A vaccination campaign in response to an outbreak of the neglected disease which is particularly fatal to pregnant women has been carried out for the first time ever in the world, in South Sudan.
For decades, health workers have been responding to outbreaks of hepatitis E in countries around the world, attempting to tackle the spread of the disease among displaced populations living in some of the most appalling conditions.
Unable to offer a cure, they have been left frustrated by the impact of the deadly disease on people who contract it, particularly pregnant women. But a world-first vaccine campaign completed in South Sudan in October brings hope that the fight against hepatitis E may one day be won.
Médecins Sans Frontières (MSF) and the South Sudanese government completed the vaccination drive, following a three-stage campaign launched in March in the country’s largest displacement camp.
Created in 2014 at the height of the civil war, Bentiu camp is home to roughly 112,000 people, many who have fled violence and the recent floods that forced tens of thousands of people to abandon their homes.
Bentiu has experienced a number of deadly hepatitis E outbreaks in recent years as a result of appalling living conditions. The disease spreads through contaminated food and water, and often breaks out in areas where there has been mass displacement and where people live in overcrowded conditions with poor sanitation.
There are an estimated 20 million infections and 44,000 deaths from the disease each year. It is especially fatal for pregnant women, killing up to 25 per cent of those it infects as well as increasing the risk of miscarriages and stillbirths.
Symptoms include jaundiced skin, fevers, malaise and, in more severe cases, liver failure. There is no cure for the disease, and experts say it can take years to dissipate once an outbreak starts. A vaccine to prevent Hepatitis E has been developed and used in China, but this hasn’t been available elsewhere until now.
A neglected disease
“Although the overall mortality is not so dramatically high during outbreaks, the particularity of this disease is that it is killing pregnant women,” said Dr Iza Ciglenecki, an operational research coordinator at MSF. “It is very impactful when you are working in an outbreak setting and you have a number of pregnant women that are dying of something that should be preventable. The emotional weight this bears in a society is very heavy.”
There is no treatment against the disease and it progresses very fast, Ciglenecki added. “So as a clinician, you can only provide supportive care that doesn't necessarily make a big difference. If we were in Europe, you would try to do a liver transplant or something like that, but obviously that's not possible in the context where the outbreaks are happening.”
Like many other neglected diseases that primarily hit poor or displaced populations in developing countries, the impact of hepatitis E is largely underestimated, and there has been little incentive for global pharmaceutical companies to find a treatment for the disease.
The only available vaccine, Hecolin, was developed in 2011 by a biotech company in China, which has been hit by several major outbreaks of hepatitis E in the last forty years. Even so, it has been principally used on an individual basis to vaccinate travellers.
Although the vaccine has proved highly effective in clinical trials in preventing the disease, it has never been used at scale, partly because it is difficult to purchase enough vaccines from the supplier in bulk. This is despite the fact that the World Health Organization (WHO) has recommended that it be considered for use in outbreak responses since 2015.
“Hepatitis E is a neglected disease,” said Ciglenecki. “No one really knows about it although it's very common. Even in the places that are experiencing outbreaks, the disease is mainly affecting the poorest and most neglected people. So from a policy point of view, there is maybe less interest in addressing the issue.”
Until this year, no health authority had taken the step to implement a vaccination campaign, with many decision-makers largely unaware of the existence of vaccines or the WHO recommendations.
A long road to a cure
For decades, MSF teams have been fighting outbreaks of hepatitis E in displacement and refugee camps around the world, frustrated by its devastating impact on patients who they are unable to treat or vaccinate against the disease.
Since 2014, the organisation has been working to make it possible for the existing vaccine to be used in future outbreaks, but have been met with a number of logistical obstacles. An attempted vaccination campaign in Burkina Faso in 2021 ultimately failed because there were no doses available to treat the outbreak.
However, with the support of the South Sudanese Government, MSF ordered and pre-positioned hundreds of thousands of doses of the vaccine in 2021 in preparation for a future outbreak in Bentiu camp, which has experienced spikes of the disease since 2015.
Infections began to rise once more in Bentiu following the massive floods in summer of last year, which submerged the surrounding areas and pushed thousands more people into the camp. MSF has seen more than 750 patients in Bentiu with confirmed hepatitis E since July 2021, with around 20 deaths. It became clear that the situation was only going to worsen as living conditions deteriorated.
The government was well aware of the dangers of the disease and keen to support a vaccination campaign, however the severity of the floods halted its progress, with Benitu largely inaccessible due to the dirty, stagnant water which organisations were concerned might flood the camp itself.
MSF was finally able to begin vaccination in March 2022, with the second round carried out in April and the final round completed last month. Around 25,000 people were vaccinated in the first two rounds respectively, and just over 30,000 people in the third round.
Hope for the future
The organisation hopes the campaign will be transformative in the fight against the disease and prompt wider vaccination campaigns elsewhere.
“Responding to hepatitis E outbreaks is so frustrating because we don't have treatment and we don't know how to prevent it, but then we have this vaccine that hasn't been used until now,” said Ciglenecki. “So now if we are able to use the vaccine as a prevention tool, then we should be able to prevent the outbreaks and the mortality linked to it. We do hope that this experience will serve as a catalyst for future use that will help the vaccine be more available.”
MSF is now advocating for the vaccine to be used worldwide to target outbreaks of the disease in similar contexts. Ciglenecki also hopes there will be additional studies that would allow it to be used on children under the age of 16, who are particularly vulnerable to the disease but are currently not eligible for the vaccine.
“We hope that this experience will serve as a lesson learned for us but also for anyone else that is trying to stop an outbreak of hepatitis E,” said Ciglenecki. “The outbreaks are unpredictable but are happening regularly in Sub-Saharan Africa and Asia. So it would be great to have this vaccine in the toolbox that we have to control these outbreaks.”