Namibia's Nationwide Hepatitis E Outbreak, 2017–2020

In September 2017, Namibia's Ministry of Health and Social Services (MoHSS) noticed a rise in cases of acute jaundice in Khomas region, which includes the capital, Windhoek. The cause was hepatitis E, a liver disease caused by the hepatitis E virus, which spreads by the fecal-oral route. Hepatitis E is rarely fatal, but it can be severe in pregnant women, causing sudden liver failure and death.

The outbreak

The MoHSS declared an outbreak in Khomas on December 14, 2017. It grew into a long-running nationwide epidemic, centered on informal settlements with poor sanitation. By February 2, 2020, 7,247 cases had been reported, and all 14 of Namibia's regions had detected cases.

Cases were counted through surveillance, active case finding and health facility records, and classed as:

• 59% of cases were male, and 72% were aged 20–39.
• 61 people died (0.8%), including 24 pregnant or postpartum women — a maternal case fatality rate of 6%.
• 6,068 cases (84%) came from Khomas and Erongo regions, which have large informal settlements; 2,677 came from three of the largest — Havana and Goreangab in Khomas, and the Democratic Resettlement Community in Erongo.

Hepatitis E cases (N = 7,247) by week of detection and region. CDC figure.

Why informal settlements

Rural-to-urban migration has led many low-income workers to live in informal settlements with substandard housing and poor sanitation. The government estimates that about 40% of urban households are in informal settlements with minimal infrastructure, limited latrines and piped water, and poor hygiene. While Namibia's population grows about 1.4% a year, informal settlements have been growing 8%–15% a year.

The response

CDC's Namibia office gave technical help from the start, and an expanded CDC team joined in October 2018. With international partners, CDC helped the MoHSS strengthen surveillance and data management by standardizing case lists, training 54 staff in four national sessions, redesigning situation reports for clearer communication, and supporting outbreak control and prevention.

This was the third hepatitis E outbreak described in Namibia since 1983, the largest, and the first nationwide. Stopping it requires better hand hygiene and sanitation and access to safe water — urgent given the danger to pregnant women. Efforts in the hardest-hit areas were improving latrine access and use through Community-Led Total Sanitation.

Sources

• Bustamante ND, Matyenyika SR, Miller LA, et al. "Notes from the Field: Nationwide Hepatitis E Outbreak Concentrated in Informal Settlements — Namibia, 2017–2020." Morbidity and Mortality Weekly Report 69(12), Centers for Disease Control and Prevention.
• The percentages the report gives for each case category do not quite match its case counts; this page gives the counts only.