Médecins Sans Frontières (MSF) has been providing healthcare assistance to Rohingya communities in Myanmar and Bangladesh for more than 30 years. Since 2009, it has run a clinic near the makeshift settlement at Kutupalong in Cox’s Bazar. This was significantly scaled up to assist with the unprecedented influx beginning in August 2017. The Rohingya are a particularly vulnerable population, exposed for decades to overt racial and discriminatory policies and practices. Segregation, discrimination and forced displacement, com-bined with severe movement restrictions, have excluded many Rohingya from basic services including healthcare. Demographic and socioeconomic indicators in Rakhine State are well below the average for Myanmar, including significantly higher levels of malnutrition, maternal mortality and under-five mortality. WFP, Myanmar: Food Security Assessment in the Northern Part of Rakhine State, July 2017. Routine vaccination rates are reported to be very low. WHO, Situation Report: 02 21 Emergency Type: Bangladesh/Myanmar: Rakhine Conflict 2017, September 2017 (http://www.searo.who.int/about/administration_structure/hse/20170921_searo_sitrep02.pdf?ua=1). Healthcare facilities, for example in antenatal and emergency obstetrics, are in chronically short supply, and MSF’s antenatal programme often saw the effects of unsafe abortions, haemorrhage and pre-eclampsia. MSF ran large ante-natal programmes in its clinics in Maungdaw town and Maungdaw South and in Sittwe between 2008 and the outbreak of violence in 2012. Organisations attempting to provide assistance to the Rohingya have been confronted with hostility and violence. In early 2014, restrictions placed on aid organisations forced the suspension of lifesaving activities, including by MSF.
Across the border, in camps in Cox’s Bazar, the majority of refugees live in appalling conditions, crammed into areas around one-tenth of the accepted minimum humanitarian standard. Sphere standards recommend a minimum covered floor area in excess of 3.5m2 per person. The unprecedented numbers of people arriving in such a short period led to the merging of Kutupalong and Balukhali camp, making this ‘mega-camp’ the biggest in the world. See map at https://cdn.knightlab.com/libs/juxtapose/latest/embed/index.html?uid=9e7bbfd6-9bec-11e8-b263-0edaf8f81e27. Many Rohingya had only had limited exposure to humanitarian interventions, including medical assistance, prior to their displacement, with direct impacts on health-seeking behaviours and health status among newly arrived refugees. In December 2017, MSF health surveys in the settlements found that 49% of people who reported being ill said they had not visited a health facility; 9% said they did not access any form of healthcare, and 37% reported self-medicating. MSF, Health Survey in Kutupalong and Balukhali Refugee Settlements, Cox’s Bazar, Bangladesh, December 2017.
Prior to 25 August 2017, only a handful of NGOs were operating in Cox’s Bazar, most of them local. During the refugee influx the Ministry of Health and Family Welfare took the lead in ensuring a coordinated response by health actors. Due to limited presence during the initial phase of the emergency, it took several months for the demand for health services to be covered. MSF deployed hundreds of community health workers to conduct outreach within settlements to find people in need of healthcare and conduct surveillance activities. The situation was further complicated by the chronic lack of health education and awareness of health issues within the Rohingya community. Vaccination proved a particular challenge; large-scale health promotion and education efforts were required to overcome fear and suspicion among the Rohingya population.
Low vaccination coverage and its consequences in the mega-camp
Conditions in the settlements, notably extreme overcrowding and poor water, sanitation and hygiene infrastructure, create significant disease risks. MSF, as well as other national and international health actors, conducted assessments to determine vaccination rates prior to mass vaccination campaigns, as well as catch-up campaigns for Expanded Programme for Immunization (EPI). Coverage for measles, polio, MenACWY, DPT-Hib-HepB (Pentavalent) and pneumococcal (PCV) vaccinations among under-fives in the Kutupalong and Balukhali settlements was very low. Just 23% 95% CI: 19.9-26.5, n=171. of children under five had received a measles vaccine. Coverage for the pentavalent vaccine Vaccine for Haemophilus influenzae type B (that causes meningitis, pneumonia and otitis), whooping cough, tetanus, hepatitis B and diphtheria. was low among adults, and non-existent in under-fives. MSF, Health Survey in Kutupalong and Balukhali Refugee Settlements.
The appalling living conditions in the mega-camp were highly conducive to the spread of diphtheria, which thrives in overcrowded and unsanitary settings. The first suspected case was reported by MSF to the Bangladesh health authorities on 10 November 2017. Until 18 December, MSF was the only actor with in-patient capacity for suspected diphtheria cases, with 280 beds across three facilities for both mild and severe cases. At times these facilities had a bed occupancy rate above 100% for several weeks.
International and local staff, most of whom were seeing diphtheria for the first time, had to be rapidly trained and facilities allocated across the settlements. Knowledge of the disease regarding transmission dynamics, clinical symptoms, optimum treatment strategies and ideal outbreak response was extremely limited at the start of the outbreak. Globally, there had not been a large outbreak of diphtheria for more than 50 years. This, combined with the low vaccine coverage in the population, made it extremely difficult to predict how many people might become infected and at what rate. Further challenges to the outbreak response came from the difficult terrain and the absence of a formalised system of house and street identification in the settlements. This led to a lack of clarity in the location of people’s place of residence, making monitoring, surveillance and follow-up of suspected cases and their potential contacts extremely complicated. At the time of the outbreak, there was a global shortage of the antitoxin required to treat diphtheria. Fewer than 5,000 vials were available worldwide, during a period when five outbreaks were happening in parallel: as well as the outbreak in Bangladesh, there were outbreaks in Haiti, Indonesia, Venezuela and Yemen. This meant that, at the beginning of the outbreak, patients did not receive effective treatment. In the absence of antitoxin administration, secondary effects can lead to permanent neurological damage. When the antitoxin did reach Bangladesh, supplies were insufficient, and health practitioners and experts were forced to prioritise who should receive treatment.
To tackle the outbreak, MSF supported the Ministry of Health-led vaccination effort by setting up fixed vaccination points at health posts, and deployed a mobile team to reach people in their shelters. Most of MSF’s efforts were focused on case management, contact tracing and treatment. All suspected cases and their contacts were vaccinated. An additional 35-bed purpose-built isolation and treatment centre was constructed. MSF also ensured that all its staff members had received their primary series plus a booster (although Bangladesh has good EPI coverage, boosters are not routinely provided to adults). The vaccination campaign began on 12 December 2017, targeting children up to six years of age. A vaccination campaign for children aged seven to 15 started on 19 December 2017. This was shortly after a large-scale measles vaccination campaign, and ensuring that refugees with little prior experience of vaccination in Rakhine State understood the need for a new immunisation was a particular challenge and required significant health education efforts. Since then, new arrivals in the camps mean that coverage has become diluted. This has been exacerbated by population movements, with ongoing resettlement within the mega-camp mixing vaccinated and unvaccinated populations.
The diphtheria outbreak as experienced by Rohingya refugees in the settlements in Cox’s Bazar is evidence of the chronic denial of access to health services over a long period. Responding to a large, unvaccinated and fearful population, with limited experience in accessing healthcare services, in a mega-camp setting was challenging, and required a specific response. Refugees remain vulnerable to outbreaks: without regular and sustained EPI, continued access to healthcare and improvements in living conditions in the camp, there could be further outbreaks in the years to come.
Gina Bark is Humanitarian Affairs Coordinator for MSF in Amsterdam. Kate White is a Medical Emergency Manager for MSF. Amelie Janon works with MSF’s emergency team as a Humanitarian Affairs and Advocacy Manager.