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      Risks of COVID19 outbreaks in Rohingya refugee camps in Bangladesh

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          Abstract

          The COVID-19 pandemic was confirmed to have started spreading in Bangladesh since March 2020. Since then the new infections grew exponentially and now the rate is highest in Asia along with wider community-level transmission. In Bangladesh, the preventive measures have been found challenging to implement due to a lack of general awareness of COVID-19 and the absence of a social safety net. In this situation, there is a concern about the heightened risk of infection and its aftermath in Rohingya refugee camps in the southwest part of Bangladesh, where the world’s largest refugee population resides. If COVID-19 starts spreading in the camps, there will have a devastating consequence given that almost one million people live in precarious and unhygienic conditions in an area of only five square kilometres. In this paper, the risk for the Rohingya refugee population of getting COVID-19 disease and the preparedness to diagnose new cases and their management by the facilities of government and international organizations are discussed. Several suggestions are also offered to protect the Rohingya refugee population from deadly COVID-19 disease.

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          Most cited references 7

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          COVID-19 and Italy: what next?

          Summary The spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has already taken on pandemic proportions, affecting over 100 countries in a matter of weeks. A global response to prepare health systems worldwide is imperative. Although containment measures in China have reduced new cases by more than 90%, this reduction is not the case elsewhere, and Italy has been particularly affected. There is now grave concern regarding the Italian national health system's capacity to effectively respond to the needs of patients who are infected and require intensive care for SARS-CoV-2 pneumonia. The percentage of patients in intensive care reported daily in Italy between March 1 and March 11, 2020, has consistently been between 9% and 11% of patients who are actively infected. The number of patients infected since Feb 21 in Italy closely follows an exponential trend. If this trend continues for 1 more week, there will be 30 000 infected patients. Intensive care units will then be at maximum capacity; up to 4000 hospital beds will be needed by mid-April, 2020. Our analysis might help political leaders and health authorities to allocate enough resources, including personnel, beds, and intensive care facilities, to manage the situation in the next few days and weeks. If the Italian outbreak follows a similar trend as in Hubei province, China, the number of newly infected patients could start to decrease within 3–4 days, departing from the exponential trend. However, this cannot currently be predicted because of differences between social distancing measures and the capacity to quickly build dedicated facilities in China.
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            First-wave COVID-19 transmissibility and severity in China outside Hubei after control measures, and second-wave scenario planning: a modelling impact assessment

            Summary Background As of March 18, 2020, 13 415 confirmed cases and 120 deaths related to coronavirus disease 2019 (COVID-19) in mainland China, outside Hubei province—the epicentre of the outbreak—had been reported. Since late January, massive public health interventions have been implemented nationwide to contain the outbreak. We provide an impact assessment of the transmissibility and severity of COVID-19 during the first wave in mainland Chinese locations outside Hubei. Methods We estimated the instantaneous reproduction number (R t) of COVID-19 in Beijing, Shanghai, Shenzhen, Wenzhou, and the ten Chinese provinces that had the highest number of confirmed COVID-19 cases; and the confirmed case-fatality risk (cCFR) in Beijing, Shanghai, Shenzhen, and Wenzhou, and all 31 Chinese provinces. We used a susceptible–infectious–recovered model to show the potential effects of relaxing containment measures after the first wave of infection, in anticipation of a possible second wave. Findings In all selected cities and provinces, the R t decreased substantially since Jan 23, when control measures were implemented, and have since remained below 1. The cCFR outside Hubei was 0·98% (95% CI 0·82–1·16), which was almost five times lower than that in Hubei (5·91%, 5·73–6·09). Relaxing the interventions (resulting in R t >1) when the epidemic size was still small would increase the cumulative case count exponentially as a function of relaxation duration, even if aggressive interventions could subsequently push disease prevalence back to the baseline level. Interpretation The first wave of COVID-19 outside of Hubei has abated because of aggressive non-pharmaceutical interventions. However, given the substantial risk of viral reintroduction, particularly from overseas importation, close monitoring of R t and cCFR is needed to inform strategies against a potential second wave to achieve an optimal balance between health and economic protection. Funding Health and Medical Research Fund, Hong Kong, China.
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              Health risks of Rohingya refugee population in Bangladesh: a call for global attention

              In Bangladesh, more than 836 000 Rohingya refugee population is in need of humanitarian assistance [1]. These refugees faced discrimination in their native land in terms of various restrictions imposed on them due to the effective denial of their citizenship. This led to several human rights violations including limited access to health care services [2]. Currently they are under significant health risks and it has become a challenge to address their health needs. Due to the increasing number of Rohingya refugees and their congested living conditions in camps, there has been an overwhelming increase in their health risks [3]. Refugees and affected community require 9 million liters of safe water daily, and water, sanitation and hygiene (WASH) services are reaching only 30% of the Rohingya people in need. Thus leaving them with no other option than to fetch dirty water from muddy streams [4]. 85% of the refugees still have no access to latrines [5]. All of which in turn increases the risk of communicable disease outbreak [4]. There has been reports of measles outbreak amongst new arrivals, the number of cases reported is 419 [6]. The largest oral cholera vaccination was held in the refugee camps and even though it was able to reach 100% of the targeted population, the risks of waterborne and other infectious diseases are still exceptionally high due to their unhygienic living conditions [7]. Diphtheria outbreak has resulted in 38 deaths and more than 5800 suspected cases of diphtheria have been reported as of February 2018 [8]. There have also been reports on respiratory problems and skin diseases among the refugees who have arrived since 25th August-with 10 846 and 3422 cases respectively [9]. Among the refugees, 720 000 are children [4]. 14 740 orphan Rohingya children have been identified since September 20, 2017 in the settlements in Ukhia and Teknaf [10]. An estimated 250 000 children under the age of 8 require life-saving interventions through community-based activities such as vaccination campaigns whereas 240 000 children under-five years need malnutrition prevention and treatment support through nutritious supplementary food.16 965 children with severe acute malnutrition (SAM) require inpatient and outpatient treatment. 204 000 adolescent girls need nutritional support and 237 500 children from 6 months to 15 years need to receive measles-rubella (MR) vaccine [11]. Photo: Some of the shelters at Kutupalong camp site for the Rohingyas in Cox's Bazar (from the collection of Helena Derwash, used with permission) In the refugee camps, 54% of the Rohingya are below the age of 18; 52% are women with 23% of them between the ages of 18 and 59 years [12]. Among 91 556 adolescent girls and women, 54 633 are pregnant or lactating mothers [4]. Lactating mothers (9.2% of total refugees) and pregnant women (4.9% of the total population) have been identified as the two highest numbers of vulnerable group within the Rohingya Refugees [13]. As of 22nd October, an estimated 42 000 pregnant women, 72 000 lactating mothers and 240 000 under-five children need health assistance [11]. Majority of women are giving births at home, and only 22% of births occur in health facilities [14]. 2592 lactating women and 1145 pregnant women have been admitted for malnutrition treatment [5]. They are also among the first to experience additional barriers in accessing the scarce and overstretched humanitarian relief services. Furthermore, not only are they among the most affected groups but are also usually the last to be consulted (if at all) about their needs and provided with the least information about where and how to claim relief services [10]. 120 000 pregnant and lactating mothers require prevention and treatment from malnutrition through nutritious supplementary food [11]. Even though both Myanmar and Bangladesh have low prevalence of HIV among the South Asian countries, however the Rakhine state had the highest prevalence of HIV in 2015. In addition to this, the current predicament makes the victims of sexual violence more predisposed to the risks and transmission of HIV [15]. There have also been 21 cases of HIV patients reported among the refugees until Oct 8, 2017 [16]. There is an inadequate supply of essential reproductive along with maternal, child and new-born health services. Furthermore, there is insufficient clinical management of rape survivors, family planning as well as adolescent friendly health services, especially in the provision of these services in hard-to-reach areas. Moreover, there are no extensive HIV and TB services, although there have been cases of HIV reported among the refugees [17]. There is limited accessibility to inpatient as well as secondary health services which also includes referral system and quality of care and health care services implemented at the settlement lack standardization [8]. Overcrowded settlements and the rapid influx of refugees challenge the ability of service providers to identify private and safe services for women. There is incessant new influx of refugees which leads to overburdening of the existing facilities like WASH or health facilities and thus services are still not available and accessible to many of the refugees. The sheer size, density and unplanned nature of the make-shift settlements hosting refugees remain a major obstacle to setting up the communal infrastructures necessary to coordinate services at site level [17]. Mental health impact on the forcibly displaced refuges are significant. Refugees are reported to suffer from the flashback of the massacre, anxiety, acute stress, recurring nightmares, sleep deprivation, eating or even speaking disorder [18]. Methodical rape on women and girls and violent deaths of family members have compounded the mental health situation of the survivors of this physical violence. Women and children reported facing sexual violence including gang rapes which resulted in vaginal tears, infections and posttraumatic disorders [19]. There has been increase in the incidence of sexual violence among the refugees in Bangladesh which was exacerbated by the unavailability and low quality of post-rape care services [20]. From the end of August 2017 to the end of February 2018, MSF has treated 226 survivors of sexual violence at MSF’s Sexual and Reproductive Health Units, out of which 162 of them were rape survivors. Majority of the survivors were below 18 years [21]. Children face the danger of long-term psychological and social distress [22]. Since refugees are dependent on the humanitarian assistance for their survival and struggle daily for food assistance, this acts as a stressor for majority of them as well [23]. In addition, the overall situation and health risks will be exacerbated when the monsoon season arrives as flooding will adversely affect the latrines, tube wells and health facilities built in the camps [24]. The international community and Bangladesh government need to address the vulnerability of these refugees by giving humanitarian and financial assistance to them. There is need to scale up health services and increase access to essential reproductive health and child newborn care, especially for Rohingyas living in hard-to-reach areas. Community health workers need to be effectively trained to ensure adequate health promotion, promotion of hygiene and home visits to pregnant women. Scaling up of mental health service provision in primary health care settings is needed. Information needs to be adequately provided to the refugees. Furthermore, in the case of epidemics, rapid response is necessary and to ensure that reliable health statistics remain paramount. Thus, organizations need to give more attention to the collection and dissemination of data. As refugees, their condition has aggravated because of limited financial aids and overcrowded unhealthy living conditions in settlements and camps. All of which will exacerbate their access to health care services, predisposing them to numerous health risks and increase the chance of disease outbreak. Thus along with the government, private sectors and international communities must collaborate to assist the refugees in their dire condition for the improvement of their health status.
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                Author and article information

                Contributors
                Journal
                Public Health in Practice
                The Author(s). Published by Elsevier Ltd on behalf of The Royal Society for Public Health.
                2666-5352
                2666-5352
                2 June 2020
                2 June 2020
                Affiliations
                [a ]Department of Population Scences, Jatiya Kabi Kazi Nazrul Islam University, Bangladesh
                [b ]Department of Public Health, La Trobe University, Melbourne, Australia
                [c ]Bangladesh
                Author notes
                []Corresponding author. Department of Population Sciences, Jatiya Kabi Kazi Nazrul Islam University, Mymensingh, Bangladesh, Tel.: +8801737151554, sumonrupop@ 123456gmail.com
                Article
                S2666-5352(20)30017-3 100018
                10.1016/j.puhip.2020.100018
                7265827
                © 2020 The Author(s)

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

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                rohingya refugee in bangladesh, covid-19

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