Early Online Publication, 31 January 2014
Polio in Syria
R Bruce Aylward a, Ala Alwan b
“In war, truth is the first casualty.”
Aeschylus (525 BC — 45 BC)
Jan 31, 2014, marks the mid-point in the initial phase of the international emergency response1 to the ongoing Middle East polio outbreak, one of the most challenging and visible outbreaks the Global Polio Eradication Initiative has tackled since its launch 25 years ago.
The challenges have not been due to the scale or speed of this polio outbreak (figure). To date, 23 laboratory-confirmed cases of polio have been reported by the Government of Syria.2 Even accounting for missed cases, and the additional 13 cases confirmed from opposition-controlled areas but not yet reflected in figures from the Government of Syria, this outbreak is smaller than the explosive outbreaks of polio that left hundreds of people paralysed in countries such as Somalia, the Republic of the Congo, and Tajikistan in recent years.3 Nonetheless, within 24 hours of the region’s Ministers of Health declaring the outbreak an “emergency for all Member States”,4 the outlines of a massive multi-country emergency response were agreed; the Government of Syria approved fast-track registration of bivalent oral polio vaccine for the response and to facilitate its delivery across lines of control to all opposition-held areas. All parties in the crisis rapidly committed to ensure that all children were vaccinated.
Fully implementing this response plan, however, has required overcoming immense hurdles to reach every child amid the wreckage of Syria’s public infrastructure and health system, the active conflict and insecurity, the dearth of trust, and one of the largest refugee crises since World War 2. These challenges have been compounded by erroneous allegations that—rather than doing everything possible to protect all Syrian children and the huge international investment in global polio eradication—UN agencies, and WHO in particular, had “blocked a vaccination campaign”,5 were “obstructing the testing of polio samples”,6 and by extension disregarding fundamental humanitarian principles.
Every day, thousands of local and international public health workers, community members, and volunteers on all sides of this conflict risk their lives to deliver basic services, including and especially immunisation, to all Syrians. It is essential that the complexities of the environment in which they are working are properly understood and that where information is incomplete, or is not shared for security reasons, it is not replaced with speculation or accusation.
The context of this outbreak is important. With the exception of Egypt, which had its last case of indigenous polio in 2005, most of the Middle East has been free of the disease since the 1990s as the result of a concerted, regionally coordinated effort.7 Protecting this achievement from importations of wild poliovirus from Pakistan, Nigeria, and, until recently, India has been a priority. Recognising the increasing risk of polio (and other vaccine-preventable diseases) as the Syrian crisis intensified, WHO, UNICEF, and partners helped organise and support at least five immunisation campaigns within Syria between March, 2011, and the end of 2012. In the surrounding countries, mass campaigns with oral polio vaccine (OPV) were undertaken in areas of low routine immunisation coverage, while refugees who arrived at registration points or camps were to be systematically vaccinated by host governments or the United Nations High Commissioner for Refugees (UNHCR).8
In December, 2012, poliovirus of Pakistan origin was first detected in Cairo’s sewage. A mass immunisation response was implemented immediately and the entire region was put on alert.9 Recognising the particular vulnerability of Syrian children, surveillance was heightened across that country, including through WHO’s Early Warning, Alert and Response Network that now comprises more than 450 reporting sites, many of which are in opposition-controlled areas. At the same time, 1.5 million children were vaccinated against polio (and 1.3 million against measles) in all of Syria’s 14 governorates, including, by January, 2013, Deir al-Zour where activities were delayed by 1 month due to insecurity. Despite these efforts, the risk escalated as this wild poliovirus type 1 was found in Israeli sewage from February, 2013, and then in the occupied Palestinian territory in mid-2013.10 It was while additional, region-wide mass campaigns were being planned for November to December, 2013, that the first polio-paralysed children were reported in Syria.
Information from opposition-controlled areas rapidly led to WHO’s first international alert on the polio outbreak within Syria on Oct 19, 2013.11 Within 5 days a nationwide vaccination campaign was launched, this time reaching a reported 2 million Syrian children, including 600,000 from Raqua, Rural Damascus, and Deir al-Zour. Nonetheless, many communities, particularly in opposition-controlled and besieged areas, were unable to access vaccine. WHO consolidated information on the major coverage gaps, especially across northern Syria, and had frank discussions with the Government of Syria, partners, and surrounding countries on additional approaches to address these gaps in each subsequent campaign. Preliminary results from the most recent campaign in Syria suggest that nearly 3 million children were vaccinated, with OPV reaching most if not all districts, more than at any time in the past 2 years.12 Preliminary results, consistent from multiple sources, suggest that vaccine coverage was greater than 85% in all but three of Syria’s governorates, and that coverage was greater than 75% in two of those three. Substantial numbers of children are still unreached, however, including in besieged communities, and further efforts are required to ensure that all parties have the vaccine they need to immunise all Syrian children.
Collecting, reconciling, and disseminating comprehensive surveillance information has been as difficult as assessing vaccine availability and coverage. All humanitarian organisations and health authorities have been encouraged to ensure that any case of polio is immediately reported, properly investigated, and rapidly acted upon, irrespective of where it is detected. Substantial negotiations have been required on everything, from ensuring a common case investigation form to agreeing on laboratories from which results will be accepted and recorded by the Government of Syria in its national figures. WHO considers all results from all WHO-accredited laboratories in assessing the international risk posed by this outbreak and additional response requirements; WHO has neither the motive nor the means to block the testing of any specimens in any laboratory.
As with all of its humanitarian work, WHO is impartial in aiding communities on all sides of this crisis, despite the restraints placed on all humanitarian actors whether they operate from within Syria or from neighbouring countries. In Syria, we work with local health workers and authorities, local and international non-governmental organisations (NGOs), UN agencies, civil society groups, the Syrian Arab Red Crescent, and other humanitarian partners to reach all Syrians, throughout the country, with health interventions and services.13 Over the past 12 months, and under extremely difficult conditions, WHO has, for example, also distributed medicines and supplies to meet the needs of 4.6 million people, trained more than 2,500 health workers, and supported health services delivery through 36 local NGOs, in both government and opposition-controlled areas.14
The prospects for interrupting this polio outbreak in Syria and the Middle East are promising. As a result of high vaccination coverage rates historically, overall susceptibility to polio in Syria is relatively low and concentrated among children younger than 2 years. Syrians remain deeply concerned for the welfare of their children and demand for vaccination remains high; no party to the conflict has voiced opposition to the ongoing OPV campaigns. Furthermore, winter has arrived in Syria, bringing with it the low season for poliovirus transmission when the impact of mass vaccination with OPV is usually highest.
Halfway through the Syrian polio outbreak response, many critical programme indicators are improving, particularly in terms of access to vaccine, coverage, and surveillance performance. Addressing the remaining gaps in programme implementation in Syria is a deadly serious issue; compounding this challenge with inaccurate information unnecessarily complicates an already very difficult and dangerous operating environment.
RBA is WHO’s Assistant Director-General for Polio and Emergencies. AA is Regional Director of WHO’s Regional Office for the Eastern Mediterranean.
1 WHO, UNICEF. Global Polio Eradication Initiative. Strategic plan for polio outbreak response in the Middle East November, 2013. The Syrian Arab Republic, Iraq, Jordan, Lebanon, Turkey, West Bank and Gaza Strip. Geneva: World Health Organization, 2013. http://polioeradication.org/Portals/0/Document/InfectedCountries/MiddleEast/ME_StrategicPlan.pdf. (accessed Jan 29, 2014).
2 Global Polio Eradication Initiative. Polio this week. http://polioeradication.org/Dataandmonitoring/Poliothisweek.aspx. (accessed Jan 30, 2014).
3 WHO. Wild poliovirus 2009—2014. http://www.polioeradication.org/Portals/0/Document/Data&Monitoring/Wild_poliovirus_list_2008_2014_21Jan.pdf. (accessed Jan 30, 2014).
4 WHO. Escalating poliomyelitis emergency in the Eastern Mediterranean Region. Document EM/RC60/R.3. 60th Session of the Regional Committee for the Eastern Mediterranean, October, 2013. Geneva: World Health Organization, 2013.
5 Reuter C. An apolitical virus: strife fuels polio’s return to Middle East. Der Spiegel Nov 21, 2013.
6 Coutts AP, Fouad MF. Syria’s raging health crisis. The New York Times Jan 1, 2014.
8 UNHCR. Inter-agency regional response for Syrian refugees. Egypt, Iraq, Jordan, Lebanon, Turkey. http://reliefweb.int/sites/reliefweb.int/files/resources/Inter-Agency%20Regional%20Response%20-%20Syrian%20Refugees%2020130418.pdf. (accessed Jan 29, 2014).
9 WHO. Global alert and response. Poliovirus detected from environmental samples in Egypt. Disease Outbreak News, Feb 11, 2013. Geneva: World Health Organization, 2013. http://www.who.int/csr/don/2013_02_11/en/index.html. (accessed Jan 29, 2014).
10 WHO. Global alert and response. Poliovirus detected from environmental samples in Israel and West Bank and Gaza Strip. Disease Outbreak News, Sept 20, 2013. Geneva: World Health Organization, 2013. http://who.int/csr/don/2013_09_20_polio/en/index.html. (accessed Jan 30, 2014).
11 WHO. Global alert and response. Report of suspected polio cases in the Syrian Arab Republic. Disease Outbreak News, Oct 19, 2013. Geneva: World Health Organization, 2013. http://www.who.int/csr/don/2013_10_19_polio/en/index.html. (accessed Jan 29, 2014).
12 Polio Control Task Force Syria. End polio in Syria. House-to-house polio vaccination campaign, first round final report. Jan 28, 2014. Polio Control Task Force Syria, 2014.
13 United Nations Office for the Coordination of Humanitarian Affairs. Syrian Arab Republic Humanitarian Assistance Response Plan (SHARP). https://docs.unocha.org/sites/dms/CAP/2014_Syria_SHARP.pdf. (accessed Jan 30, 2014).
14 WHO. WHO Response to the Syria crisis in the country 2013. http://www.who.int/hac/donorinfo/who_donor_snapshot_2013_a.pdf. (accessed Jan 30, 2014).
a World Health Organization, CH-1211 Geneva 27, Switzerland
b World Health Organization, Regional Office for the Eastern Mediterranean, Nasr City, Cairo, Egypt