Real-time analysis of the diphtheria outbreak in forcibly displaced Myanmar nationals in Bangladesh

Abstract

AbstractBackgroundBetween August and December 2017, more than 625,000 Rohingya from Myanmar fled into Bangladesh, settling in informal makeshift camps in Cox’s Bazar district, joining 212,000 Rohingya already present. In early November, a diphtheria outbreak was reported in the camps, with 440 cases being reported during the first month. A rise in cases during early December led to a collaboration between teams from Médecins sans Frontières – who were running a provisional diphtheria treatment centre – and the London School of Hygiene & Tropical Medicine with the goal to use transmission dynamic models to forecast the potential scale of the outbreak and the resulting resource needs.MethodsWe first adjusted for delays between symptoms onset and case presentation using the observed distribution of reporting delays from previously reported cases. We then fit a compartmental transmission model to the adjusted incidence stratified by age-group and location. Model forecasts with a lead-time of two weeks were issued on 12th, 20th, 26th and 30th December and communicated to decision-makers.ResultsThe first forecast estimated that the outbreak would peak on 16th December in Balukhali camp with 222 (95% prediction interval 126–409) cases and would continue to grow in Kutupalong camp, requiring a bed capacity of 200 (95% PI 142–301). On 16th December, a total of 70 cases were reported, lower than forecasted. Subsequent forecasts were more accurate: on 20th December we predicted a total of 701 cases (95% PI 477–901) and 105 (95% PI 72–135) hospitalizations until the end of the year, with 616 cases actually reported during this period.ConclusionsReal-time modelling enabled feedback of key information about the potential scale of the epidemic, resource needs, and mechanisms of transmission to decision-makers at a time when this information was largely unknown. By December 20th, the model generated reliable forecasts and helped support decision-making on operational aspects of the outbreak response, such as hospital bed and staff needs, and with advocacy for control measures. Although modelling is only one component of the evidence base for decision-making in outbreak situations, suitable analysis and forecasting techniques can be used to gain insights into an ongoing outbreak.