WHO: Hepatitis E Virus – Republic of South Sudan (23 December 2021)

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Source: https://www.who.int/emergencies/disease-outbreak-news/item/hepatitis-e-virus-republic-of-south-sudan


Hepatitis E Virus – Republic of South Sudan
23 December 2021


Cases of Hepatitis E Virus (HEV) have been consistently reported in South Sudan since 2014, with recurrent outbreaks occurring in Bentiu, Rubkona county, Unity state (central-north part of South Sudan), where a camp for internally displaced persons (IDP) is located.
In 2021, the number HEV cases have risen significantly in the country, increasing from 564 reported during the triennium 2018-2020, to 1143 suspected cases with five deaths in 2021 (as of 29 November). In last two years (2020-2021), a total of 1420 suspected cases were reported, of which 47 have been laboratory confirmed by polymerase chain reaction (PCR) at the Uganda Virus Research Institute (UVRI).
The current 2021 outbreak is occurring in Unity State, with cases mainly being reported from Bentiu IDP camp. This led the Ministry of Health (MoH) to declare a HEV outbreak in Bentiu internally displaced people (IDP) camp in August 2021. A proportion of cases (323; 28.3%) has been reported from outside the camp, in Bentiu and Rubkona towns, suggesting ongoing transmission in the surrounding community. Males aged 15-44 years are being reported as the most affected group, followed by male children 1-4 years, and females aged 15-44 years. There are no cases currently hospitalized, with clinical management implemented in outpatient departments (OPD).
Bentiu IDP camp hosts over 107,000 people and is divided into five sectors. HEV cases are reported from all sectors, highlighting widespread transmission.
Unity State, is also affected by a flood that has caused a massive displacement and the development of new IDP sites, adding 30,000 more IDPs hosted in the Bentiu IDP camp.


Public health response

Leadership and coordination

• The Ministry of Health has activated a state HEV taskforce that includes camp management and cluster (health and water, sanitation and hygiene - WASH) partners which convenes regularly to review the health situation and humanitarian response.
• The overall humanitarian response to the flooding is underway to address the acute needs of displaced populations and ensure dignified living conditions.

Surveillance

• The MOH with support from WHO and partners, continues the HEV surveillance through Integrated Disease Surveillance and Response/Early Warning, Alert and Response System.
• A joint assessment team has been ensembled to perform active case search, sample collection, WASH-related non-food items (NFI) distribution, and risk communication.
• Rapid diagnostic testing is ongoing at the community and primary care clinics, with identified cases referred to the Médecins Sans Frontières (MSF) hospital.

Supportive case management

• The MSF hospital is providing outpatient supportive case management for mild to moderate cases, as well as admission for severe HEV cases for specialized supportive case management. There are no cases currently hospitalized.

WASH

• A contingency borehole has been activated, water pumping hours increased, daily latrine repair is occurring and maintenance of sanitation facilities.
• Construction started in November of 54 new stances of latrines supported with handwashing stations, and weekly water quality tests.
• Distribution of 200 WASH kits to a targeted population of HEV cases, pregnant, and lactating women.
• The road to the liquid waste treatment facility and landfill outside the site has been reclaimed to ensure that WASH services can continue (treatment of sludge from IDP site, Humanitarian Hub and United Nations Mission in South Sudan).

Community engagement

• Camp Coordination and Camp Management (CCCM) cluster outreach teams continue to sensitize the community in all five sectors of Bentiu IDP camp, on the risks posed by HEV and other water-borne diseases.
• Risk communication messaging is broadcast via a local radio talk show to sensitize listeners on good hygiene practices and HEV prevention.
• Communication centres in each of the five camp sectors are providing information and receiving feedback from the community pertaining to HEV.
• Partners are conducting hygiene promotion activities by disseminating messages through house visits for infection prevention and control with a focus on HEV, acute watery diarrhoea, and COVID-19 awareness.

HEV Vaccination

• An HEV vaccination campaign microplan has been developed which will entail three vaccination rounds and targets camp residents aged 16-40 years including pregnant women.
• A total of 57,000 doses of HEV vaccine are already in South Sudan and will be used for the first two rounds of the campaign.
• Partners along with community actors have engaged the population to support the campaign as well as other HEV control interventions.
• Surveillance for adverse events following vaccination will be monitored at each of the fixed sites and a post coverage survey will be undertaken.

WHO risk assessment

Hepatitis E is a liver disease caused by the hepatitis E virus, transmitted by the faecal-oral route, mainly through contaminated water. It can lead to serious public health impacts particularly among special populations: those in IDP camps and pregnant women. Risk factors for HEV are linked to poor sanitation conditions, allowing viruses excreted in the stools of infected individuals to enter water intended for human consumption.
Usually, the infection resolves spontaneously within 2 to 6 weeks, with a case fatality ratio (CFR) of 0.5-4%. In rare cases, acute hepatitis E can be severe and progress to fulminant hepatitis (acute liver failure). Generally, CFR for pregnant women is reported to be higher than the overall CFR for HEV infections, reaching 25%. Displaced persons and refugees experience the highest attack rates when outbreaks occur given the overcrowded nature of their living conditions and poor hygiene situation.
Cases of HEV have consistently been reported from Bentiu IDP camp since 2014 but have risen and surpassed epidemic threshold levels in 2021.
The overall risk at the global level remains low, while at the national level is assessed as high due to:

• Poor sanitation and hygiene practices especially in the Bentiu IDP camp and limited availability of safe drinking water.
• Limited access to essential medical services in the Bentiu IDP camp and surrounding area.
• The overall population movements in the affected area, and the presence of large internally displaced population, with a worsening situation due to the ongoing flooding, and the influx of new IDPs that might increase the risk of HEV spread.
• The ongoing floods have impacted the implementation of response activities pausing the HEV vaccination response and consequently increasing the risk of death in high-risk individuals including pregnant women. It has also exacerbated the already-existing poor hygiene conditions in the Bentiu IDP camp.

As the affected area is close to the border with Sudan and Ethiopia, at the regional level the overall risk is considered moderate due to the presence of the mobile IDP populations and refugees that cross these borders. While there have been fewer documented refugees coming from Ethiopia into South Sudan, a significant amount of traffic occurs for people heading to Sudan, particularly from Rubkona county - where the Bentiu IDP camp is located - to Khartoum, the capital of Sudan.
Additionally, there is a current outbreak of HEV at the border with South Darfur state in Sudan, that poses potential risk of cross-border spread...

 

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WEEKLY BULLETIN ON OUTBREAKS
AND OTHER EMERGENCIES

Week 52: 20 – 26 December 2021
Data as reported by: 17:00; 26 December 2021

...

Hepatitis E South Sudan

1 143 Cases
5 Death
0.4% CFR

EVENT DESCRIPTION

A hepatitis E virus (HEV) outbreak has continued in South Sudan
with, a total of 1 143 cases and five deaths (CFR: 0.4%) reported
as of 29 November 2021. The majority of cases (778, 68.1%) have
been reported from a camp hosting internally displaced persons
(IDPs) in Bentiu. Another 323 cases (28.2%) have been reported
from outside the camp living in Bentiu and Rubkona Towns and
have shown increased trends in recent weeks. Comparing to the
past three years of national HEV information, cases have risen
significantly this year and since week 19 (ending 16 May 2021)
cases have surpassed epidemic threshold trends from 2018-
2020 and have continued to remain high. Five deaths have been
reported this year with one of the deaths occurring in a 27 year old
pregnant mother. Overall, 53% of the HEV cases were males
with those in the age group 15-44 years being most affected.
Flooding has also dramatically increased during 2021, with the
first floods occurring in May and escalating in October 2021. As
of 15 December 2021, over 835 000 people have been affected
in over 33 counties across eight states with the communities
in Jonglei, Upper Nile and Unity states being the most affected.
There are more than 32 650 flood-affected people in Rubkona,
Unity State. The water, sanitation, and hygiene conditions have
deteriorated due to the floods causing damages for farmlands,
crops, roads, latrines, houses, health facilities and other essential
services.

The Bentiu IDP camp is located in Rubkona county of Unity state
and shares a border with Sudan to the north. As of July 2021,
the camp hosted 107 130 IDPs where an estimated 52% were
male and 28% were female. The camp relies heavily on resources
from international and national non-governmental organizations
as well as multiple United Nations agencies to provide support
to the camp. Due to the floods, there has been an increase in
movement of IDPs as new arrivals continue to be reported into
the camp which has put demand on existing water, sanitation,
and hygiene resources and amenities.

A vaccination campaign has also been developed with the support
from Medecins Sans Frontieres to complement the ongoing
response with priority to target the most vulnerable- pregnant
women and women of child-bearing age. The campaign will
include concurrent studies to assess the vaccine effectiveness,
safety, and coverage. The first round of vaccination was slated
for November 2021 but is currently on hold until effective
engagement of communities and stakeholders following the
acute flood situation can occur.

Engagement with the communities is important to ensure
successful implementation of the campaign, research component,
and to optimize vaccination coverage.

PUBLIC HEALTH ACTIONS

The MOH has activated the state HEV taskforce that
meets weekly to review the health situation and ongoing
outbreak and humanitarian response. The flood response
is simultaneously ongoing by another team to address the
needs of IDPs and ensure dignified living conditions.

MOH continues to monitor the HEV surveillance situation
through Integrated Disease Surveillance and Response/
EWARS via partners and WHO to detect trends and inform
the outbreak response

Case identification and referrals is coordinated with
implementing partners and supported by primary care
clinics with partners supporting case management at health
facilities.

Partners are continuing with hygiene promotion activities of
disseminating messages through house visits for COVID-19,
infection prevention and control/WASH, Hepatitis E and acute
watery diarrhoea awareness.

Weekly radio talk shows broadcasted to sensitise listeners
on good hygiene practices and HEV prevention messaging.
Five communication centres have been established in
all 5 sectors of the IDP site and receive feedback from
the community as well as provide reliable and accurate
information pertaining to HEV.

200 kits have been distributed to three targeted groups 1)
pregnant mothers registering at the camp for the first time,
2) pregnant women at delivery, and 3) mothers attending 9
month immunizations of their children.

To respond to WASH conditions, a contingency borehole has
been activated, water pumping hours increased, daily latrine
repairs and maintenance of sanitation facilities are ongoing,
construction on new stances of latrines supported with hand
washing stations conducted, and weekly water quality tests
performed.

The road to the liquid waste treatment facility and landfill
outside the site has been reclaimed to ensure that WASH
services can continue.

An HEV vaccination campaign microplan has been developed
which includes three vaccination rounds and targets camp
residents aged 16-40 years including pregnant women. A
total of 57 000 doses of HEV vaccine are already in South
Sudan and will be used for the first two rounds of the
campaign.

Partners along with community actors have engaged the
population to support the campaign as well as other HEV
control interventions.

Surveillance for adverse events following vaccination will
be monitored at each of the fixed sites and a post coverage
survey will be undertaken.

SITUATION INTERPRETATION

The HEV outbreak is facing new challenges from the
effects of flooding in the country including Unity State.
Water, sanitation, and hygiene conditions will continue to
deteriorate with the effects of flooding and the influx of IDPs
in the camp. Problems from the flooding situation make it
more difficult to achieve the promoted interventions against
HEV. A vaccination campaign microplan has been developed
which includes three vaccination rounds. Furthermore,
partners along with community actors have engaged the
population to support the campaign as well as other HEV
control interventions.

PROPOSED ACTIONS

Widen the scope of surveillance and response interventions
to include health facilities and community health workers
in the host communities outside the camp since they are
increasingly more affected by HEV.

Initiate HEV response interventions in host communities
guided by an assessment to identify affected locations and
the drivers of transmission in those locations.

Continue with HEV communication messages to ensure they
are used to affect behavioural change and reduce current
community transmission.

Initiate the HEV as soon as possible once conditions allow for
proper implementation.

...

OEW52-2026122021.pdf (‎2.288Mb)‎

 

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WEEKLY BULLETIN ON OUTBREAKS
AND OTHER EMERGENCIES

Week 12: 13 - 19 March 2023
Data as reported by: 17:00; 19 March 2023
...
All events currently being monitored by WHO AFRO
...

South Sudan Hepatitis E Ungraded

Date notified to WCO 3-Jan-18
Start of reporting period 1-Jan-19
End of reporting period 16-Mar-23

Total cases 3 990
Cases Confirmed 104
Deaths 27
CFR 0.7%

The current outbreak in the Bentiu IDP camp is ongoing. As of 16 Mar 2023, a total of 3 990 cases of hepatitis E including 27 deaths (CFR: 0.7%) have been reported since January 2019. A total of 15 new cases were reported in week 9 (ending 16 Mar 2023). Approximately 53% of cases are male.

https://apps.who.int/iris/bitstream/handle/10665/366585/OEW12-1319032023.pdf?sequence=1&isAllowed=y