambodia – Pailin, Bantey meanchey and Oddar Meanchey – with training and technical support, which included implementing triage infrastructure in six hospitals bordering Thailand. More than 300 staff members of the Ministry of Health were trained on the new guidelines and protocols concerning COVID-19, among them ambulance drivers, cleaners, laboratory technicians, doctors and nurses, on IPC measures and the treatment of people with suspected or confirmed cases of COVID-19. MSF also contributed to the development on national treatment protocols.
Activities closed. An outbreak of COVID-19 among crew members on a cruise ship docked for repairs in Nagasaki, in western Japan, led to 149 out of 623 staff on board testing positive for the new coronavirus. MSF sent a team of one doctor and two nurses to provide onshore medical assistance. The team assessed patients and assisted with referrals to further health facilities, depending on patients’ condition and the urgency of medical care. In Suginami, a district of Tokyo, MSF teams provided epidemiological analysis, supporting local health authorities.
In November, MSF started a small project in nursing homes in the Czech Republic, in partnership with the Ministry of Labour and Social Affairs. Even though the staff of these facilities is not obliged to have a formal medical education, they are on the front line of the COVID-19 response, treating one of the most vulnerable groups. In the first-ever MSF intervention in the country, two small mobile teams are providing assessments and training on IPC measures in nursing homes.
Working in facilities in the regions of Plzensky, South Moravian, Zlinsky and Central Bohemian, all located outside the country’s capital, Prague, the teams visited almost 40 nursing homes in the first three weeks. Our teams are providing training either on-site or through a Czech version of a website developed by MSF’s Barcelona section for their similar activities earlier this year - https://msfcovid19.org/. We are also receiving requests to provide support from other regions as well. Other areas of support are still being assessed.
In Italy, which had been an epicentre of the pandemic, our teams continue to work in Rome, where we working in informal settlements and squats, where we have been tasked by local health authorities to manage contact tracing and isolation for COVID-19 clusters in 10 buildings. In these settlements, we aim to strengthen COVID-19 surveillance among marginalised urban communities – who include migrants, refugees, and some Italian nationals – through the creation of COVID community health and hygiene surveillance committees.
We are training the committees on improving infection prevention and control measures in their structures and communities, and on identifying and temporarily isolating people with suspect cases, and how to alert the authorities and medical staff.
On the island of Sicily, the outbreak is growing exponentially in the city of Palermo, where we continue our activities in several centres hosting migrants. An MSF team is working in four reception centres in the province of Palermo, which have been quarantined after one person tested positive for COVID-19.
In the Lombardy region, in the country’s north, the original epicentre of the outbreak, we supported three hospitals with infection prevention and control (IPC) measures, as well as provided care to patients. We also undertook outreach activities in order to reach vulnerable people, such as the elderly in nearly 20 nursing homes, and local organisations working with homeless and migrants. We also supported a telemedicine programme (medical assistance via video conference), which assisted people under isolation at home.
We had also been working in one of the most affected regions, the Marche region in central eastern Italy, where we are supported 30 nursing homes across several cities to prevent the virus spreading in such vulnerable locations.
In the Lombardy, Piedmont and Liguria regions, MSF teams had worked in 15 prisons, to protect detainees, prison and police officers. The MSF team included doctors, nurses and hygiene experts, who implemented measures to contain the spread of the virus and protect people inside the prisons. We designed procedures which will identify suspected cases among new detainees, verify their diagnosis and identify the contacts of confirmed cases.
On Sicily, our team supported epidemiological surveillance service in Catania and Enna provinces.
In Belgium, MSF has relaunched activities in nursing homes, as the second wave of the pandemic is again hitting these facilities hard. Three mobile teams are working in the three regions of the country. The focus this time is on accompanying nursing homes in carrying out medical/clinical care activities for residents, a new area of work for these structures. Our teams also carry out mental health sessions for nursing home staff.
An MSF outreach team is continuing to provide medical support to homeless and vulnerable people with confirmed or suspected cases of COVID-19, in the capital, Brussels. Our team is providing testing and follow-up of patients, and is part of an ‘Outreach Support Team’ working in partnership with other NGOs, which provides health promotion, IPC support, contact follow-up and testing (limited to a maximum of 30 people/day); priority is given to people living in non-approved structures, such as squats.
MSF rented out a hotel to provide accommodation to facilitate the follow-up of patients with suspected or confirmed cases of COVID-19. This structure doubles up both as accommodation and as a health structure in the centre of Brussels.
Mobile teams were supporting nursing homes for the elderly and reached 115 homes across Brussels, Flanders, and Wallonia. Support included psychological counselling and webinars for staff, and assessing residents for potential coronavirus cases. MSF established a 150-bed medical facility for vulnerable people, including migrants and refugees, in Brussels’ Tour & Taxis area. The facility, in which we also provided medical care for COVID-19, allowed people to isolate.
MSF teams had been supporting 10 hospitals to increase their admission capacity and on IPC measures. Support included providing technical and strategic advice, plus operating post-intensive care units.
Other MSF COVID-19 response activities in Europe:
In France, MSF is setting up teams of doctors, nurses and psychologists to reduce the burden on the most vulnerable nursing homes and strengthen medical care. This is in addition to our mental health support programme for nursing homes launched in July, which is currently focused on the Paris region. However, the programme will also be expanded to other regions of France in the coming weeks, depending on our capacities and the most pressing needs
In the Île-de-France region and Parisian suburbs, we have resumed screening people who are homeless and living in precarious settings for COVID-19. Our teams are doing this via mobile clinics, where they also provide general medical care.
MSF teams had been helping to detect people with, and provided care for, coronavirus COVID-19 among the most vulnerable populations in Paris and the surrounding region. This included working in shelters, and involved mobile consultations and screening of vulnerable people, and support with diagnosis, isolation and patient care. MSF teams in Marseille, in the south of France, used mobile clinics to reach people living in extremely precarious situations, away from healthcare centres, and often without health insurance coverage.
Between April and June, we provided support to nursing homes: teams worked in care homes across Paris and the suburbs, providing medical and psychological care assistance to residents, and psychosocial and IPC support to staff. We reached over 30 nursing homes, and more than 2,000 elderly residents.
We had been running two COVID centres for homeless and migrant people infected with the new coronavirus – where they could self-isolate and where our teams provided some medical assistance – in Châtenay-Malabry and in Aulnay-sous-Bois, in Paris’s southwestern and northwestern suburbs, respectively. Both centres are now closed.
We had also been providing support to hospitals, including setting up inflatable tents to temporarily increase the ICU capacity at the hospital in Reims, east of Paris. In addition, 5 nurses, 5 assistant nurses, and 2 doctors had been in charge of managing a 10-bed care ward at Henri-Mondor hospital in Créteil, in Paris’s southeastern suburbs, to increase capacity treating patients with severe COVID-19 who were well enough to leave intensive care, but still required inpatient medical care. With the diminished number of people with COVID-19 in France, we have now ended our support to both hospitals.
In Marseille between mid-April and 31 May, we had conducted nearly 1,000 COVID-19 tests in support of two health centres in the city’s impoverished neighbourhoods. We have now handed over these activities.
A team from MSF Switzerland had crossed the border to assist nursing homes, providing advice on IPC and medical awareness to staff, in the French département of Haute-Savoie, southeast of Geneva.
After initially closing all activities in mid-May, our activities in Switzerland have now resumed with the second wave of the pandemic. MSF teams are this time working with a focus on marginalised people and in closer contact with nursing homes. An MSF mobile team is working in collaboration with the Hôpitaux Universitaires de Genève (HUG), the university teaching hospital in Geneva, to provide strengthened access to testing and medical support to people with limited access to medical-social services.
The team is also in touch with different local solidarity organisations and nursing homes in the cantons (states) of Geneva and Jura, as well as over the border in the neighbouring department of Haute-Savoie, in France.
In Geneva, where MSF's international headquarters are located, our staff had provided logistical and sanitation support to areas where vulnerable people are living – reaching 1,300 families in the canton of Geneva – and provided training for staff and volunteers working with these groups. A logistician also supervised a weekly food distribution organised by different NGOs to 2,500 people.
We exchanged medical expertise with staff from the HUG, the university teaching hospital in Geneva. MSF medical staff detached to HUG focused on patient care and managing medical teams. In partnership with HUG, our teams tested people for free based on their symptoms, and we also undertook contact tracing among vulnerable groups of people who have confirmed cases of COVID-19. We also provided recommendations to public and private mortuary services on procedures to avoid any post-mortem transmission of the disease.
In neighbouring canton Vaud, we undertook IPC and health promotion activities with staff working in structures that support vulnerable groups, such as the homeless, in Lausanne, Vevey and Yverdon-les-Bains.
MSF is providing support on the migrant hotspot islands of Samos and Lesbos in Greece, including through health promotion activities and increased water and sanitation supplies and services.
In Athens, our teams are collaborating with the 3rd Clinic of Internal Medicine of Athens University (NKUA-EKPA) by providing psychological support to frontline health workers, COVID-19 patients and their relatives.
After being issued with fines and the threat of criminal charges, local authorities on Lesbos forced us to close our COVID-19 isolation centre in Moria on 30 July. The centre had provided a space in which people on the island – among whom are 15,000 refugees, migrants and asylum seekers – could safely isolate and receive medical care if they had displayed symptoms of the new coronavirus.
In Ukraine, MSF is supporting the Ministry of Health to respond to COVID-19 in Donetsk and Zhytomyr regions. In Mariinka raion (district), Donetsk region, two mobile teams provide home-based care for people with mild coronavirus symptoms, in order to prevent health structures from being overwhelmed.
At Central District Hospital in Krasnogorívka, MSF is supporting health authorities in establishing an isolation ward for patients with moderate symptoms by providing 22 oxygen points, technical support to reinforce triage and patient screening, conducting refresher training for health workers on treatment and infection prevention and control (IPC). We are also undertaking screening and isolation activities, plus waste management, in four health facilities and a nursing home. Training and psychological support is also being provided to healthcare workers in Zhytomyr region, where our teams have visited around a third of the centres designated to treat COVID-19 patients.
In Donetsk and Zhytomyr regions, MSF is also providing psychological support through telephone hotlines for health workers, COVID-19 patients and their relatives.
In Russia, MSF teams have developed information leaflets on TB and COVID-19. The leaflets are being distributed by Ministry of Health nurses during visits with MSF staff to multidrug-resistant and extensively drug-resistant TB patients in Arkhangelsk region, in the country’s north. MSF teams are distributing food and hygiene packages during the patient visits.
In addition, we have partnered with two community-based NGOs in Moscow and St Petersburg to support vulnerable people. So far, PPE (masks, gloves and hydroalcoholic gel) have been distributed with information materials developed on COVID-19, TB and HIV. MSF is also developing training on COVID-19 for these organisations.
Activities closed. Elderly and aged care homes have been hit particularly hard in Spain, and we focused many of our activities on aged care homes. Our teams worked in more than 300 aged care homes with a wide range of activities, including supporting management teams and authorities, implementing emergency measures to separate COVID-positive or symptomatic residents from the rest, supporting disinfection, and training of staff in IPC and risk mitigation. We worked with steering committees that manage aged care homes, to help protect the elderly through patient care and infection prevention and control measures. These activities were undertaken in Madrid, the Catalonia region (including Barcelona), the Basque country, Castilla y Leon, in Andalucia, Tarragona, Palencia and Asturias.
MSF had set up two health units to support hospitals around Madrid, with a total capacity of 200 beds. The units received patients with moderate cases, helping decongest the hospitals’ emergency and intensive care services, and were run by hospital staff, while our teams are provided them with logistical and infection prevention and control advice to protect healthcare workers and patients.
MSF also advised hospitals on staff and patient flow to manage infection control in Barcelona and the Catalonia region.
All MSF COVID-19 operations in Spain had ended, closed or been handed over by 22 May.
Activities closed. In Germany, MSF advised organisations, volunteer groups and state institutions working with the homeless, migrants and other vulnerable groups on IPC measures, to enable them to continue their services; this support had finished by the end of June.
Until early May, an MSF team had supported the authorities in the federal state of Saxony-Anhalt in a centre for asylum seekers in the city of Halberstadt, in which hundreds of inhabitants were under quarantine, with health education activities and psychological support.
Activities closed. In the United Kingdom, our staff are provided nursing and logistics support at the London COVID CARE Centre, in partnership with the University College London Hospital Find & Treat team. The project provided rapid testing, accommodation in which to self-isolate, and medical care for homeless people with suspected or confirmed COVID-19; with the decline in new cases, MSF staff ended their support on 8 June.
Activities closed. In the Netherlands, we provided mental health support to frontline workers. This included a short video with a highly experienced and well-known MSF clinical and health psychologist which had been widely shared in hospitals and nursing homes across the country.
Activities closed. MSF teams in Portugal visited nursing homes, and supported authorities and management teams to train staff and establish basic IPC measures. Our work in Portugal came to an end on 22 May.
Activities closed. In Norway, MSF provided strategic advice and IPC support to a hospital close to Oslo which was located in one of the main clusters of cases in the country.
Protecting people living in precarious conditions
Of particular concern is how coronavirus COVID-19 might affect people in precarious environments, such as the homeless, refugees living in camps in Greece or Bangladesh, or conflict-affected populations in Yemen or Syria. These people live under harsh, often unhygienic and overcrowded conditions, where their access to healthcare is already compromised.
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 of protective measures (such as washing their hands often) and help ensure 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 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 or on the Greek islands, for example) or high-density slum dwellings (Kibera in Kenya or Khayelitsha) needs to be implemented immediately.
Keeping healthcare workers safe
Protecting healthcare workers from contracting the virus is paramount for ensuring the continuity of care for general and COVID-19-related health needs. However, global shortages of personal protective equipment (PPE) pose a great threat. Healthcare workers must have access to the equipment they need to do their jobs safely and effectively.
As research and development is underway to find effective treatment for coronavirus COVID-19, we are closely tracking the trials and evidence concerning the potential medicines in the pipeline.
Any drugs, tests and vaccines for COVID-19 should be made available to all those who need them. It is crucial that governments prepare to suspend or override patents for COVID-19 medical tools by issuing compulsory licences. Removing patents and other barriers will be essential in helping ensure that suppliers can sell tests and treatments at prices everyone can afford.
Challenges in ensuring continuous care in MSF projects
We want to ensure continuous care for all patients where we work today and prepare our medical teams 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. 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.
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 a 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 travel restrictions linked to COVID-19 are limiting our ability to move staff between different countries. We are trying to find ways to manage this, to avoid heavily impacting 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.