Between 8 September and 24 November, 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 Barsalogho health district with 387 cases and 16 deaths, representing a case-fatality rate of 4.1% (see Figure 1 and 2). A total of 15 out of 16 deaths were reported in pregnant or postpartum women.
A total of 10 cases were confirmed by polymerase chain reaction (PCR). Currently 38 patients are being followed up at the Barsalogho medical center; 10 of which are in hospital. Case descriptions according to individual characteristics show that 67% of cases were less than 30 years old (mean age is 25 ± 12 years); 54% of febrile jaundice cases were female; and nearly 5% of cases were less than 5 years old.
As early as 11 September, WHO advised the Ministry of Health that the cause could be hepatitis E given the following contexts:
- Fourteen (14) samples were collected and sent to the National Reference Laboratory for Viral Hemorrhagic Fever (LNR-VHF); one sample came back positive for yellow fever positive by IgM (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 the 14 collected during the survey) were sent to Lapeyronie Hospital, Montpellier, France for hepatitis E testing: 8 of the 9 samples were IgM positive for hepatitis E (results shared on 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 were sent for testing to the NRL-FHV (Muraz Center, Bobo Dioulasso) resulting in 2 IgM positive cases for yellow fever by IgM and one undetermined.
- The two probable and one indeterminate sample from the second batch along with the one probable sample from the first batch (total four samples) were sent on September 30, 2020 to the Pasteur Institute of Dakar (IP Dakar) for additional yellow fever and differential tests. Two of the four samples tested positive for hepatitis E by PCR; none tested positive for yellow fever by PCR (results shared on October 20). These same four samples were then tested and came back positive for yellow fever by serum neutralization, but with low-titers (results shared on October 26) and are therefore not interpreted as acute yellow fever infection in this context.
- To date, a total of 349 samples (out of 387 suspect cases) have been collected; of which 163 have been analyzed at the FHV NRL for yellow fever.
There are many internally displaced persons (IDPs) in the region, most of them with host families and some living in camps . In addition, the North-Central region is affected by the closure of health facilities due to insecurity resulting from regular attacks by Unidentified Armed Men (HANI). In the Health District of Barsalogho, three out of four communes are heavily affected by these attacks resulting in displacement of the population. A total of 40% of the country’s IDPs are registered in the North-Central region, but only 6 out of 15 health facilities are in operation. Burkina Faso is affected by the COVID-19 epidemic and as of 23 November, 2020, 2 757 cases and 68 deaths have been reported. The context of the COVID-19 pandemic further complicates the response.
Figure 1: Daily evolution of febrile jaundice cases in Barsalogho Health District from September 8 – 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 carried out or are underway at country level:
- Development of a hepatitis E response plan at the regional level.
- Development of a yellow fever response plan is underway.
- A first session was held by the Regional Epidemic Management Committee on the outbreak of febrile jaundice on 26 October, chaired by the Governor of the North-Central Region.
- Regular consultation meeting at regional and district level
- Weekly Consultation meeting at the central level with the participation of technical and financial partners.
- Activation of the Emergency Health Response Operations Centre (CORUS) with the appointment of a national incident manager.
- Strengthening surveillance of jaundice cases in North-Central Region districts
- Drawing up of the descriptive case list (line list)
- Ongoing briefing of health workers, community-based health workers and traditional healers on epidemiological surveillance, especially febrile jaundice.
- Development of a microprogram for sensitization of the population.
- Support shipment of samples to IP Dakar
- Hospitalization and case management at the Medical Center with surgical unit in Barsalogho and at the Regional Hospital Center in Kaya.
- Development at the central level and sharing to the district level of a hepatitis E management protocol based on WHO guidelines.
- Development of a WASH response plan
- Verification of water points: sampling and analysis (13/56 water points) with the support of OXFAM. Water did not comply with drinking standards and bio-controlled parameters (E.coli, faecal streptococci, thermotolerant coliforms).
- Treatment of a well in Sector 3 of Barsalogho
- Disinfection of 56 main water points
- Distribution of hygiene kits
- Training of community relays on hygiene
- Decommissioning of 120 latrines
WHO risk assessment
Although hepatitis A, B, and C are common in Burkina Faso, this is the first-time hepatitis E has been reported in the country. The national HIV/hepatitis reference laboratory at the Muraz Center in Bobo Dioulasso has an efficient technical platform capable of diagnosing hepatitis E but lacks reagents and rapid diagnostic kits. Efforts to improve case management and strengthen surveillance are ongoing. Additionally, the majority of hepatitis E cases have been reported within Barsalogho health district, which houses many internally displaced persons (IDPs) experiencing difficult living conditions. Aside from overcrowding, the main contributing factors leading to this outbreak 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 this is a hepatitis E epidemic, occurring in a geographical area where the population has little access to essential water, and sanitation and hygiene services, requiring the implementation of effective and rapid prevention measures. Since January 2019, the North-Central region has been regularly subject to attacks by unidentified armed men (HANI), resulting in a dysfunction in the provision of care and the massive displacement of populations. The spread of this epidemic to other neighbouring health districts is possible if additional support measures are not put in place. The limited capacity of local actors to effectively support the response actions also constitute a risk of spreading this epidemic to other sub-prefectures or neighbouring health districts.
The risk at the regional and global level remains low.
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 areas of humanitarian emergencies.
The hepatitis E virus is transmitted by the fecal-oral route, mainly through contaminated water. The risk factors for hepatitis E are related to poor sanitation conditions, allowing the viruses excreted in the feces of infected subjects to reach water intended for human consumption. In general, the infection heals spontaneously in 2-6 weeks with a lethality of 0.5-4%. Fulminant hepatitis is more common when hepatitis E occurs during pregnancy. Pregnant women, especially in their second and third trimester, are at increased risk of acute liver failure, fetal loss, and mortality. The case-fatality rate can be as high as 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 the transmission of HEV and the number of hepatitis E cases are: provision of safe drinking water, quality standards for public water supplies, and the provision of adequate sanitation. At the individual level, infectious risks can be reduced by maintaining hygienic practices such as washing hands with clean water and soap – especially before handling food, avoiding consumption of water and/or ice of unknown purity, and following WHO hygiene practices for food safety.
To prevent the spread of acute hepatitis E, WHO recommends improving access to safe drinking water and adequate sanitation. The quality of drinking water should be regularly monitored in neighbourhoods affected by this epidemic. Coverage of latrines and drinking water sources should be increased to prevent open defecation and to ensure hand hygiene. Health promotion and prevention activities, as well as ensuring early, appropriate, and equitable health care services to combat hepatitis E epidemics, can help improve public health outcomes, especially in resource-limited settings. Since the incubation period for hepatitis E ranges from 2-10 weeks, cases may continue to occur up to the tenth week (maximum incubation period) even after measures to ensure safe water, sanitation and hygiene promotion have been adopted.
The intervention must continue to target vulnerable populations by establishing or strengthening antenatal diagnosis for pregnant women with symptoms, improving the population’s hygiene conditions, strengthening national capacities for diagnosis and clinical case management, and cross-border collaboration with neighbouring countries.
To date, a hepatitis E vaccine has been developed for commercialization and licensed in China and Pakistan. While WHO does not recommend the introduction of the vaccine as part of national routine population immunization programs, WHO recommends that national authorities may decide to use the vaccine in outbreak settings, including in populations at high risk, such as pregnant women. Vaccine use should therefore be considered to mitigate or prevent an outbreak of hepatitis E, as well as to reduce the effects of an outbreak in high-risk individuals, such as pregnant women.