We had the opportunity to chat with Barbara Saitta (RN, MPH). Barbara has been working with MSF since 2009. She is the Vaccination Operational Advocacy Focal Point for the Access Campaign & MSF-OCP. Barbara recently spent 6 weeks in Cox’s Bazar helping with our efforts in the field.
Which projects in Bangladesh are dealing with Diphtheria right now?
Right now, every MSF project is receiving suspected cases of Diphtheria from all over the camps. Suspected cases include people that show symptoms of the disease but for whom the diagnosis is not yet confirmed. Once we confirm that a patient has Diphtheria, we transfer them to an OCA or OCB Diphtheria Treatment Center. We have 15 health posts which are the clinics closest to the communities. In all the clinics we have Rohingya volunteers that do outreach in the community. In these health posts, we do primary health care consultations, vaccination, and we take care of women during as well as right after pregnancy. The clinics are positioned in key places in the camp to ensure that we are close to the people.
I was in Cox’s Bazar from the 17th December until the 27th January and worked for MSF France while I was there. We had 3 health posts and 1 hospital with 50 beds. MSF France is also building a new hospital that will have 100 beds and will include an emergency room, adult & pediatric wards, as well as an intensive care unit, isolation unit, and a maternity ward.
In 3 of the health posts, which we call the OPD (Outpatient Clinic or DEPA), we do daily consultations and this is where all suspected cases of Diphtheria arrive. To avoid the spread of diseases to other patients we receive and examine them in an isolated part of the OPD where the “Diphtheria Team” attend to them. This team is composed of a physician and 4 or 5 Rohingya volunteers. The physician checks for symptoms and signs of Diphtheria, and if there is a strong suspicion of Diphtheria, they send our Rohingya volunteers to the house of the patient’s family because if there is a suspected case, everyone who has been in contact with this person could potentially be infected. We usually call these people contacts.
They must be treated with antibiotics and vaccinated as a preventative measure. As you can imagine it is a lot of work and it can be quite challenging to find & follow up with the contacts.
Are the contacts brought back to the health post too?
Yes, if the contacts display symptoms that are consistent with Diphtheria, we bring them back to the OPD so that the physician can confirm if they are sick or not. If the contacts do not display symptoms, they receive antibiotic treatment and would be asked to come to the OPD to be vaccinated against Diphtheria in order to help stop the spread. The volunteers going out to the community are not doctors but they have been trained and ad-hoc supervised to do their job. The work of our Rohingya volunteers is actually very important. The volunteers explain how the antibiotics should be taken to the family – different age groups require different dosages which makes this part very important. The importance of getting vaccinated, what the vaccines are, and what they do is also explained to the families. One of my tasks was to train the volunteers on how to explain and answer questions related to vaccinations. Locating and following up with contacts was also an enormous task. At high peak times, we had 100 to 120 patients a week & we would need to follow up the patients as well as the members of each patient’s households.
This seems like a lot of work. What does the whole process of treating a Diphtheria case entail?
It is an incredible amount of work. There are 3 components to the treatment of Diphtheria, the vaccination, the actual treatment of the patient, and the follow up with the family – including other people that have had contact with the patient. Since we give out antibiotics and they must take them for 7 days, it is important to have follow-ups to make sure they are taking their dosages correctly. We usually visit them 4 days into their treatment when the main part is complete, and then 8 days after their treatment (24hours after the end of the course of antibiotics). We go into the communities to check this, which also helps us check how other people around the family are doing.
Another concern is that there is a tremendous amount of antibiotics going into these areas so we want to make sure that they are taking their antibiotics appropriately. The effort from the national staff is immense. If a patient was diagnosed with Diphtheria we had to refer them to the hospital for treatment. We usually use a Diphtheria Anti-Toxin (DAT) to suppress the toxin that is spreading in the body, but most importantly to slow down the growth of the pseudomembrane which is the white/green membrane that grows in their nose or pharynx, which can lead to asphyxiation. This membrane is caused by the toxin that Diphtheria releases in your body. Administering the DAT can be dangerous because it is given intravenously and in some cases, it can cause an anaphylactic shock. We usually perform a test on their skin to make sure this is possible. We also continuously monitor the patient during the administration of the DAT. Unfortunately, it is not a simple process and it requires well trained medical staff.
Another challenge to providing treatment is there a huge shortage of DAT globally, which means we do not have enough doses of DAT available. In addition, Bangladesh is not the only country that is experiencing a Diphtheria outbreak, other countries such as Yemen, Indonesia, and Venezuela have also reported cases.
The Diphtheria vaccine was one of the first vaccines provided in the routine immunization package. In 1974 when the Expanded Program for Immunization (EPI) was founded, DTP (Diphtheria-Tetanus & Pertussis) were the first course of vaccines on the EPI schedule, but these days you have whole communities that have low levels of vaccinations. DT used to be one of the primary vaccines given so when we start to see a resurgence of Diphtheria, it is an indication that the level of immunization coverage has been low. This can be taken as a warning to the global community and as a sign of the problems in the local communities.
The last time we had an official outbreak of Diphtheria was about 20 years ago in Russia. To achieve herd immunity (resistance to the spread of a contagious disease within a population that results in a sufficiently high proportion of individuals being immune to the disease, especially through vaccination) for Diphtheria, the literature says that 80-85% coverage is enough. However, in the case of the Rohingya population, coverage was far from the desired 80-85% mark.
We have been experiencing insurgencies in diseases that we have not dealt with in a while, such as Yellow Fever and Cholera but unfortunately, there are not enough vaccines for patients. This is a huge issue for the global health community. That is why this year the Access campaign is focusing on the global shortage of vaccines, and so is the World Health Organization (WHO). We are realizing that there is something wrong in the system because many Pharma – Vaccine companies stopped producing or are not producing enough vaccines.
What was it like when you first arrived in Cox’s Bazar?
When I arrived, the Ministry of Health (MoH) was implementing the 5th vaccination campaign happening in the camp in less than 5 months. They had 2 rounds of Cholera and 2 Rounds of Measles & Rubella. When I arrived, they had just started a vaccination campaign for Diphtheria and other vaccines. It was a lot to work for the team. There were some new field workers in their first mission, and there were some others with more experience but not necessarily in vaccination. This was probably one of the first times I had gone to a mission where we had to start from scratch. We had 380 staff members that needed to be vaccinated in order to protect them since they would be working with the population. The first week and a half consisted of us vaccinating staff members and conducting various training sessions, as well as organizing the cold chain. As a team, we started negotiating where we would start vaccinating, how long we would vaccinate for, and discussed other logistical issues.
What made you go to Cox’s Bazar & can you elaborate on your time there?
When I went there I went on behalf of OCP Operations. There were looking for someone with experience in vaccination campaigns as well as planning them, and who had preferably worked with Access Campaign to help negotiate with the MoH, WHO, and UNICEF. These negotiations would be about creating access for the population in need of vaccinations, the type of vaccinations that would be used, and how we should plan the vaccination campaign. We also needed to discuss the possibility of starting routine vaccinations as an integral part of our medical activities. The negation took place at the country level but also in Geneva where the HQs of important global health actors are based.
As I mentioned earlier when I arrived in Cox’s Bazar the MoH had already done 4 mass vaccination campaigns to either prevent outbreaks (Cholera) or stop the epidemics that were already underway (Measles & Diphtheria). We already knew that coverage in the camp was not the best, and many more refugees had arrived since November after the Cholera & Measles campaign was done. We also knew that the rainy season was coming in March. Our prediction is that there is a potential outbreak of Cholera and other water-borne diseases about to unfold so we were pushing for Cholera & Measles vaccines to be added to the most recent vaccination campaign.
This would help us catch up with the new arrivals in the camps and the ones that were not vaccinated in November. We also suggested that refugees older than 15 years old should be vaccinated for Diphtheria. The vaccination campaign I was there to support only vaccinated youth up to 15 years old. However, data showed that more than 25% of suspected cases of Diphtheria were older than 15 years of age. This demographic still needed to be vaccinated. Of course, it is true that people under the age of 15 are at high risk for mortality & morbidity but if we leave a big proportion of people who are older unvaccinated, we would be leaving a big pool of people susceptible to the disease. This means that not only are we putting them at risk of getting sick but these people can also spread the diseases to more people around them. To stop any outbreak, you need to reach as many people as possible in the shortest amount of time possible.
Negotiating for the inclusion of more people and better-planned campaigns was part of the messaging the team and I pushed to UNICEF, WHO, and the MoH.
Another issue we faced was the unreliable population data available, like the number of people and children in the camps. We knew that the target group number to be vaccinated was greatly underestimated so we worked hard to advocate and make sure that the number of people needing these vaccinations was accounted for.
When I arrived, there were just 2 expats who had experience with vaccinations. Due to the amount of work needed and issues we had to deal with, we basically started from square one. We had a lot of training sessions with national staff as well as Rohingya volunteers. As I already mentioned, we had to vaccine all 380 MSF staff while continuing to vaccinate the population. We also had to negotiate better access to them. Of course, meeting and seeking the support of the Imams and Magi (community leaders) of each camp was very important too. Imams and Magi are the gatekeepers of the community, they are respected and trusted by the people so it was important that we involve them in the planning as well as the implementation of vaccination activities. They can help us to efficiently be able to vaccinate the people in the camps. We had to meet and explain what we were doing, why, and what were the benefits of vaccinating their people. During these discussions, it was important that we discussed and understood everyone’s needs.
I also worked with our expat and national midwives to make sure that all the pregnant women were vaccinated before giving birth. We did this to prevent their new-born from having tetanus, and in this case Diphtheria too. The issue for us was the fact that the MoH did not provide vaccinations for pregnant women. Fortunately, while we negotiated to have vaccines for pregnant women, we could use a stock of Diphtheria and tetanus vaccines we had in the project, the same supply we used to vaccine our staff.
Do you feel that MSF is making significant strides in providing emergency care as we set out to do in Cox’s Bazar?
Yes, I do. As far as vaccinations, we have made great progress. When you consider that in November 2017, we were not even allowed to vaccinate, we were only asked to only help with transportation but after we supported the MoH for the first 3 campaigns, they saw the added value we could bring beyond logistical support. The MoH started allowing us to directly vaccinate people and even started including us in the plans for both vaccination campaigns and routine immunizations. We were finally allowed to integrate vaccination in our daily medical activities.
We have made great strides in this area but there is still more to be done. For example, while I was there, MSF was not allowed to have a stock of vaccines in our cold chain so every morning at 7 am, some of us had to go to the MoH’s health center to pick up the vaccines, then distribute them to the health posts and OPDs in the area. We also had to return the vaccines back at 5 pm. This required a lot of logistical work which was handled very effectively by the team.