PAGE 1

SYRIA CRISIS Whole-of-Syria update

Situation report # 4

JUNE 2018

WHO supported partners in southern Syria, including the Syrian Arab Red Crescent, by providing them with 189,000 numbers of treatments since 17 June. Photo: WHO

11.3 M IN NEED OF HEALTH CARE

6.6 M INTERNALLY DISPLACED

5.6 M REFUGEES

8,100 PEOPLE LIVING IN BESEIGED AREAS

9 ATTACKS ON HEALTH CARE

KEY FIGURES HIGHLIGHTS

130 WHO STAFF IN WOS

WHO responded to multiple dynamic emergency situations across Syria, including in Afrin (Tal Refaat, Nabul, Zahraa, and Fafin), eastern Ghouta, and northern rural Homs. The humanitarian situation in Idleb remained particularly dire, which is linked into massive new displacements since the end of 2017.

In southern Syria, violence escalated with heavy artillery and aerial shelling. By end June, an estimated 66,000 people were displaced due to the fighting, mostly from eastern Dar’a governorate to areas near the Jordanian border and the Golan Heights.

There were registered cases of measles and leishmaniosis in northern Syria and acute diarrhoea in northeast Syria.

At the end of June, of the 111 assessed public hospitals (MoH and MoHE), 55 (50%) were reported fully functioning, with 27 (24%) hospitals reported partially functioning (i.e., shortage of staff, equipment, medicines, or damage to the building), while 29 (26%) were non-functioning.

121 HEALTH CLUSTER PARTNERS IN DAMASCUS, GAZIENTEP AND AMMAN

11.2 M TARGET POPULATION FOR HEALTH RESPONSE IN 2018

HEALTH FACILITIES

111 TOTAL NUMBER OF HOSPITALS

82 HOSPITALS FUNCTIONING (55 FULLY AND 27 PARTIALLY)

WHO FUNDING

141 M US$ REQUESTED AS PART OF SYRIA HUMANIATRAIN RESPONSE PLAN

22 M US$ RECEIVED BY WHO (16.2%)

PAGE 2

1 One standard treatment course (e.g. a course of antibiotics for 8 days) is considered as treatment for one person. Treatment courses are determined for each medicine distribution based on international WHO standards. 2 Data from April 30, 2018 to June 16, 2018 (epidemiological weeks 18 -24)for all EWARN-covered areas in Syria

Whole of Syria

Situation overview The escalation of hostilities in southern Syria created huge humanitarian needs in Dar’a, Quneitra, and Sweida governorates, with up to 66,000 people displaced by the end of June. UN agencies discussed new mechanisms for access as more areas that have recently experienced change in lines of control. In total, WHO delivered 166,863 treatments to southern Syria from Damascus by the end of June. The interagency cross-border convoy scheduled to depart Ramtha, Jordan, on 27 June was placed on hold and remained on standby at the end of the month. Throughout the country, there continues to be a need for increased humanitarian access to areas that have recently experienced change in lines of control, which are highly vulnerable to disease outbreaks due to recent population movements within the country and lack of access to basic services, including poor water and sanitation. Across Syria, new measles cases continued to be reported with the highest disease burden occurring in northern Syria. Additional pockets of leishmaniosis and acute diarrhoea were reported in northern Syria and northeast Syria respectively. Nine attacks on health care were reported through the country in the month of June, killing three health workers, injuring five, and reinforcing the need for the protection of patients, health workers, and health facilities, particularly during transitional phases. From 24-27 June alone, eight health facilities were attacked and either partially or fully destroyed during hostilities in eastern Dar’a, leading to the loss of critical health services in the area, including outpatient consultations, inpatient admissions, emergency obstetric care, trauma and surgical care, dialysis, mental health services, physical rehabilitation and blood banks. In northeast Syria, there are concerns over displaced populations who are returning to their homes facing the threat of landmines, unexploded ordnances, and explosive remnants of war. June also saw continued high transmission of communicable diseases including measles, acute diarrhoea, and cutaneous leishmaniosis In total during the month of June, WHO and its implementing partners delivered 326,109 medical treatments1 to eight governorates during the month of June. WHO conducted no cross border deliveries from Jordan or Turkey this month; however, there was one cross-border convoy from Iraq.

SITUATION OVERVIEW Northwest Syria (Idleb, Aleppo, Afrin, Hama, Latakia, Tartus)

136,000 people were estimated to remain in Afrin district, with 134,000 people remaining displaced to the Tall Refaat sub-district, Nabul and Zahraa towns, and surrounding communities.

In Afrin and across northwest Syria, there was a shortage of essential medicines, medical staff, and specialized services.

Leishmaniosis remained a pressing concern in Aleppo and Idleb governorates, especially in camps and remote areas of the region. The only NGO in Idleb Governorate providing leishmaniosis treatment has insufficient funding to assure a comprehensive response.

Tuberculosis treatment was also reportedly unavailable in some non-government controlled areas of rural Aleppo and Idleb Governorate, and the referral system for tuberculosis and thalassemia is suboptimal and requires strengthening.

The measles epidemic remains a concern, particularly in Idleb, which reported 3611 positive cases during the first two weeks of June, and Aleppo, which reported 2060 in the same period.2

Mental health remained a point of concern due to the weak referral system, lack of integration of

PAGE 3

mental health services at the primary health care level, and dearth of professionals properly trained and qualified to respond to the needs of the affected population.

The destruction of Kafr Zeita hospital created a large gap in northern Hama countryside for health services to women and children, as it was the major provider of maternity and child health services in the area.

For IDPs displaced from Afrin, WHO supported 13 mobile medical teams (MMTs) and one primary-health-care centre in providing essential health care services. MHPSS services are integrated with 13 medical teams, and nutrition surveillance services are integrated with 10 MMTs. Coordination is in place, including with SARC and DoH, on the effective mechanism to transport critical emergency patients to Aleppo city facilities.

Northeast Syria (Ar-Raqqa, Hasakeh, Deir Ez-Zor)

There are reports of a deteriorating humanitarian situation in the Dashisha area in Al-Hasakeh Governorate following an escalation of hostilities since 1 May. Reportedly, limited groups of IDPs from these areas managed to reach IDP sites in Al-Hasakeh Governorate and are being hosted in the existing IDP sites. An estimated 138,000 individuals returned to Ar-Raqqa city since October 2017 and 188,000 to Deir-ez Zor governorate since November 2017, although conditions for returns remain unsafe due to high levels of contamination of explosive hazards.

A flash flood in Ein Essa in week 23 significantly damaged the IDP camp; an estimated 40% of the camp’s tents were destroyed, and 10% of the health and medical centres were damaged.

From 18-31 June, WHO led a joint WHO-UNICEF field investigation of acute diarrhoea cases along the Euphrates river in Dier Ezzor Governorate .As of 24 June, 578 cases, including 12 deaths, of acute diarrhoea were reported in Deir Ez-Zor. To date, the distribution of symptoms includes acute diarrhoea (100%), bloody diarrhoea (94%), abdominal pain (93%), fever (80%), vomiting (15%) and dehydration (8%).

WHO’s ongoing partners in Northeast Syria include GOPA, 11 medical mobile teams, and Al-Hikmah Private Hospital.

In coordination with UNHCR, WHO evacuated two TB cases from Al Roj camp to Al-Hikmah private hospital for advanced care and follow up.

Damascus, Rural Damascus, East Ghouta

By the end of June, 18,543 people remained housed across seven shelters across eastern Ghouta in Rural Damascus. As of 30 June, 21,450 have returned to communities across East Ghouta. One IDP shelter in Adra was closed.

Fixed/mobile teams providing emergency referrals and outpatient services including reproductive health, nutrition screening, mental health services, EWARS and WASH cover the other seven shelters.

The provision of health services in eastern Ghouta communities remains disrupted with only five public health centres now partially functional in Duma, Saqba, Hazzeh, Ein Tarma and Arbin.

UN agencies still have no regular access granted into communities in eastern Ghouta.

In South Damascus following the end of hostilities in Yarmouk Camp, increased service coverage is required in Yalda, Babila and Beit Sahm. A lack of medicines (especially chronic diseases, anemia, skin diseases); treatment for injuries resulting from trauma; oral health/dentistry; and nutrition surveillance was reported. Mobile teams necessary as conditions to receive and distribute health supplies are not currently in place.

From March until the end of June, WHO provided the following support: o 16 shipments containing 772,543 medical treatments were delivered, accounting for 56.5 tons

of health supplies o 48 EWARS sentinel sites reported surveillance information, with 309 reports produced and 28

alerts investigated and responded to. o 13 WHO-supported NGOs deployed for the response. o Nine MHPSS mobile teams deployed, with three operating in the past week, and 71 static

medical points provide integrated MHPSS services. 7,018 basic psychological interventions

PAGE 4

have been provided to people. o 2,048 patients hospitalized in public hospitals. o 42,568 children under five years of age vaccinated (polio and EPI). WHO has supported 32

DoH mobile teams.

On 14 June, WHO delivered 15,058 treatments of essential and life- saving medicines mainly anaesthetics, analgesics, and antibiotics to SARC in Yelda, Babila and Beit Sahem.

Southern Syria (Dar’a, Quneitra, Sweida)

Since 17 June, hostilities in southern Syria – an area that is part of the ceasefire agreement adopted in July 2017 between Jordan, the Russian Federation, and the United States-- have been escalating. Hostilities have already claimed the lives of tens of civilians, rendered civilian infrastructure out of service, and displaced tens of thousands of individuals.

As populations were exposed to increased hostilities, the strain on trauma services increased. Additionally, with displaced populations living in remote and underserved areas along the border, the need for mobile outreach services increased.

By the end of June, an estimated 66,000 people had been displaced, the majority displaced within eastern Dar’a governorate to areas near the border with Jordan.

Disease surveillance sites in non-state-armed-group (NSAG)-controlled eastern Dar’a began to go offline as health facilities were attacked and/or evacuated, health care workers became displaced and lines of control shifted. The single reference lab in the same region also ceased operations due to changes in lines of control. Routine immunization in areas under NSAG-control was also largely disrupted due to the conflict escalation. Initially, there were 31 sentinel sites in Dar’a and 11 sentinel sites in Quneitra before the start of conflict.

At the end of June, EWARN was effectively non-operational in areas that were under NSAG control until recently. Reporting from EWARS disease surveillance sites across non-state-armed-group (NSAG)-controlled areas decreased to 30% due to the military operations.

Of 90 public health centres in the area, 54 were reported partially functioning, and 36 were completely out of service.

Homs, Northern Rural Homs

In northern rural Homs, there were acute shortages of health care staff, with only 10 doctors and 10 midwives present, and lack of functioning health care facilities (only nine of 22 public health centres have been reactivated to provide immunization service). Only one NGO and SARC have approval to operate inside Homs.

Referral services for seriously ill and wounded patients who require further hospitalization are suboptimal.

Reproductive health services and contraceptives available are inadequate for the needs of the population.

In an interagency convoy to Al Rastan, WHO dispatched 18,394 treatments, medicines, and supplies for 200 trauma cases.

WHO conducted four health information assessments in AlHoula area, in Burj Alqae, Tal Dahab, Tal Daw, Tayba and Kafr Laha.

HEALTH SYSTEM STATUS The quarterly HeRAMS data is collected and verified during June and July. The database is currently being consolidated at a Whole of Syria level. Data and maps will be available early August. PUBLIC HEALTH CONCERNS

The main health concern is the continued disruption to health services across the country, including the interruptions in services occurring during and after localised military offensives or local

PAGE 5

agreements.

Overcrowding and lack of clean water, latrines and suitable shelter in several IDP sites has put many IDPs at risk of vector-borne and water-borne diseases.

Cases of measles across the country, leishmaniosis in northern Syria, and acute diarrhoea in northeast Syria are on the rise.

Attacks on patients, health care workers, and health facilities continue.

It is proving increasingly difficult to receive regular approvals from national authorities for road deliveries of health supplies to northeast Syria.

The number of displacements continues to increase with escalation of hostilities around the country.

WHO ACTIONS Leadership and Coordination

WHO leads regular coordination meetings from its hubs in Amman, Gaziantep, and Damascus with health cluster partners to identify gaps and priorities.

Coordination is in place with DoH and SARC on the most effective mechanisms to transport critical emergency patients to Aleppo city facilities.

WHO’s Response Plan for Southwest Syria was activated to respond to the increased conflict and displacements witnessed since the escalation of hostilities.

Information and planning For WHO’s Early Warning, Alert and Response System (EWARS) and the Early Warning and Response Network (EWARN), 1471 facilities reported across the whole of Syria during the month of June. The two databases are currently being consolidated, and a single WoS information product will be produced at the end of July. The weekly bulletins are available at the following links: EWARN: https://www.acu-sy.org/en/epi-reports/ and EWARS: http://www.emro.who.int/syr/information-resources/ewars-weekly-bulletins-2018.html/ Health expertise and operations

In Aleppo and Afrin, WHO provided support to 13 NGO-supported MMTs, one NGO-supported public health centre, and six mobile clinics run by SARC and DoH. There were seven mobile clinics in the pipeline as of the end of June. MHPSS services were integrated into 13 MMTs, with nutrition surveillance was integrated into 10.

Site visits were conducted to 41 primary health care and community health centres to follow up on the implementation of the MhGAP programme.

WHO completed training in 35 of 46 health facilities in Idleb governorate to ensure integrated health services at the primary level and a well-functioning referral system. In May and June, 3128 referrals were conducted in northwest Syria in 28 trained health facilities in the network.

WHO trained 22 Syrian surgeons on a range of life-saving procedures such as tracheotomy and management of cardiac tamponade and fatal bleeding. Another 16 Syrian doctors were trained to serve as trainers for trauma management to other health care workers operating in northern Syria.

A WHO team visited the Moadamiya public health centre, which reopened in June after being rehabilitated by WHO. Nineteen health workers are providing essential life-saving health care services in the center. WHO also donated the only ambulance in Moadamiya.

In southern Syria, WHO deployed 5 medical mobile teams to the following areas:

o two medical mobile teams in Dar’a city and the neighbouring areas.

o one medical mobile team in Izra and the neighbouring areas.

o one medical mobile team in As Sanamain and the neighbouring areas.

o one medical mobile team in the northeast of the governorate of Dar’a and the neighbouring areas.

PAGE 6

Immunization

Routine immunization for children under five continued in 84 out of 86 centres in Idleb, Hama, and Aleppo governorates, providing in total 45,902 Penta vaccines in June. The second of four cross-border polio immunization campaigns planned for 2018 was conducted, reaching more than 781,000 children in Idleb, Aleppo, and Hama governorates. 109% of targeted children were reached with oral polio vaccines.

WHO participated in the monitoring of the destruction of 141,860 monovalent oral polio vaccine type II doses that expired in May 2018.

An immunization workshop, to be held in southern Syria and planned for June involving local health authorities, cross border partners and regional technical experts from WHO and UNICEF, has been put on hold indefinitely due to the conflict.

Operational support and logistics

WHO and its implementing partners delivered 326,559 medical treatments to eight governorates during the month of June.

WHO conducted no cross-border deliveries from Jordan or Turkey this month; there was one cross-border convoy from Iraq.

The interagency convoy scheduled to depart Ramtha, Jordan, and cross into southern Syria on 27 June was placed on hold and was still on standby at the end of the month.

WHO delivered 166,863 treatments to southern Syria from Damascus Hub by the end of June. Capacity-building

WHO supported 49 capacity-building activities for 1311 participants on topics including disease surveillance, preventing HIV transmission, life-saving measures such as tracheotomy and management of cardiac tamponade and fatal bleeding.

PLANNED HEALTH ACTIONS From inside Syria

Plan and implement a measles vaccination campaign in two rounds in July in seven governorates (Hasakeh, Deir Ez-Zor, Raqqa, Aleppo, Hama, Rural Damascus, and Homs).

Establish fixed health posts supplemented by mobile teams and revitalize non-functioning health facilities across all areas newly accessible to WHO from inside Syria

Continue to increase the coverage and quality of health services in NES, and respond to communicable disease events over the summer season.

Support health authorities and partners to increase health service delivery in Southern Syria with further supplies, including medicines for non-communicable diseases.

Health authorities and partners to increase health service delivery in Southern Syria

Prepare for the deterioration of the humanitarian situation in other areas of Syria including Idleb Governorate and other parts of the northwest.

Cross-border from Turkey

Finalize the cholera contingency plan and update the scenario-based contingency plan for Idleb, Euphrates shield area, and Afrin.

Update the scenario-based contingency plan for Idleb, Euphrates shield area and Afrin.

Conduct a second IPV campaign to complete the 2017 cVDPV2 outbreak response.

Deliver medical supplies to priority health care facilities in northern Syria, provide support to PHCs and hospitals that were identified as priority sites, and advocate for a safe corridor for delivery medical supplies to Afrin.

Conduct measles campaign for children between 5 to 15 years old to interrupt transmission and complete measles outbreak response.

PAGE 7

Cross-border from Jordan

Continue advocacy to support emergency medical referral of war-wounded and other critical cases from Syria to Jordan.

Ensure emergency response is ongoing where operational space remains for cross-border partners

Work with cross border health partners to address duty-of-care issues for staff and prepare for transition in lines of control.

FUNDING STATUS OF APPEALS US$

NAME OF APPEAL

REQUIRED FUNDS FUNDED %

FUNDED

WHO 2018 Syria Humanitarian Response Plan

US$ 141,475,561 US$ 22,946,983 16.2%

Resource mobilization

Contacts:

Adelheid Marschang, WHO Emergency Operations Manager a.i., marschanga@who.int

Hala Khudari, WHO Technical Officer, khudarih@who.int

PAGE 8