Syndromic surveillance of respiratory infections during protracted conflict: experiences from northern Syria 2016-2021.

OBJECTIVE: Northern Syria faces a large burden of influenza-like illness (ILI) and severe acute respiratory illness (SARI). This study aimed to investigate the trends of Early Warning and Response Network (EWARN) reported ILI and SARI in northern Syria between 2016 and 2021 and the potential impact of SARS-CoV-2. METHODS: We extracted weekly EWARN data on ILI/ SARI and aggregated cases and consultations into 4-week intervals to calculate case positivity. We conducted a seasonal-trend decomposition to assess case trends in the presence of seasonal fluctuations. RESULTS: It was observed that 4-week aggregates of ILI cases (n = 5,942,012), SARI cases (n = 114,939), ILI case positivity, and SARI case positivity exhibited seasonal fluctuations with peaks in the winter months. ILI and SARI cases in individuals aged ≥5 years surpassed those in individuals aged <5 years in late 2019. ILI cases clustered primarily in Aleppo and Idlib, whereas SARI cases clustered in Aleppo, Idlib, Deir Ezzor, and Hassakeh. SARI cases increased sharply in 2021, corresponding with a severe SARS-CoV-2 wave, compared with the steady increase in ILI cases over time. CONCLUSION: Respiratory infections cause widespread morbidity and mortality throughout northern Syria, particularly with the emergence of SARS-CoV-2. Strengthened surveillance and access to testing and treatment are critical to manage outbreaks among conflict-affected populations.

Mental Health and Integration: A Qualitative Study on the Struggles of Recently Arrived Refugees in Germany.

Introduction: Forcibly displaced people are at particular risk of mental health problems and also face specific integration challenges upon resettlement. Existing literature suggests that there may be a bidirectional relationship between mental health and integration. The present study seeks to understand the relationship between integration processes and mental health problems or significant negative emotional experiences among adult refugees in Germany. Method: Applying a qualitative approach, we conducted 54 semi-structured interviews with refugees and asylum seekers who arrived in Germany between 2013 and 2018 currently residing in Berlin, Leipzig, or the Duisburg area in North Rhine-Westphalia. Data was collected between December 2018 and September 2019. We analyzed transcripts inductively using thematic analysis. Results: Five themes covering the various links between integration and mental health problems or significant negative emotional experiences were identified. First, we found that the mental health consequences of past adverse experiences, as well as ongoing worries about those left behind in the homeland, can seriously impede refugees' ability to pursue activities key to integration. Second, the process of applying for and securing asylum can result in uncertainty and fear, which, in turn, burden the individual and may impact motivation for integration. Third, many of our participants described mental health ramifications related to feeling stuck and thwarted in the pursuit of building a life, especially in securing employment. Fourth, some participants described feeling so overwhelmed by fundamental tasks throughout the integration process, namely, language learning and bureaucratic processes, that these take a psychological toll. Fifth, we identified several forms of social disconnection between refugees and members of the host community due to xenophobia, social and cultural differences, physical and emotional isolation in refugee camps, as well as with co-nationals and fellow refugees. Negative emotions, mistrust, and socio-cultural differences that emerge throughout the integration processes seem to erode social cohesion among refugee communities, potentially further threatening mental health. Conclusion: Mental health problems and integration processes appear to be closely related across different areas of integration. Innovative solutions to challenges identified by members of the refugee community in Germany stand to benefit mental health and integration outcomes simultaneously.

Coronavirus 2019 and health systems affected by protracted conflict: The case of Syria.

INTRODUCTION: Two thirds of countries globally are unprepared to respond to a health emergency as per the International Health Regulations (2005), with conflict-affected countries like Syria being particularly vulnerable. Political influences on outbreak preparedness, response and reporting may also adversely affect control of SARS-CoV-2 in Syria. Syria reported its first case on 22 March 2020; however, concerns were raised that this was delayed and that underreporting continues. DISCUSSION: Syria's conflict has displaced more than half of its pre-war population, leaving 6.7 million people internally displaced. The consequent overcrowding - with insufficient water, sanitation and healthcare (including laboratory capacity) - could lead to conditions that are ideal for spread of SARS-CoV-2 in Syria. Political changes have led to the formation of at least three health systems within Syria's borders, each with its own governance, capacity and planning. This fragmentation, with little interaction between them, could lead to poor resource allocation and adversely affect control. As such, COVID-19 could overwhelm the health systems (particularly intensive care capacity), leading to high deaths across the population, particularly for the most vulnerable such as detainees. CONCLUSIONS: Locally implementable interventions that rapidly build WASH and health system capacity are required across Syria to ensure early detection and management of COVID-19 cases.