The impacts of the Syrian conflict on child and adolescent health: a scoping review.

BACKGROUND: The Syrian conflict has had a profound impact on Syrian children and adolescents. We sought to determine the extent and range of literature on the conflict's health effects on this vulnerable population. METHODS: A scoping review describing the impact of the Syrian conflict on children was undertaken while utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Extension for Scoping Reviews methodology. Qualitative thematic analyses were undertaken to both identify patterns of morbidity and mortality and gaps in evidence. RESULTS: A total of 982 articles meeting search criteria were identified between 1 January 2011 and 30 April 2021. After iterative screening, 12 were identified from academic databases and 4 were identified from grey literature and hand searching, yielding a total of 16 studies for final, full-text analysis. Four distinct themes recurred in the literature; these include children suffering from violent injury, a resurgence of communicable diseases, malnutrition and micronutrient deficiency and impacts on their mental health. CONCLUSIONS: The health of children and adolescents in Syria has been significantly impacted by the indiscriminate attacks against civilians, flagrant human rights violations and the disintegration of the national health care system. Neonates were largely absent from the literature. The themes from this scoping review can inform health programming priorities by aid organizations.

Experiences of Egypt as a destination and transit country for Syrian refugee healthcare workers: a qualitative study.

BACKGROUND: Refugee healthcare workers (HCWs) can make important contributions in host countries, particularly in the wake of the ongoing COVID-19 pandemic, which has exacerbated existing shortages of frontline HCWs. However, refugee HCWs often face challenges entering the labour markets of such countries even where needs exist. Syria's decade-long conflict has forced thousands of HCWs from their homes; however, data on this population are limited, impeding the formation of policies that can support them. This study explores the experiences of Syrian refugee HCWs in Egypt. METHODS: Key informants (KIs) were selected using purposive and snowball sampling method and semi-structured interviews were conducted in person in Cairo and remotely from the UK during July 2019. Interviews were conducted in Arabic and analysed using a combined deductive and inductive thematic analysis framework after transcription into English. RESULTS: Fifteen KI interviews were analysed. The main emerging themes from the qualitative interviews are those relating to 1. Education, training, and licensing 2. Politics and bureaucracy 3. Societal factors 4. Economic factors. Political changes in Egypt altered opportunities for Syrian HCWs over time; however, refugee HCWs broadly reported acceptance among Egyptian patients and colleagues. Bureaucratic factors which impede the ability of Syrian refugee HCWs to obtain a full license to practice and leave to remain and the absence of clearly defined policies were reported as barriers. Economic factors including the risk of economic exploitation e.g. in the informal sector and financial insecurity were noted to have a negative psychosocial impact. CONCLUSIONS: This is the first qualitative research study which explores the experiences of Syrian refugee HCWs in Egypt. It adds to the sparse literature on the topic of Syrian refugee HCWs but provides evidence for further discussions on how to support refugee HCWs in Egypt and in other host countries in the region. Though interviews were conducted before the COVID-19 pandemic, the pandemic itself lends urgency to the discussion around refugee HCWs on an international level.

Re-emphasising the importance of histopathological diagnosis in suspected bacterial endocarditis.

Infective endocarditis (IE) carries a high risk of morbidity and mortality. Timely diagnosis, effective treatment and prompt recognition of complications are essential to favourable patient outcomes. A collaborative, multidisciplinary team approach to the management of IE has been shown to improve prognosis. However, the clinical heterogeneity of IE and atypical presentations pose challenges to the endocarditis team. We present a case highlighting the role of valve histopathology in suspected IE, where there may be diagnostic uncertainty.

Policy versus practice: Syrian refugee doctors in Egypt.

The COVID-19 pandemic has renewed interest in streamlining processes which allow refugee doctors and other healthcare workers to make up for the shortfall in healthcare delivery, which many countries are facing increasingly. The protracted conflict in Syria is the biggest driver of forced displacement internationally with refugees, including healthcare workers seeking safety in host countries, however many face challenges to entering the workforce in a timely manner. The majority are in countries surrounding Syria (Lebanon, Jordan and Turkey) however the restrictive labour policies in these countries, particularly for healthcare workers have forced many to look further afield to Europe or the Gulf. Egypt's context is interesting in this regard, as it hosts a smaller number of registered Syrian refugees and was initially welcoming of Syrian medical students and doctors. However, recent socio-political changes have led to restrictions in training and work, leading doctors who initially considering staying in Egypt to increasingly consider it a transit country rather than a destination country. Here, we explore the processes by which Syrian doctors in Egypt can work and how documented policies may differ to practice. We do this through a document review and from the first-hand experiences of the authors.

Fluoroquinolones and isoniazid-resistant tuberculosis: implications for the 2018 WHO guidance.

INTRODUCTION: 2018 World Health Organization (WHO) guidelines for the treatment of isoniazid (H)-resistant (Hr) tuberculosis recommend a four-drug regimen: rifampicin (R), ethambutol (E), pyrazinamide (Z) and levofloxacin (Lfx), with or without H ([H]RZE-Lfx). This is used once Hr is known, such that patients complete 6 months of Lfx (≥6[H]RZE-6Lfx). This cohort study assessed the impact of fluoroquinolones (Fq) on treatment effectiveness, accounting for Hr mutations and degree of phenotypic resistance. METHODS: This was a retrospective cohort study of 626 Hr tuberculosis patients notified in London, 2009-2013. Regimens were described and logistic regression undertaken of the association between regimen and negative regimen-specific outcomes (broadly, death due to tuberculosis, treatment failure or disease recurrence). RESULTS: Of 594 individuals with regimen information, 330 (55.6%) were treated with (H)RfZE (Rf=rifamycins) and 211 (35.5%) with (H)RfZE-Fq. The median overall treatment period was 11.9 months and median Z duration 2.1 months. In a univariable logistic regression model comparing (H)RfZE with and without Fqs, there was no difference in the odds of a negative regimen-specific outcome (baseline (H)RfZE, cluster-specific odds ratio 1.05 (95% CI 0.60-1.82), p=0.87; cluster NHS trust). Results varied minimally in a multivariable model. This odds ratio dropped (0.57, 95% CI 0.14-2.28) when Hr genotype was included, but this analysis lacked power (p=0.42). CONCLUSIONS: In a high-income setting, we found a 12-month (H)RfZE regimen with a short Z duration to be similarly effective for Hr tuberculosis with or without a Fq. This regimen may result in fewer adverse events than the WHO recommendations.

Health workers and the weaponisation of health care in Syria: a preliminary inquiry for The Lancet-American University of Beirut Commission on Syria.

The conflict in Syria presents new and unprecedented challenges that undermine the principles and practice of medical neutrality in armed conflict. With direct and repeated targeting of health workers, health facilities, and ambulances, Syria has become the most dangerous place on earth for health-care providers. The weaponisation of health care-a strategy of using people's need for health care as a weapon against them by violently depriving them of it-has translated into hundreds of health workers killed, hundreds more incarcerated or tortured, and hundreds of health facilities deliberately and systematically attacked. Evidence shows use of this strategy on an unprecedented scale by the Syrian Government and allied forces, in what human rights organisations described as a war-crime strategy, although all parties seem to have committed violations. Attacks on health care have sparked a large-scale exodus of experienced health workers. Formidable challenges face health workers who have stayed behind, and with no health care a major factor in the flight of refugees, the effect extends well beyond Syria. The international community has left these violations of international humanitarian and human rights law largely unanswered, despite their enormous consequences. There have been repudiated denunciations, but little action on bringing the perpetrators to justice. This inadequate response challenges the foundation of medical neutrality needed to sustain the operations of global health and humanitarian agencies in situations of armed conflict. In this Health Policy, we analyse the situation of health workers facing such systematic and serious violations of international humanitarian law. We describe the tremendous pressures that health workers have been under and continue to endure, and the remarkable resilience and resourcefulness they have displayed in response to this crisis. We propose policy imperatives to protect and support health workers working in armed conflict zones.

Screening contacts of patients with extrapulmonary TB for latent TB infection.

2016 TB National Institute for Health and Care Excellence (NICE) guidelines imply that contacts of extrapulmonary TB do not require screening for latent TB infection. At our high TB prevalence site, we identified 189 active cases of TB for whom there were 698 close contacts. 29.1% of the contacts of pulmonary TB and 10.7% of the contacts of extrapulmonary TB had active or latent TB infection. This supports screening contacts of extrapulmonary TB at our site and presents a way to access high-risk individuals. We propose to continue to screen the contacts of our patients with extrapulmonary TB and recommend other TB units audit their local results.

Drug-induced liver injury from antituberculous treatment: a retrospective study from a large TB centre in the UK.

BACKGROUND: We describe drug-induced liver injury (DILI) secondary to antituberculous treatment (ATT) in a large tuberculosis (TB) centre in London; we identify the proportion who had risk factors for DILI and the timing and outcome of DILI. METHODS: We identified consecutive patients who developed DILI whilst on treatment for active TB; patients with active TB without DILI were selected as controls. Comprehensive demographic and clinical data, management and outcome were recorded. RESULTS: There were 105 (6.9%) cases of ATT-associated DILI amongst 1529 patients diagnosed with active TB between April 2010 and May 2014. Risk factors for DILI were: low patient weight, HIV-1 co-infection, higher baseline ALP, and alcohol intake. Only 25.7% of patients had British or American Thoracic Society defined criteria for liver test (LT) monitoring. Half (53%) of the cases occurred within 2 weeks of starting ATT and 87.6% occurred within 8 weeks. Five (4.8%) of seven deaths were attributable to DILI. CONCLUSIONS: Only a quarter of patients who developed DILI had British or American Thoracic Society defined criteria for pre-emptive LT monitoring, suggesting that all patients on ATT should be considered for universal liver monitoring particularly during the first 8 weeks of treatment.

Time to detection in liquid culture of sputum in pulmonary MDR-TB does not predict culture conversion for early discharge.

OBJECTIVES: UK guidelines advise that patients with pulmonary MDR-TB are isolated in hospital until the results of sputum cultures are negative (culture conversion), typically after 42 days of incubation with no growth. MDR-TB patients may be isolated ≥42 days longer than is necessary for public safety, which has major implications for patients and hospitals. Our objective was to determine whether analysis of time to detection (TTD) in liquid culture could predict the earliest safe discharge date of MDR-TB patients. PATIENTS AND METHODS: Fifteen pulmonary MDR-TB patients were identified retrospectively from the London TB Register and hospital records. We performed linear regression of TTD against days elapsed between admission and sample date. If the regression line crossed the observed culture-conversion date at TTD = 42 days, the data were deemed to give 'precise prediction' of the earliest safe discharge date. RESULTS: The median length of stay was 91 days (IQR 79-131 days). Culture conversion occurred at a median of 59 days (IQR 46-86 days). Twelve patients were hospitalized beyond culture conversion, with a median overstay of 52 days (IQR 35-68 days). TTD tended to lengthen until culture conversion and, for nearly half of the patients (7/15, 47%), linear regression of TTD against time from admission gave a good fit to the data (r(2) ≥ 0.6) and supported precise prediction. However, data from the remaining patients showed considerable variation, and linear regression did not support prediction of safe discharge. CONCLUSIONS: TTD data from these pulmonary MDR-TB patients did not support a simple clinical prediction tool, but our analysis was limited by the small size of our sample.

Lessons for control of heroin-associated anthrax in Europe from 2009-2010 outbreak case studies, London, UK.

Outbreaks of serious infections associated with heroin use in persons who inject drugs (PWIDs) occur intermittently and require vigilance and rapid reporting of individual cases. Here, we give a firsthand account of the cases in London during an outbreak of heroin-associated anthrax during 2009-2010 in the United Kingdom. This new manifestation of anthrax has resulted in a clinical manifestation distinct from already recognized forms. During 2012-13, additional cases of heroin-associated anthrax among PWIDs in England and other European countries were reported, suggesting that anthrax-contaminated heroin remains in circulation. Antibacterial drugs used for serious soft tissue infection are effective against anthrax, which may lead to substantial underrecognition of this novel illness. The outbreak in London provides a strong case for ongoing vigilance and the use of serologic testing in diagnosis and serologic surveillance schemes to determine and monitor the prevalence of anthrax exposure in the PWID community.

The cascading impacts of attacks on health in Syria: A qualitative study of health system and community impacts.

Syria has experienced over a decade of armed conflict, characterized by targeted violence against healthcare. The impacts of these attacks have resulted in both direct and indirect attacks on health and reverberating effects on local communities. This study aims to explore the perspectives of health workers based in northern Syria who have experienced such attacks on health to understand the impacts on the health system as well as communities served. In-depth interviews were conducted with health workers in the northern regions of Syria where attacks on health have been frequent. Participants were identified using purposive and snowball sampling. Interviews were coded and analyzed using the Framework Method. Our inductive and deductive codes aligned closely with the WHO Health System Building Blocks framework, and we therefore integrated this framing into the presentation of findings. We actively sought to include female and non-physician health workers as both groups have been under-represented in previous research in northern Syria. A total of 40 health workers (32.5% female, 77.5% non-physicians) who experienced attacks in northern Syria between 2013 and 2020 participated in interviews in 2020-2021. Participants characterized attacks on health as frequent, persistent over years, and strategically targeted. The attacks had both direct and indirect impacts on the health system and consequently the wider health of the community. For the health system, participants noted compounded impacts on the delivery of care, health system governance, and challenges to financing, workforce, and infrastructure. Reconstructing health facilities or planning services in the aftermath of attacks on health was challenging due to poor health system governance and resource challenges. These impacts had ripple effects on the health of the community, particularly the most vulnerable. The impacts of attacks on health in Syria are multiple, with both short- and long-term consequences for the health system(s) across Syria as well as the health of communities in these respective areas. Though such attacks against healthcare are illegal under international humanitarian law, this and other legal frameworks have led to little accountability in the face of such attacks both in Syria and elsewhere. Characterizing their impacts is essential to improving our understanding of the consequences of attacks as a public health issue and supporting protection and advocacy efforts.

An analysis of paediatric clinical presentations in Northwest Syria and the effect of forced displacement, 2018-2022.

Background: One in six children worldwide lives in a region exposed to armed conflict. In conflicts, children are among the most vulnerable, and at risk of adverse health outcomes. We sought to describe trends in child and adolescent morbidity in northwest Syria (NWS) and understand how forced displacement affects clinical utilisation during the Syrian conflict. Methods: Retrospective data between January 2018 and December 2022 were obtained from the Syrian American Medical Society (SAMS), a non-governmental organisation that operates health facilities in NWS. After initial descriptive analyses were completed, we performed a seasonal-trend decomposition to estimate the seasonality of clinical presentations. We subsequently employed a multivariate regression model incorporating age, gender, residency status, season, and a random district-level intercept to measure the association between the odds of clinical consultation and forced displacement. Findings: Across 51 reporting SAMS facilities, 2,687,807 clinical consultations were studied over a five-year period. Seasonality was demonstrated for every clinical consultation category. Higher levels of forced displacement were associated with increased odds of consultations for nutrition, trauma, NCDs and mental health and decreased odds of consultation for communicable diseases. Aside from traumatic injury, internally displaced persons (IDPs) had higher AORs of clinical consultations compared to host populations. Interpretation: Forced displacement differentially impacts clinical utilisation among children in northwest Syria, and the effects of displacement persist for at least six months. Clinical needs vary by host/IDP status, sex, age, and season. This study can assist policymakers in forecasting the health needs of children in northwest Syria.

Multidrug-resistant pathogens contaminate river water used in irrigation in disenfranchised communities.

OBJECTIVES: The contamination of fresh surface waters poses a significant burden on human health and prosperity, especially in marginalized communities with limited resources and inadequate infrastructure. Here, we performed in-depth genomic analyses of multidrug-resistant bacteria (MDR-B) isolated from Al-Oueik river water that is used for irrigation of agricultural fields in a disenfranchised area that also hosts a makeshift Syrian refugee camp. METHODS: A composite freshwater sample was filtered. Faecal coliforms were counted and extended spectrum cephalosporins and/or ertapenem resistant bacteria were screened. Isolates were identified using MALDI-TOF-MS and analysed using whole-genome sequencing (WGS) to identify the resistome, sequence types, plasmid types, and virulence genes. RESULTS: Approximately 106 CFU/100 mL of faecal coliforms were detected in the water. Four drug-resistant Gram-negative bacteria were identified, namely Escherichia coli, Klebsiella pneumoniae, Enterobacter hormaechei, and Pseudomonas otitidis. Notably, the E. coli isolate harboured blaNDM-5 and a YRIN-inserted PBP3, representing an emerging public health challenge. The K. pneumoniae isolate carried blaSHV-187 as well as mutations in the gene encoding the OmpK37 porin. Enterobacter hormaechei and P. otitidis harboured blaACT-16 and blaPOM-1, respectively. CONCLUSION: This report provides comprehensive genomic analyses of MDR-B in irrigation water in Lebanon. Our results further support that irrigation water contaminated with faecal material can be a reservoir of important MDR-B, which can spread to adjacent agricultural fields and other water bodies, posing both public health and food safety issues. Therefore, there is an urgent need to implement effective water quality monitoring and management programs to control the proliferation of antibiotic-resistant pathogens in irrigation water in Lebanon.