Northern Uganda – Kitgum: “There were 188 latrines on paper, in town I found only 20 actually in place”

06 July 2008

An outbreak of Hepatitis E started in Kitgum in November 2007, and six months later it is still ongoing and spreading. By June 2008, MSF had treated 2,228 Hepatitis E patients - 42 of whom have died from the disease. Pregnant women are most at risk as case fatality in this group can be as high as 20%. There is no cure or vaccine for Hepatitis E. The only actions that can be taken are with case management of the most sick and activities aimed at controlling the spread of the disease. The outbreak has further complicated the unpredictable and precarious health situation of the displaced populations. Some improvement in the security situation has resulted in some people returning to their homes or moving to smaller camps closer to their original villages. However, most of the large camps in Kitgum District remain havens for approximately 300,000 internally displaced people.  In these camps living conditions are congested and maintaining good hygiene is problematic.

Matt Arnold, Water Sanitation responsible for the emergency team in Amsterdam is back from a six-week assignment and explains what he saw.

What is the situation like in the camps?
People live in very cramped conditions, which I would describe as concentrated rural slums. The Kitgum District is a large area. Generally the camps correspond in name and location to a sub-county. Roughly 60% of the population remains in the camps, 20% in return sites or ‘satellite camps’ and 10% are in their villages of origin. We hear various reasons why it is taking longer for people in Kitgum to leave the camps. Principally, they were affected for a much longer period by the attacks of the Lord’s Resistance Army (LRA) and the government reprisals and relocations of the population. In some camps there is an almost complete lack of sanitation facilities and the camps are filthy with human and animal faeces everywhere. It was no surprise to me that this outbreak started.

What did you do when you arrived?
When I arrived we were already carrying out disease control activities in Madi Opei Camp, one of the large camps in the district. Thanks to the current MSF teams, the sanitation situation there had greatly improved with the construction of latrines and the installation of hand washing points. There were other standard elements of response also already in place, such as outreach teams, active case finding, hygiene promotion and community mobilisation. My primary objective was to carry out a rapid assessment of other sites to determine the best course of action to take and to identify the gaps that needed to be filled. The large number of other actors present and the scale of the problem needed some field-based advocacy. This greatly complicated the situation as I found plenty of differences between the reported sanitation situation and the actual situation on the ground. People were not taking their responsibilities.

How could it end up in such a vast Hepatitis E outbreak, after these camps exist for so many years?
All the actors, including the population, have been negligent for far too long. Poor supervision of water and sanitation programmes has played a role. Now, after security improved, most aid agencies have moved to a development agenda, which means their focus has moved away from the camps. The local authorities need to take a more serious coordination and implementation role, rather than criticising those who were trying to intervene. Unfortunately the problem is so large now that the chances of complete control are unlikely.

Why is it so difficult to deal with a Hepatitis E outbreak?
In previous recorded outbreaks, the source is one or a few contaminated water sources. In Kitgum, the virus seems to break the normal pattern and due to the massive contamination occurring in Kitgum, it might be relevant to study the possibility of a person-to-person transmission of the virus since the epidemic control measures will change if it is the case. Seeing the scale of the outbreak and how it has spread, it cannot be just a few water sources infecting all these people in such a vast area.  The disease has a relatively long incubation period of 4 to 8 weeks, so it is difficult to know where to act next. There is little data available about Hepatitis E. It is unsure whether standard water treatment methods are effective enough as regular field water quality testing is insufficient. A more coordinated and comprehensive response was needed from the beginning.  MSF made the mistake of only doing case management in the early stages.

What is the best response to such an outbreak?
The best response combines the effort of the medical and water-and-sanitation components of the project. Prevention should be the aim of water and sanitation actors.  We need to target the most vulnerable groups, to get to the unaffected areas to improve sanitation coverage; Deal with potentially contaminated water sources, and we need to increase hygiene promotion. Advocacy has to play a large role to get all actors to carry out their responsibilities. Outreach teams play the most essential role in the control of the outbreak. They act as the eyes and ears of the community whilst carrying out active case finding, case follow-up, targeted hygiene promotion, community mobilisation and monitoring of hygiene behaviour.

Is there awareness in the population about Hepatitis E?
Most people understand the nature of the illness. The most vulnerable group are pregnant women. The overall case fatality rate in mid May was 2%, but amongst pregnant women it was closer to 20%. Pregnant women are particularly scared and there has been a marked increase in the number of women seeking contraception in the Madi Opei clinic. I think that the population here is generally well informed about matters related to sanitation and hygiene but for various reasons adequate motivation is lacking to deal with the underlying problem.

Is the peak reached and the outbreak under control?
In Madi Opei, it seems that the peak has passed. I am not so sure, however, what difference the various interventions have made to the numbers affected. Whether or not this is so I feel that the intervention can reduce the likelihood of other epidemics: cholera is a real possibility if the conditions remained as they were. Other sub-counties and even districts have been affected by the Hepatitis E outbreak and there is no way that we can consider the peak to have been reached there, this outbreak will carry on for some time, I am sure.