Rare Disease Finds Fertile Ground In Rohingya Refugee Camps

Patients are treated at the Samaritan’s Purse diphtheria clinic in the Balukhali Rohingya refugee camp in Chittagong district, Bangladesh.

Diphtheria poses one more threat to already beleaguered Rohingya refugees.

The outbreak started in the sprawling camps in Bangladesh in November soon after hundreds of thousands of Rohingya arrived. It appeared to have peaked around New Year’s but now there is renewed concern as the potentially fatal disease continues to spread.

“Yesterday was a very busy day for us,” Dr. Andy Doyle said earlier this week at the Samaritan’s Purse diphtheria treatment center in the Balukhali refugee camp. “We saw 117 patients come in to be screened [for diphtheria]. That’s the most we’ve seen in any given day.”

By mid-January, there had been nearly 5,000 reported cases of diphtheria in the camps and 33 deaths.

Doyle is the medical director of the tented field hospital.

The waiting area, which is just some benches under a tarp roof, is jammed with people waiting to be checked for diphtheria. Doyle says it looks as if they could have a record number of patients for a second day in a row.

Doyle and his team only treat diphtheria at this facility. So the very first thing the staff members do is screen the patient for the disease and make sure it’s not just a bad cold.

Patients with diphtheria have a high fever, a sore throat, often a runny nose and severe inflammation in the back of the throat.

“[Diphtheria] is not something we see in the West,” Doyle says of the airborne bacterial infection. “Most of us from the West that are working here never saw this disease until we got here a week or two ago. And now we’re experts on it.”

“Sometimes they get swelling in their necks, especially in the younger children, and their neck itself will get really big,” he says. “It’s called bull neck. And those are the signs that the airway is in impending danger. So that’s what we look for.”

That’s how diphtheria kills: The neck swells up and a membrane develops in the throat that blocks breathing.

One day this past week, 117 patients came into the clinic to be screened for diphtheria.

As of the middle of January there’d been nearly 5,000 reported cases of diphtheria in the camps and 33 deaths. This is a far lower fatality rate than in past diphtheria outbreaks. That’s probably because patients get access to health care quickly in the half a dozen clinics that have sprung up in the camps.

Simple cases of diphtheria can be treated with antibiotics. But if the airway is in danger of being blocked, an anti-toxin is administered via an intravenous drip to wipe out a poison that the bacteria makes. But the anti-toxin has the potential to spark a fatal reaction.

Nur Aysia Begum is examined by Mollie McCully while her mother, Nayna Khatun, looks on. When her daughter got sick, Khatun was afraid she didn’t have money to pay for a doctor or medicine. But the Samaritan’s Purse clinic is free.

Her mother, Nayna Khatun, who’s sitting by her side, says they feared they’d be killed by the soldiers if they stayed. Now her family depends on international food aid to survive. When her daughter got sick, Khatun was worried because she didn’t have any money to pay for a doctor or medicine.

All of the treatment at this clinic is free.

Doyle says administering the anti-toxin is difficult and time-consuming.

“That nurse,” he says pointing to the nurse at Begum’s bedside, “will sit at that bedside watching for the slightest hint that an allergic reaction is about to start.”

Public health officials are very concerned how vulnerable the hundreds of thousands of Rohingya refugees are to diphtheria and other infectious diseases. The refugees are packed together in makeshift shelters. Toilets and water wells have been randomly dug all over the camps, often side by side. Marcella Kraay, a project coordinator with Doctors Without Borders, says another key factor putting the Rohingya at risk is that back in Myanmar they lacked access to even the most basic immunizations.

Humanitarian groups have launched a campaign to try to immunize nearly a million people in and around the refugee camps against diphtheria and other vaccine-preventable diseases.

“We’ve had a big measles outbreak and we’ve also had the biggest diphtheria outbreak that the world has seen in a long time,” she says.

Health care isn’t the only thing the long-persecuted Rohingya lacked in Myanmar.

Myanmar doesn’t consider the Rohingya to be citizens. The Muslim minority have faced discrimination in schools and the workforce. They need permission from the government to leave their villages. Some were forced to live in camps. And this was all before the military started attacking them and burning their villages to the ground last year.

Myanmar denies harassing the Rohingya. Myanmar officials say the military was conducting a cleanup operation against terrorists at the time that hundreds of thousands of Rohingya fled across the border in to Bangladesh.

Kraay with Doctors Without Borders says the Rohingya had very little access to health care. Some had never been to a clinic or seen a doctor.

Humanitarian groups have launched a massive campaign to try to counter that long history of medical neglect. Health workers from international nonprofits and the Bangladesh ministry of health are trying to immunize nearly a million people in and around the refugee camps against diphtheria and other vaccine-preventable diseases.

The diphtheria vaccine, however, is a difficult one to administer. It requires three shots spaced usually several months apart. Health officials here did a first round of diphtheria vaccinations at the end of December and hope to cram in the final two rounds in the coming weeks.

Until then diphtheria has hundreds of thousands of susceptible targets in the camps.

The diphtheria outbreak in the refugee camps is the biggest the world has seen in some years, says Marcella Kraay, a project coordinator with Doctors Without Borders.

Health scare in Denmark as refugees bring back diphtheria after 20yr absence

© Michael Dalder
Danish authorities have warned hospitals over possible outbreak of infectious diseases as several cases of diphtheria, tuberculosis and malaria carried by the refugees have already been registered.

“The infection can be very dangerous if one isn’t vaccinated against it. The dangerous type is very rare and we last saw it in Denmark in 1998,” Kurt Fuursted, spokesperson for the Danish State Serum Institute (SSI) told Metroxpress referring to the potential return of diphtheria. This disease was last diagnosed in Denmark about 20 years ago.

© Kacper Pempel

“There is no doubt that infectious diseases are coming in with the refugees that we aren’t used to. There have been discussions on whether all refugees who come to Denmark should be screened,” he added.

At present Denmark doesn’t follow the World Health Organization (WHO) recommendation to vaccinate incoming migrants, unlike some other European countries.

“Refugees, asylum-seekers and migrants should be vaccinated without unnecessary delay according to the immunization schedule of the country in which they intend to stay for more than a week,” reads a joint WHO-UNHCR-UNICEF guidance on general principles of vaccination of refugees, asylum-seekers and migrants in Europe, published on November 23 last year. It urges countries to provide migrants access to the “full vaccination schedule.”

The immigration officials and the Danish Health and Medicines Authority, a supreme healthcare authority in Denmark, are expected to review screening policy, according to Health Minister Sophie Lunde.

In recent months, Denmark has begun to tighten the screws in an effort to curb the refugee influx. On Thursday the Danish Parliament is set to vote on a bill proposing to strip refugees of valuables, including cash and jewelry, to cover the costs the country bears in connection with their stay. It would allow authorities to claim individual items valued at more than 10,000 kroner (US$1,450).

In the Danish cities of Thisted, Sonderborg and Haderslev, local club owners have started to introduce ‘language controls’, turning people away if they don’t speak Danish, English or German.

In 2015, some 18,000 refugees sought asylum in Denmark according to the migration agency, a far cry from almost 163,000 refugees in the neighboring Sweden.

Tetanus, Diphtheria, and Pertussis Vaccination during Pregnancy .

Tetanus, diphtheria and pertussis can be very serious diseases, even for adolescents and adults. These diseases are caused by bacteria. Diphtheria and pertussis are spread from person to person through coughing or sneezing. Tetanus enters the body through cuts, scratches, or wounds.

Tetanus, Diphtheria, and Pertussis Vaccination during Pregnancy

TETANUS (Lockjaw) causes painful muscle tightening and stiffness, usually all over the body. It can lead to tightening of muscles in the head and neck so you can’t open your mouth, swallow, or sometimes even breathe. Tetanus kills about 1 out of 5 people who are infected.

DIPHTHERIA can cause a thick coating to form in the back of the throat. It can lead to breathing problems, paralysis, heart failure, and death.

PERTUSSIS (Whooping Cough) causes severe coughing spells, which can cause difficulty breathing, vomiting and disturbed sleep. It can also lead to weight loss, incontinence, and rib fractures. Up to 2 in 100 adolescents and 5 in 100 adults with pertussis are hospitalized or have complications, which could include pneumonia or death.

The overwhelming majority of morbidity and mortality attributable to pertussis infection occurs in infants who are less than or equal to 3 months of age. Infants do not begin their own vaccine series against pertussis (with the diphtheria, tetanus and acellular pertussis vaccine [DTaP]) until 2 months of age. This situation leaves a window of significant vulnerability for newborns, many of whom appear to contract serious pertussis infections from family members and caregivers, including the mother.

Advisory Committee on Immunization Practices (ACIP) Recommendations

The ACIP of the Centers for Disease Control and Prevention (CDC) published its updated recommendation in February 2013, which recommends that health care personnel administer a dose of Tdap during each pregnancy, irrespective of the patient’s prior history of receiving Tdap. To maximize the maternal antibody response and passive antibody transfer and levels in the newborn, optimal timing for Tdap administration is between 27 weeks and 36 weeks of gestation, although Tdap may be given at any time during pregnancy. Receipt of Tdap at some point during pregnancy is critical, and there may be compelling reasons to vaccinate earlier in pregnancy (e.g., under “Special Situations During Pregnancy” [Click to follow link]).

For women who previously have not received Tdap, if Tdap was not administered during pregnancy, it should be administered immediately postpartum to the mother in order to reduce the risk of transmission to the newborn.

The ACIP recommends that all adolescents and adults who have or who anticipate having close contact with an infant younger than 12 months (e.g., siblings, parents, grandparents, child care providers, and health care providers) who previously have not received Tdap should receive a single dose of Tdap to protect against pertussis and reduce the likelihood of transmission. Ideally, these adolescents and adults should receive Tdap at least 2 weeks before they have close contact with the infant.

American College of Obstetricians and Gynecologists (ACOG) Recommendations

(a) General Considerations Surrounding Immunization during Pregnancy:

ACOG recommends routine assessment of each pregnant woman’s immunization status and administration of indicated immunizations. The benefits of nonlive vaccines outweigh any unproven potential concerns. There is no evidence of adverse fetal effects from vaccinating pregnant women with an inactivated virus or bacterial vaccines or toxoids, and a growing body of robust data demonstrates safety of such use. Co-administration of indicated inactivated vaccines during pregnancy (i.e., Tdap and influenza) is also acceptable, safe, and may optimize effectiveness of immunization efforts. It should be remembered, however, that live attenuated vaccines (e.g., measles-mumps-rubella [MMR], varicella, and live attenuated influenza vaccine) do pose a theoretical risk (although never documented or proved) to the fetus and generally should be avoided during pregnancy. All vaccines administered during pregnancy as well as health care provider-driven discussions about the indications and benefits of immunization during pregnancy should be fully documented in the patient’s prenatal record. In addition, if a patient declines vaccination, this should be documented in the patient’s prenatal record, and the health care provider is advised to revisit the issue of vaccination at subsequent visits.

(b) Special Situations During Pregnancy:

  • Ongoing Epidemics

Pregnant women who live in geographic regions with epidemics of pertussis should be immunized as soon as feasibly possible for their own protection in accordance with local recommendations for nonpregnant adults. Less emphasis should be given to targeting the proposed optimal gestation window (between 27 weeks and 36 weeks of gestation) in these situations given the imperative to protect the mother from locally prevalent disease. Newborn protection will still be garnered from vaccination earlier in the same pregnancy. Importantly, a pregnant woman should not be re-vaccinated later in the same pregnancy if she already received the vaccine in the first or second trimester.

  • Wound Management

As part of standard wound management care to prevent tetanus, a tetanus toxoid-containing vaccine is recommended in a pregnant woman if 5 years or more have elapsed since her previous tetanus and diphtheria (Td) vaccination. If a Td booster vaccination is indicated in a pregnant woman for acute wound management, health care providers should administer Tdap irrespective of gestational age. A pregnant woman should not be re-vaccinated with Tdap in the same pregnancy if she received the vaccine in the first or second trimester.

  • Due for Tetanus and Diphtheria Booster Vaccination

If a Td booster vaccination is indicated during pregnancy (i.e., more than 10 years since the previous Td vaccination) then health care providers should administer Tdap during pregnancy, preferably between 27 weeks and 36 weeks of gestation. Because of the nonurgent nature of this indication, waiting until 27–36 weeks of gestation appears to be the appropriate management plan to obtain maternal immunity and maximize antibody transfer to the newborn.

  • Unknown or Incomplete Tetanus Vaccination

To ensure protection against maternal and neonatal tetanus, pregnant women who have never been vaccinated against tetanus should begin the three-vaccination series, containing tetanus and reduced diphtheria toxoids, during pregnancy. The recommended schedule for this vaccine series is 0, 4 weeks, and 6–12 months; Tdap should replace one dose of Td, preferably given between 27 weeks and 36 weeks of gestation.