Reaching the unreached: Combatting tuberculosis in the Rohingya refugee camps

Aminul Jamman had experienced similar chest pain once before, when he was diagnosed with tuberculosis in Myanmar five years ago. Today, as a Rohingya refugee living in the world’s largest refugee settlement, he had no hesitation in visiting the nearest doctor in the camps as soon as he began noticing the first symptoms.    

“I completed my six-month tuberculosis (TB) treatment in Myanmar in 2016, but I got infected again few months after arriving here in 2018”, says 53-years old Aminul Jamman. “I had fever, cough, chest pain and weakness, and I realized they were the same symptoms I have had, so I went to the BRAC healthcare center to give the sputum for TB testing. After two days, I received the results and started the treatment. One month later, I already felt better”.

Aminul got cured after completing six-month TB treatment in the Rohingya refugee camps, with regular follow-up visits to the BRAC primary health care facility located in Camp 1E. There he received free TB care and medication under the framework of the National Tuberculosis Control Programme (NTP) which provides TB diagnosis and treatment services completely free of cost to all citizens, including the refugee population.

After having been infected twice, Aminul Jamman is now taking care of his wife who has been recently diagnosed with tuberculosis and is undertaking TB treatment. WHO Bangladesh/ Irene Gavieiro Agud

Tuberculosis is a potentially serious but curable infectious disease, however it can only be cured if patients are able to complete their treatment. In Bangladesh, as in many low and middle-income countries all over the world, TB continues to be a major public health concern mostly affecting marginalized and vulnerable communities, such as displaced and refugee populations.

“The Rohingya people are exposed to a high risk for tuberculosis. Myanmar and Bangladesh are among the 30 countries with the highest burden of TB in the world, and the poor shelter and living conditions in the refugee camps combined with the risk of poor health outcomes for the Rohingya people make them even more vulnerable”, says Dr Kai von Harbou, Head of WHO Emergency Sub-Office in Cox’s Bazar.

Through human resources, technical and logistical assistance, WHO is supporting the National TB Control Programme (NTP) of the Government of Bangladesh to scale up early diagnosis for unreached populations and to provide appropriate treatment to patients suffering from various forms of TB. Under the NTP led by Ministry of Health & Family Welfare, an extensive partnership between various Ministries, civil society, NGOs, development agencies and private sector coordinates towards a common goal: end the TB epidemic in Bangladesh.

Moriom, a 46-years-old Rohingya refugee, regularly receives a visit of WHO Field Assistants to check on the progress with her TB treatment. WHO Bangladesh/ Irene Gavieiro Agud

Since 1984, BRAC is the largest implementing partner of the NTP which, in coordination with WHO and multiple organizations, strives to make quality TB care services equally available to all, with special focus on the vulnerable populations living in the most remote areas of the country.

However, despite the efforts employed and substantial progress achieved over the past decades, the disease continues to kill 38 000 people every year in Bangladesh according to the data provided by the Directorate General of Health Services (DGHS).

“The TB treatment coverage increased from 67% in 2018 to 81% in 2020 with a sustained treatment success rate over 95%, and yet tuberculosis continues to be a major public health challenge in Bangladesh”, expressed the Minister of Health and Family Welfare of Bangladesh, H.E. Mr Zahid Maleque, during the high-level meeting for renewed TB response in the WHO South-East Asia Region held this week. “There is a need to trace missing 18% TB cases annually. Access to rapid diagnostic has been ensured below sub-district level while new treatment options and people-centered services have commenced. We are committed to and are on track to end Tuberculosis”, Mr Maleque added.

BRAC Project Assistant, Bibi Rulshum, disseminated TB related information among Rohingya refugees and refers suspected cases to the nearest health care facility. WHO Bangladesh/ Irene Gavieiro Agud

Since January to June 2021, 3888 cases of tuberculosis have been registered in Cox’s Bazar district, of which 2563 have been diagnosed through GeneXpert (GXP) tests. Out of the total of GXP tests conducted, 2369 were performed in Ukhiya and Teknaf Upazila Health Complexes (UHC), of which 346 were tested from the Rohingya refugees and 2023 from the host community.

Two medical technologists supported by WHO diagnose TB cases in these Government facilities, which provide testing services for both Rohingya and host communities. Md Golam Sorowar is responsible for conducting GeneXpert diagnosis and to carry out supervisory activities on TB laboratory services in Ukhiya UHC, including sputum collection and smear preparation to ensure the quality of TB diagnosis. “Throughout the pandemic response, TB sample collection increased in the Rohingya camps”, Md Golam said, pointing out that: “People from the host community can easily come to the Upazila health complex to get tested, but Rohingya refugees sometimes find difficulties to come here because they have to request permission”.

Within the camps, there are eight TB laboratories and two mobile vans with GeneXpert machines for diagnosis of TB, out of the five available in Cox’s Bazar district. Due to the limited capacity, sputum samples from highly suspected persons are being transported to the UHC for further testing, where an X-ray machine is also available.

WHO Medical Technologist, Md Golam Sorowar, conducts an average of 12 GeneXpert test every day at the Ukhiya UHC for TB diagnosis. WHO Bangladesh/ Irene Gavieiro Agud

With proper disease monitoring and high patient adherence, TB treatment is very successful, with over 95% cure rate in Bangladesh.  

“Our approach requires close collaboration with all stakeholders, including civil society and communities. By giving patients and vulnerable populations a voice and an active role, we are accelerating case detection, limiting further transmission, reducing progression to permanent lung damage and achieving higher cure rates”, says Dr Sabbir Ahmed, WHO TB District Coordinator.

To increase awareness among the Rohingya people, community engagement sessions are regularly conducted at primary health care and household level. “Rohingya people are not very conscious about tuberculosis and other infectious diseases. With our field visits, we listen to them and try to understand their needs. We explain them the risks associated with TB and that the disease can be spread to their family members if they don’t follow proper health hygiene measures”, says Jannatul Ferdous, WHO TB Field Coordinator.

Equipped with pictograms and other educational materials, WHO Field Assistants increase TB awareness among Rohingya refugees. WHO Bangladesh/ Irene Gavieiro Agud

Thanks to these awareness sessions, about a thousand people are reached every month for community health education on TB control. These community sessions are usually followed by distribution of sputum collection pot and the referral of suspected TB patients to the nearby BRAC facility for further evaluation and diagnosis.

“Liaison between TB medical officers, BRAC staff and WHO is essential. Every day we receive suspected cases of TB and we counsel and diagnose them properly”, states Dr Mahmud, Medical Officer at BRAC PHC in Camp 1E. “Besides the prescription of medication, counseling plays a vital role when long-term medication is needed. These patients are not well educated and in most cases they don’t know what is tuberculosis, so they won’t take the medicines if they don’t get proper counseling”

WHO TB District Coordinator, Dr Sabbir Ahmed, meets stakeholders involved in the TB control programme at all levels to ensure well-coordinated interventions. WHO Bangladesh/ Irene Gavieiro Agud

As many essential health services, the TB programme in Cox’s Bazar has been impacted by the COVID-19 pandemic hindering its progresses among host and refugee communities due to the stigma and fears associated to both conditions. “COVID-19 and early TB symptoms are quite similar to some extent. Very often Rohingya refugees do not want to share they are suffering from cough or fever because they are afraid of being sent to the isolation center”, explains Jannatul Ferdous, WHO TB Field Coordinator.

In those cases, people-centered care and risk communication becomes instrumental to increase the trust of the community. “The fight against tuberculosis must not be forgotten in the COVID-19 outbreak. Community engagement sessions for TB awareness were adjusted to the pandemic scenario thanks to the hard work of exceptional frontline health care workers who were highly committed to ensure prevention and care services to the vulnerable populations of Cox’s Bazar” adds Dr Bardan Jung Rana, WHO Representative to Bangladesh.

Despite the  restrictions imposed by the pandemic, WHO field teams continued their work at household level for TB contact tracing and referral for diagnostics test and clinical management. WHO Bangladesh/ Irene Gavieiro Agud