Illness and Cholera Vaccination Among Rohingya Refugee Children, Cox's Bazar, 2017

Violence in Myanmar's Rakhine State, beginning on August 25, 2017, drove huge numbers of Rohingya across the border into Cox's Bazar district, Bangladesh. Nearly 213,000 Rohingya were already living there. An estimated 45,000 more settled in two existing refugee camps, Kutupalong and Nayapara, and nearly 550,000 in new makeshift settlements.

Violence and flight, combined with malnutrition, crowding, poor hygiene and little access to safe water or health care, leave children especially vulnerable to infections such as pneumonia and diarrhea. Cholera is endemic in Bangladesh, so to head off an outbreak a mass oral cholera vaccination (OCV) campaign offered vaccine at fixed sites to everyone aged 1 year and older on October 10–18, 2017, followed by a second round for children aged 1–4 on November 4–9.

The surveys

Between October 22 and November 27, 2017, three household surveys — one each in Kutupalong, the makeshift settlements and Nayapara — measured:

• how many children aged 6–59 months had had diarrhea (three or more loose stools) or an acute respiratory infection (ARI) (cough with rapid or difficult breathing, plus fever) in the previous two weeks;
• where caregivers took sick children: the formal health system (clinics or hospitals run by the Bangladesh government or humanitarian organizations), a traditional healer, a pharmacy, somewhere else, or nowhere;
• whether people aged 1 and older had received at least one dose of cholera vaccine.

The surveys covered every household, whether or not it was registered with the UN refugee agency (UNHCR). Registered refugees had access to UNHCR's full range of services, including health care, food vouchers and nutrition programs.

What they found

Illness was widespread everywhere. In the two weeks before the survey:

• Unregistered refugees fared worse. In Kutupalong, unregistered children had significantly more diarrhea (51.8% against 30.4%) and ARI (65.3% against 47.8%) than registered children. In Nayapara, only diarrhea was significantly higher among the unregistered (40.7% against 26.9%).
• Many sick children never reached a clinic. Across the sites, 27.4%–44.2% of children with ARI and 36.4%–49.6% of children with diarrhea were taken somewhere outside the formal health system or not taken for care at all — even among registered refugees.

Cholera vaccine coverage was mostly high. At least one dose had reached more than 81% of people in Nayapara and the makeshift settlements. Kutupalong lagged — 72.6% of children aged 1–4 and 78.9% of people aged 5 and older — because coverage among its unregistered refugees was low (48.4% and 49.6%). Those refugees may have arrived in the middle of the campaign; the survey didn't ask why people went unvaccinated. In Nayapara, young children's coverage ran about 10 percentage points above that of older people in every group.

What it means

Crowded camps with little infrastructure or sanitation are prone to disease outbreaks, and these rates of ARI and diarrhea were high. One dose of oral cholera vaccine has been shown to give 40% protection six months later in people vaccinated at age 1 or older where cholera is highly endemic, so at least two doses are recommended, depending on the vaccine — especially for younger children.

Because of the heavy burden of respiratory illness and an ongoing diphtheria outbreak, a further campaign in mid-December 2017 offered children aged 6 weeks to 6 years pentavalent vaccine (against diphtheria, pertussis, tetanus, Haemophilus influenzae type b and hepatitis B) and pneumococcal conjugate vaccine.

The authors recommend:

• better access to safe water and sanitation, and hygiene promotion focused on handwashing;
• strengthening the World Health Organization's Expanded Programme on Immunization for all Rohingya refugees;
• community outreach that steers families toward established health facilities for safe, appropriate treatment.

Sources

• Summers A, Humphreys A, Leidman E, et al. "Notes from the Field: Diarrhea and Acute Respiratory Infection, Oral Cholera Vaccination Coverage, and Care-Seeking Behaviors of Rohingya Refugees — Cox's Bazar, Bangladesh, October–November 2017," MMWR Vol. 67, No. 18, CDC; a work of the United States government in the public domain. The imported copy cut off mid-results; the full text came from PubMed Central (PMC5944978).