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Bangladesh/Myanmar: Rakhine Conflict 2017 - Public Health Situation Analysis And Interventions, 10 October 2017

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Executive summary

Since 25 August 2017, more than half a million people are estimated to have crossed from Myanmar to Cox’s Bazar, Bangladesh following violence in Rakhine state, Myanmar. People have moved into settlements/ camps, several spontaneous settlements have come up and many are with host communities. The speed and scale of the influx has resulted in a critical humanitarian emergency with increasing needs for food, health, shelter, water and sanitation, as well as protection and education.

Basic services that were available prior to the influx are under severe strain due to the massive increase in the population. In some of the sites that have spontaneously emerged, there is virtually no access to water and sanitation facilities. Additionally, overcrowded conditions increase the risk of disease outbreak.

Both Bangladesh and Myanmar and their affected regions of Cox’s Bazar and Rakhine are endemic for various communicable diseases. Both sites have witnessed in recent times, outbreaks of measles, dengue, chikungunya and malaria. Endemic transmission of HEV and leptospirosis is expected to be high in the affected areas/populations.

While progress has been made in malaria control, Cox’s Bazar’s continues to be among the malaria endemic districts of Bangladesh. In addition, there is high burden of acute respiratory diseases especially among under five year-olds. Tuberculosis disease burden, including MDR TB rates are high in both countries. Sub-optimal water and sanitation conditions, inadequate vaccination coverage and vector control capacity are some of the important drivers of common communicable diseases in the two countries.

Against this backdrop of endemicity of communicable diseases and worsening health, nutrition and environmental conditions due to the current crisis, affected populations are at high risk of local outbreaks of waterborne (cholera, hepatitis E, dysentery), foodborne (cholera, dysentery) and vectorborne diseases (dengue, chikungunya, JE, malaria, scrub typhus) as well as skin diseases (scabies).

A site development task force has been established with Ministry of Disaster Management and Relief,
Government of Bangladesh (GoB), which is working closely with donor and multilateral agencies, NGOs and international NGOs (iNGO). The Inter Sector Coordination Group (ISCG) was assigned the task of coordinating all the work on the sites, operating as a one stop information hub for agencies like WHO, Doctors Without Borders / Médecins Sans Frontières (MSF), International Organization for Migration (IOM), United Nations High Commissioner for Refugees (UNHCR), United Nations Population Fund (UNFPA), United Nations Children's Fund (UNICEF), Action Contre la Faim (ACF International) Bangladesh (ACF), International Federation of Red Cross and Red Crescent Societies (IFRC), International Committee of the Red Cross (ICRC), Bangladesh Rural Advancement Committee (BRAC), Bangladesh Red Crescent Society (BDRCS), International Committee of the Red Cross (ICRC), MUKTI and International Centre for Diarrhoeal Disease Research (ICDDRB). Since 25 August, 30 000 households, 150 000 people have been provided emergency shelter kits in the Kutupulong, Balukhali, Shamlapur and Leda makeshift settlements in addition to Roikhong/Unchiprang.

Overwhelming the health system

The sheer magnitude of new arrivals has put massive pressure on all health services and the cramped living conditions, presenting significant public health risks. Poverty ridden and without access to resources, the vulnerable people are completely dependent on what the Bangladesh government and the relief agencies can provide to them - such as primary and secondary health care, trauma care and rehabilitation, reproductive, maternal, neonatal, child health and mental health services and psychosocial support. The existing facilities in Cox’s Bazar and surrounding areas have reported a 150-200% increase in patients, overwhelming current capacity and resources. It is estimated that it will take up to two more months (October and November) to provide basic emergency shelter coverage and water, sanitation and hygiene (WASH) services.

Emerging health needs of the vulnerable population include immunization against vaccine preventable diseases, reproductive health services, referrals to health facilities, prevention of Cholera/acute watery diarrhoea and malaria and services for people subjected to sexual and gender-based violence (SGBV).
An early warning and surveillance systems has been established as part of preparedness to mitigate the risk of communicable disease outbreak.

Setting priorities

Based on health needs, priority interventions have been identified and introduced. Health planning at the new locations is being undertaken with government and partners to ensure that health risks of men, women, children and the elderly in the settlements are minimized and precautions are taken to diffuse build-up of any disease outbreak. Some of the urgent next steps that are being taken and strengthened include:

• Establishing health posts within the new settlements especially in areas where people are settling and there are no immediate health services in the vicinity. One health post will aim to cover 20 000 population and will include space and services for outpatient services, reproductive, maternal, newborn, child, and adolescent health (RMNC+A) including family planning, nutrition, family planning, mental health and psychosocial support (MHPSS), sexual and gender-based violence (SGBV) and disability support services;

• Providing immunization and nutrition support through the Ministry of Health as well as WHO and UNICEF who have already carried out one campaign and have launched the second one covering about 150 000 children aged 6 months to 15 years;

• Implementing reproductive health services based on emerging needs; and • Improving WASH conditions through the assigned Government Agency and UNICEF.

Public health actions

With arrivals of Rohingya reducing in numbers as of 27 September and air loads of supplies, relief and shelter materials being received, a more streamlined and systematic health response is being developed, this comprehends:

• Support given for safe deliveries of over 200 pregnant women who were assisted by 35 specially deputed midwives by UNFPA. Government of Bangladesh has meanwhile stepped up its birth control campaign and has been distributing contraceptives and providing other reproductive health services to the affected population across the makeshift sites;

• Improvment of water and sanitation facilities, which has been ongoing since the time the influx of Rohingyas began. From constructing nearly 250 makeshift toilets to making efforts to halt open defecation to providing drinking water (3.5 litre per person per day) through mobile trucks and installing tubewells, this major concern is being addressed. Water samples are also being tested;

• Early Warning and Surveillance System developed by WHO and the Directorate General of Health Services (DGHS) has been currently put on trial and will soon be fully operationalized.
All partners have been asked to report daily data from medical teams to Control Room at Civil Surgeon Office. WHO will be compiling data for disease surveillance and completeness of reporting will be closely monitored and shared.

Qualitative risk assessment on communicable and infectious disease scenario

In the setting of a complex emergency, with a sudden influx of hundreds of thousands of people in a brief period, health needs are bound to be varied and complex. These health needs will necessarily evolve as the crisis evolves.

This qualitative risk assessment based on the available evidence has been done to prioritize and guide public health actions in affected communities covering conditions that include acute febrile illness with rash, measles, dengue and chikungunya, scrub typhus, acute respiratory infection (ARI), influenza, acute diarrheal diseases including cholera and dysentery, acute jaundice syndrome, hepatitis E, leptospirosis, skin disease scabies, acute encephalitis syndrome (AES) and malaria, tuberculosis, HIV/AIDS. This situation analysis aims to provide some direction to government departments, donors and other agencies, which are in the process of mounting a more focused intervention plan.