Mauro Saio from the Nairobi GeoSentinel® site (KEN) reported a case of acute hepatitis E in a missionary/humanitarian worker who acquired his infection, while working for a period of 16-months, in South Sudan. He presented on the 29th of December to the MSF dispensary in Sudan with vomiting, fever and severe pain in the right hypochondrium but decided to go to Nairobi for further care. The patient history showed two doses of Twinrix® (in 2016). The third Twinrix® dose was missed. The liver was enlarged and tender. Laboratory data included Hb 13.8g/dl; WBC count 7.02 with 34% neutrophils, 42% lymphocytes and 19% monocytes; malaria negative by QBC and antigen tests; platelets were 443 and CRP was 5.4 mg/dl. His liver function tests were very abnormal: total bilirubin 163umol/L, direct 124, ALT 720U/L, AST 372U/L,ALP 205U/L, gamma GT 300, albumin 34g/L. U/E/Cs were normal and INR was 1.2. Hepatitis A was initially suspected due to the incomplete Twinrix® vaccination schedule. Lab results, however, showed positive hepatitis E antibodies (IgM 10.7) and IgG (5.8) confirming the diagnosis of acute viral hepatitis E. The patient was treated with i.v. fluids and parenteral vitamin B, and his condition improved. He was discharged on the 14th of January. Currently, in the GeoSentinel® database, there are 29 reports of hepatitis E over the last 2 years. This is, however, the first case from South Sudan. Hepatitis E virus (HEV) is thought to be responsible for over 3 million symptomatic cases of acute hepatitis and more than 50,000 deaths each year worldwide. Over the past decade, large outbreaks of HEV have been reported in displaced populations in east Africa, including one in South Sudan with more than 5,000 cases and a CFR in excess of 10% among pregnant women. A recent paper (Azman et al, High Hepatitis E Seroprevalence among Displaced Persons in South Sudan,Am. J. Trop. Med. Hyg., 96(6), 2017, pp. 1296–1301.) suggests that, in South Sudan, there is more transmission than was previously thought with potentially many unrecognized deaths related to the disease. While access to safe water and improved sanitation will halt most, if not all, HEV (genotypes 1 and 2) transmission, water and sanitation interventions, including chlorine disinfection, in low-resource settings have proven less effective than anticipated in reducing HEV risk, probably due to poor adherence with these interventions. A recombinant vaccine, HEV239 (Hecolin®; Innovax, Xiamen, China), has been shown to be highly efficacious in a large randomized clinical trial in China. This vaccine is not currently World Health Organization (WHO) prequalified; however, the WHO recommends that it be considered for use in outbreak settings. The vaccine has a three-dose schedule, with the third dose given 6 months after the first, making it less than ideal for outbreak response, although data from the clinical trial suggest that reduced (one or two) dose schedules may be highly protective. Sites seeing migrants should be alert to possible HEV infections and those advising humanitarian workers should include a discussion of HEV prevention in the pre-travel consultation.
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Mauro Saio from the Nairobi GeoSentinel® site (KEN) reported a case of acute hepatitis E in a missionary/humanitarian worker who acquired his infection, while working for a period of 16-months, in South Sudan. He presented on the 29th of December to the MSF dispensary in Sudan with vomiting, fever and severe pain in the right hypochondrium but decided to go to Nairobi for further care. The patient history showed two doses of Twinrix® (in 2016). The third Twinrix® dose was missed. The liver was enlarged and tender. Laboratory data included Hb 13.8g/dl; WBC count 7.02 with 34% neutrophils, 42% lymphocytes and 19% monocytes; malaria negative by QBC and antigen tests; platelets were 443 and CRP was 5.4 mg/dl. His liver function tests were very abnormal: total bilirubin 163umol/L, direct 124, ALT 720U/L, AST 372U/L,ALP 205U/L, gamma GT 300, albumin 34g/L. U/E/Cs were normal and INR was 1.2. Hepatitis A was initially suspected due to the incomplete Twinrix® vaccination schedule. Lab results, however, showed positive hepatitis E antibodies (IgM 10.7) and IgG (5.8) confirming the diagnosis of acute viral hepatitis E. The patient was treated with i.v. fluids and parenteral vitamin B, and his condition improved. He was discharged on the 14th of January. Currently, in the GeoSentinel® database, there are 29 reports of hepatitis E over the last 2 years. This is, however, the first case from South Sudan. Hepatitis E virus (HEV) is thought to be responsible for over 3 million symptomatic cases of acute hepatitis and more than 50,000 deaths each year worldwide. Over the past decade, large outbreaks of HEV have been reported in displaced populations in east Africa, including one in South Sudan with more than 5,000 cases and a CFR in excess of 10% among pregnant women. A recent paper (Azman et al, High Hepatitis E Seroprevalence among Displaced Persons in South Sudan,Am. J. Trop. Med. Hyg., 96(6), 2017, pp. 1296–1301.) suggests that, in South Sudan, there is more transmission than was previously thought with potentially many unrecognized deaths related to the disease. While access to safe water and improved sanitation will halt most, if not all, HEV (genotypes 1 and 2) transmission, water and sanitation interventions, including chlorine disinfection, in low-resource settings have proven less effective than anticipated in reducing HEV risk, probably due to poor adherence with these interventions. A recombinant vaccine, HEV239 (Hecolin®; Innovax, Xiamen, China), has been shown to be highly efficacious in a large randomized clinical trial in China. This vaccine is not currently World Health Organization (WHO) prequalified; however, the WHO recommends that it be considered for use in outbreak settings. The vaccine has a three-dose schedule, with the third dose given 6 months after the first, making it less than ideal for outbreak response, although data from the clinical trial suggest that reduced (one or two) dose schedules may be highly protective. Sites seeing migrants should be alert to possible HEV infections and those advising humanitarian workers should include a discussion of HEV prevention in the pre-travel consultation.