Suchergebnisse

Abstract
Background
The Syrian conflict has dramatically changed the public health landscape of Syria since its onset in March of 2011. Depleted resources, fractured health systems, and increased security risks have disrupted many routine services, including vaccinations, across several regions in Syria. Improving our understanding of infectious disease transmission in conflict-affected communities is imperative, particularly in the Syrian conflict. We utilize surveillance data from the Early Warning Alert and Response Network (EWARN) database managed by the Assistance Coordination Unit (ACU) to explore trends in the incidence of measles in conflict-affected northern Syria and analyze two consecutive epidemics in 2017 and 2018.

Methods
We conducted a retrospective time-series analysis of the incidence of clinically suspected cases of measles using EWARN data between January 2015 and June 2019. We compared regional and temporal trends to assess differences between geographic areas and across time.

Results
Between January 2015 and June 2019, there were 30,241 clinically suspected cases of measles reported, compared to 3193 cases reported across the whole country in the decade leading up to the conflict. There were 960 regional events that met the measles outbreak threshold and significant differences in the medians of measles incidence across all years (p-value < 0.001) and in each pairwise comparison of years as well as across all geographic regions (p-value < 0.001). Although most governorates faced an elevated burden of cases in every year of the study, the measles epidemics of 2017 and 2018 in the governorates of Ar-Raqqa, Deir-Ez-Zor, and Idlib accounted for over 71% of the total suspected cases over the entire study period.

Conclusions
The 2017 and 2018 measles epidemics were the largest since Syria eliminated the disease in 1999. The regions most affected by these outbreaks were areas of intense conflict and displacement between 2014 and 2018, including districts in Ar-Raqqa, Deir-Ez-Zor, and Idlib. The spread of measles in northern Syria serves as an indicator of low immunization coverage and limited access to care and highlights the Syrian peoples' vulnerability to infectious diseases and vaccine preventable diseases in the setting of the current conflict.

Abstract
Introduction
Attacks on healthcare in armed conflict have far-reaching impacts on the personal and professional lives of health workers, as well as the communities they serve. Despite this, even in protracted conflicts such as in Syria, health workers may choose to stay despite repeated attacks on health facilities, resulting in compounded traumas. This research explores the intermediate and long-term impacts of such attacks on healthcare on the local health professionals who have lived through them with the aim of strengthening the evidence base around such impacts and better supporting them.

Methods
We undertook purposive sampling of health workers in northwest and northeast Syria; we actively sought to interview non-physician and female health workers as these groups are often neglected in similar research. In-depth interviews (IDIs) were conducted in Arabic and transcribed into English for framework analysis. We used an a priori codebook to explore the short- and long-term impacts of attacks on the health workers and incorporated emergent themes as analysis progressed.

Results
A total of 40 health workers who had experienced attacks between 2013 and 2020 participated in IDIs. 13 were female (32.5%). Various health cadres including doctors, nurses, midwives, pharmacists, students in healthcare and technicians were represented. They were mainly based in Idlib (39.5%), and Aleppo (37.5%) governorates. Themes emerged related to personal and professional impacts as well as coping mechanisms. The key themes include firstly the psychological harms, second the impacts of the nature of the attacks e.g. anticipatory stress related to the 'double tap' nature of attacks as well as opportunities related to coping mechanisms among health workers.

Conclusion
Violence against healthcare in Syria has had profound and lasting impacts on the health workforce due to the relentless and intentional targeting of healthcare facilities. They not only face the challenges of providing care for a conflict-affected population but are also part of the community themselves. They also face ethical dilemmas in their work leading to moral distress and moral injury. Donors must support funding for psychosocial support for health workers in Syria and similar contexts; the focus must be on supporting and enhancing existing context-specific coping strategies.

Abstract
Background
In Syria, disruption to water and sanitation systems, together with poor access to vaccination, forced displacement and overcrowding contribute to increases in waterborne diseases (WBDs). The aim of this study is to perform a spatiotemporal analysis to investigate potential associations between interruptions to water, sanitation, and hygiene (WASH) and WBDs in northeast Syria using data collected by the Early Warning Alert and Response Network (EWARN) from Deir-ez-Zor, Raqqa, Hassakeh and parts of Aleppo governorates.

Methods
We reviewed the literature databases of MEDLINE and Google Scholar and the updates of ReliefWeb to obtain information on acute disruptions and attacks against water infrastructure in northeast Syria between January 2015 and June 2021. The EWARN weekly trends of five syndromes representing waterborne diseases were plotted and analysed to identify time trends and the influence of these disruptions. To investigate a potential relationship, the Wilcoxon rank sum test was used to compare districts with and without disruptions. Time series analyses were carried out on major disruptions to analyse their effect on WBD incidence.

Results
The literature review found several instances where water infrastructure was attacked or disrupted, suggesting that water has been deliberately targeted by both state and non-state actors in northeast Syria throughout the conflict. Over time, there was an overall upwards trend of other acute diarrhoea (OAD, p < 0.001), but downwards trends for acute jaundice syndrome, suspected typhoid fever and acute bloody diarrhoea. For the major disruption of the Alouk water plant, an interrupted time series analysis did not find a strong correlation between the disruption and changes in disease incidence in the weeks following the incident, but long-term increases in WBD were observed.

Conclusions
While no strong immediate correlation could be established between disruptions to WASH and WBDs in northeast Syria, further research is essential to explore the impact of conflict-associated damage to civil infrastructure including WASH. This is vital though challenging given confounding factors which affect both WASH and WBDs in contexts like northeast Syria. As such, research which includes exploration of mitigation after damage to WASH is essential to improve understanding of impacts on quantity and quality of WASH. More granular research which explores the origin of cases of WBDs and how such communities are affected by challenges to WASH is needed. One step towards research on this, is the implementation of adequate reporting mechanisms for real time tracking of the WASH attacks, damages, direct effects, and likely impact in conjunction with environmental and public health bodies and surveillance systems.

INTRODUCTION: Ten years of conflict has displaced more than half of Northwest Syria's (NWS) population and decimated the health system, water and sanitation, and public health infrastructure vital for infectious disease control. The first NWS COVID-19 case was declared on July 9, 2020, but impact estimations in this region are minimal. With the rollout of vaccination and emergence of the B.1.617.2 (Delta) variant, we aimed to estimate the COVID-19 trajectory in NWS and the potential effects of vaccine coverage and hospital occupancy. METHODS: We conducted a mixed-method study, primarily including modeling projections of COVID-19 transmission scenarios with vaccination strategies using an age-structured, compartmental susceptible-exposed-infectious-recovered (SEIR) model, supported by data from 20 semi-structured interviews with frontline health workers to help contextualize interpretation of modeling results. RESULTS: Modeling suggested that existing low stringency non-pharmaceutical interventions (NPIs) minimally affected COVID-19 transmission. Maintaining existing NPIs after the Delta variant introduction is predicted to result in a second COVID-19 wave, overwhelming hospital capacity and resulting in a fourfold increased death toll. Simulations with up to 60% vaccination coverage by June 2022 predict that a second wave is not preventable with current NPIs. However, 60% vaccination coverage by June 2022 combined with 50% coverage of mask-wearing and handwashing should reduce the number of hospital beds and ventilators needed below current capacity levels. In the worst-case scenario of a more transmissible and lethal variant emerging by January 2022, the third wave is predicted. CONCLUSION: Total COVID-19 attributable deaths are expected to remain relatively low owing largely to a young population. Given the negative socioeconomic consequences of restrictive NPIs, such as border or school closures for an already deeply challenged population and their relative ineffectiveness in this context, policymakers and international partners should instead focus on increasing COVID-19 vaccination coverage as rapidly as possible and encouraging mask-wearing.