The forgotten threat of cholera in Syria

This paper, which might be the first in the Syrian context, provides a preliminary overview of the epidemiological situation of the 2022 cholera outbreak and suggests a multisectoral approach that addresses context-specific elements contributing to the outbreak spread in the light of present humanitarian and geopolitical realities. The article also indicates the potential for a new practical and evidence-based household-centered community engagement approach to effectively control the cholera spread after the semi-failure of community engagement during the COVID-19 pandemic.

The last reported cholera outbreak in Syria dates back to 2009, when an epidemic in the northeast infected more than 1,000 people and killed several children (Sparrow et al. 2016). The 2009 outbreak was likely due to contamination of the Euphrates river and crops (Raad et al. 2018). A report published in 2015 pointed out the risk of the cholera outbreak resurgence in Syria due to the poor surveillance system, the lack of resources, and previous cover-ups by the Syrian MoH of cholera (Sparrow 2015).

Since declaring the 2022 cholera outbreak in Syria, the number of cases has been increasing significantly despite the government's claims of controlling the situation (Al-Monitor 2022; Qreima 2022). In the northeast, governed by a Home Rule Government, the epidemiological situation looks disastrous due to the sudden increase in cases, lack of health services, and contamination of the Euphrates river (Oxford Analytica 2022). On 19 September 2022, the first cholera case in north-west Syria (NWS), a non-governmental area, was confirmed (OCHA 2022). By 15 October 2022, more than 20,000 suspected cases had been reported across the country, with nearly 1,000 positive cases at an attack rate of 0.1% and a case fatality rate of 0.37%. Most cases are reported from non-governmental areas (Ahmad et al. 2022).

Considering the geopolitics and humanitarian context of Syria, it could be said that the country constitutes a breeding ground for cholera risk factors. Since the start of the conflict in 2011, the region has been witnessing disastrous conditions due to the collapsed health and education system and the lack of access to shelter and safe drinking water (Bahaa et al. 2022). The water and sanitation infrastructure in Syria has been severely damaged due to attacks on water facilities, contamination, looting of materials, and the absence of regular maintenance (Daher 2022). The crowded residency settings and harsh living conditions prevent adherence to public health precautions, especially in non-governmental areas (Al-Abdulla et al. 2021).

Securing the basic life requirements, like water, in such dire conditions drives people to use insecure sources, like rivers and irrigation ditches, without water quality management (Borgomeo et al. 2021). Recently, new evidence has erupted of a significant receding of Euphrates river water (Jongerden et al. 2021), which might lead to an increase in the concentration of diversified pathogens in the water (Nusrat et al. 2022). In a recent study investigating the quality of the Euphrates river waters, 178 bacterial pathogens were isolated due to pollution associated with water levels receding (Alduihi & Hammal 2020).

A well-coordinated, timely, and effective response to outbreaks is critical during emergencies (Ohene et al. 2016). The drivers of cholera transmission are usually diverse according to the context but functionally interdependent. Therefore, it is essential to emphasize the importance of adopting a multisectoral approach that addresses context-specific elements contributing to outbreak spread (graphical abstract) (Elimian et al. 2020). Prevention, including vaccination and access to safe drinking water, is a core in controlling the disease and reducing the burden on the health systems (Andre et al. 2008). Health education and community engagement are cornerstones in mitigating the risk of infectious diseases (Obregon et al. 2022). Indeed, community engagement was an essential pillar of the COVID-19 response in Syria. However, it was not as effective as planned because it was not practical for people suffering from conflict woes and poor economic conditions for more than a decade (Douedari et al. 2020). Therefore, thinking of context-specific approaches to engage communities in controlling cholera is a matter of urgency. While the global guidelines highlighted community-level engagement, pandemic fatigue in protracted emergencies and the inability to engage people in outbreak control mechanisms were overlooked. Recent evidence showed that effective cholera control should focus on case-centered and within-household approaches (D'Mello-Guyett et al. 2020). This method seems practical, especially in NWS where there is no administrative government to enforce laws (Al-Abdulla & Kallström 2022), by assigning the family responsibility to control the spread of the disease at the household level and consequently reflecting the impact on the community level.

The absence of government and lack of local leadership, as in NWS, might immensely contribute to poor public health and sanitation systems (Wilkinson et al. 2020). The humanitarian actors could play an important role in covering the gaps due to the governmental instability in Syria by adopting a systematic need-based approach and establishing a field coordination mechanism for legitimate decision-making pertaining to the local context.

The Syrian MoH declared a cholera outbreak in September 2022, which is not the first emergence of this outbreak in the country. Cholera has been hidden and resurged multiple times. The fragmented health system, water and sanitation infrastructure deficiencies, poor education and hygiene levels, unstable governance structure, and deteriorated socioeconomic conditions contributed to the emergence of the cholera outbreak in Syria. The multisectoral response must look beyond medical intervention. Vaccination and access to safe drinking water and sanitation are pivotal at this point to control the disease's spread.

NGOs must develop community engagement plans basing out of the family level, considering the crisis protraction and deteriorating conditions. In non-governmental areas, establishing a reliable and coordinated parallel field response mechanism is essential to overcome the gap due to the unstable governance structure.

The decision to submit this article was made by the Strategic Research Center (ÖZ SRC), Gaziantep, Turkey

All relevant data are included in the paper or its Supplementary Information.

The authors declare there is no conflict.