In January, physicians in northwestern Syria felt they had nearly conquered a massive cholera outbreak. Between August and December, an estimated 50,000 illnesses and almost 100 fatalities were documented in Idlib and neighboring Aleppo governorates. The outbreak has also spread to neighboring Lebanon, which recorded its first instance since 1993, resulting in at least one fatality.

However, a planned vaccination effort was supposed to signal the end of the outbreak.

In early February, two earthquakes slammed the region, exacerbating the already dire living circumstances, damaging infrastructure, and displacing many more people who had flocked to Idlib to avoid violence elsewhere. The earthquakes caused about 4,000 casualties in northwestern Syria, and resulted in ruptured subterranean pipes and damage to hospitals. Thousands of houses were devastated by floods and windstorms in the weeks after the earthquakes.

Almost 2 million internally displaced people were already fighting to subsist in temporary houses in a limited section of rebel-controlled terrain, in flimsy tent camps strewn across the steep hills. Many individuals lacked basic sanitation and a stable water supply, making them vulnerable to disease spread by tainted food and water.

The earthquake's destruction rendered a cholera comeback unavoidable. By early April, the area registered over 13,000 cases and at least 23 confirmed deaths.

Health official Hussein Bazaar said officials did their best to contain the outbreak. He claims that cholera vaccinations arrived in Idlib 10 days before the earthquakes. “The cholera outbreak got cast aside as bigger things happened, given our limited capacity.”

Dr. Wajih al-Karrat expresses worry that the earthquakes affected the water supply and left basic infrastructure destroyed.

Settings in Syria fostering epidemics

The cholera revival in Syria, one of 22 nations that have recorded cases in the last year, is fueled by long-term infrastructural concerns in the country's north, as well as disrupted relief deliveries.

Mohammed al-Jasem, the International Rescue Committee's health coordinator in Syria, said that the earthquakes made it even more difficult to treat cholera due to damage to the healthcare infrastructure and the movement of displaced populations. A shortage of funding is still impeding development. 

He describes that overcrowding, water, sanitation, and hygiene issues characterize reception center conditions, and details that a setting like this fosters the development of infectious disease epidemics and jeopardizes the progress made in cholera control.

According to UNICEF, an oral cholera vaccine program in the weeks leading up to Ramadan reached 1.7 million individuals across northern Syria. A second cholera vaccine program, targeting an additional 1.2 million individuals, is set to begin after the conclusion of the Islamic holy month.

Despite the immunization program, Ammar Ammar, a spokesperson for UNICEF, believes that the circumstances in temporary housing may still contribute to disease transmission. "Despite the fact that the number of displaced people in reception centers is decreasing, the risk of an increase in waterborne diseases such as cholera remains extremely high due to overcrowding, extensive damage to water and sanitation infrastructure, and damage and disruption to cholera treatment infrastructures," he says.

Aid organizations believe their mandate in Syria makes it difficult to address the root causes of cholera.

According to Ammar, ensuring safe water sources or large infrastructural upgrades are required to prevent the illness from becoming endemic.