Kashmir-based medical doctor Samreen Hussain recently returned from Cox’s Bazar in Bangladesh, where she worked as part of a Doctors Without Borders/Médecins Sans Frontières (MSF) team providing medical care to Rohingya refugees from Myanmar. In this piece, she describes the challenges posed by the re-emergence of diphtheria.
I arrived in Bangladesh in November 2017 at the peak of a measles outbreak. Within two weeks I found myself in the midst of one of the largest diphtheria outbreaks in recent history.
Although there is a diphtheria vaccine, the Rohingya population’s lack of access to healthcare in Myanmar meant they weren’t adequately protected against the disease. Diphtheria is highly contagious, and the crowded living conditions in refugee camps in Bangladesh made Rohingyas even more vulnerable.
I had never seen diphtheria in my life. It was no different for my colleagues, as the last major outbreak was in Russia in the 1990s though a diphtheria outbreak was also re-emerging in Yemen around the same time. Literature was limited. The world had almost forgotten about diphtheria.
We were educating ourselves as we went along – seeing patients through the day, reading and discussing late into the night – WHO case definitions, guidelines and very limited research documents. Within a few weeks, the medical team had become very effective in diagnosing suspected diphtheria. We went on to train and educate the nurses and outreach workers as well as medical teams from other NGOs.
In its early stages, diphtheria resembles flu or tonsillitis – making early diagnosis extremely difficult. Isolation of patients is critical, but due to the similarity of symptoms, we found diphtheria patients in the wards with other patients a few times. As a result, anybody who had been in a three-metre radius of these patients had to be prescribed the seven-day antibiotic prophylaxis.
Severe diphtheria is treated using the diphtheria antitoxin (DAT). As DAT was in short global supply in the initial days, our diphtheria treatment facility had very strict criteria for administering the antitoxin – only the severely ill with a high chance of survival, children and pregnant women could receive it.
The outbreak created challenges from all sides. We were already stretched with the measles outbreak, and the diphtheria outbreak pushed us to the brink. At the peak of the outbreak, we were seeing close to 150 suspected diphtheria patients every day in the facility I worked in alone. All our wards were full.
Contact tracing is as important as the treatment in tackling diphtheria; our team of outreach workers identifies the people the patient had been in contact with in order to protect them with the diphtheria vaccination/prophylaxis. You can imagine how challenging it is to implement contact tracing in a crowded refugee camp.
By 22 January, MSF had treated more than 4,371 cases of diphtheria. From the second week of January onwards, the cases dropped significantly because of rigorous contact tracing and mass vaccination campaigns. The availability of DAT also increased. MSF assisted the Bangladesh Ministry of Health in the vaccination campaigns by training their nurses and outreach staff.
It is safe to say that the worst of the diphtheria outbreak is behind us. But with the onset of the monsoons, the danger of water-borne diseases is imminent. The medical and water and sanitation teams have been preparing ahead of time and hopefully will be ready for whatever is thrown at them.