Overview
Syria's ongoing three-year civil war has displaced 6.5 million Syrians, left hundreds
of thousands wounded or killed by violence, and created a vacuum in basic infrastructures
that will reverberate throughout the region for years to come. Beyond such devastation,
the civil war has introduced epidemics of infections that have spread through vulnerable
populations in Syria and neighboring countries. In this article, we discuss the growing
epidemics of poliomyelitis, measles, and cutaneous leishmaniasis in Syria and the
region to examine the impact of conditions of war on the spread of infectious diseases
in a public health emergency of global concern.
Introduction
In March 2011, unrest from the Arab Spring found its way to Syria, interrupting over
40 years of political stability and igniting a civil war that continues to ravage
the country with no end in sight [1]. Beyond direct casualties, war, particularly
civil war, provides ideal conditions for outbreaks of infections, and Syria's ongoing
three-year civil war has been no exception to this rule [2]. Measles, hepatitis A,
leishmaniasis, poliomyelitis, meningitis, and scabies have spread through vulnerable
populations in Syria and refugee camps in neighboring countries, creating a health
crisis that will require immense resources to address (Table 1) [3]. Concurrently,
the shattered medical infrastructure, the exodus of health care workers, and the deterioration
of immunization programs have created a dangerous vacuum in essential health care
provision [4]. In the context of Syria's devastated health care infrastructure, we
will discuss the spread of infectious diseases, particularly poliomyelitis, measles,
and cutaneous leishmaniasis, among Syrian civilians, refugees, and citizens of neighboring
countries, to examine what is nothing short of a regional, and arguably global, public
health emergency.
10.1371/journal.ppat.1004438.t001
Table 1
Reported cases of communicable diseases per year between 2011 and 2014 in Syria, Lebanon,
and Jordan.
NUMBER OF COMMUNICABLE DISEASE CASES REPORTED PER YEAR
Syrian Arab Republica
Lebanese Republicc
Syrian Refugees in Lebanonc
Hashemite Kingdom of Jordand
2011
2012
2013
2014∧
2011
2012
2013
2014*
2013
2014*
2011
2012
2013
2014
Poliomyelitis
0
0
35b
1b
0
0
0
0
0
0
0
0
0
n/a
Measles
n/a
13
n/a
n/a
9
9
1760
219
232
92
30
24
205
n/a
Cutaneous Leishmaniasis
n/a
52,982
n/a
n/a
5
2
1033
381
998
364
136
103
146
n/a
Hepatitis A
n/a
2203
n/a
n/a
448
757
1551
738
220
127
418
509
1082
n/a
Typhoid Fever
n/a
1129
n/a
n/a
362
426
407
102
21
7
2
4
4
n/a
a
Data obtained from the Syrian Ministry of Health website in the Quarterly Report of
Communicable Diseases [30].
b
Data obtained from the Global Polio Eradication Initiative website [16].
c
Data obtained from the Epidemiologic Surveillance Department of the Lebanese Ministry
of Public Health [26].
d
Data obtained from the Communicable Diseases System on the Jordan Ministry of Health
Website [25].
∧
2014 Data last reported on 08/13/14 from the Global Polio Eradication Initiative website
[16].
* 2014 Data last reported on 08/01/14 from the Epidemiologic Surveillance Department
of the Lebanese Ministry of Public Health [26].
The War on Health Care
Prior to the conflict, the health care system in Syria consisted of a government-run
public system that provided mostly primary care services, with the private sector
concentrated in urban areas providing the majority of advanced care services [1].
The past three decades were characterized by an improved capacity of the health system,
as well as rapidly improving national health indicators such as a falling infant mortality
rate and an increased child immunization rate. Yet the onset of the civil war led
to the complete deterioration of the health infrastructure through the wide destruction
of facilities, the shortage in health care personnel and medicines, and a lack of
secure routes and transportation.
Rather than providing a safe place of care and refuge, the Syrian health care system
has been integrated into the civil war battlefield. Both the regime's military forces
and antigovernment armed groups have attacked and appropriated medical facilities
as a tactic of warfare [5]. According to the World Health Organization (WHO), 40%
of Syria's ambulances are destroyed and 57% of public hospitals are severely damaged,
with 37% remaining out of service [6]. At least 160 doctors have been killed and hundreds
jailed, leading to the emigration of an estimated 80,000 doctors [4]. The 90% of pharmaceutical
needs that were locally produced prior to the conflict has now been reduced to only
10%, contributing to significant drug shortages in essential medications [1]. Such
shortages, power outages, and the lack of security and mobility to seek care all contribute
to the growing humanitarian crisis in Syria.
This health care crisis has extended beyond Syria's borders with one of the largest
refugee crises since World War II [2]. Millions have entered the neighboring countries
of Lebanon, Jordan, and Turkey in search of security. In Lebanon, over a million Syrian
refugees currently represent a quarter of the country's population, residing among
the local population in over 540 sites, as refugee camps are yet to be built [7].
In Jordan, there are 3,500 Syrian refugees crossing the border each day, with 20%
residing in the Al Zaatari camp and the remaining 80% living in urban areas in the
north of Jordan [8]–[10]. In both countries, Syrian refugees utilize local health
care resources. This has significantly strained local health care systems with insurmountable
demands ranging from continued chronic care to the management of spreading communicable
diseases [11]. The underfunding of UNHCR (United Nations High Commissioner for Human
Rights) and other humanitarian organizations has reduced the medical subsidies to
refugees, leading many to forgo necessary yet unaffordable treatment [12]. In Syria
and its neighboring countries, critical gaps in essential health care delivery continue
to aggravate what has been described as the worst humanitarian crisis of the 21st
century [6].
War and Infectious Diseases
The conditions of war among civilian populations exacerbate risk factors for the spread
of infections [13].
Vaccine-preventable diseases: Poliomyelitis, measles, and an international wake-up
call
The devastated health care infrastructure in Syria has hindered immunization programs,
leaving millions of citizens vulnerable to vaccine-preventable diseases [14]. Vaccination
coverage in Syria is estimated to have dropped from 91% in 2010 to as low as 45% in
some regions by 2013, indicating rapid collapse of immunization systems in conditions
of war [3]. Of the 1.8 million Syrian children born since the conflict, over 50% are
unvaccinated [15]. Consequently, 36 cases of poliomyelitis have been officially reported
in Syria after 15 years of eradication [16]. Although the opposition-held northeastern
province of Deir Ez Zur has been the epicenter of the outbreak, cases have been encountered
in rural areas of Damascus, Aleppo, and other regions [17].
The poliomyelitis virus lives in sewage, water, and contaminated food. In Syria, raw
sewage is pumped directly into the Euphrates River, which provides drinking and washing
water to villages and chlorination to decontaminate the water has been discontinued
since 2012 [15]. The strain of poliomyelitis in Syria has been linked to the wild-type
poliovirus 1 (WPV1) from Pakistan, which is suspected to have been introduced to Syria
by Pakistani jihadist fighters [18], [19]. The same strain was detected in the sewage
of Cairo in December 2012 and in sewage in Israel and the West Bank shortly thereafter,
without any clinical cases thanks to high vaccination rates in these areas [20]. WPV1
can easily and undetectably spread, with only one in two hundred unvaccinated infected
individuals developing acute flaccid paralysis [18]. WHO estimates that over 7,600
Syrians are currently infected, since poliomyelitis thrives in unsanitary, crowded
conditions and among malnourished children [21].
In response to this outbreak, the biggest immunization campaign in the region's history
led to the vaccination of over 2.7 million Syrian children and 23 million in neighboring
countries [13]. The campaign employed the bivalent oral polio vaccine, which challenges
a child's immune response with the two remaining types of virus and can be used in
short intervals for acute outbreak responses [20], [22]. Nevertheless, the constantly
migrating population, the lack of precise monitoring mechanisms, and besieged locations
that remain out of reach to immunization threaten the success of this campaign. While
cases are yet to be reported in Lebanon and Jordan, Iraq has confirmed the first case
of poliomyelitis, after a 14-year hiatus, in northern Baghdad [23].
This poliomyelitis outbreak has helped focus international attention on the severity
of the ongoing health crisis in Syria, as well as the importance of reinvigorating
eradication campaigns in the endemic countries of Afghanistan, Pakistan, and Nigeria
to prevent the recurrence of such outbreaks [17]. Polio in Syria has been declared
a public health emergency that requires international efforts and solidarity to prevent
a global epidemic.
The hampering of immunization efforts has also contributed to the spread of other
vaccine-preventable diseases such as measles. Overcrowding, unsanitary conditions,
and the efficient transmissibility of measles make the Syrian population highly susceptible
to acquiring and spreading the infection. Measles has swept through Syria, including
Aleppo and the northern regions, with over 7,000 confirmed cases [24]. This epidemic
has not spared refugees in neighboring countries, even among highly vaccinated populations
[14]. In Jordan, 24 cases of measles were reported in 2012, while over 200 cases were
reported in 2013 [25]. In Lebanon, nine reported cases of measles in 2012 increased
to 1,760 cases in 2013, only 13.2% of which were among Syrian refugees [26]. The growing
rate of infection among Lebanese nationals reveals how conditions of unrest have exploited
deficiencies in Lebanon's measles immunization coverage to contribute to a regional
crisis. In response, the Lebanese Ministry of Public Health launched a national immunization
campaign in April 2014 with over 4,200 trained volunteers administering vaccines for
polio, measles, and rubella [27].
While ongoing vaccination campaigns have tried to address this epidemic, challenges
continue to prevent adequate coverage. Unlike the poliomyelitis vaccine, which is
relatively easy to transport and is administered orally, the measles vaccine must
remain chilled and is administered by injection, posing a challenge for aid workers
trying to reach vulnerable populations. Although immunization campaigns continue to
deliver vaccines for measles and poliomyelitis to millions of adults and children
in Syria and the surrounding region, the ongoing civil war restricts access to entire
districts, threatens the lives of volunteers in the immunization campaign, and hinders
efforts to quell the ongoing humanitarian crisis.
Leishmaniasis and a region at risk
The risk factors for cutaneous leishmaniasis, including malnutrition, poor housing,
population displacement, and poverty, are unfortunately all met in the case of the
Syrian crisis, transforming the national epidemic of cutaneous leishmaniasis into
a regional threat [28]. Cutaneous leishmaniasis has been endemic in parts of Syria,
mainly Aleppo, for decades [29]. However, the Syrian conflict and vast population
displacement has significantly increased the incidence of the vector-borne disease
within Syria and spread this epidemic into neighboring countries. Reported cases of
cutaneous leishmaniasis in Syria continue to rise, with the last official figure reporting
52,982 confirmed cases in 2012 [30].
Lebanon had no cases of cutaneous leishmaniasis before 2008 and sporadic cases in
the following years. By 2013, 1,033 cases were confirmed, 96.6% (998) of which were
among Syrian refugees [26]. In recently published data on 1,275 patients from 213
displaced Syrian families in Lebanon, the average age among infected individuals was
17 years, with many patients presenting with multiple disfiguring lesions (Figure
1). 77% of the patients manifested the disease after being in Lebanon for more than
eight weeks, which is the known incubation period for cutaneous leishmaniasis, suggesting
that the sand fly vector was transported to Lebanon with the incoming refugees [31].
Speciation by PCR showed that 85% of cases were caused by Leishmania tropica, with
15% of cases as Leishmania major
[31].
10.1371/journal.ppat.1004438.g001
Figure 1
Syrian child from a Lebanon refugee camp, presenting multiple lesions from cutaneous
leishmaniasis, courtesy of Dr. Ibrahim Khalifeh
The dense concentration of refugees, the similar environmental conditions, and the
limited health care access in rural areas contribute to the higher burden of leishmaniasis
in Lebanon. This epidemic has raised concerns that the sand fly vector may find a
permanent habitat in Lebanon, particularly in rural areas with a high density of Syrian
refugees such as the Bekaa valley, which holds 70% of all reported cases [32]. This
outbreak has been the first of its kind in more than a decade and will continue to
grow within the upcoming summer months if left unaddressed [32]. The Lebanese Ministry
of Public Health (MOPH) and relevant governmental departments are planning a coordinated
campaign to contain the spread of the infection, which includes spraying pesticides
to kill the vector, providing free treatment and diagnosis for emerging cases and
monitoring disease activity [32]. In April 2013, the Lebanese MOPH, in conjunction
with WHO, organized workshops to train doctors across Lebanon to recognize the condition.
In addition to the growing threat of leishmaniasis, experts have warned against the
emergence of other vector-borne diseases such as dengue fever and malaria [33].
A Civil War and a Global Threat
Without security, there can be no health. All efforts to quell the humanitarian crisis
and to rebuild the broken health infrastructure in Syria will be largely futile as
long as the civil war continues to rage on. The immediate end of war is inextricable
from efforts to spare innocent lives and control this global threat of infectious
diseases. Yet while the political borders of a conflict can be delineated, health
care repercussions are uncontained by geopolitical borders. The spillover of refugees
and communicable diseases into Lebanon, Jordan, and Iraq demonstrates the rippling
consequences of the protracted Syrian conflict. In addition to the aforementioned
infections, diseases such as typhoid fever, hepatitis A, meningitis, scabies, and
lice continue to affect an increasingly vulnerable population. The international community
has fallen short in its response to the crisis of infectious diseases in the Syrian
conflict, and the consequences of this failure will continue to grow until there is
a coordinated and exhaustive global effort.