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30 JAN 2018
icddr,b is playing a key role to prevent disease outbreak among the Forcibly Displaced Myanmar Nationals (FDMNs) seeking refuge in Bangladesh. The plight of the FDMNs was mostly hidden from the world until August 2017 when they fled from Myanmar due to a violent military crackdown.
A camp for FDMNs in Cox's Bazar. Photo: icddr,b
Limited space in registered camps operated by national and international NGOs has created a vast challenge for Bangladesh where FDMNs have set up ‘home’ in informal shanties made from polythene and bamboo sticks. Camps are now spread throughout Ukhiya and Teknaf upazilas across the Cox’s Bazar district and Naihkongchari upazila of the Bandarban district.
An initial risk assessment was conducted, and based on the findings, the Directorate General of Health Services (DGHS) brought together international partners, as well as scientists from icddr,b and all mutually decided that pre-emptive action must be taken to avoid an outbreak, recognising that prevention is better than cure.
icddr,b has dealt with large-scale cholera outbreaks worldwide since the 1960s. More recently, under the leadership of the executive director, Professor John D Clemens, MD and emeritus scientist Dr Firdausi Qadri, as part of a massive oral cholera vaccine (OCV) trial and feasibility studies, icddr,b has used over 900,000 doses of OCV both in urban and rural areas of Dhaka.
Prof John Clemens and Dr Firdausi Qadri visiting Cox's Bazar. Photo: icddr,b
Dr Ashraful Islam Khan, a scientist from icddr,b’s Infectious Diseases Division (IDD) explained that “the scale of the problem was such that we did not know what was the best course of action.Diarrhoea cases were observed in the camps, and the water and sanitation status was an ideal situation for a cholera outbreak”.
After an initial suggestion from Professor Clemens, icddr,btook the crucial initiative to jointly apply, with the DGHS and its partners for OCV from the global stockpile, managed by the International Coordination Group (ICG). Convinced of the appalling conditions, the ICG responded within 24 hours, actioning the request to send 900,000 doses of OCV.
At the government’s request, a trained, well-experienced vaccination team of 150 people from icddr,b worked in Cox’s Bazar – the largest among the teams deployed by a single organisation to complete the operation.
Dr Khan feeding an OCV vaccine in Cox's Bazar. Photo: icddr,b
Dr Md. Shariful Islam, a project coordinator with icddr,b’s enteric and respiratory infections programme, explained that they followed “a shifting strategy, often completing vaccinations in one area and moving quickly onto the adjacent area the next day”.
icddr,b’s Expanded Program on Immunization (EPI) team, along with representatives from international partners, developed a comprehensive strategy for the distribution of the vaccine, including a Vaccine Delivery Guideline, a Micro Plan, and Training Manual to ensure the campaign was successful.
“There was no defined area where the displaced people were camped and the exact number of people to be vaccinated was not known, nor did we have information on whether they had previously been vaccinated or their general acceptability of vaccines”, explained Dr Md Tajul Islam A Bari, a consultant with IDD.
Md Bodrul Ahsan Prodhan, a consultant with the IDD, spoke of the difficulties in storing the vaccines: “a small team acted quickly at Cox’s Bazar to assess potential vaccine storage facilities. Due to insufficient space in Cox’s Bazar, a considerable number of the government’s routine EPI vaccines were shifted to freezers nearby to store the OCV”.
Photo: icddr,b
Overcoming these hurdles, the campaign successfully immunised approximately 700,000 FDMNs from 10–16 October 2017; an additional two days were required to cover everyone scattered across the numerous camps. A second dose of OCV, along with a second dose of oral polio vaccine (OPV) was administered from 4-9 November, including around 200,000 children aged 1-5 years.
“It is one of the fastest vaccination campaigns ever undertaken to protect people from cholera,” says Professor Clemens.
Post-campaign, icddr,b, in collaboration with the Institute of Epidemiology, Disease Control and Research, established seven surveillance sites at Ukhiya and Teknaf upazilas, to test stool from acute watery diarrhoeal cases. Testing was conducted at frontline treatment centres by diagnostic testing for cholera; subsequently, stool samples were sent to icddr,b in Dhaka for culture confirmation of V. cholerae.
From mid-November 2017, icddr,b in partnership with UNICEF and other institutions have been measuring the long term effectiveness of the OCV among the FDMN population. Additionally, icddr,b’s OCV team has been leading a post-campaign vaccine evaluation to measure the effectiveness of other vaccines including OPV and MMR. This has been developed by the government and WHO but is being executed by icddr,b.
Recognising the effectiveness of collaboration, Dr Qadri says, “This is an example of how we can work together and use our combined experiences to overcome hurdles and tackle issues which persist in Bangladesh”.
To date the number of cholera cases has been low, itself an indicator of the success of the vaccination programme. However, for the cholera vaccine to be effective, it is imperative that a second dosage be administered and icddr,b is currently in discussion with the government of Bangladesh and other partners to procure more vaccines from the stockpile or from various funding agencies to be used for this susceptible group.
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