Medical and health risks associated with communicable diseases of Rohingya refugees in Bangladesh 2017

  • Emily Y.Y. Chan
    Correspondence
    Corresponding author at: CCOUC, Faculty of Medicine, The Chinese University of Hong Kong, Rm. 308, JC School of Public Health and Primary Care, Prince of Wales Hospital, Shatin, Hong Kong SAR, China.
    Affiliations
    Collaborating Centre for Oxford University and CUHK for Disaster and Medical Humanitarian Response (CCOUC), Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China

    Nuffield Department of Medicine, University of Oxford, Oxford, UK

    FXB Center for Health and Human Rights, Harvard School of Public Health, Harvard University, Boston, MA, USA
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  • Cheuk Pong Chiu
    Affiliations
    Collaborating Centre for Oxford University and CUHK for Disaster and Medical Humanitarian Response (CCOUC), Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
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  • Gloria K.W. Chan
    Affiliations
    Collaborating Centre for Oxford University and CUHK for Disaster and Medical Humanitarian Response (CCOUC), Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
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Open AccessPublished:January 09, 2018DOI:https://doi.org/10.1016/j.ijid.2018.01.001

      Highlights

      • Urgent health emergency disaster risk management (H-EDRM) is needed in the camp setting.
      • Limitations in access to water and poor water quality, food poisoning, hepatitis A and E, and nutritional deficiencies are pending health risks.
      • Environmental health risks include fire, poor indoor air quality, vector-borne diseases, injury, and floods.
      • There is a lack of non-food items to protect health, e.g., footwear, and to maintain dignity, e.g., female hygiene packs.
      • Portable medical documentation should be provided, e.g., immunization card and basic medical history summary card.

      Abstract

      Complex emergencies remain major threats to human well-being in the 21st century. More than 300 000 Rohingya people from Myanmar, one of the most forgotten minorities globally, have fled to neighboring countries over the past decades. In the recent crisis, the sudden influx of Rohingya people over a 3-month period almost tripled the accumulated displaced population in Bangladesh. Using the Rohingya people in Bangladesh as a case context, this perspective article synthesizes evidence in the published literature regarding the possible key health risks associated with the five main health and survival supporting domains, namely water and sanitation, food and nutrition, shelter and non-food items, access to health services, and information, for the displaced living in camp settlements in Asia.

      Keywords

      Introduction

      Complex emergencies remain a major threat to human well-being in the 21st century. More than 300 000 Rohingya people from Myanmar, one of the most forgotten minorities globally (

      International Organization for Migration. Humanitarian Response Plan September 2017/February 2018; 2017a. https://reliefweb.int/sites/reliefweb.int/files/resources/2017_HRP_Bangladesh_041017_2.pdf. [Accessed 28 November 2017].

      ), have fled to neighboring countries, mainly Bangladesh, over the past decades (

      United Nations High Commissioner for Refugees. Joint Statement on the Rohingya Refugee Crisis; 2017. http://www.unhcr.org/news/press/2017/10/59e4c17e5/joint-statement-rohingya-refugee-crisis.html. [Accessed 29 November 2017].

      ,

      International Committee of the Red Cross. Rakhine, Myanmar crisis: Lives shattered, needs urgent; 2017. https://www.icrc.org/en/document/myanmar-rakhine-crisis-lives-shattered-needs-urgent. [Accessed 27 November 2017].

      ,
      • Beyrer C.
      • Kamarulzaman A.
      Ethnic cleansing in Myanmar: the Rohingya crisis and human rights.
      ,
      • White K.
      Rohingya in Bangladesh: an unfolding public health emergency.
      ). Using the Rohingya people in Bangladesh as a case context, this perspective article synthesizes evidence in the published literature regarding the possible key health risks associated with the five main health and survival supporting domains, namely water and sanitation, food and nutrition, shelter and non-food items, access to health services, and information, for the displaced living in refugee camp settlements in Asia.

      The case: Rohingya people in Bangladesh 2017

      The Rohingya people have long been marginalized (
      • Mahmood S.S.
      • Wroe E.
      • Fuller A.
      • Leaning J.
      The Rohingya people of Myanmar: health, human rights, and identity.
      ). Maungdaw in Rakhine State of Myanmar has been the epicenter of violence, and in August 2017, due to an escalation of the violence, an estimated 624 000 people fled from Rakhine State to Bangladesh (

      International Organization for Migration. Situation Report: Rohingya Refugee, Crisis Cox’s Bazar; 2017b. https://reliefweb.int/sites/reliefweb.int/files/resources/171126_weekly_iscg_sitrep_final.pdf. [Accessed 28 November 2017].

      ). Some of these asylum seekers crossed the border by land, while others crossed the Naf River, a natural border between the two countries, and landed at Shah Porir Dwip, the southern tip of Bangladesh. Poorly equipped, overcrowded boats often capsized, and the fleeing population mostly arrived in Bangladesh at night or in the early morning after sailing the 3–4-km perilous journey across the Naf River at high tide (

      International Organization for Migration. Rohingya children drown fleeing Myanmar Violence: IOM; 2017c https://www.iom.int/news/rohingya-children-drown-fleeing-myanmar-violence-iom. [Accessed 29 November 2017].

      ). Those asylum seekers who managed to reach the shore were met by the Bangladeshi army, who coordinated their settlement and the provision of small quantities of food, water, and non-food items (such as buckets, water containers, shelter material, and sometimes even cash). Some were offered medical consultations and drug prescriptions, which were provided by health teams at the military and local hospitals.
      Most of these refugees were relocated to Cox’s Bazar in south-eastern Bangladesh. Two registered refugee camps (United Nations High Commissioner for Refugees (UNHCR): Kutupalong and Nayapara) and two makeshift settlements existed at Cox’s Bazar before the refugee surge in August 2017. The influx of refugees after August 25, 2017 stretched the capacity of the existing camps and makeshift settlements, and additional spontaneous settlements were established in Hakimpara, Jamtoli, and Unchiprang (

      International Organization for Migration. Situation Report: Rohingya Refugee, Crisis Cox’s Bazar; 2017b. https://reliefweb.int/sites/reliefweb.int/files/resources/171126_weekly_iscg_sitrep_final.pdf. [Accessed 28 November 2017].

      ). The survival of these people depends on the already overstretched aid agencies and their resources (
      • Milton A.H.
      • Rahman M.
      • Hussain S.
      • Jindal C.
      • Choudhury S.
      • Akter S.
      • et al.
      Trapped in statelessness: Rohingya refugees in Bangladesh.
      ).

      Medical and health risks associated with the context

      In emergency and crisis settings, water and sanitation, food and nutrition, shelter and non-food items, access to health services, and information are the five crucial domains securing the health and survival of the affected population (
      • Chan E.Y.Y.
      Public health humanitarian response to natural disasters.
      ).

       Water and sanitation

      Although clean drinking water points are available in the makeshift settlements (e.g., United Nations Children’s Fund), the international water accessibility standard of “water availability within 500 meters from households” (
      • The Sphere Project
      Humanitarian charter and minimum standards in humanitarian response.
      ) has often not been achievable. Refugees have had to drill holes for underground water and some have collected water directly from the river; this water is of questionable quality for basic hygiene (
      • White K.
      Rohingya in Bangladesh: an unfolding public health emergency.
      ) (Figure 1). Water safety has been compromised, as people have bathed, washed, and practiced open defecation in the drinking water sources (

      Physicians for Human Rights. Stateless and Starving: Persecuted Rohingya Flee Burma and Starve in Bangledesh; 2010. http://burmacampaign.org.uk/images/uploads/Stateless-and-Starving.pdf. [Accessed 21 November 2017].

      ) (Figure 2). Recent water testing in the settlements showed that 92% of the water was contaminated with Escherichia coli and that 48% was highly contaminated (>100 CFU/100 ml) (

      World Health Organization. Mortality and Morbidity Weekly Bulletin (MMWB): Cox’s Bazar, Bangladesh, Volume No. 6: 19 November 2017; 2017a http://www.searo.who.int/bangladesh/mmwbvol6.pdf. [Accessed 29 November 2017].

      ). In 2015, acute watery diarrhea (AWD) was found to account for 7–9% of morbidity in the refugee camps (
      • Milton A.H.
      • Rahman M.
      • Hussain S.
      • Jindal C.
      • Choudhury S.
      • Akter S.
      • et al.
      Trapped in statelessness: Rohingya refugees in Bangladesh.
      ), and the prevalence of AWD was reported to be around 22% of consultations. An overall upward trend of reported cases was observed during the first 3 months of the crisis.
      Figure 1
      Figure 1A refugee making a well for underground water.
      Figure 2
      Figure 2A group of children playing and bathing in a river that is heavily contaminated. People were also collecting water directly from the river for daily use.
      Water-borne disease outbreaks such as cholera, bloody diarrhea, typhoid, and hepatitis E have been a major concern in the camps. As cholera is considered the greatest health risk (
      • White K.
      Rohingya in Bangladesh: an unfolding public health emergency.
      ), the United Nations Children’s Fund (UNICEF)/World Health Organization (WHO) launched the world’s second largest oral cholera vaccination campaign in October 2017, and 900 000 doses were prepared for a vaccination campaign in Ukhiya and Teknaf, two sub-districts of Cox’s Bazar in Bangladesh. As the first round of the campaign, 650 000 doses were targeted at those aged 1 year or older. Children between 1 and 5 years of age could opt to receive an additional dose during the second round of the campaign for enhanced protection (

      United Nations Children’s Fund. World’s second largest oral cholera vaccination campaign kicks off at Rohingya camps in Bangladesh; 2017a. http://www.unicef.org.hk/en/worlds-second-largest-oral-cholera-vaccination-campaign-kicks-off-at-rohingya-camps-in-bangladesh/. [Accessed 21 November 2017].

      ,

      United Nations Children’s Fund. Bangladesh steps up vaccination for new Rohingya arrivals as measles cases rise; 2017b. http://www.unicef.org.hk/en/bangladesh-steps-up-vaccination-for-new-rohingya-arrivals-as-measles-cases-rise. [Accessed 21 November 2017].

      ). However, although a single dose of oral cholera vaccine has been proven to be efficacious in children older than 5 years and in adults (
      • Qadri F.
      • Wierzba T.F.
      • Ali M.
      • Chowdhury F.
      • Khan A.I.
      • Saha A.
      • et al.
      Efficacy of a single-dose, inactivated oral cholera vaccine in Bangladesh.
      ), the gaps in refugee registration, fluidity of the refugee population, and problems in vaccination record management have continued to affect the effectiveness of this campaign (

      Centers for Disease Control and Prevention. Cholera — Vibrio cholerae infection: Vaccines; 2017a. https://www.cdc.gov/cholera/vaccines.html. [Accessed 27 November 2017].

      ).
      Highly contagious fecal oral diseases such as hepatitis A and E infections are also common. In refugee camps where settlers are predominantly young and there are pregnant women, hepatitis E infection is a significant concern. Although the case fatality rate for hepatitis E in the general population is about 1% (
      • Emerson S.
      • Purcell R.
      Hepatitis E.
      ), the death rate from hepatitis E infection in pregnant women can increase to 20–25% if the infection occurs in the third trimester (

      World Health Organization. Fact sheet: Hepatitis E; 2017b. Available from: http://www.who.int/mediacentre/factsheets/fs280/en/. [Accessed 28 November 2017].

      ). Hepatitis E infection outbreaks have occurred in the region; for example, Nepal reported 7000 cases in an outbreak occurring in 2014 (
      • Shrestha A.
      • Lama T.K.
      • Karki S.
      • Sigdel D.R.
      • Rai Utsav
      • Rauniyar S.K.
      • et al.
      Hepatitis E epidemic, Biratnagar, Nepal, 2014.
      ). In the displaced camp setting, hepatitis E infection has been reported in Ethiopia (2014/2015) and South Sudan (2012/2013) (

      Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report: Hepatitis E outbreak among refugees from South Sudan-Gambella, Ethiopia, April 2014-January 2015; 2015. https://www.cdc.gov/mmwr/pdf/wk/mm6419.pdf. [Accessed 27 November 2017].

      ,

      Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report: Investigation of hepatitis E outbreak among refugees-Upper Nile, South Sudan, 2012-2013; 2016. https://www.cdc.gov/mmwr/pdf/wk/mm6229.pdf. [Accessed 28 November 2017].

      ). Although hepatitis E infection has not yet been reported in the Rohingya camps, an increasing trend in reported cases of acute jaundice syndrome (AJS) has appeared in certain specific settlements (

      World Health Organization. Mortality and Morbidity Weekly Bulletin (MMWB): Cox’s Bazar, Bangladesh, Volume No. 6: 19 November 2017; 2017a http://www.searo.who.int/bangladesh/mmwbvol6.pdf. [Accessed 29 November 2017].

      ).

       Food security and nutrition

      Food security and chronic nutrition stress will put the population at high risk of communicable disease. In Maungdaw, Myanmar, global acute malnutrition (GAM) was reported to be 24.9% and severe acute malnutrition (SAM) to be 4.7% in 2013 (

      Rakhine Commission of Inquiry. Final Report of Inquiry Commission on Sectarian Violence in Rakhine State; 2013. http://www.burmalibrary.org/docs15/Rakhine_Commission_Report-en-red.pdf. [Accessed 21 November 2017].

      ). In the two registered UNHCR camps, GAM was reported to be 13% and stunting to be 52–57% in children aged 6–59 months in 2015 (
      • Milton A.H.
      • Rahman M.
      • Hussain S.
      • Jindal C.
      • Choudhury S.
      • Akter S.
      • et al.
      Trapped in statelessness: Rohingya refugees in Bangladesh.
      ). Furthermore, a report from November 2017 stated that an estimated 240 000 children are in need of nutritional support (

      International Organization for Migration. Situation Report: Rohingya Refugee, Crisis Cox’s Bazar; 2017d. https://www.humanitarianresponse.info/system/files/documents/files/171119_weekly_iscg_sitrep_final.pdf. [Accessed 28 November 2017].

      ). Children with SAM complications require hospitalization, but the current medical and health facilities may have limited capacity to manage SAM complications. In addition, untreated parasitic intestinal infections might worsen the nutritional status, as severe and prolonged diarrhea may further induce malnutrition and contribute to the vicious cycle of poor nutritional outcomes across all age groups. Data from the Inter Sector Coordination Group (ISCG) have shown that the rate of SAM in the refugees could be as high as 7.5% (

      International Organization for Migration. Situation Report: Rohingya Refugee, Crisis Cox’s Bazar; 2017b. https://reliefweb.int/sites/reliefweb.int/files/resources/171126_weekly_iscg_sitrep_final.pdf. [Accessed 28 November 2017].

      ).
      The quantity and quality of food are not guaranteed, even with the daily distribution of food. A 2013 report on nutrient deficiencies in the Rohingya people in Rakhine State, showed that 30% of children under 5 years of age were in need of micronutrient supplementation (
      • Office for the Coordination of Humanitarian Affairs
      Myanmar: humanitarian bulletin.
      ). In 2015, anemia was found to be prevalent in children (43–49%) and women of reproductive age (13%) (
      • Milton A.H.
      • Rahman M.
      • Hussain S.
      • Jindal C.
      • Choudhury S.
      • Akter S.
      • et al.
      Trapped in statelessness: Rohingya refugees in Bangladesh.
      ). In addition, although no specific report has highlighted food poisoning and safety issues in camps, diarrhea patterns associated with food-borne/fecal–oral diseases should be closely monitored.

       Environment, shelter, and non-food items

      Overcrowding, indoor cooking practices, and suboptimal shelters constructed with air-impermeable plastic sheets all contribute to fire and injury risks, poor indoor air quality, and the proliferation of infectious diseases such as acute respiratory infections, measles, and tuberculosis within the camps. Acute respiratory infection has remained the primary cause of death for the camp population living in Cox’s Bazar (28%) and for children under 5 years of age (38%) (

      World Health Organization. Mortality and Morbidity Weekly Bulletin (MMWB): Cox’s Bazar, Bangladesh, Volume No. 6: 19 November 2017; 2017a http://www.searo.who.int/bangladesh/mmwbvol6.pdf. [Accessed 29 November 2017].

      ). Chronic communicable diseases such as tuberculosis should be of concern, as Myanmar, from where the recent refugees have come, was ranked as one of the top 30 countries for tuberculosis in 2016 (

      World Health Organization. Global Tuberculosis Report 2017; 2017c. http://apps.who.int/iris/bitstream/10665/259366/1/9789241565516-eng.pdf?ua=1. [Accessed 28 November 2017].

      ). A lack of resources, technical capacity gaps in implementation (e.g., contact tracing), and non-completion of the 6–9 months directly observed therapy (DOTS) in this mobile population remain key dilemmas when offering TB management for the refugee population in suboptimal camps or unorganized residential settings.
      Chittagong and Cox’s Bazar in Bangladesh, where most of the refugee settlements are currently located, are prone to natural disasters. The makeshift nature of the settlements, compounded by poor water and sanitation infrastructure, has rendered the camp settlers extremely vulnerable to the impacts of the monsoon and flooding. Proactive disaster preparedness and mitigation measures to reduce the population and environmental vulnerability are urgently needed before the annual rainy and monsoon season: in this area, over 80% of the annual rainfall falls during April to October (

      Bangladesh Water Development Board. Annual Flood Report 2014; 2014 http://www.ffwc.gov.bd/index.php/reports/annual-flood-reports. [Accessed 27 November 2017].

      ).
      In addition, even before the rainy and flooding seasons, poor water drainage, improper management of non-food items (such as buckets), and the undulating surface of the plastic sheets of shelters and bamboo poles may encourage the accumulation of stagnant water, which may provide an ideal breeding site for disease vectors such as flies and mosquitoes. Reports have already indicated fever of unknown origin (FUO) to be the most commonly reported reason for consultations in various clinics (

      World Health Organization. Mortality and Morbidity Weekly Bulletin (MMWB): Cox’s Bazar, Bangladesh, Volume No. 6: 19 November 2017; 2017a http://www.searo.who.int/bangladesh/mmwbvol6.pdf. [Accessed 29 November 2017].

      ). Given that the settlements are in areas prone to malaria and Japanese encephalitis (

      Centers for Disease Control and Prevention. Health Information for Travelers to Bangladesh: Clinical View; 2017b. https://wwwnc.cdc.gov/travel/destinations/clinician/none/bangladesh. [Accessed 27 November 2017].

      ), a protracted stay in these camp locations will expose the population to the risk of vector-borne disease if environmental measures and awareness are not highlighted. The distribution of mosquito nets and other measures for mosquito control (community education regarding the regular clearing of stagnant water) should also be attempted before the next rainy season.
      Moreover, refugees generally lack essential non-food items to protect and maintain their health and dignity (e.g., female hygiene packs, etc.). Most refugees in the Bangladesh camps do not possess any footwear. Not only does being barefoot predispose the person to foot injury and trauma in this precarious settlement environment, but the risks of contracting contagious tinea and parasitic intestinal infections such as hookworm and whipworm (
      • Chan E.Y.Y.
      Public health humanitarian response to natural disasters.
      ) are high. Such infections may worsen any pre-existing malnutrition, increase the anemia risk, and complicate wound healing.

       Health care

      Continuous efforts are required to maintain childhood immunization for vaccine-preventable diseases (

      Rakhine Commission of Inquiry. Final Report of Inquiry Commission on Sectarian Violence in Rakhine State; 2013. http://www.burmalibrary.org/docs15/Rakhine_Commission_Report-en-red.pdf. [Accessed 21 November 2017].

      ). Recent field reports have indicated measles and suspected diphtheria cases in the camp area (

      World Health Organization. Mortality and Morbidity Weekly Bulletin (MMWB): Cox’s Bazar, Bangladesh, Volume No. 6: 19 November 2017; 2017a http://www.searo.who.int/bangladesh/mmwbvol6.pdf. [Accessed 29 November 2017].

      ). In particular, one death from measles and 412 suspected measles cases were reported in November 2017, with 82% of cases occurring in children under 5 years of age. With the support of UNICEF and the WHO, the Ministry of Health and Family Welfare of Bangladesh launched a measles and rubella vaccination campaign in September/October 2017 (

      United Nations Children’s Fund. World’s second largest oral cholera vaccination campaign kicks off at Rohingya camps in Bangladesh; 2017a. http://www.unicef.org.hk/en/worlds-second-largest-oral-cholera-vaccination-campaign-kicks-off-at-rohingya-camps-in-bangladesh/. [Accessed 21 November 2017].

      ,

      United Nations Children’s Fund. Bangladesh steps up vaccination for new Rohingya arrivals as measles cases rise; 2017b. http://www.unicef.org.hk/en/bangladesh-steps-up-vaccination-for-new-rohingya-arrivals-as-measles-cases-rise. [Accessed 21 November 2017].

      ). Nearly 55% of children under 15 years of age (n = 186 929) have been vaccinated (

      International Organization for Migration. Situation Report: Rohingya Refugee, Crisis Cox’s Bazar; 2017b. https://reliefweb.int/sites/reliefweb.int/files/resources/171126_weekly_iscg_sitrep_final.pdf. [Accessed 28 November 2017].

      ), but to achieve the >95% coverage required for herd immunity, the vaccination campaign must be continued and expanded. The constant population movement and lack of official registration increase the complexity of the field vaccination operations. Reports on the Rohingya people in Malaysia have shown that despite the host government’s intention to vaccinate the refugees, the vaccination rate in children under 5 years of age in the refugee community is lower than that in the host community (
      • Mahmood S.S.
      • Wroe E.
      • Fuller A.
      • Leaning J.
      The Rohingya people of Myanmar: health, human rights, and identity.
      ).

       Gynecological and obstetric care needs

      A report published in 2017 stated that one in seven Rohingya women in Northern Rakhine State had undergone at least one unskilled abortion under unhygienic conditions (
      • Mahmood S.S.
      • Wroe E.
      • Fuller A.
      • Leaning J.
      The Rohingya people of Myanmar: health, human rights, and identity.
      ). Thus, the female asylum seekers may present with various gynecological and obstetrics needs. Although data on sexual and gender-based violence are not available, reports from other displaced camp contexts (
      • Krause U.
      A continuum of violence? Linking sexual and gender-based violence conflict, flight, and encampment.
      ,
      • Iyakaremye I.
      • Mukagatare C.
      Forced migration and sexual abuse: experience of Congolese adolescent girls in Kigeme refugee camp, Rwanda.
      ) have highlighted that gynecological and obstetric services and the treatment and management of sexually transmitted diseases (STD) and HIV/AIDs are essential to address the needs of populations living in camp settlements.

       Information needs

      The lack of proper documentation of the Rohingya people in their country of origin has rendered the arrangement of re-settlement challenging (
      • Mahmood S.S.
      • Wroe E.
      • Fuller A.
      • Leaning J.
      The Rohingya people of Myanmar: health, human rights, and identity.
      ). To reduce health risks and other medical emergency and disaster vulnerabilities, the medical response community could provide immunization cards for children and a basic medical history summary to those who have sought treatment during their stay in the temporary settlements. Not only would these documents facilitate future medical consultations, but they might also serve as valuable proof of identity.

      Conclusions

      The situation of the Rohingya people in Bangladesh once again reminds the medical community of the importance of health emergency disaster risk management (H-EDRM) (
      • Chan E.Y.Y.
      • Murray V.
      What are the health research needs for the Sendai Framework?.
      ) in camp settings. Perpetual violence and context instability have left the Rohingya population in a dire situation, and global collaboration is urgently needed to reinforce and facilitate negotiations between Myanmar and Bangladesh in order to improve the fate and well-being of the Rohingya refugees. Ultimately, it is not only about respecting life and preserving dignity, but also to ensure the survival of this forgotten population.

      Conflict of interest

      None.

      Funding

      None.

      Authorship

      EC was responsible for the conception and design of the study. CC was responsible for the acquisition of data and interpretation of the data. EC, CC and GC drafted the article. EC, CC, and GC revised the paper critically for important intellectual content. EC approved the final version for submission.

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