Keywords cholera - conflict - Syria - outbreaks - WASH - water and sanitation
Introduction
For many years, there has been concern in Syria that an outbreak of cholera could
occur given the poor state of water, sanitation, and hygiene (WASH) across the country
from the protracted conflict, climate change-related droughts and floods, and insufficient
water quality and quantity to meet the population's needs.[1 ] The conflict has caused public health, which was weak even before the conflict,
to further deteriorate.[2 ] In August 2022, there was an increase in cases of acute watery diarrhea (AWD), the
syndrome associated with cholera, in Aleppo governorate and in the northeast of Syria.
As of May 20, 2023, there have been 132,782 suspected cases with Idlib (35%) and Aleppo
(29%) in northwest Syria and Deir Ez-Zor (16%) and Ar-Raqqa (16%) in northeast the
most affected.[3 ]
Syria's conflict has led to the emergence of multiple subnational health systems;
these have evolved differently across the country due to varying population needs,
governance structures, and resources.[2 ] In northwest Syria, humanitarian organizations (both local and international) have
provided important support to primary and secondary care services. This area has seen
among the most intense conflict with deliberate targeting of hospitals.[4 ] Additionally, there has been targeting and interruption of WASH; the summer of 2020
saw the greatest interference of WASH in Idlib, with multiple attacks by the Syrian
regime and its allies interrupting water to vulnerable populations in the area.[5 ]
In February 2023, cholera control in the area was further affected by the severe earthquakes
in southeastern Türkiye and northern Syria that caused increased forced displacement,
over 8,000 deaths, and interrupted cholera control measures.[6 ] However, in early March 2023, an oral cholera vaccine campaign that had been delayed
due to the earthquakes resumed and ultimately reached 1.7 million people in the area.[7 ]
Our aim is to provide a detailed description of water sources and clinical status
of a cohort of patients seen at a cholera treatment center (CTC) in northwest Syria
during the 2022 outbreak.
Materials and Methods
Study Area and Setting
Northwest Syria comprises Idlib and parts of Aleppo governorates, which are outside
of Syrian government control. Their estimated population is around 4.2 to 4.6 million
individuals, of whom more than 65% are internally displaced.[8 ] Around 1.5 million live in tented settlements with poor access to WASH. This area
has experienced severe bombardments by the Syrian government and its allies including
to hospitals and WASH infrastructure.[5 ] This has further worsened access to water and health care, which is similarly compounded
by widespread poverty. The targeting of health and civil infrastructure has contributed
to the reemergence and spread of diseases such as cholera, tuberculosis, and leishmaniasis
that were rare before the conflict. The fragile health system in northern Syria is
insufficient to meet the growing needs of the population: there are too few hospitals
for a large number of people and insufficient laboratory equipment to aid in the diagnosis
of diseases. For example, there is only one laboratory that can culture stool in Idlib
governorate.
Following the appearance of AWD cases in Idlib, a CTC was established in Darkoush
following the World Health Organization guidelines. The CTC had 2 wards with 10 beds
each, and an isolation chamber in which patients were initially examined. In addition
to doctors and nurses, the CTC included a health awareness team that taught people
about cholera, how it is transferred, and how to prevent its spread. Following standard
practice, patients with severe dehydration and danger signs received Plan C treatment,
patients with some dehydration but no danger signs received Plan B treatment, and
patients with no dehydration received Plan A treatment.[9 ]
Data Collection
Patient information was originally collected by the CTC medical staff during routine
patient intake following admission to the CTC and a positive stool culture sample
from October 8, 2022 to December 18, 2022. Data included information on demographic
variables, the clinical case, and treatment. These data were deidentified prior to
the research team obtaining them. Cholera case severity was classified according to
the Global Cholera Task Force staging where Plan A is no signs of dehydration, Plan
B is some signs of dehydration, and Plan C is severe dehydration.[9 ]
Analysis
In this report, we included all patients (n = 94) admitted to the CTC. Patient ages were aggregated into age groups of < 2 years
old, 2 to 10 years old, and groups of 10 years up to age 80. Analysis was done in
both Arabic and English using R v.4.0.4.
Ethics Statement
This study was deemed exempt by the Human Research Protections board at the University
of California, Irvine.
Results
Patient characteristics can be found in [Table 1 ]. The majority of patients (70.2%; 66/94) were admitted to the CTC in November 2022
and were from the Harim district of Idlib (47%; 44/94), followed by Idlib district
(19%; 18/94), Jisr ash-Shughur district (16%; 15/94), and Atma camp (15%; 14/94) ([Fig. 1 ]).
Table 1
Demographic details, risk factors for cholera, and patient treatment classification
for the 94 patients included in this study
Patient characteristics
Female
(n = 42)
Male
(n = 52)
Total
(n = 94)
Demographics
n
%
n
%
n
%
Age, y
< 2
3
(7)
3
(6)
6
(6)
2–9
9
(21)
16
(31)
25
(27)
10–19
4
(10)
10
(19)
14
(15)
20–29
5
(12)
3
(6)
8
(9)
30–39
10
(24)
9
(17)
19
(20)
40–49
3
(7)
3
(6)
6
(6)
50–59
6
(14)
3
(6)
9
(10)
60–69
2
(5)
1
(2)
3
(3)
70–80
0
(0)
4
(8)
4
(4)
Living type
Village
17
(40)
15
(29)
32
(34)
City
16
(38)
19
(37)
35
(37)
Camp
9
(21)
18
(35)
27
(29)
Risk factors[* ]
Not washing food
42
(100)
51
(98)
93
(99)
Poor sanitation
32
(76)
35
(67)
67
(71)
No sewage network
29
(69)
35
(67)
64
(68)
No clean water
27
(64)
35
(67)
62
(66)
Contact with cholera patient
26
(62)
28
(54)
54
(57)
Travel to endemic area
23
(55)
25
(48)
48
(51)
Ate uncooked fish
0
(0)
1
(2)
1
(1)
Patient treatment
Plan A
0
(0)
5
(10)
5
(5)
Plan B
24
(57)
30
(58)
54
(57)
Plan C
18
(43)
17
(33)
35
(37)
Note: Patients with severe dehydration and danger signs received Plan C treatment,
patients with some dehydration but no danger signs received Plan B treatment, and
patients with no dehydration received Plan A treatment.
* Patients could face multiple risk factors.
Fig. 1 Map of Syria with cholera treatment center (CTC) patients' districts highlighted.
Note that Atma camp is located in Harim district. Figure made with QGIS 2.33.1.
Seventy-eight percent (73/94) of patients had less than a secondary school education,
with 41% (39/94) considered illiterate. Forty-five (48%) were 19 years old or under
and 21 (22%) were students. Thirty (61%) were homemakers and 8 (17%) were government
workers.
Across all patients, water from public wells was most frequently used for all water
purposes, but water sources varied across residential locations ([Table 2 ]). Patients from camp settings relied primarily on trucked water, whereas patients
from cities used public wells and patients from villages often used both public wells
and water trucks. Seventy-two (77%) patients did not use chlorine to treat water with
70 stating they did not have access to chlorine. Only two patients treated water by
boiling.
Table 2
Water sources for drinking, food preparation, bathing, and washing by living situation
for the 94 cholera patients included in this study
Drinking
Food preparation
Bathing
Washing
Camp
(n = 27)
City
(n = 35)
Village
(n = 32)
Camp
City
Village
Camp
City
Village
Camp
City
Village
Source
Public well
n
1
30
14
1
30
14
2
31
14
3
30
15
%
(4)
(86)
(44)
(4)
(86)
(44)
(7)
(89)
(44)
(11)
(86)
(47)
Water truck
n
25
2
15
24
2
15
24
2
15
24
2
14
%
(93)
(6)
(47)
(89)
(6)
(47)
(89)
(6)
(47)
(89)
(6)
(44)
Borehole
n
1
3
3
2
3
3
1
2
3
0
3
3
%
(4)
(9)
(9)
(7)
(9)
(9)
(4)
(6)
(9)
(0)
(9)
(9)
Clinical Characteristics
Upon admittance to the CTC, the median patient heart rate was 110 (interquartile range
[IQR]: 30), oxygen saturation level was 97% (IQR: 3), systolic blood pressure was
100 (IQR: 10), and diastolic blood pressure was 70 (IQR: 0). All patients but one
were given a rapid cholera test, on which all but two patients tested positive. All
patients had diarrhea, 93 (99%) were vomiting, 88 (94%) experienced abdominal pain,
and 2 (2%) had a fever. Most patients (52%; 49/94) were experiencing diarrhea 5 to
10 times a day or more than 10 times a day (44%; 41/94). Few patients reported comorbidities:
5 reported diabetes, 5 reported hypertension, 3 reported heart failure, and 1 patient
was pregnant.
Patients were treated using oral rehydration salts (94%; 88/94), intravenous fluids
(91%; 86/94), oral or intravenous zinc sulfate (84%; 79/94), and oral or intravenous
antibiotics (70%; 66/94). Most patients (66%; 62/94) received all four treatments.
Antibiotic choices were based on Early Warning and Response Network (EWARN) microbiological
confirmation of sensitivity. For antibiotics, azithromycin was used most frequently
(62%; 41/66), followed by ciprofloxacin (32%; 21/66).
Outcomes
Patients remained in the CTC for an average of 2.7 days (range: 1–7 days). Of the
94 total patients, 6 were transferred to another treatment center and 3 died (case
fatality rate: 3.2%). Of the 6 who were transferred, 1 was because of gastrointestinal
bleeding, 1 because of acute electrolyte imbalance, 1 because of appendicitis, and
3 patients did not have a reason listed. Of the 3 patients who died, 2 received Plan
B treatment (some dehydration) and 1 received Plan C treatment (severe dehydration).
The causes of death differed: one died of metabolic acidosis and electrolytes disorder,
another from multiple organ dysfunction syndrome, and the third cause of death is
unknown following transfer to another hospital. The remainder were discharged.
Discussion
This study highlights the poor availability of WASH for patients presenting to the
CTC with confirmed cholera as well as the geographical variation across Idlib governorate.
Harim district accounted for 47% of cases though proximity to the CTC (25 km) may
have led to Harim residents being overrepresented. However, when overall cases in
northwest Syria are noted (86,404 as of May 29, 2023), Harim accounts for the largest
number of cases and 29.5% of all recorded cases in the area.[10 ] Importantly, following a surge in patients from Harim at the CTC, the CTC alerted
local health officials of the cases and prompted an investigation. They were told
of a leak from the sewage network which contaminated the water sources used for drinking
and a reduction in available chlorine.
Our study also shows a high prevalence of risk factors, in particular of not washing
food (which 99% of cases reported); this is likely compounded by other relevant factors
such as poor availability of clean water (reported by 66%) and contact with a cholera
patient (57%). Though Risk Communication and Community Engagement have been key activities
in response to the cholera situation in northwest Syria, this suggests that more can
be done to provide the local population with the means to protect themselves and their
families. The absence of adequate WASH in northwest Syria has been highlighted at
both the macro[5 ] and micro[11 ] levels; the latter has been particularly relevant during the coronavirus disease
2019 pandemic.
Though there was a slightly higher proportion of men in this cohort (55%), it is notable
that a larger proportion of females were in the Plan C treatment group. This warrants
further exploration, particularly as males and females in Plan B are similar at 57%.
In northwest Syria broadly, females are 48% of cases, though more detail about the
severity is not available.[10 ] Though cholera is described as an “equal opportunity” infection, there is important
literature on the gendered aspects of cholera susceptibility and control. Reports
from Sierra Leone discuss how gender roles and differing social responsibilities may
lead to differential interactions with cholera.[12 ] A 2010 United Nations International Children's Emergency Fund briefing note on gender
and the cholera outbreak in Haiti also noted the importance of integrating gender
considerations in cholera response.[13 ] They reference prior studies in Indonesia and Kenya which noted higher rates of
cholera in adult females and school-aged girls as well as higher case fatality and
morbidity among females in studies from South Africa and Bangladesh.[14 ]
[15 ]
[16 ]
[17 ]
[18 ]
[19 ] Owing to social and gender norms, females play important roles in both prevention
and response. For example, a key prevention method is the boiling or treatment of
water which, for the most part, falls to women and girls. Consideration must therefore
be given to the gender lens as it relates to the sociocultural, economic, and environmental
factors that may contribute to an individual's risk of disease.
Despite public health campaigns including the distribution of soap and chlorine, most
of the 77% of patients who reported not using chlorine to treat water reported that
they did not have access to chlorine. It is unclear whether this was due to intermittent
distributions, a lack of sustainable distributions, and/or if there were incomplete
distributions. An alternative to chlorine is boiling water, which only two patients
reported doing; it is likely that this is not a sustainable intervention in the overcrowded
and underresourced settings of northwest Syria, especially with limited fuel resources.
These findings highlight the importance of sustained provision of chlorine tablets
or other equivalent water purifiers, especially given the unreliability of water cleanliness.
Such tablets are often included in humanitarian outbreak response,[20 ] but proactive and uninterrupted provision would be more useful for preventing future
outbreaks.
The sources of water for drinking, food preparation, bathing, and washing show expected
variability between camp, city, and village settings. Camp settings rely heavily on
water trucking for all usages compared to the others. This is unsurprising, given
that camps frequently lack sufficient WASH infrastructure, and especially infrastructure
that can withstand harsh camp conditions. Private water trucking is not heavily regulated[21 ] and can cost a high proportion of a household's daily income. Well water was the
most used in the cities, and villages used a roughly even split between public wells
and water trucking. Importantly, access to a public well does not infer that the water
at the well is suitable for drinking,[22 ] as evidenced by this outbreak. Because of the price of trucked water, however, many
individuals do not have an alternative.
The association between conflict, insecurity, and cholera has been described previously
in the literature with examples from Yemen,[23 ] Nigeria,[24 ] and Haiti.[25 ] In Syria, not only has the conflict adversely affected WASH infrastructure,[5 ] but associated poverty[26 ] has also affected the population's ability to ensure safe access to water, particularly
for children.[27 ]
We present findings from a single CTC and, as such, the data may not represent the
situation or patient demographics found in other CTCs. The presence of other CTCs
in northwest Syria may also affect the representation of reported age ranges and living
situations. Our clinical data for some patients is also incomplete, which prevents
us from providing full case details for each patient. This is particularly of note
for the two Plan B patients who died (as this would be unexpected if the patients
did not first become Plan C) and the patients who were transferred to another health
facility. However, we are able to provide complete clinical details for most patients'
cholera cases. There may be risk of social desirability or recall bias in several
of the risk factor and water procurement questions. However, because of the high rates
of positive responses for certain risk factors, we do not believe that this bias was
prominent.
This piece offers important insight to the ongoing cholera outbreak in northern Syria.
We are able to report on the demographic makeup of patients, their clinical outcomes,
water sources, and relevant risk factors. In doing so, we can illustrate the differences,
especially in water sources, between patients residing in distinct areas (camp, city,
and village) and between sexes. This can be especially useful in outbreak response,
as a one-size-fits-all approach may not be appropriate in such settings. Indeed, without
being receptive to differences across water sources and risk factors, outbreak response
may miss key transmission routes or risk factors in specific groups. The insights
presented in this study also emphasize the need for routine provision of chlorination
tablets or other water purifiers, especially given that boiling water is often infeasible
for many. Cholera is entirely preventable, though Syria's protracted conflict has
resulted in conditions that are extremely hospitable to infectious diseases. Depoliticization
of WASH, health care, and humanitarian aid, in addition to more robust prevention
measures, are necessary to prevent future outbreaks of this sort.
