Background

Armed conflict began in the Syrian Arab Republic (Syria) in March 2011, escalating quickly into civil war (details), and a prolonged conflict situation (see summary including timeline). The crisis is now in its 13th year, with the situation remaining unpredictable, and profound economic and humanitarian impact. Since the beginning of the conflict, more than half the Syrian population has been displaced.

• Syrians make up one of the largest refugee populations globally, with UNHCR reporting 5.1M registered Syrian refugees (Jan 2024); 47.8% are children <18 years. Syrian refugee populations are predominantly in Turkiye (3.19M), Lebanon (785K), Jordan (649K), Iraq (273K) and Egypt (154K). Large numbers of Syrian refugees have reached Europe - with an influx of around 700K Syrian asylum seekers in 2015-16 and ongoing flows. In 2022, there were 132K Syrian first-time asylum applicants in the European Union (EU, see Eurostat). EU asylum applications increased further in 2023, with Syrians the largest group of people seeking asylum.
• UNHCR estimates more than 16.7M Syrians will need humanitarian assistance in 2024, and that there are more than 6.8M internally displaced people (Dec 2023).
  
• In June 2022, the UN published updated estimates of deaths related to the Syrian conflict (Mar 2011 - Mar 2021) with 350,209 documented deaths, including 143,350 civilian deaths and a further estimated 163,537 civilian deaths.
• Earlier (2016) estimates from the Syrian Centre for Policy Research suggested 11.5% of the population had been killed or injured, with 1.9M people wounded.       
  

Demography

• Population - Syria’s pre-conflict population was 22.8 million (World Bank 2013). Approximately 90% Syrians are of Arab descent, the largest minority is Kurdish (~9%). 
• Languages - official language is Arabic, Kurdish, Armenian, Aramaic, and Syriac are also spoken. French and English may be additional languages in educated groups. 
• Religion - predominantly Sunni Muslim (70-75%), minority Christian (~10%), Alawite Shi'a (<10%) and other populations
• Education - prior to conflict, Syria had almost 100% primary school enrolment and literacy rates over 90%, although a 2013 study of pregnant Syrian women in Lebanon found 75% had no or primary level education, a 2014 cluster survey of Syrian refugees in Jordan (outside camps) found <25% had completed secondary school and a 2017-18 population survey of Syrian refugees in Jordan found 15% adults had completed secondary/post-school education, and only 21% of 17-year olds were attending secondary school.

Other

• Living conditions for Syrian refugees in other countries remain very difficult, with issues of overcrowding, poor sanitation, food scarcity, and variable availability of shelter. Conditions are often more difficult outside of established camps and settlements. The large volume of Syrian refugees over many years has placed significant strain on host countries’ health systems, public finance and security; and created tension between refugee and host populations (EMRO). Example: 2022 Oxfam summary conditions in Za'atari refugee camp, and 2017-18 survey of conditions in/outside camps in Jordan.
• Health - The conflict decimated Syrian health systems, with a dramatic drop in life expectancy, especially for males, loss of health services, health staff, pharmaceutical production capacity and immunisation programs (see detail), also with implications for children. There have been significant communicable diseases outbreaks including polio in 2013, measles in 2014, 2017 and 2018, typhoid in 2018, and leishmaniasis (>78,000 cases by 2021), with subsequent impact from the Covid pandemic. High prevalence of disability (25% in 2021), mental health problems and exposure to violence and traumatic experiences are reported.
  
• Economy - currency - Syrian pound - in 2022, inflation in Syria was 85% (see OCHA Jan 2024), and health inflation rates (2009 vs 2022) were 5000-6000%.
• Education - school attendance was <30% by 2013, and by 2015 there were 2.6 - 2.8 million children out of school. UNICEF reported thousands of schools were damaged, or turned into shelters/storage/military bases. In 2023, there are still 2M Syrian children out of school and a further 1.6M at risk of stopping school (World Vision).
• Earthquakes - on 6 Feb 2023, a 7.8 magnitude earthquake struck central/south Turkiye and north/western Syria, causing damage over an area of 350,000 km2, killing more than 59,000 people, injuring more than 121,000 people and displacing 15.7M people in Turkiye and 5.4M in Syria (see summary).

Australian response

Australia has provided $525M in humanitarian support for Syria since 2011, including a $249M Syria Crisis Humanitarian and Resilience Package (2017-20) - see DFAT information. On 9 Sep 2015, Australia announced an intake of 12,000 Syrian and Iraqi refugees (in addition to the existing humanitarian intake - see press release and media), with priority will given to those: i) assessed to be most vulnerable – women, children, and families with the least prospect of ever returning safely and ii) located in Lebanon, Jordan, and Turkey. This group arrived in Australia in late 2016/early 2017. 

Pre-arrival health screening

All permanent migrants to Australia, including humanitarian entrants, undergo an Immigration Medical Examination (IME) 3-12 months before travel. Humanitarian entrants are offered an additional Departure Health Check (DHC), see summary on Initial assessment guideline, and also DHA Panel Members Instructions (Jul 2023) and DHC supporting material (Sep 2023).

• From 2015, the additional intake of Syrian and Iraqi refugees underwent enhanced pre-migration screening, combining the IME and DHC, with additional screening tests. Additional screening included hepatitis B sAg (all ages), tuberculosis (TB) screening (TST or IGRA) in children 2-10 years, mental health screening for children and adults, and extended immunisation (polio, MMR and DT-containing vaccines for all ages, using hexa- or pentavalent vaccines in children <10 years). since incorporated into the IME. Many of these changes were subsequently incorporated into the IME on a permanent basis.
  

Health screening

All Syrian arrivals should have an initial health assessment and catch-up immunisation. Immediate health triage (for all ages) should assess for acute physical health issues (including malnutrition and injuries), acute mental health issues, disability, frailty/mobility issues in elders, pregnancy and medication type and supply. 

Recommended health assessment Syrian arrivals

Recommended investigations are based on the 2016 Refugee guidelines, updated based on prevalence below (including HCV screening for adults). Malaria screening is not required.

Screening tests children 

• All: FBE/film, ferritin, vit D/ALP, IGRA or TST, HBsAg, cAb, sAb, Strongyloides, Schistosoma, faecal COP 
• Age/risk based: nutrition, including B12/folate, HCV, HIV (15y+/clinical/UHM), STI screening, syphilis (clinical/UHM), consider MMR and varicella serology adolescents, H pylori (symptoms)

Screening tests adults

• All: FBE/film, IGRA, HBsAg, cAb, sAb, HCV, HIV, Strongyloides, Schistosoma, consider MMR and varicella serology, faecal COP
• Age/risk based: ferritin (women, men with RF), vit D, nutrition, including B12/folate/nutrition (especially for breastfeeding women), rubella (women), STI screening, syphilis, H pylori (Sx)
  
• Catch-up primary care: HPV screen (women 25-74y), Alb:creat/eGFR (30y+ if high risk), BSL/HbA1C (40y+), lipids (45y+), FOBT (50y+), Mammogram (women 50-74y)

Catch-up immunisation

Prior to the conflict, Syria had a strong immunisation program and high compliance with vaccinations (coverage >95%). The Syrian vaccination schedule includes: BCG, DTwP-Hib-HepB, OPV/IPV, MMR and influenza vaccine, in the following schedule:

Missing compared to Australian schedule: rotavirus, pneumococcal, meningococcal ACWY, (meningococcal B - risk groups only), varicella, zoster, and HPV. Also consider both covid and influenza vaccines.

• Catch-up immunisation is required for all new arrivals, including full catch-up for anyone without a written record of vaccination, Covid vaccination remains a priority and can be given with other vaccines age 5 years and older.
  
• Where written records are not available, full catch-up vaccination is recommended - see Catch-up immunisation guidelines. When entering information on to the Australian Immunisation Register (AIR) - use 'encounter overseas', schedule = 'other', add dates, and use generic vaccine type where needed (e.g. for pentavalent vaccines, may need to record as DTPa generic, Hib generic and HepB generic). Enter dose numbers accurately, and the record should submit. AIR will not allow entry of the same antigen on the same day, which means overseas schedules with simultaneous OPV and IPV cannot be entered accurately. AIR records can be created for people without Medicare.
• Note - RCH/MVEC protocols for catch-up vaccination after chemotherapy use infanrix-hexa and MMR-V up to age 18y, this reduces needles required, and we use this in practice. AIR will accept these vaccines for adolescents, **AIR data entry - use other, and enter by antigen, and then accept queries. 
• Translated catch-up information:  Pre-immunisation checklist, childhood vaccinations, catch-up summary.

Prevalence data for Syria

Immunisation

• Immunisation coverage fell from 95% in 2010 to 45% by 2013, leaving large numbers of children unimmunised or under-immunised
  • Polio - after eradication in 1999, polio re-emerged in Syria in Oct 2013 (35 cases in 2013 and 1 in 2014 - WHO). Cases were reported in Syrian refugees in Iraq (see media and discussion); 105 cases of acute flaccid paralysis were reported in 2014, and there was a further outbreak of vaccine derived polio in 2017 (74 cases). Polio eradication initiatives continued, and after an 18-month intensive vaccination campaign, the outbreak was closed in Dec 2018. 
  • Measles - outbreaks were reported in Syria and surrounding countries from the start of the conflict, with 7000 cases in 2013, and large scale outbreaks in 2017 and 2018 (with ~18,000 cases), with subsequent mass vaccination campaigns.
  • (Hepatitis - see below)

Hepatitis and HIV

• Hepatitis A outbreaks were reported in Syria, with >1000 cases/month in 2015, and outbreaks in Syrian refugees in Lebanon, notably in adolescents. Further outbreaks have occurred in 2018, 2022 and 2023.
• Hepatitis B virus (HBV) - prevalence of hepatitis B infection in Syria is 3.35% (2019) - medium endemic. HBV immunisation coverage was high in children born <2011, so children aged over 13 years (in 2024) are likely to be immune to HBV.  2015 IOM screening data in Syrian refugees found HBV prevalence of 1.5%, and a 2016 study of 488 unaccompanied Syrian minors in Germany found 0% had HBV.
• Hepatitis C virus (HCV) - prevalence of hepatitis C infection in Syria is 3.04% (2019). 2015 IOM screening data in Syrian cohorts found HCV prevalence of 0.5%.
• HIV - prevalence of HIV in Syria is <0.1% in adults 15-49 (2020). 2016 Canadian migration screening in 26,166 Syrian arrivals found 0% prevalence and 2015 IOM screening data in Syrian cohorts found HIV prevalence of 0.11%.
  • A 2018 RCH survey of 128 Syrian and Iraqi refugee children found no cases of HBV, HCV or HIV infection, only 70.3% children were immune to HBV (HBsAb+.

Tuberculosis

• Tuberculosis - 2022 WHO data for Syria show 3068 new TB cases (7% aged 0-14 years), with an incidence of 17/100,000 population, and 1.3% new cases as MDR/RR-TB. 2014 screening of 69,000 Syrian refugees in Jordan 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. 2016 Canadian migration screening in Syrian cohorts found 0% prevalence TB disease in 26,166 arrivals. 2015 IOM screening data in Syrian cohorts found prevalence of CXR consistent with TB disease was 1.6%.   
  • A 2018 RCH survey of 128 Syrian and Iraqi refugee children found 11.8% had positive post arrival TB screening results.
    

Parasites

• 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. CL is endemic in Syria - with Leishmania tropica in 85% and L. major in 15%. CL is transmitted by sandflies, with peak incidence in the summertime (May – October). CL presents with ulcerated skin lesion and local lymphadenopathy See CDC information. Dermnet is another useful resource.  
  • Cases of CL have increased since the conflict began, and more than 89,000 cases were reported in Syria in 2019, and >78,000 in 2021.       
• Schistosomiasis (primarily S. haematobium) has been endemic in Syria and surrounding countries. Schistosomiasis is considered to be eliminated in Iran, Lebanon, Morocco and Tunisia, and low endemnicity has been achieved in Syria, Jordan, Libya, Oman and Saudi Arabia. A 2016 study on 488 unaccompanied Syrian minors in Germany found Schistosoma serology was positive in 1.4%. 
• Strongyloides infection - A 2012 systematic review documented a general prevalence of 0.03% in Jordan, 0.6% in Turkey, 0.6% in Iran, but 24.2% prevalence in a hospital-based survey in Iraq.
• Other - a 2016 study of 488 unaccompanied Syrian minors in Germany found Giardia in 7%.
  • A 2018 RCH survey of 128 Syrian and Iraqi refugee children found 3.2% prevalence of Strongyloides, but no cases of Schistosoma or faecal parasites (noting Albendazole used offshore).

Other infections

• Skin infections - Increased rates and outbreaks of scabies, lice, and bacterial skin infections were common and reported by MSF and others.
• Syphilis - 2016 Canadian migration screening in Syrian cohorts found 0% prevalence in 26,166 arrivals. 2015 IOM screening data found prevalence of 0.26%.  

Nutrition

• Syrian children remain at risk for poor nutrition, with high risk of both macronutrient (energy intake/protein) and micronutrient (vitamins and trace elements) deficiencies. UNICEF (2023) reported more than 609,900 children < 5 years are stunted, and OCHA (Nov 2023) reports more than 5.9M people, including 3.75M children require urgent nutritional assistance, and inflation is increasingly driving food insecurity.   
• Low vitamin D is common, especially in veiled women and girls. Studies of vitamin D deficiency in refugees to Australia from the Middle East show a prevalence of 20-66%, a 2018 RCH survey of 128 Syrian and Iraqi refugee children found 63.6% had low vitamin D.
  

Non communicable diseases (NCD)

• A 2014 cluster survey of 1550 Syrian refugees outside refugee camps in Jordan reported prevalence for 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.
• A 2013 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 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.
  

Mental health, trauma

• 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. The conflict produced a high proportion of female-headed households – the loss of fathers and of family integrity creating acute and ongoing stress for mothers and children. In addition, millions of children lost the physical, mental, and social protective environment  provided by schools and education.
  • A 2014 study of 6357 Syrian IDPs and refugees in Lebanon, Jordan, and Turkey receiving mental health services found: adults: 54% severe emotional disorders, including depression and anxiety, and 11% had psychotic disorders; and in children 27% had developmental disorders and 3.6% had severe emotional disorders.
  • 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
  • The Syrian Center for Policy Research (2023) reports a 2020 WHO nationwide survey found prevalence of 44% severe mental disorders, 27% both severe mental disorders and PTSD and 37% PTSD; >60% of people were traumatised by war experiences, >40% had experienced direct military attack, >33% had experienced disappearance/killing of relatives, 20% had been tortured, and >6% had been raped. 

Gender based violence, early marriage

• The Syrian crisis has included systematic gender-based violence against women and girls (see media). Women and girls may have been subject to sexual violence or early marriage, which may be seen as a means to physical and economic protection. 
  • 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.
  • A 2017 study in Syrian refugee women and girls in Lebanon found more than one third had married before 18 years and 24% of 15-17 year old girls were married; with increasing prevalence of child marriage over the conflict.
  • A 2017-18 population survey of Syrian refugees in Jordan found 14% of 15-year olds were married.
• Rates of family violence were high in the Syrian population pre-conflict - a 2005 UNIFEM survey reported 67% of women experienced “punishment” by their husbands, and a 2011 UNPFA study found that one-third of women in Syria suffered from domestic violence.
  

Sexual and reproductive health (SRH)

• The adolescent fertility rate for girls 15-19 years in Syria is 39/1000 (2021) compared to 8.1/1000 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 study 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.
• 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. Care was more likely in UNHCR refugees, and 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%).
  
• 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.
• A 2020 systematic review described barriers to SRH for Syrian refugees in Jordan, noting a higher total fertility rate (4.7 children per woman vs 2.6 in Jordan), and high rates of IPV, sexual violence, forced marriage, unintended pregnancy and unsafe births.
• A 2023 report on pregnancy outcomes for 1065 Syrian refugee women in Lebanon found increased rates of caesarean deliveries, spontaneous abortions and maternal complications, reduced pregnancy spacing and decreased breastfeeding rates.

Disability

• In 2015,  World Vision reported more one million people had been wounded in the conflict, with many injuries resulting in longer-term disability. In 2016, the Syrian Centre for Policy Research reported 1.9 million people have been wounded. 
• A 2021 nationwide UN humanitarian needs assessment in Syria found 19% of children 2-17 years have a disability 

Resources

• ABS - People in Australia who were born in Syria
• ASID-RHEANA Refugee Guidelines (2016)
  • ASID guidelines country-based screening
  • Quick guide screening tests in children 2024 
  • Quick guide screening tests in adults 2024 
• CDC - Syrian refugee health profile 
• DFAT - Syria humanitarian response
  
• Eurostat - asylum statistics
• Syrian Centre for Policy Research - Devastation of the right to health during the conflict in Syria (2023)
• UNHCR Syria and situation report.

_{RCH Immigrant Health - additional information. Authors: Karen Kiang and Georgie Paxton. Initial Sep 2015, updated January 2024. Contact: georgia.paxton@rch.org.au}