Syria was declared polio free in 1999. But with at least 10 recent confirmed cases of the paralyzing virus, international health workers are worried about a regional outbreak of the virus, particularly given the constant flow of Syrians to neighboring countries.
Before the Syrian uprising began in March 2011, the vaccination rate in Syria was above 90 percent, bolstered by a relatively strong public health system. But after almost three years of violent and destructive civil conflict, that figure has dropped to 68 percent. Most unvaccinated children are under two years old, making them particularly vulnerable to polio, which is usually spread through fecal matter.
Preliminary evidence shows that the polio virus now spreading in Syria originated in Pakistan, according to the United Nations Children's Fund (UNICEF). Similar strains have been detected in Egypt, Israel, the West Bank and Gaza Strip and some speculate it was brought by foreign fighters and jihadis who have been pouring into the country as refugees flee.
The fears have spurred a regional vaccination campaign. Doctors and nurses are giving polio vaccinations to every child registered with the United Nations in Syria's neighbors, which now host 2.2 million Syrian refugees.
The UN program is the largest immunization response ever in the Middle East and will target children in seven countries and territories: Syria, Iraq, Egypt, Turkey, Lebanon, Jordan, and the Palestinian Territories. More than 20 million children will be vaccinated.
Last week, at a UNHCR mobile clinic on the outskirts of Tripoli, Dr. Salam El-Ghamrawi squeezed pink liquid into the mouths of young Syrian children as dozens of families lined up outside.
“In Lebanon we vaccinated everyone. In Syria it was the same before the war. Everyone was vaccinated,” says Dr. El-Ghamrawi, a Lebanese doctor working with the government.
Thousands of Syrians are crossing into neighboring countries each month, bringing with them the threat of polio and other diseases—including measles, mumps and chicken pox. Vaccination stations have been set up at the borders to vaccinate upon entry. But reaching the thousands of children already inside these countries is proving a major challenge, especially because the vaccine needs to be administered in three doses at one-month intervals to be effective.
“We have teams that are going from home to home,” says Wafaa Kanaan, a coordinator with Lebanon’s Ministry of Public Health, as she supervises vaccinations at a primary school in Beirut. In urban centers Lebanese children are being reached through schools and community organizations, but in rural areas public health workers are going door to door and tent to tent.
Lebanon has committed to vaccinating every child under five on Lebanese soil, regardless of nationality – an estimated 750,000 children in total.
“We are a very risky country because displaced Syrians are entering everyday, so we are afraid the virus is coming here,” says Ms. Kanaan.
Lebanon is now hosting more than 1 million Syrians in 1,600 informal camps and settlements across the country. While Syrians are being vaccinated in official refugees camps in Jordan and Turkey, the Lebanese government has prohibited UNHCR from setting up formal camps, making it difficult to locate and vaccinate all children.
“If you talk about the camps in Jordan or Turkey, it’s easier,” says Azzeddine Zeroual, a UNICEF employee who is helping to coordinate the vaccination effort with UNICEF in Lebanon. “In Lebanon we have hundreds of informal settlements and there is no access to health care, no access to sanitation. Here, we are using mobile clinics to reach them and minimize the risk.”
Vaccinating children in Syria itself, where President Bashar al-Assad’s military continues to battle the opposition, will be especially challenging.
“This is not an easy mission,” said Dr. Fouad Fouad, a Syrian epidemiologist and public health expert originally from Aleppo and currently teaching at the American University of Beirut. “There are so many challenges – lack of transport, lack of human resources, working in heavy conflict areas.”
The outbreak’s center, Deir ez-Zor province, is one of the most contested and violent regions in the country. “What we really need is an agreement between the fighters so we can reach every inch of Syrian soil,” said Dr. Fouad.
UNICEF plans to buy 1.7 billion doses of the polio vaccine, which costs only pennies.
“At the end, it’s not the cost of the vaccine, but the logistics of how to reach every child,” Dr. Fouad. “This is the challenge all these authorities are facing.”