Hepatitis E, tetanus, and hepatitis B all pose significant but under-reported threats to the health and lives of women and girls, especially in low-income countries with limited access to health care. These threats can be a matter of life or death for their babies.
Some diseases have far greater negative consequences in women and girls, especially during pregnancy and childbirth. Hepatitis E, a waterborne infection that affects the liver, is one of them.
“A lot of people call it ‘the Ebola for pregnant women', because there is a really high mortality rate in pregnant women, although we don’t understand why it affects them so much,” said John Johnson, vaccination advisor for Doctors Without Borders/Médecins Sans Frontières (MSF). “The mortality rate is around 20 to 30 percent [during] pregnancy.”
“I almost lost my life while I was pregnant,” said Nyakuola Nguot Gang, who lives with her extended family in Fangak County, South Sudan, which has been experiencing a deadly hepatitis E outbreak. “I thought it was only symptoms of my pregnancy, because my body was aching and I had a fever. I went for a blood test, and that’s when hepatitis E was discovered.”
For pregnant women with hepatitis E, the risk of death is highest in the third trimester. Pregnancy is also a critical time to vaccinate women and girls against tetanus, if they haven’t been before. Tetanus is a serious infection for people of any age and it’s deadly for newborns, so protecting the mother is lifesaving for her baby.
A third, lesser-known disease of concern is hepatitis B. If not prevented, it has lifelong consequences.
Both hepatitis B and tetanus pose significant health threats for victims of sexual violence, who are far more likely to be women and girls. The good news is that there are vaccines available, but the reality is that they’re not reaching everyone who needs them, especially the women and girls who are most at risk.
A groundbreaking vaccination campaign in South Sudan
Hepatitis E is the most common cause of acute viral hepatitis, linked to approximately 20 million infections and 70,000 deaths per year. This overlooked disease predominantly affects people experiencing poverty, and it is especially dangerous for pregnant women. It is transmitted through fecal contamination of food and water. Large-scale outbreaks typically occur when water and sanitation conditions are inadequate.
Hepatitis E outbreaks are unusually long compared to other epidemics. Unlike measles, for example, which might race through an unvaccinated community in six weeks, hepatitis E’s long incubation period means transmission is slower, and outbreaks can last for months.
There is only one vaccine available, HEV 239, which was developed in China. MSF first piloted its use during an epidemic in Bentiu, South Sudan, in 2022. Subsequent research has shown strong evidence of its safety and effectiveness.
Fangak county is one of the most remote and hard-to-reach areas of South Sudan. Recurrent floods have inundated the area in recent years, so its people have had to learn to survive in a changing environment.
Why I got vaccinated against hepatitis E
While Nyakuola was pregnant with her youngest child, MSF provided her first vaccination against hepatitis E.
“We are surrounded by water in all aspects,” said Fangak resident Bhan Gutjiath Wal. “You go to the market, you go through water. You stay at home, there is water too.”
In September 2023, these conditions led to an outbreak of hepatitis E, declared by the Ministry of Health. Within two months, MSF launched only the second vaccination campaign in the world reacting to an active hepatitis E outbreak, and the first ever to take place during the acute stage of an outbreak in such hard-to-reach communities. This joint undertaking with the Ministry of Health eventually spanned almost a year.
"Thank God I was vaccinated,” said Nyakuola. “That’s why I got better. But it was bad.”
Patient story
“If you are strong, nothing will shake you”
When Nyasebit Chan moved to Old Fangak, a hepatitis E outbreak was well underway. A mother to two sons, Nyasebit had left her immediate family in New Fangak to support her stepbrothers at a difficult time.
“I came here in May [2024], working in the market,” she said. “My stepbrothers’ mother had passed on. So the only person who has remained as their mother is me. That’s what brought me from New Fangak to Old Fangak.”
Nyasebit heard about the vaccination campaign in Old Fangak for women and girls of reproductive age. “When I came in May, I found that people have been vaccinated,” Nyasebit says. “I wanted to be vaccinated as well.”
Launched by MSF in December 2023, the campaign consisted of multiple rounds of vaccination to reach as many women as possible in Old Fangak and the isolated communities of the flooded marshlands across Fangak County.
Lifesaving protection against tetanus between mother and baby
The bacteria that causes tetanus is widespread in the environment and cannot be eradicated. The risk to newborns occurs when the umbilical cord is infected after being cut, usually due to unsterile tools or conditions. If a woman is vaccinated against tetanus before she gives birth, lifesaving antibodies will transfer through the placenta into the baby’s blood.
“Babies, especially in what we call the neonatal period, in their first 28 days—that is when they're most susceptible to death from certain diseases and infections,” explained Isabella Mayes, a midwifery activity manager in MSF’s Old Fangak project. “So providing mothers with vaccinations gives them a little bit of protection until [their babies] can receive their vaccine later in life.”
Why are vaccines essential health care?
Read moreKnown also as lockjaw, tetanus limits a baby’s ability to feed. The rigidity spreads through the whole body, and the baby’s muscles spasm uncontrollably. A baby will need intensive nursing care and isolation in a dark and quiet room to prevent reactive spasms, and hospitalization for up to a month. Untreated, some 90 percent of affected newborns will die.
An estimated 24,000 newborns died of tetanus in 2021, according to the most recent global data available. While this figure represents a gradual decline over time, it tells us that women and girls continue to miss out on vital vaccinations, prenatal care, and safe delivery care, especially in low-income countries.
Access to health care in South Sudan is extremely limited. MSF's hospital in Old Fangak is the only facility of its kind providing care to the 20,000 people in the immediate vicinity, as well as in villages that are only reachable by boat and hours away. This includes maternal immunization as part of prenatal care.
Timely care for victims of sexual violence
The value of post-exposure vaccination is highlighted in sexual violence care. A victim can be protected against both tetanus and hepatitis B after an assault or rape, but the window of opportunity to kickstart immunity is only 72 hours.
“We [vaccinate] every patient that has any wounds,” said Renda Kella Dhol, a clinical officer with MSF’s team in Old Fangak. “We just do it immediately to prevent the disease because [tetanus] is really very serious.”
Hepatitis B is often transmitted through sexual contact, and it is up to 100 times more infectious than HIV. When treating a victims of sexual violence, “we don't know the status of the perpetrator,” added Dhol. “That's why we provide hepatitis B [vaccination] to prevent the patient from being infected.”
The hepatitis B virus often causes a long-term infection. It is a major public health problem, with an estimated 254 million people chronically infected worldwide and 1.1 million deaths from hepatitis B-related liver disease, including liver cancer, in 2022. A woman can unknowingly pass it to her baby during childbirth, and the baby will also need vaccination to avoid a 90 percent likelihood of death.
To raise awareness about sexual violence and the medical and psychological care available, MSF conducts health promotion in schools and other places where people gather, among community leaders and with the police.
Dhol acknowledges that people are afraid of discussing the topic of sexual violence, which carries a stigma that MSF is trying to dispel.
“We told them in song: ‘Don't be afraid. We are here for you’,” said Dhol. “We are going to support you. It will never be [revealed] to everybody. But we need you to have the medication and the treatment to prevent anything that might have happened during [the incident] … it’s not your fault, and it’s happening everywhere in the world.”
