In December 2017, an outbreak of diphtheria started to take hold in the sprawling Kutupalong refugee camp, near Cox's Bazar in southern Bangladesh. The camp is home to over 700,000 mainly Rohingya people, the majority of whom arrived there since August 2017, fleeing violence in neighbouring Myanmar.
Diphtheria is a highly contagious respiratory disease that can be fatal, and there were fears that the outbreak could quickly turn into an epidemic and spread throughout the camp. The government of Bangladesh and the World Health Organisation issued a call for international medical assistance. The UK was first to respond, quickly deploying an advance party of its Emergency Medical Team (EMT).
The EMT arrived in Bangladesh just before Christmas and started work immediately alongside local medics from the Bangladesh Ministry of Health, the International Organisation for Migration and Medicins Sans Frontieres, helping to quickly set up 3 dedicated Diphtheria Treatment Centres at strategic sites around the sprawling camps.
Within a few days, the specially-constructed treatment centres, made of bamboo and plastic sheeting, were kitted out as fully functioning medical facilities, and the teams started to triage and treat patients.
Diphtheria is hardly ever seen around the world, as most people are vaccinated from the disease at birth. But many Rohingya children in Myanmar have not been vaccinated against it, and the cramped and squalid conditions in Kutupalong meant there was a high chance an outbreak of the disease would spread quickly.
Left untreated, diphtheria can be fatal. It causes a pseudo-membrane, a thick, mucous-like coating on the back of the throat, which can cause breathing difficulties. It can also cause longer-term brain, heart and kidney problems, even if people receive treatment. Mild cases can be treated with antibiotics, but more severe cases require diphtheria antitoxin, a powerful drug, which itself can be dangerous as some people can suffer an allergic reaction to it.
The UK's Emergency Medical team is made up of doctors, nurses, paramedics and other specialists drawn from across the NHS. They volunteer their time on a rota-based system so that the team can be quickly assembled and deployed anywhere in the world with 72 hours of being requested, 365 days a year . A rapid advance team can be deployed with 8 hours of being alerted.
The team is funded and supported by UK aid from the Department for International Development, and co-ordinated by UK Med, an NGO based at the University of Manchester. Logistics support is provided by specialist logisticians drawn from Fire & Rescue Services across the UK, who are also part of the UK's International Search & Rescue team. Specialist support for people with disabilities is provided by the international NGO Humanity & Inclusion.
In total, 40 British medics were deployed to Bangladesh, including specialists in infectious diseases, emergency medicine and paediatric trauma care. One of them, Dr Andy Lockyer from Bristol Royal Infirmary, explains how the team is working a few days into their deployment.
"Without UK aid, we would not have been able to respond as we have to the diphtheria outbreak"
Another member of the team, Dr Freda Newlands, from Dumfries & Galloway in Scotland, has previously volunteered with Medicins Sans Frontieres on the northern Jordanian border in the emergency response to the Syria Crisis. She also worked in Khartoum with the World Health Organisation.
Freda explains why she feels it is important that the UK provided assistance to help treat the disease:
"Without UK aid, we would not have been able to respond as we have to the diphtheria outbreak.
"The point of us coming out here was to provide support to all the other agencies who were being overwhelmed – on top of all of their over work – to this outbreak of diphtheria, which could have caused chaos.
"We've been able to provide a targeted, expert response, allowing all the other agencies to get on with what they do."
In the ward next door, Dr Iain Lennon, a consultant in emergency medicine from Nottingham, examines 8-year-old Saddam for symptoms of diphtheria. Like many of the children being brought to the clinic by their worried parents, Saddam has been feeling unwell for a few days, with a sore throat and a fever. A quick throat inspection reveals the distinctive membrane coating at the back of Saddam's throat.
Dr Lennon immediately asks one of the Bangladeshi doctors to explain to Saddam's father that his son needs to given diphtheria antitoxin. After a brief conversation, Saddam and his father agree to the treatment. Within a few minutes, Saddam is admitted to the clinic and being prepared for the treatment by nurse Kathleen Shields.
Diptheria antitoxin (DAT) is a powerful drug that needs to be administered very carefully in a series of gradually increasing doses via injections and finally an intravenous infusion. All the while Saddam is monitored closely for any signs of allergic reaction. The whole process can take up to 8 hours, and then the patients will be kept in overnight for observations the following day.
By the next morning the change in Saddam is remarkable. He's sitting up in bed, alert and visibly already much better. Dr Lennon examines him again, and is pleased with his progress, explaining to Saddam and his father that they should be able to go home tomorrow.
However, that's not the end of Saddam's story. His father, brother and entire immediate family are also prescribed with a course of antibiotics, to help ensure that none of them contract the disease either. This is a vital part of helping to contain the outbreak and prevent it from spreading more widely.
The wider work to contain and prevent the outbreak spreading is being led by Bangladeshi medics working with the International Organisation for Migration, UNICEF and the World Health Organisation. The UK is working alongside them all, in a number of ways.
Firstly, the UK EMT is helping train Bangladeshi IOM medics to be able to identify and treat diphtheria themselves, in order to build long-term local capacity to be able to manage the disease. IOM staff are then also separately managing the contact-tracing process, which will ultimately help bring the diphtheria outbreak to an end. For every person identified as suffering from the disease, the IOM contact tracing teams need to find every other person that the infected person has been in close contact with over the previous 72 hours. Those people then need to be prescribed with a course of antibiotics to prevent them from contracting the disease and spreading it to others. In an enormous refugee camp like Kutupalong, this is a massive challenge.
The UK is also funding the majority of the WHO and UNICEF diphtheria vaccination campaign. This is working in parallel with the contact tracing teams to identify and vaccinate around 450,000 people in total, both in the Rohingya refugee camps and in the wider Bangladeshi community. This is the estimated number of people that need to be vaccinated in order to achieve so-called 'herd immunity' from the disease.
"The EMT are really helping. We were waiting for then to arrive before we could give the DAT treatment. We have learnt lots of things with them. It will be so useful for us in the future."
Ummul Jesmin is one of the nurses with the International Organisation for Migration who is working alongside the UK EMT. She explains how she's been working with the UK team:
"I've been working in the camps since 3 January. I was brought here specifically to assist in the Diphtheria response. I'm helping to train the other nurses. I am enjoying it because I used to work in the UK. It makes me enjoy the memories of my five and half years in Britain, in London.
"We are working as a team. When they arrived in January, there were lots of things missing from the treatment centre and it was not ready. Myself and all of the other doctors cleaned everything, built everything and prepared the medication. The British doctors were there sweeping the hospital floor with us before we opened the door.
"The EMT are really helping. We were waiting for then to arrive before we could give the DAT treatment. We couldn't start working without them. We have learnt lots of things with them. It will be so useful for us in the future."
The EMT returned back to the UK at the start of February, after 6 weeks in Bangladesh, as the diphtheria outbreak now seems to be under control. The team triaged over 3,000 people and treated just under 500 in total for suspected or confirmed diphtheria.
UK aid continues to provide wider humanitarian support to the Rohingya crisis, both to Rohingya people who've fled to Bangladesh and to those who are still inside Myanmar. The UK has committed £59 million in response to the crisis since August 2017, providing food, water, shelter, healthcare and more to hundreds of thousands of people in need.
To help, please donate if you can, to the Disasters Emergency Committee appeal.
Story, images and videos: Russell Watkins/Department for International Development.
