Protecting healthcare workers in conflict zones during the COVID-19 pandemic: Northwest Syria
Authors: Naser Almhawish, Nabil Karah, Yasir Elferruh, Aya Aksh, Aula Abbara
Journal: Journal of Infection (2021)

•In northwest Syria, healthcare workers account for 13% of confirmed COVID-19 cases.•Surveillance systems e.g. EWARN are key to outbreak identification and response.•Understanding SARS-CoV-2 dynamics in conflict is key to mitigating spread.•Protection of healthcare workers in Syria, e.g. vaccine prioritization is important. We read with interest Jones et al's correspondence on SARS-CoV-2 seroprevalence among health workers and share experiences of COVID-19 cases among health-workers in Northwest Syria (NWS).1Jones C.R. Hamilton F.W. Thompson A. Morris T.T. Moran E. SARS-CoV-2 IgG seroprevalence in healthcare workers and other staff at North Bristol NHS Trust: a sociodemographic analysis.J Infect. 2020; (0)Abstract Full Text Full Text PDF Scopus (12) Google Scholar This geographical area includes parts of Aleppo and Idleb governorates and shelters 4.17 million civilians (of whom 2.6 million are internally displaced and 1.4 million reside in camps). It shares closed borders with Turkey on one side and closed lines with areas under government control on the other side. (See Fig. 1) Most people in NWS live in overcrowded, unhygienic conditions with poor access to water, sanitation and hygiene (WASH) and healthcare.2Abbara A. et al.Coronavirus 2019 and health systems affected by protracted conflict: the case of Syria.Int J Infect Dis. 2020; https://doi.org/10.1016/j.ijid.2020.05.003Abstract Full Text Full Text PDF Scopus (35) Google Scholar This area has seen protracted conflict with recurrent attacks on WASH infrastructure, healthcare facilities and healthcare workers in contravention of International Humanitarian Law.3Fouad F.M. et al.Health workers and the weaponisation of health care in Syria: a preliminary inquiry for The Lancet –American University of Beirut Commission on Syria.Lancet. 2017; 6736: 1-11Google Scholar Healthcare workers face numerous challenges relating to the effects of conflict on the health system, inadequate personal protective equipment (PPE,) poor infection prevention and control (IPC) practices, insufficient resources and severe under-staffing. Our aim is to identify the trajectory of COVID-19 cases and the proportion of infected healthcare workers in Northwest Syria. We retrospectively reviewed data collected by the Early Warning, Alert and Response Network (EWARN) in NWS. At present, there are two parallel surveillance systems for infectious diseases in Syria with the Early Warning, Alert and Response System (EWARS) covering areas under government control since 2012, and EWARN predominantly operating in areas outside of government control since 2013.4Ismail S.A. et al.Communicable disease surveillance and control in the context of conflict and mass displacement in Syria.Int J Infect Dis. 2016; 47Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar In March 2020, the NWS COVID-19 Task Force was established with the aim of addressing lab testing, contact tracing, establishing isolation centres and COVID-19 treatment centres, as well as measures to interrupt transmission (lockdown, self-isolation, quarantine, and public health education) at the community level.2Abbara A. et al.Coronavirus 2019 and health systems affected by protracted conflict: the case of Syria.Int J Infect Dis. 2020; https://doi.org/10.1016/j.ijid.2020.05.003Abstract Full Text Full Text PDF Scopus (35) Google Scholar Each suspected case which met the case definition (adapted from WHO's global surveillance guidelines) was investigated and data were collected via Excel forms then by using the Go.Data application (https://www.who.int/godata). A nasopharyngeal swab was collected for rt-PCR testing in Idleb city. Although EWARN was established in mid-2013 and aggregated data for acute respiratory illnesses has been collected since then, PCR testing only became available at the start of 2020, and testing for SARS-CoV-2 as of March 2020. The first case of COVID-19 in NWS was confirmed in a doctor working in Bab Al Hawa (a border-located hospital) on 9th July 2020; after this, a cluster was noted among Bab Al Hawa staff before several community clusters became evident towards the end of July 2020, suggesting community transmission. Since then, there has been a steady increase in cases across the region, reaching (as of 16th January 2021) 20,822 cases among 80,326 tests (26% positivity.) (See Fig. 2) Of these, more cases were detected among males (12,993, 62%) than females (7829, 38%), with 16,324 (78%) of cases aged between 15 and 50 years. After the initial phase where most cases were reported from Al Bab city in Aleppo governorate (1505 reported cases), the trend shifted towards Idleb city with 4160 reported cases and an increase in the cases detected from districts where camps were concentrated. These were mainly in Dana in Idleb governorate with 3111 confirmed cases and A'zaz in Aleppo governorate with 1465 cases. Camps accounted for 10% of cases (2176.) 5% (1041) of the total cases had moderate manifestations in addition to 142 severe cases. There have been 376 (1.8%) attributed fatalities to date out of 423 deaths among cases with confirmed SARS-CoV-2. The percentage of healthcare providers amongst the overall cases dropped from almost 25% during the early stages of community transmission to just under 16% (a total of 1837 cases among healthcare workers) as of 28th December 2020 and down to 13% (2692 cases) as of 16th January 2021. As of 19th January 2021, there have been 1076 cases among nurses and 390 among physicians. 6 healthcare workers (5 physicians and 1 nurse) have died. As of January 2021, there are 9 hospitals (8 active), with 615 available beds, 142 available intensive care beds and 55 ventilators available for COVID-19 patients. In addition to 36 community treatment centres (22 active), including 960 beds. The increase in the numbers of cases of COVID-19 in NWS was initially slow however as of mid-September 2020, cases increased rapidly and have overwhelmed hospital and staff capacity though the rate of new cases appears to be slowing. We highlight a number of findings. As elsewhere, the impact on healthcare workers both personally and professionally has been grave with a large proportion affected; however, healthcare workers in this area work in an already exhausted and under-resourced health system after almost a decade of conflict and face ongoing attacks.5Bdaiwi Yamama Rayes Diana Sabouni Ammar Murad Lina Fouad Fouad Zakaria Waseem Hariri Mahmoud Ekzayez Abdelkarim Challenges of providing healthcare worker education and training in protracted conflict: a focus on non-government controlled areas in north west Syria.Confl Health. 2020; 14Crossref PubMed Scopus (23) Google Scholar The effects on the health workforce in areas under government control have been even more stark with suggestions that at least 165 doctors have lost their lives, however, official confirmation has been suppressed.6Human rights Watch. Syria: health Workers Lack Protection in Pandemic. https://www.hrw.org/news/2020/09/02/syria-health-workers-lack-protection-pandemic (2020).Google Scholar Seroprevalence studies among healthcare workers have not been performed so the true extent of exposure remains unknown. The high representation of healthcare workers among positive cases is likely due to increased exposure as in other contexts but also access to testing, particularly early in the outbreak. Secondly, early in the outbreak, there were fewer cases than expected in the camps however, as of the end of October 2020, cases are increasing; the slow increase is likely a result of poor access to testing, poor trust in local healthcare providers and restricted movement. This is being addressed and a number of activities including more sampling locations, camp screening around the first confirmed cases in some camps, and more community engagement activities were conducted targeting the camps area. Lastly, the declared number of cases (around 0.5% of the population) likely represents an underestimate of cases due to under-testing and under-diagnosis due to weakened health system capacity after almost a decade of protracted conflict. Conclusions: The high prevalence of COVID-19 among healthcare workers in NWS is of major concern. Measures to protect healthcare workers from increased rates of infection are urgently required; these include prioritization for vaccination, improved access to PPE, and refining IPC precautions in health facilities.