Syrian Epidemiological Bulletin

The establishment of the Early Warning Alert and Response System (EWARS) in the Syrian Arab Republic followed a WHO risk assessment that determined the need for such a system during the current situation prevailing in the country.
Thus EWARS was designed, developed and initiated in September 2012.
The purpose of this current formal review is to identify EWARS strengths, weaknesses, opportunities and gaps, with clear recommendation on how best to address the weak points in the system.
It was not intended to be a formal evaluation of the EWARS system.
A mixed-method approach was used for this review.
The methods included a desk review, original data collection using both quantitative and qualitative methods and site visits. A total of 63 persons were involved in this review via individual or group effort.
Strengths, weaknesses, opportunities and gaps were identified for the following subject areas: added value of the system and usefulness to the community, quality of the outputs, technical performance that includes completeness and timeliness, quality of data, representativeness, sensitivity and specificity, and structure and management of the system that included system management, decision-making, training, resources and costs, and processing and dissemination of data.
Findings showed that EWARS is of added value in the current emergency situation in Syria as it is has a good potential to do early warning and alert in a timely manner. The great interest by all stakeholders seemed very valuable for the functionality of EWARS. The WHO technical and financial support seemed essential to the system as well. EWARS bulletins have been in production and dissemination on the web since the establishment of the system in September 2012. The utility of this output at the periphery is questionable as it does not reach those in the periphery and it is not used for feedback or to monitor the action or response. Completeness and timeliness is an integral part of the bulletin and it is well monitored. Dilemmas in calculating completeness and timeliness were discussed.
The main weaknesses in EWARS as identified by this review include mainly the issue of data quality. Furthermore, documentation is lacking for certain important items such as full outbreak documentation and responses that take place.
Another major gap is related to the representativeness of the sites. The great potential of recruiting the shelters (IPD centers) was not taken in its full potential. Involvement of service providers other than MOH is minimal. Training, though an important pillar in EWARS, those in major need for training were not trained. Monitoring and evaluation is not functioning in its utmost potential. Managerial issues threaten the system, especially at the MOH and also with regards to the relationship with WHO. The full reliance on WHO fund can threatens the sustainability of the system.
A list of recommendations was drawn accordingly on the basis of findings from this review. Those who are interested in finding out more about these recommendations can access the whole report at the Directorate of Health Care in the Ministry of Health, or at the WHO office in Damascus.

Prof. Hyam Bashour

This study aimed to probe the situation of infectious hepatitis cases admitted in the University Children Hospital in Damascus following the notice of marked increase of their number.
The study was of the retrospective type and included the files of patients admitted in the hospital during 2012 and the first 7 months of 2013. The total case number was 77 (26 cases in 2012 with admission percentage 2.3 per thousand, and 51 cases in 2013 with admission percentage 3.4 per thousand). The percentage of children aged <= 5 years was 54.5%. Male percentage was 48%. About one third of cases originated from Rural Damascus. There was a history of nearby infection in 28% of cases.
Table 1 displays the most frequent symptoms in the study.

Table 1, most frequent symptoms in the study

The main clinical sign was jaundice (76.6%) followed by hepatomegaly (50.6%)
On the laboratory side the results were as follows (table 2).
Table 2, lab results

The length of hospital stay ranged from 1 to 38 days (mean 8.1).
Table 3 shows the output of hepatitis cases.
Table 3, output of hepatitis cases

Fulminant hepatic failure occurred in 26 cases. It was accompanied by elongation of prothrombin time less than 60% and elevated blood ammonia level. These cases development is described in table 4.
Table 4, development of fulminant hepatic failure

Prof. Isam Anjak

The Child Health Department in the Directorate of Health care/ MOH in cooperation with WHO and UNICEF held a workshop under the title of “Preparation of Vaccination Campaign against Polio” during the last month of 2013 in Blue Tower Hotel.
This workshop was a chapter among activities series implemented by the EPI (Expanded Immunization Program) in MOH with the aim of boosting immunity status of Syrian children against childhood diseases that are amenable to control by vaccination.
The workshop, which lasted 3 days, was run by the staff of the Child Health Department under the supervision of the director of the Directorate of Health care, and was attended by representatives and experts of WHO and UNICEF. The participants included: heads of Health care departments, heads of Child Health divisions, vaccine officers, and WHO and UNICEF coordinators in all governorates.
The workshop objectives included displaying the results, the obstacles, and how smoothly the latest bivalent polio vaccination campaign was implemented. Another objective was to prepare for five consecutive polio vaccination campaigns in the first half of 2014.
The workshop discussed the following topics: polio epidemiological situation in Syria with recent findings, final results of the national vaccination campaign started on 8/12/ 2013, how to implement door to door campaign, evaluation results of the aforementioned campaign on governorate level, how to plan for campaign evaluation, campaign supervision, campaign obstacles on governorate level and relevant suggestions to avoid them in future, planning for the coming campaign on governorate level, a discussion with the Directorate of Preparedness in MOH regarding the logistics of vaccines and other supplements especially in hard to reach areas, and the role of volunteers in national vaccination campaigns.

Health Care Directorate - Child Health Department

The Department of Reproductive Health in the Directorate of Health Care/ MOH in cooperation with the United Nation People Fund UNFPA and the University of Damascus implemented two workshops on the “Minimum Initial Service Package’ in the last quarter of 2013 as a response to the extraordinary situation that Syria is going through. It aimed at providing good quality reproductive health services to the citizens in their current dwellings.
A group of International Agencies has created the concept of the minimal package, and then it has been applied since the early nineties of the last century in other countries under similar conditions. The application of this concept is supported by supplying 12 types of packages that contain Medical sets, medicines, and other relevant materials.
The director of Health Care Directorate and staff of the Reproductive Health Department were the facilitators. In addition to the heads of Health Care Departments in some governorates (Damascus, Rural Damascus, Daraa, Quneitrah, Sweidah), the participants were heads of district health centers and heads of health centers.
The topic discussed included the following: gender concept, perinatal care, safe delivery, family planning, planning for prevention of sexually transmitted diseases STDs, and health services provided by UNFPA.

Dr. Rustom Jafari