Thomas Handzel

Hepatitis E Epidemic, Uganda

In October 2007, an epidemic of hepatitis E was suspected in Kitgum District of northern Uganda where no previous epidemics had been documented. This outbreak has progressed to become one of the largest hepatitis E outbreaks in the world. By June 2009, the epidemic had caused illness in >10,196 persons and 160 deaths.

Novel Risk Factors Associated with Hepatitis E Virus Infection in a Large Outbreak in Northern Uganda: Results from a Case-Control Study and Environmental Analysis

An outbreak of hepatitis E virus (HEV) began in October 2007 in northern Uganda. To determine risk factors and sources for ongoing transmission, we conducted both a case-control study and an environmental investigation. A case patient was defined as having serologic evidence of HEV infection, whereas controls were seronegative. We identified risk factors for infection by univariable and multivariable analyses using conditional logistic regression. Several water sources were tested for HEV RNA. Among 112 cases and 145 controls, storage of drinking water in large-mouthed vessels (adjusted odds ratios [AOR] = 2.83; 95% confidence interval [CI] = 1.16-6.94) and washing hands in a group basin (AOR = 1.90; 95% CI = 1.07-3.38) were associated with HEV infection. HEV RNA was detected from communal hand-rinse and surface-water samples. The epidemiologic and environmental water-testing results suggest that household-level factors played an important role in the transmission of HEV-modalities that have been previously underappreciated.

Hepatitis E outbreak, Dadaab refugee camp, Kenya, 2012.

To the Editor: Hepatitis E virus (HEV) is transmitted through the fecal-oral route and is a common cause of viral hepatitis in developing countries. HEV outbreaks have been documented among forcibly displaced persons living in camps in East Africa, but for >10 years, no cases were documented among Somali refugees (1,2). On August 15, 2012, the US Centers for Disease Control and Prevention (CDC) in Nairobi, Kenya, was notified of a cluster of acute jaundice syndrome (AJS) cases in refugee camps in Dadaab, Kenya. On September 5, a CDC epidemiologist assisted the United Nations High Commissioner for Refugees (UNHCR) and its partners in assessing AJS case-patients in the camp, enhancing surveillance, and improving medical management of case-patients. We present the epidemiologic and laboratory findings for the AJS cases (defined as acute onset of scleral icterus not due to another underlying condition) identified during this outbreak. Dadaab refugee camp is located in eastern Kenya near the border with Somalia. It has existed since 1991 and is the largest refugee camp in the world. Dadaab is composed of 5 smaller camps: Dagahaley, Hagadera, Ifo, Ifo II, and Kambioos. As of December 2012, a total of 460,000 refugees, mainly Somalians, were living in the camps; >25% were recent arrivals displaced by the mid-2011 famine in the Horn of Africa (3). Overcrowding and poor sanitation have led to outbreaks of enteric diseases, including cholera and shigellosis (4); in September 2012, an outbreak of cholera occurred simultaneously with the AJS outbreak. During July 2–November 30, 2012, a total of 339 AJS cases were reported from the camps and 2 nearby villages: 232 (68.4%) from Ifo II, 57 (16.8%) from Kambioos, 26 (7.7%) from Ifo, 12 (3.5%) from Dagahaley, 10 (3.0%) from Hagadera, and 1 each (0.6%) from the nearby Kenyan villages of Biyamadow and Darkanley. The epidemic curve of the outbreak is shown in the Figure. Figure Cases of acute jaundice syndrome, Dadaab, Kenya, July–November 2012. The arrow indicates the point at which outbreak control measures (e.g., construction of new latrines and hygiene messaging) were initiated by health authorities. Of the 339 AJS case-patients, 184 (54.3%) were female. The overall median age was 23.5 years (range 1 month−91 years). The median age among female and male residents was 24 years and 20 years, respectively. Among the 134 women of reproductive age (15−49 years), 72 (53.7%) reported being pregnant; the median gestational age was 17.4 weeks (range 8.7−35.3 weeks). Death was reported for 10 of the 339 case-patients (case-fatality ratio 2.9%), 9 of whom were postpartum mothers (case-fatality ratio 12.5%) and 1 a 2-year-old child. Serum samples were obtained from 170 (50.1%) AJS case-patients for testing at the Kenya Medical Research Institute/CDC laboratories in Nairobi, Kenya. Of the 170 samples, 148 were tested for hepatitis E virus (HEV) IgM by using an ELISA (Diagnostic Systems, Saronno, Italy), and 93 were tested for HEV RNA by using the GeneAmp Gold RNA PCR Reagent Kit (Applied Biosystems, Foster City, CA, USA). Of the 170 samples tested, 131 (77.1%) were positive for HEV IgM, HEV RNA, or both: 120 (81.1%) of 148 tested for HEV IgM and 48 (51.6%) of 93 tested for HEV RNA were positive. In response to the outbreak, UNHCR and partners initiated control measures, including training of health care workers, increasing community awareness, improving hygiene promotion activities, and hastening latrine construction. The outbreak also affected refugee resettlement to the United States and other countries. At the onset of the outbreak, ≈100 Dadaab refugees per month were scheduled for US resettlement. The incubation period for HEV is 15–60 days (5); thus, there was concern that refugees could become ill in transit or within weeks of US resettlement. Acute HEV infection, including progression to fulminant hepatitis, had been reported among travelers returning from regions where the disease is endemic (6). As a precaution, the International Organization for Migration and CDC conducted heightened AJS surveillance during pre-departure and arrival health screenings. As of February 2013, no cases of AJS were reported among refugees from Dadaab who resettled in the United States. Dadaab has faced grave insecurity: aid workers were abducted from the camp in late 2011, and Dadaab has experienced numerous blasts from explosive devices (7). Thus, UNHCR and CDC have been limited in their capacity to collect data and conduct a thorough outbreak investigation to identify risk factors. An earlier study in the Shebelle region of Somalia suggested an increased incidence of HEV during the rainy season and elevated risk for infection in villages dependent on river water (8). Further evaluation is needed to identify the risk factors for HEV transmission and HEV-associated deaths in this region, including the role of person-to-person transmission. UNHCR and CDC investigations of HEV outbreaks in refugee camps in southern Sudan may provide data to answer these questions. HEV is believed to have infected humans for centuries (9); however, the reemergence of the disease in refugee camps is a major concern because of the difficulty in implementing effective preventive measures under camp conditions. Point-of-care tests will be useful for rapidly detecting outbreaks and could potentially save lives. The progress made in developing effective vaccines is encouraging (10). Once available, HEV vaccination should be prioritized in this population, especially for pregnant women.

Water, Sanitation and Hygiene in Haiti: Past, Present, and Future

Haiti has the lowest rates of access to improved water and sanitation infrastructure in the western hemisphere. This situation was likely exacerbated by the earthquake in 2010 and also contributed to the rapid spread of the cholera epidemic that started later that same year. This report examines the history of the water, sanitation, and hygiene (WASH) sector in Haiti, considering some factors that have influenced WASH conditions in the country. We then discuss the situation sine the earthquake and subsequent cholera epidemic, and the responses to those events. Finally, drawing on Haitis National Plan of Action for the Elimination of Cholera in Haiti 2013–2022, we suggest some actions that could help bring about long-term WASH improvements for the future. Because the current WASH situation has evolved over decades of limited attention and resources, it will take a long-term, sustained effort to improve the situation.

Access to Safe Water in Rural Artibonite, Haiti 16 Months after the Onset of the Cholera Epidemic

Haiti has the lowest improved water and sanitation coverage in the Western Hemisphere and is suffering from the largest cholera epidemic on record. In May of 2012, an assessment was conducted in rural areas of the Artibonite Department to describe the type and quality of water sources and determine knowledge, access, and use of household water treatment products to inform future programs. It was conducted after emergency response was scaled back but before longer-term water, sanitation, and hygiene activities were initiated. The household survey and source water quality analysis documented low access to safe water, with only 42.3% of households using an improved drinking water source. One-half (50.9%) of the improved water sources tested positive for Escherichia coli. Of households with water to test, 12.7% had positive chlorine residual. The assessment reinforces the identified need for major investments in safe water and sanitation infrastructure and the importance of household water treatment to improve access to safe water in the near term.

HIV, syphilis, herpes simplex virus 2, and behavioral surveillance among conflict-affected populations in Yei and Rumbek, southern Sudan

Little is known about the HIV epidemic in conflict-affected southern Sudan. During 2002–2003, we conducted behavioral and biological surveillance surveys and sequential sampling in antenatal clinics in Yei, Western Equatoria, and Rumbek, Bar-el-Ghazal. HIV prevalence among individuals aged 15–49 years ranged between 0.4% in Rumbek town and 4.4% in Yei town, and among pregnant women between 0.8 and 3.0%, respectively. After the recent peace agreement, targeted prevention programmes are urgently needed to prevent further spread.

Preventing Maritime Transfer of Toxigenic Vibrio cholerae

Organisms, including Vibrio cholerae, can be transferred between harbors in the ballast water of ships. Zones in the Caribbean region where distance from shore and water depth meet International Maritime Organization guidelines for ballast water exchange are extremely limited. Use of ballast water treatment systems could mitigate the risk for organism transfer.

Ascaris and Escherichia coli Inactivation in an Ecological Sanitation System in Port-au-Prince, Haiti.

The goal of this study was to evaluate the microbial die-off in a latrine waste composting system in Port-au-Prince, Haiti. Temperature data and samples were collected from compost aged 0 – 12+ months. Samples collected from compost bin centers and corners at two depths were assessed for moisture content, E. coli concentration, and Ascaris spp. viability. Center temperatures in compost bins were all above 58 °C, while corner temperatures were 10 – 20 °C lower. Moisture content was 67 ± 10% in all except the oldest compost. A 4-log reduction in E. coli was observed over the first sixteen weeks of composting at both locations and depths, after which E. coli was undetectable (LOD: 142 MPN g-1 dry weight). In new compost, 10.4% and 8.3% of Ascaris eggs were viable and fully embryonated, respectively. Percent viability dropped to zero in samples older than six weeks. These findings indicate that the Haitian EcoSan composting process was effective in inactivating E. coli and Ascaris spp. in latrine waste within sixteen weeks. This study is one of the first to document efficacy of an ecological sanitation system under field conditions and provides insight into composting methods and monitoring for other international settings.

Community Mortality from Cholera: Urban and Rural Districts in Zimbabwe

In 2008-2009, Zimbabwe experienced an unprecedented cholera outbreak with more than 4,000 deaths. More than 60% of deaths occurred at the community level. We conducted descriptive and case-control studies to describe community deaths. Cases were in cholera patients who died outside health facilities. Two surviving cholera patients were matched by age, time of symptom onset, and location to each case-patient. Proxies completed questionnaires regarding mortality risk factors. Cholera awareness and importance of rehydration was high but availability of oral rehydration salts was low. A total of 55 case-patients were matched to 110 controls. The odds of death were higher among males (adjusted odd ratio [AOR] = 5.00, 95% confidence interval [CI] = 1.54-14.30) and persons with larger household sizes (AOR = 1.21, 95% CI = 1.00-1.46). Receiving home-based rehydration (AOR = 0.21, 95% CI = 0.06-0.71) and visiting cholera treatment centers (CTCs) (AOR = 0.07, 95% CI = 0.02-0.23) were protective. Receiving cholera information was associated with home-based rehydration and visiting CTCs. When we compared cases and controls who did not go to CTCs, males were still at increased odds of death (AOR = 5.00, 95% CI = 1.56-16.10) and receiving home-based rehydration (AOR = 0.14, 95% CI = 0.04-0.53) and being married (AOR = 0.26, 95% CI = 0.08-0.83) were protective. Inability to receive home-based rehydration or visit CTCs was associated with mortality. Community education must reinforce the importance of prompt rehydration and CTC referral.

Perceptions of Health Communication, Water Treatment and Sanitation in Artibonite Department, Haiti, March-April 2012

The international response to Haiti’s ongoing cholera outbreak has been multifaceted, including health education efforts by community health workers and the distribution of free water treatment products. Artibonite Department was the first region affected by the outbreak. Numerous organizations have been involved in cholera response efforts in Haiti with many focusing on efforts to improve water, sanitation, and hygiene (WASH). Multiple types of water treatment products have been distributed, creating the potential for confusion over correct dosage and water treatment methods. We utilized qualitative methods in Artibonite to determine the population’s response to WASH messages, use and acceptability of water treatment products, and water treatment and sanitation knowledge, attitudes and practices at the household level. We conducted eighteen focus group discussions (FGDs): 17 FGDs were held with community members (nine among females, eight among males); one FGD was held with community health workers. Health messages related to WASH were well-retained, with reported improvements in hand-washing. Community health workers were identified as valued sources of health information. Most participants noted a paucity of water-treatment products. Sanitation, specifically the construction of latrines, was the most commonly identified need. Lack of funds was the primary reason given for not constructing a latrine. The construction and maintenance of potable water and sanitation services is needed to ensure a sustainable change.