Syria excluded polio-afflicted province from vaccination campaign

At least 15 cases of polio have been recorded in Deir Ezzor, where Syrian government said most people had left

A child in Egypt reacts after receiving drops of polio vaccine administered as part of a joint campaign by WHO and the Egyptian government.

Syria’s Ministry of Health excluded the predominately rebel-held province eastern province of Deir Ezzor — where polio broke out this year — from a 2012 vaccination campaign, insisting that most residents had fled the violence and outbreak of disease, Reuters reported Tuesday.

Hundreds of thousands of people remain, however, and at least 15 children have contracted polio, the World Health Organization announced in November. Public health experts and local doctors say the government’s failure to vaccinate citizens in the province contributed to polio’s reemergence there.

Polio — a highly infectious, incurable virus that causes paralysis in severe cases — has been eradicated in most parts of the world with the advent of a polio vaccine. Yet Syria is experiencing its first outbreak of the disease since 1999. Cases have also been recorded in Aleppo and on the outskirts of Damascus.

Last year, WHO announced a campaign to vaccinate “all children below the age of five against polio,” in conjunction with the Syrian Ministry of Health and the United Nations Children’s Fund. The campaign began on Dec. 6, 2012 and mobilized 4,000 health workers to cover approximately 2.5 million children in every Syrian province except for Deir Ezzor, a region of 1.2 million people that had more than 600,000 under the age of 15 before the war began.

“The majority of its residents have relocated to other areas in the country,” the Syrian report said, citing the outbreak of violence and disease that has caused over 125,000 deaths and displaced more than 8 million people since the civil war began two-and-a-half years ago.

But a doctor working in Deir Ezzor with the opposition relief group Assistance Coordination Unit dismissed that assessment in a Skype interview with Al Jazeera, and said the Health Ministry has not had any presence in the province for months.

The doctor, who asked that his name be withheld for safety reasons, also said the ACU has confirmed 52 cases of polio in the province – much higher than the 15 confirmed by the WHO.

The ACU does not work with the WHO, which can only undertake relief efforts like the vaccination campaign under the supervision of the Syrian government.

Al Jazeera was unable to reach the Syrian Ministry of Health for comment.

It was not clear why the remote province near Syria's border with Iraq was singled out. The city of Deir Ezzor is partially controlled by Syrian government forces while the countryside around it is in the hands of rebels fighting to remove President Bashar al-Assad.

When asked to comment on researchers' allegations that aid groups should have raised the alarm earlier and prepared better, Chris Maher, who is coordinating the regional polio response for WHO, said the organization had warned vaccination rates were falling.

The December 2012 campaign and a subsequent one in October and November of 2013 were planned and organized to respond to the dropping vaccination rates, he said. "In a complex emergency setting, it is not that easy to continue routine campaigns."

Sanitation poor

Upon realizing the problem, the WHO first attempted to right the course in Deir Ezzor by vaccinating 67,000 children under the age of five in January 2013, Maher said. The ACU doctor confirmed to Al Jazeera that a limited number of children had been vaccinated, “but not enough.”

The outbreak had already begun, and the new WHO campaign has only achieved a coverage rate of around 50 percent, insufficient to prevent polio from spreading, public health experts say.

“Only a house-to-house campaign could be considered a successful campaign,” the ACU doctor said. Repeated vaccinations and high coverage levels are needed to interrupt transmission of the virus and prevent outbreaks.

"There was a lack of a proper campaign to vaccinate children across the country over the past two years," said Adam Coutts, a public health researcher based in Lebanon who has been studying the humanitarian response in Syria. "With the breakdown of the health system, sanitation and nutrition, the exclusion of Deir Ezzor from the vaccination campaign provided the ideal conditions for an outbreak to occur.”

Asked if he thought leaving a gap in the 2012 campaign allowed polio to take hold in Deir Ezzor, Maher said: "There are unimmunized kids all over Syria." He added that polio vaccination coverage had dropped across Syria from more than 90 percent in 2010 to below 70 percent in 2012 – a casualty of the widespread violence that has forced doctors to flee and prevented aid groups from operating in certain areas.

U.N. humanitarian agencies work in Syria with the permission of the Syrian government, which has blocked aid convoys to some rebel-held areas of the country.

The doctor with the ACU, which is affiliated with the Western-backed Syrian National Coalition, said the clashes were blocking access to this remote province, and that there was a dire shortage both of volunteers and funding for his group’s efforts. On top of that, sanitation has degraded since the war broke out.

“We should undertake a campaign to clean up the environment before we undertake a vaccination campaign,” he said. “The water isn’t suitable for animals, so how can it be for humans?”

Too little too late

Despite dramatic progress in many parts of the world due to a 25-year-old campaign to eradicate the disease, polio remains endemic in Pakistan, Afghanistan and Nigeria.

Because there is no cure, the WHO's long-standing and repeated warning on the disease is that as long as any child remains infected, children everywhere are at risk.

The WHO says the largest-ever immunization response in the Middle East is under way, with a goal to vaccinate more than 23 million children against polio in Syria and neighboring countries.

"Inside Syria, the campaign aims to reach 2.2 million children, including those who live in contested areas and those who were missed in an earlier campaign. Many children in Syria remain inaccessible, particularly those trapped in sealed off areas or living in areas where conflict is ongoing," the WHO report said.

WHO says almost two million children in Syria have already been vaccinated, including 600,000 in contested areas of the country, in the first of several rounds.

But Coutts says public health professionals in the region are concerned that this response is "too little too late and is exposing a deeper failure of regional health agencies and systems to respond to a very predictable health crisis." 

Al Jazeera and Reuters. Michael Pizzi contributed reporting.

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