Alarming increase in Hepatitis E in Northern Uganda

17 September 2008

Kitgum District, in Northern Uganda, is home to hundreds of thousands of internally displaced people (IDPs). Since October 2007, the camps and recently resettled villages have been host to a spreading Hepatitis E outbreak. Many residents have been infected and the virus is continuing to spread south to Gulu and Pader Districts. By the end of July, the number of seriously ill patients seeking hospitalisation had dramatically increased to more than 5,700. In one week in July, 410 new cases of Hepatitis E were diagnosed by MSF. While the disease just makes some people itch and become jaundiced, others can die of severe haemorrhaging or complications while in a comatose state. Thousands of people have been infected, but we have only seen the worst cases.

The place that more than 200,000 displaced people now call home looks like an ocean of small mud huts. The people here have fled their lands after being terrorised by the Lord’s Resistance Army (LRA) or have been moved into camps by the government. Living in makeshift shelters with poor sanitation facilities and little freedom of movement, they are especially prone to disease outbreaks.

The first case of Hepatitis E was diagnosed in November 2007, after a patient from the Madi Opei IDP camp arrived bleeding and in a comatose state, at first feared to be symptoms of the Ebola hemorrhagic fever. The patient was quickly isolated and blood samples were sent to the Uganda Viral Research Institute supported by the Centre for Disease Control in Atlanta, which identified Hepatitis E. In the following weeks, more cases were found. In the Madi Opei Health Centre, where Doctors Without Borders/Médecins Sans Frontières (MSF) is working in collaboration with the Ministry of Health, a ward has been completely dedicated to isolating and treating Hepatitis E cases. Patients have come in from the entire district and from Southern Sudan.

There is no cure or vaccine for Hepatitis E – it must simply run its course. The source of the primary contamination remains unclear as people in most of the villages and camps have been or are infected. By the end of July 2008, MSF treated 1,394 patients with Hepatitis E and recorded 40 deaths in Madi Opei. For the Kitgum district a total of  5,749 cases of Hepatitis E had been reported  at the end of July, with 96 deaths.

Guro Steine, an MSF doctor in Madi Opei, treated a female patient transferred to the MSF health centre. “I could not find a pulse on the woman, she vomited and was in a coma. In the hospital we inserted a peripheral intravenous line, gave her fluid, and all we could do was wait. The woman’s baby daughter received her feeding through bottle feeding as her mother could not breastfeed her anymore. This is a common and serious problem for lactating women who have Hepatitis E,” she said. The mortality rate for pregnant women may reach 20% during the third trimester. Infant mortality can reach up to 33% and women also become more prone to premature deliveries. 

Health centres in Northern Uganda are often understaffed and the medics who are there often know very little about managing Hepatitis E. As a result, medications are often used that cause complications for the patients. People infected with Hepatitis E should not take drugs that interact with the liver as the liver is affected by the virus. A seemingly harmless dose of paracetamol can put a patient into a coma.

How has Hepatitis E spread in Northern Uganda
While chlorinating the water can reduce the virus, this basic precaution is not enough to control an outbreak. In Kitgum, poor hygiene practices at household level, such as a lack of hand washing with soap after using the latrine or before meals, sharing of contaminated pots and buckets, a lack of high-heat cooking methods, ingestion of contaminated locally brewed alcohol and extremely low latrine coverage all play a role in the continued transmission of Hepatitis E.

Villages that were abandoned during the war are now being repopulated by displaced people, encouraged to go back home by the government. Their water points are not necessarily safe and chlorine tablets are not provided for people living outside the camps. During resettlement, latrines do not rank high on the list of priorities: “When we got back, our first priority was to build new houses for our families. Then we had to make sure we could grow crops again, so we prepared the fields. We were lucky that we had one of our two boreholes still working, but no latrines. So we went to the bush and were using the water carefully,” explains farmer Olak Marco who recently returned from Madi Opei to his village, where he contracted Hepatitis E.

People start by building shelters and tending to their crops in order to feed their families. They have no latrines and often do not have access to clean water as the borehole pumps are broken and people cannot afford the necessary maintenance. Thus they have to defecate in the bush behind their houses and their water sources become easily contaminated when the rain comes. Some villages are still without boreholes and take water directly from potentially contaminated streams. Kodjo Edoh, MSF Head of Mission in Uganda, explains: “In fact many people in the camps have not yet moved back. More than 50% of the population still remains in congested camps, because at the return site there is a lack of basic services and people are still fearing renewed insecurity.”

Even if Hepatitis E is not fatal for the majority of the people infected, it does leave most weakened for months. As people are trying to move back to villages and plant their crops, they need their full strength to rebuild and protect their families.