12 July 2017

On 18 June 2017, the Nigerian Ministry of Health notified World Health Organization (WHO) of an outbreak of hepatitis E located in the north-east region of the country. The first case was detected on 3 May 2017 in Damasak, a locality at the border with the Republic of the Niger. Samples were collected from the case and sent to laboratory for confirmation. Cases were later reported in Ngala, one of the local government areas in Borno State that borders Cameroon. As of 2 July 2017, 146 confirmed and suspected cases were reported including 21 confirmed cases.

In Ngala, 25 infected pregnant women (21%) were reported, including two deaths (case fatality rate = 8%). Cases were reported from three local government areas: Ngala (112), Mobbar (19), and Monguno (14). The number of hepatitis E cases is highest in Ngala with 29 cases reported from 19 June to 2 July 2017. Twenty-seven samples were shipped to the virology laboratory in Lagos for further diagnosis. Among the samples collected and tested, 21 tested positive (10 in Ngala, seven in Mobbar, four in Monguno) and six tested negative. Twenty-three samples have been collected and are pending laboratory tests.

This hepatitis E outbreak can propagate rapidly due to the ongoing humanitarian crisis in the region which arises from the volatile security situation in north-eastern Nigeria and continues to persist. This crisis in Nigeria has been ongoing for eight years and as a result 1.9 million people are internally displaced. The region has been facing intense movements of population coming from refugee camps or displaced populations in the areas bordering Chad and Niger. In addition, the fresh wave of returnees from neighbouring countries is overwhelming the current humanitarian capacity. Returnees began entering the town in January 2017 and so far the town has an estimated population of 90 000, according to International Committee of the Red Cross (ICRC) and immigration officials. The town has one unofficial camp hosting returnees considered as strangers or people not affiliated to any of the indigenous communities who have settled in the town. As a result there is overcrowding which is overwhelming the already weak systems in place. Lack of access to essential water, sanitation, hygiene, and health services may lead to propagation of this disease at a very rapid rate.

Public health response

Coordinating partners in this response include WHO, United Nations Children’s Fund (UNICEF), Oxfam (representing the Water, Sanitation and Hygiene (WASH) sector), Médecins Sans Frontières (MSF), FHI 360, ICRC (working with Nigerian Red Cross) and North East Regional Initiative (NERI). Response activities for this outbreak include the following:

• WHO and MSF are supporting case management at no cost to patients and this includes hospitalization of those in need, availability of drugs, and health personnel. Symptomatic case management is supported by MSF at the district level.
• Epidemiological surveillance system at health facilities exists with the support of local partners.
• Technical support is being provided from WHO and other partners.
• As of 15 June 2017, WASH assessed and mapped the current water sources and established contacts for a rapid response in the chlorination of water.
• A multisectoral approach needs to be emphasized and coordinated between the State Ministry of Health, Nigeria Centre for Disease Control, and Ministries of Water and Environment.
• Public health awareness through sensitizations and announcements in mosques and other public places by local government area health educators is taking place. In addition, local health personnel are being sensitized, eight Volunteer Community Mobilizers (VCMs), the health care staff, MSF, UNICEF and FHI 360.

WHO risk assessment

Nigeria shares an international border with four countries, Chad and Cameroon in the east, Republic of the Niger to the north, and Republic of Benin on the west. The areas of insecurity are located in north-eastern Nigeria, bordering Republic of the Niger, Cameroon, and Chad. The hepatitis E outbreak is taking place in this same area.

This area is characterized by a hepatitis E outbreak in neighbouring Chad and in Republic of the Niger. The ongoing humanitarian crisis and insecurity, high numbers of Internally Displaced Persons (IDP) and refugees, and poor access to safe water leads to the spread of disease. There are also an increasing number of displaced persons moving back to the region post occupation. In addition, the potential cross-border contamination and subsequent increased risk of spread from Republic of the Niger and other neighbouring countries should be considered. There are a number of refugee and IDP camps that are overcrowded and have poor sanitation conditions thereby increasing the risk of hepatitis E. Therefore the observed risk at the national level is high.

The risk at regional level is moderate especially in the countries around the humanitarian crisis in north-eastern Nigeria. The risk at global level is low.

WHO advice

WHO recommends the improvement of the quality and access to safe drinking water, through different methods including the use of at home water purification techniques. The quality of water should be regularly monitored in the affected areas.

In addition, WHO recommends the improvement of sanitation by treating and dispensing of human waste correctly as well as improving personal hygiene and the preparation of safe and clean food. The number of latrines in different camps should be increased to address open defaecation.

The ongoing interventions should target at risk populations through establishment of antenatal counselling for pregnant women, improving housing conditions for refugees and IDPs and supporting partners in improving health facilities and care.

The local and national reference laboratory capacities should be improved for timely confirmation of suspected cases. Cross-border interventions should be strengthened through the Lake Chad sub-regional approach for the management of the current outbreak.

WHO does not recommend any restriction on travel and trade to Nigeria on the basis of the information available on the current event.