An outbreak of acute jaundice syndrome (AJS) among the Rohingya refugees in Cox’s Bazar, Bangladesh: Findings from enhanced epidemiological surveillance

Abstract

In the summer of 2017, an estimated 745,000 Rohingya fled to Bangladesh in what has been described as one of the largest and fastest growing refugee crises in the world. Among numerous health concerns, an outbreak of acute jaundice syndrome (AJS) was detected by the disease surveillance system in early 2018 among the refugee population. This paper describes the investigation into the increase in AJS cases, the process and results of the investigation, which were strongly suggestive of a large outbreak due to hepatitis A virus (HAV). An enhanced serological investigation was conducted between 28 February to 26 March 2018 to determine the etiologies and risk factors associated with the outbreak. A total of 275 samples were collected from 18 health facilities reporting AJS cases. Blood samples were collected from all patients fulfilling the study specific case definition and inclusion criteria, and tested for antibody responses using enzyme-linked immunosorbent assay (ELISA). Out of the 275 samples, 206 were positive for one of the agents tested. The laboratory results confirmed multiple etiologies including 154 (56%) samples tested positive for hepatitis A, 1 (0.4%) positive for hepatitis E, 36 (13%) positive for hepatitis B, 25 (9%) positive for hepatitis C, and 14 (5%) positive for leptospirosis. Among all specimens tested 24 (9%) showed evidence of co-infections with multiple etiologies. Hepatitis A and E are commonly found in refugee camps and have similar clinical presentations. In the absence of robust testing capacity when the epidemic was identified through syndromic reporting, a particular concern was that of a hepatitis E outbreak, for which immunity tends to be limited, and which may be particularly severe among pregnant women. This report highlights the challenges of identifying causative agents in such settings and the resources required to do so. Results from the month-long enhanced investigation did not point out widespread hepatitis E virus (HEV) transmission, but instead strongly suggested a large-scale hepatitis A outbreak of milder consequences, and highlighted a number of other concomitant causes of AJS (acute hepatitis B, hepatitis C, Leptospirosis), albeit most likely at sporadic level. Results strengthen the need for further water and sanitation interventions and are a stark reminder of the risk of other epidemics transmitted through similar routes in such settings, particularly dysentery and cholera. It also highlights the need to ensure clinical management capacity for potentially chronic conditions in this vulnerable population.

Hepatitis E Virus (HEV) Synopsis: General Aspects and Focus on Bangladesh

“…From January to June 2018, 2253 cases of acute jaundice were recorded in the Cox’s Bazar refugee camp, raising the possibility of an HEV outbreak that could quickly spread in this susceptible population. However, a recent study investigating 275 blood samples collected from that outbreak through an enhanced surveillance system during less than a month (28 February to 26 March 2018) found that 56% of samples were positive for hepatitis A virus (HAV) compared to 0.4% for HEV diagnosed by anti-HEV ELISA for IgM with evidence of HAV-HEV co-infection [ 51 ]. It is important to note that sampling was conducted at selected sites for a brief period during this surveillance.…”

Prevalence of hepatitis B virus amongst refugees, asylum seekers and internally displaced persons in low‐ and middle‐income countries: A systematic review

“… 44 Another study of Rohingya refugees in Cox's Bazaar evaluated causes of 272 cases of acute jaundice, reporting 13% were positive for hepatitis B. 45 This is unlikely to representative of the true hepatitis B prevalence in this population as only acute jaundice cases were included, which mostly reflects cases of acute hepatitis A (154 cases, 56%).…”

Public health status of Myanmar refugees in South East Asia: A Malaysian case study

“…Viral infections of the liver are classified according to the different viruses responsible i.e., A, B, C, D and E. The most important human viruses include hepatitis B virus (HBV) and hepatitis C virus (HCV) which are primarily transmitted through infectious body fluids. Both varieties have been reported among Burmese refugees with infections of less than 15% (Chaves et al, 2009;CDC, n.d.;Khokon, 2017;Mazhar et al, 2021;Paxton et al, 2012). Hepatitis A and E were commonly found in refugee camps and had similar clinical presentations (Mazhar et al, 2021).…”

“…Both varieties have been reported among Burmese refugees with infections of less than 15% (Chaves et al, 2009;CDC, n.d.;Khokon, 2017;Mazhar et al, 2021;Paxton et al, 2012). Hepatitis A and E were commonly found in refugee camps and had similar clinical presentations (Mazhar et al, 2021). A study in 2015 reported high prevalences of any previous HBV infection, as well as chronic or acute infections among Burmese refugees (36.0% past; 9.4% chronic or acute) (Scott et al, 2015).…”