Fighting TB amidst the fighting in Syria

29 March 2020

While the true extent of tuberculosis (TB) in the Syrian Arab Republic is unknown, a new diagnostic machine will drastically speed up and strengthen the fight against the disease. More than 9 years of conflict have provided an ideal breeding ground for TB. Reported cases are only the tip of the iceberg and the threat of drug-resistant TB looms. Failure to address the drivers of TB in the war-torn country could also have consequences beyond its borders.

WHO/Khaled Akacha

Fighting TB amidst... 1

Idris, aged 5, receives a chest X-ray at the Syria Relief and Development (SRD) TB centre in Azaz in Aleppo Governorate. In 2011, when the Syrian crisis started, national TB prevalence was 23 per 100 000 population. Since then, the progress made prior to the war to combat TB has stalled. Political instability coupled with violence directed at health-care infrastructure and workers has limited case-finding and control of the disease and delayed and disrupted treatments, heightening the risk of TB transmission and drug resistance.

WHO/Khaled Akacha

Fighting TB amidst... 2

Dr Akram examines Moustafa, aged 28, who is 5 months into the treatment against skeletal TB at SRD’s centre in Azaz. The duration of TB treatment is at least 6 months for drug-sensitive TB and 9–18 months for drug-resistant TB.

WHO/Khaled Akacha

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Jamal (left) and Idris (right) are to be tested for TB after having been in close contact with a TB patient in Bab Al Salama camp. The camp on the border to Turkey is home to thousands of internally displaced people. Overcrowding is a hallmark of the living conditions of millions of internally displaced Syrians in Idleb and Aleppo, and a key risk factor for transmission. It is imperative that screening and active case-finding are focused on these groups.

WHO/Khaled Akacha

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Mahmoud, a laboratory technician at the SDR centre in Azaz, prepares a sputum test. In Syria’s northwest, WHO and its partners run 3 specialized TB centres, equipped with medical supplies and laboratories, catering to Idlib, Afrin and rural Aleppo.

WHO/Khaled Akacha

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Microscopes in the laboratory of the SDR centre in Azaz. Northwestern Syria has seen mass displacement in the past months, with nearly 1 million people displaced since 1 December 2019. This poses grave challenges to the control of TB and treatment of patients. TB services in the region are weak, and it is likely that more than half of all cases go undetected.

WHO/Khaled Akacha

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Amina, aged 30, was referred to SRD’s centre in Azaz when she suspected she had TB. Amina was lucky – X-rays and 3 sputum tests returned negative and she was diagnosed with acute bronchitis. Increasing awareness of TB in emergencies is vital not only among affected populations, but also among health-care providers.

WHO/Khaled Akacha

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Mohammad is a pharmacy technician at SRD’s centre in Azaz. Accessing medicines is a challenge for many TB patients. There is a general fear that the number of TB cases in Syria is considerably higher than figures currently show, as the disease continues to go undetected.

WHO/Khaled Akacha

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Mohammad hands medicine to a TB patient at SRD’s centre in Azaz. In many countries, stigma against those with TB is considerable as the disease is often associated with poverty and incarceration. “I work in the Azaz TB centre to reduce the disease spread and raise community awareness,” says Mohammad’s colleague Samer.

WHO/Khaled Akacha

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Dr Akram reads an X-ray during a consultation with a patient. The Syrian conflict, now in its 10th year, has stalled progress in the fight against TB in Syria. WHO’s focus is on strengthening general awareness of TB and improving patient services. As soon as doctors identify suspected cases of TB and complete referral forms developed by WHO, patients are taken to TB centres for qualified care.

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Moustafa (right) and a family member wait their turn in the waiting room at SRD’s centre in Azaz. Armed conflicts, like those Syria has endured over the past decade, destroy basic medical infrastructure, hamper immunization efforts and lead to shortages of health-care workers and life-saving medicines. The targeting of hospitals and health-care workers is an additional threat. Services and treatments for TB patients are some of the many services that have been impacted.

WHO/Khaled Akacha

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Dr Akram examines Moustafa. “When I got diagnosed, I didn’t know anything about TB. I wasn’t able to work and I was so confused. My mental health got worse and worse,” Moustafa says. Health-care disruption, stress, illness, migration and poor living conditions contribute to the risk of contracting, reactivating and transmitting TB. “We have first-line medication but no second-line medicine against drug-resistant TB,” Dr Akram explains.

WHO/Khaled Akacha

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Dr Akram fills out a form to request a sputum test for a patient. Protracted conflict and insecurity lead to delays in the diagnosis of TB, while multiple displacements and restricted humanitarian access impede surveillance. These characteristics of the Syria conflict – the most serious humanitarian crisis in recent times – have directly and indirectly affected TB control. Armed conflicts and population displacements are associated with a significant increase of the risk of TB.

WHO/Khaled Akacha

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Yasmin, a laboratory technician, gives a sputum-collecting container to a patient who has come to SRD’s centre in Azaz to be tested. In Syria, the threat of multidrug-resistant TB looms due to displacement, stigma, limited access to treatment in areas of active conflict and interrupted treatments. “It’s my humanitarian and medical duty to do what I do. I remember one patient, aged 69, who simply refused the idea of having TB. Six months later, his life had changed for the better,” Yasmin says.

WHO/Khaled Akacha

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Dr Akram conducts a clinical examination of young Idris. “Unfortunately, there are negative connotations and shame linked to having TB – one patient told me about feeling like a stain on society. But luckily we also see how our awareness-raising efforts are having an impact. Patients are informing their families about the disease, leading to more people getting tested and having access to treatment,” Dr Akram says.

WHO/Khaled Akacha

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Mohammad is the receptionist at SRD’s centre in Azaz. Last year saw strengthened TB prevention and care across Syria, continuous provision of medicine and gradually improving laboratory capacity.

WHO/Khaled Akacha

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Moustafa and his relative leave SRD’s centre in Azaz after a check-up. In March 2020, WHO donated a state-of-the-art machine to a laboratory in Hatay in Turkey, across the Syrian border. The machine, used for the diagnosis of TB in both Turkey and northwestern Syria, can detect Mycobacteria tuberculosis and rifampicin resistance in less than 2 hours instead of a couple of weeks, as was previously the case. A referral network established by WHO ensures that samples from Syria reach the laboratory in Turkey.