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Epidemiology of malaria in Rohingya refugee camps in Bangladesh within 2017–2020



Malaria causes significant morbidity and mortality in tropical and sub-tropical regions, particularly in humanitarian emergencies including refugee camps in malaria endemic areas. An epidemiological investigation was conducted on malaria disease distribution and risk factors in the world’s largest refugee settlement, the Rohingya refugee camps on the south-eastern border area of Bangladesh, within 2017–2020.


From February 2017 to March 2020, 30,460 febrile patients were tested for malaria using light microscopy and rapid diagnostic tests. Most were self-presenting symptomatic patients and a minority were from door-to-door malaria screening. Diagnostic tests were done by trained medical technologists upon the advice of the concerned physicians in the camps. Test positivity rate (%) and annual parasite incidence were calculated and compared using chi-squared (χ 2) test or odds ratios.


The overall average annual test positivity rate (TPR) was 0.05%. TPR was highest in people who had travelled to the forest in the previous 2 months, at 13.60%. Cases were clustered among male adults aged 15–60 years. There were no cases among children under five years or pregnant women and no deaths from malaria.


This study found very few malaria cases among Rohingya refugees with the majority of cases being imported from hilly forested areas, which were thus assumed to act as the reservoir for transmission.


Malaria remains a major cause of morbidity and mortality in tropical and sub-tropical regions and the most deadly mosquito-borne infectious disease. In 2020, globally there were an estimated 241 million malaria cases and 627,000 deaths with the majority in Africa followed by Asia [1]. Human movement is a major contributor to changes in transmission within and between countries through circulation between endemic areas, reintroduction to formally endemic regions and introduction to new areas [2]. Surveillance for malaria in mobile and migrant populations is more challenging than in static populations and their contribution to disease burden may be under-recognized. Since 2017, more than 1.3 million Rohingya refugees migrated from Myanmar to Bangladesh [3]. Many of these came from malaria endemic regions of Myanmar, thus there was concern that they could bring with them a substantial burden of malaria infections. The area they migrated into in Bangladesh was also endemic for malaria, with potential for local transmission among this incoming population. A previous study in north-east Bangladesh described similar importation from neighbouring India [4]. Thus an epidemiological survey was conducted to quantify the burden of malaria among the Rohingya refugee population in south-east Bangladesh to understand the risk factors for infection.


From March 2017 to February 2020, unselected individuals self-presenting to Primary Health Care Centers (PHCC) in Kutupalong registered camp (KRC, population 18,223), Ukhiya upazila and Nayapara mega camp (NMC, population 68,274), Teknaf upazila, both in Cox’s Bazar district, were tested for malaria using rapid diagnostic test (RDT) or light microscopy of peripheral blood as part of routine healthcare. Of the 34 refugee camps and/or makeshift settlements in Ukhiya and Teknaf, these two camps were the largest at the time of the study, and their demographic breakdown is shown in Fig. 1.

Criteria for malaria testing were tympanic temperature > 37.5° C and any age or sex [5, 6]. This passive case detection comprised 96% of tested individuals. An additional 4% of tested individuals were identified during door to door visits by the health workers using the same criteria. The tests were all done in the concerned PHCC in the camp and the data were recorded and stored in malaria surveillance registers on paper before being transferred to a secure electronic database. Two types of RDT were used, as provided by the National Malaria Elimination Programme: SD Bio Line Malaria Pf/Pv, a one-step malaria Anti-Pf/Pv (HRP-2/pLDH) test kit (Alere Medical Pvt. Ltd, Haryana, India) during 2017–2019, and Biocredit Malaria Ag Pf/Pan (HRP-2/pLDH) test kit (RapiGene, INC, Gyeonggi, Republic of Korea) during 2019–2020. Anonymized and routinely collected data on age, sex, pregnancy, travel to forests in the previous 2 months, and use of bed nets were also analysed. Test positivity rate (TPR), proportion (%), and annual parasite incidence (API) were calculated. Chi-squared (χ2) test and odds ratio (OR) were used to compare groups and assess potential risk factors. Data were also analyzed by year, month, and season as pre monsoon (hot, March-June), monsoon (wet, July-October), and post monsoon (cold and dry, November-February) [7].

Fig. 1
figure 1

(Adapted from [8])

Demographic breakdown of the population in each camp.


Overall, 30,460 people were tested for malaria, of which 1940 were in KRC and 28,520 in NMC. Testing results are summarized in Table 1 and TPR by month in Fig. 2. Of these, 49 (0.16%) had a positive test and there were no deaths from malaria. Plasmodium falciparum mono infection was found in 53% (TPR 0.09%), 37% Plasmodium vivax (TPR 0.06%), and mixed P. falciparum / P. vivax in 10% (TPR 0.02%). The API was 0.19 per 1000 population.

Table 1 Summary of annual malaria testing results from 2017 to 2020

TRP was higher by RDT (0.25%) compared to microscopy (0.04%, p < 0.001).

There was no consistent seasonal pattern of TPR in 2017–2018, 2018–2019, or 2019–2020 in either camp or combined (Figs. 3, 4 and 5). Overall, TPR was 0.13% in pre-monsoon, 0.23% in monsoon, and 0.09% in post-monsoon seasons (p = 0.03). Overall annual malaria TPR was highest in 2017–2018 at 0.33% (p < 0.001). From 2017 to 2020, overall TPR was higher in KRC than in NMC, p = 0.01.

Malaria TPR was higher in KRC than in NMC during 2017–2018 (1.92% vs. 0.16%, p < 0.001) but not in the other years (0.13% vs. 0.10%, p = 0.79, in 2018–2019; 0.18% vs. 0.12%, p = 0.71, in 2019–2020; Fig. 6).

TPR was highest among people aged 15–60 years (OR (95% CI) = 6 (2–19), p = 0.01), and males (OR (95% CI) = 3 (2–6), p < 0.001).

TPR among people who had travelled to the forest in the previous two months (13.60%) was much higher than in those who had not (0.11%, OR (95% CI) = 120 (60–238), p < 0.001). TPR among the 1858 people who slept under bed nets was 0%, all cases occurring in people who did not use bed nets, (p = 0.01, Fig. 7). All malaria positive cases were treated (with chloroquine plus primaquine for P. vivax and artemether-lumefantrine for P. falciparum). No cases presented again with malaria, thus all were presumed cured.

Fig. 2
figure 2

Overall number of confirmed cases and TPR by month from 2017 to 2020

Fig. 3
figure 3

Seasonal malaria TPR, 2017–2018

Fig. 4
figure 4

Seasonal malaria TPR, 2018–2019

Fig. 5
figure 5

Seasonal malaria TPR, 2019–2020

Fig. 6
figure 6

Annual and overall malaria TPR from 2017 to 2020

Fig. 7
figure 7

Overall malaria TPR by demographics, parasite species, and diagnostic test method from 2017 to 2020


This study found very few malaria cases and no deaths among 86,490 Rohingya refugees in 2 camps in Southeast Bangladesh. Furthermore, it demonstrated that the majority of these cases were likely locally infected after arriving in Bangladesh thus importation of malaria from Myanmar in this group is low. This is in contrast to other trans-border elimination settings in Africa and South-east Asia where incidence among refugees was relatively high [8, 9]. The high proportion of cases that had travelled to the forest in Bangladesh warrants further investigation as, similar to other neighbouring countries, this is where most malaria transmission occurs [10, 11]. In particular, more detail about where they went and why, would help to inform strategies to further reduce transmission. It would also be informative to have more information about previous malaria treatment of participants in Myanmar and/or Bangladesh before refugees arrived at the camps as this would have reduced importation. These findings are in agreement with other studies in Rohingya refugees during this period. In 2018, a household survey among refugee settlements in the same area found no malaria positive people among 1239 (all aged 1–14 years) tested [7]. IgG seroprevalence in the same study was higher among those who had arrived during the high transmission season in Myanmar, interpreted by the authors as suggesting increased exposure to infection during their transit. In another study of Forcefully Displaced Myanmar Nationals (FDMN) presenting to public health facilities in Cox’s Bazar, Bangladesh, of 9,421 individuals seeking healthcare during July 2018-December 2019, only 3 had malaria [7].

There were no positive cases among children under five years or pregnant women, both groups with higher risk of severe malaria. This is likely because these groups had not travelled to the forest and thus been exposed to transmission. That were no cases who presented twice suggests high cure rates by the national standard treatment regimens of chloroquine plus primaquine and artemether-lumefantrine. This suggests that anti-malarial resistance to these drugs is not a significant problem in this area, as has been shown in other studies [12,13,14,15,16].

This study had a number of limitations. The data used were routinely collected from passive surveillance and house-to-house screening. Thus, very limited information was available about each case. In particular more details about when individuals travelled from Myanmar, where and when they had gone to the forest in Bangladesh, and previous malaria history would have been very informative. It was also only possible to include data from 2 out of 34 camps with 6.7% of the estimated 1.3 million total refugees. The unselected nature of participants, however, means that the sample should be representative of the included populations.

The findings imply that preventing travel to the forest, provision of transmission prevention measures to people visiting forests, and testing and treating those who have visited forests, should be prioritized to minimize malaria in this population. Further study is needed to identify where transmission is happening and the best prevention methods for this group.


Malaria among Rohingya refugees in 2 camps in Southeast Bangladesh is rare and mostly acquired by adult males during visits to the forest inside Bangladesh. Thus importation of malaria from Myanmar by this group is likely to be low and efforts to reduce malaria in this population should be targeted at adult forest goers.

Availability of data and materials

Not applicable.



Average annual incidence


Annual parasite incidence


Forest linked


Forcibly displaced Myanmar nationals


Histidine rich protein-2


Kutupalong registered camp


Nayapara mega camp


National Malaria Elimination Programme


Primary health care centre


Plasmodial lactate dehydrogenase


Test positivity rate


United Nations High Commission for Refugees


World Health Organization


  1. WHO. World malaria report 2021. Geneva, World Health Organization. 2021.

  2. Pindolia DK, Garcia AJ, Huang Z, Smith DL, Alegana VA, Noor AM, et al. The demographics of human and malaria movement and migration patterns in East Africa. Malar J. 2013;12: 397.

    Article  PubMed  PubMed Central  Google Scholar 

  3. United Nations High Commissioner for Refugees. Rohingya Refugee Response Bangladesh: Camp Profiles, December, 2019. Keeping a close watch to prevent malaria outbreak in Cox’s Bazar. Retrieved at Accessed 31 Jul 2020.

  4. Karim MA, Kabir MM, Siddiqui MA, Laskar MS, Saha A, Naher S. Epidemiology of imported malaria in Netrokona District of Bangladesh 2013–2018: analysis of surveillance data. Malar Res Treat. 2019;2019: 6780258.

    PubMed  PubMed Central  Google Scholar 

  5. Pampana E. A textbook of malaria eradication. 2nd ed. Oxford: Oxford University Press; 1969.

    Google Scholar 

  6. Montanari RM, Bangali AM, Talukder KR, Baqui A, Maheswary NP, Gosh A, et al. Three case definitions of malaria and their effect on diagnosis, treatment and surveillance in Cox’s Bazar district, Bangladesh. Bull World Health Organ. 2001;79:648–56.

    CAS  PubMed  PubMed Central  Google Scholar 

  7. Lu A, Cote O, Dimitrova SD, Cooley G, Alamgir A, Uzzaman MS, et al. Screening for malaria antigen and anti-malarial IgG antibody in forcibly-displaced Myanmar nationals: Cox’s Bazar district, Bangladesh, 2018. Malar J. 2020;19:130.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. United Nations High Commissioner for Refugees. Population Map. 2019. Retrieved at

  9. Anderson J, Doocy S, Haskew C, Spiegel P, Moss WJ. The burden of malaria in post-emergency refugee sites: a retrospective study. Confl Health. 2011;5: 17.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Alam MS, Kabir MM, Hossain MS, Naher S, Ferdous NE, Khan WA, et al. Reduction in malaria prevalence and increase in malaria awareness in endemic districts of Bangladesh. Malar J. 2016;15:552.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Rosenberg R, Maheswary NP. Forest malaria in Bangladesh. Transmission by Anopheles dirus. Am J Trop Med Hyg. 1982;31:183–91.

    Article  CAS  PubMed  Google Scholar 

  12. van den Broek IV, Maung UA, Peters A, Liem L, Kamal M, Rahman M, et al. Efficacy of chloroquine + sulfadoxine–pyrimethamine, mefloquine + artesunate and artemether + lumefantrine combination therapies to treat Plasmodium falciparum malaria in the Chittagong Hill Tracts, Bangladesh. Trans R Soc Trop Med Hyg. 2005;99:727–35.

    Article  PubMed  Google Scholar 

  13. Haque R, Thriemer K, Wang Z, Sato K, Wagatsuma Y, Salam MA, et al. Therapeutic efficacy of artemether-lumefantrine for the treatment of uncomplicated Plasmodium falciparum malaria in Bangladesh. Am J Trop Med Hyg. 2007;76:39–41.

    Article  CAS  PubMed  Google Scholar 

  14. Rahman MM, Dondorp AM, Day NP, Lindegardh N, Imwong M, Faiz MA, et al. Adherence and efficacy of supervised versus non-supervised treatment with artemether/lumefantrine for the treatment of uncomplicated Plasmodium falciparum malaria in Bangladesh: a randomised controlled trial. Trans R Soc Trop Med Hyg. 2008;102:861–7.

    Article  PubMed  Google Scholar 

  15. Kawai A, Arita N, Matsumoto Y, Kawabata M, Chowdhury MS, Saito-Ito A. Efficacy of chloroquine plus primaquine treatment and pfcrt mutation in uncomplicated falciparum malaria patients in Rangamati, Bangladesh. Parasitol Int. 2011;60:341–6.

    Article  CAS  PubMed  Google Scholar 

  16. Haque U, Glass GE, Haque W, Islam N, Roy S, Karim J, et al. Antimalarial drug resistance in Bangladesh, 1996–2012. Trans R Soc Trop Med Hyg. 2013;107:745–52.

    Article  CAS  PubMed  Google Scholar 

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We (authors) thank the University Grants Commission (UGC) of Bangladesh for their financial support through granting a PhD fellowship for this project. Special thanks are offered to the Ministry of Education, Bangladesh for granting deputation (study leave) to the principal author of this research work. Sincere gratitude also goes to Mr. Abul Kalam Azad, the then chairman of the Refugee, Relief, and Repatriation Commission (RRRC) for his dedicated assistance in providing secured boarding during field work and data collection.


The University Grants Commission of Bangladesh gave financial aid towards completing a major part of the field work through a PhD fellowship programme; Memorandum no- UGC/Scholarship/1.157/PhD/2015/Part-2/9831 (date: 04/12/2018). This research was funded in part by the Welcome Trust [220211]. For the purpose of Open Access, the author has applied a CC BY public copyright license to any Author Accepted Manuscript version arising from this submission.

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MAAK conceptualized the study, analyzed the data, and drafted the manuscript. RJM supervised the project and extensively revised and edited the draft of the manuscript. SM and HK also supervised the project. All authors have read and approved the final version of this manuscript.

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Correspondence to Md. Ariful Anwar Khan.

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This work was performed using human data collected under the ethical clearance (Ref. 47/ Biol.Scs./ 2017–2018; date: 16/11/2017) from the Ethical Review Committee of the Faculty of Biological Sciences, University of Dhaka, Bangladesh. All data were anonymized prior to analysis and written, informed consent was not required.

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Khan, M.A.A., Maude, R.J., Musa, S. et al. Epidemiology of malaria in Rohingya refugee camps in Bangladesh within 2017–2020. Malar J 22, 288 (2023).

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