Health of migrants, refugees and asylum seekers in detention in Tripoli, Libya, 2018-2019: Retrospective analysis of routine medical programme data.

Libya is a major transit and destination country for international migration. UN agencies estimates 571,464 migrants, refugees and asylum seekers in Libya in 2021; among these, 3,934 people are held in detention. We aimed to describe morbidities and water, hygiene, and sanitation (WHS) conditions in detention in Tripoli, Libya. We conducted a retrospective analysis of data collected between July 2018 and December 2019, as part of routine monitoring within an Médecins Sans Frontières (MSF) project providing healthcare and WHS support for migrants, refugees and asylum seekers in some of the official detention centres (DC) in Tripoli. MSF had access to 1,630 detainees in eight different DCs on average per month. Only one DC was accessible to MSF every single month. The size of wall openings permitting cell ventilation failed to meet minimum standards in all DCs. Minimum standards for floor space, availability of water, toilets and showers were frequently not met. The most frequent diseases were acute respiratory tract infections (26.9%; 6,775/25,135), musculoskeletal diseases (24.1%; 6,058/25,135), skin diseases (14.1%; 3,538/25,135) and heartburn and reflux (10.0%; 2,502/25,135). Additionally, MSF recorded 190 cases of violence-induced wounds and 55 cases of sexual and gender-based violence. During an exhaustive nutrition screening in one DC, linear regression showed a reduction in mid-upper arm circumference (MUAC) of 2.5mm per month in detention (95%-CI 1.3-3.7, p<0.001). Detention of men, women and children continues to take place in Tripoli. Living conditions failed to meet minimum requirements. Health problems diagnosed at MSF consultations reflect the living conditions and consist largely of diseases related to overcrowding, lack of water and ventilation, and poor diet. Furthermore, every month that people stay in detention increases their risk of malnutrition. The documented living conditions and health problems call for an end of detention and better protection of migrants, refugees and asylum seekers in Libya.

Seroprevalence and risk factors of recent infection with hepatitis E virus during an acute outbreak in an urban setting in Chad, 2017.

BACKGROUND: From September 2016-April 2017, Am Timan, Chad, experienced a large HEV outbreak in an urban setting with a limited impact in terms of morbidity and mortality. To better understand HEV epidemiology in this context, we estimated the seroprevalence of anti-HEV antibodies (IgM and IgG) and assessed the risk factors for recent HEV infections (positive anti-HEV IgM) during this outbreak. METHODS: A serological survey using simple random sampling was implemented in Am Timan at the tail-end of the outbreak (sample size aim = 384 household). Household members provided us with blood samples and household heads answered questions around water, sanitation and hygiene practices and animal ownership. Blood samples were tested for HEV IgG and IgM antibodies using Enzyme-Immune-Assay (EIA). We calculated weighted prevalence estimates and prevalence ratios (PRs) for possible risk factors for recent infection using multivariate Cox regression. RESULTS: We included 241 households (1529 participants). IgM prevalence decreased with age: 12.6% (< 5 years) to 4.3% (> 15 years). IgG prevalence increased with age: 23.5% (< 5 years) to 75.9% (> 15 years). Risk factors for recent HEV infections included: sharing the sanitation facility with other HHs (PR 1.72; 95%CI: 1.08-2.73), not systematically using soap for HW (PR 1.85; 95%CI: 1.30-2.63) and having animals sleeping inside the compound (PR 1.69; 95%CI: 1.15-2.50). CONCLUSIONS: Evidence suggests that Am Timan was already highly endemic for HEV before the outbreak, potentially explaining the limited extent of the outbreak. Recent infection with HEV was linked to household level exposures. Future HEV outbreak response must include ensuring access to safe water, and reducing household level transmission through active hygiene and sanitation promotion activities.

Learning from water treatment and hygiene interventions in response to a hepatitis E outbreak in an open setting in Chad.

In September 2016, Médecins Sans Frontières responded to a hepatitis E (HEV) outbreak in Chad by implementing water treatment and hygiene interventions. To evaluate the coverage and use of these interventions, we conducted a cross-sectional study in the community. Our results showed that 99% of households interviewed had received a hygiene kit from us, aimed at improving water handling practice and personal hygiene and almost all respondents had heard messages about preventing jaundice and handwashing. Acceptance of chlorination of drinking water was also very high, although at the time of interview, we were only able to measure a safe free residual chlorine level (free chlorine residual (FRC) ≥0.2 mg/L) in 43% of households. Households which had refilled water containers within the last 18 hours, had sourced water from private wells or had poured water into a previously empty container, were all more likely to have a safe FRC level. In this open setting, we were able to achieve high coverage for chlorination, hygiene messaging and hygiene kit ownership; however, a review of our technical practice is needed in order to maintain safe FRC levels in drinking water in households, particularly when water is collected from multiple sources, stored and mixed with older water.

A large outbreak of Hepatitis E virus genotype 1 infection in an urban setting in Chad likely linked to household level transmission factors, 2016-2017.

BACKGROUND: In September 2016, three acutely jaundiced (AJS) pregnant women were admitted to Am Timan Hospital, eastern Chad. We described the outbreak and conducted a case test-negative study to identify risk factors for this genotype of HEV in an acute outbreak setting. METHODS: Active case finding using a community based surveillance network identified suspected AJS cases. Pregnant or visibly ill AJS cases presenting at hospital were tested with Assure® IgM HEV rapid diagnostic tests (RDTs) and some with Polymerase Chain Reaction (PCR) in Amsterdam; confirmed cases were RDT-positive and controls were RDT-negative. All answered questions around: demographics, household makeup, area of residence, handwashing practices, water collection behaviour and clinical presentation. We calculated unadjusted odds ratios (ORs) and 95% confidence intervals (95% CI). RESULTS: Between September and April 2017, 1443 AJS cases (1293 confirmed) were detected in the town(attack rate: 2%; estimated 65,000 population). PCR testing confirmed HEV genotype 1e. HEV RDTs were used for 250 AJS cases; 100 (40%) were confirmed. Risk factors for HEV infection, included: having at least two children under the age of 5 years (OR 2.1, 95%CI 1.1-4.3), having another household member with jaundice (OR 2.4, 95%CI 0.90-6.3) and, with borderline significance, living in the neighbourhoods of Riad (OR 3.8, 95%CI 1.0-1.8) or Ridina (OR 3.3, 95%CI 1.0-12.6). Cases were more likely to present with vomiting (OR 3.2, 9%CI 1.4-7.9) than controls; possibly due to selection bias. Cases were non-significantly less likely to report always washing hands before meals compared with controls (OR 0.33, 95%CI 0.1-1.1). DISCUSSION: Our study suggests household factors and area of residence (possibly linked to access to water and sanitation) play a role in HEV transmission; which could inform future outbreak responses. Ongoing sero-prevalence studies will elucidate more aspects of transmission dynamics of this virus with genotype 1e.