Women’s health in Northwestern Syria: Findings from Healthy-Syria 2017 study.

Objectives: Since the uprising in 2011, there have been limited health-care data from inside Syria regarding women’s health. This study aimed to provide an updated account of women’s health, including pregnancy, perinatal care, childbirth, and other conditions to identify obstacles and challenges to health-care delivery in Northwestern Syria.

Methods: This is a prospective data registry study, using a medical electronic records system that builds on the International Classification of Diseases, Tenth Revision (ICD-10) codes. We collected data from one medical center in Northwestern Syria during 2017. We conducted a survey to understand patients’ knowledge of and barriers limiting antenatal care (ANC).

Results: We studied 7213 patients’ health status and surveyed 134 regarding ANC. Prenatal care, delivery, and miscarriage treatment represented the most common (70%) reasons for women’s health-care visits, followed by menstrual disorders (17%). From 2057 delivery records, 70% delivered vaginally and 30% required cesarean delivery. Our findings showed that 1169 (24%) of the pregnant women (4936) in 2017 were adolescents, of them 22 (0.44%) were 14 years old. Regarding ANC visits, 85% of respondents did not have a single ANC visit in the first trimester, 82% had no visits in the second trimester, and 44% had no visits in the third trimester. Thirty-one percent had no ANC visit throughout the entire pregnancy. Only 13% had postnatal care (PNC) visits. Women who live in the refugee camp are 2.7 times less likely to meet the World Health Organization (WHO) criteria for focused ANC (FANC = 4 visits) compared to those who reside in town (P < 0.001), with only 14% having met the FANC. The major barrier to ANC is related to transportation (34%), followed by factors related to the study center (29%) and knowledge and education (19%). We estimated the number of obstetrics-gynecology doctors per 1000 populations to be 0.02.

Conclusions:We found a huge deficiency in ANC and PNC visits, a high adolescent birth rate, and a higher cesarean-to-vaginal delivery ratio than what is recommended by the WHO. We also found a severe shortage in the number of obstetrician-gynecologists serving this population.

Full reference: Terkawi AS, Bakri B, Alsadek AS, Alsibaee RH, Alasfar EM, Albakour AH, Aljouja AY, Alshaikhwais NA, Fares FA, Flood PD, Jnaid H, Najib AA, Saloom DA, Zahra NA, Altirkawi KA. Women’s health in Northwestern Syria: Findings from Healthy-Syria 2017 study. Avicenna J Med 2019;9:94-106. Available at:


Child and adolescent health in northwestern Syria: Findings from Healthy-Syria 2017 study.

Objectives: Since the uprising in 2011, there has been limited health-care data from inside Syria in the academic literature. This study aims to provide an updated account of pediatric health needs in the northwestern part of Syria; this should help inform the management and delivery of health-care services in this population.

Methods: This is a prospective study, using a data registry, of all pediatric patients seen in a single center in northwestern Syria, between February and December 2017. We used international classification of diseases (ICD-10) codes to define cases, and tested several covariates, including age, sex, season of the year, and conditions of living for possible correlations with major illness categories.

Results: We included 11,819 patients, of whom 5,288 (45%) were male and 6,531 (55%) were female. Collectively, these patients had 23,427 encounters. Respiratory diseases were the most encountered illnesses among all age groups (6320 [27%]), except late teen females, among whom gynecological/obstetric complaints dominated. Infectious diseases caused the greatest disease burden across all age groups, with upper respiratory tract infections (URTIs), infectious diarrhea, and otitis media representing almost half (47%) of all cases in this category. Nutritional deficiencies were diagnosed in 978 patients (8%), mostly in infants and toddlers (92%). We identified 1192 (17%) cases of acute diarrhea among all age groups, making it the second most common condition after URTIs. As compared to town residents, patients living in camps for internally displaced people accounted for more cases of infectious diarrhea (58%), chronic anemia (60%), and malnutrition (66%), especially severe acute malnutrition (76% of malnutrition cases). Vaccine-preventable illnesses represented a sizable category; we reported 69 cases of hepatitis A, 2 of poliomyelitis, 9 of pertussis, 37 of varicella, 11 of mumps, 8 of rubella, and 1 case of measles.

Conclusion: We have identified urgent health-care issues in this population, including extreme malnutrition, high rates of infectious diseases, and high rates of teenage pregnancy. Also, we observed a relapse of some vaccine-preventable illnesses, such as mumps and rubella, which are likely associated with the decline in vaccination rates.

Full reference: Terkawi AS, Bakri B, Alsadek AS, Al-Hasan AH, Alrahhal MS, Alsaleh FM, Alsatouf FA, Arab MI, Jnaid H, Hadid AA, Terkawi RS, Zahran MM, Alghannam NA, Altirkawi KA. Child and adolescent health in northwestern Syria: Findings from Healthy-Syria 2017 study. Avicenna J Med 2019;9:61-74. Available at:


Psychosocial Sequels of Syrian Conflict

Background: Victims of political violence and genocide survivors are highly vulnerable to mental and psychological distress. The aim of this study is to explore the level of psychological distress and mental health disorders including depression, anxiety, and post-traumatic stress disorder (PTSD) amongst Syrian Refugees in South Turkey and to investigate their association with socio-demographic variables.

Methods: A cross-sectional survey wherein three hundred questionnaires were distributed in four Syrian Refugee Camps located in South Turkey. Surveys included demographic data, Impact of Event Scale-Revised (IES-R), and Hospital Anxiety and Depression Scale (HADS). Snowball sampling method was utilized. Surveys missing any item were excluded. Data were processed and analyzed using SPSS v.16.

Results: Surveys were returned by 178 (59.3%) respondents of which 83 were incomplete. Therefore 95 (31.6%) of total responded questionnaires were analyzed. Mean age of respondents was 34.2 ± 11.9 years and 85.3% of them were males. IES-R concluded PTSD among 58 (61.1%). Moreover HADS estimated pathologic anxiety among 50 (52.6%) and borderline anxiety among 18 (18.9%), whereas pathologic depression 26 (27.4%) and borderline depression 37 (37.9%) were the other disorders. HADS anxiety was strongly associated with PTSD (p<0.001), while PTSD and Depression did not bear significant difference. Anxiety, depression, and PTSD were not significantly associated with age, gender or marital status.

Conclusions: The political violence in Syria resulted in a high level of psychological distress and traumatization within civilians. This is characterized by the high level of PTSD amongst Syrian refugees. This requires a prompt crisis intervention campaign and urgent psychological support. Further research is required to explore the issue on a larger scale.

Full reference: Marwa KI (2016) Psychosocial Sequels of Syrian Conflict. J Psychiatry 19:355 doi:10.4172/2378-5756.1000355. Available at:


Cholera in the time of war: implications of weak surveillance in Syria for the WHO’s preparedness-a comparison of two monitoring systems

Background: Public health breakdown from the Syrian government’s targeting of healthcare systems in politically unsympathetic areas has yielded a resurgence of infectious diseases. Suspected cholera recently reappeared but conflict-related constraints impede laboratory confirmation. Given the government’s previous under-reporting of infectious outbreaks and the reliance of the WHO on government reporting, we sought to assess the reliability of current surveillance systems.

Methods: We compared weekly surveillance reports of waterborne diseases from the Syrian government’s (WHO-associated) Early Warning and Response System (EWARS), based in Damascus, and the independent, non-governmental Early Warning and Response Network (EWARN) headquartered in Gaziantep, Turkey. We compared raw case rates by EWARS and EWARN and assessed the quality of reporting against the WHO benchmarks.

Results: We identified significant under-reporting and delays in the government’s surveillance. On average, EWARS reports were published 24 days (range 12–61) after the reference week compared with 11 days (5–21) for EWARN. Average completeness for EWARS was 75% (55–84%), compared with 92% for EWARN (85–99%). Average timeliness for EWARS was 79% (51–100%), compared with 88% for EWARN (70–97%). EWARS made limited use of rapid diagnostic tests, and rates of collection of stool samples for laboratory cholera testing were well below reference levels.

Conclusions: In the context of the current Syrian war, the government’s surveillance is inadequate due to lack of access to non-government held territory, an incentive to under-report the consequence of government attacks on health infrastructure, and an impractical insistence on laboratory confirmation. These findings should guide the WHO reform for surveillance in conflict zones.

Full reference: Sparrow AAlmilaji KTajaldin B, Teodoro N, Langton P.  Cholera in the time of war: implications of weak surveillance in Syria for the WHO’s preparedness—a comparison of two monitoring systems.


Defining Polio: Closing the Gap in Global Surveillance

Background: By late 2012 the Global Polio Eradication Initiative (GPEI) had nearly eradicated this ancient infectious disease. Successful surveillance programs for acute flaccid paralysis however rely on broad governmental support for implementation. With the onset of conflict, public health breakdown has contributed to the resurgence of polio in a number of regions. The current laboratory based case definition may be a contributory factor in these regions.

Objective: We sought to compare case definition rates using strict laboratory based criteria to rates obtained using the clinical criteria in modern day Syria. We also sought to examine this distribution of cases by sub-region.

Methods: We examined the World Health Organization (WHO) reported figures for Syria from 2013-2014 using laboratory based criteria. We compared these with cases obtained when clinical criteria were applied. In addition we sought data from the opposition controlled Assistance Coordination Unit which operates in non-Government controlled areas where WHO data maybe incomplete. Cases were carefully examined for potential overlap to avoid double reporting.

Findings: Whilst the WHO data clearly confirmed the polio outbreak in Syria, it did so with considerable delay and with under reporting of cases, particularly from non-government controlled areas. In addition, laboratory based case definition led to a substantial underestimate of polio (36 cases) compared with those found with the clinically compatible definition (an additional 46 cases). Rates of adequate diagnostic specimens from suspected cases are well below target, no doubt reflecting the effect of conflict in these areas.

Conclusions: We have identified a gap in the surveillance of polio, a global threat. The current laboratory based definition, in the setting of conflict and insecurity, leads to under diagnosis of polio with potential delays and inadequacies in coordinating effective responses to contain outbreaks and eradicate polio. Breakdown in public health measures as a contributing factor is likely to result in a resurgence of previously controlled infectious diseases. The clinical definition should be reinstituted to supplement the lab-based definition.

Full reference: Tajaldin B, Almilaji K, Langton P, Sparrow A. Defining Polio: Closing the Gap in Global Surveillance. Ann Glob Health. 2015 May-Jun;81(3):386-95. doi: 10.1016/j.aogh.2015.06.007.

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