WHO Syria: SITUATION REPORT Weeks 28 – 29 (5 – 18 July), 2019
I. General Development, Political and Security Situation (22 June - 4July), 2019 The security situation within the country remains volatile and unstable. The main hot spots remain Daraa, Al- Hassakah, Deir Ezzor, Latakia, Hama, Aleppo and Idlib governorates. The Turkish military preparations along the Syrian /Turkish borders escalated the tension in the Euphrates region ushering in an imminent military operation against the Kurds. The Eastern governorates are still witnessing a high level of asymmetric attacks against SDF personnel in the form of of IEDs and VBIEDs explosions. The security situation in North rural Hama remained tense; SAA regained control over a town that was seized by NSAGs a week ago . Military operations are still taking place against NSAGs held towns in Idlib, Hama, Latakia and Aleppo Governorates. An increase in the number of Indirect Artillery Fire attack (AIF) has been noted in Aleppo city in comparison with the previous week. At least five Syrian soldiers were killed after being attacked in the governorate of Daraa, 90 km south of the capital Damascus. Military sources asserted that the terrorists ambushed a military vehicle between Yadouda and Dahya, leaving five soldiers dead and 16 injured. Air strikes targeted rebel-held cities in northwest Syria on Friday, a war monitor reported, widening bombardment of the last major insurgent enclave to areas that had mostly escaped it. The strikes killed three people in Idlib and three in Maarat al-Numan, two of the largest cities in the region, the Britain-based Syrian Observatory for Human Rights said according to a Reuters report. The United Nations is close to agreement with Syria on setting up a constitutional committee, a long-awaited step in a stalled peace process, the U.N. Syria envoy said on 10 July. “I believe we have made a very solid progress and we are very close to have agreement on establishing the constitutional committee,” Gerd Pedersen told reporters after meeting the Syrian Foreign Minister Walid al-Moualem. Thousands of Syrian refugees have returned to their country in the last 24 hours from Jordan and Lebanon, the Lebanese immigration authorities reported A new batch of displaced Syrians arrived in Jlaighem corridor in Homs eastern countryside coming from al- Rukban Camp as the displaced were held against their will for years in the camp due to terrorism and the US occupation forces. SANA reporter said that tens of families on 10 July arrived with their belongings at Jlaighem corridor by buses coming from al-Rukban Camp in al-Tanf area
II. Key Health Issues
With the displacement of approximately 330,000 individuals, there is an increasing demand for health services in northern Idleb and a pressing need to reach every person with much needed healthcare. Health Cluster partners have deployed more than ten mobile clinics to provide primary healthcare services for displaced people in the arrival areas. Each mobile clinic, consisting of a doctor, a midwife, a nurse and a community health worker, offers services for child health, nutrition, communicable and non-communicable diseases, maternal and newborn health, and is equipped with essential medicines and medical devices. Mobile units rotate across several communities for internally displaced people, ensuring the provision of basic health care services and coordinating the referral and transportation of patients to other health facilities whenever this is required. Each of these mobile clinics provides between 1,500 and 1,800 consultations per month.
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In Al Hol Camp the: Twelve static medical points, 18 medical mobile teams, two vaccination teams, a leishmaniasis team and three maternity clinics are providing daily health care services to the camp inhabitants. 11 health points were reporting to Early Warning And Response System (EWARS) during the reporting period. Common morbidity cases are related to influenza-like illnesses, acute diarrhoea, tuberculosis, leishmaniasis, measles, wormborne diseases and lice. Most of the water tanks are still without covering causing a water contamination. The result of random 56 water samples shows that most of the water sources are non-drinkable due to the bacterial contamination. III. WHO Response
1) Non-Communicable diseases & Primary health care:
Represented WHO at the Strategic Framework meeting. Participated with the joint meeting between MOH & UN Agencies to discuss the new updated list of health centers for minor rehabilitation process. Participated in WebEx discussion concerning WHO/UNICEF joint cooperation to improve PHC health care with a focus on community level, the objectives were as follows: o Background information - joint letter from both RDs , o Briefing from UNICEF and WHO representatives on the current activities related to strengthening PHC. o Suggested mechanism for approaching the MOH by the two organizations jointly. o Suggestions for developing a joint Work-plan - October 2019. Communicating officially with MoH concerning the need of a national consultant expert to follow up on the Primary Health Care Measurement and Improvement Initiative /PHCMI initiative relevant data collection and PHC improvement at MOH level. Coordination with EMRO & MOH counterparts is in place. Submitted Donor Report under PHC/NCD programs for the 1st half of 2019. Continued follow up with PICC for SDGs ; Syria profile, the health & sectors’ indicators are under updating process. A total of 280 NCD kits under ECHO were received and under distribution process to NES, NWS, SW & Rural Damascus. Dispatching life-saving medicines to SACSN NGO in Lattakia, 62 NCD kits to SARC Aleppo and 11 NGOs in several governorates: Homs (Shabab Al Khair , Odad Alfuqara NGO & Al Bir NGO), Draa ( Al Birr Association) , Aleppo ( Health promotion NGO - Al-Ihsan NGO & Al –Taalouf NGO ) , Rural Damascus (YOUTH CHARITY /EG & Circassian Charity Association /EG) and Damascus ( Nour Foundation For Relief And Development /EG (YBB)) , ALBIR Hama NGO. A total number of PHC/NCD treatments was provided 252,155 during the reporting period.
2) Trauma
About 150 health workers were trained on trauma and disability in three governorates (Aleppo, Lattakia, Tartous and Damascus). The following deliveries of (8,000 treatments and 500 trauma cases of trauma medicines and medical kits) were provided during the reporting period: 2 Trauma kits (200 trauma cases) and 1 IEHK Basic kit ( 1000 treatment) were delivered to Bab Al Sebaa NGO in Homs. 1 surgical supplies kit (100 trauma cases) was delivered to Mar Afram NGO in Al –Hassakeh. 3,000 treatments of medical supplies were delivered to Bab Al Sebaa NGO in Homs. Delivered 15,000 bags of Sodium chloride 0.9% to SARC as part of the response to the urgent need in the North West Syria health facilities. 40 first aid kits were delivered to UNICEF in Damascus. Participated in PSEA meeting, prevention of sexual exploitation and abuse, with focal points from UN agencies and discussed the challenges, trainings materials, gaps in the PSEA area in preparation for the upcoming UNCT meeting this month that is dedicated for PSEA discussions and decision making.
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3) Immunization
The WR a.i. has highlighted the main strategic directions for the coming period in order to support the MOH achieve its planned Goals. Respect, quality of the performance, high accountability and decentralization are the main benchmarks that will be followed by WHO in relation to our set objectives. WR a.i. met with the EPI/Polio program staff to examine the organogram, program update and future plans. He emphasized the duly update of the Polio risk assessment (finalized and sent to EMRO for review) and the stages reached in the routine immunization acceleration plan for Syria (to be discussed with the MOH and partners). The comprehensive field EPI review and data quality assessment of the different components of the EPI is completed by the international/national experts; currently the team is compiling the findings for final report to the MOH on 21st of July 2019. This will pave the way for the GAVI project implementation in coordination with EPI program in Syria. The VPD Regional adviser, in person, have reviewed the EPI infrastructure at the central level and met with essential partners (UNRWA, UNICEF and SARC) as well in Damascus. Meeting of the EPI Regional advisor with H.E. the deputy minister of health; the strong commitment of central and governorate level health staff was elicited during the completion of the EPI review and the Data Quality Assessment (DQSA), hence H.E. was thanked for the hospitality and good cooperation. The GAVI proposal was also discussed ; the regional advisor urged his excellency for the rapid finalization of the draft proposal to expedite the process and reduce the risk of stock-out of vaccine in 2020; it was agreed to finalize the document within this week to enable the start of the process of drafting the proposal before the end of the year since the September deadline was already missed. Conducting a workshop for the development of The EPI Improvement plan, the workshop was facilitated by experts from EMRO office . It took place in Damascus and was attended by EPI mangers of all 13 governorates. The objective is to critically review the main points for improvement of the Program and endorse it by the MOH and ensure its implementation at the grass root level. The Polio Expert Review Committee Meeting (16 July 2019) at central EPI department in Damascus reviewed the documents of 27 non Polio AFP cases and all were discarded based on the provided documents and field investigations for each of them. EPI improvement plan workshop (17-18 July 2019). The objective is to facilitate the development of specific improvement plan per governorate (lead is EMRO EPI team.).
4) Mental Health
MHPSS services were delivered by NGOs through five Active family wellbeing centers as follow:
o HAMA with Al-Bir Hama NGO, Lattakia, with Syrian Association for Children with Special Needs, NES in Al-Hassakeh/ Al-Hol camp with, Archbishopric of Syria Catholic Center Mar Assia and Al-Yamama, Dez with Syrian Pulse NGO, o Integrated MHPSS services delivered on community level in Qunaitra, Rural Damascus, Aleppo, Homs and Al-Hassakeh through agreement with 10 local NGOs.
The procured caravans are posed in Al-Hol camp and active as field family center. Following up with MOH/ MH director to integrate MH into chronic disease porgrammes " NCD, HIV-TB" to achieve a comprehensive approach in addition to providing information regarding the SDG, MH and substance use section to be provided before the intercountry meeting to review the implementation of the Regional Framework for Scaling up action on Mental health in the Eastern Mediterranean Region and the process of amendments to the WHO’s comprehensive mental health action plan in September 2019. Finalizing with Gzt HUB MH and MHPSS NES TWG to jointly conduct a mhGAP training course in NES for health partners. The training will be roll-out modality rather than ToT, with joint training for MHPSS workers on the ground. Follow up MHPSS TWG action points by shaping 2 tools for mapping capacity building programmes among partners and align the referral pathway with global standards to cover all categories and sub-categories of services in addition to developing one training course for MHPSS M&E targeting project managers and project reporters. Providing supportive supervision sessions for partners in different governorates on MH programme "mhGAP, Counselling, SMHP". Page | 3
5) Nutrition and Child Health
Data collection of IMCI program from international medical committee from 3 centers for April 2019, in addition to data collection of IMCI program from international medical committee from 3 centers for April 2019, with a total of 4552 beneficiaries. Meeting with family medicine society to plan trainings on Nutrition surveillance and Infant and Young Child Feeding Counselling programs in different governorates to be applicable in private clinics. Condcuting the Meeting of the Sub-Sector Nutrition Group for the Southern Region (Damascus, Rural Damascus, Dar’a, Sweida and Quneitra) to review the first 6 months achievements and plan for the next coming 2019 months . Conducting a technical meeting for the elderly nutrition program to review the questionnaire of the planned survey . Data collection of IMCI program in 114 health centers across the country, with 9069 beneficiaries.
6) Secondary Health Care
Finalized the surge mission report to Al –Hasakeh and complied it with other mission’s reports conducted at the same period. Continued working with Al Qamishli hub and agreed on the way forward in updating the availability of services in the field hospitals at Al-Hol Camp. Conducted a site visit to the Children Hospital in Al- Hassakeh governorate to assess the health needs of medical equipment to be provided after the completion of the rehabilitation works of the infrastructure under UNDP support. Started the procurement process of medical equipment to improve the functionality and preparedness of the diagnostic unit, operating theatre, intensive care, paediatric, emergency and haemodialysis unit in Harasta national hospital in Rural Damascus. Continued the preparation for the upcoming mission of the RO consultants scheduled from 3- 7 August,2019 to monitor the progress of work at the children hospital and to confirm and certify the acceptance tests related to the rehabilitation project.
7) Communicable Diseases, Surveillance and WASH Communicable Diseases/Surveillance
Provided the reference control strain of salmonella, shigella, cholera for further investigations of diarrhea cases to the reference microbiology laboratory in Damascus. Provided 80 cholera rapid diagnostic kits for 800 tests to 14 governorates. Supported zoonotic national programme in securing 8000 ant-rabies vaccines to be distributed to all governorates including Aleppo and NES in addition to providing 2000 praziquantel tablets for treatment of hydatid cysts. Indoor residual spraying campaign to respond to the increase of leishmaniasis cases in Aleppo had been conducted in the priority neighborhoods/areas where the prevalence of leishmaniasis exceeds 1%. 11 locations were covered in Aleppo city by the reporting period. The number of beneficiaries is 51 196 including 10 277 households.
TB active case finding in Sheik Maqsood in Aleppo: WHO in cooperation with Aleppo DOH is implementing TB active case finding activity in Sheikh Maqsood neighborhood in Aleppo targeting IDPs and the most vulnerable population from 11th July till now. During this activity, more than 20 health workers were trained on field work methodology and 2100 individuals have been screened. 119 suspected cases has been identified, and among them,7 cases were confirmed as TB. Leishmaniasis response in Al-Hol camp: WHO continues to support the leishmaniasis medical points operated by DoH in Al Hol camp. In total, 360 suspected leishmaniasis cases were registered during the reporting period. Among them, diagnosis of leishmaniasis was confirmed for 19. In total, 1155 leishmaniasis cases have received treatment since March 2019.
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WASH
The water quality monitoring visits were conducted in Rural Damascus, Aleppo and Al-Hol camp. o Rural Damascus: the water samples from 30 water tanks, 5 car tanks, 29 wells and 9 water networks in 20 sites were tested. Among them, 3 tanks, 2 car tanks, 3 wells and 2 water networks found not safe microbiologically. 1 car tank and 25 well were not chemically safe for drinking. o Aleppo: The water samples from 72 wells, 29 water reservoirs and 18 jerry cans in 18 villages were tested. Among them 10 wells, 20 reservoirs, 14 jerry cans were microbiologically not safe for drinking. The water samples from 8 water trucks, 10 jerrycans, 1 ice samples from Jassem Al-Baier ice factory were tested by ATP measurement. Among them, 8 jerry cans and the ice samples were contaminated.
8) Information and Planning
Joint technical meeting by HIS team and counter partners in MoH (Directorate of Planning and International Cooperation and other technical directorates) to follow up IM transition from emergency to early recovery context (Secondary Health Care Information System). Conducted site visits to health facilities affiliated with MoH, NGOs, SARC, UNRWA to monitor HeRAMS in Homs governorate). Attended WebEx two-day training of Activity Info, 10-11 July 2019 by WHE-EMRO. Attended MRM training for CTFMR focal points and facilitators in Beirut 15-16 July by UNICEF. Attended Technical focal points training: Syria Return Portal (SRP) - 14 July 2019 at UNHCR Office, Damascus. Attended M&E TWG meeting on 17 July 2019 with UN agencies in Damascus. Attended WebEx for Digital Strategy Mapping with WHE-EMRO. The following information products were published and distributed: o Summary of WHO-WoS key performance indicators snapshot for May 2019. o Summary of WHO key performance indicators snapshot for May 2019 (Across Syria, North-east Syria, North-west Syria, Southern Syria). o Statistical analysis of Exit Interview & Shorten SARA tool as part of the Assessment of the Health Situation and Services in Al Hol IDP Camp. o Narrative report on the urgent needs of Assad Hospital in Deir-ez-Zor. o Narrative report on Mahmudli camp in Al-Raqqa governorate. o Shared report of attacks on health from Jan to June 2019 at WoS level. Monitored a weekly update on shift of control, functionality status of public HFs, and control areas for NSAG areas of North West Syria. Provided selected 5 country-specific key performance indicators for WCO-Syria to EMRO as part of Results measurement framework - Phase 2. Provided inputs on Q4 2018 HeRAMS infographic snapshot to WoS. Provided inputs on Attacks on health for May and June infographic snapshots to WoS.
9) National NGO Coordination
Damascus and Rural Damascus: o 1 PHC center in Al Zahera run by Nour Foundation for Relief and Development continues to provide the essential package of health care services to affected host community and IDPs. o 1 PHC center in Al Qutaifeh and 4 MMTs run by Al Qutaifah Health Charity operating in Eastern Ghouta (Douma and Harasta) maintain the provision of the essential health care services to the host community, IDPs and returnees to eastern Ghouta. o 1 PHC center in Al Tal and 1 MMT in the surrounding areas o 3 PHC centers in:Qudsaya , West Kiswah and Harasta suburb and 3 Medical mobile clinics in rural Damascus. South Syria: 3 MMTs by Charity and Social Service Society Organization continue to provide the essential primary health care services in Dar'a governorate including Dar’a, Tassil, Shaqraniyeh, Sharae, Bweidan, Masmiyyeh, Barraq (Masmiyyeh), Bali and Northern Karim in addition to 2 medical mobile teams in Al Qunaitera. Preparation for the upcoming consultancy assignment to enhance the capacity of the NGOs network for effective engagement in health and healing activities guided by “Health Diplomacy” principles for rapid and Page | 5
longer term programmatic interventions, based on the NGO Strategic Plan 2017-2022. 3 ended MOUs were technical and financially cleared and 3 progress reports were reviewed and cleared. 3 project proposals are under preparation to be submitted for clearance. # of ongoing MOUs is 23 – Annex 4
10) External Relations and Communications
Engaged in discussions with Japan to secure new funding under the new JSB applications. In coordination with HQ, responded to queries from Austria to about a possible funding decision for NES. Leading the preparation of the WoS six-months donor update. Conducting a field visit to Aleppo governorate to follow up on WHO response there. The mission aimed at reinforcing the capacity of WHO sub-office in Aleppo in its meetings with the local health authorities as well as following up on related preparedness to respond to the situations in NWS and NES areas . Different meetings were conducted with the Director of Health, the Director of Aleppo University Hospital and the president of SARC in Aleppo. Communicating officially with MoH concerning: a. the upcoming sixty-sixth session of the World Health Organization Regional Committee for the Eastern Mediterranean, Tehran – Iran 14-17 October 2019. b. The Foundation of the State of Kuwait Prize for the Control of Cancer, Cardiovascular Diseases and Diabetes in the Eastern Mediterranean Prize for 2019. Developing a visibility video documenting the Japanese support to the health sector in Syria through supplying medical equipment to public hospitals and training for bio-medical engineers: https://youtu.be/cM9ovnfZyDc. Preparing in cooperation with EMRO communication unit a profile story about Ms Hoff on the occasion of the end of her appointment as WR in Syria : http://www.emro.who.int/syr/syria-news/elizabeth-hoff-seven- years-of-tireless-work-in-war-torn-syria.html Preparing a visibility story to be published in the SDGs and Health Country Profiles Brochure for the upcoming 66th Session of the Regional Committee for the upcoming RC66 Exhibition focusing on innovation action on public health quite distinguished at the national level. Preparing Al-Hol sitrep, issue 10 . Providing photo documentary on WHO supported capacity building activities covering different intervention areas. Posting several tweets on WHO-Syria Twitter account about WHO interventions and health response: WHO Syria (@WHOSyria) | Twitter
11) Training and capacity building
During the reporting period, 465 participants benefitted from 18 WHO-supported capacity strengthening activities (Annex 2).
12) Operational Support and Logistics
Dispatched 53.5 tons of medical, lab supplies and printing materials – covering 9 governorates (Aleppo, Daraa, Damascus, rural Damascus, Al-Hasakeh, Raqqa, Lattakia, Homs & Hama). The recipients included 3 MoH facilities, 21 NGOs, SARC & UN agency. The total number of treatments is 332,095 and 500 trauma cases. The dispatched supplies included: 500 Haemodialysis sessions which were delivered to the Kidney hospital in Aleppo. 200 devices of Log Tags (temperature recorder) with 10 chargers and 250 sets of both national immunization system & the surveillance system were delivered to MoH central warehouse in Damascus. Lab items were delivered to MoH - public health labs – microbiology lab. 2 Oxygen generating stations and 1 high pressure booster system were delivered to Al-Tabqa national hospital in Raqqa.
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5 sphygmomanometers, 4 digital thermometers, 1 patient monitor, 2 trauma kits A, 1 compressor nebulizer, 1 IEHK kit, 84 NCD kits, 1 surgical supply kit and different types of EWARS, Trauma, MH, PHC & STHC medical supplies & printing materials were delivered to 21 NGOs in Aleppo, Daraa, Damascus, rural Damascus, Al- Hasakeh, Lattakia, Homs & Hama governorates. 15,000 bottles of IV fluids were delivered to SARC warehouse in Damascus as an urgent response to support the SARC health facilities in North West Syria. 800 Haemodialysis sessions, 600 IV fluids, 900 vials of Vancomycin 1g and 12 NCD kits were delivered to SARC warehouse in Aleppo. 40 first aid kits were handed over to UNICEF.
IV. WHO Response in Hotspot Areas
The following sections describe the security and health situation, including WHO response in the hotspot areas in Syria. It is subdivided into:
1. Northeast Syria (Al-Hasakeh; Ar-Raqqa, Deir-ez-Zor), and
2. North West (Aleppo, Homs & Latakia)
Northeast Syria (Al-Hasakeh; Ar-Raqqa, Deir-ez-Zor)
1. Political/Security Situation The current situation of NES: Political Headlines ISIS flag raised at Syrian camp holding jihadi families On Monday 15th July in a video posted online, across the web and social media, women and children were cheering while the homemade flag flutters from a pole. The crowds were heard shouting “baqiya” – the Arabic word for “remaining” – a reference to the Isis slogan “remaining and expanding” The black flag of Isis has been hoisted in a Syrian camp holding thousands of the terror group’s family members, nearly four months after the caliphate was officially declared defeated. This is not the first such incident at the sprawling Al-Hol camp in northeast Syria. It comes amid warnings of growing radicalization at the facility. The Independent Islamic State Oil minister 'killed' in Syrian hideout The Islamic State ISIL oil minister was killed in eastern Syria this week after the Syrian Democratic Forces (SDF) carried out a joint operation with the U.S.-led Coalition. According to a statement from the SDF, their troops managed to kill Thabit Sobhi Fahd Al-Ahmad while conducting an operation near Al Busyrah in Deir Ezzor Governorate. He was one of the highest-ranking Islamic State commanders in the Deir Ezzor Governorate. He was responsible for the sale and smuggling of oil from the previously ISIL-occupied areas in Syria and Iraq. Almasdarnews ISIL launches heavy attack on largest oil field and nearby Coalition airport in eastern Syria: ISIL sleeper cells carried out their heaviest attack of the year on the U.S.-backed Syrian Democratic Forces’ (SDF) positions at the Al-Omar Oil Field. The pro-opposition Syrian Observatory for Human Rights (SOHR) reported that intense clashes took place near the Al-Omar Oil Field and nearby Coalition airport, resulting in several casualties for all parties involved. SOHR Turkey reacts to threat of US sanctions with military deployment near Syria: A significant deployment of heavy weapons has taken place near the strategic northern border town of Tal Abyad, controlled by the Syrian Kurdish YPG militia. The Turkish operation into Syria might be linked with the risk of approaching US sanctions through the Countering America’s Adversaries Through Sanctions Act (CAATSA) over the purchase of Russia’s S-400 missile defense system.
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Security situation: The security environment in the area is still volatile and unpredictable in a continuation of the trend of violence against SAA and SDF positions. Deir Ezzor Governorate: ISIL presence continues to be noticeable in the Syrian desert, West of the Euphrates river, in the areas under GoS control, and they conduct operations between Deir Ez-Zor and Homs governorates. Meanwhile, in northeastern Syria, the US-backed Syrian Democratic Forces (SDF) have continued their operations against the IS Sleeping cells on the eastern bank of the Euphrates River. The high rate of retaliatory attacks against US/SDF forces is continuing. Ar Raqqah Governorate: During the last two weeks 3 IEDs and 2 SAF (Small arm fires)were reported against SDF patrols in Ar-Raqqa city and Rural Ar-Raqqah. In the same context, SDF carried out wide arrest campaign looking for ISIL affiliated members and some defectors from the military conscription in Ar-Raqqah governorate. Reportedly, the total of (25) twenty-five men accused of ISIL affiliation was captured in this campaign in several areas of Ar-Raqqah countryside Turkey has increased its military deployment near the Syrian border, including heavy weapons, armored vehicles and tanks and artillery batteries were deployed near Tal Abyad, located next to Turkey's border district of Akchakale , an area controlled by the People's Protection Units (YPG). The latest deployments and tactical mobility on the ground have very strong indications for an offensive east of the Euphrates. Al Hasakah Governorate: Al Hasakah governorate is still more stable than Ar-Raqqah and Deir Ezzor with notable increasing of the rate of IEDs, VBIEDs attacks in Al Hasakah city and its south rural (Markada, Shaddadi districts). They could underline the intent to impose a degree of instability in the Governorate. On 11th July, three IEDs planted under a motorbikes went off close to Al- Salihiyah in the vicinity of Salihiyah neighborhood and Kallasah neighborhood in Al Hasakah city. On 11 July a VBIED targeted Aladra charge in Alwesta neighborhood of Al Qamishli city not far from UN Offices causing seven causalities among civilians and worshippers . On 17 July a VBIED went off near Beiruty bridge targeting SDF Check point , resulting in three injuries. Coordination: Conducted the regular health working group meeting twice in Al-Hol camp; the meetings discussed the following topics : Updates on the general health situations, The analyzing of EWARS weekly updates, The referrals of the cold cases, The map of health services, The Isolation area establishing, Updates by the three field hospitals and the Weekly mortality analyzing. Participated in the regular coordination meetings of Al-Hol camp, where many crosscutting issues related to health were raised to the other sectors ; the main issue was WASH interventions and enhancements in addition to the coordination in terms of the departure trips with the protection sector. Conducted a meeting with the internal operational desk in the camp to follow up the main challenges and the appropriate solutions. Conduced a meeting with the camp authorities to discuss the acute needs to establish 24/7 services in the annex as a part of the health sector advocacy. The checklist of the availability of the services within the three field hospitals was prepared by WHO and was updated for this week and will be shared with the health actors as soon as the final analyzing is ready. Emergency response: Vaccination 2 vaccination teams are working on a daily basis in Al-Hol ; EWARS & CDs& Water quality;
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In coordination with AlHasaka – DoH, Leishmania treatment mobile team supported by WHO provided treatment to the camp residents in phase 5. The Early warning system is ongoing effectively within the camp. During the reporting period , medical points provided reports for the epidemiologic weeks 27 and 28. During the epidemiological period an average of 12 heath facilities reported on time, in week 28 . A total of 5856 consultations were recorded in 13 health facilities in the camp in week 27 and 5675 in week 28 in n addition to 5935 recorded in MSJM and KRC field hospitals. The leading causes of morbidity among all age groups remained acute diarrhea (13%) and influenza-like illnesses (10%) out of all consultations in PHC. The trends of AD remain in the same point of 13% for the last 3 weeks and ILI at 12% of all consultations. In total, 741 cases of acute diarrhea were reported in week 27and 719 AD (in week 28), a slight decreased over the previous weeks and total consultations are decreased also. WHO’s response activities include provision of medical supplies and improving water quality in the camp. One suspected Measles case in Al-Hol and one case in Ain Essa camp, 2 suspected Meningitis and 2 suspected TB cases in Al-Hol during the reported period. The EWARS focal point is following up with RRT(DOH) for more investigations. During this week, 2 Acute Flaccid Paralyses cases were reported in Al- Hol and followed by EWARS focal point Various trainings were conducted on TB, HIV and Leishmaniosis for DOH medical staffs. Static point in Phase 5 in Al-Hol was established and run by DOH staff for the treatment of Leishmania, diarrhea and other national programs (TB, HIV..) water tests were conducted for many samples from various resources (Water trucks, Water tanks, jerrycans, Fountains) by ATP Hygiene ; the results were: 30 Analyses were applied on samples from various resources by ATP devices as the below: 8 samples were taken from the water trucks and the result was drinkable with no contamination. 11samples were taken from the water tanks, 11 of them were drinkable and only 0 sample was contaminated. 10 samples were taken from the jerry cans, 2 of them were drinkable and 8 of them were contaminated. Based on the above results, 9 samples were collected and submitted to the high level of analyzing in the reference laboratory of the general water company; the results showed that the samples are non-drinkable with bacterial contamination ratio. Mental health 23 health workers provided PFA and counseling. Mh-GAP services were provided through the functioning medical points in the camp.
Nutrition and child care 2 training sessions were provided to Syria Al-Yamama NGO in Al-Hol camp on IMCI. 98 children were screened in Al-Mawada association medical point; 7 of them were SAM and 7 MAM ; all children were referred to OTP for follow up. 8 SAM with complications admitted in Al-Hikma and Al-Hayah 3 discharge 5 still under treatment 0 deaths. Al-Tabqa SC stopped admission because no milk formula is available. HIS activities : Visited private hospitals in AlHasaka city (Al -Hikma, Dar Al-Shifaa, Al-Hayat, Shabo, Alnejma) to collect HeRAMS data . collected data at Ras Al-ain hospital ,Tel-Abiad and Tabqa hospitals during June 2019 . collected data of health centers in Tel Abiad in the second quarter of 2019 . collected data from private hospitals in Qamishli, Malkieyah, Ras Al Ain, Amouda and Al-Derbasia during June of 2019 . collected data of the health centers of NGOs for Hermes in the second quarter of 2019 in the governorate of AlHasaka . reported 190 cases of brucellosis in Ain Issa camp in the governorate of Raqqa . visited Mahmoudli camp in Al-Raqqa governorate to assess the health reality .
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Pharmacy and Secondary Health care: Supported Altabka hospital with a Medical Oxygen Station. With productivity of 10 m³/hour, the station will play a vital role in the functionality of the hospital through ensuring the continuity of services especially in pediatric department (incubators) and surgical operations. It will also allow the hospital to kick off intensive care services. Delivered 86,195 treatments of different types of medicines to 5 partner NGOs to support their work in NES , especially Al-Hol camp. Delivered 3,000 treatments of ORS and cholera kits to 11 health centers in Dier-ez-zor in response to increased cases of diarrhea . Follow up with Qamishli National Hospital on the installation of several donated medical equipment. Follow up on hemodialysis need in NES. The lack of sessions at Alhasaka National Hospital and Altabka National Hospital remains a concern. Conducted a workshop on Infection control in Qamishli hospital, targeting 30 health workers from the latter, Alhasaka DOH, Alhekma and Alhayat hospitals.
NGOs coordination in NES: Conducted a training on the referral mechanisms in Al-Hol camp ( External and internal referrals) , the training workshop included representatives of all the health facilities in the camp. Al-Hikmah hospital contract has started and the admission processes are in place for the SHC, Trauma and Malnutrition cases. Started the full package of health services through the new established static medical point in phase 5 and the mobile team in the annex within the MoU of Mar Assia Al-Hakim center supported by WHO. Many technical discussions on the planned ORS corners in the camp ; up to now two corners about to start. Coordinated with MSJM/UNFPA field hospital and allocated a space to start activities of WHO surgical team within the hospital as part of the current ongoing process ; the team will provide surgical consultations and triage to support the functionality of the field hospital. Conducted a field visits to Al-Hayat and Al-Hikmah hospitals to follow up the ongoing activities and provided the technical administrative and financial advice. The relocation process of Al-Twehenah camp residents to Al-Mahmoudli camp is ongoing ; WHO has started a static medical point in Al-Mahmoudli new camp, two caravans became in place and a medical team consisting of: internist, gynecologist, pediatrician, 2 nurses, paramedic and MHPSS processor; WHO is committed to continuing the supporting of both locations Al-Twehenah and Al-Mahmoudli camps . In this regard, a field visit into Al-Mahmoudli new camp was conducted to follow up the ongoing activities ; a coordination meeting was in place and the crosscutting issues were discussed. A meeting was in place with Mar Assia Al-Hakim center ; the needed guidance regarding the administrative and financial issues was provided in addition to the reporting mechanisms Conducted a field visit into the three field hospitals to follow up the ongoing activities and ensure effective referral mechanism.
Annex 3 shows the number and type of services provided in NES (5th July -18h July 2019)
North West (Aleppo, Homs, Latakia)
1- Aleppo:
Security Situation
Violence in northwest Syria has continued unabated since the beginning of May and is putting civilians at risk, violence in areas directly affected by the conflict is driving displacement into densely-populated areas. A further escalation of violence is triggering waves of displacement and provision of humanitarian assistance. During the reporting period, the city of Aleppo witnessed an intensified fighting and escalating violence in several western and central neighborhoods resulting in dozens of injured people and many deaths. Page | 10
Service provision:
1 ongoing MOU with WHO implementing partner (Al-Taalouf national NGO). 4 WHO MMTs in rural areas are functioning as follows: a) 2MMTs in south rural of Aleppo (2 Al-Taalouf , ) in addition to 1 PHC in Dier Hafer. b) 2 MMTs in north rural (Afrin IDPs response), (1 CCS, 1 Al-Taalouf NGO ) In addition to 1 PHC in AL-Hader South rural Aleppo. The total Number of health services provided through MMT is 1251. Two cost extension requests were finalized with two WHO implementing partners (YBY, ASSLS) in order to expand the coverage areas of WHO supported health facilities. 2 Field visit were conducted to (ASSLS Health PHC, CCS NGO). Nutrition Orientation session was conducted by WHO nutrition focal point targeting 22 NGO’s to raise the capacity building of health workers who are deployed in rural areas to follow up on the national NGOs nutrition activities. In the same context, a meeting was conducted between WHO and UNICEF in order to coordinate the distribution of nutrition materials provided by UNICEF through WHO supported MMTs , 4 national NGOs partners were involved in this joint planning process ( Ihsan , Taalouf , CCS and YBY ). MHPSS orientation session was conducted targeting 10 MHPSS services provided by WHO through the ongoing MOU with Al-Taalouf national NGO to follow up on the MHPSS activities. WHO supported the provision of 750 haemodialysis sessions as in-kind donation to SARC – ( AL-Ihsan Implementing partner ) , which will cover the health needs of more than 45 kidney failure patients in Hamdi AL-Zaim hospital. Following up on 61 identified TB cases in Fafin area (28 completed treatment, 2 dropouts, 33 under treatment) Aleppo DoH continuing the insecticide spraying campaign as a part of the vector control of Leishmaniasis supported by WHO as 35 days were completed and 45 days remain; the Campaign ends at the end of September. 17 neighbourhoods have been completed in Aleppo city and 14 remain in Aleppo city; 4,573,900 m2 were sprayed till now and 91,478 people were targeted. 40 villages have been completed in rural Aleppo, 2,547,900 m2 were sprayed till now and 50,958 people were targeted. 114 workers in Aleppo city and 56 workers in rural Aleppo are working in this campaign. Aleppo DoH started a TB survey in Al-Shiekh Maksoud neighbourhood on the 10th of July supported by WHO targeting around 11.000 families; 6 days were completed ; the survey will finish on 10th of August 2019, 5 ; teams are doing this survey. 2090 people were surveyed (119 suspected cases,”7 TB cases of them were diagnosed and started their treatment”)
Mental Health: WHO supported: a) Ibn Khaldoun psychiatric hospital - 3212 consultations; b) Mental Health directorate – 145 consultations; 6 individual supportive supervision sessions were conducted for training doctors on mhGAP working for NGOs. 8 individual supportive supervision sessions were conducted for training psychologists working with MoE on SMHP working for MoE. Psychotropic needs assessed with 6 NGOs, a full distribution plan in place to NGOs and Ibn khadloun mental hospital, Orientation session took place for 10 MHPSS workers in NWS response ; with contracting NGOs, roles were specified, referral system to other services, and capacity building needs were identified. A follow up meeting with MH director at DoH level to enhance mhGAP doctors reporting mechanism. Psychotropic shipments received in Aleppo warehouse, Meeting with SSSD manager to revise the family well-being center according to the available fund, special discussion to include interactive theatre in the activities of the project, which is considered as a powerful tool to enhance the psychological status of participants. Discussion with HIV/TB unit to pilot a special integration between the two units in Aleppo. MHPSS services delivered to community through the contracted NGOs in the city, northern, eastern and southern rural of Aleppo.
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Trauma: 6 killed and more than 28 war wounded have been reported (in Al Razi and Aleppo University hospitals) on Mon and Tue 15 - 16 Jul 2019 due to the escalating violence in several neighborhoods in western part of Aleppo city. A (HazMat and evacuation of buildings) training was conducted. A coordination meeting was conducted with the UNPD in Aleppo to discuss the issues related to the artificial limb center and disability and the needed support. Annex 1 shows the number and type of services provided in Aleppo (5th July – 18th July 2019)
2) Homs: The 22nd group from Rukban arrived in Homs at the night of 10 July with 530 people (122 males, 145 females, 184 children and 79 infants) and were all hosted in the Arts Institute in Al Bayada, bringing the total number of people who left Rukban to 16,624 people (39.86%) out of 41,700 residents. In Homs: attended the meeting of all UN heads of Homs Office with the RC/HC a.i, the Agenda of the meeting was: the humanitarian situation in the area of responsibility regarding the NW developments, Rukban arrivals and the return movement to Al Qusair district. EPI review was done in Homs and Hama where joint visits with WHO experts to the governorate, districts and community levels were conducted . DQS and EPI reports were completed and submitted. HERAMS: Joint monitoring visits were conducted (WHO team and the responsible officers in DOH, SARC, Albir NGO, UNRWA) to assist the quality of the data entry in the system. Homs DoH will start a TB survey – supported by WHO- targeting around 3000 returnees families from Rukban camp; the survey will be in 5 shelters in Homs city and the second destination. In Homs; a field monitoring visit to Bab Sebaa NGO hospital was conducted by Homs WHO FP to follow up medicine distribution donated by WHO.
1. Health situation
110 children under 5 years from the last arriving 22nd group were vaccinated by mobile teams supported by WHO.
NGO activities Albir Homs NGO started health project supported by WHO in Homs governorate on 9/7/2019: 3 static points in Northern Rural Homs (Talbessah, Al-Hula and Rastan) and 3 Mobile Clinics (Northern and Eastern Countryside). Total provided consultation :578 Annex 7
Orthodox Association for Helping the Poor health project provided health services through 3 fixed health points in Alghasaniya old Homs city, Fairouza village in east Homs, Ayoun Alwadi in Mesyaf Hama district. The total number of beneficiaries was 1451 (Annex 6). Albir Hama NGO health project provided services from one fixed health point and 2 mobile health teams in Hama city and villages across eastern and northern Hama. The total No of beneficiaries during the period was 3240 and 1239 PSS consultations were provided .
3) Latakia:
Security Update: Latakia governorate, southern countryside, Basil al-Assad International Airport: the loud sounds which have been heard in the vicinity of Jableh city were due to Russian air defence which shot down multiple drones heading toward Basil al-Assad International Airport. Back and forth fight continued between SAA and NSAGs in north east of Latakia, mainly the Kabani axes. Heavy armed clashes took place between SAA and NSAGs in the north eastern part of Rural Latakia. NSAGs managed to proceed towards SAA position then retreated. High number of casualties were sustained by both sides. Russian air defenses shot down multiple drones over Jableh city..
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NGO:
Clinics Ramel Jnoubi HC Squbben HC Qnenas HC Mobile team 1 Mobile team 2 Internal 301 327 517 Pediatrics 537 649 649 gynecology 291 298 504 PSS support 92 27 148 270 288 Total 1221 1301 1818 270 288
POLIO: Participated in the national EPI assessment tool in Lattakia and Tartous governorate, which included EPI assessment tool and DQA assessment tool. The visited sites were: Lattakia: Al-Adeen Health Centre, Ramel Shamale Health Centre, Jbleh Health Centre, Jbebat Health Centre in addition to two sub-districts and Lattakia DOH Tartous: Al-Rahma Health Centre, Daher Safra Health Centre, Al-Qusor Health Centre, Al-Sheikh Saad Health Centre, and Banias and Tartous Health Districts. EWARS: Seven cases of acute erythrocyte syndrome were reported: 1 case in the Lattakia National Hospital + 2 cases at the First Health Centre in Jableh + 4 cases in the Ibrahim Naameh hospital in Jableh Two suspected measles cases were reported: at the Skantory Health Centre.
Capacity building: Supporting the following workshops: o Adults Life Support workshop at Tartous governorate. o Ventilator management workshop at Latakia governorat. Logistics: Dispatching 15 tons NCD kits Model Medicines, equipment and renewable to NGOs and WHO HUBs and DOHs in many governorates. Providing 3 NGOs in Lattakia with 507 KG of MH, PHC and STHC medicines. No received shipment during this period
IV. Key Operational Challenges
PHC/NCD: MOFA approval is still pending MOH feedback for Al Hol response under SHF /OCHA. Shortage of PHC/NCD items at free stocks. NCD kits under OFDA is not received yet :26 NCD 1a & 33 NCD 1b /Insulin.
Trauma Care: Lack of fund allocated for capacity building has affected the number of trained health workers on trauma topics.
Secondary Health Care:
The Ministry of Health approval on the rehabilitation project at Children hospital in Al-Hasakeh is a prerequisite for the provision of medical equipment to support the functionality of the hospital.
Difficulties in including big quantities of hemodialysis supplies in air shipments to NES.
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Operational support and Logistics: No approval as per MOFA’s letters to deliver any health supplies to NES through road transportation. The only possible way to deliver supplies is through airlift which is very expensive The MOH and MOFA approval process to approve import of supplies sometimes takes 1-3 months which affects procurement using short-term funds, especially if the awards are close to expire. WHO is obliged to deliver supplies to MOH central WH directly as per MOH instructions, which makes it difficult to follow up on the redistribution to the end user such as DOH and other hospitals. Some of the supplies are approved to be delivered directly to DOH.
HIS: Timelines of HeRAMS reporting by health partners. Shortage of fund to cover the activities of CRVS (Civil Registration and Vital Statistic) for deaths and births modules. WHO will collaborate with UNFPA to cover some activities.
V. Key Health Actions for the Next 2 Weeks
Secondary Health Care: To share with MoH the Arabic translation of the final cancer study on patients’ and their families’ views and experiences of cancer care and to agree on the way forward and follow up actions to implement the recommendation of the study. To analyze the collected data on the availability of services at the field hospital in Al Hol camp. EPI: Present the EPI and DQS review findings to the Ministry of Health led by EMRO EPI team Follow up on the new request of the National Polio Laboratory for the procurement of essential Kits (approval received from EMRO and procurement department in WHO Damascus is working on it) PHC: Invitation to the Extended Pillars Group Meeting 21 July at PICC, called by RCO/ UN Resident Coordinator Office. Presentation under pillar 1 is shared with RCO. Surge mission to Al Hol IDP camp is on 14-21 July, still awaiting MOFA approval. Hama mission 4-7 August 2019, to visit diabetes center, thalassemia center & national hospital in Hama to assess the health needs. NGO Team: Maintain close follow up with EMRO / BFU unit to clear the rest of the submitted LOAs. Finalize and submit the listed under preparation LOAs as well finalize conducting financial and technical closure of 2 LOAs. Review and clear 2 due progress reports. Complete the final phase of the assessment in terms of report developments and share it with the technical officers and stakeholders for review and feedback
KEY CONTACTS:
Representative a.i. Dr. Nima Saeed Abid [email protected] Emergency Team Lead Isiaka Stevens ALO [email protected] Communication Officer Yahya Bouzo [email protected]
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V. Annexes
Annex 1 No of health services provided by NGOs:
NGO Health Location # of # of # of # of #of Facility outpatient patients SHC MHPSS Trauma and consultations received services services Rehabilitation PHC services assistance provided Services with medicines South rural Aleppo
Al-Taalouf PHC AL-Hadier 212 98 - 88 AL-Taalouf MMT Hadher , Abtin , 95 110 - 65 Wdeihi , Haddadin AL-Taalouf MMT Blaas , Big Oweinat , Tall 132 98 - 56 Ed-dama Sub Total 439 306 0 209
Afrin IDPs response Al-Taalouf MMT Tal Qerah , AL-Alousheh 154 65 - 65 Camp , Tal Refaat CCS MMT AL-Asser 658 320 - 258 Camp Sub Total 812 385 0 323
Annex 2: WHO supported capacity strengthening (supported 18 activities for 465 participants):
Date No of Detailed title Venue Program participants Obstetrics and 06- Hazmat management & 25 Gynecology Hospital Trauma 09/07/2019 evacuation of buildings /Aleppo
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Al-Bassel educational 06- 25 Ventilator Management complex – Trauma 10/07/2019 DOH/Damascus 4 activities on the Expansion MoH/Homs, R. 07- of nutrition surveillance clinics + 100 Damascus, Aleppo, Nutrition 11/07/2019 Infant and Young Child Feeding Araqqa (IYCF) counselling 07- Ibn Nafice 25 Rheumatoid arthritis Disability 09/07/2019 Hospital/Damascus 07- DOL in 25 Infectious Substance Shipment EWARS 09/07/2019 Damascus/Damascus EWARS surveillance, El Herafeyin 10/7/2019 25 investigation and response to Restaurant Hall/ Al EWARS disease alerts Hassakeh 11- Ambulance system/ 25 Adults Life Support Trauma 13/07/2019 Tartous 11/7/2019 25 Patient safety Qamishli SHC El Herafeyin Leishmaniosis active case 11/7/2019 25 Restaurant Hall/ Al EWARS detection Hassakeh 14- Evaluation Nutrition program Hall reservation/ 25 Nutrition 16/07/2019 during 2018 Damascus 14- Rehabilitation of osteoporosis Ibn Nafice 25 Disability 16/07/2019 patients Hospital/Damascus 15- 25 Ventilator management DOH/ Lattakia Trauma 19/07/2019 PHC 16/07/2019 25 Polio follow-up committee PHC department/Damascus 17- National Code Committee of Milk 25 MoH/ Damascus Nutrition 18/07/2019 Substitutes Development of Expand 17- Dama Rose Hotel/ 40 program on Immunization ( PHC 18/07/2019 Damascus EPI) improvement plan
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Annex 3: No and Types of services provided in NES (5th July-18 July 2019 :
PHC services SHC services Trauma services # Referral # of First # of of aids and # of # of # of Mental referrals treatment # of emergenc Governorat outpati beneficiarie Health Area for for children trauma y services e ent s reached Psychosoci secondar with Severe referral in the with the consult y health Acute s camps al medicines ations services Malnutritio Services n Hassakeh city 0 0 528 415 3 33 0 center Al-Mabrouka 2 150 787 761 27 6 160 camp 0 0 Ras Al-Ain city 481 456 25 0 0
Al-Areesha 1 100 790 723 2 0 106 camp Al-Hol camp / 24 108 Al-Hassakeh 752 752 5 12 299 Phase 1 Al-Hol camp / 8 0 291 566 566 0 243 Annex Al-Hol camp / 0 0 136 774 706 0 94 Phase 6 Al-Hol camp/ 0 0 22 425 425 0 56 phase 7 Al-Hol camp/ 0 0 0 77 400 400 96 phase 8 Al-Raqqa city 413 271 0 0 0 0 406 Al-Jurneay + Al- 0 0 0 48 299 243 69 Mansoura Al-Tabqa 352 310 0 0 0 35 79 Al-Raqqa Ain Issa camp 1840 1696 0 0 0 156 485 Al-Mahmoudli 936 936 0 0 0 2 214 Al-Karama 826 826 0 0 0 69 256 Al-Kasrat 836 836 0 0 0 9 225 Aleppo Manbij 1054 1054 0 0 0 13 177 Hajin 871 280 0 0 0 115 109 Al-Busayra 467 398 0 0 0 91 122 Al-Jerzi 1012 634 0 0 0 44 112 Dier Ezzour Abu Khashab 0 0 0 48 1146 1146 416 camp Dier Ezzour city 645 361 0 0 0 0 0 Sub-total: 16200 14195 70 27 51 1514 3724
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Annex 4: List of current WHO agreement with national NGOs (by NGO): # of # of MOUs Governorate Location of current of ongoing MOUs ongoing in MOUs preparation
1 Damascus Al Zahera
Rural Damascus Qutaifeh - Douma - Harasta - Al Tal - Yalda 5 2
1 Lattakia Lattakia city- Al Baset - Saqubeen- Qnanas and Al Ramel Al Janoubi Dara'a Dara'a , Al Laja'at, Al Yarmouk 1 1 Qunaitera Qunaitera 1
Old Homs, Al Ghassani and Ayoun Al Wadi 2 1 Homs Hama city, Souran, Moardes ,Taybet alemam, Alsawa'aek ,Alhashimyaa , ean albad, Jarjesah ,tal kartal,tellef 1 Hama ,herbenafsah,maardeften and alzarah.
Agior , Deir Hafer , Rural villages of Aleppo city ((Babiri -Upper Babiri , Babiri -Lower Babiri , Rasm Elbokhar , Kayariyieh , Big Habbuba , Little Aleppo 3 0 Habobieh , Southern Rasm Elharmal ). Hananou , AL-Martini , Tal Refaat and surrounding villages
NES Deir- Ez-zor - Ar Raqqa city - Al Hasakeh. 8 3
Total 23 7
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Annex 5: Health Service provision in Northern Homs area:
# of outpatient Partner District Commune/Village/Town consultations PHC services
Albir Al Rastan clinic Rastan city 323
Albir Al Hola clinics Kafr Laha 15
Alfarhamiya Garbiya Mobile clinic Albir Ghanto 240
Almkaramiya
Sub-total: 578
Annex 6: Health Service provision in Alghasaniya old Homs city, Fairouza village in East Homs, & Ayoun Alwadi in Mesyaf Hama district:
Commune/Villa # of SHC District # of outpatient consultations PHC services #Trauma patients ge/Town services
Alghassani Homs city 1044 30 4 Fairouza. Eastern Homs 283 6 1 Ayoun Alwadi. Western Homs 5 6 0 Total: 1451 42 5
Annex 7: Health Services Provision-Albir Hama NGO: Provision of medical PSS PSS Area consultations with Individual group sessions free medicines sessions Hama city and villages across eastern and northern Hama Eastern-northern rural Hama villages Al- 1543 60 416 Hamraa district (20 locations) Northern Hama (20 locations) 1087 62 250 Health center Abi Alfidaa 610 77 474 Total 3240 199 1140
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