Infection Control & Hospital Epidemiology
preventable. A measles epidemic has been reported in Syria during the current period of unrest, particularly in the northern regions of the country such as Aleppo. An estimated 7,000 cases have been reported by the WHO and Médecins Sans Frontières (MSF) organizations: ~200 cases in 2013; 4,309 in 2014; 1,617 in 2015; only 85 cases in 2016; and an upsurge in 2017 with 733 laboratory-confirmed cases (Table 2).35,36 The measles epidemic disseminated to neighboring countries such as Jordan, where 24 cases were reported in 2012 and >4-fold more (>200 cases) were reported in 2013.37 These estimates declined to 38 by 2015. In addition, only 9 cases were reported among the Lebanese popu- lation in 2012, but this number increased to 1,760 by 2013. Then, the reported numbers of measles cases went down to 205 in 2014, to 39 in 2015, and to 44 in 2016. Such trends have been similar among the Syrian refugees in Lebanon: 232 measles cases were reported in 2013, 107 in 2014, 12 in 2015, and 18 in 2016.38 Moreover, a decline has been documented in the rates of
measles vaccinations in Yemen, which has reached as low as 41%.39 This vaccination decline resulted in increased numbers of cases, with >847 measles cases by December 2011; 2,143 cases in 2012; and 1,634 cases in 2017.40,41 Measles vaccination rates dropped nationwide in Syria from a
stable rate of 82% in 2010 to as low as 53% in 2015, dipping to 17% in some northern cities like Kobanî.42,43 Through December 2016, an estimated 4.56 million children had been immunized against measles in the accessible areas of the Syria, but despite all efforts, the national vaccination rates have remained low, reach- ing only 65% for 2016.35 To address this void, the WHO held health education conferences in areas considered to be at high risk because the resistance of parents hindered the immunization campaigns.35,36 Unfortunately, a muscle relaxant (atracurium) was accidently mixed up with a diluent used with the measles vaccine and caused the deaths of 17 children, thus causing further anxiety for parents needing to vaccinate their children.44 Vaccination campaigns are critically important to vulnerable populations in these areas of the world. However, the escalating conflicts in the northern areas of Iraq and Syria, as well as Yemen, are hampering these immunization campaigns significantly.
Table 3. Leishmaniasis Outbreaks Associated with Conflict in the Middle East
Infectious Disease
Cutaneous leishmaniasis Year
Geographic Area
2008 Iraq
Est. No. of Cases
1,250
Sources of Outbreak
∙ Mass population displacement, increasing numbers of Syrian refugees
∙ Sand fly, increasing rodents
2009 2011 2012
2012 Yemen 2012 Syria 2013 2014
2013 Lebanon
5,000 2,978 2,486 2,475
52,000 71,000 46,000 1,033
Exacerbating Factors
∙ Collapse of healthcare infrastructure
Proposed Interventions
∙ Spraying pesticides ∙ Using insect repellent ∙ Surveillance and vigilant monitoring of disease activity
Reference 52
Leishmaniasis
Leishmaniasis is transmitted to humans by the bites of infected female phlebotomine sand flies, and it constitutes a major public health problem in the eastern Mediterranean region (EMR).45 Four types of Leishmania spp cause most of these infections in humans; cutaneous leishmaniasis accounts for the largest number of cases. Globally, the estimated numbers of cases of leishmaniasis annually are 12 million for cutaneous leishmaniasis and 2.5 million for visceral leishmaniasis. Also, an estimated 1.5 million cases of cutaneous leishmaniasis and 500,000 cases of visceral leishmaniasis are reported annually among 88 countries.45,46 The EMR is an ill-defined geographical region in which most coun- tries have experienced some form of hostilities or civil war over the past 20 years, whether major invasions, internal strife, or cross-border clashes. This unrest has led to massive movements of populations, including refugees and military personnel, which have contributed to several outbreaks of cutaneous leishmaniasis. For decades, cutaneous leishmaniasis has been recognized as a skin-deforming infection transmitted by a sand fly. It is endemic in northern Syria, particularly Aleppo and Damascus.1 However, with the recent conflict in Syria, increasing violence from civil war, and terrorist activity leading to vast population displace- ment, an epidemic in 2012 involved >52,000 confirmed cases (Table 3).47,48 Despite leishmaniasis being endemic in Lebanon, a cutaneous
leishmaniasis outbreak began among Syrian refugees in Lebanon in September 2012, and by 2013, 1,033 cases had been confirmed; 97% of them were among Syrian refugees. The average age of these patients was 17 years, with 80% being <18 years old.44,49,50 In this particular outbreak, 85% of the cases were caused by L. tropica,a species epidemic to Aleppo that causes aggressive large, disfiguring lesions and a prolonged disease course that necessitates intramus- cular treatment.49 TheLebaneseMinistryofPublicHealth, in col- laboration with the WHO, launched a coordinated campaign to contain the spread of this infection, which included spraying pes- ticides to kill the vector, providing free treatment and diagnosis for new cases, establishing a referral system with 12 treatment clinics
1233
58 24
59 47 35
50
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