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This report is produced by the World Health Organization (WHO) and the Office for the Coordination of Humanitarian Affairs (OCHA), in collaboration with humanitarian partners. The next report will be issued on or around 30 November 2020.

HIGHLIGHTS

• As of 9 November, the Syrian Ministry of Health (MoH) reported 6,215 laboratory-confirmed cases, 317 fatalities, and 2,357 recoveries in Government of Syria (GoS)-controlled areas

• To date, 194 cases amongst healthcare workers (HCWs) in GoS-controlled areas have been reported

• In northwest Syria (NWS), as of 3 November, 7,059 confirmed cases of COVID-19 were reported, including 42 deaths

• In northeast Syria (NES), 4,978 cases were confirmed as of 3 November, including 758 recoveries and 133 deaths

• Areas of concern: Densely populated areas, notably Damascus/Rural Damascus, Aleppo and Homs, and those living in camps and informal settlements in NES, collective shelters throughout the country, as well as other areas, including Deir-Ez-Zor, where hostilities may make ongoing sample collection more challenging

SITUATION OVERVIEW

In GoS-controlled areas of the country, 6,215 laboratory-confirmed cases have been reported by the Syrian MoH as of 9 November. Of these, seven were in Ar-Raqqa; 22 in Deir-Ez-Zor; 35 in Al-Hasakeh; 90 in Quneitra; 226 in Dar’a; 303 in Tartous; 250 in Hama; 222 in As-Sweida; 900 in Homs; 710 in Rural Damascus; 530 in Lattakia; 1,274 in Aleppo; and 1,646 in Damascus.

As of 9 November, 211 HCWs have tested positive for COVID-19 in GoS-controlled areas. Of these, 12 fatalities have been reported, while 114 cases remain active. Humanitarian actors continue to receive reports that HCWs in some areas do not have sufficient personal protective equipment (PPE). The WHO continues to lead efforts to support increased distribution of PPE where needed to ensure the protection of HCWs.

Meanwhile, the prevention of transmission in schools continues to prove a challenge as a result of overcrowded classrooms, insufficient qualified teaching personnel, and poor/damaged infrastructure. At the time of writing, 303 confirmed COVID-19 cases among school children and teachers and school personnel were reported by the Ministry of Education (MoE) including three deaths. Both WHO and UNICEF, along with Health and Education sector partners, continue to support schools in COVID-19 preventive actions, including through teacher and school health worker trainings, PPE distributions, and infection prevention and control (IPC) measures including increased water trucking and soap distributions.

While current official numbers remain relatively low, it is clear the epidemiological situation in Syria continues to rapidly evolve and all factors. – including that the vast majority of announced cases to date have not been linked to exposure/contact with a known case – point to widespread community transmission. Since July, official numbers have risen sharply; including a peak of over 2,000 confirmed cases in August.

With limited testing facilities still a challenge, the actual number of cases may far exceed official figures, with a significant number of asymptomatic and mild cases going undetected. Contact tracing is also a particular challenge, including in more remote governorates and camps. A significant number of people with symptoms are likely not seeking testing or treatment or are obtaining private services offering homecare. This could be due to community stigma and individual reluctance to go to hospitals. This in turn makes determining the actual numbers of cases difficult to ascertain, which may increase the risk of late referral of severe/complicated cases for treatment, negatively impacting the long-term health prospects and survival of patients.

In NES (as of 4 November), 4,978 reported cases of COVID-19 have been confirmed. Of these, there were 4,087 active cases, 758 recoveries and 133 deaths.

In addition to high levels of transmission in Al-Hasakeh and Quamishli districts, notable increases have been reported in Malakiye District (Al-Hasakeh Governorate), Ar-Raqqa District (Ar-Raqqa Governorate), and Ain Al Arab District (Aleppo Governorate). Overall, the number of confirmed cases does not provide an accurate reflection of infection prevalence.

While there has been an increase in testing, under-testing due to limited testing capacity and low detection/surveillance capacity remains a challenge. Low levels of cases are linked to under-reporting due to social stigma, misapplication of the case definition/clinical screening protocols, as well as challenges in activating rapid response teams (RRTs). The high risk of undetected transmission is compounded by limited adherence to preventative measures, making transmission more likely, low case management capacity and continued high levels of transmission amongst HCWs. As of 3 November, 496 cases among HCWs were reported, including 167 in Al-Hasakeh city alone.

On 30 October, a 10-day partial curfew came into effect across NES lasting until 8 November. All major markets/public facilities have been ordered closed for the duration of the ban, excluding shops selling food and restaurants (for takeaway orders only provided they close by 3pm in the afternoon); places of worship must close except for Friday prayers and Sunday mass and; mass gatherings (wedding halls, condolence tents and conference meetings all specifically mentioned) are prohibited. Education facilities and administrative buildings are permitted to remain open, but are encouraged to implement basic preventative measures.

Although the directive requires the population to wear masks, no enforcement mechanism has been put in place to promote compliance. On 3 November, following a recent surge in cases in Malakiyeh (Derik), the Executive Council of Jazeera Canton announced a full 14-day lockdown in ‘Derik city and its countryside’ (understood as the whole of Malakiyeh District) which will come into effect on 6 November and last until 19 November.

Under this lockdown, schools (excluding shops selling food between 6 am and 1 pm), places of worship, shops, restaurants, playgrounds and private clinics will be closed, while movements in and out of Derik city will be prohibited (excluding emergency cases and food shipments). Humanitarian actors are exempted from these restrictions.

In NWS (as of 3 November) a total of 7,059 confirmed cases of COVID-19 were reported (4,265 from Idleb and 2,794 from Aleppo governorates), including 42 deaths. 2,728 people have reportedly recovered.

As of 3 November, there were 7,059 confirmed cases of COVID-19 in NWS. 4,265 cases were in the Idleb area and 2,794 were in northern Aleppo governorate. Of the total, 42 COVID-19 associated deaths have been reported and 2,728 people have reportedly recovered.

Of all cases, 693 (12.2 per cent) were among HCWs as of 31 October. WHO has attempted to limit spread and transmission of COVID-19 in NWS by issuing official guidance on the management of HCWs exposed to suspected or confirmed COVID-19 in healthcare settings put together by the COVID-19 Taskforce (TF) and case management and IPC working groups. Risk Communication and Community Engagement (RCCE) must be targeted to HCWs, as well as other vulnerable groups.

Strong emphasis is being placed on surge planning in hospital settings, simultaneously focused on infection control, clinical operational challenges, triage staffing and maintenance of staff wellness through psychosocial support. To this effect, a survey of 250 health facilities was conducted focusing on triage preparedness and the implementation of IPC measures to help identify gaps and strengthen facility preparedness.

Increasing testing capacity continues to be the focus as well in NWS, particularly in hotspot areas such as Al Bab,
Jarablus, Dana and Idleb. In total 26,028 polymerase chain reaction (PCR) tests have been completed (as of 31 October), with a test positivity rate of 24.0 per cent. Currently three laboratories have been operationalized (Idleb, Jarablus and Afrin), with a total of four PCR machines (two of which were delivered in September 2020). Daily testing capacity has nearly quadrupled since September, to an average of over 800 tests per day. Procurement of additional testing kits is ongoing, as are efforts to enhance human resources, including through training.

NWS currently has nine hospitals for case management, with a capacity of 188 intensive care unit (ICU) beds and 645 step-down ward beds (exclusively separated for isolation treatment). Targets for increasing ventilator capacity has been reached (164 new ventilators have been added) to have adequate capacity to treat critical cases.

To reduce additional burden on hospitals and utilize health resources more efficiently, particularly with regard to critical cases, WHO and the TF are working to set up COVID-19 Community-Based Treatment Centres (CCTCs) to isolate and treat the mild cases. CCTCs are placed strategically near communities to ensure easy access and to act as the first point of contact before a patient is referred to a COVID 19 referral hospitals (if symptoms intensify). A total of 20 such centres with in-patient capacity are currently operational with a bed capacity of more than 900. New CCTCs are being planned to open in Afrin and north Aleppo, including in current hotspot zones – Al-Bab, Jandaris, Raju, and Azaz.

Challenges include increased global demand for COVID-19 testing supplies and PPE globally, which is impacting the timely procurement in required quantities and cross-border delivery to NWS. There also remains significant funding shortages to procure supplies, including PCR kits and lab consumables. Furthermore, transmission risks remain high in this densely populated NWS, exacerbated by a general shortage of crucial items, including PPE, for the wider public, inhibiting complementary preventative measures. Given an acute shortage of masks in the market, local procurement and the production of fabric masks in the field need to be enhanced.

In addition, given the crowded living conditions in both urban and camp settings across NWS, a significant challenge in countering COVID-19 remains the difficulty of physically isolating people. Efforts are currently being concentrated on establishing quarantine centres, however, funding for such centres remains limited.

Lastly, there remains a critical need to expand field surveillance capacity and laboratory human resources, given the opening of new labs. This includes skill enhancement/capacity building (surveillance, CT, rapid response, lab methods).

In NWS, there continues to remain a funding gap of nearly US $11 million through the end of the year across preparedness and response plan (PRP) pillars, with an urgent need to fill gaps in expanding testing, strengthening surveillance and further IPC materials across northwest Syria in order to mitigate COVID-19 outbreaks, particularly in informal camp settings.