1232
the Office of Foreign Disaster Assistance (OFDA), are working on optimizing their surveillance systems to be able to detect, inves- tigate, and intervene adequately when an outbreak is suspected.24 The WHO and partners recently directed a cholera risk assess- ment program to classify cholera into 4 risk categories based on (1) population density, (2) access to clean water and sanitation, (3) level of service in camps, and (4) direct exposure to conflicts. This effort aimed at predicting future outbreaks during these presumably high-risk periods.25
Poliomyelitis
In 2014, the WHO estimated that more than 7,600 Syrians were infected with poliomyelitis, with subsequent spread of the infec- tion to Iraq (Table 2).26 This outbreak occurred after 15 years of eradication of poliomyelitis in Syria during the preconflict era.27 Most of the polio reported in Syria occurred in the northeastern province of Deir El Zur, which was the epicenter of the out- break.26 However, several other cases were reported in the rural areas of Damascus, Aleppo, and other rural regions. Poliomyelitis is a virus that lives in sewage-contaminated water
and food. Hence, several war-related factors contributed to this poliomyelitis outbreak. First, particularly during the war, raw sewage was pumped directly into the Euphrates River, which provides drinking and wash water to many villages. This occurred simulta- neously with the discontinuation of chlorination of previously potable water.28 Second, poliomyelitis is a vaccine-preventable disease, and the vaccination coverage in Syria dropped from ~91% in 2010 before the conflict to as low as 45% by 2013.3 An estimated 58% of the polio cases reported in children during the outbreak in Syria and Iraq had never received the polio vaccine.29 Third, several boosters of polio vaccines are required to confer protective immu- nity, which impedes the success of polio vaccination programs. Incomplete vaccination was reportedin37% of thechildrenwith
Infectious Disease
Year
Geographic Area
Poliomyelitis 2014 Syria
Est. No. of Cases
7,600
Sources of Outbreak
∙ Inadequate vaccination ∙ Overcrowded living quarters
∙ Poor sanitation and hygiene
Measles 2013–2016 Syria 7,000
∙ Lack of or inadequate vaccination
∙ Crowded refugee camps Jordan Lebanon
Syrian refugees in Lebanon
Hepatitis A
2012–2017 Yemen 2015 Syria
373
2,078 369
5,773
49,300 ∙ Poor sanitation and hygiene
∙ Crowded refugee camps ∙ Lack of or inadequate vaccination
∙ Collapse of healthcare system
∙ Restricted access to care
∙ Proper hand hygiene ∙ Health education sessions ∙ Early detection
∙ Collapse of healthcare system
∙ Restricted access to care
Issam I. Raad et al
polio in Syria and Iraq in October 2013.29 In addition to the war- related factors described above, overcrowding of tens of thousands of displaced and refugee populations inside and outside Syria has occurred. This population has limited healthcare access, unsanitary living conditions, and limited (or no) access to communicable dis- ease vaccinations.1 In addition, the strain of poliomyelitis in Syria has been linked
to a wild-type strain found in Pakistan, which is suspected to have been introduced into Syria by a jihadist fighter from Pakistan.30,31 The dissemination of this virus within the region has also been reported; cases of polio have been described in Lebanon, Jordan, as well as Iraq.32 Polio in Syria has been declared a public health emergency that requires international efforts and solidarity to prevent a global epidemic. Fortunately, this outbreak was successfully contained and interrupted within 6 months through the imple- mentation of proper surveillance measures. After multiple vaccina- tion campaigns in Syria,monitoring coverage improved from 79% in December 2013 to 93% in March 2014.29 Thelast caseofpolio in Syria was reported in January 2014. A similar positive response was also seen in Iraq. In addition to providing humanitarian aid, health hygiene, clean water and sanitation, as well as facilitating healthcare delivery and vaccination, a high level of systematic surveillance should be maintained to prevent further outbreaks.29,33 No polio cases have been documented in Yemen since the
beginning of the conflict. To maintain the polio-free status achieved in Yemen in 2006, and after the last immunization campaign in April 2016, a nationwide polio immunization cam- paign was launched in February 2017, targeting the general population and particularly children in high-risk groups.34
Measles
Measles is a highly contagious viral illness that has a high effi- ciency of airborne transmission, but the disease is vaccine
Table 2. Viral Outbreaks (Polio/Measles) Associated with Conflict in the Middle East Exacerbating Factors
∙ Collapse of healthcare system ∙ Sloppy surveillance
Proposed Interventions
∙ Hygiene medicine and environmental health: decontaminating water, treating sewage, and restoring sanitation.
∙ Routine immunization (Sabin oral and Salk inactivated poliovirus vaccines) ∙ Surveillance for acute flaccid paralysis
∙ Vaccination campaigns and access to care
∙ Active surveillance
37 38
35
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