Immigrant Health Service

Syrian refugees - key issues

  • Background

    Syria’s pre-conflict population was 22.8 million (World Bank 2013). The main languages spoken are: Arabic, including the Levantine Arabic dialect, Kurdish, Armenian, and Turkmen. People from Aleppo and Damascus may also speak English and European languages. 

    Armed conflict began in the Syrian Arab Republic (Syria) in March 2011, escalating quickly into civil war (details). Since the beginning of the conflict, over half the Syrian population has been displaced.  

    The greatest numbers of Syrian refugees are located in neighbouring countries (November 2017, UNHCR).

    • Turkey  - 3.25 million.
    • Lebanon - 1.0 million.
    • Jordan – 655,000.
    • Iraq – 244,000.

    Large numbers of Syrians have reached Europe by land or sea. Key estimates include:

    • Eurostat - applications for asylum to EU member countries rose from 431,000 in 2013, to 627,000 in 2014, 1.26 million (363,000 Syrians) in 2015, and 1.2 million in 2016 (335,000 Syrians). In both 2015 and 2016, 83% of asylum applicants were aged <35 years.
    • Eurostat - there were 69,000 UAM arrive in Europe over 2014-15, and 63,300 unaccompanied minors applied for asylum in 2016
    • As of 30 September 2015, almost 530,000 refugees (70% Syrians) had crossed the Mediterranean Sea into Europe since the beginning of the year (UNHCR). Large numbers of people arrived by this route in early 2016 (also see UNHCR longitudinal statistics)

    Living conditions

    Living conditions for Syrian refugees in other countries are difficult, with issues of overcrowding, poor sanitation, food scarcity, and variable availability of shelter - conditions are often even worse outside of established camps and settlements (EMRO). The large volume of refugees has also put significant strain on host countries’ health systems, public finance, and security, and has created tension between refugee and host populations (EMRO)

    Within Syria, there has been significant disruption of the health system, with 60% of public hospitals out of service, a significant drop in immunisation rates, a 60-70% reduction in pharmaceutical production, and over half of the doctors having left the country (see:  UNICEF, WHO, WHO - health sector news, Save the Children and Physicians for Human Rights).

    Education     

    Similarly, the education system has been disrupted – prior to conflict, Syria had almost 100% primary school enrolment and literacy rates over 90%. In 2015, there were 2.6 - 2.8 million children out of school, and school attendance was <30% in 2013. UNICEF has reported more than 1 in 4 schools (5000 – 14,000 schools) have been damaged, or turned into shelters, storage facilities or military bases (see: UNICEF, UNICEF - Children under siege and World Vision). Recent health studies suggest low rates of education in adults.

    • A 2013 study of pregnant Syrian women in Lebanon found 75% had no or primary level education (see Benage et al, 2015).
    • A 2014 cluster survey of Syrian refugees in Jordan (outside refugee camps) found less than 25% had completed secondary school (see Doocy et al, 2015).

    Australia’s response to the Syrian conflict

    Australia has provided $213 million in humanitarian funding since the beginning of the conflict ($87.5 million to assist people inside Syria, $126 million to help refugees in the region and their host communities).

    On 9th September 2015, the government announced Australia will accept 12,000 Syrian and Iraqi refugees as part of the Humanitarian Program, in addition to Australia’s annual humanitarian intake of 13,750 people (which will also include people from Syria). The DIBP has indicated priority will given to those:

    • Assessed to be most vulnerable – women, children, and families with the least prospect of ever returning safely.
    • Located in Lebanon, Jordan, and Turkey.

    This large group is expected to start settling in Australia from mid 2016.

    Pre-arrival health screening

    All permanent migrants to Australia, including Humanitarian entrants undergo pre-arrival Immigration Medical Examinations (IME) 3-12 months prior to travel. Additional screening for LTBI in children 2-10 years was introduced in November 2015, including for all Humanitarian arrivals. Humanitarian entrants are offered an additional Departure Health Check (DHC), which includes measles-mumps-rubella (MMR) immunisation for those aged 9 months – 54 years. Additional measures for polio vaccination were implemented for Syrians travelling to Australia from May 2014.

    • Humanitarian arrivals from Syria undergo enhanced pre-migration screening, combining the IME and DHC. This health assessment includes the IME, with the addition of hepatitis B screening, LTBI screening for children 2-10 years, albendazole, mental health screening, and additional immunisation (polio, MMR, and DT-containing for all ages, using hexavalent or pentavalent vaccines in children <10 years).

    Specific health issues

    Considering the nature of the Syrian conflict, the following areas are important:

    Vaccine-preventable diseases and catch-up immunisations

    • Immunisation rates in Syria fell from 95% in 2010 to 45% in 2013, suggesting large numbers of children will be unimmunised or under-immunised (EMRO).
    • The immunisation schedules for Syria and source countries for Syrian refugees (and Australia) are shown below. The Syrian schedule does not include rotavirus, pneumococcal, varicella or human papilloma virus (HPV) immunisations in the Australian schedule.
    • See immunisation catch-up ( http://www.rch.org.au/immigranthealth/clinical/Catchup_immunisation_in_refugees/) for dosing and schedule of catch-up immunisation. 

    Vaccine Australia Syria Lebanon Jordan Turkey
    BCG   X X X X
    DTPa X X X X X
    Polio X (IPV) X (IPV & OPV) X (IPV & OPV) X (IPV & OPV) X (IPV & OPV)
    Hib X X X X X
    Hep B X X X X X
    Hep A         X
    Rotavirus X        
    13vPCV X   X (since 6/15)   X
    MMR X X X X X
    Varicella X       X
    Meningococcal X (C) X (ACWY @6y)      
    HPV X        

    Polio

    Measles

    • See Australian Immunisation Handbook - Measles.
    • Measles outbreaks have been reported in Syria and surrounding countries since the start of the conflict. Cases peaked in 2013, with an outbreak of up to 7,000 cases in northern SyriaSee WHO surveillance data for numbers and trends and Sharara and Kanj 2014 PLoS Pathog)
    • In Syria, measles vaccination reduced from 82-99% pre-conflict to 49-66% in 2014; and is 52-69% in 2016 (WHO). Like polio, mass measles vaccination campaigns are ongoing in Syria and surrounding countries (see UNICEF).
    • Syrian arrivals should have received MMR during their offshore health screening, however health providers should be aware of measles as a differential diagnosis in new arrivals who are febrile/unwell (especially if they have cough and rash).

    Hepatitis A

    Hepatitis B

    Other communicable or infectious diseases  

    Tuberculosis

    • TB screening of 69,000 Syrian refugees in Jordan from January to June 2014 found only 3 smear positive cases and a total of 33 culture confirmed cases. 45% of those screened were children, and children <15 years had significantly lower disease prevalence than the general screened population (see: Cookson et al 2015 Conflict and Health )
    • The prevalence of active TB (TB disease) in Syria, Lebanon, and Turkey is similar to that of overseas-born Australians, while Jordan’s prevalence similar with Australia’s overall general prevalence. See table (2013 WHO data):
    • Canadian migration screening in Syrian cohorts found 0% prevalence in 26,166 arrivals (see Hansen et al, 2016). 2015 IOM screening data in Syrian cohorts suggest the prevalence of CXR consistent with TB disease is 1.6%.
    • See RCH Immigrant health: Tuberculosis screening.
    2013 WHO data     Syria Iraq Lebanon Jordan Turkey Australia
    Total population 22.8M 33.4M 4.5M 6.5M 74.9M 23.1M
    Total cases 2816 8883 689 350 13,409 1256
    % in <15 years 14 8 8 6 4 4
    Pulm confirmed 805 2738 248 91 5975 612
    Pulm clinical 330 2238 142 104 1816 86
    Extra pulmonary 1562 3274 291 151 4561 512
    Cases with HIV 1 0 5 0 32 20
    Prevalence 24(11-42) 75 (35-129) 19 (6.7-37) 8.1 (3.7-14) 23 (11-39) 7.6 (3.1-14)
    Incidence 17 (14-20) 45 (39-50) 16 (14 – 18) 5.8 (5.1-6.5) 20 (19-22) 6.2 (5.8-6.8)
    MDR new % 6.2 (3.9-9.3) NA 1.1 (0.1-3.8) 6.3 (2.4-13) 2.5 (2.1-3) 2.3 (1.2-3.9)
    MDR re-Rx % 31 (21-44) NA 29 (3.7-71) 29 (3.7-71) 18 (15-21) 4.2 (0.1-21)

    HIV

    Hepatitis C

    Cutaneous leishmaniasis

    • Cutaneous leishmaniasis (CL) is a parasitic disease caused by approximately 20 species of the Leishmania parasite, with L. tropica and L. major being most prevalent in the Middle East. Both forms of CL are endemic in Syria - with Leishmania tropica in 85% and L. major in 15%. It is transmitted by sandflies, with peak incidence in the summertime (May – October) See Centers for Disease Control (CDC) for lifecycle, clinical disease, and treatment. Dermnet is another useful resource.
    • CL is endemic to the Eastern Mediterranean region, with an average of >100,000 cases/year in the last 10 years and >120,000 cases/year in the last 3 years.
    • CL presents with ulcerated skin lesion and local lymphadenopathy (for pictures see DermNet and CDC).
    • There has been a surge in CL cases in Syria since the start of the conflict, from 42,000 cases in 2010 to 72,000 cases in 2013 (WHO). In Lebanon, only a handful of cases had been reported prior to 2013, when 1000 cases were found amongst Syrian refugees (see Sharara and Kanj 2014 PLoS Pathog and Saroufim et al. 2014 Emerging Infect Dis).        

    Schistosomiasis

    Strongyloides

    Other intestinal parasites

    Middle East respiratory syndrome coronavirus (MERS-CoV)

    • Middle East Respiratory Syndrome (MERS) is a viral respiratory disease caused by a novel coronavirus (MERS‐CoV) first identified in Saudi Arabia in 2012.
    • Transmission of MERS-CoV occurs through both zoonotic and direct (person-person) contact. Camels and raw camel milk are likely to be a major source of infection to humans. Human-to-human transmission requires close contact, such as providing unprotected care to an infected patient.
    • From September 2012 to September 2015, 1570 cases and 555 deaths have been reported on the Arabian peninsula, with >85% of cases from Saudi Arabia (see WHO).
    • Symptoms include fever, cough, and shortness of breath, and infection may lead to pneumonia. The clinical spectrum is wide, ranging from no/mild symptoms to severe acute respiratory disease.
    • MERS has a high case fatality rate (36%) and generally causes more severe disease in older people, and people who are immunosuppressed or have chronic illness (e.g.  diabetes, cancer, or chronic lung disease) -  see WHO fact sheet.

    Skin infections

    • Increased rates and outbreaks of scabies, lice, and bacterial skin infections have been reported regularly by humanitarian aid organizations such as MSF, and International Medical Corps (IMC) as well as WHO. A review by MSF of medical diagnoses seen amongst Syrian refugees in Lebanon in 2013 found that skin diseases such as CL, scabies, lice and Staphylococcal skin infections accounted for 41% of presenting conditions (El-Khatib et al. 2013 Conflict and Health).
    • Myiasis (infection of the skin with fly larvae) was reported for the first time in Syria in November 2014 with 3 documented cases (see ProMED and  media reporting). The appearance of myiasis is not in itself a major concern but reflects the significant degree of deterioration of sanitation and hygiene conditions in the country.

    Sexually transmitted infections

    Nutrition

    Syrian children are at risk for poor nutrition, with high risk of both macronutrient (energy intake/protein) and micronutrient (vitamins and trace elements) deficiencies. Multiple sources have reported widespread malnutrition in child refugees in Lebanon and Jordan (see UNICEF and World Food Programme (WFP), and others. See  RCH Immigrant Health: Growth and nutrition.

    • Pre-crisis data on Syrian children showed poor nutrition for younger children, with an estimated 9.3% wasted, 10.3% underweight and 23% stunted (Syrian Family Health Survey, 2009). Micronutrient deficiencies were also common, with the prevalence of anaemia estimated at 29.2% (Syria Ministry of Health, Nutrition Surveillance System Report 2011 - see WHO).
    • Inter-agency (WFP, UNICEF, UNHCR, WHO, Save the Children, UN Population Fund, and Jordan’s Ministry of Health) nutritional assessments have been carried out in Syrian refugees in the Zaatari refugees camp and non-camp settlements in Jordan in November 2012 and April-May 2014.
      • Rates of acute malnutrition (wasting) within the Zaatari camp fell from 4.8% in 2012 to 1.2% in 2014, and from 3.9% to 0.8% outside the camp.
      • However, rates of stunting (chronic malnutrition with reduced height) continued to be high: 
        • 2012 - 16% inside the camps, and 7.9% outside the camp.
        • 2014 -  17% inside the camps and 9.0% outside the camp. 
        • Additionally, 48% of children aged <5 years and 45% of women aged 15-49 years in the camps were anaemic in 2014 (see UNHCR  and CDC MMWR 2014).                            

    Vitamin D deficiency 

    • Low vitamin D is likely to be common in veiled women and girls.
    • Studies of vitamin D deficiency in refugees to Australia from the Middle East show a prevalence of 20-66%, though specific information is not available for Syria and surrounding countries.
    • See RCH Vitamin D guidelines.

    Non-communicable diseases

    • A 2014 cluster survey of 1550 Syrian refugees outside refugee camps in Jordan reported the following prevalence figures for non-communicable diseases (NCD) in adults: hypertension 9.7%, arthritis 6.7%, diabetes 5.3%, chronic respiratory diseases 3.1%, cardiovascular disease 3.7%. The prevalence was higher in people aged >40 years. In this study, people with tertiary education and those with primary level education had markedly lower rates of seeking care than those with no education. The most common NCD in children was chronic respiratory diseases in 3% (see Doocy et al, 2015).
    • A 2013 systematic study of 210 older (>= 60 years) Syrian and Palestinian refugees in Lebanon found 2/3 described their health as poor/very poor, and reported the prevalence of NCD in older adults was: hypertension 60%, diabetes 47%, and heart disease 30%. Functional impairment was common: difficulty walking 47%, visual impairment 24%, hearing impairment 18%, 10% were unable to leave their homes due to disability, and 4% were bedridden; 64% were independent in activities of daily living (see Strong et al, 2015).

    Oral health

    There is remarkably little published information on oral health in Syrian refugees, although it was identified as a key priority in post-arrival health care in Canada (see Hansen et al, 2016).

    Mental health, trauma, and family impact

    High rates of post-traumatic stress disorder (PTSD), depression, and anxiety are reported in Syrians and Syrian refugees arising from mass displacement, exposure to conflict and violence, including sexual violence, and with many people experiencing death or loss of family members. This conflict has produced a high proportion of female-headed households – the loss of fathers and of family integrity creates acute and ongoing stress for mothers and children. In addition, many children have lost the physically, mentally, and socially protective environment that is provided by schools and education.

    A 2014 International Medical Corps (IMC) assessment of 6357 Syrian IDPs and refugees in Lebanon, Jordan, and Turkey receiving mental health services in 2014 found:

    • In 5181 adults attending mental health services, 54% suffered severe emotional disorders, including depression and anxiety and 11% had psychotic disorders.
    • In 1176 children attending mental health services, 27% had developmental disorders and 3.6% had severe emotional disorders.

    Another recent study of Syrian refugees in Germany by the German Chamber of Psychotherapists, (also see media summary in English) found:

    • Over half had psychological illness, most commonly PTSD and depression/suicidality.
    • Over 70% had witnessed violence and more than half had been victims of violence themselves.
    • Among children, 40% had witnessed violence, 26% had watched family members being attacked, and 20% suffered PTSD.

    A 2013-14 multi-centre survey of 765 Syrian refugees in Jordan (86% aged 18-49 years) found one third had significant depression, and that 35-40% had comorbidities (see Gammouh et al, 2015)

    Gender-based violence, early marriage

    The Syrian crisis has included systematic gender-based violence against women and girls (see media reporting). Accurate reporting and statistics is compromised by intense stigma and a “culture of silence” surrounding the issue.

    • Women and girls may have been subject to sexual violence or early marriage
    • Reports by a UN Interagency task force on gender-based violence and another by the International Federation of Human Rights provide interviews and detailed accounts from women and girls.
    • Another study by the International Rescue Committee reported on fear of harassment or assault experienced by women and girls - many felt imprisoned in their own homes, 60% expressed feelings of insecurity leaving the home, and one-third felt too scared or overwhelmed to leave their homes at all. Married adolescent girls and women reported less risk of harassment than those who were divorced or single. 
    • A 2012 needs assessment of 452 Syrian refugee women aged 18-45 years in Lebanon found 30.8% had experienced conflict-related violence, and 3.1% had experienced non-partner sexual violence. Most women (64.6%) who had experienced violence did not seek medical care (see Reese Masterson et al, 2014).

    In conflict situations, adolescent girls are also at risk of forced and early marriage, although this may be seen as a means to physical and economic protection.

    • UN Inter-Agency task force report documents that amongst Syrian refugees in Jordan, 51% of girls and 13% of boys married before the age of 18. Risks of early and forced marriage for girls include family violence and early pregnancy.  

    Rates of family violence were high in the Syrian population pre-conflict.

    Reproductive health and neonatal outcomes

    • The adolescent fertility rate for girls 15-19 years in Syria is 40/1000 compared to 14/1000 in Australia. Girls younger than 15 years of age are five times more likely to die in childbirth than women in their 20s.
    • A 2012 needs assessment of 452 Syrian refugee women aged 18-45 years in Lebanon found more than half had gynaecologic problems, pregnancy/delivery complications were common, and 34.5% were using contraception/family planning - which was reduced compared to 58.5% pre-conflict (see Reese Masterson et al, 2014).
    • A 2013 study of 420 pregnant Syrian women in Lebanon found 83% received some form of antenatal care, although only 15.7% had the expected 4 antenatal visits, and care was more likely in UNHCR refugees. Care was less likely in older women and women with less education. Nearly 60% had inadequate dietary intake of folate, and vitamins, 90% had not received the recommended tetanus prophylaxis. Rates of smoking were low (9.5%) (see Benage et al, 2015).
    • A 2015 report on 457 Syrian women delivering in a tertiary hospital in Turkey raises concern about neonatal outcomes, the mean maternal age was 18 years, 26% of infants were pre-term, 50 required ICU admission, and overall mortality was 1.9%, compared to the Turkish neonatal mortality rate of 0.04% (see Buyuktiryaki et al, 2015).  
    • A 2015 report on Toxoplasma serology in pregnant women found rates of nearly 5% toxoplasma IgM positive in pregnant Syrian refugees in Turkey, which was more than double the rates for the local population (see Bakacak et al, 2015)

    Disability

    • In 2015, World Vision reported more one million people had been wounded in the conflict, with many injuries resulting in longer-term disability. 2016 reporting from the Syrian Centre for Policy Research suggests 1.9 million people have been wounded. 
    • Although there are no data on disability in Syrian children related to the conflict, extrapolation of global averages based on other armed conflicts ( UNICEF Children in War - State of the World’s Children 1996 and here) suggests that for every child death there are 3 children with serious injury. Given that 2015 figures suggested approximately 12,000 Syrian children have died in the conflict, this would equate to 35,000-40,000 children injured. Injuries may result in physical disability and sensory impairment, in addition to psychological trauma. 
    • A 2014 report on Syrian IDPs by Handicap International found 60% of injuries were caused by explosive weapons, 20% of injured individuals were infants and children, and 25% had undergone amputation as a result.
    • The National Syria Project for Prosthetic Limbs (based in Syria and Turkey) estimates that 30,000 people have lost limbs and reports fitting 1000 people with prosthetic limbs.
    • See RCH Immigrant health: Developmental assessment and Education assessment.

    Post-arrival health screening

    • Initial reports (2016) from Canadian IME screening in 26,166 Syrian refugees found 0% HIV, 0% syphilis, and only 2 abnormal CXRs. Quarantine officers assessed 274 people (1%) on arrival, 10 people were referred to local hospitals for further assessment, none had a communicable disease of public health concern. Additional medical teams assessed a further 1213 people on arrival, 54 were transferred to hospital, many were known to require urgent medical care. For the overall cohort, key needs were catch-up immunisations and urgent dental care (see Hansen et al, 2016).
    • IOM screening in Syrian refugees (2015) has found the following prevalence figures: CXR findings of TB disease 1.61%, HIV 0.11%, syphilis 0.26%, hepatitis B 1.47%, and hepatitis C 0.5%.

    Resources

    Most of the relevant web-links are contained in the text of this page. Please let us know about other useful resources. 

    RCH Immigrant Health - additional information. Authors: Karen Kiang and Georgie Paxton, updated Georgie Paxton November 2017. Contact: georgia.paxton@rch.org.au