August 2020 Fig.: Critical Actions to Control COVID-19 Transmission

HEALTH CLUSTER BULLETIN August 2020 Fig.: Critical actions to control COVID-19 transmission. (WHO)

Turkey Cross Border Emergency type: complex emergency

Reporting period: 01.08.2020 to 31.08.2020

2.8 MILLION* 2.66 MILLION 3.7 MILLION 24**ATTACKS HEALTH PIN IN IDP IN NWS SYRIAN REFUGGES AGAINST HEALTH CARE NWS HNO 2020 31 AUG 2020 IN TURKEY (**JAN - AUG 2020) HIGHLIGHTS • At the end of August, there were 80 SARS-CoV-2 132 HEALTH CLUSTER MEMBERS (COVID-19) cases confirmed in NW Syria, 32 from 40 IMPLEMENTING PARTNERS REPORTING 1 Idleb and 48 from Aleppo governorates. MEDICINES DELIVERED TREATMENT COURSES FOR COMMON • After the increase in transmission between Health 385,045 DISEASES Care Workers the NWS COVID-19 Taskforce FUNCTIONAL HEALTH FACILITIES HERAMS recommended, and the local Health Directorates FUNCTIONING FIXED PRIMARY HEALTH requested in a written announcement that health 150 CARE FACILITIES workers, specially doctors, must avoid dual 63 FUNCTIONING HOSPITALS employment (work in more than 1 health facility) 66 MOBILE CLINICS • As per CCCM Cluster, during the period from 1 HEALTH SERVICES2 August to 31 August 2020, over 30,000 699,537 CONSULTATIONS displacements took place in NW Syria, with DELIVERIES ASSISTED BY A SKILLED departures principally occurring from A’zaz, and 9,057 ATTENDANT other notable departures from Ehsem, as well as 14,233 REFERRALS Dana. The main locations where displaced people 777,852 MEDICAL PROCEDURES arrived to included Atareb, Dana and Maaret 25,831 TRAUMA CASES SUPPORTED Tamsrin sub-districts. 1,760 NEW CONFLICT RELATED TRAUMA CASES • In terms of needs, the top three needs reported for VACCINATION

newly displaced persons were Shelter (29%), Safety 10,055 CHILDREN AGED ˂1 VACCINATED3 and security (23%), and Cash (15%). • In NWS, according to HNAP the rate of households MENTAL HEALTH SERVICES who selected health services as a priority need was 6,663 MENTAL HEALTH CONSULTATIONS notably quite low. This is likely due to the comparatively higher level of already existing DISEASE SURVEILLANCE SENTINEL SITES REPORTING OUT OF A humanitarian health provision in the region. 439 • In August, more than 2 million certificates were TOTAL OF 445 4 issued from the WHO’s open learning platform WOS HEALTH HRP & COVID-19 2020 FUNDING $US HRP $82.9 M (18.7% funded) (OpenWHO.org), including 126 courses produced RECEIVED COVID19 for the COVID-19 response. IN 2020 $36.1 M (22.8% funded)

* 2.8 Million PIN in NWS includes an estimated 100,000 in NES Tal-Abyad and Ras Alyn under the Government of Turkey control areas. 1 Supplies were cross border delivered by the WHO Gaziantep Hub and distributed to implementing health cluster partners in northwest Syria. 2 Figures reported and updates are from 1 – 31 August 2020. 3 Routine immunization with pentavalent vaccine (5 in 1 vaccine) 4 Source: OCHA Financial Tracking System, Syrian Arab Republic Humanitarian Response Plan (HRP 2020) as of 31 August 2020. https://fts.unocha.org/ 1

Situation Update:

According to HNAP Priority Needs & Access to Services -HNAP Summer 2020 Report Series-6 and the CCCM Cluster, by end of August, around 30,000 movements were recorded. Over three quarters of displacements (78%) were recorded in areas under the control of Non-State Armed Groups and Turkish Backed Armed Forces. Specifically, in a trend (see CCCM crop insert graph) that has remained constant since March 2020. Idleb and Aleppo governorates were both the top origin and arrival governorates for the newly IDPs. The most common drivers of displacement were the deterioration of the economic situation (39%) and the deterioration of the security situation (38%), while the improvement of the security situation was the most common reason for arrival into current location (37%). In terms of needs, the top three needs reported for newly displaced persons were Shelter (29%), Safety & security (23%), and Cash (15%). In NWS, ‘health services’ was selected as the highest priority need for only 1% of households, and as one of the top three for 12% of households. Since this was quite low (12th most selected as highest priority needs and 9th most selected as one of the top three priority needs, out of a total of 15), we may conclude that this is likely due to the comparatively higher level of already existing humanitarian healthcare provision in the NWS region.

As for the COVID-19 Response, since the first laboratory confirmed case was identified on 9th July, the numbers are as expected increasing. EWARN have confirmed community transmission taking place. Current cases are predominantly in Northern Aleppo while there are still active cases in Idleb area. At the end of August, there were 80 cases confirmed, with 32 from Idleb and 48 from Aleppo governorates. The mean age of the cases was 35 years. Two cases are under 5 years old and 6 cases are over 60 years old. Mild symptoms were reported by 86%, while 6 cases had moderate to severe symptoms and were hospitalized, the rest were asymptomatic. Out of the total 80 cases, 70% recovered. Since the confirmation of the first positive case, one death associated with COVID-19 was recorded.

During the reporting period, 7 isolation hospitals and 8 isolation treatment centres for primary care level management (called COVID-19 Community Treatment Centres, or CCTCs) were active in NW Syria. The major focus has been shifted on curbing transmission among Health Care Workers (HCWs), as the number of HCWs infected is significantly high and the outbreak continues to infect the medical community. Over 30% of the cases were among HCWs. To this this effect the task force is drafting a renewed testing strategy for NWS, based on WHO recommendations, adopting to context. Salient features include: testing of HCWs in high risk facilities dealing with respiratory illness, periodicity of testing of HCWs in focus areas (hotspots), HCW where multiple co-infection related service delivery points (for e.g. TB), Health Directorates and Health Cluster recommendations to implementing partners to avoid dual employment of HCWs for the time being.

Efforts remain concentrated on contact tracing, interrupting virus transmissions and reducing secondary infections. Health partners continue to raise awareness about COVID-19 precautions among local communities and other stakeholders, emphasizing practices to prevent transmissions including hygiene practices, self- isolation and physical distancing. Distribution of masks based on risk-based prioritization of vulnerable groups and considering distribution modalities. Work is ongoing to intensify interventions to strengthen infection prevention and control at health facilities as means to protect healthcare workers and prevent transmission from healthcare service delivery points, which is as well of high priority.

To increase laboratory testing capacity, under the pipeline to be deliver, WHO is providing two PCR machines, one to a laboratory in Afrin city in northern Aleppo governorate, and another to the existing laboratory in Idleb city to complement the existing testing. In addition to the 86 ventilators installed with support from SCHF, 5 ventilators through an in-kind donation from health cluster partners and 15 Continuous Positive Airway Pressure Units (CPAP) are as well on the pipeline. More than 16 million “personal protective equipment” (PPE) items including masks, gloves, goggles and face shields were shipped into NWS on 22 August with the support of the Turkish Red Crescent Society (TRCS) and funded by OCHA managed common pooled funds. Protective gowns are in pipeline and the Personal Protective Equipment (PPE) will be provided to the staff of more than 80 humanitarian organizations who shared speciﬁc needs with the COVID-19’s taskforce. 2

Public health risks, priorities, needs and gaps

• Community and in-hospital (staff to staff) exposure and transmission are the main routes of the 2019 novel coronavirus (SARS-CoV-2) spreading among health care workers (HCWs) who are the frontline fighters in NWS. One third (medical and non-medical/ancillary personnel) of the total confirmed cases are linked to a health facility; therefore, curbing transmission among HCWs is high on the agenda as the contamination continue to spread. • As COVID-19 spreads, health and social systems across the NWS are struggling to cope in the already disruptive health system. Worsening the picture, the dire ongoing economic crises had further opened the door specially for doctors to work in more than one health facility (a financial incentive), as a result increasing the chances of transmission between health facilities as has been the case. • Densely populated areas in NWS, such as camps and informal settlements, are considered so challenging to apply self-quarantine. This is coming with the the worsening economic situation in NWS as a factor identified to refuse the admission to isolation or quarantine facilities nor even to self-quarantine in their own home due to fear of losing their bread win - when no paid leave system and/or financial support is guaranteed. • There is a need to scale-up testing for HCWs with a special focus on those who are working in COVID-19 designated health facilities (e.g. hospitals, COVID Community Treatment Centres) and those who are providing care for the most vulnerable groups like in TB clinics, dialysis centres, in addition to the expanding timely contact tracing and laboratory capacities. • Precautionary measures should be rigorously implemented at community level; therefore, the camp managers need to be aware on preventive activities and to emphasize hand washing, physical distancing, avoiding mass gatherings and other measures as recommended by the NWS Health Cluster COVID-19 taskforce and WHO. • Although improving, the personal protective equipment (PPE) and infection control and hygiene items for medical staff and community health workers (CHWs) continues to be a gap been prioritised. • Due to shortage of masks in the market, there is a need to enhance the local procurement and production of fabric masks in the field. This should be done in line with the COVID-19’s taskforce recommendations and WHO’s global guidelines for mask usage.

Health Cluster Coordination and Service Delivery

Coordination is conducted along existing formal coordination structure. The Turkey-based Humanitarian Liaison Group (HLG) leads strategic coordination for Cross-Border partners. Operational coordination is led by the Inter-Cluster Coordination Group (ICCG). Access issues affecting the humanitarian community are addressed jointly by the humanitarian community through the Access Working Group (AWG), while the Health Cluster lead COVID-19 Task Force leads the preparedness and response to the pandemic. Coordination continues with Whole of Syria (WoS)-level interlocutors. Clusters continue to convene regular and ad-hoc meetings with their members, including with specialised sub-groups, coordination groups and technical working groups.

As per the month of August, two virtual dedicated Health Cluster meetings were held attended by all members, partners and colleagues. As part of the fix agenda, COVID-19 updates continue to be a priority in each coordination meeting. In addition, WHO as the Health Cluster lead agency chairing the NWS COVID-19’ taskforce, held biweekly meetings as well as to continuous weekly meetings held by each response pillar focal points and members for technical and strategic planning and a coordinated response. The COVID-19 taskforce welcomed the Programs Manager of the acting Syrian Interim Government Ministry of Health in NWS to be liaison with the National Syrian COVID-19 Response Team of the NWS local authorities.

At the Inter-Cluster Coordination Group level, the Health Cluster identify the priority readiness and response activities and gaps as part of the NWS Humanitarian Readiness and Response Plan. This multi-cluster plan focuses on critical gaps in people’s humanitarian needs and funding related to possible increased hostilities and new displacement in NWS, projected until the end of 2020. The full scope of the humanitarian response in northwest Syria is detailed in the 2020 Humanitarian Response Plan and its COVID-19. The revised plan should be issued in September 2020. 3

On Health Cluster partners Service Delivery, 40 implementing partners shared their monthly 4Ws reports on monitored health indicators. There was a slight decrease in the provision of some services. OPD consultations, medical procedures, mental health consultations, and deliveries attended by skilled birth attendants were slightly lower this month, but roughly matching the average number of such services provided this year. Compared to last year, so far, this year the total number of mental health consultations (new cases as well as follow-up cases) have been about equal to number of such services provided last year and are well poised to substantially surpass by the end of this year.

The number of new patients receiving therapeutic physical rehabilitation services registered a 10.4% increase. The increase in physical rehabilitation sessions provided might be linked to an opening of two new centres in July and by that an increase of the total number of consultations reported in the system by all partners.

Referrals inside Syria essentially remained the same. While referrals to Turkey registered a sizable decline (43.3%) from the previous month. Hostility-related trauma consultations were increased by 22.6% compared to previous month. August was this year’s third highest month in terms of such consultations, perhaps reflecting the upsurge in hostilities resulting in higher morbidity burden.

The number of hospitalizations this month, both for wards and intensive care units, were a little lower than last month, but this was owing to slight upsurge in the previous two months. For August both types of hospitalizations are following the usual trend in hospitalizations that have been observed for the year.

Regarding vaccination of children under 1 y/o covered with DPT3 or equivalent pentavalent vaccine, this month over 10k children received this vaccination. And there was 31% increase from the previous month, and well above the monthly average to date. Similarly, vaccination for children 1-2 y/o covered with MMR2 or equivalent measles vaccine, was also 20% higher compared to previous month, with over then thousand children having received this vaccination. The vaccination centres implemented 99 % of the total planned sessions in August so the reported data shows an increase in number of vaccinations provided for children. Seen the cruciality of vaccination to avoid deadly outbreaks in NWS, the field teams continue its normal implementation plan with a rigorous application of Infection Prevention and Control (IPC) measures by all the trained vaccination field teams.

During the month of August and so far during this year, the Health Cluster service delivery is summarised in the cumulative monthly 4Ws indicators as per below table:

Table 1: Health Cluster NWS monthly & cumulative indicators for January to July 2020- Disclaimer: figures may change due to late inputs by partners and data cleaning 5

Health Cluster Technical Working Groups and Partners Updates The Swasia Centre for Orthotics & Prosthetics and Physiotherapy, in Afrin care for 40 patients with Syria Relief and Development (SRD) conducted prosthesis & orthosis, 33 assistive devices were a Clinical Management of Rape (CMR) training in Afrin. provided to 27 beneficiaries and 503 physical The training aimed to teach participants on how to rehabilitation sessions conducted for 74 patients. In manage the case of survivors from gender-based addition, 158 mental health sessions were conducted violence. The procedures of clinical measures for for 121 patients. victims of rape and/or sexual assault were taught to 24 participants: 17 midwives, 6 nurses and 1 gynaecologist.

Fig: SDI – Physical rehabilitation session for a patient with prosthetic at the Swasia Centre for Orthotics & Prosthetics and Physiotherapy, in Afrin.

On capacity building, a Gender Based Violence and

Fig: SRD – CMR training with IPC measures. Protection against Sexual Exploitation and Abuse (GBV & PSEA) training was conducted for 80 staff from Save Social Development International (SDI) the Soul Hospital during this month; the IPC protocols continues provision of primary, secondary, and and prevention measures were applied for the tertiary health care services to vulnerable people in training. NWS with application of IPC measures. In August, Al- Hakeem PHC Centre in Afrin provided about 2,796 Al-Resala Foundation (RF) continues providing medical consultations for 1,800 beneficiaries and public health services via Al-Resala and Shamarin 4,663 laboratory services. Primary Health Care centres, both in Al-Resala Camp in Afrin, and 2 mobile clinics operating in Al-Manarah Save the Soul Hospital for Maternal and Child health camp in Al Dana, in Bulbul and Sharran. (Salqin) and Harim General Hospital (Harim) provided 6,571 medical consultations including 695 trauma In August, 8,907 consultations, 352 vaginal and C-sections deliveries, beneficiaries 96 major surgeries in addition to 17,550 medical received health services including treatment courses provision, care services out laboratory services, in-patient and MHPSS services. of which 4,579 are IDPs with Two mobile clinics are still covering 10 communities in application of Salqin sub-district, Harim, Idleb since May 2020 and IPC measures serving the community with health and nutrition (photo insert) in services while 9 Rapid response teams in Harim, Idleb line with the global recommendations. and Afrin sub-districts are serving 25 communities and provided 5,371 awareness session on COVID-19. A COVID-19 awareness campaign and a Psychological First Aid (PFA) training was simultaneously conducted SDI Blood Bank in Afrin provided in August about by the Community Health workers (CHWs) with 1,026 blood units and other blood components for the distribution of 1,194 dignity hygiene kits in Afrin. patients in the health facilities in Afrin.

The Medical Education Council (MEC), In addition to orthopedic and surgical care, the continued providing physical rehabilitation service in following specialties are available at the hospital: the “Academic Center for Physical Therapy”. In pediatrics, internal medicine, ENT, radiology, August, the physical rehabilitation sessions provided gynecology and Reproductive Health (RH), dentistry, were 309 while 33 patients were reported as new ophthalmology and psycho-social services. patients. There is still a need for support in terms of assistive devices, however, 30 devices were delivered The WATAN IDL #1 (Khayr 3) Thalassemia Specialized to beneficiaries in August 2020. Center, Medical Laboratory and Blood Bank, in Idleb care for 54 thalassemia patients. The laboratory and UOSSM launched a complete package of mental Blood Bank (photo insert below) supported 765 health and psychosocial support services with the goal beneficiaries with medical tests and 323 beneficiaries of providing these services to underserved received blood units. communities. The services package includes outpatient clinics for mental health consultations and The blood bank in Azaz, the support of two mental health mobile clinics in WATAN ALE #2 (Khayr 2), underserved areas on the Syria-Turkish border. (Ref. delivered 5524 health UOSSM NEWSLETTER AUGUST 2020). services for 1,797 beneficiaries; laboratory In partnership with the Urfa Health Directorate in tests were 3,918 and 669 Turkey, opened a kidney dialysis centre in the National received blood units. Hospital in Tal Abyad. It is the only centre of its kind in the area and provides free haemodialysis services to On another hand, there patients that suffer from renal diseases. (Ref. UOSSM had been 116 oxygen NEWSLETTER AUGUST 2020) cylinders provided to health partners’ facilities.

MENTOR Initiative is currently supporting 63 health facilities in NWS and operating 8 leishmaniasis mobile treatment clinics: 4 in Idleb governorate, 1 in Afrin, 2 in Azaz and 1 in west rural Aleppo. These 8 mobile treatment clinics are covering 72 different community locations.

Regarding the reported Leishmaniasis cases, there is a drastic increase in the caseload of both cutaneous and visceral leishmaniasis in 2020. To-date 41 Visceral Leishmaniasis (VL) cases were diagnosed: 35 cases in Idleb governorate and 6 in Aleppo governorate. The

Fig: UOSSM- New dialysis centre in Tal Abiyad graph below shows the caseload of VL per year in NWS for the past 3 years. The VL caseload for the first 8 WATAN Organization delivered a total of 13,689 months of 2020 is doubled than prior years: health services, in Idleb and Aleppo (5 districts), for 10,100 beneficiaries: 4,422 were men, 5,264 women, 2,124 boys and 1,765 girls. VL cases NWS 2020

In its Primary Health Center WATAN ALE #1 (Khayr 1) 2020 41 in Azaz, about 2,358 health services were delivered for 2019 22 1,789 patients and in WATAN ALE #3 (Kafr Janna) in Afrin 1,454 beneficiaries received 1,822 health 2018 20 services while WATAN IDL #2 Al-Amal Orthopedic 0 10 20 30 40 50 Hospital in Harim offered 2,197 medical consultations and served 206 beneficiaries for minor and major VL cases surgeries.

On Cutaneous (CL) Leishmaniasis, 2,774 new cases On 19 August 2020, the eleventh year that the were diagnosed in August 2020 (47% Female, 53% humanitarian community marked the World Male) from which 69% were children. In that regards, Humanitarian Day (WHD), the UN OCHA payed special 23,883 leishmaniasis treatment consultations were tribute to the real-life heroes who have committed conducted this month. their lives to helping others in the most extreme circumstances around the world.

CL Cases Humanitarian workers are overcoming unprecedented access hurdles to assist people in 3658 humanitarian crises in 63 countries. #RealLifeHeroes 3486 3288 2774 focuses on what drives humanitarians to continue to 2613 2511 2276 save and protect lives despite conflict, insecurity, lack 1700 1455 of access, and risks linked to COVID-19. (Ref.: OCHA 1103 https://www.unocha.org/world-humanitarian-day-2020)

To commemorate the WHD, WHO published a human interest story in collaboration with Hand in Hand for Aid and Development (HIHFAD) published on the Fig: Cutaneous Leishmaniasis cases in 2020 “WHO EMRO platform” on the role of healthcare workers in the COVID-19 response effort in NWS. Sexual and Reproductive Health (SRH) TWG: started an initiative to estimate the proportion of COVID-19 Task Force (TF) home deliveries in NWS and the reasons behind such Note: The following inputs are as complementary/additional information trend. The survey was conducted for 3 months (April- for the narrative in the Situation Update section of this bulletin June 2020) covering 78 health centres in 54 communities in Idleb and Aleppo governorates. On Point of Entry (PoEs): SRD conducted referral system training (4 sessions) for referral system health The survey reached 12,741 respondents and 93% of facilities focal points on referral system SOPs and them mentioned the birth took place at the health processes in Idleb governorate and targeted 98 facility, while 7% of respondents reported been at trainees. home. On Case Management, the 8 COVID-19 Community There had been no maternal death reports in August Treatment Centers (CCTCs) and 7 hospitals were within the 81 facilities and 4 mobile clinics reporting active in NWS end of August and were ready to receive to the SRH WG 18 implementing partners. COVID-19 cases. The available capacity was 645 hospital beds, of which 114 were intensive-care unit beds. Advocacy and Communication WG meetings were held twice per month with an emphasis on On IPC measures, COVID-19 and advocacy to support the response to SRD’s IPC field team COVID-19 in NW Syria. conducted a training on IPC standard guideline for COVID- 19 for CCTCs’ staff targeted 200 trainees working for 3 health partners. Fig: SRD – IPC training

As well, an online orientation session on IPC’ Standard guidelines for COVID-19 was held and targeted 23 psychosocial workers. A training on triage protocol & questionnaire on COVID-19 suspected cases was held for 11 participants.

WHO in recognition of World Mask Week, which Monitoring of violence against health care: ran from 7 to 14 August, on the WHO open learning As of 31 August, 24 attacks were reported in the Syrian platform highlighted its courses that illustrate how to Arab Republic as illustrated in below Health Cluster safely wear a mask in the context of COVID-19. WoS infographic snapshot. Over the past 12 months (1 Sep 2019 – 31 Aug 2020) 75% of the attacks were reported as violence with heavy weapons as recorded in the WHO Surveillance System for Attacks on Health Care (SSA) http://ssa.who.int

Fig.: WHO myth busting fact: Wearing a mask for an extended period of time DOES NOT cause CO2 intoxication.

The course Health and safety briefing for respiratory diseases – ePROTECT features video demonstrations that show how to put on and take off medical (Module 4) or fabric masks (Module 5). Masks alone will not stop the virus — we must do it all: ➢ Wear a mask that covers nose, mouth & chin ➢ Keep physical distance ➢ Clean your hands ➢ Keep away from big crowds ➢ Cover your mouth and nose when coughing

A reduction in levels of hostilities has similarly decreased the number of attacks on health care and number of trauma consultations relative to the same time last year. Every effort must be made to maintain and improve the status quo as any escalation in hostilities producing numerous casualties and displacement would not only cause immediate harm but would also be likely to accelerate the spread of The massive increase in participation in OpenWHO COVID-19, as recently seen following the 4th August courses during the COVID-19 pandemic has resulted in Beirut Port explosion in neighboring Lebanon. a landmark number of certificates being awarded. By the end of August, the platform had issued more than Plans for future response: events & dates 1 million Record of Achievement certificates, which are awarded based on quiz scores. In total, ➢ World Suicide Prevention Day (WSPD), on 10 OpenWHO.org hosts more than 200 active courses. September, is organized by the International A record 126 courses have been produced for the Association for Suicide Prevention (IASP). WHO COVID-19 response, covering 17 topics across 39 has been co-sponsor of the day. The purpose of languages. Overall, the platform has more than 4.2 this day is to raise awareness around the globe million course enrolments. that suicide can be prevented.