Acute hepatitis E – Burkina Faso

Between September 8 and November 24, 2020, the north-central region of Burkina Faso reported a cumulative total of 442 cases of febrile jaundice. The vast majority of cases (87.5%) were reported from the Barsalogho health district with 387 cases and 16 deaths, representing a mortality rate of 4.1% (see Figures 1 and 2). A total of 15 of 16 deaths were reported in pregnant women or postpartum women.

A total of 10 cases were confirmed by polymerase chain reaction (PCR). Currently, 38 patients are being monitored at Barsalogho Medical Center; Of which 10 are in the hospital. Case descriptions by individual characteristics show that 67% of cases were younger than 30 years (mean age 25 ± 12 years); 54% of febrile jaundice cases were women; and almost 5% of cases were less than 5 years old.

As early as September 11, the WHO advised the Ministry of Health that the cause could be hepatitis E, given the following context:

• Fourteen (14) samples were collected and sent to the National Reference Laboratory for Viral Hemorrhagic Fever (LNR-VHF); one sample was returned positive for IgM-positive yellow fever (collected during the survey) (first batch). The sample was then sent to Dakar for additional yellow fever and differential testing.
• Nine (9) samples (out of 14 collected during the survey) were sent to Lapeyronie Hospital in Montpellier, France for hepatitis E testing: 8 of 9 samples were IgM positive for hepatitis E (results shared September 25). Genotyping of 8 samples for viral hepatitis E showed that the virus was genotype 2; therefore, no zoonotic infection was detected.
• A second batch of 43 samples was sent for testing to NRL-FHV (Muraz Center, Bobo Dioulasso) resulting in 2 IgM positive cases for yellow fever by IgM and one indeterminate.
• Two probable and one indeterminate sample from the second series, together with one probable sample from the first series (four samples in total), were sent on 30 September 2020 to the Pasteur Institute in Dakar (IP Dakar) for additional yellow fevers and differential tests. . Two of the four samples tested positive for hepatitis E by PCR; no test was positive for yellow fever by PCR (results were divided on October 20). These same four samples were then tested and returned positive for yellow fever by neutralizing serum but with low titers (results were divided on October 26) and are therefore not interpreted in this context as an acute yellow fever infection.
• To date, a total of 349 samples have been collected (out of 387 suspicious cases); of which 163 were analyzed for FHV NRL for yellow fever.

There are many internally displaced persons (IDPs) in the region, mostly with host families, and some living in camps. In addition, the north-central region has been affected by the closure of health facilities due to insecurity resulting from regular attacks by Unidentified Armed Men (HANI). In the Barsalogho health district, three of the four municipalities have been hit hard by these attacks, which have resulted in displacement. A total of 40% of IDPs in the country are registered in the north-central region, but only 6 of the 15 health facilities operate. Burkina Faso has been affected by the COVID-19 epidemic, and as of November 23, 2020, 2,757 cases and 68 deaths have been reported. The context of the COVID-19 pandemic further complicates the response.

Figure 1: Daily development of febrile jaundice cases in Barsalogho Health District from September 8 to November 24, 2020 (n = 387)

Figure 2: North-Central region with febrile jaundice, November 24, 2020

Public health response

The following response actions have been implemented or are ongoing at the state level:

Coordination

• Development of a hepatitis E response plan at the regional level.
• A yellow fever response plan is being developed.
• The first session was held by the Regional Committee for the Management of Epidemics on the Outbreak of Febrile Jaundice on October 26, chaired by the Governor of the North-Central Region.
• Regular consultation meeting at regional and district level
• Weekly consultation meeting at central level with the participation of technical and financial partners.
• Activation of the Emergency Medical Intervention Operations Center (CORUS) by appointing a national accident manager.

Supervision

• Strengthening surveillance of jaundice cases in the North Central region
• Creating a descriptive list of cases (list of lines)
• Ongoing briefing of health workers, community health workers and traditional healers on epidemiological surveillance, especially febrile jaundice.
• Development of microprograms for population sensitization.
• Support sample delivery to Dakar IP

Case management

• Hospitalization and case management at the Medical Center with Surgical Unit in Barsalogh and at the Regional Hospital Center in Kaya.
• Central-level development and sharing of hepatitis E management protocols at the district level based on WHO guidelines.

WASHING

• Creating a response plan for WASH
• Water point verification: sampling and analysis (13/56 water points) with OXFAM support. The water did not meet drinking standards and bio-controlled parameters (E. coli, fecal streptococci, thermotolerant coliforms).
• Well treatment in sector 3 of the city of Barsalogho
• Disinfection of 56 main water points
• Distribution of hygiene kits
• Community hygiene relay training
• Putting 120 toilets out of use

WHO risk assessment

Although hepatitis A, B and C are common in Burkina Faso, this is the first time that hepatitis E has been reported in the country. The National Reference Laboratory for HIV / Hepatitis at the Muraz Center in Bobo Dioulass has an effective technical platform that is capable of diagnosing hepatitis E, but lacks reagents and rapid diagnostic packages. Efforts to improve case management and strengthen oversight are ongoing. In addition, most cases of hepatitis E have been reported in the health district of Barsalogho, where many internally displaced persons (IDPs) with difficult living conditions are housed. In addition to overcrowding, the main factors contributing to this epidemic could be limited access to clean water and poor sanitation and hygiene in the affected areas.

The level of risk at the national level is considered moderate: given that it is a hepatitis E epidemic occurring in a geographical area where the population has poor access to essential water and sanitation and hygiene services, which requires the implementation of effective and rapid prevention measures. Since January 2019, the north-central region has been regularly exposed to attacks by unidentified armed men (HANI), resulting in dysfunctional care and mass displacement of the population. The spread of this epidemic to other neighboring health districts is possible if no additional support measures are introduced. The limited capacity of local actors to effectively support response measures also poses a risk of spreading this epidemic to other sub-prefectures or neighboring health districts.

Risk at the regional and global levels remains low.

WHO advice

Hepatitis E is a liver disease caused by the hepatitis E virus (HEV). Hepatitis E is found worldwide and is common in countries with limited access to essential water, sanitation, hygiene and health services, or in humanitarian emergency areas.

The hepatitis E virus is transmitted by the faecal-oral route, mainly by contaminated water. Risk factors for hepatitis E are associated with poor sanitation, which allows viruses excreted in the feces of infected individuals to reach water intended for human consumption. In general, the infection heals spontaneously in 2-6 weeks with a mortality of 0.5-4%. Fulminant hepatitis is more common when hepatitis E occurs during pregnancy. Pregnant women, especially in the second and third trimesters, have an increased risk of acute liver failure, fetal loss, and mortality. The mortality rate from cases can be 20-25% in women in the last trimester of pregnancy.

Prevention is the most effective approach against this disease. At the population level, the most important interventions to reduce HEV transmission and the number of cases of hepatitis E are: providing safe drinking water, quality standards for public water supply, and providing adequate sanitation. At the individual level, infectious risks can be reduced by maintaining hygiene practices, such as washing hands with clean water and soap – especially before handling food, avoiding consuming water and / or ice of unknown purity, and adhering to WHO hygiene practices for food safety.

To prevent the spread of acute hepatitis E, the WHO recommends improving access to safe drinking water and adequate sanitation. The quality of drinking water should be regularly monitored in the neighborhoods affected by this epidemic. The coverage of toilets and drinking water sources should be increased to prevent open defecation and to ensure hand hygiene. Health promotion and prevention activities, as well as the provision of early, appropriate and equitable health services in the fight against hepatitis E epidemics, can help improve public health outcomes, especially in resource-constrained environments. Because the incubation period of hepatitis E ranges from 2 to 10 weeks, cases can continue to occur up to the tenth week (maximum incubation period) even after the adoption of measures to ensure safe water, sanitation and hygiene promotion.

Intervention must continue to target vulnerable populations by establishing or strengthening antenatal diagnosis for pregnant women with symptoms, improving the hygienic conditions of the population, strengthening national capacities for diagnosing and managing clinical cases, and cross-border cooperation with neighboring countries.

To date, the hepatitis E vaccine has been developed for commercialization and licensed in China and Pakistan. Although the WHO does not recommend the introduction of the vaccine as part of national routine population immunization programs, the WHO recommends that national authorities may choose to use the vaccine in outbreak conditions, including in high-risk populations, such as pregnant women. Therefore, the use of vaccines to alleviate or prevent the outbreak of hepatitis E, as well as to reduce the effects of the outbreak in high-risk individuals, such as pregnant women, should be considered.