Bangladesh: Update on MSF’s activities in Cox’s Bazar May 2018
May 2018 update on activities in Cox's Bazar, Bangladesh, providing care for Rohingya refugees who have fled Myanmar.
- Number of health facilities: 10 health posts; 3 primary health centres (open around the clock); and five inpatient health facilities (providing 24-hour secondary healthcare).
- Number of staff: To respond to the fastest growing refugee crisis in the world, our team in Cox’s Bazar has increased to more than 2,000 staff – the majority of them Bangladeshi nationals.
- Number of patients: Between August 2017 and the end of April 2018, our teams carried out 506,324 outpatient and 10,655 inpatient consultations.
- Main morbidities: Respiratory infections, diarrhoeal diseases, skin diseases – all related to poor living conditions – and non-communicable diseases.
- Water and sanitation: This is key to prevent the spread of disease. Activities include drilling boreholes and tube wells, installing a gravity-fed water supply system, trucking in water, desludging old latrines, constructing new sustainable latrines, undertaking bucket chlorination and distributing domestic water filters.
- Mental health services: This has been scaled up, with more counsellors added to existing teams, services available at additional health posts, and training outreach workers to provide basic psychosocial support.
- Outreach: Teams focus on health promotion, outbreak prevention, alert and response, while a surveillance team gathers demographic, nutritional, mortality and birth indicators, covering 80 per cent of the refugees’ settlements. The teams also do active case-finding and referral to health facilities for diagnosis and treatment, as well as defaulter tracing and mobilisation for vaccination. An all-female team spreads messages about sexual and reproductive health in the community.
Current health concerns
Upcoming monsoon season
The approaching monsoon rains and other natural hazards may lead to deaths in the camps, with hundreds of thousands of Rohingya at risk of disease outbreaks and aid disruptions. Current shelters and structures are unable to withstand extreme weather conditions such as heavy flooding or cyclones, and do not sufficiently meet the protection needs of the most vulnerable refugees. Landslides have already occurred in the pre-monsoon rains. We are preparing for mass casualty scenarios to respond to the medical needs in the aftermath of any natural disasters.
Due to the poor infrastructure in the camp, access to our health posts and clinics for patients and staff will be even more difficult.
200,000 Rohingya are at direct risk of flooding, which can also cause overflowing toilets and the contamination of drinking water.
The upcoming rainy season brings with it the increased risk of respiratory tract infections and the exacerbation of existing illnesses, as well as trauma from landslides and waterborne diseases, such as acute watery diarrhoea, cholera, typhoid, hepatitis, shigellosis, or mosquito-borne diseases such as malaria and dengue fever.
MSF currently offers clinical stabilisation and management of acute, life-threatening exacerbation of diseases such as asthma, diabetes, hypertension, and chronic obstructive pulmonary diseases. However, MSF is struggling to address continuation of care for patients with non-communicable diseases (NCDs), which require proper referral pathways, facilities, laboratory follow-up and human resources, all of which still need to be put in place. This gap will be reduced by the provision of comprehensive care for NCD patients through in-patient care for severe cases at the Hospital on the Hill, and specific out-patient follow-up in the health posts as part of the integrated health services provided there.
Vaccinations and vaccine-preventable diseases
Vaccine-preventable diseases continue to be an issue, as evidenced by the ongoing outbreaks of measles and diphtheria, though the incidence of diseases has largely reduced since mass vaccination campaigns were completed.
The level of coverage for routine immunisation is low. This, combined with crowded living conditions, a lack of adequate water and sanitation, and the little access the Rohingya population had to routine healthcare in Myanmar represents a public health risk to both the new arrivals and the host population. MSF is supporting the government in expanding routine vaccination in the camps through initiating vaccination for children and pregnant women at MSF facilities.
Staff at all MSF health facilities will have the capacity to administer immunisation for measles and rubella, oral polio, pneumococcal conjugate vaccine (PCV), pentavalent vaccine and tetanus according to national protocols. With the support of other actors, the Ministry of Health and Family Welfare has been implementing measles and diphtheria (pentavalent) vaccination campaigns. MSF has been supporting this by setting up fixed points in our health posts, reinforcing the campaign with human resources for the mobile teams and mobilisation, and implementing the vaccination with an outreach team.
Between September and the end of April, we saw 4,680 cases of measles across all the MSF health facilities. Cases are now decreasing although the outbreak is far from over. All children under 5 years newly arriving in the camps are vaccinated against measles. This remains one of MSF’s top priorities. Two rounds of a mass vaccination campaign were organised by the Ministry of Health, with MSF support.
MSF has treated 5,883 people for diphtheria in the Cox’s Bazar district as of the end of April. During the peak of the outbreak, MSF ran three dedicated diphtheria health facilities. At Rubber Garden, we set up a dedicated diphtheria treatment centre and follow up with family members and other people who have been in contact with the patients. These contacts are treated preventatively with antibiotics via an outreach team who ensure the medication is taken on a daily basis.
The contacts are also sent to the health post to get vaccinated against diphtheria. An MSF team is also responsible for tracing patients for 30 days from the date of admission to ensure medical care for post-diphtheria complications is received. Any person who reports having symptoms indicative of post-diphtheria complications or other illness are referred to MSF’s health facilities for a clinical assessment. Appropriate treatment is then given or patients are referred to other health care providers who offer palliative or rehabilitative services if needed. The Government of Bangladesh has implemented a vaccination campaign against diphtheria.
Sexual and gender-based violence
MSF has treated 377 survivors of sexual and gender-based violence (SGBV) between 25 August and 30 April, between nine and 50 years of age. However, the real figure of SGBV survivors is impossible to determine as we likely only treat a fraction of all cases. Sexual violence is often underreported due to the shame and stigma associated with sexual assault, limited knowledge about medical and psychological support available, and the fact that access to healthcare in Myanmar was restricted heavily.
Sexual and reproductive health
MSF is intensifying our activities focusing on mother-and-child and reproductive healthcare. Only a minority of expected deliveries occur in a health facility, while home deliveries often happen in unsafe and unhygienic conditions. Moreover, MSF sees many women and girls seeking medical care for pregnancies which are the result of rape. The lack of support mechanisms for rape-related pregnancy can have dangerous consequences, such as unsafe abortions and death. Some rape-related pregnancies are quite advanced and women are unable to return to their community. MSF refers these women and girls to a safe shelter under the care of a dedicated organisation, although existing capacity in the camp is extremely limited.
There is no way of telling if there will be a spike in births as a consequence of rape. We do know that there are a number of women and girls of child bearing age within the settlements of Cox’s Bazar District. We expect deliveries to continue but it is not possible for MSF to predict or speculate about the number of expected deliveries at any one time.
MSF has specialised staff on the ground to treat survivors who are referred for treatment as a result of trauma, including sexual assault and rape. MSF’s local community outreach workers visit people living in the settlements, informing them about the free services the organisation offers, including treatment for sexual violence. At our clinic, we offer these women comprehensive health care, including mental health care and counselling. We also discuss possibilities and support options with them, based on their individual needs.
Mental and psychosocial health
The mental and psychosocial impact of being forcibly displaced and living in such difficult conditions continue to affect the Rohingya refugees. Mental health services remain an important part of MSF assistance to people who have experienced extremely high levels of violence, as confirmed by the retrospective mortality surveys we published in December.
Water and sanitation (WASH)
Outside of the medical response, improving water and sanitation is a major part of our work to prevent the spread of disease. Emergency facilities that were put up quickly in the first phase of response have been of low quality. Congestion is a major concern; and overburdening existing facilities and complicating access for emptying latrines therefore increases the public health risk in these sites. Desludging and decommissioning of these latrines remains a priority to improve the inadequate sanitation environment. MSF has desludged 438 full or overflowing latrines so far.
Until now, MSF has built 1,050 latrines – serving around 50,000 people every day with an appropriate toilet.
Considering the potential for contamination of the shallow groundwater, MSF has so far drilled 10 deep productive boreholes – up to 200 metres deep – to provide clean water. These feed MSF health facilities and piped networks which reach between 5,000 and 30,000 people each. MSF has drilled 296 tube wells and maintains the hand pumps in order to provide clean water to refugees where the terrain does not allow such network construction.
A recently completed gravity water network has provided 1,790,000 litres of clean and chlorinated water to the community in the five weeks since it was put into operation. MSF provides close to 90,000 litres of water per day to health facilities and refugees using water trucking.
To provide access to clean water at household level, MSF has distributed over 1,000 bucket water filters to refugees who are being relocated to the expansion areas of the camp which lack infrastructure. Priority is given to the most vulnerable people (pregnant women, families with babies under 12 months of age, households with no adults, the elderly and widows). These water filters are also distributed as a preventive measure in areas where outbreaks of waterborne diseases are suspected.
The availability of safe drinking water is an increasing concern in the settlements. MSF monitors the water quality to ensure a proper maintenance of every facility, with the aim of increasing their uptake and use by refugees. Given the huge number of people living together, outbreaks of waterborne diseases are inevitable (acute watery diarrhoea, hepatitis E, typhoid). To ensure access to clean drinking water, we assess water sources, promote hygiene messages and chlorinate buckets at 35 water source points.
MSF includes water supply and sanitation in our emergency response for new arrivals. We deploy teams to arrival, transit and settlement locations to ensure that newly arrived refugees have access to safe drinking water and adequate sanitation facilities.
MSF project locations in Cox's Bazar
Sadar Hospital in Cox’s Bazar City
By the end of May, MSF will start providing support to the Ministry of Health and Family Welfare at the district hospital in Cox’s Bazar. Located in the centre of the town, this 250-bed district hospital is actually managing around 500 patients per day. MSF’s support will focus on implementing infection prevention and control measures for the benefit of the patients and hospital staff. MSF will train all medical and non-medical staff on standard infection prevention and control protocols, provide all required material for the implementation of these protocols, as well as recruit 50 additional cleaners. The team will also construct a new medical waste area and a laundry room to manage linen coming from the surgical and maternity departments, as well as rehabilitate the external grey water system.
Close to the Rubber Garden transit centre for new arrivals just outside camp 7, near Kutupalong makeshift settlement, in December we opened a dedicated diphtheria treatment centre in response to an outbreak of the disease. The treatment centre now has 35 beds for patients with diphtheria and capacity to increase up to 70 beds if needed. In order to reduce the spread of the disease, the team is also involved in active case finding, contact tracing (finding the patient’s household and ensuring that their family members complete the prophylactic treatment), and follow-up. Patients are traced by the MSF outreach team for 30 days after the date of admission in order to ensure that people needing medical care for post-diphtheria complications receive it. Moreover, as part of our preparedness plans for potential outbreaks, MSF is increasing the capacity of the facility with 100 more beds for a multi-outbreak response centre, including for illnesses such as acute watery diarrhoea. We are also improving awareness of the signs and symptoms of a number of diseases.
Since 25 August, the IPD has been expanded from 50 to 79 beds to cope with the influx and the increasing numbers of patients. Isolation capacity was also expanded due to the potential outbreak of communicable diseases. In order to increase the number of beds available and improve the overall infrastructure in the hospital to meet the needs of the growing population, construction works are ongoing; a temporary OPD was opened on 24 December to be used as temporary site until a new and larger OPD is finished. The OPD currently treats over 300 patients per day. We are also currently expanding maternity, sexual-based violence, neonatal, and paediatric care activities. Renovation and future expansion of the inpatient buildings are ongoing to reach a patient capacity of 110 beds.
MSF runs three health posts throughout the Kutupalong makeshift settlement expansion area (camps 3, 5 and 7) to provide basic primary healthcare. The health posts in total treat over 300 patients per day. They will be used as fixed vaccination sites for EPI (the expanded programme on immunization).
An inpatient facility in Balukhali (camp 9) had been functioning as a diphtheria treatment centre with 75 beds since early December, leaving only the ER functional for other morbidities. On 12 January the facility changed back to a mother and child healthcare facility. Services include paediatric (15 beds) and neonatal care/inpatient therapeutic feeding centre (ITFC) (15 beds), maternity (10 beds), emergency room and observation (5 beds) and an isolation ward (20 beds). MSF also runs two health posts and an outpatient facility in the settlement to provide basic primary healthcare.
Additionally, we have a stand-alone facility which, when activated, has an isolation ward with 30 beds. Health posts will be used as fixed vaccination sites for EPI, following the completion of the third round of diphtheria vaccinations. During February, teams carried out over 10,000 outpatient consultations.
Camps 11 and 18
MSF has been running two health posts providing comprehensive primary health care and sexual reproductive healthcare services (antenatal, postnatal, sexual-gender based violence, gynaecological consultations and family planning). Each health posts treats over 200 patients per day.
On 14 April, MSF opened a 100-bed inpatient facility, called Hospital on the Hill. The semi-permanent structure includes a 24-hour emergency room, adult and paediatric wards, an intensive care unit, isolation beds, a 50 bed isolation unit in case of an outbreak, a maternity ward with sexual and reproductive healthcare services, non-communicable disease (NCD) care and follow up, laboratory services and an ambulance referral system.
At a health post, MSF provides OPD services, sexual and reproductive health activities (antenatal, postnatal, sexual-gender based violence, gynaecological consultations and family planning), care to sexual violence survivors, as well as mental health care. Around a quarter of consultations are for children aged less than five years.
There are around 34,000 refugees living in Hakimpara makeshift settlement. MSF has been running a primary health centre that includes a 24-hour emergency room with eight observation beds, six isolation beds, an outpatient department (OPD), sexual reproductive healthcare including a delivery room, sexual and gender-based violence (SGBV) and mental health services. The clinic is currently seeing around 150 patients per day and operates an ambulance referral system. MSF’s outreach teams focus on health promotion, outbreak prevention, alert and response while a surveillance team gather demographic, nutritional, mortality and birth indicators.
There are around 55,000 refugees living in Jamtoli makeshift settlement. MSF has been running a primary health centre that include a 24-hour emergency room, an outpatient department (OPD), paediatric and adults wards, sexual reproductive healthcare, sexual and gender-based violence (SGBV) and mental health services. The clinic is currently seeing around 280 patients per day and offers 24-hour primary health care service, with a delivery room, eight observation beds, six isolations beds and an ambulance referral system. MSF’s outreach teams focus on health promotion, outbreak prevention, alert and response while a surveillance team gather demographic, nutritional, mortality and birth indicators.
There are over 22,000 refugees living in Moynarghona makeshift settlement. MSF started a mobile clinic in September, which has since been upgraded to a health post. The team is carrying out nearly 160 consultations per day on average. Services in this health post include an emergency, an outpatient department (OPD), including sexual reproductive healthcare and mental health services.
Our outreach teams are working in Moynarghona makeshift camp as well, with the same focus on health promotion, outbreak prevention, alert and response, while a surveillance team gather demographic, nutritional, mortality and birth indicators.
In the context of our Emergency Preparedness Plan and in line with the overall ISCG/MoH preparations for a potential acute watery diarrhoea outbreak, a Diarrhoea Treatment Unit, with 30 bed capacity, has been built at a walking distance from the MSF health post. The DTU is ready to be activated immediately if an outbreak indication is presented.
In February, MSF opened a health care facility with up to 74 bed capacity. The facility includes an outpatient department (OPD), expanded programme on immunisation (EPI), mental health, and SGBV services. The inpatient department includes paediatric, neonatal, isolation and maternity wards (with capacity for deliveries 24/7). There is also a 24/7 emergency department with ambulance services available. This facility was under construction in December when it was temporarily transformed into a Diphtheria Treatment Centre until mid-February, due to the outbreak. The hospital is located outside the refugee camps, and receives both host and refugee beneficiaries.
There are over 22,000 refugees living in Unchiprang makeshift settlement. MSF is running a primary health centre and remains the main healthcare provider in the settlement. The team carries out around 200 consultations per day. The structure includes OPD services (including EPI, mental health, sexual and reproductive health services), a 24-hour emergency room, six beds for observation and a delivery room as part of the sexual and reproductive health component. Isolation capacity is also available.
The teams also perform active case finding and referral to health facilities for diagnosis and treatment, as well as defaulter tracing and mobilisation for vaccination. In the context of our Emergency Preparedness Plan and in line with the overall ISCG/MoH preparations for a potential AWD outbreak, a Diarrhoea Treatment Unit (DTU), with 36 beds capacity, is built near the MSF primary health centre. The DTU is ready to be activated immediately if an outbreak indication is presented.
There are over 75,000 refugees living in Nayapara refugee camp and the informal settlements around it. We have been running a primary health centre, which has recently been upgraded to include a 24/7 emergency room service with capacity of five observation beds and two isolation beds. Referral capacity is also available 24/7. The services provided include an outpatient department (OPD), sexual and reproductive healthcare and mental health services. The team is carrying out around 200 consultations per day.
In line with our emergency preparedness plan MSF is currently setting up a new Diarrhoea Treatment Centre (DTC), with skeleton infrastructure and a capacity of 100 beds to be activated if an outbreak is detected.
Sabrang entry point
At the border point in Sabrang, MSF started a mobile clinic on 8 October, offering nutritional screening and basic primary health care and monitoring, whose services have been integrated in the circuit of the reception centre. The daily mobile clinic sited in Sabrang entry point screens, and provides consultations to all new arrivals. Mobile clinic services include OPD consultations (adult and paediatric), identification of severe cases, psychological first aid and referrals.