Three vaccinations you didn’t know were a priority in women’s health

Hepatitis E, tetanus and hepatitis B all pose significant but under-reported threats to the health and lives of women and girls, especially in low-income countries with limited access to healthcare. This can also mean life or death for their babies.

Nyakuola Nguot Gang lives with her extended family in Fangak County, South Sudan, where a deadly hepatitis E outbreak started in 2023 and continued through 2024. 

“I almost lost my life while I was pregnant, in September,” says 40-year-old Nyakuola. “I thought it was only symptoms of my pregnancy, because my body was aching and I had a fever. I went for a blood test, and that’s when hepatitis E was discovered.”

Some diseases have far greater negative consequences in women and girls, especially during pregnancy and childbirth. Hepatitis E, a water-borne infection that affects the liver, is one of them. 

 “A lot of people call it the Ebola for pregnant women, because you have a really high mortality rate in pregnant women, although we don’t really understand why it affects pregnant women so much,” says John Johnson, vaccination advisor for Médecins Sans Frontières/Doctors Without Borders (MSF). 

 The mortality rate is around 20 to 30 per cent in pregnancy.” 

For pregnant women with hepatitis E, the risk of death is highest in the third trimester.

Pregnancy is also a critical time for vaccinating women and girls against tetanus if they haven’t been vaccinated before. A serious infection for people of any age, tetanus is deadly for newborns, but protecting the mother is lifesaving for her baby.

A third, lesser-known disease of concern is hepatitis B. If not prevented, it has lifelong, and life-limiting, consequences.  

Both hepatitis B and tetanus pose significant health threats for victim-survivors of sexual violence, who are many times more likely to be women and girls. 

The good news is that there are vaccines available, but the reality is that they’re not reaching everyone who needs them, especially the women and girls who are most at risk.

A groundbreaking vaccination campaign in South Sudan

Hepatitis E is the most common cause of acute viral hepatitis, linked to approximately 20 million infections and 70,000 deaths per year. 

This under-recognised disease predominantly affects people experiencing poverty or disadvantage – and is especially dangerous for pregnant women. It is transmitted through faecal contamination of food and water. Large-scale outbreaks typically occur when water and sanitation conditions are inadequate. 

There is only one vaccine available, HEV 239, developed in China. MSF first piloted its use in an epidemic in Bentiu, South Sudan, in 2022, and through subsequent research has generated strong evidence of its safety and effectiveness.

Fangak County is one of the most remote and difficult to access areas of South Sudan. With the area inundated by recurrent floods in recent years, its people have had to learn to survive in a changing environment. 

“We are surrounded by water in all aspects,” says Fangak resident Bhan Gutjiath Wal. “You go to the market, you go through water. You stay at home, there is water too.”   

But in September 2023, these conditions led to an outbreak of hepatitis E, declared by the Ministry of Health. Within two months, MSF launched only the second vaccination campaign in the world reacting to an active hepatitis E outbreak, and the first-ever during the acute stage of an outbreak in such remote and hard-to-reach communities. This joint undertaking with the Ministry of Health eventually spanned almost a year.

“It was a personal decision to get vaccinated,” says Nyakuola. “Those who have witnessed people who have been vaccinated and live have made the decision to also get the vaccine. Thank God I was vaccinated, that’s why I got better. But it was bad.”

Sharing lifesaving protection against tetanus between mother and baby

“Babies, especially in what we call the neonatal period, in their first 28 days – that is when they're most susceptible to death from certain diseases and infections. So providing mothers with vaccinations gives them a little bit of protection until they can receive their vaccine later in life,” explains Isabella Mayes, midwifery activity manager in MSF’s Old Fangak project.

If a woman is vaccinated against tetanus before she gives birth, lifesaving antibodies will transfer through the placenta into the baby’s blood.

The bacteria that causes tetanus is widespread in the environment and cannot be eradicated. The risk to newborns occurs when the cut umbilical cord is infected, usually due to unsterile tools or conditions. 

Known also as lockjaw, tetanus limits a baby’s ability to feed. The rigidity spreads through the whole body, and the baby’s muscles spasm uncontrollably. A baby will need intensive nursing care and isolation in a dark and quiet room to prevent reactive spasms, hospitalised for up to a month. 

Untreated, some 90 per cent of affected newborns will die.

An estimated 24,000 newborns died of tetanus in 2021, according to the most recent global data available. While this figure represents a gradual decline over time, it tells us that women and girls continue to miss out on vital vaccinations, antenatal care and safe delivery care, especially in low-income countries. 

Access to healthcare in South Sudan is extremely limited. MSF's hospital in Old Fangak is the only facility of its kind providing care to the 20,000 people in the immediate vicinity, as well as in villages only reachable hours away by boat. This includes maternal immunisation as part of antenatal care. 

Timely protection in victim-survivors of sexual violence

The value of post-exposure vaccination is highlighted in sexual violence care. A victim-survivor can be protected against both tetanus and hepatitis B after an assault or rape, but the window of opportunity to kickstart immunity is only 72 hours.

We [vaccinate] every patient that had any wounds. We just do it immediately to prevent the disease because [tetanus] is really very serious,” says Renda Kella Dhol, a clinical officer in MSF’s team in Old Fangak.

Hepatitis B is often transmitted through sexual contact. It is up to 100 times more infectious than HIV, another sexually transmitted infection often associated with sexual violence. “We don't know the status of the perpetrator. That's why we provide hepatitis B [vaccine] to prevent the patient from being infected by hepatitis B,” says Renda.

Hepatitis B virus often causes a long-term infection. It is a major public health problem, with an estimated 254 million people chronically infected and 1.1 million deaths worldwide in 2022 from hepatitis B-related liver disease, including liver cancer. 

A woman can also unknowingly pass it on during childbirth to her baby, who will also need vaccination to avoid a 90 per cent likelihood of death.

To raise awareness about sexual violence and the medical and psychological care available, MSF conducts health promotion in schools and other places where people gather, among community leaders and with the police.