The spread of hepatitis E in Niger’s Diffa region has slowed since Doctors Without Borders/Médecins Sans Frontières (MSF) first began detecting and treating cases in early 2017, and the subsequent declaration of the outbreak by the Ministry of Health (MoH) in mid-April. Through a combination of active case finding, quicker diagnoses, a medical protocol, and working with the community through a network of volunteers, the case fatality rate has fallen.
"At the Beginning We Saw Many Cases and Many Deaths"
Dr. Roamba, an MSF obstetrician and gynecologist, treats patients suffering from hepatitis E at the main mother and child health center in Diffa, southeastern Niger. In mid-April, the MoH declared an outbreak of the disease. "At the beginning we saw many cases, and many deaths," says Dr. Roamba.
Hepatitis E has a significantly higher case fatality rate for pregnant women. MSF doctors first began to suspect that they were treating an unusual illness when patients—mainly pregnant women—began to arrive at the hospital in early 2017 in severe and often comatose states. Many did not survive.
The waterborne disease, which affects the liver and can be fatal if not treated promptly, had never before been diagnosed in Diffa. But conflict in the region has led to more than 247,000 displaced people sheltering in sites along the border with Nigeria, where overcrowded and unsanitary conditions provide an ideal environment for the spread of diseases like hepatitis E. The disease has now killed more than 40 people in the region.
Responding to the Outbreak
Since the outbreak was declared, MSF and MoH staff have supported the treatment of nearly 1,400 people for hepatitis E in MSF health centers, health posts, and in villages and clinics; and have treated more than 350 of the most severe cases at the MSF-supported mother and child health center. Since the beginning of the response by all humanitarian organizations and the Ministry of Health, the case fatality rate has fallen from 29 percent on April 25 to just 1.91 percent on October 12, according to the United Nations Office for the Coordination of Humanitarian Affairs.
Working with the community through a network of volunteers and a ramped-up water and sanitation response by humanitarian organizations have been critical in decreasing the morbidity of hepatitis E, says Dr. Roamba. This community approach involves health and sanitation staff members training volunteers to help spot the disease’s symptoms, keep houses and public spaces clean, and ensure that the water they drink is safe.
Community members now quickly bring those displaying symptoms of hepatitis E to health centers and clinics, from which point patients with medical complications are transferred to the mother and child health center in Diffa. As a result, the number of severe cases arriving at the hospital has plummeted. "Since we identified the cause as hepatitis E, there has been a big change," says Dr. Roamba. "There are far fewer patients who die, because they arrive here in a better condition [than before]."
The presence of hepatitis E in the Diffa region underscores the precarious living conditions that refugees and displaced people are facing—and the urgent need for humanitarian assistance for those affected by the ongoing conflict in the area. Many people have been displaced more than once, fleeing fighting only to have to run again as front lines shift. Such a volatile security context creates a challenging environment for humanitarian organizations and raises the specter of further deadly outbreaks occurring in communities far from medical care.
MSF has been working in the Diffa region since late 2014 to help people fleeing violence related to the militant group Boko Haram and the armies of the region. MSF teams provide free medical and psychological care in 11 health centers and posts in the Diffa region as well as supplying clean drinking water, constructing latrines, and distributing essential relief items in villages and other locations where refugees, returnees, and displaced people have gathered.
MSF also supports the MoH-run Nguigmi hospital, the main mother and child health center in Diffa town, and Maine Soroa hospital, providing reproductive and pediatric care, mental health support, and other services. At Nguigmi hospital, the MSF team also provides treatment for children with severe acute malnutrition.