Fatal Diphtheria in a Rohingya Refugee Settlement in Cox’s Bazar, Bangladesh: A Case Study of Clinical, Surveillance and Health-System Gaps
Abstract:
Diphtheria remains a significant threat in humanitarian settings with low vaccination coverage and fragile health systems. Global evidence indicates that outbreaks among displaced populations driven by overcrowding, immunity gaps, delayed clinical recognition, and weak surveillance systems, while limited availability of diphtheria antitoxin (DAT) further constrains effective case management. We conducted a descriptive case analysis of a fatal diphtheria infection, complemented by a public health investigation including contact tracing and surveillance review to identify gaps in clinical management and outbreak response. A 9-year-old unvaccinated boy residing in a Rohingya refugee camp in Cox’s Bazar, Bangladesh, presented with fever and sore throat managed symptomatically without a throat examination. Rapid progression to severe disease with cervical swelling (bull neck) and respiratory distress occurred. On re-presentation, suspected diphtheria and later confirmed; however, delayed recognition, lack of access to DAT, and late referral led to death during transfer. Public health investigation identified 10 contacts who received prophylaxis but revealed delayed case notification, missed identification of a probable secondary case, and weak integration between clinical and surveillance systems. This case demonstrates how failures in early clinical recognition, timely access to DAT, and surveillance responsiveness, commonly reported in fragile and outbreak prone settings can converge to result in preventable mortality. Strengthening frontline clinical capacity, ensuring reliable DAT availability, improving real-time clinical–surveillance integration, and addressing immunization gaps are essential to reduce diphtheria deaths in humanitarian contexts.References:
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