The hepatitis E outbreak declared two months ago in southeastern Niger is particularly affecting pregnant women. Of the 186 women admitted to the main maternal and paediatric health centre in the town of Diffa, 34 have died of severe complications related to the disease. According to the authorities, of the 876 cases of hepatitis E reported by 11 June, the majority of the sick are displaced people (nearly 248,000), and refugees.

As hepatitis E spreads mainly through contaminated water, the current outbreak highlights poor water and sanitation conditions and the lack of adequate sanitation facilities among these people affected by the violence of the ongoing conflict between Boko Haram and the armies of the region.

Instability and lack of infrastructure

In Diffa, where access to healthcare has been hampered – in particular by insecurity – the lack of adequate water, sanitation, and hygiene infrastructure has an even greater impact on the health situation. Several sites within the displaced camps and communities do not have an adequate supply of drinking water, leaving some of the needs of the most vulnerable populations unmet. In addition, there is a lack of latrines, and those that are in place are in poor condition.

From the experience of other hepatitis E outbreaks in Africa, the outbreak in Diffa could last for several more months. The number of suspected cases may increase further with the arrival of the rainy season, usually from June to September.

“Given the scarcity of water for the most vulnerable populations, the risk is that alternative water sources that can spread the outbreak will be used, such as the supply from streams and other natural water points formed by accumulated rain water. These collection points are considered as potential vectors of the disease,” explains Audace Ntezukobagira, emergency coordinator for MSF in Diffa.

“It is also important to take into account that these people do not have the material or financial means to stock up on wood or gas to boil the water in order to make it suitable for consumption.”

Water, hygiene and sanitation

To respond to an outbreak of hepatitis E, one of the priorities is bolstering water and sanitation activities. However, the response in the current outbreak has lagged due to insufficient resources and coordination between humanitarian actors.

At certain sites, jerry cans that are unsuitable for transporting water are not systematically collected when they are replaced.

“This provokes a clear problem in terms of the risk of spreading the disease, as well as creating confusion, as new jerry cans could be distributed several times in the same place,” says Sabiou Mansour, logistics manager for the MSF emergency team in Diffa.

“It is deplorable, considering the efforts already provided in the region and the magnitude of the needs.”

Since April, MSF has strengthened its capacity to deploy emergency sanitation and hygiene measures at 11 sites. The teams working on more than 130 functional water points ensured that more than 6,300 m³ of water was chlorinated, 127,300 jerry cans were washed, nearly 3,400 old ones were replaced with new ones, and cleaning kits, including more than 36,800 bars of soap, were distributed.

 “The chlorinated water we bring home is useful to avoid getting sick, which is why we collaborate with the health agents present at the water points,” says Sani Toubomrabo, a Nigerian community leader based in Garin Wazam.

Patient treatment

The response to the outbreak also includes treating patients in community health facilities and referral to hospital for patients who develop complications.

MSF teams are supporting the health authorities with human and material resources that have been sent to help with the situation. In addition to medical treatment, patients with hepatitis E receive psychological support. MSF also provides technical support for health staff to ensure free and high quality care for patients. A decrease in mortality was also observed among women with severe complications related to hepatitis E, who were admitted to the main maternal and paediatric health centre in the town of Diffa.

Awareness-raising in the heart of the community

MSF has also set up health promotion activities in the health facilities and the community. To date, nearly 32,000 people have been informed about the disease, including patients and their families. At the same time, MSF is actively looking for cases in villages, which has already led to the referral of more than 400 people to health centres.