Author: Jawahir Habib, November 14 2013        "Anytime where you have areas with complex emergencies where health systems deteriorate, where immunisation levels deteriorate, children are much more vulnerable to diseases such as polio," Oliver Rosenbauer, World Health Organization

2.5 million children under the age of 5 years are at the risk of a polio epidemic in Syria(1). More than 200,000 Syrians are currently living in refugee camps established in Jordan, Lebanon, Turkey and Iraq(2, 3). An estimated 4.2 million Syrians are internally displaced (3).

13 cases of polio have been confirmed in Syria so far; the country had been polio free for more than a decade with the last case found in 1999(4). Poliomyelitis, commonly known as polio, is a highly contagious disease; it spreads through the oral-fecal route; and, for every confirmed polio paralysis case, 200 children can be infected(1).

99% of polio has been eradicated; Pakistan, Afghanistan and Nigeria are the only three countries where polio still remains endemic(2). Through the efforts of the Global Polio Eradication Initiative (GPEI), the number of polio cases have been reduced from thousands in 1990’s to merely 223 in 2012(5). The World Health Organization confirms that the polio virus in Syria is genetically linked with the virus found in Pakistan, reflecting how the disease can spread to other vulnerable populations across the globe(4).

In Syria, the disruption of healthcare delivery has resulted in discontinuation of immunization services, leading to lower immunity in the population(6). 40 % of the public hospitals in Syria are out of service(3). Only 30% of the basic health units are currently functioning in such areas as Aleppo, Idlib and Deir-ez-Zor (Deri-ez-Zor is the province where polio cases were confirmed)(3) .

Similarly, this year polio outbreaks were also observed in Somali refugee camps in Kenya, Ethiopia and Somalia(6, 7). 175 children were paralyzed for their lifetime due to this crippling disease in Somalia, 14 cases were confirmed in Kenya and 4 in Ethiopia(6) .The vaccination campaign targeting children in Somalia also faced resistance from Al-Shabab, a terrorist group, they announced a ban on polio vaccination in areas under their control resulting in vaccination being denied to 600,000 Somali children (7).

The risk of infectious disease outbreaks increases in the refugee camps due to: lower levels of immunity following disruption of immunization services, overcrowding, compromised hygiene and sanitation conditions and acute malnutrition (3). Apart from polio, the displaced population in camps are at the risk of other communicable diseases, which alone or with underlying malnutrition are the main cause of morbidity and mortality in refugee and IDP [internally displaced persons] camps (8, 9).Communicable diseases account for the three quarters of deaths amongst the affected populations in a humanitarian crisis (8, 9) .  The most common causes of death during humanitarian emergencies are infections, such as cholera, dysentery, measles, malaria, acute respiratory tract infections and tuberculosis(8, 9).

The transmission of poliovirus has been interrupted in complex emergency situations, such as that in Sri Lanka, Cambodia, and El Salvador(8). International aid organizations are calling for a “humanitarian cease fire” to improve access and security so that vaccine can be delivered to all the children under age of 5 in conflict hit areas.(10) Similar cease-fires have previously been successfully implemented for polio campaigns in Sudan, Democratic Republic of Congo and Afghanistan(1, 10, 11).

To decrease the morbidity and mortality from communicable disease in complex emergencies, three main strategies include prevention and control, surveillance, and case management(8). Prevention and control measures include immunization, site planning and shelter, vector control, and water and sanitation interventions(8).

Experts fear that the polio outbreak in Syria may spread to Europe and the neighboring Arab countries. The virus knows no borders; it will travel, attack the most vulnerable and spread where the immunity levels are low. This outbreak is not only a setback for the GPEI but it’s also a major challenge for humanitarian efforts in Syria.



1.         World Health Organization. Over 20 million children to be vaccinated in Syria and neighbouring countries against polio Geneva: WHO; 2013 [cited 2013 10 November]. Available here.

2.         Cole D. Syria’s Polio Outbreak Is a Reminder of the Disease’s Power. National Geographic Daily News. 2013.

3.         World Health Organization. Health impact of the crisis in the Syrian Arab Republic Cairo: EMRO WHO,; 2013 [cited 2013 10 November]. Available here.

4.         World Health Organization. Polio in the Syrian Arab Republic - update Geneva: World Health Organization 2013 [cited 2013 11 November]. Available here.

5.         WHO. Polio Case Count Geneva: World Health Organization; 2013 [cited 2013 10 November]. Available here.

6.         Besant A. Polio: A common enemy from Syria to Somalia (Q&A). Global Post. 2013.

7.         'Explosive' polio outbreak in Somalia. Aljazeera America. 2013.

8.         Máire A Connolly, Michelle Gayer, Michael J Ryan, Peter Salama, Paul Spiegel, Heymann DL. Communicable diseases in complex emergencies: impact and challenges. The Lancet. 2004;364:1974-83.

9.         Connolly M. Deadly comrades: war and infectious diseases. The Lancet. 2002; 360:23-4.

10.       Arie S. Polio outbreak leads to calls for a “vaccination ceasefire” in Syria. British Medical Journal. 2013; 347.

11.       WHO. Health as a Bridge for Peace - Humanitarian Cease-Fire Projects  (HCFP) Geneva: WHO; 2013 [cited 2013 10 November]. Available here.

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