Using technology to tame an outbreak

The first case of diphtheria, a highly infectious disease, was reported in Cox’s Bazar, Bangladesh in November 2017. The disease quickly spiraled to 150 suspected cases a day. Taming the outbreak has been a combined effort of international organizations, nongovernmental organizations and government agencies. One of their key tools has been the World Health Organization’s (WHO’s) Early Warning, Alert and Response System.

Dr Mazhar, Surveillance and Outbreak Officer, examines Hosnin, 8, who recovered from diphtheria. Photo: WHO/Mehak Sethi

In a room without windows at the WHO office in the town of Cox’s Bazar, Bangladesh, a group of epidemiologists sits around an oval table, eyes glued to their laptop screens. As they do every Monday, they are sifting through disease alerts submitted via the Early Warning, Alert and Response System (EWARS), a disease surveillance system developed by WHO.

Each week dozens of disease alerts come in from 170 health facilities spread across Rohingya camps as well as the general population. Diseases reported include measles, acute watery diarrhoea, mumps and diphtheria. Each alert is reviewed, verified and assessed and, if more evidence is needed, a team is sent out to investigate

Basel Karo and Khadimul Anam Mazhar examine alerts in EWARS dashboard in WHO’s office. Photo: WHO/Mehak Sethi

Why diphtheria?

For the past few months the epidemiologists working with EWARS have been largely focused on diphtheria. “The first suspected case of diphtheria was reported in Balukhali camp on 8 November, 2017,” recalls Dr Khadimul Anam Mazhar who has witnessed the diphtheria outbreak unfold in Cox’s Bazar, “Then when diphtheria patients were documented in multiple facilities in higher numbers, an outbreak was declared.”

When Mazhar studied historical diphtheria cases back in medical school, he never expected to see a diphtheria case in real life, not to mention a large-scale outbreak. “It was something you would only read about,” he says. Until November 2017, diphtheria was not a common disease in Bangladesh, thanks to high immunization coverage. “Diphtheria is a dangerous disease because it is highly infectious and it is spread by droplets. If the patients sneeze or cough, then you could get infected,” says Mazhar.

“Although we have very high immunization coverage, immunity to the disease starts to decrease five years after taking the vaccine. So, without a regular booster, everyone is susceptible.”

Mazhar inspecting the medicine taken by Halima, 25, who with her son recovered from diphtheria. Photo: WHO/Mehak Sethi

Before seeing the disease outbreak, he witnessed the waves of thousands of tired, hungry and scared families with children crossing into Cox’s Bazar after fleeing Myanmar. In just a few months, the numbers have grown to one million displaced people. This constitutes one of the largest population movements in recent history. “Their immunization coverage was really poor. We don’t have any data if they received the vaccines or not,” says Mazhar.

The diphtheria outbreak spread across camps across approximately 5000 acres of undeveloped forest land. From more than 150 suspected cases reported daily, the numbers have now decreased to 20 cases per day. According to Mazhar, establishing diphtheria treatment centres with patient isolation was crucial to fighting the outbreak. Another critical tool is contact tracing, which allows officials to track the spread of the disease.

A health worker administering diphtheria anti-toxins to a patient at Samaritan’s Purse, diphtheria treatment center. Photo: WHO/Mehak Sethi

“We followed each patient and provided preventive medicines and vaccines to their family members. This helped in containing the outbreak,” he says. But all of this wouldn’t be possible without the correct data. “EWARS is the main platform for disease surveillance here. All the health services must report to EWARS so we can get an idea of the latest numbers, geographical location and population affected at the end of the day and plan our action accordingly,” he says.

EWARS’ dashboard was introduced into Cox’s Bazar in January, allowing health workers to introduce the information via laptops and cell phones. “This feels like luxury. Before January, all the alerts were submitted in hard copy so we used to have to go through more than 150 paper reports and enter them into the system on a daily basis,” says Dr Uzzal Roy, one of the doctors who has been working with EWARS since it was introduced in September.

A health worker enters data in the EWARS interface at a health facility of Samaritan’s Purse in Cox’s Bazar. Photo: WHO/Mehak Sethi

The strength of EWARS is that it can work even when doctors and health workers are in remote areas, using their smart phones to enter data even when they are offline. The information, which is gathered on the spot, is updated when the device is connected to an internet network.

WHO developed EWARS to detect disease outbreaks in humanitarian and emergency settings and has been used around the world in countries including Bangladesh, Democratic Republic of the Congo, Fiji and South Sudan. It is designed and operated by local people to benefit communities at risk. Despite great efforts and long hours of work put in by many doctors and health-workers like Dr. Mazhar, the health sector is heavily underfunded.

A child in Cox’s Bazar observing his mother talking to Dr Mazhar. Photo: WHO/Mehak Sethi

The international humanitarian community’s joint response plan released in March called for US$ 113 million for the health sector. So far less than 12% of that plan has been funded. Unless necessary funding is secured soon, life-saving health services, including disease surveillance, vaccination, diagnostics and treatment for 1.3 million people — Rohingya refugees and host communities — living in Cox’s Bazar are under serious threat.

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