Epidemiological, clinical, and public health response characteristics of a large outbreak of diphtheria among the Rohingya population in Cox's Bazar, Bangladesh, 2017 to 2019: A retrospective study.
<h4>Background</h4>Unrest in Myanmar in August 2017 resulted in the movement of over 700,000 Rohingya refugees to overcrowded camps in Cox's Bazar, Bangladesh. A large outbreak of diphtheria subsequently began in this population.<h4>Methods and findings</h4>Data were col...
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Public Library of Science (PLoS)
2021-04-01
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| Online Access: | https://doi.org/10.1371/journal.pmed.1003587 |
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| author | Jonathan A Polonsky Melissa Ivey Md Khadimul Anam Mazhar Ziaur Rahman Olivier le Polain de Waroux Basel Karo Katri Jalava Sirenda Vong Amrish Baidjoe Janet Diaz Flavio Finger Zakir H Habib Charls Erik Halder Christopher Haskew Laurent Kaiser Ali S Khan Lucky Sangal Tahmina Shirin Quazi Ahmed Zaki Md Abdus Salam Kate White |
| author_facet | Jonathan A Polonsky Melissa Ivey Md Khadimul Anam Mazhar Ziaur Rahman Olivier le Polain de Waroux Basel Karo Katri Jalava Sirenda Vong Amrish Baidjoe Janet Diaz Flavio Finger Zakir H Habib Charls Erik Halder Christopher Haskew Laurent Kaiser Ali S Khan Lucky Sangal Tahmina Shirin Quazi Ahmed Zaki Md Abdus Salam Kate White |
| author_sort | Jonathan A Polonsky |
| collection | DOAJ |
| description | <h4>Background</h4>Unrest in Myanmar in August 2017 resulted in the movement of over 700,000 Rohingya refugees to overcrowded camps in Cox's Bazar, Bangladesh. A large outbreak of diphtheria subsequently began in this population.<h4>Methods and findings</h4>Data were collected during mass vaccination campaigns (MVCs), contact tracing activities, and from 9 Diphtheria Treatment Centers (DTCs) operated by national and international organizations. These data were used to describe the epidemiological and clinical features and the control measures to prevent transmission, during the first 2 years of the outbreak. Between November 10, 2017 and November 9, 2019, 7,064 cases were reported: 285 (4.0%) laboratory-confirmed, 3,610 (51.1%) probable, and 3,169 (44.9%) suspected cases. The crude attack rate was 51.5 cases per 10,000 person-years, and epidemic doubling time was 4.4 days (95% confidence interval [CI] 4.2-4.7) during the exponential growth phase. The median age was 10 years (range 0-85), and 3,126 (44.3%) were male. The typical symptoms were sore throat (93.5%), fever (86.0%), pseudomembrane (34.7%), and gross cervical lymphadenopathy (GCL; 30.6%). Diphtheria antitoxin (DAT) was administered to 1,062 (89.0%) out of 1,193 eligible patients, with adverse reactions following among 229 (21.6%). There were 45 deaths (case fatality ratio [CFR] 0.6%). Household contacts for 5,702 (80.7%) of 7,064 cases were successfully traced. A total of 41,452 contacts were identified, of whom 40,364 (97.4%) consented to begin chemoprophylaxis; adherence was 55.0% (N = 22,218) at 3-day follow-up. Unvaccinated household contacts were vaccinated with 3 doses (with 4-week interval), while a booster dose was administered if the primary vaccination schedule had been completed. The proportion of contacts vaccinated was 64.7% overall. Three MVC rounds were conducted, with administrative coverage varying between 88.5% and 110.4%. Pentavalent vaccine was administered to those aged 6 weeks to 6 years, while tetanus and diphtheria (Td) vaccine was administered to those aged 7 years and older. Lack of adequate diagnostic capacity to confirm cases was the main limitation, with a majority of cases unconfirmed and the proportion of true diphtheria cases unknown.<h4>Conclusions</h4>To our knowledge, this is the largest reported diphtheria outbreak in refugee settings. We observed that high population density, poor living conditions, and fast growth rate were associated with explosive expansion of the outbreak during the initial exponential growth phase. Three rounds of mass vaccinations targeting those aged 6 weeks to 14 years were associated with only modestly reduced transmission, and additional public health measures were necessary to end the outbreak. This outbreak has a long-lasting tail, with Rt oscillating at around 1 for an extended period. An adequate global DAT stockpile needs to be maintained. All populations must have access to health services and routine vaccination, and this access must be maintained during humanitarian crises. |
| format | Article |
| id | doaj-art-8c795d6909074678a4aae2120eb5c7ea |
| institution | Kabale University |
| issn | 1549-1277 1549-1676 |
| language | English |
| publishDate | 2021-04-01 |
| publisher | Public Library of Science (PLoS) |
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| spelling | doaj-art-8c795d6909074678a4aae2120eb5c7ea2025-08-20T03:46:25ZengPublic Library of Science (PLoS)PLoS Medicine1549-12771549-16762021-04-01184e100358710.1371/journal.pmed.1003587Epidemiological, clinical, and public health response characteristics of a large outbreak of diphtheria among the Rohingya population in Cox's Bazar, Bangladesh, 2017 to 2019: A retrospective study.Jonathan A PolonskyMelissa IveyMd Khadimul Anam MazharZiaur RahmanOlivier le Polain de WarouxBasel KaroKatri JalavaSirenda VongAmrish BaidjoeJanet DiazFlavio FingerZakir H HabibCharls Erik HalderChristopher HaskewLaurent KaiserAli S KhanLucky SangalTahmina ShirinQuazi Ahmed ZakiMd Abdus SalamKate White<h4>Background</h4>Unrest in Myanmar in August 2017 resulted in the movement of over 700,000 Rohingya refugees to overcrowded camps in Cox's Bazar, Bangladesh. A large outbreak of diphtheria subsequently began in this population.<h4>Methods and findings</h4>Data were collected during mass vaccination campaigns (MVCs), contact tracing activities, and from 9 Diphtheria Treatment Centers (DTCs) operated by national and international organizations. These data were used to describe the epidemiological and clinical features and the control measures to prevent transmission, during the first 2 years of the outbreak. Between November 10, 2017 and November 9, 2019, 7,064 cases were reported: 285 (4.0%) laboratory-confirmed, 3,610 (51.1%) probable, and 3,169 (44.9%) suspected cases. The crude attack rate was 51.5 cases per 10,000 person-years, and epidemic doubling time was 4.4 days (95% confidence interval [CI] 4.2-4.7) during the exponential growth phase. The median age was 10 years (range 0-85), and 3,126 (44.3%) were male. The typical symptoms were sore throat (93.5%), fever (86.0%), pseudomembrane (34.7%), and gross cervical lymphadenopathy (GCL; 30.6%). Diphtheria antitoxin (DAT) was administered to 1,062 (89.0%) out of 1,193 eligible patients, with adverse reactions following among 229 (21.6%). There were 45 deaths (case fatality ratio [CFR] 0.6%). Household contacts for 5,702 (80.7%) of 7,064 cases were successfully traced. A total of 41,452 contacts were identified, of whom 40,364 (97.4%) consented to begin chemoprophylaxis; adherence was 55.0% (N = 22,218) at 3-day follow-up. Unvaccinated household contacts were vaccinated with 3 doses (with 4-week interval), while a booster dose was administered if the primary vaccination schedule had been completed. The proportion of contacts vaccinated was 64.7% overall. Three MVC rounds were conducted, with administrative coverage varying between 88.5% and 110.4%. Pentavalent vaccine was administered to those aged 6 weeks to 6 years, while tetanus and diphtheria (Td) vaccine was administered to those aged 7 years and older. Lack of adequate diagnostic capacity to confirm cases was the main limitation, with a majority of cases unconfirmed and the proportion of true diphtheria cases unknown.<h4>Conclusions</h4>To our knowledge, this is the largest reported diphtheria outbreak in refugee settings. We observed that high population density, poor living conditions, and fast growth rate were associated with explosive expansion of the outbreak during the initial exponential growth phase. Three rounds of mass vaccinations targeting those aged 6 weeks to 14 years were associated with only modestly reduced transmission, and additional public health measures were necessary to end the outbreak. This outbreak has a long-lasting tail, with Rt oscillating at around 1 for an extended period. An adequate global DAT stockpile needs to be maintained. All populations must have access to health services and routine vaccination, and this access must be maintained during humanitarian crises.https://doi.org/10.1371/journal.pmed.1003587 |
| spellingShingle | Jonathan A Polonsky Melissa Ivey Md Khadimul Anam Mazhar Ziaur Rahman Olivier le Polain de Waroux Basel Karo Katri Jalava Sirenda Vong Amrish Baidjoe Janet Diaz Flavio Finger Zakir H Habib Charls Erik Halder Christopher Haskew Laurent Kaiser Ali S Khan Lucky Sangal Tahmina Shirin Quazi Ahmed Zaki Md Abdus Salam Kate White Epidemiological, clinical, and public health response characteristics of a large outbreak of diphtheria among the Rohingya population in Cox's Bazar, Bangladesh, 2017 to 2019: A retrospective study. PLoS Medicine |
| title | Epidemiological, clinical, and public health response characteristics of a large outbreak of diphtheria among the Rohingya population in Cox's Bazar, Bangladesh, 2017 to 2019: A retrospective study. |
| title_full | Epidemiological, clinical, and public health response characteristics of a large outbreak of diphtheria among the Rohingya population in Cox's Bazar, Bangladesh, 2017 to 2019: A retrospective study. |
| title_fullStr | Epidemiological, clinical, and public health response characteristics of a large outbreak of diphtheria among the Rohingya population in Cox's Bazar, Bangladesh, 2017 to 2019: A retrospective study. |
| title_full_unstemmed | Epidemiological, clinical, and public health response characteristics of a large outbreak of diphtheria among the Rohingya population in Cox's Bazar, Bangladesh, 2017 to 2019: A retrospective study. |
| title_short | Epidemiological, clinical, and public health response characteristics of a large outbreak of diphtheria among the Rohingya population in Cox's Bazar, Bangladesh, 2017 to 2019: A retrospective study. |
| title_sort | epidemiological clinical and public health response characteristics of a large outbreak of diphtheria among the rohingya population in cox s bazar bangladesh 2017 to 2019 a retrospective study |
| url | https://doi.org/10.1371/journal.pmed.1003587 |
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