With the recent arrival of more than 655,000 Rohingya refugees living in squalid conditions in Cox’s Bazar in Bangladesh, an outbreak of an infectious disease might have seemed inevitable. But not diphtheria. This deadly respiratory disease is as preventable as it is infectious, thanks to one of the most widely available vaccines in the world. So, while the densely populated conditions may have facilitated the spread of the disease, the refugee camps are not the cause.
The fact that there is a diphtheria outbreak in the first place is a clear indication that these people did not have access to even the most basic vaccines and brings into question the conditions they were living in before they arrived at the camp. This outbreak is not the product of conditions within the camps, but rather a deadly legacy of the conditions in which they had been living before they fled Myanmar.
A highly contagious bacterial infection of the upper throat and airways, diphtheria is characterized by breathing problems. In addition to this, the bacterium produces a toxin that can affect other organs, such as the heart and the nervous system. Between 5–10 percent of cases result in death, with young children being particularly vulnerable.
A century ago, there were many as 200,000 cases a year in the United States, resulting in up to 15,000 deaths. Today it has been all but eliminated in the U.S., with fewer than five cases in the last decade. Globally it’s a similar story. In recent decades, the global number of cases of diphtheria has fallen from around 100,000 in 1980 to a little over 7,000 in 2016, thanks to vaccination.
Yet in Cox’s Bazar alone there have already been more than 4,000 suspected cases and 32 confirmed deaths since last November. With 100 new cases each day and 475,000 children living in such close proximity in the refugee camps, the fear is that without a major vaccination campaign the transmission of this airborne and contact-spread disease will rapidly escalate.
This has prompted a response by the global health community, led by the World Health Organization and UNICEF, to vaccinate half a million children in the camps and surrounding areas. The campaign began in December, but was stepped up this week as the outbreak intensified. My organization, Gavi, the Vaccine Alliance, is also providing routine vaccines for all of the refugees.
Such campaigns are not uncommon in refugee camps. Often sanitation and hygiene is poor, while overcrowding is also an issue. When combined, all this can create a fertile breeding ground for droplet-transmitted as well as waterborne infectious disease (such as cholera), and insect vectors that spread diseases like malaria and dengue fever.
But for diphtheria such campaigns should not be necessary. That’s because diphtheria vaccinations are given as part of routine immunization, either as part of a combined shot with vaccines against tetanus, called Td, tetanus and pertussis, known as DTP3, or these days more commonly in a 5-in-1 pentavalent shot that combines DTP with vaccines against hepatitis B and Haemophilus influenzae type b (Hib).
Currently 86 per cent of the world’s children receive all three doses of a diphtheria-containing vaccine, and at least 91 per cent receive at least one dose. This means that not only do the world’s poorest children have access to it, but also coverage should be high enough to create herd immunity to protect the few that do miss out.
Certainly, this is the case in Myanmar, where coverage for the third dose of pentavalent has recently risen to 90 per cent and Gavi has been providing support to help vaccinate all children, include the Rohingya. Despite this, enough Rohingya children have missed out to trigger an outbreak. This clearly indicates a major public health failure, which has compromised the Rohingya’s human right to lead healthy lives through the prevention of vaccine-preventable disease.
By way of comparison, at the moment two other major diphtheria outbreaks are taking place in Venezuela and Yemen, one a failing state, the other a country torn apart by a civil war. In Venezuela, there have been around 500 cases, while in Yemen it’s nearly 700. Despite the different situations in these two countries the cause of the outbreaks is the same: a basic lack of vaccination.
Given how both these countries are struggling in their own ways, the fact that there are 10 times more suspected cases of diphtheria in Cox’s bazar, and counting, speaks volumes about what the Rohingya have endured. So, while the focus now must be on ending the outbreak in the refugee camps, it is important to remember that whenever diphtheria is involved, the camps are not the problem.