The COVID-19 pandemic has led to a drastic and profound shift in routine disease prevention behaviour. Handwashing, physical distancing and isolation have been brought into place to reduce the transmission of the virus, transforming human relationships across the globe.
Favorable results following these changing behavior strategies were evident. But many middle- and low-income countries as well as fragile and vulnerable settings encountered challenges in implementing preventive measures to contain the virus' spread due to congestion, inadequate water supply, poor sanitation facilities, poverty and lack of awareness, among others. Such was the case for the Rohingya refugee camps in Cox’s Bazar, the most densely populated in the world and home of 890 000 refugees.
Despite the challenging context, the World Health Organization (WHO) has been leading the creation of a model Infection Prevention and Control (IPC) network which is currently being replicated at district level.
WHO Infection Prevention and Control (IPC) Specialist, Rebecca Rachel Apolot, assisting a doctor to properly wear the Personal Protective Equipment (PPE) before entering the Red Zone. WHO Bangladesh/Irene Gavieiro Agud
Human behavior is central to control the transmission of SAR-CoV-2. This is the centerpiece around which Dr Aritra’s job unfolds at one of the specialized COVID-19 treatment centers for the Rohingya refugees and surrounding Bangladeshi population. Dr Aritra Das works as Infection Prevention and Control (IPC) Focal Point at the Food for the Hungry/UNHCR Severe Acute Respiratory Infection Isolation and Treatment Center (SARI ITC) in Camp 5 and his job is to maintain, support and monitor the day to day implementation of standard precautions in this healthcare facility.
Like many Bangladeshi doctors working at the refugee camps in Cox's Bazar, Dr Aritra was working as a medical officer providing essential healthcare services to the Rohingya population when the COVID-19 pandemic broke out. “I was very concerned about the situation in the refugee camps, as I thought it would be very difficult to control the spread of the virus due to the overcrowded conditions of the settlement, poor ventilation in the shelters and the use of common latrines and water points”, explains Dr Aritra.
In March 2020, after receiving WHO training on IPC, he decided to become a frontline healthcare worker and voluntarily joined a SARI ITCs in Ukhiya. “IPC immediately caught my attention. I thought that given the conditions in the camps, we might struggle to treat a high number of COVID-19 positive cases and prevention would be the most viable solution to control the spread of the virus”, Dr Aritra added.
Since then, together with other two IPC Focal Points, he has been directly supervising a hardworking team of over sixty frontline workers responding to the COVID-19 pandemic in the world’s largest refugee camp, including doctors, medical assistants, nurses, cleaners and volunteers. He is also providing IPC support to other primary healthcare centers run by Food for the Hungry in the camps to ensure that prevention measures are followed by each and every professional. “From doctors to drivers, we have trained everyone involved in the response and made them realize the importance of IPC in the fight against COVID-19”.
Dr Aritra Das voluntarily decided to join one of the COVID-19 treatment and isolation centers before the pandemic broke out in the Rohingya refugee camps. WHO Bangladesh/Irene Gavieiro Agud
Dr Aritra is one of 43 qualified COVID-19 IPC Master Trainers in Cox’s Bazar district trained by WHO on a wide range of health and safety topics, including standard precautions, proper use of Personal Protective Equipment (PPE), physical space requirements to limit spread of infection, sanitation and hygiene, management of accidental injuries, exposure to blood, and decontamination of equipment, among others. Representing a keystone within the newly established IPC network in the refugee camp, Dr Aritra has contributed to build the capacities of over 3600 healthcare workers from Government and partner-led facilities under the guidance of WHO.
“WHO has always considered IPC interventions crucial to reduce the risk of exposure to infectious diseases in the health care settings, becoming more apparent over the past year due to the pandemic. We have been encouraging Health Sector partners running the SARI ITCs to designate dedicated IPC professionals, define clear IPC objectives and include IPC in their workplans to enhance patients and healthcare workers’ safety”, says Rebecca Rachel Apolot, WHO IPC Specialist in Cox’s Bazar.
All SARI ITCs that have been set up are in line with the WHO minimum standards for an isolation and treatment center. This includes design considerations to ensure staff and patient safety. WHO Bangladesh/Irene Gavieiro Agud
IPC beyond healthcare facilities: raising community awareness
The COVID-19 crisis has had an impact on disease prevention behaviour not only among clinical staff but also for the general population. In the Rohingya refugee camps, where information is often scarce, healthcare facilities have become benchmarks in raising awareness of preventive measures.
“Since the pandemic started, we have seen massive changes in the lifestyle of the people, not only among healthcare workers who had been trained but also in the worldwide population. People constantly get messages from the media, they know the complications of the virus, how to prevent it, how to secure from it. All this has an impact”, says Masud Sohel, IPC supervisor at the UNCHR/Relief International SARI ITC.
He nevertheless acknowledges that starting to change people’s behaviour was not easy: “People in our country were not aware about proper hand hygiene, physical distance, or how to wear a mask properly, so we had to train everyone from the very beginning”.
An extensive communication and engagement strategy involving key community members and religious leaders was put into place to increase awareness among the Rohingya refugees and protect them against the virus. In collaboration with the Risk Communication and Community Engagement working group (RCCE WG) and key partners on the ground, WHO has been disseminating public messages on COVID-19 awareness in all 34 camps.
Clinical and non-clinical trained staff have also become a cornerstone to spread the message on preventive measures. “When I come back home from work, I keep telling my husband, my three children, and people from my community that the virus is transmitted by sneezing or coughing, and that we have to maintain physical distance, wear a mask and wash our hands regularly” explains Anowara Begum, Rohingya refugee working as a cleaner at the IOM SARI ITC in Camp 20 Extension.
Rohingya refugee Anowara Begum washing her hands at one of the multiple handwashing stations installed in the IOM SARI ITC at Camp 20 Extension. WHO Bangladesh/Irene Gavieiro Agud
As the rest of her colleagues, Anowara received on-site training on Infection Prevention and Control (IPC) from IPC Master Trainers before starting to work at the SARI ITC nine months ago.
“Together with Government and partners, we have built an effective and integrated IPC network which involves every person responding to COVID-19 in the camps. The fight against the pandemic begins with self-determination and individual responsibility, and each of our healthcare workers have demonstrated a strong commitment to maintaining IPC protocols and raising awareness not only inside but also outside health care facilities”, says Dr Kai von Harbou, Head of WHO Emergency Sub-Office in Cox’s Bazar.
All persons entering the SARI ITCs need to be screened for possible signs and symptoms of COVID-19, including staff, patients and visitors. WHO Bangladesh/Irene Gavieiro Agud
A model system: institutionalizing IPC in Cox’s Bazar district
The successful prevention and control experiences observed in these isolation and treatment centers have triggered an IPC reform at district level beyond the SARI facilities. Currently, WHO is supporting the Government of Bangladesh through the Civil Surgeon’s office to build consensus on the institutionalization of IPC in the public health system in Cox’s Bazar envisioning improved patient and healthcare workforce safety.
To this effect, a district IPC committee has been formed in February 2021 to guide the institutionalization of IPC in the district, and the formation of IPC structures, among other crucial activities.
So far, 119 (87%) health facilities in the camps –including 91 health posts, 27 primary health care centers and one Field hospital– have reported the creation of IPC structures with the assignment of IPC focal persons in the health posts and the establishment of IPC committees and focal points in primary and secondary healthcare facilities. These structures are anticipated to carry out essential IPC functions including advocacy, budgeting and maintenance of day-to-day IPC activities at different levels to ensure sustainability of IPC in the district.
IPC Supervisor, Masud Sohel explains their IPC performance using the score card at the Relief International/UNHCR SARI ITC. WHO Bangladesh/Irene Gavieiro Agud
WHO continues providing a wide range of IPC guidelines to the SARI ITCs and other health care facilities in the camps to guide their daily execution of clinical and non-clinical tasks and thus reduce the risk of exposure to infections. These guidance documents are accompanied by regular supportive supervision visits by WHO specialists to monitor progress and equip healthcare workers with new strategies against further spread of the virus.
Additionally, checklists and other assessment tools have been developed to monitor healthcare workers’ actions, identify gaps and find appropriate interventions. A daily IPC checklist and a monthly IPC score card for facilities at different levels have been developed to enhance continuous performance improvement in the health facilities.
All this takes place as part of WHO’s efforts to enhance clinical case management of patients with COVID-19 and implement cost-effective strategies to empower frontline workers responding to the pandemic.