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Syria: losing ground in the fight to eradicate polio

Polio resurfaced in Syria late last year, and has now been found in Iraq as well, leading to concerns that this could reverse gains in international efforts to eradicate the virus.

A side effect of the conflict in Syria, now running for over three years, is that for many children vaccinations have lapsed.  According to the BBC‘Vaccination rates in Syria fell from 91 per cent of children before the war to an estimated 68 per cent in 2012. But those are national figures. In rebel-held territory, where all the polio cases so far have occurred, immunisation levels are much lower’. In some cases, the Syrian Government has been accused of deliberately excluding rebel-held areas from vaccination campaigns.

As well as reduced vaccine coverage, the conflict has led to a breakdown of health services and water supply in Syria, which makes it easier for the disease to spread. IRIN reported, ‘Inadequate sanitation, contaminated water sources and poor public health systems are also major factors in the spread of polio’.

Polio cases were confirmed in Syria in October 2013, 15 years since the last reported case. According to the latest World Health Organization (WHO) update on the situation, as of 20 March 2014, 37 polio cases had been reported in Syria. The WHO has also confirmed a case of polio in Iraq, which indicates the disease is spreading in the region. ‘[This is] the first polio case in [Iraq] since 2000,’ the report said. ‘A six-month old boy from Baghdad, who had not been immunized, developed paralysis on 10 February 2014’. Tests are reported to be underway to confirm whether a Syrian toddler in Lebanon has the disease.

In 2012, even before these cases of polio were confirmed, a strain of the virus was identified in environmental samples from Egypt; in 2013 the strain was also found in samples from Israel and the Palestinian Territories. A joint WHO and UNICEF publication explained that examination of the genetic sequences of these samples, and the virus samples found in Syria, ‘indicate that the imported viruses have been circulating in the Syrian Arab Republic and other Middle Eastern countries over a prolonged period, and other parts of the Syrian Arab Republic and the region are likely infected’. It is thought the virus spread to the Middle East from Pakistan—one of only three countries where polio is still endemic.

In around one in 200 cases polio causes irreversible paralysis—sometimes within hours—though in 90 per cent of cases symptoms are mild and the highly contagious disease goes unnoticed. This means it can spread silently, as appears to be the case with the infant from Baghdad who contracted a strain of the virus closely related to the strain identified in Syria, despite his family having no obvious links or a history of visits to the country.

In 1988, the Global Polio Eradication Initiative (GPEI) was launched, led by national governments, the WHO, Rotary International, the US Centers for Disease Control and Prevention and UNICEF. Since then, cases have decreased by over 99 per cent, from around 350,000 cases annually, to 406 reported cases in 2013.  By 2014, polio was only endemic in three countries—Afghanistan, Nigeria and Pakistan—down from more than 125 countries in 1988. As recently as 2013, the WHO was optimistic about progress continuing, pointing to decreasing cases in Pakistan and Afghanistan, and increasing vaccine coverage in Nigeria.

The gains made in polio eradication have required significant investment from countries including Australia—Australia has given bipartisan support to the campaign, and since 2011 has committed $130 million to eradicating polio.

While a few dozen polio cases may not seem like a significant concern in a conflict that has killed nearly 150,000 people, created more than 2.6 million refugees, and displaced 6.5 million people within Syria itself, it could have global ramifications if it is not addressed. After the polio cases were confirmed in Syria, the WHO described re-emergence of the virus in a previously polio-free area as ‘a public health emergency’.

The WHO warns, ‘As long as a single child remains infected, children in all countries are at risk of contracting polio. Failure to eradicate polio from these last remaining strongholds could result in as many as 200,000 new cases every year, within 10 years, all over the world’.

Even prior to the cases of polio being discovered, aid agencies had been working with national governments to vaccinate Syrian children, including those in refugee camps whose regular vaccinations were disrupted by displacement. Now, in response to the outbreak, the WHO and UNICEF have scaled up efforts and launched a US$39.6 million vaccination campaign in the region, aiming to reach more than 22 million children in Syria and nearby countries. 

Sustained efforts will likely be needed to ensure progress stays on track to meet the GPEI’s goal of ridding the world of polio by 2018.