mortality and morbidity weekly bulletin (mmwb)...a global information system (gis) unit established...

This document is built on the Early Warning and Response System (EWARS), daily data received through MOHWF and WHO from the service providers in settlements of the Unregistered Myanmar Nationals (UMNs) and from health facilities in Cox’s Bazar. As such, it can only be considered a snapshot of conditions in those reporting facilities. The presented information may hardly be viewed as representative of the overall health situation in Cox’s Bazar; nonetheless we believe that it gives all actors in the field a stepping stone for building a true picture of morbidity and mortality in the UMNs. We thank all partners contributing to the EWARS.

The EWARS itself and the resulting reports can only be a work in progress. We welcome all comments, feedback and further inputs that

can help to improve the system and our joint understanding of the prevailing epidemiological situation, and ultimately - to avert spread

of diseases.

Contact Information Dr. Edwin Salvador, Deputy WHO Representative / Incident Manager, [email protected] Dr. Hammam El Sakka, Team Leader, Health Emergency Programms, [email protected]

WHO Bangladesh: http://www.searo.who.int/bangladesh

)Mortality and Morbidity Weekly Bulletin (MMWB

Cox’s Bazar

Volume No 1: 15 October 2017

Photo Credit: WHO Bangladesh, Dr. Syed Mahfuzul Huq

WHBangladesh

mailto:[email protected]

mailto:[email protected]

http://www.searo.who.int/bangladesh

MMWB Morbidity and Mortality Weekly Bulletin, Cox’s Bazar, Bangladesh 15 October 2017 / Vol. 1

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1. Early Warning and Response System (EWARS)

The main goal of the Early Warning and Response System (EWARS) in Cox’s Bazar District is the early

detection of and timely response to public health threats. The main attributes of the system are

sensitivity and timeliness.

Sensitivity defines the capacity of the system to detect all occurring public health alerts. Since any

signal can be the starting point of an outbreak or a public health crisis, EWARS must have the capacity to

detect all of them. At the level of reporting, sensitivity refers to the proportion of cases of a given

disease detected by the surveillance system. At the level of data analysis and decision-making,

sensitivity refers to the ability to detect outbreaks, including the ability to detect new and emerging

pathogens.

Timeliness defines the capacity of the system to detect a public health alert early enough for control

measures to have the greatest possible impact on morbidity and mortality. EWARS is designed to

reduce delays in reporting and to detect public health emergencies even when affecting individual or

limited disease clusters. Data received through surveillance must be analysed correctly, synthesized

clearly, and disseminated effectively. Other attributes to be taken into consideration during the EWARS

development and implementation are acceptability, usefulness, simplicity, representation, and

sustainability.

The success of effective EWARS functions in a national surveillance system depends on strong

commitment of both national authorities and health partners working in the field.

1.1 EWARS data collection form

All new cases and deaths are reported through a standardized data collection form, which has been

developed for the ongoing emergency in Cox’s Bazar. The data collection form includes the following

information: identification number, date of reporting, GPS coordinates, district, upazila, union, name of

the camps or health facility, total population, population under 5. In addition, name of responsible

person filling the form has to be included together with the contact information. The reporting form in

English is attached as Annex 1.

1.2 Health events under surveillance and case definitions

The EWARS reporting form contains the list of priority diseases and syndromes compiled based on the

epidemiological profiles of both Bangladesh and Myanmar; standardized case definitions were

developed and distributed to health partners along with the reporting forms.


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The list of priority diseases/syndromes includes: acute watery diarrhoea (AWD), bloody diarrhoea (BD),

acute respiratory infections (ARI), suspected measles/rubella (SMR), acute flaccid paralysis (AFP),

suspected meningitis (MEN), acute jaundice syndrome (AJS), suspected haemorrhagic fever (HF),

neonatal Diseases (NNT), adult tetanus (AT), suspected malaria (SM), confirmed malaria (CM),

unexplained fever (UXF), severe malnutrition (SMN), skin diseases (SKN), eye infections (EIF), injuries

(INJ) and other consultations (OTH).

To facilitate data management, software has been developed by WHO and installed in the Control Room

of the Civil Surgeon Office in Cox’s Bazar. WHO Surveillance and Immunization Medical officers (SIMOs)

and MoHFW staff have been trained on standardized data collection tools. From daily collected and

processed data, trained data managers are able to generate reports down to the upazila level. On a daily

basis the data is shared with the MoHFW at central level. A global Information System (GIS) unit

established in the Control Room is actively mapping disease patterns in all settlements in Cox’s Bazar.

1.3 Population under surveillance and reporting units

The population under surveillance is the entire population of Unregistered Myanmar Nationals (UMNs)

living presently in different locations such as public places, established or informal camps, and within

host community in Cox’s Bazar. To calculate disease incidences, the denominator is calculated based on

IOM estimated population data as of 10 October 20171. New cases and deaths of health events under

surveillance are reported daily using the EWRAS standardized data collection tool form District Sadar

hospital Cox’s Bazar, health complexes in Ukhia and Teknaf, and humanitarian health partners providing

health services to UMNs through static or mobile units as shown in table 1.

Table1: Estimated Population and Health Service Providers by upazila, Cox’s Bazar, Bangladesh, 2017.

Ukhia Teknaf

Camp/Settlement Provider Population Camp/Settlement Provider Population

Hakimpara BDRCS 52,204 Ali Akbar Prara IOM 6,500

Jamtoli/ /Thangkhali IHA, MSF 27,459 Leda Make Shift IOM 26,015

Kutupalong Registered Camp

UNHCR, MSF, IOM

33,900 Rangikhali IOM 7,500

Kutupalong, Balukhali Expansion

IOM, MSF 300,460 Shamlapur Settlement IOM 35,756

Baggoha/Potibonia MSF 20,792 Nayapara Registered Camp

UNHCR 34,230

Ukhia Health Complex

IOM, MOHFW

39,559 Roikhong / Unchiprang MSF 28,494

TOTAL 474,374 Teknaf Health Complex MOHWF 71,607

TOTAL 210,102 IHA=Indonesia Humanitarian Alliance, BDRCS: Bangladesh Red Crescent Society, MOHWF: Ministry of Health and Family

Welfare.

1 https://reliefweb.int/report/bangladesh/bangladesh-situation-update-rohingya-refugee-crisis-cox-s-bazar-10-oct-2017;


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2. Proportion of primary causes for cases and deaths

During the period of 25 August-10 October 2017, a total of 38,209 consultations under surveillance were

reported through the EWARS system of which 32% (12,165) were due to ARI, 10% (3,876) due to AWD,

7% (2,585) due to SKN, 6% (2,272) due to unexplained fever (UNFEV), 4% (1,460) INJ, 2% BD, the rest

40% from other disease including severe malnutrition, eye infection, suspected measles/rubella,

jaundice, and malaria.

During the same period, there were 71 reported deaths, 41% due to ARI, 8% injury, 7% AWD, 7%

neonatal tetanus, 4% cardio vascular disease, 3% suspected malaria, 3% meningitis like disease, and 7%

unknown causes. The rest of the deaths were due to other causes and reported under the category

“Others”. The proportion of primary causes for the reported cases and related deaths is shown in

Figure2.

Figure 2: Proportion of primary causes for all reported cases and deaths, Cox’s Bazaar, Bangladesh, 25 August -10 October 2017.

(ARI: Acute Respiratory Tract Infection, AWD: Acute Water Diarrhoea, BD: Bloody Diarrohea, CVD: Cardio Vascular Disease, INJ:

Injuries, MEN: Meningitis like Disease, MAL: Malaria, NNT: Neonatal Diseases, OTH: Other diseases, SKN: Skin Disease, UNFEV:

Fever of unexplained origin and UNK: Unknown Causes).

For under-5 year age group, a total number of 14,015 cases of health events were reported through

EWARS constituting 37% of the total consultations. 39% (5,461) of these cases were attributed to ARI

while 16% (2,190) were due to AWD. There were 29 reported deaths in the children under-5

representing 41% of total deaths reported from Cox’s Bazar. Of these figures, 59% (17 deaths) were ARI-

related, 17% (5 deaths) were due to neonatal diseases and 10% (3 deaths) due to AWD. The proportion

of primary causes for the reported cases and deaths for the children under-5 year is shown in Figure 3.

Cases (n=38,209) Deaths (n=71)


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Figure 3: Proportion of primary causes for the reported cases and deaths in the under-5 year age group, Cox;s Bazar, Bangladesh, 25 August -10 October 2017.

For the over-5 year age group, a total number of 24,194 cases of health events were reported through

EWARS constituting 63% of the total number of consultations. 28% (6,704) of these cases were

attributed to ARI and 7% (1,686) to AWD. There were 42 reported deaths in this age group, representing

59% of total deaths reported from Cox’s Bazar. Of these, 29% (12 deaths) were due to ARI, 4% to injury,

10% to AWD and 5% to CVD. The proportion of primary causes for the reported cases and deaths for the

children under-5 year is shown in Figure 4.

Figure 4: Proportion of primary causes for the reported cases and deaths in the Over 5 year age group, Cox;s Bazar, Bangladesh,

25 August -10 October 2017.

3. Measles cases

Between 10 and 25 September 2017, a total of 22 suspected measles cases were reported from Cox’s

Bazar district: 55% (12/22) from Ukhia, 41% (9/12) from Teknaf and 4% (1/22) from Ramu upazila. No

cases were reported from Bandarban district. Case investigations were conducted for all suspected

cases and samples collected for laboratory confirmation. Laboratory results showed that 64% (14/22)

were positive for measles specific IgM, 18% (4/22) were negative for measles specific IgM and 18%

(4/22) are still pending the laboratory results. From all confirmed cases, 93% (13/14) were among UMNs

while one confirmed case was reported from the host community in Teknaf upazila.

3.1 Measles vaccination campaign in Cox’s Bazar

Measles vaccination is one of the most recommended priority health interventions during emergencies.

In 2016, a total of 945 confirmed measles cases were reported from Bangladesh, and Cox’s Bazar

reported the highest attack rate in the country (>120/100,000 population). Measles incidence rate by

district in Bangladesh (2016) is shown in the Figure 5.


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A recent (2017) needs assessment carried out by

WHO showed that measles vaccination coverage in

Cox’s Bazar was below 90%, which may explain

several reported outbreaks over the last few years.

On 16 September 2017, a mass measles vaccination

campaign was carried out in Cox’s Bazar for 14 days.

Activities included vaccination using a combination

of fixed posts and outreach immunization teams,

the use of checklists to monitor vaccination

sessions, social mobilization activities, and

surveillance for adverse events following

immunization. The campaign targeted 122,580

children <15 years old in the 2 upazilas of Cox’s

Bazar (Tekaf, Ukhia) and Naikhongchhari upazila in

Bandarban district. The total number of vaccinated

children is shown in table 2.

The Civil Surgeon’s Office in Cox’s Bazar was

responsible for planning, monitoring, coordinating

and implementing the campaign activities. The role

of the staff in the Control Room was to monitor

preparedness on a day-to-day basis, especially

mobilization of human and other resources like transport, inter-sectoral coordination and full utilization

of resources. In addition, the Control Room staff was providing regular updates on progress and

obstacles in implementing the campaign to the central level. The campaign faced several challenges,

including difficulty to correctly estimate the target population due to the continuing influx of UMNs into

the camps; heavy rains rendered most of the settlements inaccessible, forcing the vaccination teams to

turn around and return to the sites later.

Table2: Number of vaccinated children, Special Vaccination Campaign, 16 September –to 3 October 2017.

District Upazila Estimated Target Total Vaccinated/Vaccine Type

0-59 M 6M to <15 Y bOPV

(0-59 M) MR

(6 M to <15 Y) VIT A

Cox's Bazar Teknaf 14,450 29,410 20,826 36,116 21,265

Cox's Bazar Ukhia 28,800 84,000 48,713 93,634 47,676

Bandarban Naikhongchhari 3,915 9,170 2,795 5,769 3,123

TOTAL 47,165 122,580 72,334 135,519 72,064

Figure 5: Measles attack rate per district, Bangladesh, 2016


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4. Acute respiratory infection

Between 25 August and 10 October 2017 (epidemiological weeks 34-41) , a total of 12,165 ARI cases

including 29 related deaths (CFR 0.24%) were reported from Cox’s Bazar district: of these 45%

(5,461/12,165) were under 5 years old. The peak in epidemiological week 39 was due to the increase in

the number of reporting units participating in EWRAS. The weekly distribution of ARI cases is shown in

Figure 5.

Figure 5: Weekly distribution of reported ARI cases by age groups, Cox’s Bazar, Bangladesh, 25 August –to 10 October 2017.

Teknaf reported 76% (9,278/12,165) of the total reported ARI cases followed by Ukhia and Cox’s Bazar

with 23% and 1% respectively. The weekly distribution of ARI cases by district is shown in Figure 6.

Figure 6: Weekly distribution of reported ARI cases by district, Cox’s Bazar, Bangladesh, 25 August –to 10 October 2017.


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5. Acute watery diarrhoea

Between 25 August and 10 October 2017 (epidemiological weeks 34-41), a total of 3,876 AWD cases

including 10 related deaths (CFR 0.25%) were reported from Cox’s Bazar district: of these 57%

(2,190/3,876) were under 5 years old. The weekly distribution of AWD cases by age group is shown in

Figure 7.

Figure 7: Weekly distribution of reported AWD Cases by age groups, Cox’s Bazar, Bangladesh, 25 August -10 October 2017.

Ukhia reported 71% (2,736/3,876) of total reported AWD cases followed by Teknaf and Cox’s Bazar with

27% and 1% respectively. The weekly distribution of AWD cases by district is shown in Figure 8.

Figure 8: Weekly distribution of reported ARI cases by district, Cox’s Bazar, Bangladesh, 25 August –to 10 October 2017.


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5.1 Drinking water testing results

Between 18 September and 5 October 2017, a total of 112 water samples from different water sources

were collected from the Cox’s Bazar UMNs settlements. Using membrane filtration technique, only 23%

(37/112) of the samples were found negative for E. Coli, meeting the Bangladesh Standard and WHO

guideline value (0 cfu/100ml). The remaining 77% (86/112) tested positive for faecal contamination (E.

Coli); 40% (34/86) of all the positive samples were very highly contaminated (>100 cfu/100ml), 17%

(15/86) highly contaminated (>50 and <100 cfu/100ml) and intermediate contamination (<50

cfu/100ml) was found in 43% (37/86).

Out of all contaminated samples, 59% (51/86) were collected from water stored at household level, and

35% (30/86) from tube-wells, the remaining 5% were collected from other sources. . No contamination

was found in any of the tested supply reservoirs. Location-wise, the highest contamination level was

detected in Kutupalong settlement (33/86).

In addition to contamination at a source, the reasons for such high level of water contamination at

household level seem to be poor hygiene practices. Only 2% of surveyed households reported using

soap for handwashing after defecation and for washing water containers between refills. Often

containers are not covered, and other safe water handling practices not maintained.

Table 3: Contaminated Samples by Settlement and Water Source, Cox’s Bazar, Bangladesh, 2017 Camp/Settlement

Name Household

Supply Reservoir

Surface Water

Water Tank

Tube Well Other Total

Balukhali 4 0 1 0 6 0 11

Hakim Para 9 0 0 0 5 0 14

Jamtali 4 0 0 0 1 0 5

Kutupalong 23 0 0 0 10 0 33

Kutupalong Hindu 4 0 0 0 2 0 6

Moinnerghona 1 0 0 0 2 0 3

Sapmarajhuri 5 0 0 0 0 0 5

Shamlapur 0 0 0 0 2 0 2

Tajanirmarkhola 0 0 0 0 1 0 1

Unchiprang 1 0 1 1 0 0 3

Other 0 0 0 1 1 1 3

TOTAL 51 0 2 2 30 1 86

To reduce the high level of microbiological contamination of water at household level and associated

public health risk the following measures should be considered: installation of tube-wells at deep

aquifer; treatment and chlorination of surface water; removal of latrines installed adjacent (within 10

meter) to the water points; boiling water or disinfecting drinking water by aluminium or halogen tablets;

elimination of open defecation practice and ensuring improved sanitation facilities; hygiene awareness

campaign for preventing water contamination and recontamination; ensuring proper excreta

management including disposal of sludge; and constant surveillance of the water supply systems,

including regular water testing to monitor the risks and plan appropriate measures.

More partners will be added upon

participation

Morbidity (disease) and Mortality (death) Daily Reporting Surveillance Form (V-2.0)

Date: / / 2017 Latitude: Longitude:

District: Upazila: Union:

Health Facility/Camp:

Estimated Population: Population <5 years:

Agency/NGOs:

Name of contact person:

Phone: Email:

Events Under Surveillance Cases < 5 yrs Cases >=5 yrs Deaths < 5 yrs Deaths >=5 yrs

M F M F M F M F

Acute Water Diarrhoea

Bloody Diarrhoea

Other Diarrhoea

Acute Respiratory Infection

Suspected Measles/Rubella

Acute Flaccid Paralysis (AFP)

Suspected Meningitis

Acute Jaundice Syndrome

Suspected Hemorrhagic Fever

Neonatal Tetanus

Adult Tetanus

Suspected Malaria

Confirmed Malaria

Unexplained Fever > 101F/38.5C

Severe Malnutrition

Skin Diseases

Eye Infection

Injuries/Wounds

Others

- Please indicate ONLY those cases examined/admitted during the reporting week. Each case should be counted once only.

- Write Zero if you have no cases or death of one of the health events listed in the form.

- Deaths should be included in the mortality section, please fill the following table for each reported death:

No Name Age Sex Cause Location

1

2

3

4

5 A

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