Outbreak in the Middle East
War in Syria Opens the Door to an Old Enemy

Polio

July 2014

M

ore than eight months after the start of the polio
outbreak in the Middle East, mass global action
is needed to guard the progress made in protecting
children in Syria and across the region. The challenges
are immense, especially how to gain regular access toapproximately 3 million children in Syria and some 25
million in the region as a whole.

© UNICEF/NYHQ2006-0778/Noorani

This report sets out the steps needed to stop theoutbreak and eradicate polio in the Middle East. Thisis the only way to ensure no more children in Syria, or
the region, are affected by this crippling and incurable
virus.

Driving home the need for decisive action, theDirector-General of the World Health Organization(WHO) declared on 5 May 2014 that the international
spread of polio is a Public Health Emergency ofInternational Concern[1]. This is only the second
time WHO has ever issued such a declaration. Theinternational spread of polio during what is normallythe low-transmission season, including within the
Middle East, is an extraordinary event that constitutes
a major public health risk to other countries andrequires a concerted international response.

April 2006 - A child receives a dose of oral vaccine from a member of a mobile vaccination team in the Karm Al Afandi neighbourhood of
the city of Aleppo. At that time, Syria had made considerable progress towards improving the situation of children andwomen and was on track to achieve almost all Millennium Development Goals.

1. WHO statement on the meeting of the International Health Regulations Emergency Committee concerning the international spread of wild poliovirus, May 2014.

2 | Polio

Collateral Damage of Syria’s War
In a Syrian city shattered by war, a small boy peersfrom a bullet-pocked doorway. His eyes go wide
when he sees Salma, before he runs off into the
rubble.
Meanwhile, vaccine cooler strapped across hershoulder, Salma keeps knocking on one door after
another. A mother squints as she comes into the stark
sunlight. She holds a baby at one hip, while a toddler
tugs at the hem of her tunic.
Across Syria and another six countries in the region[2],medical staff and volunteers are facing – andovercoming – daunting obstacles on their mission toreach every last child with polio vaccine.
Vaccinators go from door to door, travel in mobile
clinics, and set up in medical centres in war-torn
Syrian cities, villages and towns. To reach children
they may have to cross up to 50 military checkpoints,
where their vehicles are sometimes stopped at
gunpoint.

The region’s largest-ever mass polio immunisation
campaign is reaching more than 25 million children
with multiple doses of the vaccine. But many children
in Syria and Iraq remain unreached because they
live under siege or in areas where the conflict isescalating. As long as this is the case, polio – a virusthat does not need permission to travel – will never becontained and the risk of it spreading within Syria andto neighbouring countries and beyond will continue tothreaten the lives of millions of children.
“Some villages in Syria are currently inaccessible due
to ongoing violence and fighting. We missed many
children living north of the Euphrates River in Deir
Ezzor over the past two rounds,” says a UNICEF
facilitator in eastern Syria. “However, we will not giveup. We will continue to push for access to all Syrian
children, wherever they live.”© UNICEF/syria-2014/Rashidi

In neighbouring countries, medical teams andvaccinators are travelling from one tent to another inrefugee camps and informal settlements, providing
vaccines in schools, hospitals and medical centres, atborder points and at airports.

2. Phase 1 (initial six months of the response) included seven countries (Syria, Iraq, Lebanon, Jordan, Turkey, Palestine, and Egypt). Phase 2 of the response (from May 2014) covered eight
countries with Iran added after the first case was reported in Iraq

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War Paves Way for Return of PolioIn March 2011, Syria’s crisis began. The fighting,and a failure by parties to the conflict to respect
the neutrality and sanctity of health facilities, havedestroyed the country’s once highly developed
health services. Now, as well as opening the door
to grave physical dangers, the war has also usheredin life-threatening health problems, ranging frommalnutrition to polio, a long forgotten enemy in theregion.

© UNICEF/UNI162509/YurtseverOn 29 October 2013, WHO reported that the firstcase of polio since 1999 had been detected in Syria.

4 | Polio

A number of factors have contributed to its return:

1. Disruption of routine immunization
Most children born since the Syrian war have missed
some or all of the four (or more) polio vaccinations
they should have received as part of the routine
immunisations children need in their first five years,
and which newborns and young children require toremain healthy even in regular times, let alone in a
warzone.
Immunization rates across Syria have fallen from 99
percent pre-war to just 52 per cent in 2012[3].

2. Devastating damage to Syria’s health infrastructure and an exodus of health workers
An estimated 60% of Syrian hospitals have been
destroyed or damaged, 70% of health centres areeither damaged or out of service, and fewer than athird of public ambulances and health centres still
function. Production of medicines has fallen by 70%
and prices have risen so high that few people canafford to buy them[4].
Many of Syria’s first responders and emergency room
medics, including doctors and nurses, have been
killed or injured. Half of Syria’s doctors have left thecountry[5]. In Aleppo, it is reported that there are now
only 40 doctors for a population of 2.5 million people.
Once there were more than 2,000[6].
Nearly all vaccination, supply and service vehicles
have been damaged or are permanently out ofservice[7]. Most critically for polio response, cold
chain equipment that keeps polio vaccine at the righttemperature until it is administered has been lost in a
number of districts.

3. Continuous displacement and crowded, unhygienic living conditions
The polio virus is particularly active in areas with poor
water and sanitation services as it spreads by contact
with, or consuming food and drink contaminated by
faeces.
In crowded environments, the speed of transmission
can be amplified when vulnerable children are
exposed to the virus.

3. UNICEF and WHO Polio Response Strategy, November 2013
4. Save the Children: A Devastating Toll. The impact of three years of war on the health of
Syria’s children. March 2014
5. UNICEF: Under Siege. The devastating impact on children of three years of conflict,
March 2014.
6. Joint statement by heads of UN humanitarian agencies on Syria, April 2014.
7. OCHA Humanitarian Bulletin, Issue 36, 8 October-4 November 2013.

The number of Syrian children forced to flee theirhomes, either as refugees or within the country’s
borders, is staggering. More than 3 million children areinternally displaced while about 1.5 million children are
refugees in neighbouring countries.
Both inside and outside Syria, places of refuge are
crowded and often highly unsanitary. Some families
are squatting in public shelters where 70 or more
people share a single toilet. Others have moved intoalready crowded family homes, tents, chicken coops
and garages. A third of Syria’s water treatment plants
no longer function. The amount of water consumed
by Syrian families has fallen by 40% compared to precrisis levels in 2011 and treatment of the country’s
sewage has halved[8].
These conditions provide a perfect environment not
only for the spread of polio but also for typhoid, an
infection caused by the salmonella bacterium with
1,650 cases of typhoid have been reported in Deir
Ezzour[9]; for hepatitis A, a highly contagious viralliver disease; and for leishmaniasis, a skin infectionthat flourishes in situations where people’s immune
systems are weakened and conditions are unsanitary.

4. Missing children
An estimated 765,000 children under the age of fivecurrently live in hard-to-reach areas within Syria andlack regular access to vaccines. Over a two-year period
during the conflict, at least 500,000 children did notreceive the polio vaccine, due to violence, population
displacement and access restrictions from both parties
to the conflict[10].
When aid convoys have managed to enter besieged
areas they have carried polio vaccine as a priority item.
However, even when children are physically accessible,
they may not receive the vaccine due to the ongoingviolence. Syria does not have recent experience ofpolio and caregivers sometimes hesitate before taking
their children to get vaccinated, do not prioritize polio
vaccination among the other survival challenges they
face, or do not realize the importance of ensuringchildren receive multiple doses of the vaccine.

8. UNICEF: Drying up. The growing water crisis facing Syria and the region, June 2014.
9. UNICEF and WHO call on parties to the conflict to stop targeting access to safe water,
3 July 2014
10. Press release: UNICEF and senior Syrian officials agree on urgency of reaching more
war-affected children, as UNICEF Executive Director Visits Syria, 29October 2013.

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Inside Syria: Vaccination in the Line of Fire
Since the announcement of the polio outbreakin the Middle East, 36 Syrian children have beenparalysed by polio. Of these, 25 are in the contested
governorate of Deir Ezzour, five are in Aleppo, three in
Idlib, two in Al-Hasakah and one in Hama.
In a country facing one of the most violent conflicts
in recent history, the obstacles to reaching every lastchild with multiple doses of the vaccine are extreme.
But the goal is clear.
“We need to get two drops of polio vaccine into
the mouth of every child under the age of five,
regardless of their previous immunization history,
every time there is a campaign,” says Khousama, a
medical worker at a health centre in Qudssaya, Rural
Damascus. “If we can do that, the virus won’t be able
to find a single child to infect, and we can put a stopto this disease.”© SARC Al-Mayadeen

Inside Syria, despite heavy fighting in many areasand challenges of access, seven vaccination rounds
took place between December 2013 and June 2014
through close cooperation with local partners andvolunteers. They were held in schools and healthcentres, on public buses and at the doorsteps of
Syrian homes.

A volunteer from the Syrian Arab Red Crescent crosses ariver during a polio campaign in Al-Mayadin, Deir Ezzour.

6 | Polio

UNICEF led the communication campaigns andhas provided 18 million doses of polio vaccine,four freezers and 8,661 cold boxes. WHO has
deployed international consultants to assist with thestrengthening of acute flaccid paralysis surveillance
and the training of Ministry of Health staff at thenational, governorate and district level. In addition
to covering the implementation costs of polio
campaigns, WHO facilitated the revision of microplans, the training of vaccinators, and the training anddeployment of 445 independent monitors to conduct
monitoring after every campaign.
A UNICEF health facilitator in the northeastern
province of Deir Ezzor has braved intense fighting
to deliver vaccines, often carrying vaccine coolers
on foot to reach remote communities. “An airstrikein May last year destroyed the bridge that connects
the two river banks. Now, together with two or threebrave volunteers, we take the boat to reach the otherside,” he says.
In a vaccination round in April 2014, 4,580 healthworkers participated in the campaign at fixed healthcentres, and an additional 2,563 travelled around thecountry in mobile clinics. In Deir Ezzour, where thefirst polio cases were found, vaccinators reached
60,000 children in October 2013, just days after thesecases were announced.
“In the beginning people felt afraid. They started
to ask us who we are,” says Muhammed, a local
volunteer working to immunise children against polio
in Syria’s Al-Hasakah governate, where heavy fighting
has taken place. “I have taken the vaccine myself infront of the families, just to show them it is safe.”
It is people like Muhammed and other volunteers,social mobilizers, and polio vaccinators who are thereal “polio warriors” in this humanitarian crisis. They
are on the front lines of this fight against polio in very
demanding, often insecure areas, and they all have
one goal – to protect the children by getting two dropsof polio vaccine into their mouths during each andevery campaign, averting the risk of life-long disability
and death.

Vaccine Reaches Children Living
Under Siege for Two Years
On 20 March, 2014, a three-hour ceasefire allowed
a UN convoy to enter the besieged town ofDouma, 12 kilometres from Syria’s capital.
Douma had been under siege for nearly two years.
Until now, humanitarian aid had not been able
to get through. The convoy carried 6,000 dosesof polio vaccine to the area, along with otherlifesaving humanitarian supplies.
“Parents were eager to get their young ones
vaccinated, especially following the sad news
about the polio outbreak,” Mohsein, a volunteer,
told UNICEF’s team while they were on the
ground in Douma.

A girl waves at UN convoy in Douma.

@UNICEF/Syria-2014/Rashidi| 7

A Mega-Vaccination Campaign in a Battered Region
Polio does not respect borders. Recognising the risk
of further spread, eight countries across the Middle
East have launched vaccination campaigns since thedetection in Syria of a strain of the polio virus thatoriginated in Pakistan.
Across the Syrian border in Iraq, chubby-cheeked,
six-month-old Moossa is a heart-wrenching reminderof polio’s threat to spread within the region. Iraq
declared a polio outbreak on 31 March, 2014, whensix-month-old Moossa’s paralysis was confirmed aspolio. Moossa had not been immunized. Nor had his
four siblings.
“I am working so hard to support my family, andhad no time to think about taking my children for
vaccinations,” says Moossa’s father, Abood Hezam,
who works as a driver to support his family in apoverty-ridden neighbourhood outside Baghdad.
“I truly regret this now. If only Moossa had been
vaccinated, he would have been polio free now. I
never thought my child could be paralyzed.”

70% of Syrian refugees live outside refugee camps inurban areas.
Lebanon hosts the largest number of Syrian refugees.
There are no official refugee camps in the country, yetmore than 1 million Syrians have been registered[11].
Many live in informal tented settlements with little
or no access to basic services, and over half arechildren[12].
To help ensure all children crossing into countries
receiving refugees are vaccinated, polio drops havebeen given upon arrival at airports, and vaccination
stations have been set up at official border points.
UNICEF, WHO, Ministries of Health and otherpartners have launched regional and national publicawareness campaigns to reach parents with themessage that it is crucial for children under the age offive to take the vaccine multiple times.

Moossa’s story proves yet again that wherever one
child goes unvaccinated, every child is at risk. Since
Moossa became ill, another child in Iraq has alreadycontracted the virus.

In the months since Syria’s polio outbreak began, theregion’s largest-ever mass immunisation campaign
has been carried out. The Global Polio Eradication
Initiative, which includes UNICEF, WHO and otherkey global partners, has led the effort along withnational governments and local partners on the
ground. Children across Iraq, Egypt, Lebanon, Jordan,
Turkey, Palestine and Iran are being reached with thevaccine between three and six times, and the aim isto repeatedly cover more than 25 million.
Challenges around the region are immense. The
vaccine must be swiftly and repeatedly delivered
to children across eight countries. Mobile medical
teams travel long distances to remote areas to reachchildren. In some parts of the region, door-to-door
campaigns where vaccinators go directly to people’s
homes are being conducted. The campaigns aim toreach every refugee child crossing Syria’s border– a challenging task, since many refugees remain
unregistered with local authorities, and more than
8 | Polio©UNICEF/Iraq-2014/Fahmi“The case in Iraq after a 14-year absence is a reminderof the risk currently facing children throughout theregion,” says Maria Calivis, UNICEF Regional Director
for the Middle East and North Africa. “It is now evenmore imperative to reach every child multiple times,
and to do whatever we can to vaccinate children we
could not reach in previous rounds.”

Moossa, Iraq’s first case of polio in 14 years.

11. Syria Regional Refugee Response. Inter-agency Information Sharing Portal. UNHCR,
July 2014
12. UNICEF Syria Crisis Monthly Humanitarian Situation Report, June 2014

Ending Polio in Syria and Iraq – Not a Mission Impossible
UNICEF and WHO are calling for the following critical actions be taken to end the polio outbreak in Syria and Iraq
before it spreads further.

1. End the violence in Syria now
Children have suffered for far too long. Syria’s polio
outbreak is firm evidence of war’s far-reaching impact
on children. It threatens individual children and thefuture of generations of children across the region.

2. Grant immediate and unhindered access tomore than 765,000 children under the age of fivein hard-to-reach areas inside Syria
Some children living in hard-to-reach areas in Syria
and where heavy violence is ongoing have received
polio vaccine thanks to commitments from concerned
parties on the ground. But these children are notbeing reached as often or as consistently as isneeded. Children’s health and immunity levels must
be prioritised by all parties to the conflict, to stop the
spread of the virus.

5. Secure funding for continuous vaccination
campaigns across the region
To stop the virus from spreading any further inside
Syria and beyond its borders, more vaccination
campaigns are planned from now until the end of
2014. These campaigns aim to reach 25 million
children in eight countries.
The cost to implement the second phase of thecampaign comes to US$59 million. This covers
procuring and delivering vaccines to children, including
the hardest-to-reach; providing technical assistance to
Ministries of Health for the training and recruitmentof health workers; raising awareness on the needto vaccinate children among local communities; andmaintaining the cold chain to ensure the vaccine
remains safe and effective.

All parties to the conflict are urged to facilitate
unconditional, ongoing humanitarian access tochildren in need, using all available routes.

3. Within Syria, guarantee the safe passage ofhealth workers and protect medical vehicles andother cold chain equipment
Health workers and vaccinators are acting heroicallyevery day to deliver the polio vaccine to children in
Syria. These workers must be guaranteed protection
and safe access to continue their mission to vaccinate
all children, wherever they are across Syria. The cold
chain, including medical vehicles, is vital to ensure theefficacy of the vaccine. It must never be targeted.

4. Raise awareness on polio and champion theneed to vaccinate all children under the age offive across the region
Region-wide public awareness must be drummed up,
and caregivers inspired to take action. Caregivers may
not have a full understanding of the risk to their own
children, especially in countries where polio has notbeen seen for many years.
Within Syria, war already poses families with many
daunting challenges to raising healthy, happy children.
Polio may be perceived by some as a lower risk thanventuring out onto still-volatile streets. It is important
to ensure caregivers understand the clear and present
risk of polio not just in Syria but throughout the region.

Image from awareness raising campaign| 9Polio Crisis In Numbers
Since October 2013:

38 polio cases confirmed,
36 in Syria and 2 in Iraq

105 million

57m

doses of polio vaccine procured

25 million children under theage of 5 reached, multiple times in Syria,
Lebanon, Iraq, Jordan, Turkey, Egypt,
Palestine and Iran.

9.8m
1.5m

2.5m

13m

3.2m

State of Jordan Lebanon Turkey
Palestine

Iraq

13,819 cold boxes to transport the vaccines
544 freezers to keep them safe
Inside Syria:

7,143 health workers
participated in the campaign

4,580 in health centres
2,563 in mobile teams

765,000 children under the age of 5 living in hard-to-reach areas in Syria notvaccinated on a regular basis with Polio vaccine.

59.3 million (US$) is the cost of the campaign’s second phase10 | Polio

18m

Syria

Egypt

Turkey

LebanonState of Palestine

Syria
Iraq

Iran

Egypt

Primary outbreak countries
Risk Reduction Countries© UNICEF/UKLA2013-03829/Lyon© UNICEF/UKLA2014-04856/Schermbrucker

The boundaries and names shown and the designations used on this map
do not imply official endorsement or acceptance by the United Nations.

Children in the Domiz refugee camp in Northern Iraq.
| 11

Cover Photo:© UNICEF/syria-2014/Rashidi

For further information, please contact:
Juliette Touma

Bahaa Elkoussy

UNICEF Regional Office for the Middle East &North Africa

WHO Eastern Mediterranean Regional Office+962 79 867 4628
Email: jtouma@unicef.org+20 100 601 93 16
Email: elkoussyb@who.int