1. de Lima Pereira A1, Southgate RJ1,2, Ahmed H3, Cramond V2, Lenglet A2
Risk for vaccine preventable diseases in Northern Syria after 5 years of Civil War Scientific Day June 2017, Malawi ]
de Lima Pereira A1, Southgate RJ1,2, Ahmed H3, Cramond V2, Lenglet A2
1MSF -OCA, Kobanê, Syria; 2 MSF - OCA, Amsterdam, The Netherlands; 3Kobanê Health Administration, Kobanê, Syria

2. Kobanê, Syria
Syrian border town (with Turkey) – accessible from Turkey then – now border completely closed
Médecins Sans Frontières (MSF) and Kobanê Health Administration (KHA) undertook a vaccination prioritisation exercise in Kobanê, Syria
Also provided primary and secondary care services as part of medical activities
24,000 people in 4,400 households
continuous influx of returning refugees (upto 3,000 per week)

4. Background The Syrian crisis is now in its seventh year
Health services, including immunisation, have broken down
Combined with poor shelter and water/sanitation, this increases the risk of vaccine preventable disease (VPD)
Little information is available on vaccine services and coverage in north Syria

5. Objectives and Timeline
To describe the methods and results of the vaccination prioritisation activity in Kobanê, north Syria
Timeline:
Vaccine Preventable Disease (VPD) Risk Analysis- April 2015
Vaccination Coverage Survey – May 2015
Measles Supplementary Immunisation Activity (SIA) – August 2015
Post Vaccination Coverage Survey – September 2015

7. Methods 1) VPD Risk Analysis
Using the two-step MSF ‘Preventive Vaccination in Humanitarian Emergencies’ tool:
Assesses general contextual risk factors and local disease-specific factors
2) Baseline Coverage Survey
ENA for SMART – 135 households
Simple Random Sampling – Epop and Google Earth
3) Measles SIA
Children 6-59 months and lessons learned were gathered.
4) Post-campaign Coverage Survey
Similar methodology to baseline coverage survey households.
Ethics: Met the criteria for exemption from review by the MSF ethical review board

9. VPD Risk Analysis: Spread Likelihood

10. VPD Risk Analysis: Aggravating Risk Factors
MSF clinic data showed respiratory and diarrhoeal illness in Kobanê. There was reports of measles, polio, typhoid, hepatitis A in the country.
Overall, the most important vaccinations were assessed as: measles, Hib, pneumococcal (PCV).
Recommendations:
measles SIA (plus Polio),
restarting routine childhood immunisations
discussions regarding the novel introduction of PCV.

11. Baseline Coverage Survey

12. Baseline Coverage Survey
100% response rate from the 135 households, with 212 children under 5 years of age.
Coverage for key antigens in the childhood vaccination schedule
Only one in five children (43/212; 20.3%; 95%CI= %) had received all vaccines due for age.
Only one of the 51 children under one year old had received all vaccines due for age (2.0%; 95%CI= %). These were received outside of Syria.

13. Measles SIA
Four decentralised vaccination sites over a five-day SIA campaign, targeting children 6-59 months.
3410 children were vaccinated (48.0% female).
Decentralised sites reduced crowds, which reduced risk for potential armed attack
Intensive training and support required from MSF due to lack of health workers remaining in Kobanê.
KHA continued with vaccination in the surrounding region in subsequent Phase 2 (not described here)

14. Post-campaign Coverage Survey
100% response rate from the 282 households, with 280 children months old.
81.8% (229/280; 95%CI= %) received a measles vaccine in the SIA.

16. Discussion Progressive collapse of the health care system in Kobanê
- low vaccine coverage rates
- younger age groups more affected
- potentially worsened since 2015
There are repeated displacements of the population, attacks on health institutions and exodus of healthcare workers
-challenges the resumption of routine immunization
-decreased effectiveness of SIAs to ensure sustainable immunity

17. Discussion Security Challenges
-Armed attacks– decentralized and multiple days to decrease risk
- Possibility of house to house vaccination was also discussed
Coordination
-Scarred by adverse events following SIA in Idlib previous year
-Coordination actors and UN agencies based in Turkey
-Other agency plans for polio vaccination delayed
Logistic Challenges
-Limited experienced staff presence
-Cold room maintenance
-Importation of vaccines

18. Conclusions
Childhood vaccination is a key example of effect of war on public health.
Children in Kobanê are unprotected against VPDs, the youngest children are least protected. Could only have worsened since 2015.
In a context where outbreaks are more and more likely, this exposes children to the potentially devastating effects of preventable diseases.
We call on Governments and the UN to re-establish childhood vaccination in as a priority.

19. Acknowledgements Kobanê Health Administration
MSF and MoH staff in Kobanê and the rest of Syria who continue to save lives and bear witness everyday
But other hearts in other lands are beating,
With hopes and dreams as true and high as mine………