{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,27]],"date-time":"2026-10-27T07:51:57Z","timestamp":1793087517980,"version":"4.5.0"},"update-to":[{"DOI":"10.1371\/journal.pmed.1003587","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2021,4,21]],"date-time":"2021-04-21T00:00:00Z","timestamp":1618963200000}}],"reference-count":68,"publisher":"Public Library of Science (PLoS)","issue":"4","license":[{"start":{"date-parts":[[2021,4,1]],"date-time":"2021-04-01T00:00:00Z","timestamp":1617235200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosmedicine.org"],"crossmark-restriction":false},"short-container-title":["PLoS Med"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Background<\/jats:title>\n<jats:p>Unrest in Myanmar in August 2017 resulted in the movement of over 700,000 Rohingya refugees to overcrowded camps in Cox\u2019s Bazar, Bangladesh. A large outbreak of diphtheria subsequently began in this population.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Methods and findings<\/jats:title>\n<jats:p>Data were collected during mass vaccination campaigns (MVCs), contact tracing activities, and from 9 Diphtheria Treatment Centers (DTCs) operated by national and international organizations. These data were used to describe the epidemiological and clinical features and the control measures to prevent transmission, during the first 2 years of the outbreak. Between November 10, 2017 and November 9, 2019, 7,064 cases were reported: 285 (4.0%) laboratory-confirmed, 3,610 (51.1%) probable, and 3,169 (44.9%) suspected cases. The crude attack rate was 51.5 cases per 10,000 person-years, and epidemic doubling time was 4.4 days (95% confidence interval [CI] 4.2\u20134.7) during the exponential growth phase. The median age was 10 years (range 0\u201385), and 3,126 (44.3%) were male. The typical symptoms were sore throat (93.5%), fever (86.0%), pseudomembrane (34.7%), and gross cervical lymphadenopathy (GCL; 30.6%). Diphtheria antitoxin (DAT) was administered to 1,062 (89.0%) out of 1,193 eligible patients, with adverse reactions following among 229 (21.6%). There were 45 deaths (case fatality ratio [CFR] 0.6%). Household contacts for 5,702 (80.7%) of 7,064 cases were successfully traced. A total of 41,452 contacts were identified, of whom 40,364 (97.4%) consented to begin chemoprophylaxis; adherence was 55.0% (<jats:italic>N<\/jats:italic> = 22,218) at 3-day follow-up. Unvaccinated household contacts were vaccinated with 3 doses (with 4-week interval), while a booster dose was administered if the primary vaccination schedule had been completed. The proportion of contacts vaccinated was 64.7% overall. Three MVC rounds were conducted, with administrative coverage varying between 88.5% and 110.4%. Pentavalent vaccine was administered to those aged 6 weeks to 6 years, while tetanus and diphtheria (Td) vaccine was administered to those aged 7 years and older. Lack of adequate diagnostic capacity to confirm cases was the main limitation, with a majority of cases unconfirmed and the proportion of true diphtheria cases unknown.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Conclusions<\/jats:title>\n<jats:p>To our knowledge, this is the largest reported diphtheria outbreak in refugee settings. We observed that high population density, poor living conditions, and fast growth rate were associated with explosive expansion of the outbreak during the initial exponential growth phase. Three rounds of mass vaccinations targeting those aged 6 weeks to 14 years were associated with only modestly reduced transmission, and additional public health measures were necessary to end the outbreak. This outbreak has a long-lasting tail, with Rt oscillating at around 1 for an extended period. An adequate global DAT stockpile needs to be maintained. All populations must have access to health services and routine vaccination, and this access must be maintained during humanitarian crises.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pmed.1003587","type":"journal-article","created":{"date-parts":[[2021,4,1]],"date-time":"2021-04-01T18:43:00Z","timestamp":1617302580000},"page":"e1003587","update-policy":"https:\/\/doi.org\/10.1371\/journal.pmed.corrections_policy","source":"Crossref","is-referenced-by-count":77,"title":["Epidemiological, clinical, and public health response characteristics of a large outbreak of diphtheria among the Rohingya population in Cox\u2019s Bazar, Bangladesh, 2017 to 2019: A retrospective study"],"prefix":"10.1371","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8634-4255","authenticated-orcid":true,"given":"Jonathan A.","family":"Polonsky","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1795-5108","authenticated-orcid":true,"given":"Melissa","family":"Ivey","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9303-6541","authenticated-orcid":true,"given":"Md. Khadimul Anam","family":"Mazhar","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7726-7120","authenticated-orcid":true,"given":"Ziaur","family":"Rahman","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3458-2945","authenticated-orcid":true,"given":"Olivier","family":"le Polain de Waroux","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2178-1654","authenticated-orcid":true,"given":"Basel","family":"Karo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9106-3186","authenticated-orcid":true,"given":"Katri","family":"Jalava","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sirenda","family":"Vong","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amrish","family":"Baidjoe","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8753-531X","authenticated-orcid":true,"given":"Janet","family":"Diaz","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8613-5170","authenticated-orcid":true,"given":"Flavio","family":"Finger","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zakir H.","family":"Habib","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Charls Erik","family":"Halder","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1992-808X","authenticated-orcid":true,"given":"Christopher","family":"Haskew","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Laurent","family":"Kaiser","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8161-2823","authenticated-orcid":true,"given":"Ali S.","family":"Khan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lucky","family":"Sangal","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tahmina","family":"Shirin","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2884-5676","authenticated-orcid":true,"given":"Quazi Ahmed","family":"Zaki","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Md. 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World Health Organization.; 22 July 2020 [cited 25 Jul 2020]. Available from: https:\/\/reliefweb.int\/sites\/reliefweb.int\/files\/resources\/who-cox-s-bazar-sitrep-15.pdf"},{"issue":"Suppl 1","key":"pmed.1003587.ref010","doi-asserted-by":"crossref","first-page":"S116","DOI":"10.1086\/315551","article-title":"The pathology of diphtheria","volume":"181","author":"TL Hadfield","year":"2000","journal-title":"J Infect Dis"},{"key":"pmed.1003587.ref011","first-page":"107","volume-title":"Epidemiology and Prevention of Vaccine-Preventable Diseases","author":"AM Acosta","year":"2015","edition":"13"},{"key":"pmed.1003587.ref012","first-page":"150","volume-title":"Control of communicable Diseases Manual 20th Edition","author":"TS Tiwari","year":"2015"},{"key":"pmed.1003587.ref013","unstructured":"Expanded Access Investigational New Drug (IND) Application Protocol: Use of Diphtheria Antitoxin (DAT) for Suspected Diphtheria Cases. 21 Sep 2016 [cited 14 Nov 2018]. 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An outbreak of an ancient and vaccine-preventable disease in the third millennium","volume":"2019","author":"Harapan","journal-title":"Clin Epidemiol Glob Health"},{"key":"pmed.1003587.ref031","doi-asserted-by":"crossref","first-page":"625","DOI":"10.3201\/eid2504.181305","article-title":"Resurgence of Vaccine-Preventable Diseases in Venezuela as a Regional Public Health Threat in the Americas","volume":"25","author":"AE Paniz-Mondolfi","year":"2019","journal-title":"Emerg Infect Dis"},{"key":"pmed.1003587.ref032","first-page":"274","article-title":"Diphtheria Outbreak, Haiti, 2014\u20132017: An Epidemiological Profile and A Case Fatality Rate Trend Analysis","volume":"2018","author":"J. Clerville","journal-title":"Int J Infect Dis"},{"key":"pmed.1003587.ref033","doi-asserted-by":"crossref","first-page":"539","DOI":"10.3201\/eid0404.980404","article-title":"Diphtheria in the Former Soviet Union: Reemergence of a Pandemic Disease","volume":"4","author":"C. 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