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Health Survey in Kutupalong and Balukhali Refugee Settlements, Cox’s Bazar, Bangladesh (December 2017)

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Executive summary

Introduction

Violence in Rakhine State which began on 25th August 2017 has driven an estimated 626,000 Rohingya across the border into Cox’s Bazar, Bangladesh.1 Together with previously displaced people this took the total number of Rohingya in Bangladesh to over 800,000. The majority of these people are now living in pre-existing camps and settlements, settlement extensions (additions to pre-existing settlements), spontaneous settlements (newly-formed settlements) and amongst the host community in Cox’s Bazar District. There was a need to understand the scale and severity of the emergency in the settlements.

Methods

Four health surveys were performed in Kutupalong Makeshift Settlment (KMS), Balukhali Makeshift Settlement (BMS), Kutupalong Makeshift Settlement Extension (KMS Extension) and Balukhali Makeshift Settlement Extension (BMS Extension). These sites were chosen to ensure that the health status and conditions were measured in both the new settlements and the pre-existing settlements. The surveys measured current and retrospective mortality, the main morbidities affecting the population, global and severe acute malnutrition rates, vaccination coverage rates for key antigens and health-seeking behaviour. Simple random sampling was used with a recall period from 25th February 2017 until the date of interview (30th October to 12th November): approximately 260 days.

Results

The overall crude mortality rate (CMR) was 0.93 per 10,000 per day (95% CI: 0.77-1.13) for the period 25th February 2017 to 12th November 2017, with an under 5 mortality rate (U5MR) of 0.74 per 10,000 per day (95% CI: 0.43-1.27). However, these rates mask the variation over time. Among those displaced since 25th August 2017, almost two thirds of deaths (64.9%) occurred between 25th August and 24th September 2017. This corresponds to a CMR during the month following the crisis of 6.31 (95% CI: 4.93-8.08)2. This is nearly 15 times higher than the CMR in the same population prior to this period (0.42 [95% CI: 0.28-0.62] between 25th February and 24th August 2017) and more than 9 times higher than the CMR in the same population afterwards (0.67 [95% CI: 0.35-1.29] between 25th September 2017 and the end of the recall period).
When the 25th August-24th September 2017 mortality was stratified by age group the highest mortality was among those aged above 50 years with a mortality rate of 17.28 per 10,000 per day (95% CI: 10.58-28.20) but mortality was also high in those aged between 5 and 49 at 5.32 (95% 3.90-7.25) per 10,000 per day and in <5 year olds at 4.56 (95% CI: 2.18-9.57) per 10,000 per day.
For the recently displaced, the main cause of death was violence, responsible for 66.7% of deaths between 25th August and 24th September 2017. The most common form of violence resulting in death was shooting (69.0%) followed by “other” causes (16.7%, all but one of which was recorded as “killed by military”) and burnt to death in home (11.9%).
Between 25th August and 24th September 21.5% (95% CI: 20.1-22.9) of the recently displaced population reported experiencing at least one violent event, nearly 8 times higher than in the same population prior to this period, between 25th February and 24th August (2.8% [95% CI: 2.2-3.4]) and 20.5 times higher than in the same population between 25 September and the end of the recall period (1.1% [95% CI: 0.7-1.4]). These events included shooting, physical violence, the burning of homes and detentions / kidnapping. Sexual violence was also reported by 3.3% of all women amongst the recently displaced population during this period.
One third of respondents self-reported ill health in the two weeks prior to the survey. The most common reported illnesses were fever (66%), respiratory diseases (35%) and diarrhoea (15%). Overall, 49% of those who were ill sought healthcare from a clinic with a higher proportion of the pre-existing residents (67%) seeking healthcare in comparison to the new arrivals (46%). Reasons not to utilise healthcare services included lack of money (42%), geographical barriers (26%) and a lack of time (20%).
Measles vaccination coverage in the settlements was low (23.2% [95% CI: 19.9-26.5]), with less than one quarter of children under 5 years vaccinated. A mass oral cholera vaccination (OCV) campaign conducted by the Government in October has resulted in vaccination coverage of 68.3% (95% CI: 66.9-69.8) of the population. However, coverage varies by site with coverage ranging from 55.8% in the KMS Extension to 74.0% in the BMS Extension, 77.0% in BMS and 79.1% in KMS.
Based on the mid-upper arm circumference (MUAC) assessment, the global acute malnutrition (GAM) in the settlements is just below 10% and the severe acute malnutrition (SAM) rate 3%, above the MSF emergency threshold. However, doubts about the suitability of the MUAC methodology have been raised in a recent SMART survey performed by Action Contre la Faim (ACF) in Kutupalong refugee camp. Discordancy between anthropometric assessment and MUAC in the same individuals was observed, with GAM rates up to four times higher when using weight-for-height compared with MUAC.
Conclusions The results of these surveys reveal extremely high mortality, even in children, and exposure to violence, in the initial weeks following the crisis in Rakhine. This analysis demonstrates the widespread and indiscriminate nature of the attacks, forcing the Rohingya to flee en masse. In contrast, mortality in the pre-existing refugee population in the settlements in Bangladesh has remained stable over this period, with no obvious detrimental effect on the health of this population with the arrival of the recently displaced refugees.
Assessment and monitoring of malnutrition in the settlements remains challenging, with discussions regarding the most appropriate methods for rapid, community-level malnutrition screening ongoing and it may be necessary to repeat nutritional screening if the MUAC methodology used in this survey is deemed inaccurate.
Vaccination coverage was found to be low among the refugee population. As of November 2017, a large-scale measles outbreak occurred in the settlements to which the Government has responded with a catch-up vaccination campaign. Despite this, it is recommended that efforts to scale up expanded programme of immunisation (EPI) activities continue.