Promoting access to and use of clean and safe water to stop hepatitis E

My name is Dr. Matthew Goers, an Epidemic Intelligence Service (or EIS) officer with CDC’s Division of Global Health Protection. Our division works with other countries and international organizations to respond to international disasters, disease outbreaks, and humanitarian crises. In September of 2017, Namibia began reporting sporadic cases of acute jaundice, abdominal pain, and fatigue. These cases were later confirmed to be due to the hepatitis E virus, and by December 2017, the Namibian Ministry of Health and Social Services declared an outbreak of hepatitis E.
Hepatitis E is an enteric disease, meaning that it is caused by an intestinal infection. Because it is often found in water sources contaminated with fecal matter, the disease can spread more rapidly in areas without adequate sanitation. In Namibia, the majority of cases have been reported from informal settlements surrounding Namibia’s capital of Windhoek, but cases have now been reported in all but one of the regions in the country. These areas have limited access to piped water or latrines, making it harder to maintain adequate hygiene or sanitation.
Our team was invited by the Ministry of Health and Social Services to Namibia to support national epidemiology staff and strengthen the outbreak response. By 2018, most cases were centered in two informal settlements surrounding Windhoek as well as a settlement outside of Swakopmund in the west of the country. Under the leadership of the Ministry of Health and Social Services and along with partners such as UNICEF, and WHO, we reviewed the country’s hepatitis E surveillance activities and were able to create a standardized national list of cases to help with reporting. In addition, through implementing a standardized clinic reporting form, we helped to improve data collection methods and the national surveillance process was further streamlined. One clinic even reported 200 additional cases of hepatitis E as a result of these changes.

We also helped the Ministry of Health and Social Services to conduct a knowledge, attitudes, and practice (or KAP) survey in the informal settlements near Windhoek. This survey sought to learn what the community knows about how the disease is spread, perceptions of sanitation and healthcare, and the effectiveness of local messages on hygiene. Chlorine levels in the water supply were also tested and handwashing water was examined for hepatitis E virus. One sample from basins tested positive for hepatitis E. This is concerning because results from the survey suggests that approximately 60% of the people in the area wash hands using a communal basin. Furthermore, almost half of the people we interviewed reported they frequently or occasionally used open fields to defecate.
Based on the survey results, we suggested a number of recommendations. First, hygiene messages and campaigns should encourage people to use running water during handwashing and discourage re-using basin water. Second, Windhoek could consider additional chlorine to their municipal water supply, and water quality at these tap stands should be monitored periodically by the city. Third, the Ministry of Health should promote covering of water containers in the home and the use of narrow neck containers to prevent contamination. Most importantly, we recommended to increase latrine construction in the informal areas to decrease open defecation.
We at CDC work in partnership with countries and organizations worldwide to strengthen capacity to provide safely treated water, monitor waterborne disease outbreaks, and ensure access to water for the most vulnerable. Everyone should have the chance to lead a healthy life, and we can help people achieve this through promoting access to and use of clean and safe water.