As COVID-19 deaths rise in Cox's Bazar, is increased testing enough?

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Ahead of screening, a woman goes through a hygiene and sanitation procedure at Camp 12 Primary Health Center in Kutupalong Refugee Camp, Bangladesh. Photo by: Nihab Rahman / Food for the Hungry

MANILA — Bangladesh has reported a second death due to COVID-19 in the Rohingya refugee community in Cox’s Bazar on Tuesday along with five new positive cases.

This came on a day that Bangladesh reported a record number of over 3,000 new cases and 45 deaths over 24 hours in the country. The two deaths in the Rohingya camps and the rising number of cases highlight the need for continued vigilance in the world’s largest refugee camp, where testing capacity remains low.

In Rohingya camps, COVID-19 challenges humanitarian effort to ‘do no harm’

In Cox’s Bazar, aid groups face a dilemma. In an effort to stall a COVID-19 outbreak, they must reduce staff numbers and scale back services. But what unintended consequences will this have on nearly 1 million of the world’s most vulnerable people?

Bangladesh has put areas of Cox’s Bazar on lockdown over the weekend. Cases in the district have gone over 1,000, according to the latest government data. However, only a small percentage comes from the refugee community in Cox’s Bazar, where 35 cases have been reported to date since the first one was confirmed last May 14.

An earlier modeling analysis by Johns Hopkins University in March projected that a single case there could lead to an estimated 119-504 cases under a low- to high-transmission scenario in the first 30 days.

“The numbers are not rising as we had feared. However, all the conditions are present for an extremely serious situation for one of the most marginalized people groups in the world,” Matt Ellingson, director of relief and humanitarian affairs at Food for the Hungry, told Devex last week.

“I think that all of us humanitarian professionals are well aware that this virus overwhelmed some of the most well-developed health systems in the world. And so we fear the worst and hope and pray for the best in this situation,” he said.

Aid groups Devex has spoken to were cautious in making speculations over the numbers. But they confirmed low testing capacity in the camps. Only over 300 tests have been conducted in the camps as of last week where over 800,000 refugees live, Ellingson said. Aid groups noted that this is reflective of overall low testing across the country, at 2,412 tests per million.

There’s only one laboratory, which has a testing capacity of 200 tests per day, catering to both host communities and refugees in the entire Cox’s Bazar district, said Louise Donovan, communications officer there for the U.N. High Commissioner for Refugees.

But aid groups are hopeful testing capacity for the district will soon increase to 500 per day. The World Health Organization has recently provided the Bangladesh government with a second polymerase chain reaction or PCR machine to improve testing capacity in the laboratory in Cox’s Bazar, said Catalin Bercaru, communications officer for WHO in Bangladesh.

“At this time, it's mostly important for [us to] get access [to] COVID19 information but we can't.”

— Shamima Bibi, Rohingya refugee, founder, the Rohingya Women’s Education Initiative

But increasing testing capacity won’t be enough. Aid agencies also need to intensify sensitization efforts in refugee camps to ensure they are presenting to health centers early for testing.

Testing in the camps

Suspected cases in the camps presenting to health facilities are tested for COVID-19, regardless of symptom severity, and are isolated from the communities while they await test results, said Robert Lukwata, medical director of Food for the Hungry’s health program in Bangladesh. This is done to reduce any potential transmissions that could occur in communities.

Suspected patients await their results between 24-48 hours. If the test turned out positive for COVID-19, rapid investigation teams are activated for contact tracing and to initiate the transfer of patients to an isolation and treatment center.

WHO’s Bercaru said health staff within the camps have been oriented on infection prevention and control measures, including the appropriate use of personal protective equipment.

“Currently, we are not advocating for home isolation because as you know, the camps are densely populated and also the households are overcrowded,” Lukwata said.

“Definitely when we have [a] full-blown [disease] spread in the community, we shall not be able to admit and isolate the mild and moderate cases. The capacity won't be there. So this is an initial intervention to flatten the curve, to ensure that we reduce the rate of transmission as we prepare and as we try to strengthen the health care system,” he added, noting that there is a plan in place for home-based care for patients presenting with mild and moderate symptoms in the event cases overwhelm capacity in the health facilities.

One of the severe acute respiratory infections isolation and treatment centers in Cox’s Bazar is a 50-bed facility located inside the Kutupalong Refugee Camp, implemented by Food for the Hungry and Medical Teams International, with support from The UN Refugee Agency. But there are other facilities in the district, and plans are underway to increase bed capacity.

UNHCR’s Donovan said 10 more centers spearheaded by other humanitarian organizations are under construction and are expected to finish in two weeks. UNHCR is also supporting the establishment of an 18-bed intensive care unit in Sadar Hospital, the main district hospital in Cox’s Bazar, expected to be operational this month.

As of last week, there were only three cases in the isolation and treatment center in Kutupalong and none of them were severe, Lukwata said.

All cases they’ve had at the center to date presented voluntarily in the health centers, said the medical director, attributing these to sensitization efforts made by humanitarian agencies and community health volunteers.

However, he admits they need to further intensify this.

“Behavior change is a process,” he said. “We have done a lot of sensitization and awareness, but there are still perception challenges in the community ... Their health-seeking behavior, the refugees are kind of, I wouldn't say evading, but they're scared to come to the facility because they know when they come, they might be suspected [of having COVID-19].”

A Yale study published in May revealed that over 42% of refugees surveyed first go to pharmacies to seek advice and treatment instead of health facilities.

Internet access

Humanitarian agencies and community-led organizations employ various approaches to raise awareness and ensure the right information reaches the refugee population amid communication challenges in the camps. The international humanitarian community has repeatedly appealed to the government to lift internet restrictions which have been in place even prior to the pandemic.

“Unfortunately that hasn't changed. The internet restrictions are still in place,” Donovan said.

“We have obviously been working very hard to train volunteers and to spread awareness, the messages, within the camps. But it doesn't necessarily reach everybody,” she said.

Are local and international aid worker disparities worsening under COVID-19?

Humanitarian and development agencies have been criticized of tacitly — or explicitly — valuing international staffers over their local counterparts. COVID-19 appears to have exposed these inequalities despite efforts to bring about change.

With a significantly reduced international staff, humanitarian agencies rely on refugee volunteers to raise awareness and disseminate critical information in the camps, not just on COVID-19, but also in preparation for potential floods and landslides as the monsoon season begins. Aid groups said the recent cyclone Amphan caused minimal damage in the camps, but there could be more cyclones in the coming weeks.

Internet restrictions have also spurred concerns on efforts to dispel COVID-19 rumors in the camps, as refugees try to find ways to access information online. One of the main pieces of feedback Donovan receives from refugees is requesting access to the internet.

“Many of them are pushing and crying out for internet connection. They want additional information. They're apprehensive about sometimes going to health centers because maybe they lack information about symptoms, etc.,” she said.

Shamima Bibi, a Rohingya refugee who’s been living in the camp since September 2017 and who founded the Rohingya Women’s Education Initiative, told Devex over Twitter that apart from empowering women and girls in their community, they are raising awareness on COVID-19 in the camps.

However, she finds challenges in ensuring they have the most up-to-date information on COVID-19. Her organization, she said, doesn’t directly work with international aid organizations.

“As you know, there is no internet access in the camp but in some places we can find slow internet. So we go there and we find information and we download it and [share] it with the community,” she said.

Sometimes she gets some internet connection at her shelter, but it’s weak and sporadic. She said the internet in the camps is important for accessing information, and to communicate with others.

“Now in COVID-19 ... it's an unbelievable time for us. Impossible for social distancing, spread of rumors. At this time, it's mostly important for [us to] get access [to] COVID19 information but we can't,” she wrote.

About the author

  • Jenny Lei Ravelo

    Jenny Lei Ravelo is a Devex Senior Reporter based in Manila. She covers global health, with a particular focus on the World Health Organization, and other development and humanitarian aid trends in Asia Pacific. Prior to Devex, she wrote for ABS-CBN, one of the largest broadcasting networks in the Philippines, and was a copy editor for various international scientific journals. She received her journalism degree from the University of Santo Tomas.