December 14, 2016

Heavily pregnant, Miriam rests on the bed in the maternity ward in Am Timan Hospital in Chad as a Doctors Without Borders/Médecins Sans Frontières (MSF) gynecologist performs an ultrasound examination of her growing belly. She seems surprised when, unexpectedly, the outline of a baby appears on the monitor. Her expression quickly turns to relief as she listens to the translator standing next to the gynecologist who confirms that Miriam’s unborn child is progressing well.

Miriam is one of 44 patients with hepatitis E who have been hospitalized in Am Timan since September, with more than 320 other potential cases identified. She is from a nomadic community about five miles from Ardo, a town that is itself a three hour drive from Am Timan. A mother of nine, Miriam’s tenth child is due in February.

Miriam was brought to Am Timan after seeking treatment at an MSF mobile clinic in Ardo. “I was not able to feel the heartbeat of the baby for over a week,” says Miriam. “I spent 25 days in my bed without moving. It was the first time I felt so sick.”

The team immediately recognized the symptoms of hepatitis E, including jaundice, and decided Miriam needed further treatment at the hospital. Jaundice, also known as icterus, is the yellowing of the skin and whites of the eyes. It’s one of the most obvious signs that a person may have hepatitis E. Veronica Siebenkotten-Branca, an MSF gynecologist at Am Timan, says hepatitis E has no cure and is particularly dangerous for pregnant women like Miriam.

“Depending on how severe the hepatitis E infection is during pregnancy, it could lead to potentially serious consequences for maternal and fetal health,” Veronica explains. “Abortion, post-partum hemorrhage, premature babies, or stillbirth are among the worst situations a mother can face.”

Within days of her admission to Am Timan Hospital, Miriam’s health had improved. “Now I can finally feel my baby again,” she says. “Before I was so afraid to come to a hospital, but now I feel much better and I hope I will able to go back to my community soon.”

As she recovers, her husband and her three brothers wait outside the maternity ward, worried for her health. It is the first time she has ever been in a hospital. As a nomad, Miriam and her family rarely spend longer than a few months in one place. The group moves throughout the dry season to the far south of the country, and then, in the rainy season, to the north. The journey in between can last for over a month, with around 200 people on the move with their livestock, stopping to grow grains along the way.

Diagnosis in Am Timan

The first cases of hepatitis E were discovered in late August 2016 in Am Timan Hospital, where MSF provides HIV and tuberculosis (TB) care and works in the pediatric and maternity departments. Like cholera, hepatitis E is transmitted from one person to another mainly through contaminated drinking water, and rapidly spreads in places where hygiene and sanitary conditions are poor.

It is estimated that one in 25 patients with hepatitis E is at risk of death, but for pregnant women in their third trimester, the risks of maternal and fetal mortality are higher. Among the nine patients who have died in the hospital in the past few months, three were pregnant women with jaundice.

Since the first cases were identified, more than 600 MSF staff have been working to test for new cases of hepatitis E, treat patients, and improve the supply of water and sanitation in the region. Many of these are community health workers whose main role is to talk to people about the early signs and symptoms of hepatitis E and share information about hygiene practices. This work includes meeting with local chiefs, leaders, and officials to hear their concerns, identify needs, and encourage them to talk to their community about the urgency of the hepatitis E response. In the last three weeks, they also distributed 10,240 hygiene kits containing bars of soap and buckets.

Most people in Am Timan had not previously heard of hepatitis E. As a result, MSF staff work to address fear and suspicion about the ”sick people with yellow eyes.” In many cases, hepatitis E patients are been seen as a threat to the community, causing stigmatization and shame for those who are diagnosed. With support from community outreach workers, this is changing.

The road to survival

Ngomdimadje, a 25-year-old teacher, was the first patient to survive hepatitis E in Am Timan. He lives with his cousins in a rented house in the central Salamat District. Around four months ago, after he returned from teaching young elementary students in Harazè (near the border with Central African Republic) he started to experience severe pain in his body. At that time, he said he was feeling close to death, experiencing a loss of appetite, severe vomiting, headaches, and abdominal pains. He was barely able to move or to walk. Critically ill, Ngomdimadje managed to travel to Am Timan Hospital, where he was told he had hepatitis E. After being admitted to the hospital, his health started to deteriorate and the MSF medical team closely monitored and treated him for over two weeks. He has now made a full recovery.

“Today, I call myself a survivor because as long as I am breathing, I survived this potentially deadly disease,” says Ngomdimadje. “Before me, the other two patients didn’t make it; they were two women. Calling myself a survivor is truthful and it is hopeful.”

MSF has worked in Chad since 1981. Before the current hepatitis E outbreak, MSF ran regular medical programs in Am Timan and Moïssala. Earlier this year, MSF launched an emergency nutrition response in Bokoro, where, in partnership with the Ministry of Health, MSF runs 15 mobile outpatient clinics and an intensive therapeutic feeding center in Bokoro Hospital to treat malnourished children.

MSF also launched an emergency response in March 2015 in the Lake Chad region for people displaced by Boko Haram violence . Teams based in Baga Sola and Bol continue to provide assistance to the population around Lake Chad. In the capital, N’djamena, MSF supports Ministry of Health hospitals, training staff on the management of mass casualties in order to increase their capacity to respond to emergency situations.

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