#Tuberculosis, #war, and #refugees: #Spotlight on the #Syrian humanitarian #crisis (PLoS Pathog., abstract)

[Source: PLoS Pathogens, full page: (LINK). Abstract, edited.]


Tuberculosis, war, and refugees: Spotlight on the Syrian humanitarian crisis

Mohamad Bachar Ismail, Rayane Rafei, Fouad Dabboussi, Monzer Hamze

Published: June 7, 2018 / DOI: https://doi.org/10.1371/journal.ppat.1007014



Tuberculosis (TB) is a leading cause of mortality and morbidity worldwide. The spread of this fatal disease increases in crisis-affected populations. The ongoing Syrian civil war has led to significant damage to the national healthcare system and forced millions of Syrians to take refuge in neighboring countries, where the majority face miserable conditions. These circumstances increase the risk of TB development and spreading among Syrian refugees (SRs) and their host communities. After the beginning of the Syrian crisis in 2011, a remarkable increase in TB cases was reported in countries bordering Syria and is essentially attributed to the massive displacement of the SR population. Here, we first review the risk of TB dissemination during wars and among displaced populations, notably refugees. Then, we discuss the causes, current situation, and complications of the growing TB risk among SRs in Syria’s neighboring countries, focusing in particular on Lebanon. The aim is to highlight the spreading potential of this disease among vulnerable populations facing such complex conditions of conflicts and forced displacements.



Citation: Ismail MB, Rafei R, Dabboussi F, Hamze M (2018) Tuberculosis, war, and refugees: Spotlight on the Syrian humanitarian crisis. PLoS Pathog 14(6): e1007014. https://doi.org/10.1371/journal.ppat.1007014

Editor: John M. Leong, Tufts Univ School of Medicine, UNITED STATES

Published: June 7, 2018

Copyright: © 2018 Ismail et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: The authors received no specific funding for this study.

Competing interests: The authors have declared that no competing interests exist.

Keywords: Syria; War; Society; TB.


#Infectious Disease #Risk and #Vaccination in Northern #Syria after 5 Years of Civil #War: The #MSF Experience (PLoS Curr., abstract)

[Source: PLoS Currents Disasters, full page: (LINK). Abstract, edited.]

Infectious Disease Risk and Vaccination in Northern Syria after 5 Years of Civil War: The MSF Experience


AUTHORS: Alan de Lima Pereira, Rosamund Southgate, Hikmet Ahmed, Penelope O’Connor, Vanessa Cramond, Annick Lenglet




In 2015, following an influx of population into Kobanê in northern Syria, Médecins Sans Frontières (MSF) in collaboration with the Kobanê Health Administration (KHA) initiated primary healthcare activities. A vaccination coverage survey and vaccine-preventable disease (VPD) risk analysis were undertaken to clarify the VPD risk and vaccination needs. This was followed by a measles Supplementary Immunization Activity (SIA). We describe the methods and results used for this prioritisation activity around vaccination in Kobanê in 2015.


We implemented a pre-SIA survey in 135 randomly-selected households in Kobanê using a vaccination history questionnaire for all children <5 years. We conducted a VPD Risk Analysis using MSF ‘Preventive Vaccination in Humanitarian Emergencies’ guidance to prioritize antigens with the highest public health threat for mass vaccination activities. A Measles SIA was then implemented and followed by vaccine coverage survey in 282 randomly-selected households targeting children <5 years.


The pre-SIA survey showed that 168/212 children (79.3%; 95%CI=72.7-84.6%) had received one vaccine or more in their lifetime. Forty-three children (20.3%; 95%CI: 15.1-26.6%) had received all vaccines due by their age; only one was <12 months old and this child had received all vaccinations outside of Syria. The VPD Risk Analysis prioritised measles, Haemophilus Influenza type B (Hib) and Pneumococcus vaccinations. In the measles SIA, 3410 children aged 6-59 months were vaccinated. The use of multiple small vaccination sites to reduce risks associated with crowds in this active conflict setting was noted as a lesson learnt. The post-SIA survey estimated 82% (95%CI: 76.9-85.9%; n=229/280) measles vaccination coverage in children 6-59 months.


As a result of the conflict in Syria, the progressive collapse of the health care system in Kobanê has resulted in low vaccine coverage rates, particularly in younger age groups. The repeated displacements of the population, attacks on health institutions and exodus of healthcare workers, challenge the resumption of routine immunization in this conflict setting and limit the use of SIAs to ensure sustainable immunity to VPDs. We have shown that the risk for several VPDs in Kobanê remains high.


We call on all health actors and the international community to work towards re-establishment of routine immunisation activities as a priority to ensure that children who have had no access to vaccination in the last five years are adequately protected for VPDs as soon as possible.

Keywords: Wars; Society; Syria; Vaccines.


#Attacks against #healthcare in #Syria, 2015–16: results from a real-time reporting tool (Lancet, abstract)

[Source: The Lancet, full page: (LINK). Abstract, edited.]

Attacks against health care in Syria, 2015–16: results from a real-time reporting tool

Mohamed Elamein, PhD, Hilary Bower, MSc, Camilo Valderrama, MD, Daher Zedan, MD, Hazem Rihawi, MD, Khaled Almilaji, MD, Mohammed Abdelhafeez, MSc, Nabil Tabbal, MPH, Naser Almhawish, MD, Sophie Maes, MD, Prof Alaa AbouZeid, MD

Published: 08 June 2017 / Article has an altmetric score of 22 / DOI: http://dx.doi.org/10.1016/S0140-6736(17)31328-4

© 2017 World Health Organization. Published by Elsevier Ltd. All rights reserved.




Collecting credible data on violence against health services, health workers, and patients in war zones is a massive challenge, but crucial to understanding the extent to which international humanitarian law is being breached. We describe a new system used mainly in areas of Syria with a substantial presence of armed opposition groups since November, 2015, to detect and verify attacks on health-care services and describe their effect.


All Turkey health cluster organisations with a physical presence in Syria, either through deployed and locally employed staff, were asked to participate in the Monitoring Violence against Health Care (MVH) alert network. The Turkey hub of the health cluster, a UN-activated humanitarian health coordination body, received alerts from health cluster partners via WhatsApp and an anonymised online data-entry tool. Field staff were asked to seek further information by interviewing victims and other witnesses when possible. The MVH data team triangulated alerts to identify individual events and distributed a preliminary flash update of key information (location, type of service, modality of attack, deaths, and casualties) to partners, WHO, United Nations Office for the Coordination of Humanitarian Affairs, and donors. The team also received and entered alerts from several large non-health cluster organisations (known as external partners, who do their own information-gathering and verification processes before sharing their information). Each incident was then assessed in a stringent process of information-matching. Attacks were deemed to be verified if they were reported by a minimum of one health cluster partner and one external partner, and the majority of the key datapoints matched. Alerts that did not meet this standard were deemed to be unverified. Results were tabulated to describe attack occurrence and impact, disaggregated where possible by age, sex, and location.


Between early November, 2015, and Dec 31 2016, 938 people were directly harmed in 402 incidents of violence against health care: 677 (72%) were wounded and 261 (28%) were killed. Most of the dead were adult males (68%), but the highest case fatality (39%) was seen in children aged younger than 5 years. 24% of attack victims were health workers. Around 44% of hospitals and 5% of all primary care clinics in mainly areas with a substantial presence of armed opposition groups experienced attacks. Aerial bombardment was the main form of attack. A third of health-care services were hit more than once. Services providing trauma care were attacked more than other services.


The data system used in this study addressed double-counting, reduced the effect of potentially biased self-reports, and produced credible data from anonymous information. The MVH tool could be feasibly deployed in many conflict areas. Reliable data are essential to show how far warring parties have strayed from international law protecting health care in conflict and to effectively harness legal mechanisms to discourage future perpetrators.



Keywords: Wars; Syria; Society.


#Antimicrobial Drug #Resistance among #Refugees from #Syria, #Jordan (@CDC_EIDjournal, edited)

[Source: US Centers for Disease Control and Prevention (CDC), Emerging Infectious Diseases Journal, full page: (LINK). Edited.]

Volume 23, Number 5—May 2017 / Letter

Antimicrobial Drug Resistance among Refugees from Syria, Jordan


To the Editor: The Kassem et al. article regarding high rates of multidrug-resistant (MDR) bacteria colonizing Syrian children highlights the challenge of choosing empiric antimicrobial drugs to treat war-injured refugees from Syria (1). The findings mirror other reports (2–3) and our own experience in a charitable hospital in Amman, Jordan, which manages war-injured refugees from Syria. As part of a program of antimicrobial drug stewardship and infection prevention and control, empiric antimicrobial drug protocols were introduced. For antimicrobial drug–naive patients, the first-line choice for prophylaxis and treatment of skin and soft-tissue infections, including those involving open fractures, was a narrow-spectrum cephalosporin, as recommended by the Infectious Diseases Society of America guidelines (4); however, clinical failure was common.

We retrospectively reviewed the clinical microbiology data of 75 patients admitted in January 2015 with a history of suspected post-trauma infection. All these patients were first treated in field hospitals in Syria; 82.7% were male, and 33% were <16 years old. Twenty-four percent had multiple injuries, 20% had osteomyelitis, and 53% had metal prosthetic implants.

Thirty bacterial isolates were identified, mostly from deep wound swabs of 21 (28%) injured patients; 9/21 were infected with 2 isolates. Twenty-nine (97%) isolates were gram-negative bacteria: 10 Proteus spp., 10 Escherichia coli, 5 Pseudomonas spp., and 4 Klebsiella spp. Disk diffusion susceptibility testing showed that 20 (66%) isolates were MDR and 11 (36.7%) were carbapenem resistant.

The hospital laboratory did not have the capacity to perform further testing and confirmation of the resistant strains in line with international quality standards because they lacked suitable equipment and financial resources. Preventing further dissemination of MDR organisms among war-injured refugees from Syria at hosting healthcare facilities requires an effective surveillance system, investment in infection prevention and control, appropriate antimicrobial drug stewardship, and urgent laboratory capacity building inside Syria and in the refugee-host countries.


Aula Abbara, Nizar Al-Harbat, Nabil Karah, Bashar Abo-Yahya, Wael El-Amin, James Hatcher, and Omar Gabbar

Author affiliations: Imperial College, London, UK (A. Abbara); Syrian American Medical Society, Canfield, Ohio, USA (A. Abbara); Al Maqased Charity Hospital, Amman, Jordan (N. Al-Harbat, B. Abo-Yahya); Umea University, Umea, Sweden (N. Karah); Broomfield Hospital, Chelmsford, Essex, UK (W. El-Amin); Imperial College Healthcare National Health Service Trust, London (J. Hatcher); University Hospital Leicester, Leicester, UK (O. Gabbar)



  1. Kassem DF, Hoffmann Y, Shahar N, Ocampo S, Salomon L, Zonis Z, et al. Multidrug-resistant pathogens in hospitalized Syrian children. Emerg Infect Dis. 2017;23:166–8.
  2. Reinheimer C, Kempf VAJ, Göttig S, Hogardt M, Wichelhaus TA, O’Rourke F, et al. Multidrug-resistant organisms detected in refugee patients admitted to a University Hospital, Germany June‒December 2015. Euro Surveill. 2016;21:30110.
  3. Teicher CL, Ronat JB, Fakhri RM, Basel M, Labar AS, Herard P, et al. Antimicrobial drug-resistant bacteria isolated from Syrian war-injured patients, August 2011-March 2013. Emerg Infect Dis. 2014;20:1949–51.
  4. Hospenthal DR, Murray CK, Andersen RC, Bell RB, Calhoun JH, Cancio LC, et al.; Infectious Diseases Society of America; Surgical Infection Society. Guidelines for the prevention of infections associated with combat-related injuries: 2011 update: endorsed by the Infectious Diseases Society of America and the Surgical Infection Society. J Trauma. 2011;71(Suppl 2):S210–34.


Suggested citation for this article: Abbara A, Al-Harbat N, Karah N, Abo-Yahya B, El-Amin W, Hatcher J, et al. Antimicrobial drug resistance among refugees from Syria, Jordan. Emerg Infect Dis. 2017 May [date cited]. http://dx.doi.org/10.3201/eid2305.170117

DOI: 10.3201/eid2305.170117

Keywords: Antibiotics; Drugs Resistance; Jordan Syria; Migrants.


#Health #workers and the #weaponisation of #healthcare in #Syria: … (Lancet, abstract)

[Source: The Lancet, full page: (LINK). Abstract, edited.]

Health Policy

Health workers and the weaponisation of health care in Syria: a preliminary inquiry for The Lancet–American University of Beirut Commission on Syria

Fouad M Fouad, MD†, Annie Sparrow, MBBS†, Ahmad Tarakji, MD, Mohamad Alameddine, PhD, Prof Fadi El-Jardali, PhD, Adam P Coutts, PhD, Nour El Arnaout, MPH, Lama Bou Karroum, MPH, Mohammed Jawad, MBBS, Sophie Roborgh, MSc, Aula Abbara, MBBS, Fadi Alhalabi, MD, Ibrahim AlMasri, MD, Dr Samer Jabbour, MD

†These authors contributed equally

Published: 14 March 2017 / Article has an altmetric score of 16 / DOI: http://dx.doi.org/10.1016/S0140-6736(17)30741-9

© 2017 Elsevier Ltd. All rights reserved.



The conflict in Syria presents new and unprecedented challenges that undermine the principles and practice of medical neutrality in armed conflict. With direct and repeated targeting of health workers, health facilities, and ambulances, Syria has become the most dangerous place on earth for health-care providers. The weaponisation of health care—a strategy of using people’s need for health care as a weapon against them by violently depriving them of it—has translated into hundreds of health workers killed, hundreds more incarcerated or tortured, and hundreds of health facilities deliberately and systematically attacked. Evidence shows use of this strategy on an unprecedented scale by the Syrian Government and allied forces, in what human rights organisations described as a war-crime strategy, although all parties seem to have committed violations. Attacks on health care have sparked a large-scale exodus of experienced health workers. Formidable challenges face health workers who have stayed behind, and with no health care a major factor in the flight of refugees, the effect extends well beyond Syria. The international community has left these violations of international humanitarian and human rights law largely unanswered, despite their enormous consequences. There have been repudiated denunciations, but little action on bringing the perpetrators to justice. This inadequate response challenges the foundation of medical neutrality needed to sustain the operations of global health and humanitarian agencies in situations of armed conflict. In this Health Policy, we analyse the situation of health workers facing such systematic and serious violations of international humanitarian law. We describe the tremendous pressures that health workers have been under and continue to endure, and the remarkable resilience and resourcefulness they have displayed in response to this crisis. We propose policy imperatives to protect and support health workers working in armed conflict zones.

Keywords: Wars; Syria; Public Health; Society.


#Attacks on #HealthCare in #Syria — Normalizing #Violations of #Medical #Neutrality? (N Engl J Med., extract)

[Source: The New England Journal of Medicine, full page: (LINK). Extract.]


Attacks on Health Care in Syria — Normalizing Violations of Medical Neutrality? [   !   ]

Michele Heisler, M.D., M.P.A., Elise Baker, B.A., and Donna McKay, M.S.

N Engl J Med 2015; 373:2489-2491 / December 24, 2015 / DOI: 10.1056/NEJMp1513512


Interview with Dr. Michele Heisler on attacks on physicians and health care facilities in Syria and the response from the international community. (11:57)  –| Listen |—/ –| Download |–


In July 2015, a 26-year-old pediatrician described to our team of Physicians for Human Rights (PHR) investigators his experiences in Aleppo, Syria’s most populous city. When he was a medical student in 2012, government forces detained and severely beat him. He now works as an emergency medicine physician and surgery resident in a hospital that has twice been bombed by the Syrian government. He lives in fear of being killed by bombs on his way to work or while there. His family wants him to leave Syria as they did, but he explained, “It’s our country, and if we leave, it will fall apart. At times, I think maybe I will leave and specialize and come back with better skills, but then I see how much the people need me. Maybe that’s the biggest thing that’s keeping me inside.”


Keywords: Research; Abstracts; Wars; Public Health; Society; Bioethics.


#Merkel says downing of #Russian #plane has complicated #Syria #solution (Channel News Asia, Nov. 25 ‘15)

[Source: Channel News Asia, full page: (LINK).]

Merkel says downing of Russian plane has complicated Syria solution [   !   ]

The shooting down of a Russian warplane by Turkey has complicated the process of finding a political solution in Syria and everything must be done to avoid a further escalation, German Chancellor Angela Merkel said on Wednesday.


Keywords: Germany; Syria; Turkey; Russia; Wars.


#Ban concerned over downing of #Russian #plane by #Turkish #AirForce, urges #measures to lower #tensions (#UN News Centre, Nov. 25 ‘15)

[Source: United Nations News Centre, full page: (LINK).]

Ban concerned over downing of Russian plane by Turkish Air Force, urges measures to lower tensions [   !   ]

The United Nations Secretary-General Ban Ki-moon is seriously concerned over the downing of a Russian military jet by the Turkish Air Force earlier today, and has urged all relevant parties to take urgent measures with a view to de-escalating tensions, according to his spokesperson.


Keywords: UN; Updates; Wars; Turkey; Russia; Syria.


#Opponents of #ISIS Must #Influence Not Isolate #Russia (CFR, Nov. 24 ‘15)

[Source: Council of Foreign Relations, full page: (LINK).]

Opponents of ISIS Must Influence Not Isolate Russia [   !   ]

by Council on Foreign Relations 

The Turkish downing of a Russian warplane should not be allowed to distract efforts to build a stronger international response to the so-called Islamic State, writes CFR President Richard N. Haass.


Keywords: Turkey; Syria; Russia; Wars; ISIS.


#NATO Urges `#Calm, De-Escalation’ After #Turkey Downs #Russian #Jet (Bloomberg, Nov. 24 ‘15)

[Source: Bloomberg, full page: (LINK).]

NATO Urges `Calm, De-Escalation’ After Turkey Downs Russian Jet [   !   ]

NATO called for calm and de-escalation after alliance member Turkey shot down a Russian warplane that strayed into its airspace from Syria.


Keywords: NATO; Russia; Turkey; Syria; Wars.