BANGLADESH EMERGENCY RESPONSE 25 January 2018
SUMMARY:
Number of health facilities: 15 health posts, three primary health centres and 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 25 August, MSF has massively scaled up its operations, and we now manage 15 health posts, three primary health centres and five inpatient facilities. The main morbidities among patients in our clinics are respiratory tract infections, diarrheal diseases, which are directly related to the poor shelter, water and sanitation conditions in the settlements.
CURRENT PUBLIC HEALTH CONCERNS:
Measles: Between September and January, we saw 3,539 cases of measles across all the MSF health facilities. The epidemiological curve of measles is decreasing significantly.
Diptheria: MSF has treated more than 4371 cases of diphtheria as of 22 January.
The majority of cases are aged between 5 and 14 years. Diphtheria can result in a high case-fatality rate without the anti-toxin. MSF has been administering anti-toxin to patients but it requires a number of skilled human resources. At Rubber Garden, which used be a transit centre for new arrivals, MSF has set up a new diphtheria treatment centre and has treated more than 1,000 admitted patients since 26 December 2017. MSF has treated a total of 231 patients with DAT (Diphtheria anti-toxin). Active case investigation continues throughout the settlements and contacts are being treated prophylactically with antibiotics via the health facilities.
With the arrival of an international medical team from the UK and new treatment sites set up by other actors, the capacity of treating suspected diphtheria cases should increase, which should hopefully allow MSF to start using our inpatient facilities for other, much-needed medical care.
With the support of other actors, the 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 centre, other cases, including measles, are referred to an MSF inpatient department in Tasnimarkhola.
Outbreaks of vaccine-preventable diseases like this demonstrate just how little access the Rohingya population had to routine healthcare in Myanmar.
As part of our preparedness plans for potential outbreaks, MSF has identified sites for the Diarrhoea Treatment Units in Balukhali, Hakimpara, Jamtoli, and Unchiprang. The site preparations are finished in Balukhali and are ongoing in other locations.
SUMMARY OF MSF’S OPERATIONS IN COX’S BAZAR
MSF PROJECT LOCATIONS IN COX’S BAZAR
Rubber Garden *NEW
Rubber Garden, near Kutupalong Makeshift Settlement, was used as a transit centre for newly arrived refugees, but in response to an increase in suspected diphtheria cases, MSF opened a dedicated treatment centre at the site. The treatment centre opened on 27 December and now has 48 beds for severe cases and 150 for moderate cases.
Kutupalong
The number of refugees living in Kutupalong and Balukhali area is now over 585,000. MSF’s Kutupalong Health Facility has been operating since 2009 and is the largest MSF health facility in Cox’s Bazar.
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. 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 works are ongoing; a temporary OPD has been built on 24 December 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 Kutupalong Makeshift Settlement (KMS) Expansion area to provide basic primary healthcare. The health posts treat over 300 patients per day are now used as fixed vaccination sites for EPI (The Expanded Programme on Immunization).
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 has 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 45-bed mother and child healthcare facility. Services include pediatric and neonatal care/inpatient therapeutic feeding centre (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 healthcare. 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 1 October, MSF has been running a health post in Balukhali 2 providing basic primary health care. Newly arrived refugees are being settled in the zone named SS, which also includes Balukhali 1 and Balukali 2. MSF opened a Health Post in the SS zone on 18 November, 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 opened a health post on 26 October and has treated 12,400 patients between the opening and the end of December. Around 30% of consultations are for children under five. On 3 December, we started sexual and reproductive health activities (antenatal, postnatal, sexual-gender based violence, gynaecological consultations and family planning).
emergency room, an outpatient department (OPD), an inpatient department (IPD) including a paediatric and neonatal ward, isolation beds, a diarrhoea treatment ward, sexual and reproductive healthcare services, a mental health
Services in the clinic include a 24-hour
department, and basic laboratory services.
On 26 November, MSF opened an inpatient facility with a 25-bed capacity. The hospital is focused on paediatrics (children < 15 years), the in-patient treatment of severe acute malnutrition (10% of hospitalized patients) and currently the management of measles cases (55% of hospitalized patients). To accommodate for the high number of measles cases, we had to increase 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 centre, 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 Uchiprang 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 healthcare centre. The clinic is currently seeing around 230 patients per day and offers 24- hour primary health care service, with a delivery room and 18 hospitalisation beds and an ambulance referral system.
health post and observation
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 centre with 24-hour primary health care services and 14 hospitalisation beds where we are treating around 150 patients per day.
health post and observation
Services in this
include a 24-hour emergency room
, an outpatient department (OPD),
including a paediatric ward, sexual reproductive healthcare and mental health services.
Services in this
include a 24-hour emergency room
, an outpatient department (OPD),
including a paediatric ward, sexual reproductive healthcare and mental health services.
MSF is also running two more health posts in Hakimpara. These health facilities have suspended their daily operations and are now in standby since the Diphtheria outbreak started duet to staff detachment to the Diphtheria Treatment
Centre, 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 paediatric ward, sexual reproductive healthcare and mental health services.
Diphtheria Treatment Centre
MSF planned to open an IPD outside of the mega-camp makeshift settlement (sited nearby Jamtoli / Moynarghona makeshift settlements) with 63-bed capacity before the end of the year.
Once the diphtheria outbreak started, the site was transformed into a Diphtheria Treatment Centre and cases continue to be admitted since 11 December. The Diphtheria Treatment Centre attends severe and moderate cases. Currently an average of 4 patients is treated with DAT (Diptheria anti-toxin). The centre is also a referral point for all moderate and severe cases for both Rohingya population and host community arriving from the close by camps and villages and the South (Unchiprang, Nayapara and Teknaf). Meanwhile, the construction works to complete the inpatient structure are being finalized.
When the diphtheria cases recede, the facility will include a 24-hour emergency room, an outpatient department (OPD), an inpatient department (IPD) including a paediatric and neonatal ward, isolation beds, a diarrhoea treatment ward, sexual and reproductive healthcare services, a mental health department, a basic laboratory services and an ambulance referral system.
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 immunisation for measles and rubella, oral polio and tetanus according to national protocols.
The Ministry of Health completed a measles and rubella vaccination campaign
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.
in Balukhali were vaccinated.
Sexual violence
1 Morbidity and Mortality Weekly Bulletin Vol. 8, 3 December 2017: http://www.searo.who.int/bangladesh/mmwb/en/
on 6 December
Some 156,679 people in Kutupalong and 41,066
. It targeted more than
Key figures:

 Numberofrapecases: 101
 Number of SGBV cases under 18: 45
 Number of cases of male on male sexual violence: 0
Total number of sexual violence cases from 25 August – 31 December: 120
Since 25 August, MSF has treated 120 survivors of sexual violence at MSF’s Sexual and Reproductive Health Unit in Kutupalong. Of the survivors, 33% are under the age of 18, including one under the age of ten.
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 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.
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 drinkable 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; and latrines and water sources are set up near to each other, easily resulting in contamination.
According to the WHO1, 91% of households and 60% 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%) of all tube wells. As for sanitation, 39% 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 sanitation survey and water point survey in order to decommission the facilities where the risk is highest.
MSF is focussing 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 both 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 metres) 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 Balukali 2, for patients of malnutrition, measles and 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.
KEY Points
1. Since 25 August, over 688,000 Rohingya refugees have fled from Myanmar into Bangladesh and the influx still continues today. Five months on, the situation for refugees remains precarious; they are still living in makeshift shelters in overly populated settlements. Many lack access to safe drinking water and have poor hygiene and sanitation conditions. What we see remains an acute emergency situation with huge humanitarian needs. Living conditions for the refugees need to be massively improved with a particular focus on improvements to water and sanitation, shelter, reducing population density.
2. In the current context of dense population and poor water and sanitation conditions, the risk of people falling ill is high. Rohingya refugees are a vulnerable population who had little or no access to routine healthcare including vaccinations in Myanmar. People are already facing the spread of measles and diphtheria in the settlements. Although the government of Bangladesh has implemented a mass vaccination campaign for these diseases, the risk of an outbreak will remain unless living conditions are improved. There is an urgent need for a better response from organisations providing healthcare to mitigate the risk of additional diseases spreading and to ensure that all those who need vaccinations receive them.
3. As the settlements continue to expand, refugees face unequal access to basic services such as healthcare, food and water, which increases their vulnerability. Work is continuing on a new road but additional improvements to access need to be made to ensure aid reaches everyone.
References to Previous MSF Communications on the Rohingya Refugee Crisis
Bangladesh: Emergence of diphtheria worsens situation of Rohingya refugees
24 December 2017
Bangladesh: Crisis update – December 2017
23 December 2017
A living nightmare Part2: An everyday struggle
22 December 2017
MSF surveys estimate at least 6,700 Rohingya were killed during the attacks in Myanmar
12 December 2017
A living nightmare: Photo Story
12 December 2017
“This is still a population teetering on the edge.”
6 December 2017
Bangladesh: Crisis update
20 November 2017
Opinion – Rohingya refugees “People are in survival mode”
23 October 2017
Bangladesh ‘Voices from the Violence’
22 October 2017
Bangladesh Crisis Update
17 October 2017
Myanmar: International humanitarian access to Rakhine State must urgently be permitted
18 September 2017
Rohingya in Myanmar and Bangladesh urgently require medical and humanitarian assistance
6 September 2017