EXPLAINER: When and how can Ebola patients be evacuated? Here’s what the laws say

EXPLAINER: When and how can Ebola patients be evacuated? Here’s what the laws say

The medical evacuation of Nigeria’s index Ebola patient to Switzerland has raised questions about whether people with highly infectious diseases (HID) can be transferred across international borders while they may still pose a risk of transmission.

The patient, a Swiss citizen, and her husband were evacuated from Nigeria on Monday after she was stabilised by Nigerian health workers.

The couple arrived in Nigeria from Uganda on October 3. The woman was at a private facility in Abuja on October 11, where she was managed. She was later confirmed on October 20 to have contracted the Bondibugyo Ebola disease.

She was managed by Nigerian healthcare workers and was evacuated when she had become stable.

Following the evacuation, Mohamed Janabi, World Health Organisation (WHO) regional director for Africa, said Switzerland would assume responsibility for her continued medical management and the follow-up of her husband, who was identified as contact number 53.

Muhammad Ali Pate, Nigeria’s coordinating minister of health and social welfare, had said the patient’s improvement did not mean she was no longer infectious, adding that strict public health protocols remained in place.

When videos of the patient being wheeled into the aircraft surfaced online, several Nigerians expressed concerns over the legality of transporting infectious disease patients across international borders and the risk of exposure to the airport personnel and crew members who were without PPE.

Checks by TheCable showed that the transfer of a patient with an infectious disease across international borders is not unprecedented. During the 2014 Ebola outbreak in West Africa, dozens of patients were evacuated to Europe and the United States for treatment under specialised medical arrangements.

Nigeria’s 1926 quarantine act provides a domestic legal framework for preventing the introduction and spread of dangerous infectious diseases.

The law empowers the government to make regulations concerning the movement of infectious diseases into and out of the country, among other measures. It does not, by itself, establish that every medical evacuation is automatically permitted or prohibited.

The legality of a particular transfer therefore depends on the applicable national requirements, the public health arrangements and the circumstances of the evacuation.

 

PROVISION OF GLOBAL LAW ON EVACUATION OF HID PATIENTS

WHO’s International Health Regulations (IHR), adopted in 2005, provide the main international legal framework for managing public health risks that may cross national borders.

The regulations are legally binding on 196 countries, and the European Union is also involved in their implementation.

They require countries to develop capacities for disease surveillance, notification and response, including at international points of entry.

 

They also seek to prevent the spread of disease without unnecessarily interfering with international traffic and trade.

The regulations do not establish a blanket prohibition on the international medical evacuation of patients with infectious diseases. However, neither do they provide an automatic right to evacuate an infected person to another country.

WHO told TheCable that the authority to approve and carry out an international medical evacuation rests with the relevant national authorities, medical teams and transport operators, in accordance with applicable requirements.

The organisation said it does not routinely approve individual medical evacuations, although it can provide technical advice, facilitate coordination between countries and support public health risk assessments when requested.

Regarding the evacuation from Nigeria to Switzerland, WHO said it was not responsible for authorising or arranging the transfer but had shared relevant technical guidance with Nigerian and Swiss authorities and continues to support Nigeria’s wider response to the outbreak.

HAVE EBOLA PATIENTS BEEN EVACUATED BEFORE? YES!

During the 2014 West African Ebola epidemic, medical evacuations became an important means of transferring infected healthcare workers and other patients to specialised treatment facilities outside affected countries.

According to the European Centre for Disease Prevention and Control (ECDC), 11 confirmed Ebola patients had been medically evacuated from Sierra Leone, Liberia, and Mali to Europe by November 27, 2014. They were taken to Germany, Spain, France, the United Kingdom, Norway and Italy. An Ebola patient was also evacuated from Liberia to the US in August 2014.

 

It said two people exposed to Ebola were also repatriated to the Netherlands and tested negative, while an individual was evacuated to Switzerland and was not confirmed for EVD in September of that year.

On August 24, 2014, a British healthcare worker diagnosed with Ebola in Sierra Leone was flown to the UK aboard a specially equipped Royal Air Force aircraft.

In all recorded cases, the receiving countries, including the recent case involving Switzerland, assured their residents that their health facilities were properly equipped to handle such cases and that the repatriation posed minimal or no risk to public health.

However, evacuation does not eliminate the danger of transmission. Spain reported an Ebola infection in a healthcare worker who had cared for an evacuated patient in Madrid in 2014, highlighting the importance of strict infection prevention measures during treatment and follow-up.

According to WHO, the case represents the first human-to-human transmission of EVD outside Africa.

HOW MEDICAL EVACUATION OF NIGERIA’S EBOLA PATIENT WAS CARRIED OUT

Footage of the evacuation circulating online shows the crew of Rega Swiss Air Rescue’s Bombardier Challenger 650 air ambulance receiving the patient in a containment unit and wheeling her into the aircraft.

While the ambulance team that delivered the patient to the tarmac wore protective coveralls (hazmat suits), the receiving crew did not appear to be wearing visible personal protective equipment (PPE). The footage raised questions about the risk of transmission to the crew and other airport personnel involved in the transfer.

In an email response to TheCable’s questions about the evacuation, the Swiss Federal Office of Public Health (FOPH) said it could not comment on the footage of the boarding process in Abuja. The office, however, said it provided technical expertise for the operation and assessed the public health situation in Switzerland.

Providing further details, Rega-Center told TheCable that the patient was transported in a Patient Isolation Unit (PIU), which it described as a “so-called chemical-tight protective enclosure” designed to isolate patients throughout the journey.

The unit, Rega-Center said, protects against infection and, when used alongside meticulously documented and regularly practised procedures, enables the safe transport of people with highly infectious diseases, including Ebola, COVID-19 and other highly contagious viral infections.

Inside the Rega rescue aircraft
“To ensure that isolation does not have to be lifted during the flight, sufficient medical supplies are carried directly inside the PIU,” Rega-Center told TheCable.

It explained that gloves are integrated into the unit’s outer shell, allowing the crew to attend to the patient without opening the enclosure. The exhaust air is filtered, while cables connecting external medical equipment, including monitoring screens, pass through airtight seals.

However, Rega acknowledged the challenge of preventing contamination of the unit’s exterior while placing the patient inside it.

“The transfer of the patient into the PIU is therefore carried out according to a strictly prescribed, frequently practised, Rega-specific safety protocol,” the organisation said.

According to the centre, the patient is transferred into the PIU outside the aircraft. Once she is securely positioned inside, the protective cover remains closed until she is handed over to specialists at the receiving hospital.

The centre said in Nigeria’s evacuation case, the patient’s husband was also medically evacuated and housed in a separate PIU for the flight’s duration.

After landing at Zurich Airport, the patient and her husband were transferred by Rega helicopters to separate university hospitals. The patient was taken to Geneva University Hospital (HUG), while her husband was transported to the University Hospital of Zurich (USZ).

Rega said both remained inside their PIUs throughout the helicopter transfers and were removed from the units only upon arrival at the hospitals, where they were transferred to designated isolation wards.

It said transporting highly infectious patients is now part of normal operational activity.

TO USE PPEs OR NOT

No PPEs?

Where are the PPEs?

Are you sure that is an Ebola patient?

These are the recurrent questions that trailed the footage of the transfer of the patient from an ambulance at the airport into the aircraft.

In an email response to TheCable’s enquiry, the WHO African Region explained that PPE use should be based on a “person’s role and the risk of contact with the patient, blood, body fluids or contaminated materials”.

“Personnel who remain outside the designated patient-care area and have no direct contact with the patient, body fluids or contaminated materials may not require the same level of PPE,” WHO told TheCable.

“Footage alone may not show all the precautions in place, and it would not be appropriate to conclude from images alone whether the transfer complied with appropriate infection prevention procedures.

“In practice, a medical evacuation needs to be planned and coordinated between the sending and receiving countries. It also needs to apply infection prevention and control measures that protect the patient, the medical team, transport crews and the public.”

Pate had said the evacuation was carried out in line with best public health measures for such evacuations.

The absence of visible protective coveralls on the crew handling the patient may be explained by the use of a closed isolation system, which is designed to separate an infected patient from the surrounding environment.

A 2015 review published in the Journal of Human Virology & Retrovirology, examining the Italian Air Force’s experience transporting patients with haemorrhagic fevers, explains that closed isolation systems allow medical personnel and flight crew to remain outside the patient’s containment unit without wearing additional PPE during certain stages of transport.

The paper distinguishes this approach from open isolation systems, in which patients and medical personnel share a contained space and staff must wear PPE.

The paper also describes the decontamination procedures followed after the patient is secured inside the isolation unit.

According to the Italian Air Force team’s protocol, the unit is closed and decontaminated at the point of entry, after which the personnel involved are decontaminated and remove their PPE.

TheCable contacted the Nigeria Centre for Disease Control and Prevention (NCDC) by email to seek clarification on the evacuation process and the protocols put in place to prevent transmission during the transfer. The centre has not responded.

A representative who answered the centre’s 6232 toll-free line declined to comment, directing TheCable to contact senior officials at its headquarters in Abuja.

HOW THE EBOLA OUTBREAK SHAPED PUBLIC HEALTH RULES AND MEDICAL TECHNOLOGY

The 2014–2016 Ebola outbreak in West Africa exposed major gaps in the international response to HIDs, forcing governments and health agencies to reconsider how they prepare for, contain and manage outbreaks.

The epidemic raised questions about cross-border movement, quarantine, the protection of healthcare workers and the safe transport of infected patients.

On August 8, 2014, WHO declared Ebola a public health emergency of international concern (PHEIC), its first such declaration since the IHR came into force in 2007.

The outbreak also brought the legal implications of public health emergencies into sharper focus. Governments relied on emergency powers to enforce quarantine and isolation and restrict movement.

In Nigeria, the arrival of an infected Liberian traveller in Lagos in July 2014 tested the country’s surveillance and contact-tracing systems and highlighted the importance of screening at points of entry.

The outbreak also drew attention to the century-old quarantine act, although efforts to replace the law gained renewed momentum during the COVID-19 pandemic.

In May 2020, Femi Gbajabiamila, then speaker of the house of representatives, described the public health framework as outdated, while lawmakers proposed the control of infectious diseases bill to repeal the act.

The bill generated controversy over provisions on compulsory vaccination, isolation, arrests and the powers of health authorities.

On October 21, 2026, senators again called for the law to be reviewed and replaced.

The epidemic also prompted a reassessment of how patients with HIDs could be transported safely to specialised treatment facilities.

In October 2014, the ECDC published guidance on planning medical evacuation flights, covering patient assessment, risks to medical personnel and flight crews, and the isolation systems required for safe transport.

At the time, the agency noted that European countries did not have commonly agreed criteria for deciding when Ebola medical evacuations by air were recommended. Their technical capacity to undertake such transfers also varied.

The outbreak also accelerated the development of specialised medical transport technology.

Rega Swiss Air-Rescue said the epidemic exposed the lack of reliable systems for transporting highly contagious patients. In response, it began working with partners in 2015 to develop its PIU.

“Before the introduction of the PIU, there was hardly any reliable concept for the air transport of highly infectious patients, and Rega crews had to wear protective clothing for the entire flight – even the pilots in the cockpit,” it says.

Other countries also expanded their capabilities. The United States Air Force developed its Transportation Isolation System, while the British military used air transportable isolators to move Ebola patients from Sierra Leone to specialised facilities in the United Kingdom.

On Tuesday 20th October 2018, RAF personnel from Tactical Medical Wing (TMW) conducted an Air Transportable Isolator (ATI) assurance exercise at RAF Brize Norton.
More than a decade after the West African outbreak, safe management of HIDs still depends on countries having not only the technology, but also the laws, trained personnel and operational capacity to use it.