Measles in conflict-affected northern Syria: results from an ongoing outbreak surveillance program

Abstract

Background: The Syrian conflict has dramatically changed the public health landscape of Syria since its onset in March of 2011. Depleted resources, fractured health systems, and increased security risks have disrupted many routine services, including vaccinations, across several regions in Syria. Improving our understanding of infectious disease transmission in conflict-affected communities is imperative, particularly in the Syrian conflict. We utilize surveillance data from the Early Warning Alert and Response Network (EWARN) database managed by the Assistance Coordination Unit (ACU) to explore trends in the incidence of measles in conflict-affected northern Syria and analyze two consecutive epidemics in 2017 and 2018.

Methods: We conducted a retrospective time-series analysis of the incidence of clinically suspected cases of measles using EWARN data between January 2015 and June 2019. We compared regional and temporal trends to assess differences between geographic areas and across time.

Results: Between January 2015 and June 2019, there were 30,241 clinically suspected cases of measles reported, compared to 3193 cases reported across the whole country in the decade leading up to the conflict. There were 960 regional events that met the measles outbreak threshold and significant differences in the medians of measles incidence across all years (p-value < 0.001) and in each pairwise comparison of years as well as across all geographic regions (p-value < 0.001). Although most governorates faced an elevated burden of cases in every year of the study, the measles epidemics of 2017 and 2018 in the governorates of Ar-Raqqa, Deir-Ez-Zor, and Idlib accounted for over 71% of the total suspected cases over the entire study period.

Conclusions: The 2017 and 2018 measles epidemics were the largest since Syria eliminated the disease in 1999. The regions most affected by these outbreaks were areas of intense conflict and displacement between 2014 and 2018, including districts in Ar-Raqqa, Deir-Ez-Zor, and Idlib. The spread of measles in northern Syria serves as an indicator of low immunization coverage and limited access to care and highlights the Syrian peoples' vulnerability to infectious diseases and vaccine preventable diseases in the setting of the current conflict.

Keywords: Conflict; Epidemic; Infectious diseases; Measles; Surveillance; Syria; Vaccine; Vaccine-preventable disease; War.

Fig. 1

Population by subdistrict, 2017

Fig. 2

Total number of suspected cases of measles January 2015–2019

Fig. 3

a Weekly number of suspected measles cases by governorate, January 2015–June 2019. b Weekly incidence of suspected measles cases, January 2015–June 2019

Fig. 4

a Annual incidence of measles in Syria at the subdistrict level, 2017. b Annual incidence of measles in Syria at the subdistrict level, 2018

Fig. 5

Relative proportion of measles cases by age and gender

Fig. 6

Weekly number of suspected measles cases by age group, January 2015–2019