Surveillance teams risk all to track disease outbreaks in northern Syria

EWARN

Zakaria was in a rush to reach Turkey. The small blue cooler that he was carrying held valuable cargo that he had collected from one of northern Syria’s most besieged areas. He had to get its contents to the National Polio Laboratory in Turkey – and he had to get it there cold, or his work and the efforts of dozens of other Syrian health workers would be wasted. Worse, children’s lives would be at risk.

This time, Zakaria would not make it to Turkey. He was killed in an air strike before he could reach the border, and the precious samples he was carrying were destroyed.

Zakaria worked for the Early Warning Alert and Response Network (EWARN), set up in Gaziantep, Turkey in 2013 to track disease patterns in Syria, sound the alarm when outbreaks are suspected, and to monitor outbreaks of infectious diseases, like polio, cholera, measles and influenza, when they are confirmed. The work often requires EWARN staff, like Zakaria, to collect samples in neighbourhoods consumed by violence and safely deliver them to laboratories – facing bombs, armed checkpoints and extreme weather along the way.

“Disease surveillance is risky business in Syria, but it’s also critical and life-saving work,” says Dr Asm Amjad Hossain, who coordinates WHO support, guidance and training for EWARN members, from WHO’s field office in Gaziantep. “It was the efforts of these risk-takers that led to the detection of a new polio outbreak in Syria just over a year ago.”

Polio detected through field surveillance against all odds

Dr Naser Mhawish of EWARN remembers how the outbreak was first detected. The initial case was a little girl in eastern Deir Ez Zor whose mother took her to see a paediatrician.

“The girl had a fever and other signs of flu, but she also couldn’t walk properly,” recalls Dr Mhawish. Her leg was limp, a symptom of paralytic polio.

EWARN was alerted to the case by the paediatrician and quickly dispatched staff members to collect stool specimens.

For polio, suspected samples must be tested and the disease confirmed by a WHO-accredited laboratory. “In this case, the nearest accredited lab was in Ankara, Turkey, around 1000 km away, as the crow flies,” explains Dr Mhawish. “With the destruction of dams and bridges and armed conflict in the middle of the route, it was going to be a long journey to get the samples to the lab.”

According to Dr Mhawish, the EWARN staff member assigned to the case was surrounded by fighting for more than 3 weeks and was unable to communicate his whereabouts. His obstacles seemed endless, but the staffer eventually made it safely to Turkey with the specimens.

Tests soon confirmed that the girl had circulating vaccine-derived poliovirus (cVDPV). The disease had previously been wiped out in Syria, but the conflict has significantly curtailed routine immunization activities, putting millions of children at risk of contracting preventable and treatable diseases. The conflict also created conditions ripe for disease spread – mass population movement, crowded living conditions, poor sanitation and contaminated water.

“The hygiene and sanitation situation in many villages had become very bad,” says Dr Mhawish. “And because polio is transmitted via faeces, EWARN teams knew the disease was likely to spread.”

It became urgent to get samples from more suspected cases – even in dangerous or hard to reach areas of Syria. In the months that followed, in spite of ongoing unrest, EWARN field staff investigated and sampled hundreds of suspected cases of polio, reported by a close network of physicians, nurses, laboratory technicians and community health workers.

“This kind of timely data from EWARN enabled WHO and our health partners to respond quickly to the disease outbreak and plan information and emergency vaccination campaigns to fight it,” says Dr Hossain of WHO.

To contain the polio outbreak and protect Syrian children everywhere from the highly-contagious and crippling disease, WHO procured polio vaccine and worked with partners and field teams to conduct a series of mass polio vaccination campaigns in 2017 that immunized hundreds of thousands of children. The most recent WHO-supported polio vaccination campaigns took place in March 2018, reaching over 2 million children, in every governorate in the country.

To date, 74 cases of polio (cVDPV) have been confirmed in eastern Syria since the outbreak was declared in March 2017. The last case of the disease was in September 2017.

Surveillance lays the groundwork for response

Dr Radwan Al-Obeid of EWARN says the effectiveness of the early warning system is a credit to the organization’s field teams and the network of health workers with whom they coordinate.  
“The team makes huge sacrifices and takes great risks to collect samples and bring them to labs for testing,” says

Dr Al-Obeid. “It is their ground work that enables us to study trends of an outbreak and to work with health partners to figure out where and how to respond.”

Dr Al-Obeid said Zakaria was a perfect example of this commitment: “I remember him very well. He loved his work and was killed while doing it. He was one of our best”.