In response to a deadly Hepatitis E outbreak in South Sudan, Doctors Without Borders/Médecins Sans Frontières (MSF) has launched a mass vaccination campaign in collaboration with the Ministry of Health to safeguard women and girls of reproductive age, who are at greatest risk of death from the disease.

Since April 2023, 501 cases of Hepatitis E have been treated at the MSF hospital in Old Fangak, Jonglei state, and 21 people have died—mainly women. The fatality can be as high as 40 percent for pregnant women, and there is no cure, meaning that many people with advanced stages of illness do not survive. MSF's vaccination campaign is the first to be conducted during the acute stages of an active Hepatitis E outbreak anywhere in the world. It is made more challenging by the remoteness and isolation of the area of South Sudan where it is taking place. But if the campaign succeeds, it will save lives.

What is Hepatitis E? 
“Hepatitis E is a waterborne disease that can be fatal,” explains Mamman Mustapha, MSF’s head of mission in South Sudan. “Around 20 million people become infected every year, and of these, three million people experience symptoms that require treatment. However, not everyone is able to access treatment in time, especially in countries with limited health facilities like South Sudan. Even if people do eventually manage to get to a hospital, it is often too late. There is no cure for hepatitis E and sadly, 70,000 people die from the disease each year. This is why the vaccine is so important—it can save lives.”

The vaccine was developed in 2012 and has been approved for use in emergency settings by the World Health Organization (WHO) since 2015. However, despite its approval, it has only ever been used once: In 2022, the vaccine was used for the first time ever in a mass vaccination campaign carried out by MSF in Bentiu displacement camp, also in South Sudan, protecting over 25,000 people. The latest campaign in Fangak County builds on the experience in Bentiu, but the context is vastly different.  

Reaching people in flood-ravaged Old Fangak 
“Fangak County is situated in an extremely remote part of northern South Sudan on the Sudd marshes—a vast area of wetland dotted with small communities, where people have exceptionally limited access to even the most basic of health care,” Mustapha says. “Even getting our routine childhood vaccinations to Old Fangak is a challenge. It is only possible to reach the hospital by boat, using the River Nile, or by air. But the airstrip at Old Fangak has been flooded for the past four years, so we first had to fly the vaccines to a nearby village, and then transport them for a further 35 km [about 21 miles] along the river to our hospital. The vaccines need to be kept between 2 and 8 degrees Celsius, and although this is relatively easy at our hospital, it is a completely different ballgame trying to ensure that we do not break the cold chain during the eight hours it takes to reach some of the communities we are targeting with this campaign.” 

People in Fangak County were facing many challenges even before Hepatitis E began to claim people’s lives. Over the past four years, recurrent flooding has destroyed crops and drowned cattle. Villages that were previously accessible by foot have become islands, and people now have no choice but to use canoes to get from one place to another. Cases of malaria have increased because the floodwaters have not receded, leaving pools of stagnant water that have created the perfect breeding ground for mosquitoes. At the same time, cases of malnutrition have risen as people have had to change their diets, with many either learning to fish or resorting to eating waterlilies to survive. Now, they are facing a new threat as Hepatitis E spreads through the water that they drink and rely on for survival. 

"Reaching a health facility was already hard for people in this harsh environment—now, the flooding has made it even more difficult,” Mustapha says. “For many, an eight-hour journey by canoe is the only way to get to one, and it is likely that many do not attempt the journey due to the cost of transport and the long distance. We know for certain that 21 people have died from Hepatitis E during this current outbreak, but that is only because they were able to reach the hospital. It is very likely that many more people have passed away at home, without being able to even try and access treatment.” 

To prevent people from having to attempt this journey, MSF is trying to reach them first. It’s not without its challenges: “Some of the communities are so remote that at times we ourselves have had to use canoes to reach them,” says Mustapha. “We regularly use speedboats to get our mobile clinics to remote villages, but due to the location of the communities affected by the outbreak, we have had to adapt our regular activities to reach those who are at risk.”

Other barriers impede vaccine access
The limited availability of the Hepatitis E vaccine, which requires three doses, presents another challenge—as well as its high cost. Only one manufacturer in China is licensed to produce it, and the quantity is limited. It is also bulky compared to other vaccines, and therefore difficult to transport and store, particularly in hard-to-reach areas like Old Fangak. These challenges pose significant barriers when it comes to responding to disease outbreaks in emergency settings like South Sudan. MSF is calling for these barriers to be lifted, so that far greater numbers of people can be protected—especially women and girls. 

By June 2024, when the vaccination campaign is complete, MSF intends to have fully vaccinated 12,776 women and girls between the ages of 16 and 45. In addition to the vaccination campaign, we are carrying out case management and referrals at the MSF hospital, and conducting community awareness campaigns and epidemiological monitoring.

MSF urges international and local health and humanitarian organizations to take action to improve the water and sanitation conditions in Old Fangak by raising awareness, implementing proper sewage and sanitation facilities such as toilets and waste disposal systems, and drilling boreholes to ensure the availability of safe drinking water. This is vital for stopping the spread of Hepatitis E and preventing outbreaks in the future.