Infection Control & Hospital Epidemiology (2018), 39, 1230–1236 doi:10.1017/ice.2018.177
Review
Emerging outbreaks associated with conflict and failing healthcare systems in the Middle East
Issam I. Raad MD1,Anne-MarieChaftariMD1, Rita Wilson Dib MD1,
EdwardA.Graviss PhD, MPH2 and Ray Hachem MD1
1Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas M. D. Anderson Cancer Center, Houston, Texas and 2Department of Pathology and Genomic Medicine, Houston Methodist Research Institute, Houston, Texas
Abstract
The escalating conflicts in the Middle East have been associated with the rapid collapse of the existing healthcare systems in affected countries. As millions of refugees flee their countries, they become vulnerable and exposed to communicable diseases that easily grow into epidemic crises. Here, we describe infectious disease epidemics that have been associated with conflicts in the Middle East, including cholera, poliomyelitis, measles, cutaneous leishmaniasis, and diphtheria, that call for appropriate preventive measures. Local ongoing wars and failing healthcare systems have resulted in regional and global health threats that warrant international medical interventions.
(Received 30 May 2018; accepted 3 July 2018; electronically published August 13, 2018)
The escalating conflicts in the Middle East, particularly in Syria and Iraq, have been associated with a rapid collapse of their existing healthcare systems, resulting in public health cata- strophes.1 The devastation resulting from intensifying civil and regional wars in these countries has introduced alarming and self-perpetuating epidemics that have disseminated rapidly within the regions and have the potential to spread globally, creating even greater health emergencies. In places like Iraq, Syria, and Yemen, the fighting and destruction have created favorable environments for the spread of these epidemics through widespread contamination of the water, disruption in food supplies, poor sanitation conditions, and massive displacement of large segments of the population. These conditions have resulted in overcrowding of refugees, which has been compounded by the lack of concerted and systematic public health responses.1–3 More than 10 million Syrians have been displaced, including 6.1 million within Syria and 4.8 million in bordering countries.4 Furthermore, the concurrent collapse of the public health and healthcare system in Syria has not only perpetuated the regional dissemination of several epidemics, but it has also prevented the implementation of effective infection control measures. Several factors have contributed to the collapse of the
healthcare system in Syria. These include, but are not limited to economic sanctions; wide destruction of healthcare facilities; shortage of healthcare personnel associated with large-scale immigration of healthcare workers and, at times, their physical elimination or injury; lack of access to essential drugs and medical
Author for correspondence: Dr Issam I. Raad, Department of Infectious Diseases,
Infection Control and Employee Health, Unit 1460, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030. E-mail:
iraad@mdanderson.org
Cite this article: Raad II, et al. (2018). Emerging outbreaks associated with conflict
and failing healthcare systems in the Middle East. Infection Control & Hospital Epidemiology 2018, 39, 1230–1236. doi: 10.1017/ice.2018.177
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved.
supplies; and lack of secure routes and transportation.1,5 Sanctions (among other things) leading to interruptions in the power supply have contributed to interruptions in vaccination programs.6 The World Health Organization (WHO) has esti- mated that 40% of the ambulances in Syria have been ruined; 57% of public hospitals are severely damaged; and 37% are out of service.1 Another report has indicated that at least 160 physicians have been killed in Syria alone, while hundreds others have been jailed or kidnapped, resulting in the massive migration of >80,000 physicians.5 In addition, prior to the Syrian war, 90% of phar- maceutical needs were locally produced, and this has been reduced to only 10% presently. The problem has been com- pounded by an extreme shortage of pharmaceutical supplies from outside the country due to the lack of safe uninterrupted trans- portation as well as the sanctions imposed.2,5 In the following sections, we briefly describe several infectious
disease outbreaks that have occurred in the Middle East and that are perpetuated by deteriorating healthcare systems associated with local and regional conflicts. The resulting deficient hygiene, sanitation, and water supplies in the affected areas have major health implications and have imposed a massive disease burden. We also review the interventional efforts reported and outline the preventive measures implemented in the affected areas where possible.
Cholera
Cholera is unique among waterborne bacterial infectious diseases in its potential to cause pandemics. Over the last 200 years, the world has witnessed 7 pandemics of cholera. We are currently in the second and the third waves of the seventh cholera pandemic attributed to a Vibrio cholerae O1 el Tor strain.7 Notably, the second wave of the seventh pandemic was associated with the acquisition of additional antibiotic resistance, and the third (ie, current) wave has been associated with the acquisition of a
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