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across Lebanon, and producing public awareness and health edu- cation materials.1 However, controlling the source of this infection in northern Syria, particularly in and around Aleppo, has not been possible because of the conflict in that area. Recently, due to dif- ferent war-related factors, new outbreaks have been reported from different areas bordering Syria, including Turkey and Iraq.51 Cutaneous leishmaniasis is a neglected disease in Yemen due
to the lack of awareness of the natural course of the disease and the possibility of medical treatment. Despite poor documentation and underestimation of its burden, this disease seems to be endemic in this country—it occurs nationwide.46 The interrup- tion of healthcare services, the poor housing conditions, the current armed conflict in Yemen, the human migration from cities to villages, the arrival of refugees from other endemic countries such as Iraq and Syria, the absence of active detection and national reporting systems, and the lack of systematic national efforts to control the disease are all risk factors for enhanced transmission of cutaneous leishmaniasis in Yemen.46 Effective treatment accom- panied by measures for prevention of reinfection should reduce the incidence of anthroponotic cutaneous leishmaniasis. Control of cutaneous leishmaniasis in Yemen should be based on the best knowledge of the Leishmania parasite species and of different reservoir hosts and vector behaviors so that effective control measures can be undertaken. To address the problem of leish- maniasis in the EMR in the future, collaborative efforts with the WHO and supporting ministries of health of the regions should be undertaken through a strategic plan that includes the following measures: establishing a regional surveillance system, imple- menting training strategy, allocating appropriate resources for early detection, providing free medication, and facilitating sub- regional collaboration.52
Diphtheria
Diphtheria is a bacterial infection caused by Corynebacterium diphtheria that can result in respiratory and cutaneous diseases. It can be transmitted through respiratory secretions or skin lesions of affected patients or asymptomatic carriers. Since the intro- duction of the diphtheria vaccine, the disease has become rare in developed countries. However, diphtheria is resurging in devel- oping countries as a result of poor socioeconomic status; com- promised healthcare infrastructure; poor access to care; and shortages of vaccines, antitoxins, and antibiotics. In addition to the other disease outbreaks reported in Yemen, the WHO and Reuters have reported a large outbreak of diphtheria affecting close to 500 people since August 2017, with rapid spread in multiple governorates and a high fatality rate of 10%, particularly in children.53–55 The armed conflict and imposed blockade of Yemen’s ports has resulted in shortages of food and medical supplies, poor access to care, the inability to perform the required diagnostic laboratory testing, and a decline in the rate of vacci- nation (>60% of the suspected cases had not received any vac- cination). The MSF are working with the WHO to allow diagnostic laboratory testing on suspected cases to identify cases that require isolation, to provide treatment and antitoxins, and to provide prophylaxes to the patients’ close contacts.
Other infectious diseases
Clusters of hepatitis A outbreaks have been reported during the Syrian conflict over the last 2 years, particularly among
Issam I. Raad et al
displaced Syrian populations. An outbreak of hepatitis A among Syrian refugees in northern Iraq in 2013 was halted by the efforts of the WHO, other international organizations, and local health authorities to improve conditions in the camps.56 Across Syria, 49,300 cumulative cases of hepatitis A were reported in 2015.35 In addition, other infectious diseases, such as multidrug-
resistant tuberculosis, have been reported, particularly in asso- ciation with the Syrian crisis. Lebanon has reported a 27% increase in the incidence of TB attributable to the Syrian refu- gees.57 The Al Noor Chest Disease Sanatorium in northern Jordan has reported high rates of tuberculosis, including multidrug- resistant tuberculosis, among Syrian refugees who are seen in its outpatient clinics.57 In Jordan and Turkey, this population does not have access to public health care at Ministry of Health facilities,45 which puts refugees at higher risk of contracting and transmitting the disease. In conclusion, given the catastrophic implications of these
infectious disease epidemics in the Middle East, both at the regional and the global levels, a concerted collaborative effort needs to be initiated that joins the WHO and relief governmental agencies on one side with IGOs and NGOs on the other. Numerous unanswered questions could be raised regarding
Middle East countries amid civil conflicts, and several limitations to our data should be considered. Unfortunately, countries under the siege of conflicts face difficulty collecting data, particularly from combat zones, destroyed areas, and displaced people. Therefore, the proper analysis of the actual impact of the conflicts in the re-emergence and spread of the infectious diseases, the assessment of the postconflict needs, as well as the results of the targeted interventions, should be undertaken by IGOs in colla- boration with NGOs to evaluate the capacity of the health system and its functionality in the postconflict era. Without a structured surveillance system and/or mandatory reporting mechanism, most, if not all, of the highly communicable diseases will continue to disseminate and be underreported, especially in the back- ground of regional conflicts and displaced refugees. Although there could be a correlation between emerging infectious diseases and failing healthcare systems, identifying a direct association without good surveillance systems or hard measurable data is challenging. Governments should take responsibility by acknowledging
the early appearance of these emerging diseases, which plays a tremendous role in prevention and management. Denying and hiding the initial signs of disease dissemination have been reported throughout history in different settings all over the world.18 Regional cooperation should be enhanced, and communication among various agencies providing healthcare and relief through the establishment of large network should be facilitated to disseminate information and share expenses. The opportunity certainly exists to provide public health
resources and structured support for the civilian populations in these war-torn areas to address their needs. The international community, includingmedical professionals and infectious disease specialists, can have a positive impact by alleviatingthesufferingofmillionsinthis region. Providing access to clean water, improving sanitation and hygiene, supplying medications, establishing mass vaccination campaigns, supporting medical staff, offering access to health care, and instituting surveillance programs are of paramount importance to the prevention, diagnosis, treatment, reporting, and control of infectious disease outbreaks.
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