Hepatitis Outbreak Laid to Water and Sewage Failures

[ As reconstruction monies are diverted to “security” … –BL ]

September 25, 2004 | New York Times


BAGHDAD, Iraq, Sept. 24 – A virulent form of hepatitis that is especially lethal for pregnant women has broken out in two of Iraq’s most troubled districts, Iraqi Health Ministry officials said in interviews here this week, and they warned that a collapse of water and sewage systems in the continuing violence in the country is probably at the root of the outbreak. The disease, called hepatitis E, is caused by a virus that is often spread by sewage-contaminated drinking water. The officials said they had equipment to test only a limited number of people showing symptoms, suggesting that only a fraction of the actual cases have been firmly diagnosed. In Sadr City, a Baghdad slum that for months has been convulsed by gun battles between a local militia and American troops, the officials said as many as 155 cases had turned up.

The second outbreak is in Mahmudiya, a town 35 miles south of Baghdad that is known for its kidnappings and shootings as well as for its poverty, where there are an estimated 60 cases. At least nine pregnant women are believed to have been infected, and one has died. Five deaths have been reported over all.

“We are saying that the real number is greatly more than this, because the area is greatly underreported,” said Dr. Atta-alla Mekhlif Al-Salmani, leader of the viral hepatitis section at Health Ministry’s Center of Disease Control.

The World Health Organization is rushing hepatitis E testing kits, water purification tablets, informational brochures and other materials to Iraq, said Dr. Naeema Al-Gasseer, the W.H.O. representative for Iraq, who is now based in Amman, Jordan.

But viral hepatitis comes in many forms, and another ominous set of statistics suggests that the quality of water supplies around the country has deteriorated since the American-led war began last year, Dr. Salmani said. In 2003, 70 percent more cases of hepatitis of all types were reported across Iraq than in the year before, he said. During the first six months of 2004, as many cases were reported as in all of 2002.

In yet another indication of the deteriorating safety of water and food in Iraq, the number of reported cases of typhoid fever is up sharply this year, said Dr. Nima S. Abid, the ministry’s director general of public health and primary health. Hospitals across the country are also full of children with severe forms of diarrhea, Dr. Abid said.

Those reports come as the Bush administration has proposed shifting $3.46 billion in reconstruction money for Iraq to programs that would train and equip tens of thousands of additional police officers, border guards and national guardsmen in hopes of regaining control of the security situation. The shift, which needs approval by Congress, would gut what had been an ambitious program to rebuild Iraq’s crumbling water and sewage systems, forcing the cancellation or delay of most of the projects. Last fall, Congress approved $18.4 billion for Iraq’s reconstruction; so far, only about $1 billion has been spent.

“The problem is the whole infrastructure,” Dr. Abid said of the mounting health problems, adding that many of the difficulties stemmed from neglect that began long before the invasion. But he said, “Definitely no major intervention has been done in this last one and a half years to repair the problem.”

Viral hepatitis comes in numerous forms and with a variety of consequences, from benign to fatal. The most common type, hepatitis A, can be spread from person to person or through contaminated water. Like all forms of the disease, it infects liver cells and can cause jaundice and other symptoms, but there is often no permanent damage after recovery, said Dr. William Schaffner, chairman of the Department of Preventive Medicine at the Vanderbilt University Medical Center in Nashville.

Though it is also spread through water, hepatitis E, for reasons that are not well understood, is most dangerous for pregnant women, who can lose their unborn children and die, Dr. Schaffner said. He said the disease was found mainly in Central America, India and the Middle East.

There is no vaccine to prevent the disease or standard drug regimen to treat it.

The immediate reason for the outbreaks in Sadr City and Mahmudiya appear easy to pin down, Dr. Abid said. The lack of infrastructure induces families to tap into water mains with improvised hoses, he said, citing his own visits to the communities. Small electric pumps are then used to suck water into homes. But in these same communities, sewage either seeps from damaged pipes into the ground or runs freely in the streets, then through cracks and holes into people’s houses. Sewage is sucked in too, becoming mixed with the drinking water and spreading the virus.

An assistant to the director general for water for the Baghdad municipality, who asked to be identified only as Khalid, said that a major water project had been under way for Sadr City, but that poor security had made it impossible to proceed.

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