Bangladesh: Update on Activities in Cox's Bazar

South Sudan 2014 © Valérie Batselaere/MSF
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SUMMARY:

Number of health facilities:  15 health posts, three primary health centers, five in-patient health facilities

Number of staff: Over 2,000 national and international staff, as of the end of November

Number of patients: Over 200,000 patients have been treated at MSF outpatient facilities and 4,938 patients in inpatient facilities between the end of August and the end of December

Main morbidities: respiratory infections, diarrheal diseases, diphtheria cases

Other activities: water and sanitation (water trucking and hand pump, tube well and latrine installation) and mental health services

 

Since August 25, MSF has massively scaled up its operations in Cox's Bazar district, Bangladesh, in response to the Rohingya refugee crisis. We now manage 15 health posts, three primary health centers, and five inpatient facilities. The main morbidities among patients in our clinics are respiratory tract infections and diarrheal diseases, which are directly related to the poor shelter, water, and sanitation conditions in the settlements.

 

CURRENT PUBLIC HEALTH CONCERNS:

Measles: Between September 2017 and January 2018, we saw 3,539 cases of measles across all the MSF health facilities. The epidemiological curve of measles is decreasing significantly.
 

Diphtheria: MSF has treated more than 4,371 cases of diphtheria as of January 22.

The majority of cases involve children between 5 and 14 years old. Diphtheria can result in a high case-fatality rate without the necessary anti-toxin. MSF has been administering anti-toxin to patients, however this requires a number of skilled human resources. At Rubber Garden, which was previously a transit center for new arrivals, MSF has set up a new diphtheria treatment center and has treated more than 1,000 admitted patients since December 26, 2017. MSF has treated a total of 231 patients with the diphtheria anti-toxin (DAT). Active case investigation continues throughout the settlements, and contacts are being treated prophylactically with antibiotics at health facilities.

With the support of other actors, the Bangladesh Ministry of Health and Family Welfare has been implementing a diphtheria vaccination campaign. MSF has been supporting this by setting up fixed points in our health posts.

While Balukhali inpatient department has been functioning as a diphtheria treatment center, other cases, including measles, are referred to an MSF inpatient department in Tasnimarkhola.

With the arrival of an international medical team from the United Kingdom and new treatment sites set up by other actors, the capacity of treating suspected diphtheria cases should increase, which hopefully will allow MSF to start using our inpatient facilities for other, much-needed medical care.

Outbreaks of such vaccine-preventable diseases demonstrate just how little access the Rohingya community has had to routine health care in Myanmar.

As part of our preparedness plans for potential outbreaks, MSF has identified sites for diarrhea treatment units in Balukhali, Hakimpara, Jamtoli, and Unchiprang. Site preparations are finished in Balukhali and are ongoing in other locations.

 

MSF PROJECT LOCATIONS IN COX’S BAZAR


Rubber Garden *NEW

Rubber Garden, near Kutupalong makeshift settlement, had been used as a transit center for newly arrived refugees. In response to an increase in suspected diphtheria cases, MSF opened a dedicated treatment center at the site. The treatment center opened on December 27 and now has 48 beds for severe cases and 150 for moderate cases.

 

Kutupalong

The number of refugees living in the area around Kutupalong and Balukhali is now over 585,000. MSF’s Kutupalong health facility has been operating since 2009 and is the largest MSF facility in Cox’s Bazar. Services in the clinic include a 24-hour emergency room, an outpatient department (OPD), an inpatient department (IPD) including a pediatric and neonatal ward, isolation beds, a diarrhea treatment ward, sexual and reproductive health care services, a mental health department, and basic laboratory services.

Since August 25, 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. The OPD currently treats over 300 patients per day. 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 work is ongoing; a temporary OPD was built on December 24 to be used as temporary site until a new and larger OPD is finished. Renovation and future expansion of the inpatient buildings have started.

MSF runs three health posts throughout the settlement in the Kutupalong makeshift settlement (KMS) expansion area to provide basic primary health care. The health posts treat over 300 patients per day and are now used as fixed vaccination sites for the Expanded Program on Immunization (EPI).

MSF’s network of outreach teams focus on hygiene, health promotion, and surveillance. The teams also do active case finding and referral to health facilities for diagnosis and treatment, as well as defaulter tracing and mobilization for vaccination.  For the duration of the diphtheria outbreak, MSF teams in this area completed contact tracing, treatment, and follow-up for the contacts of patients diagnosed with diphtheria.

 

Balukhali

An inpatient facility in Balukhali had been functioning as a diphtheria treatment center with 75 beds since early December, leaving only the ER functional for other morbidities. On January 12 the facility reverted to serve as a 45-bed mother and child health care facility. Services include a pediatric and neonatal care/inpatient therapeutic feeding center (ITFC) (35 beds), maternity (10 beds), emergency room and observation and an isolation ward (30 beds). MSF also runs three health posts and an outpatient facility in the settlement to provide basic primary health care. Health posts are now used as fixed vaccination sites for EPI.

MSF’s outreach teams focus on hygiene, health promotion, and surveillance. The teams also do active case finding and referral to health facilities for diagnosis and treatment, as well as defaulter tracing and mobilization for vaccination.  MSF teams in this area are also ensuring contact tracing, treatment and follow-up for the contacts of patients diagnosed with diphtheria.

 

Balukhali 2

Since October 1, MSF has been running a health post in Balukhali 2 providing basic primary health care. Newly arrived refugees are being settled in the SS zone, which also includes Balukhali 1 and Balukhali 2. MSF opened a health post in the SS zone on November 18, which treats an average of 170 patients per day.

 

Tasnimarkhola

There are over 58,000 refugees living in Tasnimarkhola makeshift settlement, formerly known as Burma Para. MSF has treated 12,400 patients at the health post between the opening on October 26 and the end of December. Around 30 percent of consultations are for children under five. On December 3, we started sexual and reproductive health activities (antenatal, postnatal, sexual and gender-based violence, gynecological consultations, and family planning).

On November 26, MSF opened an inpatient facility with a 25-bed capacity. The hospital is focused on pediatrics (children < 15 years), in-patient treatment of severe acute malnutrition (10 percent of hospitalized patients), and currently the management of measles cases (55 percent of hospitalized patients). To accommodate the high number of measles cases, MSF increased the number of isolation beds to 36. Moreover, MSF has completed the drilling of four deep production boreholes to provide water to the health posts and IPD.

 

Unchiprang

There are over 19,500 refugees living in Unchiprang makeshift settlement. MSF has been running a primary health center, which was initially opened as health post in mid-September. It is the main health care provider in the settlement and the team is carrying out around 159 consultations per day. MSF has also opened a second health post in Unchiprang and in nearby Nayapara, where we treat 200 cases per day respectively.

                                             

Jamtoli

There are 50,500 refugees living in Jamtoli makeshift settlement. MSF opened a health post in September that was upgraded later to a primary health care center. The clinic is currently seeing around 230 patients per day and offers 24-hour primary health care services, with a delivery room and 18 hospitalization beds and an ambulance referral system.  Services in this health post include a 24-hour emergency room and observation, an outpatient department (OPD), including a pediatric ward, sexual reproductive health care, and mental health services.

 

Hakimpara

There are over 32,000 refugees living in Hakimpara makeshift settlement. MSF opened a health post that was upgraded later to a primary healthcare center with 24-hour primary health care services and 14 hospitalization beds. We are treating around 150 patients per day here. Services in this health post include a 24-hour emergency room and observation, an outpatient department (OPD), including a pediatric ward, sexual and reproductive health care, and mental health services.

MSF is running two more health posts in Hakimpara. These health facilities have suspended their daily operations and are now on standby since the diphtheria outbreak started. Staff have been detached to the diphtheria treatment center in order to support contact tracing and patient follow up activities.

 

Moynarghona

There are over 19,500 refugees living in Moynarghona makeshift settlement. MSF started a mobile clinic in September, which has since been upgraded to 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 a pediatric ward, sexual and reproductive health care, and mental health services.

 

Diphtheria Treatment Center

MSF planned to open an IPD outside of the mega-camp makeshift settlement (sited near Jamtoli / Moynarghona makeshift settlements) with 63-bed capacity before the end of 2017. Once the diphtheria outbreak started, the site was transformed into a diphtheria treatment center, and cases continue to be admitted since December 11. The diphtheria treatment center attends severe and moderate cases. Currently an average of four patients are treated with the diphtheria anti-toxin (DAT). The center is also a referral point for all moderate and severe cases for both the Rohingya and host communities arriving from areas surrounding the camps, nearby villages, and the south (Unchiprang, Nayapara, and Teknaf). Meanwhile, construction work to complete the inpatient structure is being finalized.

When diphtheria cases recede, the facility will include a 24-hour emergency room, an outpatient department (OPD), an inpatient department (IPD) including a pediatric and neonatal ward, isolation beds, a diarrhea treatment ward, sexual and reproductive health care services, a mental health department, basic laboratory services, and an ambulance referral system.

 

Sabrang entry point

At the border point in Sabrang, MSF started a mobile clinic on October 8, offering nutritional screening and basic primary health care and monitoring, whose services have been integrated in the reception center circuit. The daily mobile clinic sited in Sabrang entry point provides consultations to an average of 24 new arrivals per day. Mobile clinic services include OPD consultations – adult and pediatric – identification of severe cases, and referrals.

 

OTHER ACTIVITIES

Vaccination

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 immunization for measles and rubella, oral polio, and tetanus according to national protocols.

The Ministry of Health completed a measles and rubella vaccination campaign on December 6. It targeted more than 336,000 children between the ages of 6 months and 15 years. MSF supported this campaign with community mobilization, site identification, logistics, and transportation of vaccines. Some 156,679 people in Kutupalong and 41,066 in Balukhali were vaccinated.

 

Sexual violence

Key figures:

  • Total number of sexual violence cases from August 25 – December 31: 120
  • Number of rape cases:  101
  • Number of SGBV cases under 18: 45
  • Number of cases of male on male sexual violence: 0

Since August 25, MSF has treated 120 survivors of sexual violence at MSF’s Sexual and Reproductive Health Unit in Kutupalong. Of the survivors, 33 percent are under the age of 18, including one under the age of 10.

Sexual violence is often underreported due to stigma and shame, fear of reprisals, a lack of knowledge about the medical consequences of sexual violence and the need for timely medical care, and a lack of awareness about the medical and psychological support available. Given these barriers, it is likely that the number of SGBV survivors MSF has treated so far is just a fraction of the real figure.

MSF has specialized 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 organization offers, including treatment for sexual violence.

 

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. Issues remain around clean drinking water and latrines. Water sources are insufficient and often polluted with sewage, latrines are not deep enough, and no provision has been made for a drainage system; latrines and water sources are often set up near each other, easily resulting in cross-contamination.

According to the World Health Organization (WHO), 91 percent of households and 60 percent of source samples were contaminated with Escherichia coli (E. coli). Due to the lack of a drainage system, stagnant water is present around a quarter (26 percent) of all tube wells. As for sanitation, 39 percent of emergency latrines installed by WASH partners, mostly at the early stage of the emergency response, are non-functional. Desludging and decommissioning of these latrines remains a priority to improve the inadequate sanitation environment. The WASH cluster is doing a sanitation survey and water point survey in order to decommission those facilities where the risks are highest.

MSF is focusing its water and sanitation response on the most inaccessible areas. So far, MSF has built 1,522 latrines, 218 water wells, and a gravity water supply system in the settlements located in the north as well as in the ones in the south. In Tasnimarkhola and Balukhali 2 areas, MSF plans to drill 20 wells down to the water table (a depth of 100-150 meters) and use submersible pumps.

Considering that the shallow aquifer - the main water source, abundant in quantity and easy to access – is contaminated with fecal coliforms throughout the camps, MSF has started drilling deep production boreholes up to 150-200 meters deep to have clean water. More than 16 deep boreholes have been drilled so far.

Moreover, in response to Hepatitis E cases, MSF has done assessment of water sources, soap distribution (roughly 800 households), hygiene promotion messaging, and bucket chlorination at water source (15 bucket chlorination points).

To ensure access to clean drinking water, MSF plans to distribute domestic water filters in our clinics in Tasnimarkhola and Balukhali 2, for patients suffering from malnutrition and measles, and for pregnant women.

MSF also includes water supply and sanitation in its emergency response for new arrivals. MSF has deployed teams to arrival, transit, and settlement locations to ensure that newly arrived refugees have access to safe drinking water and adequate sanitation facilities.