Resurgence of infectious diseases due to forced migration: is planetary health and One Health action synergistic?
Authors: Mahfuza Talukder Flowra, Muhammad Asaduzzaman
Journal: The Lancet Planetary Health (2018)

Forced migration is an ancient phenomenon and will continue as long as politics exists. Although it mainly evolves from persecution, development, or exploitation, its public health consequences and effects go far beyond assumption. The ongoing epidemic of a rare and controlled disease like diphtheria in Rohingya camps, in Bangladesh (figure), is a unique example of a public health disaster due to forced migration. Planetary health and One Health have approached the issue by working together as an interdisciplinary collaboration; which might be the best strategy in such conditions. Infectious diseases know no boundaries and therefore diseases like diphtheria are a global biosecurity issue. Out of 8031 clinically suspected diphtheria cases from Nov 3, 2017, to July 24, 2018, 169 cases occurred in the host community.1WHOBangladesh: Rohingya emergency response EWARS epidemiological bulletin W29 2018.https://reliefweb.int/sites/reliefweb.int/files/resources/weeklyepidemiologicalbulletinw292018_0.pdfDate: July 24, 2018Date accessed: September 4, 2018Google Scholar Therefore, the epidemic is not only a health concern for migrant populations, but also a regional public health crisis, with 44 reported deaths from a vaccine-preventable disease in a short span of time. Forced human migration, along with movement of livestock, is a well-recognised condition for emergence of infectious diseases.2Crudo Blackburn C Lenze Jr, PE Forced migration and the spread of infectious disease: impact of Syrian refugee movements on disease prevalence in the European Union. Scowcroft Institute of International Affairs, Nov 17, 2017http://bush.tamu.edu/scowcroft/papers/blackburn-lenze/Paper%20No.%2010%20Blackburn%20&%20Lenze.pdfDate accessed: September 4, 2018Google Scholar, 3Soto S Human migration and infectious diseases.Clin Microbiol Infect. 2009; 15: 26-28Summary Full Text Full Text PDF PubMed Scopus (41) Google Scholar However, the livestock movement with Rohingya refugees received little attention from the authorities. Unfortunately, several thousands of cows, buffaloes, sheep, and goats have reached the households of local Bangladeshi people without any biosecurity checking.4DhakaTribuneLivestock trade booms in Teknaf as the Rohingya sell them for whatever they can get.https://www.dhakatribune.com/bangladesh/nation/2017/09/26/livestock-trade-booms-teknaf-rohingyas-sell-whatever-can-getDate: Sept 26, 2017Date accessed: September 4, 2018Google Scholar The livestock department has not been deployed effectively in this context, and surveillance activity of livestock that belong to the migrant population is not evident. The present flow of displaced Rohingya started in August, 2017, and about 700 000 Rohingya, mostly women and children, have migrated.5Qadri F Azad AK Flora MS et al.Emergency deployment of oral cholera vaccine for the Rohingya in Bangladesh.Lancet. 2018; 391: 1877-1879Summary Full Text Full Text PDF PubMed Scopus (21) Google Scholar The Government of Bangladesh with WHO started prompt emergency vaccination6WHOWHO plans, supports delivery of life-saving vaccinations to 150 000 children in Cox's Bazar, Bangladesh.http://www.searo.who.int/mediacentre/sear-in-the-field/vaccinations-in-cox-bazar/en/Date: 2017Date accessed: September 2, 2018Google Scholar against measles, rubella, and polio from Sept 16, 2017. Vaccination against diphtheria (which needs three phases of vaccination) started on Dec 12, 2017, whereas the epidemic started on Nov 3, 2017.7UNICEFBangladesh moves to protect Rohingya children from diphtheria.https://reliefweb.int/report/bangladesh/bangladesh-moves-protect-rohingya-children-diphtheriaDate: Dec 12, 2017Date accessed: September 2, 2018Google Scholar Diphtheria might not have been prioritised in the first instance because of the scarcity of evidence synthesis or adequate risk mapping, although the pentavalent vaccine is protective for five distinct diseases. The incidence of diphtheria, and mortality caused by it, has been high in Nepal and Myanmar8Dias AA Santos LS Sabbadini PS et al.Corynebacterium ulcerans diphtheria: an emerging zoonosis in Brazil and worldwide.Rev Saude Publica. 2011; 45: 1176-1191Crossref PubMed Scopus (40) Google Scholar for many years. A 4-year cohort study9Salter SJ Turner C Watthanaworawit W et al.A longitudinal study of the infant nasopharyngeal microbiota: the effects of age, illness and antibiotic use in a cohort of south east Asian children.PLoS Negl Trop Dis. 2017; 11: e0005975Crossref PubMed Scopus (32) Google Scholar was done in the Mae La refugee camp on the Thailand-Myanmar border; children from birth to 24 months of age were included and five dominating nasopharyngeal microbiota—Moraxella, Streptococcus, Haemophilus, Corynebacterium, and an uncharacterised Flavobacteriaceae similar to Ornithobacterium—were found. Therefore, pneumonia and diphtheria are the most anticipated childhood illnesses in the population. Diphtheria is a highly infectious toxin-mediated disease caused by Corynebacterium species; usually, pharyngeal diphtheria is caused by Corynebacterium diphtheriae and cutaneous diphtheria is caused by Corynebacterium ulcerans.10Schuhegger R Lindermayer M Kugler R Heesemann J Busch U Sing A Detection of toxigenic Corynebacterium diphtheriae and Corynebacterium ulcerans strains by a novel real-time PCR.J Clin Microbiol. 2008; 46: 2822-2823Crossref PubMed Scopus (51) Google Scholar However, C ulcerans is the most common cause of pharyngeal diphtheria in the UK population,11Wagner K White J Crowcroft N De Martin S Mann G Efstratiou A Diphtheria in the United Kingdom, 1986–2008: the increasing role of Corynebacterium ulcerans.Epidemiol Infect. 2010; 138: 1519-1530Crossref PubMed Scopus (102) Google Scholar mainly due to contact with domestic animals, and its incidence is increasing worldwide. Therefore, diphtheria has a zoonotic connection with the potential of an initial zoonotic and subsequent human-to-human transmission.12Konrad R Hörmansdorfer S Sing A Possible human-to-human transmission of toxigenic Corynebacterium ulcerans.Clin Microbiol Infect. 2015; 21: 768-771Summary Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 13Meinel DM Konrad R Berger A et al.Zoonotic transmission of toxigenic Corynebacterium ulcerans strain, Germany, 2012.Emerg Infect Dis. 2015; 21: 356-358Crossref PubMed Scopus (21) Google Scholar In the Rohingya population, respiratory diphtheria could be transmitted to humans from dairy cattle. Moreover, its transmission is influenced by socioeconomic factors, such as overcrowding, poverty, and a lack of personal hygiene.14Quick ML Sutter RW Kobaidze K et al.Risk factors for diphtheria: a prospective case-control study in the Republic of Georgia, 1995–1996.J Infect Dis. 2000; 181: S121-S129Crossref PubMed Scopus (21) Google Scholar When only 32·7% reported cases are PCR positive15WHOWeekly situation report #11, Rohingya refugees 2018.https://reliefweb.int/sites/reliefweb.int/files/resources/weeklysitrep11cxbban.pdfDate: Jan 29, 2018Date accessed: September 4, 2018Google Scholar and real-time PCR failing to detect C ulcerans,10Schuhegger R Lindermayer M Kugler R Heesemann J Busch U Sing A Detection of toxigenic Corynebacterium diphtheriae and Corynebacterium ulcerans strains by a novel real-time PCR.J Clin Microbiol. 2008; 46: 2822-2823Crossref PubMed Scopus (51) Google Scholar the link should have a logical ground as the Rohingya population depends on agriculture and are more exposed to cattle and other animals, with no awareness of zoonotic disease transmission.16Arakan Rohingya National OrganisationFacts about the Rohingya muslims of Arakan 2006.http://www.rohingya.org/portal/index.php/learn-about-rohingya.htmlDate: Oct 5, 2006Date accessed: September 4, 2018Google Scholar From a planetary health perspective, there is evidence of seasonal occurrence of diphtheria (mostly in late summer), and waning of immunity affected by environmental factors.17Metcalf CJ Bjørnstad ON Grenfell BT Andreasen V Seasonality and comparative dynamics of six childhood infections in pre-vaccination Copenhagen.Proc Biol Sci. 2009; 276: 4111-4118Crossref PubMed Scopus (81) Google Scholar Amuakwa-Mensah and colleagues18Amuakwa-Mensah F Marbuah G Mubanga M Climate variability and infectious diseases nexus: evidence from Sweden.Infect Dis Model. 2017; 2: 203-217PubMed Google Scholar have described the climate-health nexus model of various infectious diseases including diphtheria; they have shown multiple relationships with climate variability—eg, linear negative effect of temperature and positive effect of overcrowding and immigration on the incidence of infection. Therefore, we recommend that along with public health experts, veterinarians, economists, environmental and social scientists, community leaders, and policy makers should all have a substantial role in preparing a contingency plan for this type of calamity ahead of a possible outbreak, or disaster. There is an urgent need for a migratory and vulnerable population health information repository, that includes public and animal health and environmental statistics based on available literature and expert opinions. The One Health and planetary health approach should be adopted for addressing migrant health issues, with a distinct action plan. MA is supported by National Institutes of Health Fogarty International Center Global Health Equity Scholars program (D43TW010540) and MTF is supported by WHO TDR Fellowship program. We declare no competing interests.