Rohingya refugees at high risk of COVID-19 in Bangladesh.

Bangladesh has been ranked among the 17 countries with the highest number of COVID-19 cases. On June 19, 2020, the number of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections in Bangladesh reached 105 535, with 1388 official recorded deaths among only 585 548 people tested in the country since the first case was identified on March 8, 2020. Several factors suggest that Bangladesh could be one of the next COVID-19 hotspots: it has a high population density; it has poor health infrastructure and resources; there has been poor adherence to physical distancing; complete lockdown has not been ensured at a national level; there is uncoordinated population mobility between rural and urban areas; there is little awareness of COVID-19 among the population; home quarantine has been used in place of institutional quarantine for returning overseas travellers; there are overcrowded urban areas with substandard housing; health institutions have limited capacities; and effective governance has been largely absent. In addition, the country is accommodating 1 118 576 forcibly displaced Myanmar nationals named as Rohingya, including 860 175 Rohingya people who are sheltering in the world's largest refugee camp in Cox's Bazar, a city in southeastern Bangladesh.1, 2

Since COVID-19 testing started in the refugee camps in early April (up to June 14, 2020), about 400 Rohingya refugees have been tested, 38 people have tested positive, and two people have died of COVID-19. The reported number of people with COVID-19 might not be accurate because Rohingya refugees with symptoms of the disease are not coming forward to get tested because fear is creating stigma in communities that is preventing people from seeking and receiving treatment. Rumours are also spreading within the camps that if anyone has COVID-19, they must be killed to prevent others becoming infected. Many refugees believe that health workers will kill them in the name of treatment. Although development agencies are working to support the Bangladesh Government, the number of tests for SARS-CoV-2 being done in the refugee camps is very low.

Rohingya refugee camps have high population densities, making it more likely that SARS-CoV-2 will spread quickly. The average population density is about 40 000 people per km2, which is much higher than most other refugee camps across the world. Maintaining physical distancing as well as self-isolation is a great challenge in these camps. Each of the 187 530 Rohingya families in the camps has an average of 4·6 members, most of whom live in a single room per family. This high population density, a lack of knowledge about COVID-19 among the people living in the camps, and a lack of access to water, sanitation, and hygiene, mean that urgent action is needed to try to avoid large numbers of Rohingya people becoming infected. Community engagement has been started to increase handwashing, and 13 500 handwashing points have been created within the refugee camps, but these are not adequate. Using facemasks, self-quarantine, and frequent handwashing are not popular initiatives among the refugees.

There are four quarantine centres and four severe acute respiratory infection isolation and treatment centres planned for the refugee camps, which will provide up to 1900 beds for patients with COVID-19. Only one intensive care unit, with 18 beds, is available at Cox's Bazar District hospital, which serves all the people of Cox's Bazar District. The Directive of the Refugee Relief and Repatriation Commissioner has restricted the movement to the camps. Only people who are providing essential services such as food supplies and health care are permitted to enter the camps. The Bangladesh Government plans to send refugees to Bhasan Char, an island off the coast of Bangladesh, within a short timeframe if cases of COVID-19 increase within the existing refugee camps. 308 Rohingya people have already been moved to the island. UN agencies and other organisations are trying to work along with the Bangladesh Government to increase response capacity at Cox's Bazar District hospital, and in nearby Ramu and Chakaria, by increasing primary medicine and the health-care workforce. However, delivering existing health services, obstetric care, and emergency care could be hampered by the efforts to respond to COVID-19. The risk of COVID-19 for health workers directly affects the health of refugees. Because of a shortage of personal protective equipment and other medical equipment, and in the absence of proper support for frontline health workers, it might not be possible to provide adequate services to the refugees without increasing the risk of SARS-CoV-2 infection; health-care workers are at the most risk of contracting SARS-CoV-2. Limited financial aids and overcrowded and unhealthy living conditions can make their situation worse. A study from May 2020, showed that COVID-19 symptoms are highly prevalent in Cox's Bazar, especially in refugee camps. Another study from June, 2020, showed that a large-scale outbreak is likely to happen after the introduction of the virus to the camps.

Bangladesh declared the Cox's Bazar areas near the Rohingya refugee camps as the first red zone (an area considered to be at very high risk for an outbreak) for COVID-19 on June 6, 2020. Thus, to reduce further spread of SAR-CoV-2, more attention is urgently needed on adequate and effective interventions, including increasing awareness about COVID-19 among Rohingya refugees. Otherwise, the Rohingya refugees and the host community are likely to be heavily affected by COVID-19.