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Hepatitis a Outbreak Afrin District – Aleppo Governorate

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Hepatitis a Outbreak Afrin District – Aleppo Governorate Hepatitis A Outbreak Afrin District – Aleppo 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 Syria 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 Afrin subdistrict, 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% Hepatitis A Outbreak Afrin District Page 3 of 8 Pages EWARN - Sex distribution of registered cases: 53% were females (109 cases) and 45% were males (98 Sex Distribution cases). 98 Female 47% 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 50 31% Cases 40 64 30 20 10% 6% 4% 2% 1% 10 20 12 9 4 3 0 Afrin Ma'btali Sharan Bulbul
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