Abstract
Hepatitis E Virus (HEV) genotype 1 and 2 infect an estimated 20 million people each year, via the faecal-oral transmission route. An urban outbreak of HEV occurred in Am Timan, Chad, between September 2016 and April 2017. As part of the outbreak response, Médecins Sans Frontières and the Ministry of Health implemented water and hygiene interventions, including the chlorination of town water sources. We aimed to understand whether these water treatment activities had any impact on the number of HEV infections, using geospatial analysis of epidemiological and water treatment monitoring data. By conducting cluster analysis we investigated whether there were areas of particularly high and low infection risk during the outbreak and explored the reasons for this. We observed two high-risk spatial clusters of suspected cases and one high-risk cluster of confirmed cases. Our main finding was that confirmed HEV cases had a higher median number of days of exposure to unsafe water compared to suspected and non-confirmed cases (Kruskal-Wallis Chi Square: 15.5; p < 0.001). Our study confirms the mixed, but shifting, transmission routes during this outbreak. It also highlights the spatial and temporal analytical methods, which can be employed in future outbreaks to improve understanding of HEV transmission.
Highlights
It is estimated that Hepatitis E Virus (HEV) infection from genotypes 1 and 2 infect 20 million people globally each year (Rein et al )
During large-scale outbreaks in humanitarian settings, public health interventions have primarily relied on the following components: (1) early detection of symptomatic cases; (2) clinical management and laboratory diagnosis of identified AJS cases; (3) community engagement and health promotion; and (4) point-of-use water treatment and safe water storage (World Health Organization )
We conducted an exposure analysis, in which we investigated whether exposure to unsafe water during an incubation period of six weeks was a determinant for confirmed HEV infection
Summary
It is estimated that Hepatitis E Virus (HEV) infection from genotypes 1 and 2 infect 20 million people globally each year (Rein et al ). HEV infection of genotype 1 is increasingly recognised as an important cause of acute hepatitis (presenting clinically as acute jaundice syndrome [AJS]) in outbreaks in lower resource and humanitarian settings in sub-Saharan Africa (Guthmann et al ; Teshale et al b; Elduma et al ; Leung et al ; Spina et al ). Even though the transmission dynamics of outbreaks of genotype 1 are currently not fully understood, contaminated water is considered to be the most common source of infection (World Health Organization ). During large-scale outbreaks in humanitarian settings, public health interventions have primarily relied on the following components: (1) early detection of symptomatic cases (especially pregnant women, who are at risk of serious clinical disease); (2) clinical management and laboratory diagnosis of identified AJS cases; (3) community engagement and health promotion (early detection and improved hygiene practices); and (4) point-of-use water treatment and safe water storage (World Health Organization ). In 2015, the World Health Organization (WHO) issued a position paper on the use of a HEV vaccine ‘to mitigate or prevent outbreaks’ in high risk groups such as pregnant women (World Health Organization )
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