Hepatitis A Outbreak – Governorate

Hepatitis A Outbreak Afrin District EWARN Contents Introduction ...... 1 Background ...... 1 Demographics ...... 1 Purpose of visit...... 2 Outbreak control team ...... 2 Date and time of visit ...... 3 Field Investigation ...... 3 Visiting Health Facilities ...... 3 Signs and Symptoms ...... 4 Water and Sanitation Situation...... 5 Afrin sub-district ...... 5 Bulbul and Sharan sub-district ...... 6 Summary ...... 6 Actions Taken ...... 6 Laboratory findings ...... 7 blood samples ...... 7 Results of water samples ...... 7 Interpretation of results...... 7 Hypothesis of outbreak ...... 8 challenges ...... 8 Recommendations ...... 8 Summary ...... 8

Hepatitis A Outbreak Afrin District EWARN Introduction Acute jaundice syndrome is one of the syndromes monitored by the Early Warning Alert and Response Network (EWARN). It mainly includes hepatitis A and E. Hepatitis A is considered as an endemic disease in before the beginning of the conflict; and there was no vaccine provided through the routine immunization program. The poor health conditions led to several outbreaks of Hepatitis A raised in several areas. During 2016, in Afrin district, an outbreak of hepatitis A occurred in the Robar and Shahba camps, and it was the only outbreak appeared during the conflict in that geographical area. Recently, also in Afrin district, the shift of controlling forces and the frequent displacement from and to the area led to an increment of AJS in several areas, the most recent one reported from schools located in Bulbul and Sharan sub-districts.

Background After reviewing data of the epi week (42), an alert of AJS was observed in Afrin sub-district with 29 cases reported and another one in Jandairis sub-district with 10 cases reported. For the 1st alert occurred in , its district level officer (DLO) verified and confirmed that the alert truly took place in Afrin city; and that most of the cases were registered in UOSSM health facility (6 cases) and in the private clinic of Dr. Rania jawish (10 cases). 8 cases out of which were in Trendy camp (50% of the cases). Whereas, the 2nd alert in Jandairis sub-district was false, due to the few cases found compatible with the case definition, as well as, the captured cases were depending on different drinking- water sources. The DLO conducted an initial investigation in Trendy camp with blood samples collected for laboratory evidence. Epi week (43), and in conjunction with the investigation of AJS in schools in the sub-district of Bulbul and Sharan, A significant increase of AJS in Afrin city was observed. The outbreak control team visited the place and did the required investigation, where they line-listed 207 cases during the epi weeks (40,41,42 and 43). Most of the listed cases resided in Afrin city and in the sub-districts of Ma’btali, Sharan and Bulbul. A study of water and sanitation was carried out. Some of drinking water sources were not safe, the hygiene and sanitation were bad. Blood samples were collected from some cases for laboratory confirmation.

Demographics Afrin is located north of Aleppo, the current population of Afrin city is 94,000 (22,000 families), the percentage of IDPs is approximately 70%, most of them are from Rural Damascus. The city is

Hepatitis A Outbreak Afrin District Page 1 of 8 Pages EWARN divided by Afrin river into western and eastern parts. In the country areas of Afrin, there are 8,800 families including 200 displaced families.

Terndy camp is located in the south-eastern part of the city, and it has the following characteristics:

 It is a random camp that was established 4 years ago  It contains 75 tents, its population is 440.  The livelihood of camp residents mainly depends on olive farming.  Its drinking water sources are uncensored tankers  A sanitary pit is the method of sanitation. The health situation in the city and rural areas has declined recently. The number of doctors decreased to 49, while before the change of controlling forces was nearly 80. In Afrin, there are 6 health facilities, 2 hospitals (Bhar Hospital and Watan Hospital) supported by different NGOs, 3 private hospitals (Dirsem, Qanbar and Jeyhan) and 16 specialist doctors.

Purpose of visit - Confirm the alert and conduct a risk assessment. - Find source of outbreak and mode of spread. - Determination of the pathogen by laboratory samples of cases. - Conduct an immediate response. - Set recommendations for control and prevention. Outbreak control team A team was convened on Nov 4th, 2018 and a plan of field investigation was set, the roles and responsibilities of all members were determined, the team consisted of the following members: - Dr. Mohammed shaker: DLO in Afrin district and team leader. - Shiar Othman (Nurse). - Yaser Bakro (Laboratory Doctor).

Hepatitis A Outbreak Afrin District Page 2 of 8 Pages EWARN - Eng. Khalil alzain (WASH). Date and time of visit - Date: Nov 6th, 2018 - Time: 8.30 am Field Investigation Visiting Health Facilities The OCT visited 9 health facilities in the city of Afrin (AlAshrafieh, AlShifa, USSOM, Watan, Bahar, Dersem, Qanbar Hospital, Cihan Hospital and Dr. Rania Jawish Clinic). They reviewed patient registers with doctors and line-listed the cases compatible with the case definition. - The line-listed cases in the mentioned HFs reached 207 between week 40 and week 43, as demonstrated in the figure below:

Cases Distribution by Health Facilities 120 110

100

80

60 Cases 40 24 24 24 20 8 7 7 2 1 0 Bahar ClinicAlAshrafieh Private AlShifa USSOM AlKhair Qanbar Dersem Trende Center Clinic Center Clinic Clinic Hospital Hospital Camp Health Facility

- More than 50% of the cases were from Bahar Facilities (110 cases).

- 56% of the registered cases (116 cases) were less or equal to 5 years, while 44% (91 cases) Age Groups were greater than 5 years.

91

44% <=5 y 116 >5 y 56%

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- Sex distribution of registered cases: 53% were females (109 cases) and 45% were males (98 Sex Distribution cases).

98 47% Female 109 53% Male

Signs and Symptoms - All registered patients Signs and Symptoms (100% of the cases) had a jaundice color, fever and Vomiting 27 fatigue. Constipation 35 Nausia 36 92% had abdominal pain Abdominal Pain (191 cases), 17% had 191 nausea (36 cases), 17% had Fever 207 constipation (35) and 13% Fatigue 207 had vomiting (27 cases). Jaundice 207 0% 20% 40% 60% 80% 100%

- Geographical distribution Cases Distribution by Sub-Discrits of cases: 143 cases were listed with known 100 90 46% addresses, while the rest 80 95 (64 cases) weren’t. 70 60 31% 50 Cases 40 64 30 20 10% 6% 4% 2% 1% 10 20 12 9 4 3 0 Afrin Ma'btali Sharan Bulbul Raju Jandairis Unknown Sub-district

Hepatitis A Outbreak Afrin District Page 4 of 8 Pages EWARN - Out of the cases with addresses, most of the Cases Distribution by Sub-Discrits cases were located in the 100 90 center of the city of Afrin 66% 80 95 (66%). The rest of the 70 cases were distributed in 60 50 Ma’btali (14%), Sharan Cases (8%) and Bulbul (6%). 40 30 20 14% 8% 6% 3% 2% 10 20 12 9 4 3 0 Afrin Ma'btali Sharan Bulbul Raju Jandairis Sub-district

The AJS epi-curve of Afrin district shows an increase in the number of AJS Epi-curve in Afrin District AJS cases in week 42 (39 cases), 140 127 hence the DLO was notified to 120 implement the verification. Week 100 43, the number of cases increased 80 60

significantly and reached to 127 AJS cses 39 cases, then there was a drop in the 40 20 8 9 7 9 next 2 weeks. 20 0 0 0 0 2 6 0 6 3 0 The peak in the trend could be W30 W31 W32 W33 W34 W35 W36 W37 W38 W39 W40 W41 W42 W43 W44 W45 explained by two factors, firstly, the Epi-week suspension of water station in Afrin during the month prior to the alert; secondly, a sensitization of AJS surveillance was carried out in the area recently.

Water and Sanitation Situation The team visited different places where the cases were originated from, which belong to Afrin, Sharan or Bulbul subdistricts. They conducted studies on the status of water and environmental sanitation in all visited places. Afrin sub-district During the month prior to the alert, the main water station (Matina station) in the city stopped, that led to the use of uncensored tankers as drinking-water sources; currently, the station has been rehabilitated by Bahar organization.

Hepatitis A Outbreak Afrin District Page 5 of 8 Pages EWARN The sanitation system uses a normal network. Waste management is done by Bahar organization regularly but not in a sufficient way. village also depends on the Matina station as the main source of drinking water. Some of the neighborhoods are totally dependent on tankers which carry water from Qara Tabah and Kafar Jannah villages. The sanitation method is a sanitary pit and an open sanitation network nearby wells. Qarizhail village is completely dependent on an uncontrolled well, there is a sanitary pit just 5 meters away from the well, and sanitation lines are open. Trendy camp is totally dependent on tankers, 80% of tankers sources are from Qurezhel village. The camp is random and there is no system for water sterilization. Sanitation is through sanitary pits. The public and personal hygiene are low. Supplement of water in Maabatly and Priyush villages is frequent and controlled. Bulbul and Sharan sub-district Water stations are not functioning in both sub-districts, and people depend on water tankers as a main source of drinking-water. There is a covered sanitation network in the sub-districts centers; however, in the villages, people depend on the sanitary pit or on an open network running towards the valley.

Summary - Some communities depend on water stations (Totally or partially) - The alternative source of drinking water is uncontrolled tankers and water transferred from uncontrolled wells. - General sterilization procedures are irregular. - Home sterilization procedures are not adequately implemented. - Sanitation system in the villages depends on sanitary pits (some of which is open). - The level of hygiene is low.

Actions Taken - Collect blood samples from some listed cases (35 samples) for laboratory confirmation. - Water tests were conducted in the main sources in the city of Afrin, in addition to, the well of Qanbar hospital, since there are several cases in the hospital neighborhood. - Collect water samples from the main reservoir of Qara Tabbah village. - Collect water samples from the main reservoir of Maabatly village. - In Qarzheel village, a sample of the well was collected and samples from the school tankers due to the increasing the AJS cases among students. - Distribution of awareness brochures and posters on AJS, water sterilization and hygiene procedures to health facilities and local population.

Hepatitis A Outbreak Afrin District Page 6 of 8 Pages EWARN - Recommendations have been delivered to health facilities in order to educate the cases and contacts about the importance of personal hygiene and the usage of safe drinking water.

Laboratory findings blood samples Most of laboratory samples (29) were positive (HAV IgM ). Results of water samples - Main sources in Afrin were safe for drinking. - The well, which supplies Qurzeihil village and Trendy camp was contaminated, as well as tankers in the schools. - The well in Kafar Jannah village and the reservoir in Qara Tabbah village were contaminated. - The well in Maabatly village was safe for drinking.

Interpretation of results - In Afrin city, there was a stoppage of the water station during the month preceding the notification, also, the team thinks there was no chlorination in water tankers, and low level of personal and public hygiene procedures. - The contaminated well that supplies Qurzehil village and Trendy camp, as well as the contamination of the village's school tankers was considered the major cause of the disease in those areas. Another problem in Terndy camp was that the tankers that supply the camp with drinking water, they were occasionally filled with uncleaned water supporting livestocks. - The contaminated well in Kafarjanna, which supplies Qibar village is a major cause of the disease in that village.

Hepatitis A Outbreak Afrin District Page 7 of 8 Pages EWARN Hypothesis of outbreak This outbreak was probably caused by the consumption of unsafe water due to the stop of the water station in Afrin city throughout the former month. The other possible factors in the rest of places in Afrin were the use of unchlorinated water tankers and the low level of hygiene and sanitation. The hypothesis can be supported by many contaminated water samples, and by the decrease of cases in Afrin city after rehabilitating the station. A case-control study is conducted to confirm or reject this hypothesis challenges - OCT was not able to conduct tests of all water sources since there are too many and scattered all over Afrin. - Some health facilities have no registers for cases documentation as required.

Recommendations - Secure safe water sources in Afrin district by supporting the operation of the water station in the city and to strengthen the control procedures for other water sources. - Implementation of water sterilization and environmental sanitation procedures in Trendy camp. - Communicate with the stakeholders working in Afrin district to open health facilities in the country. The fact that most of the health facilities are concentrated in the city, it caused difficulties to access cases. - Strengthen health education procedures. - Provide health facilities with registers for proper documentation.

Summary Hepatitis A outbreak occurred in Afrin district on Nov 2018. The laboratory was used for confirmation. It turned out that the drinking water and sanitation condition was bad due to the stop of water stations and to the dependence on unsafe and uncontrolled water sources, and finally due to the low level of hygiene and sanitation.

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