MMWB Vol5

Mortality and Morbidity Weekly Bulletin (MMWB)
Cox’s Bazar, Bangladesh

Volume No 5: 12 November 2017
Population Consultations ARI AWD Measles Deaths

819,812 332,973 49,494 36,096 611 199
Photo Credit: WHO Bangladesh, Dr. Hammam EL Sakka
The data in this document are drawn from the Early Warning and Response System (EWARS), daily data received from the Ministry of Health and Family Welfare, and information
gathered by WHO from health service providers in Forcibly Displaced Myanmar Nationals (FDMN) settlements and health care facilities in Cox’s Bazar. Although the information is
incomplete, it represents a first attempt to give health agencies in the field a reasonably accurate picture of morbidity and mortality in the refugee population. We thank all
partners who are contributing to the EWARS.
The EWARS itself and the reports generated therefrom remain a work in progress. We welcome all comments and feedback to help us improve both the system and our joint
understanding of the prevailing epidemiological situation, the ultimate aim being to prevent the spread of diseases and thereby help ensure better health outcomes for the
population affected by this crisis.
Contact Information:
Dr. Edwin Salvador, Deputy WHO Representative, salvadore@who.int

Dr. Hammam El Sakka, Senior Medical Epidemiologist, Team Leader, HSE, elsakkam@who.int
WHO Bangladesh: http://www.searo.who.int/bangladesh
1
MMWB Morbidity and Mortality Weekly Bulletin, Cox’s Bazar, Bangladesh 12 November 2017 / Vol. 5
1. Population under Surveillance and Reporting Units

During epidemiological week 45 (5-11 November 2017), there was a 3% increase in the population1 under
surveillance compared to the previous epidemiological week (806,100 and 830,312 respectively). A total
of 375 daily EWARS forms were received on time during epidemiological week 45.
Kutupalong makeshift camp population increased by 2% (437,633 vs 431,000) due to the ongoing
relocation of FDMNs from other settlements, while the remaining camp populations remained more or
less stable.
EWARS reports were received from the partner agencies active in the field and also from different
departments (admission, emergency, surgery, paediatrics, gynaecology and internal medicine) of Cox’s
Bazar Sadar hospital, and Teknaf and Ukhia Health Complexes (population of 100,400). The population of
these settlements fluctuates daily due to movements between camps and new arrivals.
For the reasons stated above, it was difficult to estimate the actual catchment population covered by the
medical mobile teams working in camps and settlement areas. During the epidemiological week 45, the
number of daily reports per camp/settlement in Cox’s Bazar increased by 19% compared with the previous
week (from 314 to 375 reports). Table 1 below shows the population per camp and the daily number of
EWARS reporting forms submitted for each one.
Table 1: Number of EWARS reports by camp/settlement, Cox’s Bazar, Bangladesh, 5-11 November 2017.
W44 W45 Week 45/Reports/Days
Camp/Settlement
Population Population
05/11 06/11 07/11 08/11 09/11 10/11 11/11
Makeshift Settlements
Kutupalong Expansion2 431,000 437,633 17 26 15 19 22 10 22
Kutupalong Registered
camp 25,743 25,743 3 1 2 2 3 2 3
Leda Makeshift 23,247 23,768 1 2 2 3 2 1 2
Nayapara Registered camp 34,557 34,557 1 1 1 1 2 2
Shamlapur 24,768 26,100 3 3 3 3 3 2 2
Sub Total 539,315 547,801 24 33 23 28 31 17 31
New Spontaneous Settlements
Hakimpara 54,898 55,082 4 1 9 6 8 5 7
Thangkhali 28,531 29,083 3 3 4 4 4 1 3
Unchiprang 30,324 30,384 2 2 2 2 4 1 3
Jamtoli 32,765 33,224 5 2 6 4 6 5 5
Moynarghona 21,460 21,460 2 2 4 2 3 1 3
Sub Total 167,978 169,233 16 10 25 18 25 13 21
MoHWF
Cox’s Bazar, Teknaf & Uhkia 100,348 102,778 2 6 4 4 4 3 4
Mobile Teams NA NA 2 4 5 4 6 3 9
Sub Total 100,348 102,778 4 10 9 8 10 6 13
TOTAL 807,641 819,812 44 53 57 54 66 36 65
1https://www.humanitarianresponse.info/system/files/documents/files/171029_weekly_iscg_sitrep.pdf
2Kutupalong-Balukhali expansion settlement includes the estimated population residing in the existing Kutupalong and Balukhali makeshift
settlements, and their surrounding expansion zones.
2
The total number of consultations reported through EWARS increased by 18% compared to the previous
week (71,756 vs 85,077). The weekly trend of reporting units participating in the EWARS and the number
of consultations is shown in figure 1.
Figure 1: Number of EWARS reports by camp/settlement, Cox’s Bazar, Bangladesh, 25 August–11 November 2017.
2. Proportion of Primary Causes of Cases and Deaths

During the period 25 August-11 November 2017, a total of 332,973 consultations were reported through
EWARS. Of these, 51% (169,233/ 332,973) were events under surveillance. Fevers of unexplained origin
accounted for 29%, (49,494), followed by acute respiratory infections (ARIs) 27% (46,077), acute watery
diarrhoea (21%, 36,096), skin diseases (9%, 15,181), injuries (3%, 4,321), eye infections (2%, 3,486) and
malaria (2%, 4,091). The remaining 7% were due to other causes including bloody diarrhoea and
malnutrition.
For the under-5 age group, a total of 66,380 events under surveillance were reported through EWARS,
constituting 39% of the events under surveillance. A total of 32% (21,498) of these cases were attributed
to ARIs, while 27% (17,841) were due to fevers of unexplained origin and 23% (15,206) were due to acute
watery diarrhoea (AWD).
For the over-5 age group, a total number of 102,853 events under surveillance were reported through
EWARS, constituting 61% of the events under surveillance. A total of 31% (31,653) of these cases were
attributed to fevers of unexplained origin, while 24% (24,579) were due to ARIs and 20% (20,890) were
due to AWD. The proportion of primary causes of reported cases for both age groups is shown in figure 2.
3
Figure 2: Proportion of primary causes for all reported cases under surveillance, Cox’s Bazar, Bangladesh, events under
surveillance, 25 August–11 November 2017. (ARI: Acute Respiratory Infection, AWD: Acute Watery Diarrhoea, BD: Bloody
Diarrhoea, INJ: Injuries, MEN: Meningitis-like Disease, MAL: Suspected Malaria, ND: Neonatal Diseases, OTH: Other diseases, SKN:
Skin Disease, UNFEV: Fever of unexplained origin, EYE: Eye Infections, and UNK: Unknown Causes).
During the same period, there were 199 reported deaths. Of this number, 28% (56) were due to ARIs,
followed by INJ (10%, 19), NDs (8%, 16), AWD (5%, 10), cardiovascular disease (6%, 11), severe
malnutrition (4%, 7), and UNK (12%, 25). The remaining 27% (55) were due to other causes.
There were 78 reported deaths in the under-5 age group, representing 39% of total deaths. Of these, 35%
(27) were ARI-related, followed by NDs (21%, 16), AWD (8%, 6), SMN (9%, 7) and INJ (5%, 4). The remaining
22% (18) were due to other causes.
There were 121 reported deaths in the over-5 age group, representing 61% of total deaths. Of these, 24%
(29) were ARI-related, followed by INJ (12%, 15), cardiovascular disease (11%, 9), AWD (3%, 4) and UNK
(15%, 18). The remaining 35% (46) were due to other causes including meningitis, jaundice, TB and
malaria. The weekly distribution of reported deaths is shown in figure 3.
4
Figure 3: Weekly distribution of reported deaths, Cox’s Bazar, Bangladesh, 25 August–11 November 2017.
ARI, UNFEV and AWD continues to contribute significantly to the overall consultations in all reporting
camps and settlements. The attack rates per 1000 population of the 3 diseases showed slight increases
compared to the last week. The weekly attack rates of ARI, UNFEV and AWD are shown in figure 4.
Figure 4: Weekly Attack Rate, ARI, AWD, and UNFEV reported cases, Cox’s Bazar, Bangladesh, 25 August–11 November 2017.
5
3. Acute Respiratory Infection

Between 25 August and 11 November 2017 (epidemiological weeks 34-45), a total of 46,077 ARI cases
were reported. Of these, 47% (21,498/46,077) were in the under-5 age group. There were 56 ARI related
deaths (CFR 0.12%). 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–11 November 2017.
Ukhia reported 82% (37,706/46,077) of total ARI cases followed by Teknaf and Cox’s Bazar with 18%
(8,274) and <1% (91) respectively. The weekly distribution of ARI cases by upazila is shown in Figure 6.
Figure 6: Weekly distribution of reported ARI cases by upazila, Cox’s Bazar, Bangladesh, 25 August–11 November 2017.
6
The highest ARI attack rate was reported from Moynarghna with 147/1,000 population followed by
Jamtoli settlement (126/1,000) and Kutupalong Registered camp (124/1,000). The ARI attack rate per
1,000 population in selected camps is shown in figure 7.
Figure 7: ARI attack rate per 1,000 population in selected camps, Cox’s Bazar, Bangladesh, 15 October–11 November 2017.
Over the last 4 epidemiological weeks (42-45), the attack rate for ARI increased in Jamtoli, Moynarghna
and Hakimpara, but decreased in Thangkhali camp. The ARI attack rate per 1,000 population in selected
camps is shown in figure 8.
Figure 8: Weekly ARI attack rate per 1,000 population in selected camps, Cox’s Bazar, Bangladesh, 15 October–11 November 2017.
7
WMMB Weekly Morbidity and Mortality Bulletin, Bangladesh 12 November 2017 / Vol. 5
4. Acute Watery Diarrhoea

Between 25 August and 11 November 2017 (epidemiological weeks 34-45), a total of 36,096 AWD cases
were reported including 10 related deaths (CFR 0.03%). A total of 42% (15,206) were in the under-5 age
group. The weekly distribution of AWD cases by age group is shown in figure 9.
Figure 9: Weekly distribution of reported AWD cases by age group, Cox’s Bazar, Bangladesh, 25 August–11 November 2017.
Ukhia reported 85% (30,745/36,096) of all AWD cases, followed by Teknaf and Cox’s Bazar with >14% and
<1% respectively. The weekly distribution of AWD cases by upazila is shown in Figure 10.
Figure 10: Weekly distribution of reported AWD cases by upazila, Cox’s Bazar, Bangladesh, 25 August–11 November 2017.
8
The highest attack rate for AWD was reported from Moynarghna with 113/1,000 populati0on followed by
Kutupalong Registered camp (98/1,000) and Thangkhali (85/1,000). The AWD attack rate per 1,000
population in selected camps is shown in figure 11.
Figure 11: AWD attack rate per 1,000 population in selected camps, Cox’s Bazar, Bangladesh, 15 October–11 November 2017.
Over the last 4 epidemiological weeks (42-45), the attack rate of AWD cases decreased in Thankgkhali,
and Moynarghna but increased in Unchprang, Jamtoli and Kutupalong Registered camp. The AWD attack
rate per 1,000 population in selected camps is shown in figure 12.
Figure 12: Weekly AWD attack rate per 1,000 population in selected camps, Cox’s Bazar, Bangladesh, 15 October–11 November
2017.
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4.1 Second round of Oral Cholera Vaccination Campaign

On 10 October 2017, the Government of Bangladesh with WHO support launched an oral cholera
vaccination (OCV) campaign with the support of WHO for 10 days, targeting 650 000 people in 11
camps/settlements in Cox’s Bazar district, Chittagong division. It was the first OCV campaign to be
conducted in the country, and comes at a critical time after FDMNs influx to the country in August 2017.
From 4-9 November 2017, the second round of OCV was conducted targeting 182,317 FDMNs between 1
and 5 years. As of 9 November 2017, a total of 199,472 persons were reported to have been vaccinated,
representing 109% (199,472/182,317) of the target population (table 2). Oral cholera vaccines represent
a tool to fight cholera and are licensed as two-dose regimens with 2-4 weeks between doses. Evidence
from previous studies suggests that a single dose of oral cholera vaccine might provide substantial direct
protection against cholera3. The number of vaccinated per settlements is shown in figures 13 and 14.
Table 2: Number of OCV vaccinated per camp/settlement, Cox’s Bazar, Bangladesh, 04-09 November 2017.
Estimated Target Pop Total %

Camp/Area Name
Pop (1-5 years) vaccinated Coverage
Kutupalong MS 230,103 55,998 48,582 87

Balukhali 79,752 25,011 30,731 123
Moinergona 71,076 28,413 38,462 135
Hakimpara 31,376 7,001 10,928 156
Shafiullah Kata 18,349 3,026 3,098 102
Bag Gona Jamtoli 58,182 8,218 8,433 103
Kutupalong RC 31,547 6,420 5,462 85
Taznirmarkhola 33,557 6,310 11,102 176
Total Ukhia upazila 553,942 140,397 156,798 112
Nilha 42,844 9,550 10,394 109
Nayapara camp 37,088 9,089 11,883 131
Ledacamp 26,179 6,829 7,282 107
Unchiprong 26,185 6,786 4,692 69
Chakmarkul 10,932 3,100 2,613 84
Baharchara 9,633 2,601 1,885 72
Sub-total Teknaf upazila 152,861 37,955 38,749 102
Bara Sonkhola 7,050 1,657 1,624 98
Konarpara 5,200 1,135 1,136 100
Uttorpara 2,600 566 642 113
Sapmarijhil 2,200 517 436 84
Bahirmat 380 90 87 97
Sub-total Naikhongchhari upazila 17,430 3,965 3,925 99
Grand total 724,233 182,317 199,472 109
3
Andrew S. Azman et al; The Impact of a One-Dose versus Two-Dose Oral Cholera Vaccine Regimen in Outbreak Settings: A
Modeling study.
10
Figure 13: Number of vaccinated and vaccine coverage per camp/settlement, first and second OCV rounds, Bangladesh 2017.
Figure 14: Number of vaccinated and vaccine coverage per camp/settlement and vaccine coverage second OCV round,
Bangladesh, 4-9 November 2017.
11
4.2 Drinking Water Testing Results

Between 18 September and 11 November 2017, a total of 1,959 water samples were collected by WHO
and Department of Public Health Engineering (DPHE) teams from household (1,335) and water sources
(624) in FDMN settlements. Using membrane filtration testing techniques, 83% (1623/1959) tested
positive for faecal contamination (E.coli) as per the Bangladesh Standard and WHO guideline value. The
remaining 17% (336/1959) of the samples were found negative for E.coli (0 cfu/100ml).
A total of 36% (710) of the samples were very highly contaminated (>100 cfu/100ml) and 23% (449) were
highly contaminated (>50 and <100 cfu/100ml). Intermediate contamination (<50 cfu/100ml) was found
in 24 % (464) of the samples. The E.coli water testing results by camp/settlement are shown in Figure 15.
Figure 15: E Coli water testing results, FDMN settlements, Cox’s Bazar, Bangladesh, 18 September - 11 November
2017.
Among household samples, 91% (1218/1,335) were found to be positive for E.coli contamination. The
level of contamination was highest at Balukhali 99% (114/115) followed by 97% at Jamtoli/Thangkhali
(112/115), 95% at Burmapara (105/110), Kutupalong MS (279/294), Shamlapur (37/39) and Kutupalong
Expansion (284/300). Nayapara RC found to have the highest percentage of safe water with 58% (23/40)
followed by 23% at Leda MS (11/47). Contamination of very high level was observed at Unchiprang 68%
(21/31) and Balukhali 63% (73/115).
Source water samples were found to be less contaminated than household samples with 35% (219/624)
of samples negative to E.coli contamination. The level of contamination, however, followed a similar
pattern with the highest 82% at Balukhali (45/55) and Jamtoli/Thangkhali (35/45), followed by 78%
(112/144) at Kutupalong MS and 75% (15/20) at Lada MS. Higher level of contamination at household
12
level indicates a requirement of health education on health hygiene practice at domicile level. The very
high level of source water contamination at Unchiprang 67% (10/15) and Leda MS 50% (10/20).
The microbiological water quality status was discussed in the last WASH partners meeting and partners
including IFRC, ACF, Oxfam, and Save the Children, started chlorination at household level. However,
chlorination at household level faces is another challenge as many shallow tube-wells have high level of
iron (one sample revealed presence of more than 9 mg/l of iron). Iron content not only increases the
chlorine demand but also produces high level of color in the water accompanied by precipitation as soon
as a water purification tablet is applied. Associated with smell this is seriously affecting the acceptability
of the water. DPHE and other sector partners are now planning to decommission the highly contaminated
shallow tube-wells and install deep tube-wells.
In addition, the higher contamination at household level demands improvement in water and hand
hygiene, use of household filtration and chlorination for iron free water; source chlorination might be
considered as well. Water safety planning as per WHO recommendation should be initiated.
5. Unexplained Fever
Between 25 August and 11 November 2017 (epidemiological weeks 34-45), a total of 49,494 cases of
unexplained fever were reported through EWARS. The number has been increasing since 18 October
2017. WHO and MoHFW are working together to enhance the laboratory capacity in Cox’s Bazar to be
able to determine the etiology for such cases.
Figure 16: Reported unexplained fever cases, Cox’s Bazar, Bangladesh, 25 August-11 November 2017.
13
The highest attack rate for UNFEV was reported from Moynarghna with 164/1,000 people followed by
Jamtoli (138/1,000) and Thangkhali (132/1,000). The UNFEV attack rate per 1,000 population in selected
camps is shown in figure 17.
Figure 17: UNFEV attack rate per 1,000 population in selected camps, Cox’s Bazar, Bangladesh, 15 October–11 November 2017.
Over the last 4 epidemiological weeks (42-45), the attack rate of UNFEV cases decreased in Thankgkhali
but increased in Moynarghna, Unchprang, Jamtoli and Hakimpara. The AWD AR per 1,000 population in
selected camps is shown in figure 18.
Figure 18: UNFEV attack rate per 1,000 population in selected camps, Cox’s Bazar, Bangladesh, 15 October–11 November 2017.
14
6. Measles Outbreak
Between 6 September and 11 November 2017, a total of 611 suspected cases of measles including two
related death (CFR, 0.33%) were reported from Cox’s Bazar. Of them 85 cases were detected during an
outbreak investigation conducted by WHO between 2-4 November 2017 in Kutupalong settlement. The
mean age of the patients was 3.5 years (3.7 and 3.2 years for males and females respectively), Standard
Deviation [SD 5.2] ranging from 36 days to 44 years. The age distribution of reported cases is shown in
figure 19.
Figure xx: Reported Measles cases by age group, Cox’s Bazar, Bangladesh, 6
September -11 November 2017.
Figure 19: Reported measles cases by age groups, Cox’s Bazar, Bangladesh, 6 September-11 November.
Of the total cases, 11% (68/611) reported a history of measles vaccination of at least one dose. According
to available evidence, approximately 85% of children develop protective antibody levels when given one
dose of measles vaccine at nine months of age4. Therefore, 15% children could develop measles even after
receiving 1 dose of measles vaccination.
For a child to develop full immunity, most of the times a second dose is required. When a second dose is
administered to children over one year of age, the majority of those who failed to develop protective
antibody levels following the first dose will develop protective antibody levels.
The major determinants of immune response to immunization are5: age at vaccination is an important
determinant of the immune response to measles vaccine, with older infants having better responses than
4
Measles vaccines, WHO position paper, http://www.who.int/wer/2009/wer8435.pdf
5
The Immunological Basis for Immunization Series, 2009, http://apps.who.int/iris/bitstream/10665/44038/1/9789241597555_eng.pdf
15
younger infants; immunological immaturity, as very young infants do not develop high levels of
neutralizing antibodies after immunization with attenuated measles virus vaccines, even in the absence
of passively-acquired maternal antibodies; concurrent acute infection which may interfere with the
immune response to measles vaccine; nutritional status as most published studies have found that
malnourished children have equivalent seroconversion rates after measles vaccination compared to
children who are well-nourished; host genetics as genetic background affects the likelihood of
seroconversion, antibody levels and cellular immune responses following measles vaccination; and HIV
infection or any other immunosuppressive conditions.
A total of 56% (342) of patients were male. Of the total cases, 82% were in the under-5 age group. A total
of 91% (557) of the cases were from Ukhia, followed by 8% (50) from Teknaf. Of the total number of cases,
98% (596/611) were from the FDMNs and the remaining 2% (15) were from the host community. The
distribution of cases by vaccination status and age group is shown in figures 20 and 21.
Figure 20: Distribution of reported measles vaccination status, Cox’s Bazar, Bangladesh, 6 September-11 November 2017.
As a response to the ongoing outbreak, intensification of MR vaccination through fixed and outreach sites
to FDMNs targeting children 06 months to 15 years will start from 18 November and will be completed
within 3 weeks. MR routine immunization started in FDMNs settlements from 11 November 2017,
targeting children under 2 years old.
WHO relocated 3 additional Surveillance Medical Officers to Ukhia, Teknaf and Bandarban. In addition,
the immunization team was mobilized to support micro planning, orientation and monitoring of the MR
catch up vaccination. A concept paper and proposal were sent to GAVI for operational support.
16
Figure 21: Distribution of reported measles cases by age groups, Cox’s Bazar, Bangladesh, 6 September-11 November 2017.
Fifty-eight samples were collected for laboratory results. Of these, 64% (37) were positive for measles-
specific IgM, 16% (9) were negative, 2% (1) were positive for rubella-specific IgM, and 19% (11) are
pending laboratory results. The onset dates of reported cases of measles are shown in figure 22.
Figure 22: Daily reported measles cases by laboratory results, Cox’s Bazar, Bangladesh, 6 September-11 November 2017.
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Mortality and Morbidity Weekly Bulletin (MMWB)

Cox’s Bazar, Bangladesh

Population Consultations ARI AWD Measles Deaths

Photo Credit: WHO Bangladesh, Dr. Hammam EL Sakka

Dr. Edwin Salvador, Deputy WHO Representative, salvadore@who.int

1. Population under Surveillance and Reporting Units

2. Proportion of Primary Causes of Cases and Deaths

3. Acute Respiratory Infection

4. Acute Watery Diarrhoea

4.1 Second round of Oral Cholera Vaccination Campaign

Estimated Target Pop Total %

Kutupalong MS 230,103 55,998 48,582 87

4.2 Drinking Water Testing Results

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