The authors have declared that no competing interests exist.
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.
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
NUMBER OF COMMUNICABLE DISEASE CASES REPORTED PER YEAR | ||||||||||||||
Syrian Arab Republic |
Lebanese Republic |
Syrian Refugees in Lebanon |
Hashemite Kingdom of Jordan |
|||||||||||
2011 | 2012 | 2013 | 2014 |
2011 | 2012 | 2013 | 2014 |
2013 | 2014 |
2011 | 2012 | 2013 | 2014 | |
0 | 0 | 35 |
1 |
0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | n/a | |
n/a | 13 | n/a | n/a | 9 | 9 | 1760 | 219 | 232 | 92 | 30 | 24 | 205 | n/a | |
n/a | 52,982 | n/a | n/a | 5 | 2 | 1033 | 381 | 998 | 364 | 136 | 103 | 146 | n/a | |
n/a | 2203 | n/a | n/a | 448 | 757 | 1551 | 738 | 220 | 127 | 418 | 509 | 1082 | n/a | |
n/a | 1129 | n/a | n/a | 362 | 426 | 407 | 102 | 21 | 7 | 2 | 4 | 4 | n/a |
Data obtained from the Syrian Ministry of Health website in the Quarterly Report of Communicable Diseases
Data obtained from the Global Polio Eradication Initiative website
Data obtained from the Epidemiologic Surveillance Department of the Lebanese Ministry of Public Health
Data obtained from the Communicable Diseases System on the Jordan Ministry of Health Website
2014 Data last reported on 08/13/14 from the Global Polio Eradication Initiative website
* 2014 Data last reported on 08/01/14 from the Epidemiologic Surveillance Department of the Lebanese Ministry of Public Health
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
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
This health care crisis has extended beyond Syria's borders with one of the largest refugee crises since World War II
The conditions of war among civilian populations exacerbate risk factors for the spread of infections
The devastated health care infrastructure in Syria has hindered immunization programs, leaving millions of citizens vulnerable to vaccine-preventable diseases
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
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
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
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
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.
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
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
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
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.
We would like to acknowledge the critical review of the manuscript by Dr. Abdel Rahman Bizri and the leishmania data and figure provided by Dr. Ibrahim Khalifeh.