19 Jan 2018
Humanitarian Aid workers to BangladeshNEW - Updated recommendations for aid workers travelling to assist with the Rohingya refugee crisis in Bangladesh
Between 25 August and 23 December 2017, the World Health Organization estimate that 655,000 Rohingya have crossed the border from Myanmar into Cox’s Bazar, Bangladesh joining approximately 300,000 that had fled in earlier waves of displacement . Respiratory and skin infections, measles, and acute watery diarrhoea risks remain high with increasingly crowded living conditions, inadequate water and sanitation facilities, and low vaccination coverage .
As of 6 January 2018, a total of 3,523 clinically suspected cases of diphtheria have been reported; of the 185 cases tested, 58 have been laboratory confirmed . Emergency medical teams are travelling from the UK to support the treatment of severe diphtheria cases within some of the newly operational diphtheria treatment and isolation centres . Additional travel health advice and recommendations are available for these travellers [see below].
Advice for travellers
Ensure you are up to date with routine vaccinations (e.g. MMR) and booster doses as recommended in the UK. Those working with refugees in this crisis should seek advice regarding diphtheria vaccination from their deploying organisation, even if up to date with the UK schedule. Further general advice for those going to areas of humanitarian crisis can also be found in our factsheet.
While diphtheria is vaccine preventable, the diphtheria vaccine is directed against the toxin produced by toxigenic strains of diphtheria which is responsible for the characteristic disease manifestations. This means that whilst vaccinated individuals are protected from disease, they can still carry the organism without showing any symptoms. Given the nature of the work undertaken by some healthcare workers providing direct clinical care to suspected cases and therefore high levels of exposure, there is a low risk of asymptomatic carriage of toxigenic diphtheria amongst clinical staff returning to the UK.
As many clinical staff are returning to work in the NHS and may expose vulnerable patients, PHE has advised that as a precautionary measure, these staff should be screened (throat and nasopharyngeal swabs, plus swabs of any skin lesions) on arrival to the UK, prior to returning to work. It would be expected that given the high levels of vaccine coverage and high population immunity in the UK, that staff members families will be protected and largely healthy. This is in contrast to the patient population who may have altered immunity and therefore be more vulnerable. Identifying asymptomatic carriers through swabbing will enable the treatment of the individual appropriately as well as any contacts, and prevent patient exposures when healthcare workers return to work in the UK.
Detailed advice is provided below for those working with refugees who have had a significant exposure to diphtheria and/or are returning to healthcare work in the UK.
Aid workers including healthcare workers from the NHS and other organisations returning to the UK
All workers travelling to the outbreak area should have been advised to receive a diphtheria booster dose prior to travel.
A risk assessment should be made by the deploying organisation (and /or their UK employer, if different) regarding swabbing and exclusion from clinical duties on return to the UK. NHS Trusts employing returning workers should be informed of the risk assessment.
Management of aid workers, including healthcare workers, with a significant exposure
All staff with a significant exposure should commence on an appropriate course of antibiotics and should be managed as ‘close contacts’ according to the national PHE guidelines . The guidance recommends a clearance swab at the end of the antibiotic course to ensure they have effectively eradicated the organism.
For health care workers, they should not return to clinical duties until clearance has been confirmed. Depending on which antibiotic treatment has been received, additional swabbing may be recommended.
Management of aid workers, including healthcare workers, who have started antibiotic chemoprophylaxis without a defined significant exposure
In the absence of a significant exposure, antibiotic chemoprophylaxis is NOT being routinely recommended for returning staff. However, if staff have started a course of antibiotics without a defined significant exposure they are advised to be swabbed on return to the UK. Given the overall risk is low, these staff can return to clinical duties once cleared from this initial swab. However, as the efficacy of an incomplete course of antibiotics, such as azithromycin, is unknown and culture results may be affected, as a precautionary measure, additional swabbing may be recommended.
In the event that an NHS staff member is found to be carrying the toxigenic strain, the NHS Trust would be required to notify the local Health Protection Team and initiate contact tracing as recommended in the PHE national public health guidance on diphtheria .
Guidance on the management of cases and close contacts can be found in Public Health England’s Public health control and management of diphtheria and the ‘Green book’ diphtheria chapter.
Malaria is present in Bangladesh. The 2017 Advisory Committee on Malaria Prevention guidelines recommend antimalarial tablets for the Chittagong Hill Tracts district, see map . Some of the refugee camps are positioned between Cox’s Bazar and the Chittagong Hill Tracts district. Antimalarial tablets are not usually recommended for these areas, but due to the large numbers of people moving in the area, it is possible that an increase in mosquito borne illness may be seen. As a precautionary measure, antimalarial tablets (Atovaquone/proguanil, doxycycline or mefloquine) are recommended if you are visiting this area. You should also take insect bite avoidance measures and be aware of the symptoms of malaria and the need for prompt treatment.
Other vaccinations and precautions for travel to Bangladesh can be found on our Country Information page.
Advice for health professionals
Advice on immunisation against diphtheria is available for those whose immunisation status is uncertain.
In the UK, diphtheria is a notifiable disease. Any case of suspected diphtheria should be notified immediately to the local Health Protection Team and PHE guidance on public health control and management of diphtheria should be followed.
- World Health Organization, WHO Weekly situation report no 9. 6 January 2018 [Accessed 19 January 2018]
- World Health Organization, Diphtheria outbreak response update, Cox’s Bazar, Bangladesh. 27 December 2017 [Accessed 19 January 2018]
- Public Health England, Public health control and management of diphtheria (in England and Wales) 2015 guidelines. March 2015, [Accessed 19 January 2018]
- Public Health England, Advisory Committee on Malaria Prevention (ACMP) Guidelines for malaria prevention in travellers from the UK, 19 October 2017, [Accessed 19 January 2018]