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Operation ‘Yellow Mama’: A model intervention of targeted pregnancy screening and home-hygiene item distribution in response to a hepatitis E outbreak in South Sudan Jan

1 Hajek ,

1 Weerdt ,

1 Meredith ,

Silvia de Caitlin Patricia Ian Ruby Siddiqui1, Louise Bishop1, and Vanessa Cramond1 1Médecins

Introduction Acute hepatitis E infection in pregnancy can be devastating with high risk of liver failure, maternal death, and fetal loss, particularly in the third trimester (average maternal case fatality rates = 20%).1 In August 2012, shortly after seasonal flooding and an influx of new refugees, several cases of acute jaundice were identified and a line list established. An outbreak of acute jaundice was recognized and on August 18 laboratory testing confirmed hepatitis E. In order to target the most vulnerable, and both intervene and assess the extent of the outbreak, the MSF team implemented operation yellow mama: a targeted 4-day screening, education and home hygiene-related item distribution for all of the pregnant women in Jamam refugee camp.

Aim To provide a descriptive review of the intervention in order to guide future hepatitis E outbreak responses.

Jamam Camp

Outbreak timeline Date


26 - 29 May

2 post-partum maternal deaths with jaundice. Cause of illness not established, hepatitis E not considered. 4 patients with acute jaundice hospitalized. 1 blood sample sent to MoH lab (results not received) Line list started for cases of acute jaundice Blood samples taken 3 new cases of acute jaundice MSF does 4-day blanket feeding of all children and their mothers in Jamam camp. Only 1 woman with jaundice was detected (not pregnant) First cluster of cases of acute jaundice (4 cases) detected by outreach workers in Midelik, Jamam Hepatitis E is confirmed. MSF team notified of positive IgM results for samples sent on 7 August Meeting with UNHCR to share results and line list Second cluster (8 cases) identified in Malefa, Jamam Meeting in Juba to discuss results with MOH/WHO Third cluster (9 cases) identified in Belmet, Jamam First mapping done with line list Pregnant woman screening in Jamam

27 July – 3 August 3 August 7 August 9-12 August 17 August 18 August 19 August 21 August 22 August 23 August 27 August 29 August – 1 September

5 5 8 12 21 21 21 29 31 46 68 159

1 Woolley ,

sans Frontières

Results and Discussion

Epi Curve

359 pregnant women were assessed over 4 days: - 102 (28%) were estimated to be in the 3rd trimester - 224 (62%) had a documented prior ANC visit

According to most recent figures (29/4/2013), there were a total of 2,075 cases of acute jaundice in Jamam camp. The two figures below illustrate the epidemiological curve and the increased case fatality in pregnant women:

1.4% (5/359) had acute jaundice In-hospital deliveries increased the week following the intervention (figure below). This was not a consistent trend, perhaps in part due to relocation movements of many refugees to other camps in the following weeks.


The intervention

Reported total number of acute jaundice cases and deaths as of April 29

Through a meeting with village leaders, all pregnant women were invited for screening at a central location. Basic demographic information was recorded for each woman and a midwife assessed stage of pregnancy and presence of jaundice. Women with jaundice were further assessed by a doctor for possible admission. Other than urinalysis, no laboratory testing was performed. All women attended educational sessions and were given a token to redeem for a bucket with lid, a collapsible jerry can and additional bars of soap.

Located in the North-East corner of South Sudan. In August 2012, the estimated total camp population was 21,584.

Outreach workers register pregnant women and record demographic data (name, age, village) on the assessment form.

Follow-up of individual women was incomplete and their individual outcomes and subsequent risk of jaundice following the screening could not be determined. Estimation of number of pregnant women: The number of pregnant women that presented for screening was lower than expected based on estimates calculated according to the Reproductive Health in Humanitarian Settings Field Manual (359 vs 604 women).

Clinical risk assessment: . Midwife performs screening for jaundice and estimates gestational age.

!Pregnant!women! Non@pregnant! women! Men!

Number!of! Documented! cases! deaths! 67! 7!

Case! fatality! 10.4%!








Of interest, in the following week, outreach workers did not identify any additional pregnant women in the camp that had missed the screening.

Mapping of cases Map of Jamam camp The size of the red dot represents the total number of cases. This illustrates the widespsread distribution of cases early after initial outbreak recognition.

Cumulative cases 2

1 Günther ,

Management and predicting outcome of pregnant women with jaundice was difficult. One pregnant woman with recent onset jaundice reported only anorexia and malaise. Outpatient follow-up was recommended. However, just 3 days later, she was carried to the hospital by her family in a coma and she died very soon after.

Conclusion The current response to hepatitis E outbreaks is largely limited to basic sanitation measures due to lack of available vaccine or antiviral therapy. Operation Yellow Mama was a unique intervention that combined targeted medical screening, education sessions, and distribution of non-food items to pregnant women at the beginning of a hepatitis E outbreak. The majority of pregnant women in the camp were reached. However, the actual impact of the intervention on morbidity and mortality and whether it should be repeated in subsequent outbreaks could not be determined.

Acknowledgements: Ludovic Dupuis, for producing the map of cases. References: Rein et al. Hepatology 2012;55:988-997.

Operation ‘Yellow Mama’:A model intervention of targeted pregnancy screening and home-hygiene