The international community has been asked to mobilize urgently to fight the current Ebola virus disease outbreak in West Africa. The World Health Organization (WHO) has declared that the “single most important” problem slowing relief efforts is “not having enough people on the ground,” and that several thousand health care workers are needed to contain the outbreak.Reference Gulland1 More Ebola Treatment Centers (ETCs) are needed to stem the disease; however, at press time, only 2 international aid agencies have supported ETCs along with national ministries of health and the WHO. Nongovernmental organizations, governments, and the WHO are mobilizing rapidly.
In the coming weeks and months, a surge of physicians, nurses, and other health care volunteers will deploy to West Africa at considerable personal risk to provide clinical care and to support disease control efforts. To date, 301 health care workers have become infected with Ebola, half of whom have died.2
Organizations participating in the Ebola response must carefully plan to carry out their responsibility to ensure the safety and security of responders. At the same time, individual health care volunteers and their employers must evaluate the ability of an aid organization to protect its workers in the complex environment of an Ebola outbreak. This evaluation is an unfamiliar and confusing task for many potential volunteers.
A consortium of Boston-based hospitals has developed the following recommendations to guide volunteer clinicians and their employers to assess the ability of an international aid organization to ensure volunteer safety. These recommendations are drawn from the consortium’s experience and the WHO, the Centers for Disease Control and Prevention (CDC), and several major organizations operating in the West African Ebola response.
First, the organization should have proven experience in humanitarian crisis response and the management of rapidly scaled, medically complex operations in resource-poor settings. In particular, the organization should know how to engage the United Nations cluster system for international response and should have in place the required logisticians, administrators, funding mechanisms, and in-country infrastructure that underpin a successful response.
Second, the organization should provide a comprehensive predeployment orientation program that includes acknowledgement of risk, a record of appropriate individual information to support deployment, and a clear delineation of the individual’s and organization’s roles and responsibilities. The organization’s personnel policy should include a nonpunitive “opt-out” clause that allows an individual to decline to participate in a role or task once deployed.
Third, organizations should provide comprehensive Ebola response training that addresses site-specific safety, health, and security concerns. This hands-on training should emphasize proper donning and doffing of the personal protective equipment (PPE) that is universally required prior to providing clinical care or other supportive activity.
Fourth, robust and reliable supply chains should be in place to ensure adequate medicine, supplies, and other support for complex medical field operations. In particular, the supply chain must guarantee an adequate supply of PPE as recommended by the WHO, the CDC, and Doctors Without Borders: disposable gloves, long-sleeve impermeable gowns, medical masks, eye protection with goggles or face shield, and closed puncture- and fluid-resistant shoes. Additional PPE, such as waterproof aprons, disposable shoe and leg coverings, heavy-duty rubber gloves, and particulate (N95) respirators, may be required depending on the task and risk.
Fifth, the organization should have clear contingency plans for medical evacuation or treatment of sick or injured staff. Because commercial medical evacuation insurance often does not cover active Ebola cases, organizations must be able to arrange and fund adequate care for staff who contract Ebola virus disease. Contingency plans should also include the management of security threats such as civil unrest, natural disasters, or other large-scale outbreaks. Plans to monitor security situations and either shelter in place or evacuate staff via predetermined overland and air routes should be redundant, written, and readily available to staff.
Finally, organizations should have a clear plan for the return of volunteers to their clinical duties back home that complies with CDC, state, and local guidelines. For example, if individuals are required to remain on 21-day home personal isolation after deployment, organizations must consider who will be responsible for the volunteers’ and their families’ needs (food, water, medicine, mental health), isolation compliance, and return-to-work considerations.3
These represent the minimum set of operational standards that a professional organization must have in place to ensure the health and security of its staff in response to the Ebola virus disease outbreak.
Individuals who plan to volunteer with an international aid organization during an Ebola epidemic should not make the decision lightly. Individuals must carefully assess their own skills, experience, knowledge, family circumstances, and personal health. Only those clinicians with the highest level of readiness—personal, mental, and professional—should consider deployment. Trainees, medical students, residents, and fellows must be strongly discouraged from volunteering. A considerable body of knowledge highlights the negative impact of untrained response workers—even though they are trained clinicians—in providing assistance during outbreaks or in the aftermath of natural disasters.Reference Merchant, Leigh and Lurie4, Reference Panosian5 Organizations with current experience in managing ETCs have provided important guidance for organizations and individuals who intend to deploy.
Individual volunteers must consider the need for personal preparation and proper equipment. Volunteering will likely require a significant time commitment. Given the scale of the outbreak and the cost of sending individuals, a 2-week deployment is wholly insufficient. Volunteers should be prepared for longer deployments and to be highly self-sufficient. The CDC has issued the primer “Advice for Humanitarian Aid Workers Traveling to Guinea, Liberia, Nigeria, or Sierra Leone during the Ebola Outbreak” for potential volunteers.3 As indicated in the CDC checklist, individuals must review their health insurance, medical evacuation insurance, accidental death and disability insurance, and even life insurance coverage in light of their personal and family circumstances.
From our own research into these issues, we know that medical assistance and, if necessary, medical evacuation for even non-Ebola illness or injury can be extremely challenging to carry out from affected countries. For Ebola-related exposure or infection of a health care worker, the likelihood of evacuation is remote, if not impossible, despite the several cases widely reported by the media.
The current Ebola outbreak is a global emergency, and our global health care community must and will rise to serve those affected. But each of us must invest in fully understanding the capabilities and limitations of the organization with which we deploy and serve.
