HEALTH SECTOR BULLETIN JANUARY 2020 Dialysis Machine in Al Tabaqa National Hospital – Photo by WHO SYRIAN ARAB REPUBLIC Emergency type: Level 3 Emergency Reporting period: 01-01-2020 to 31-01-2020

11.4 M 12 M Targeted with Health 3.4 M 445 146,200 PIN of Health Assistance Interventions IDPs Funds required Returnees

HIGHLIGHTS HEALTH SECTOR

 A total of 277 Health Facilities are supported by Health 71 HEALTH SECTOR PARTNERS

Sector Partners in 14 .

KITS DELIVERED TO HEALTH FACILITIES/PARTNERS  WHO dispatched 82.5 tons of medical & lab supplies, printing material, vehicles & generators - covering 9 governorates The shipments are sufficient to provide more 02 IEHK SUPPLEMENTARY KITS than total number of treatments is 650,223 and 1,295 12 TRAUMA A & B KITS trauma cases 12 NCD KITS

SUPPORTED HEALTH FACILITIES  As a part of the contingency response plan for the evolving situation in NWS, five WHO supported implementing partners deployed 11 medical teams to provide integrated 277 HEALTH FACILITIES health care services The teams are covering more than 40 villages in the south and north rural governorates. HEALTH ACTION

1,301,323 MEDICAL PROCEDURES  WHO supported Ministry of Health on preparedness and 948,790 TREATMENT COURSES response activities for 2019-nCoV outbreak. WHO Number of deliveries attended by provides technical support to strengthen surveillance, 23,484 TRAUMA CASES laboratory capacity, entry screening, Infection Prevention skilled attendant Number of and Control as well as risk communication. VACCINATIONdeliveries attended by skilled attendant 36,020  Security Council renewed resolution 2165 (2014), for a PENTA 3 period of six months, that is, until 10 July 2020, excluding EWARS the border crossings of Al-Ramtha and of Al Yarubiyah.

1,257 REPORTING SITES  UNICEF reached 2308 household in Al Hol Camp with information on health, nutrition and WASH while UNHCR FUNDING $US assisted more than 2300 IDPs and around 4000 refugees. 445 M REQUESTED FOR 2020

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Situation update

The security situation remains unstable and volatile, with the main hot spots in Al-Hasakah, Ar-Raqqah, Aleppo, , and governorates. Hundreds of thousands of people in northeast and northwest are at risk amid ongoing violence. The civilians continue to pay a very high price.

The Eastern region is still subject to several escalations across the three governorates. Ras A-Ain Axis witnessed escalation between the Turkish forces/SNA and the SAA/ Russian forces. Where, intense Turkish/SNA artillery shelling targeted SAA positions in the vicinities of Abu Rasin and Tal Tamer towns, the shelling expanded to several villages such as Tal Tawel, Tal Ward, Khrbat Al-Sha'ir and Umm Al-Kef. Reportedly, the attack resulted in several casualties among SAA, moreover, a large IDPs movements were noticed in the targeted area such as Abu Rasin town, Kasra and Daher Al Arab villages.

As of 29 January and since 1 December 2019, nearly 390,000 people have fled from their homes, mainly from southern Idleb and western Aleppo governorates, mostly escaping hostilities by moving to urban centers and IDP camps in northwest Idleb. Most of the people displaced in northwest Syria since 15 January have been displaced multiple times before, with each new displacement introducing new risks and intensifying existing vulnerabilities. The population of Al Hol is 66,101 people (18,208 HHs); comprising of 46 per cent Iraqis (30,724), 39 per cent (25,780) and 15 per cent third country nationals (TCNs) (9,597).

The access to primary health care services in Al Hol Camp has improved with 15 static medical points, eight medical mobile teams and three field hospitals functioning. Specialist services are also available through three delivery clinics, two HIV and TB clinics, and two static and two mobile teams for vaccinations and leishmaniosis. Five health actors are supporting Areesha Camp, while six health actors with seven health facilities are active in Al-Mahmoudli camp. The total number of people who left Rukban transiting through shelters remains at 19,054 people. People have been temporarily accommodated in five collective shelters in Homs (Mahmoud Othman in Al-Qusour, Baraa Ibn Malek in Deir Baalba, and Abdul Rahman Shattoor, the Teachers Institute and Art Institute in Al Bayada).

As of 20 January, shelters reportedly empty. After leaving the shelters, an estimated 3,230 families are now settled in Homs of whom 801 returned to their areas of origin (532 Mahin, 204 Al-Qariatein and 65 ), and 179 families settled in .

UN Inter-Agency Mission was conducted during end of January for four days to seven sites - Al Zohouryeh village, Deir Baalba neighborhood, , Industrial Hassya , Mahin, Qaryatein and Foruglus (Malaha area) area – to assess the availability of services and gaps. The main needs are essential medicines, wheelchairs, ambulance in Qareteen city, vaccination in camps and reproductive health services in Deir Baalba neighborhood. The health partners have been advised to address the needs.

Public health risks, priorities, needs and gaps

The ongoing conflict, violence and displacement have grave public health consequences with increased morbidities, mortalities and disabilities among affected and vulnerable population. The most affected are children, women and elderly people.

Despite challenges, Ministry of Health and humanitarian partners continue to assist people in need where access is possible with focus on collective shelters and IDP camps delivering essential health services.

With the deplorable condition of the health facilities and inadequate clean water, there is a likelihood of a rise in the communicable diseases. In the face of high levels of displacement and accompanying threats to physical and mental

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well-being, surveillance and response capacity for epidemic-prone diseases, as well as immunization services, must be maintained and strengthened.

Communicable diseases

EWARS and epidemiological updates at national level

Surveillance performance:

 A total of 1118 out of 1257 active reporting sites (88.9%) in all 14 reported through early warning alert and response system (EWARS) with 92.3 % of timeliness.  One reporting site was newly recruited in Al-Hasakeh.  Total number of consultations was 1 538 781. 50.2% of the cases were among females and 42.3% were among children under 5 years.  Out of the 1 538 781 total consultations, a total of 214 996 EWARS notifiable cases were reported.

Morbidity:

The leading causes of morbidity among all age groups were influenza-like illnesses, and acute diarrhoea. The breakdown was as follows:

 Influenza-like illness (ILI): 135 967, accounting for 63.2% of total cases. Most cases reported from Aleppo, Deir-ez-Zor and Tartous.  Acute diarrhoea (AD): 47 545 (22.1% of total cases), most reported from Deir-ez-Zor, Aleppo, and Idleb.  Acute jaundice syndrome (AJS): 2 371 most reported from Deir-ez-Zor, Ar-, and Idleb.  Sever acute respiratory infections (SARI): 2 358, most reported from Tartous, Hama and .  Suspected measles (SM): 157, most reported from Ar-Raqqa, Homs and Aleppo.  Acute flaccid paralysis (AFP): 22, most reported from Damascus, Hama, and Aleppo.  For the “other diseases” category 25 876 cases were reported, with the most reported cases is leishmaniasis of cases (11 861), most reported from Deir-ez-Zor, Aleppo, and Idleb

Proportional Morbidity of top 5 diseases among the total consultation ( week 4,2019 - week 3,2020) 12.0%

10.0% 8.4%

8.0%

6.0%

Percentage 4.0% 3.2%

2.0%

0.0% 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3 Week Number

ILI AD LSH LIC SCA

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EWARS and epidemiological situation in Al-Hol camp

Surveillance performance:

 Total number of reporting site is 24.  Average completeness of reporting 79.7%, and average timelines is 59.6%.  Total number of consultations were 43 512. 57.4% of the cases were among females and 52.5% were distributed among children under 5 years.

Morbidity:

 Out of the 43 512 total consultations, 8 182 EWARS notifiable cases were reported.  The leading causes of morbidity among all age groups were influenza-like illnesses (63.6%/5 200) then acute diarrhoea (21.7%/1 776).  4 suspected measles was reported, two of them were under five years old, and the other two were above five years’ old  Zero cases of AFP reported.

Public health responses

2019-nCoV

 As of end of January, no suspected case of 2019-nCoV were reported in Syria.  WHO supported MoH on preparedness and response activities for 2019-nCoV outbreak. WHO provides technical support to strengthen surveillance, laboratory capacity, entry screening, IPC measurement, as well as risk communication. Daily follow up on SARI cases and entry screening are in place. WHO has also supported them developing passenger location cards for points of entry and investigating forms for suspected 2019-nCoV. WHO has provided MOH with PPE (500 medical masks(N95), 10,000 surgical masks, 200 goggles, 10,000 gloves, etc.) 50 stethoscope and pulse oximeter for each, and 4,000 nasopharyngeal swabs for laboratory testing.  Between 2 and 3 February, a joint meeting with MOH and WHO was conducted in Damascus. WR and the Deputy Minister attended. More than 50 MOH officers participated and discuss the preparedness and response plan, investigation, and laboratory procedure. During the meeting, MOH agreed on SoP in entry screening.

Acute diarrheal cases

 An increase of acute diarrhea cases was reported from 8st of January 2020 in Tal Maskan and Bitariye in Rural Damascus. Between 8 and 18 of January 2020, a total of 190 (U5yrs:78, above 5yrs: 112) cases with no associated death were reported. The symptoms were acute diarrhea. The severity of diarrhea ranges mild to moderate. On 9 January, three samples of water network from Tal Maska and tested. The results showed all sample had no residual chlorine and identified fecal contamination (E. coli + fecal coliform) in all three samples. The water in the network was sterilized after the analysis immediately.  An increase of acute diarrhea cases was reported from 31st of December 2019 in Ashrafia Al-Wadi and Jdeideh Al-Wadi in Rural Damascus. From 31 of December till 11 of January 2020, a total of 882 (U5yrs:199, above 5yrs: 683) cases with no associated death were reported though EWARS. The common symptoms were acute diarrhea and vomiting. The severity of diarrhea ranges mild to moderate. Coliform contamination was found in water samples collected from both neighborhoods. E.Coli was detected in water samples from Jdidet el-Wadi. A laboratory analysis of human stool sample detects norovirus and campylobacter. The contaminated water sources were sterilized, and the use of the contaminated water source was banned.

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Suspected measles

 According to MOH, during 2019, a total of 1221 suspected cases reported and among them 27 cases were tested positive for measles.  There is one confirmed case of measles reported from Aleppo on 15th of January. The case was child with 8 months old. DoH in Aleppo conducted local vaccination activity of MMR vaccines with vitamin A and 38 children in the neighborhood were vaccinated.

Influenza  An increase of proportional morbidity of influenza-like illness (ILI) and severe acute respiratory infection (SARI) has been observed. This trend is in line with the seasonality of the diseases considering that the same trend was observed in the previous two years.  Between 1 January and 6 February, a total of 103 samples were collected from SARI cases admitted to ICU and tested at the influenza reference laboratory. Among them, 23 cases tested were positive for influenza (2 cases were influenza type A H1N1, 18 cases were influenza type A(not subtyped), and 3 cases were type B)and 22 cases were negative, while test results of 58 cases were pending.

Proportional morbidity of influenza-like-illness (ILI) cases among total consultations ( week 1-52,2018,2019,2020)

14.0% 12.0% 10.0% 8.0% 6.0%

Percentage 4.0% 2.0% 0.0% 1 2 3 4 5 6 7 8 9 10111213141516171819202122232425262728293031323334353637383940414243444546474849505152 Week Number

2018 2019 2020

Number of severe acute respiratory infection cases ( week 4,2019 - week 3,2020)

1200 1000 363 800 600 349 344 400 200

Number cases Number of 0

2019,4 2019,5 2019,6 2019,7 2019,8 2019,9 2020,1 2020,2 2020,3

2019,10 2019,11 2019,12 2019,13 2019,14 2019,15 2019,16 2019,17 2019,18 2019,19 2019,20 2019,21 2019,22 2019,23 2019,24 2019,25 2019,26 2019,27 2019,28 2019,29 2019,30 2019,31 2019,32 2019,33 2019,34 2019,35 2019,36 2019,37 2019,38 2019,39 2019,40 2019,41 2019,42 2019,43 2019,44 2019,45 2019,46 2019,47 2019,48 2019,49 2019,50 2019,51 2019,52 Week Number

Cutaneous leishmaniasis  Between week 1 and 3 in 2020, a total of 6178 suspected cutaneous leishmaniasis were reported and most reported from Deir-ez-Zor, Aleppo and Idleb in December. Specifically, in Deir-ez-Zor, a significant increase of suspected cutaneous leishmaniasis has been observed since mid of October.

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 From 21-22 January 2020, a training workshop on cutaneous leichmaniasis case management and early detection and treatment was conducted in Al-Hassakeh. 25 health workers were trained to respond to the severe increase of cutanious leishmaniasis cases from east countryside of Deir-ez-Zor.

Figure 9: Number of suspected Leishmaniasis cases in in Deir-ez-Zor (week 4,2019 - week 3, 2020)

1600 1326 1400 1046 1200 955 1000 924 800 600 400

Numbercases of 200 0 4 5 6 7 8 9 10111213141516171819202122232425262728293031323334353637383940414243444546474849505152 1 2 3 Week Number

Tuberculosis  WHO delivered three GeneXpert systems and testing cartridges to the National TB Programme. The delivered system will contribute to scaling up the TB laboratory up to more than 60% of their capacity. The related kits will cover testing of 2400 sputum samples plus 1200 body fluid samples. Also 45,000 Vit B6 was secured to support multi drug resistant patient from side-effects of TB medicine.  2 mobile clinics for TB diagnosis and case management started working in Aleppo and Deir-ez-Zor. 4 villages were visited in Deir-ez-Zor, 70 contact tracing were examined (25 TB suspected cases and no case was confirmed), and TB medicines for 7 TB patients were delivered.

Mental Health and Psychosocial Services

The number of mental health consultations provided by health actors stands at 28,091.

There is continue scaling up MHPSS services in NES in coordination with partners and hub.

Health facility Functionality

According to HeRAMS June 2019 report, out of 111 hospitals, 58 (52%) are fully functioning, 27 (24%) partially functioning and 26 (24%) are non-functioning. Out of 1808 Public health centers, 833 (46%) are functioning, 389 (22%) partially functioning and 586 (32%) are non-functioning.

Availability of health staff

Pharmacists represent (1%) of the total health staff at centers’ level, along with resident doctors (2%) followed by general practitioners (4%); laboratory (6%); Specialists (7%); dentists (10%); midwives (12%); and nurses (58%).

Health Sector Action

Health Sector Coordination and service delivery

During this month, two regularly scheduled health sector coordination meetings were held on 7 and 28 January and were attended by national Syrian NGOS, international NGOs, SARC and observers. The health sector partners delivered health services and the cumulative monthly indicators (December) are summarized in the below table.

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HRP Indicator 2019 (Per Month) November

1.1.1 Number of outpatient consultations provided 1,242,362

1.1.2 Total number of trauma consultations supported 23,484

1.1.3 Number of mental health consultations supported 22,649 1.1.4 Number of physical rehabilitation sessions 2,376 supported 1.1.5 Number of vaginal deliveries attended by a skilled 4,769 attendant

Medical procedures 1.1.6 Number of caesarean sections supported 4,024 1.1.7 Number of cases referred for treatment (between 1,659 levels of care, cross-line and cross-border)

Child Health

36,020 children were immunized for Penta 3

Reproductive Health

Skilled birth attendants conducted 4,769 normal deliveries while 4,976 mothers underwent caesarean sections.

Health Cluster Partners Updates – November 2019

Health Cluster Partners continued supporting health service delivery across the country. Some of the highlights are;

World Health Organization were delivered to Al-Khaldyeh & Al-Massaranyeh PHC centers. Continued support with operational cost to sustain field activities for the four medical mobile teams to cover Two surgical tables donated to MoH Alwaleed hospital in basic PHC services for Al Rukban returnees. Hama governorate. 55,175 treatments of life-saving medicines delivered to Damascus MOH, MOHE Central, Aleppo (Gyn/Obs hospital, SARC), Hama (Al Br Hama NGO).

5 ambulances delivered to the Readiness & Emergency Unit at MOH as part of the NW and the south response (Aleppo, Hama, Homs, , Qunitra). 1 ambulance delivered to the Aleppo university hospital, MOHE.

175 field workers from the Ministry of Electricity trained on first aid and basic trauma life support in three governorates (Lattakia, rural Damascus and Damascus). Interagency Mission Hama assessing needs of Rukhban arrivals Two diesel generator (5KVA) were delivered to Qunetra governorate. And two ultrasound machines model DC-N3

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UNHCR points in community centers in Hasakeh, Aleppo, rural Aleppo, rural Hama, rural  During January an estimated 23,682 IDPs, Homs, Tartous, rural Tartous, Qunetra , rural and 3916 refugees & asylum seekers assisted Daraa and rural Damascus. In to access basic package of primary health details, 3674 received basic Medical care services through 13 PHCs supported by consultation, while 6221 PoC participated UNHCR in Damascus, rural Damascus, Homs, and benefited of health promotion and Hama, Aleppo and Al Hasakeh. Services disease prevention activities conducted by included medical consultations, community health workers inside and investigations. Treatment courses were outside the community centers. provided to an estimated 12,895 IDPs and 3390 refugees & asylum seekers

 794 IDPs with critical medical conditions and 286 refugees in need for secondary care were referred by UNHCR partners to hospitals and received free of charge secondary care services.

 Estimated 9895 PoCs reached by community based health activities through 19 health UNHCR primary health care service

UNICEF as on Hygiene promotion, ten theaters were performed by 25 children and 15 adolescents C4D works on integrated community engagement from the camp. and awareness initiatives in Al Hol camp with ST, and  2,308 households were reached with comprehensive information on Health, Ehram. The achievements were; Nutrition, and WASH, and 42 mother  65 sector leaders and community services sessions conducted. committees were trained on Communication skills and key messages (Vaccine & IYCF,  The basic messages were drawn in 16 diarrhea and leishmania) in coordination kitchens in eight sectors in Al Hol camp. with camp management. Our goal was to activate the community committees to take their role as active actors in their community in addition that after this training, each sector leaders conducted ten awareness session for Community leaders in their sector.

 The child and adolescent committees that were formed by the camp management were UNICEF: Painting on kitchens targeted by training them in theaters focusing on their rights to the vaccine as well

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Plans for future response

Plan to conduct vetting of HRP 2020 projects

Ensure health sector readiness and preparedness for COVID -19

Planning to conduct Cluster coordination performance monitoring during 1st Q 2020 Finalizing health sector component of HNO and HRP 2020

CONTACTS

Damascus Aleppo Homs Lattakia/Tartous Qamishli national sub-national level sub-national level sub-national (north-east Syria): level level sub-national level Coordinators Dr Jamshed Tanoli Dr Kady Fares Dr Nadia Aljamali, Mr Hamza Hasan Dr Khaled Al Khaled Health Sector Head of WHO Head of WHO Head of WHO Head of WHO sub-office Coordinator sub-office sub-office sub-office [email protected] [email protected] [email protected] [email protected] [email protected] Information Management Unit Mr Mutasem Mohammad, Information Management Officer, WHO Syria, [email protected] Mr Ayman Al Mobayed, Information Management Officer, WHO Syria, [email protected]

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