Syria VCNA Report

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					VECTOR CONTROL NEEDS ASSESSMENT FOR SYRIA




                    DRAFT REPORT




                       Prepared by



         Intersectorl Committee for Vector Control




October 2006
Introduction

Recognizing the importance of vector-borne diseases in the Eastern Mediterranean
Region, Member States through Resolution (EM/RC.52/R.6) endorsed the Regional
Strategic Framework for integrated vector management (IVM) for the implementation of
vector control. Member States also committed themselves, among others to develop
requisite national capacities to plan and implement IVM, make specific budget
allocations and establish functional intersectoral mechanisms to enhance in-country
coordination of all relevant sectors. To be able to develop national IVM strategies and
plans of actions, however, requires the carrying out of regular vector control needs
assessment (VCNA) for all vector-borne diseases to identify needs, gaps and
opportunities for vector control.


Objectives

The objectives of carrying out VCNA are to assist countries to:

                assess the situation of vector-borne diseases in each country

                identify the relevant policy framework for vector control

                determine the place and structure of the vector control program

                describe the planning and implementation of vector control

                identify the intersectoral coordination mechanisms for vector control at
                 country level

                identify community mobilization strategies for vector control



The report in hand presents the results of the VCNA carried out for Syria. It presents the
vector control Situation Analysis and Problem Analysis. The report also includes the
process of identification of constraints facing the vector control program, needs for
improvements and means necessary to achieve the goals.
B.     Background
Country Profile

Syria is one of the Arab Republics, located in the eastern coastal area of the
Mediterranean Sea and has boarders with Turkey to the north, Jordan and Palestine to the
south, Iraq to the east and Lebanon and Mediterranean Sea to the west. The area of Syria
is 185,170 square kilometers. The population, according to an estimate made in 2001, is
16,720,000, with 56.5% below 14 years of age. The estimate of the rate of population
growth (2000/2001) is 2.45%. Population density is 85 Person/ km2. Population in rural
areas constitutes about 47.6 %, while that of urban areas constitutes52.4 %.



              Figure 1: An administrative map of Syria Arab Republic
B. Vector Control Needs Assessment (VCNA)
I. Situation Analysis

1. Policy Framework
1.     Policy framework for vector management

1.1    Health sector policies

Political commitment to the control of vector-borne diseases has been stressed by the
Syrian President during his latest meeting with the cabinet of ministers, especially for
leishmaniases control.

Several regulations in Syria set the main health sector policies, some of them date back to
the fifties. Many updates have taken place to those regulations to amend or strengthen
existing ones. Currently, the health regulations are being reviewed to amend it with
updated articles parallel to recent developments in the area of public health.

The MOH policies include the control of vectors of diseases and the provision of
treatment of cases free of charge. In addition, two insecticides spraying campaigns per
year; space spraying and larval control; have been set in the MOH policy for vector
control. These are targeted towards the vectors of malaria, leishmaniases and bilharzia.
The policies also stress the obligatory notification of vector-borne diseases on several
administrative levels and set clear procedures and define roles for this important aspect.

Policies to combat and prevent vector-borne diseases have been translated to actions
including the establishment of a “system for centers for the control of malaria and other
parasitic diseases” on the governorate level in 1993. However, despite the strong policy
and regulatory background, no national strategies have been put in place. Rather, action
plans that cover five-year periods are routinely developed. Based on those five-year
plans, yearly implementation plans are devised by the relevant units or departments. In
accordance to this, yearly budgets are requested by the MOH to cover the costs of the
implementation plans.

Health sector policies also stress intersectoral collaboration in the endeavor of the control
of vector-borne diseases. These policies also set the roles, timing and the agencies that
would collaborate with the MOH in undertaking its mandates in ordinary and emergency
situations.

Existing policies stress not only control of vector breeding instances but also its
prevention. The regulations then stipulate the steps to be taken to achieve these goals in
detail and on different administrative levels.

In addition, a system for establishing peripheral “Centers for the Control of Leishmania
and Other Parasitic Disease” has been put in place by the Ministerial decree number
22/T/1993. The system stipulates the details for epidemiological, entomological and
environmental investigations related to vector-borne diseases on the Health Directorate
level. On the governorate level, committees have also been formulated by Governors’
decrees to follow up and implement plans for the control of leishmaniases. However,
these systems are not fully functional due to lack of technical, financial and human
resources.

Environmental Health (EH), on the other hand, is one of the national health policies
where it addresses strictly traditional EH issues. The policies cover environmental
exposure to environmental risks and hazards not including vector-borne diseases.
However, a recent function of EH covers the review of environmental impact assessment
(EIA) studies from the EH point of view. In certain cases this covers the vectors or
vector-borne disease implications; however, the involvement of vector-borne diseases
department is not systematic.

1.2    Other related policies

1.2.1 Environmental policies

According to the national policies of Syria which stress the concept of problem
prevention rather than problem cure, the government has issued the Environmental
Protection Law (number 50/2004). The law includes provisions for the management of
hazardous substances and wastes including pesticides which are based on the National
Regulations for Chemical Safety (issued in 30/10/2002).

The production and safe use of pesticides in Syria are governed by environmental and
non-environmental policies and regulations. These include those relevant to the General
Authority for Environmental Affairs (GAEA) and those relevant to the Ministry of
Agriculture (MOA). Thus, those authorities have the mandate to implement, enforce and
monitor those policies.

The main development projects undertaken in the country include in their majority
industrial establishments of various types. By law, new projects and plans should submit
EIAs before licensing. These studies then are subject to review by the environmental
body and other specialized agencies as relevant to the nature and components of proposed
projects. These as has been indicated earlier, include the MOH, EH Directory which
reviews relevant aspects of the projects. Vector and vector-borne diseases are among the
issues addressed in such review; however, it is not covered with the appropriate depth.

Monitoring and enforcement of EH policies are carried out based on a program
developed in collaboration with WHO. This program is called the “Control of
Environmental Health Hazards”.      It involves EH statistics, waste management,
environmental health impact assessment of new developments, training and education.
Syria is signatory to the international RAMSAR treaty for wetlands conservation. The
country thus manages wetlands and prevents their pollution or destruction. No municipal
sanitation codes that relate to vector control exist in Syrian legislation.

1.2.2 Agricultural policies

Integrated pest management (IPM) policies have been in place in Syria since 1988. In
connection to these policies, farmer schools’ projects have been established in many
areas of the country in collaboration with the Food and Agriculture Organization (FAO).
In addition, there are 1063 agriculture extension units distributed allover the country.
Discussions with the MOA have established a good basis for future collaboration with
MOH in the area of IVM.

1.2.3 Finance and trade policies

There are due taxes for all material entering Syria but the value of these taxes vary
according to the national importance of the material. The lower value taxes are those
stipulated on agricultural-related items. Vector control pesticides and equipment are or
exempted from taxes.

2.     Structure, resources and functions

2.1    Place and structure of vector control

The Entomology Research Sector/Malaria and Other Parasitic Diseases Department,
Environmental and Chronic Disease Directorate, is the body responsible for vector
control within the MOH at the central level. This sector is responsible for all vector-
borne diseases namely Malaria, Leishmania and Schistosomiasis. The central department
has 14 Malaria, Leishmania and Schistosomiasis Control Centers working on the
governorate level. These centers are under the technical and administrative supervision of
MOH; however, they are financially under the Ministry of Local Administration and
Environment. On peripheral level, there are 250 centers for disease control covering the
whole country. On this level, no vector control activities are included, only diagnosis and
treatment.

The Entomology Research Sector/Malaria and Other Parasitic Diseases Department is
lower in rank than other disease control departments such as Community Health or MCH.

There is no vector control committee available in the MOH on the central level.

The peripheral centers are responsible for the implementation of the plans and actions
developed by the central and governorate levels collaboratively. These peripheral levels
also report results and feedback to the central level regularly. Based on the evaluation of
these feedback data and information, new and/or updated plans are developed. Any
required added costs or budgets are requested from the central government for the
coming year.
                          MOH



                Environmental and Chronic
                   Disease Directorate



             Malaria & Other Parasitic Diseases
                        Department



Entomology     Rodent    Leishmania   Malaria   Schistosomiasis
 Research      control     Control    Control       Control
  sector       sector     program     program       program




     14 Malaria, Leishmania and Schistosomiasis
        Control Centers (On Governorate level)



                  250 Peripheral Health Units




    Figure 2: Organogram of vector control system in MOH
There are no systematic procedures for monitoring and evaluation of the vector control
activities.

There is no national strategic plan for vector control, only yearly plans which are
developed based on the existing epidemiological situations.

Due to the fact that the vector control budget is secured from two independent ministries,
it is hard to calculate the different cost items of vector control.

2.2    Inter/intra sectoral collaboration and coordination

In Syria, leishmaniases, malaria and schistosomiasis are the main vector-borne dieases of
public health importance. Leishmaniases are the most important vector-borne disease in
Syria as it is showing; in general; an increase over the last years in spite of the vector
control efforts.

The Entomology Research Sector, Malaria and Other Parasitic Diseases Department,
Environmental and Chronic Disease Directorate, is the department responsible for the
control of these diseases. Vector control units are replicated on the peripheral level.
Staff of this department and its peripheral centers addresses all vector-borne diseases and
their control. At the central and peripheral levels, one focal technician is dedicated for
each of the three main vector-borne diseases, namely malaria, leishmaniases and
bilharzia. However, no separate staff is dedicated for each disease.

Information and communication flow between the different levels through written
instructions/reports during normal operations. Fax and telephone communication are
used for notification of new cases and/or exchange of information during emergency
situations.

Municipalities (Directorates of Health Affairs) and Army (Medical Services Department)
also have some roles in vector control. The former is responsible for controlling nuisance
insects and rodents while the latter is responsible for control within army installations.

2.3    Human resources
The available human resources for vector control and those required are presented in the
following table.
               Table 1: Existing and required staff for vector control program

    Category                Qualification          No. available          No. required
   Center Head               Physician                  14                      -
  Head, control              Physician                   2                     40
     program
  Dermatologist              Physician                  29                       50
  Lab supervisor             Physician                   4                       10
    Treatment             Nursing diploma              583                        -
    technician
  Lab technician          High school in lab            214                      -
                            specialization
      Agricultural              B. Sc.                  10                       7
       engineer*
      Entomology           High school in               47                       12
       technician          public health
                           specialization
     Computer               High school                  8                       4
     technician
           Drivers          Literate                    16                       14
* There is need for entomology specialists instead

There is no vector control group at the central level that can provide policy and technical
support to vector-borne disease control programs.

2.4      Financial resources

There is an annual government allocation for the department responsible for vector-borne
diseases control. From this budget, a segment goes for vector control. The segments
related to such activities may vary from one year to the other according to the existing
situation. No separate budget items exist to cover the elements of planning, monitoring
and evaluation. These elements are carried out non-systematically as part of the
implementation of vector control.

There is a 46% shortfall in funding level mainly due to the fact that the MOH is not
funding logistics of control activities, e.g. vehicles, rental of equipment, etc.

There are no international donations or loans for implementation of vector control
activities for the different vector-borne diseases in the country.

2.5      Infrastructure

2.5.1 Research

Several institutions carry out research relevant to vector-borne diseases in Syria.
Research addressing the biology, vector ecology, bionomics and vector
competence/vectorial capacity, nevertheless is very limited. Almost all available studies
deal with leishmania and its vectors.

In many instances those institutions carry out their research in collaboration with the
MOH and/or other relevant government agencies including hospitals. These institutions
include the following:

      Damascus University, Department of Biology (testing for and typing of
       leishmania parasites).
      Damascus University, Faculty of Sciences (sand fly fauna in coastal areas of
       Syria).
      Damascus University, Faculty of Medicine (sand fly fauna in southern Syria, and
       their seasonal abundance in relation to prevalence of leishmania cases).
      Aleppo University, Department of Zoology (natural leishmania infection in sand
       flies using dissection and molecular techniques).

Research carried out during the last five years addressed the geographic distribution of
sand flies in different rural, coastal and urbanized environs, seroprevalence of
leishmaniasis, and inefficiency of insecticide spraying campaigns and ecoepidemiological
difference among coastal and inland environs.

However, it should be noted that there are still many missing aspects of the scientific
bases on which a sound vector control plan could be built around. The lack of expertise
and facilities are the main reasons behind this gap.

There are no links with international research institutions abroad that carry out joint
research on entomology and vector control.

There is no systematic means by which results of scientific research are translated to
actions for implementing appropriate vector control plans. However, some ad hoc
examples may be found where some information was used for rodent control.

No budget allocation by the relevant ministry or government agency is specifically
secured for entomology and vector control research. The research carried out at the above
institutions is partly funded from the institutes’ central budget and mostly by the
researchers themselves. Some supplies are provided by international organizations
and/or research institutions through personal relations. However, there is a government
approach where ministries have to allocate 0.001 % of their budgets for research.

2.5.2 Training

There exist no institutions in the country that conduct relevant training in the area of
entomology and vector control of vector-borne diseases.
During the last five years, two technicians were trained on vector control and four
physicians were trained on disease control strategies abroad. Yearly, about 20
technicians are trained on vector collection and insecticide spraying techniques locally.

There are no continuous links with international training institutions. However, though
WHO some trainees are sent abroad for training on relevant aspects of disease and vector
control. No specific budget is allocated for training on these activities by the MOH.

2.5.3 Technical/operational facilities

There is no entomology, quality control laboratories or insectaries in the country.

Currently available facilities include the following:

      -   Spray pumps: 1059 (Only 380 VALID),
      -   Spray teams are temporary, only recruited during spray campaigns
      -   Supervisors = 55;
      -   Cars = 14 (on the gov. level only) the central dept has no separate car.
      -   Microscopes =43
      -   Dissecting scopes = 3
      -   Insect dissection tools = 3 sets
      -   CDC light traps = 15
      -   Rodent traps = 30
      -   Mouth insect aspirator = 37

These equipment/facilities are available and distributed over the central and 14
governorate-level vector control centers.

3:        Vector control planning and implementation

3.1       Major vector-borne diseases: burden, vectors and distribution

Leishmaniases

Three different types of Leishmaniasis occur in Syria:
- Anthroponotic Cutaneous Leishmaniasis (ACL).
- Zoonotic Cutaneous Leishmaniasis (ZCL).
- Zoonotic Visceral Leishmaniasis (ZVL).

Cutaneous leishmaniasis is considered, at present, a big health problem, because of it’s
rapid spreading from two focused areas (Aleppo and Euphrates plain ) before 1960 into
eight provinces (wide distribution).

A. ACL (L. tropica)

It is the main leishmania problem, where 85% of CL belong to this form.
Main infected provinces are Aleppo and Edlib (northwestern); Lattakia and Tartous
(coastal region) and Hama and rural Damascus (center). The main vector of ACL is
Phlebotomus sergenti. The reservoirs are humans.

B. ZCL (L. major)

It represents about 15% of C L, where it is less endemic in Rural Damascus, Deir Ezzour
and Al Hasakeh. The main vector of this form is P. papatasi. Reservoirs are:
Psammomys obesus, Meriones sp. and Nesokia indicas.

Figure 3: Geographic Distribution of Cutaneous Leishmaniasis in
                                Syria During 2004




                                                                   Hasakeh
                                      Aleppo
                                                  Al Raqqa
                           Idlib

             Latakia
                                      Hama                    Deir Ezzor
             Tartus


                                                Homs



                           Damascus                             % 01 ‫معدل انتشار عالي < من‬
                                                                                      %O 1-5
                                                             % 0.1 – 0.5 ‫معدل انتشار متوسط‬
                                   Rural Dama                                 %   O   0.1 – 0.5
    Al Qunaitera
                   Daraa
                                                                % 0.5 > ‫معدل انتشار منخفض‬
                            Sweida                                              %O 0.5 <
Table 3: Total number of reported cutaneous leishmaniasis cases in Syria according
                            to provinces (2000-2005)


Provinces          2000        2001         2002          2003        2004         2005
Damascus            291         400          581           836        1405          852
Rural               331         403          596           847         971         1064
Damascus
Dara                 99         142          120            81           60           35
Qunetera             29           8           14            17           22           30
Swaida                7          41           19            25           17            9
Homs                237         502          341           262          268          215
Hama               4793        5606         3627          3678         1688         1695
Edlib               927        1929         3238          3005         2377         2231
Aleppo             5885        8203         6275         11352        11471        11025
Latakia            5775        4433         2805          3246         3126         1739
Tartous            1116        2726         3621          5221         4045         1932
Al Raqqa             90         113           90            62           61           57
Dair Ezor           106         124           91           118          229          192
Al.Hasakeh          151         209          142           131         1138          875
Total
                  19,837      24,839       21,560        28,881      26,878        21,951



C. ZVL (L. infantum)

The total number of reported cases is very low. It is distributed in villages of 4 provinces
including Edlib, Latakia, Aleppo and Dara’a. The main vector is P. tobbi. Reservoirs are
stray dogs.

      Table 4: Number of reported ZVL cases in Syria between 1999 and 2005

                               Year                No. cases
                               1999                   55
                               2000                   37
                               2001                   30
                               2002                   38
                               2003                   36
                               2004                   19
                               2005                   18


In fact, the vast geographic distribution of leishmaniases and its spread over 300-500
villages make it hard to investigate its epidemiology and to control the vectors over such
huge areas. Therefore, insecticide spraying appears to be inefficient. Heterogeneity of
topography and land forms also makes it difficult to reach all infested areas to carry out
studies or control activities. Reluctance of the communities in new developed areas and
in rich districts towards insecticide spraying is also one of the factors leading to
inefficient control.

Malaria

Syria had suffered from endemic malaria. Up to the 1950s, malaria was endemic
throughout the country, except deserts and mountains above 1100 m, both P. vivax and P.
falciparum were present with predominance of the latter.

Malaria eradication program started in 1956, led to an interruption of transmission of P.
falciparum during the 1960s, in the course of a campaign using indoor DDT spraying,
with the cooperation with WHO. However, transmission of P.vivax continued at varying
degrees, mostly along the Turkey and Iraq borders.

During the 1990s, the maximum incidence of indigenous malaria was recorded in 1993
(966 cases), these cases were recorded in two provinces (Aleppo and Al Hasakeh), a
downward trend of malaria in Syria was observed from 582 cases in 1995 to 6 cases in
2000.

An outbreak of 63 local cases occurred in 2001 mainly in Ras El Ain district (55 cases)
and Al Malkeih district (8 cases) of Al Hassaka province bordering Turkey, then few
sporadic cases were found in communities along the borders with Turkey and Iraq.

In 2004, only one indigenous malaria case was reported in Al Malkeih district.

Al Hasakeh province, which has all indigenous Malaria cases, has an area of about
23.150 km2, and total population of 1.326.000 (7.4 % of total population).
The population at risk is estimated at 300,000 living in 110 villages in Al Hasaka
province.

Table 2: Number of imported and local malaria cases in Syria between 1996 – 2005


                  Year        Imported cases         Local cases
                  1996             65                   280
                  1997             74                    83
                  1998             46                    14
                  1999             37                     5
                  2000             36                     6
                  2001             16                    63
                  2002             12                    15
                  2003             16                     2
                  2004             12                     1
                  2005             28                     0
Malaria vectors include Anopheles Sacharovi, which is the primary vector, An. Claviger,
which is the secondary vector. An. superpictus and An. sergentii are also present but
they are of less importance.

Schistosomiasis

Schistosomiasis is not essentially endemic in Syria. The old foci were in the northeastern
provinces bordering Turkey and Iraq along Belikh and Euphrates rivers during the
Second World War. The total number of positive cases ranged between 2,444 in 1987 to
433 in 1993; to only 1 case in 2004. The intermediate host is Bulinus truncatus. Only
five cases were reported during 2005 in AL Raqqa province.

Table 5: Number of reported Schistosomiasis cases in Syria between 1993-2005


                             Year                    No. of cases
                             1993                        344
                             1994                        273
                             1995                        194
                             1996                         80
                             1997                         35
                             1998                          9
                             1999                          4
                             2000                         81
                             2001                         11
                             2002                          5
                             2003                          1
                             2004                          1
                             2005                          5

Other potential vector-borne diseases

During October 2006, an epidemic of a livestock disease occurred in Syria as reported by
MOA. As this disease is transmitted by mosquitoes, MOA has carried out intensive
control activities including aerial pesticide spraying to cover the vast area of mosquito
breeding habitats. This disease is known to affect nearby countries including Jordan,
Turkey and Israel. Until the production of this report, neither the iteology nor the vector
of such disease is identified. In addition, it is not known whether it is a zoonotic disease
or not.

Vector studies

It should be noted here that no recent information is available on the ecology, bionomics,
vector competence or insecticide resistance of the main vectors of the previously
described diseases in Syria. The latest information was collected during 1990 when a
malaria epidemic occurred.

In addition, no attempts have been made to stratify neither the vector-borne diseases nor
the vectors in Syria. Lack of expertise and facilities are the main reasons behind this.

It is estimated that the population at risk for malaria is 350,000; for schistosomiasis
150, 000 and for leishmaniases about one million persons.

3.2     Tools, strategies and coverage

The different control methods used in Syria as well as the targeted vector-borne diseases
are shown in the following table.

 Table 6: The different vector control methods used in Syria and targeted diseases

               Vector control methods                  Diseases Targeted
          Environmental management               Cutaneous      &      visceral
                                                 leishmaniases, Bilharzia &
                                                 malaria
          Chemical control                       Malaria, Leishmaniases &
                                                 Bilharzia
          Personal protection                    Malaria & Leishmaniases

          Behavioral change                      Bilharzia
          Biological control                     Malaria

Vector control/management activities are planned at the peripheral level where the
control centers prepare yearly plans indicating available and required resources (mainly
pesticides) as well as the timeframe for the implementation. Centers’ plans are then
discussed and evaluated at the central level with the centers’ managers and the plans are
adopted with the required quantities of chemicals. No systematic procedures are in place
to monitor and evaluate the implementation of vector control activities.

      Table 7: Interventions used for the different vector control methods in Syria

               Vector control methods                     Interventions
          Environmental management               - Surface water drainage
                                                 - Plant clearance and land
                                                 modification
                                                 - Drainage canals cleaning
                                                 - Safe management of organic
                                                 waste
          Chemical control                       - Space spraying
                                                 - IRS
                                                 - Larval habitats’ spraying
        Personal protection                   - Protective clothing
                                              - ITNs
                                              - Repellents
        Behavioral change                     - Education
                                              - Awareness raising
        Biological control                    Larvivorous fish


     Table 8: Quantities of different insecticides used during the last five years

Chemical intervention              Type of insecticide   Quantity (L-Kg)
Larval control for malaria              P                            058
                                       OP                            239
Spraying      for     adult             P                           5805
mosquitoes                             OP                            579
                                       C                             985
Spraying for adult sand                 P                          05666
flies                                  OP                          05352
                                       C                             009
Bilharzia                                                           3025
           Table 9: Number of houses or breeding habitats sprayed, population
             protected, and districts and area covered by chemical methods

Insecticide      No. houses     No. population   No. Breeding Area covered
intervention                                     habitats/districts
Mosquito               -               -               151          555399808
larval control
Spraying for         90776          953079             670           00002888
adult
mosquitoes
Spraying for        063876         0589553            5075           908230907
adult sand flies

         Table 10: Insecticide quantities and targeted canals for Bilharia control
                                 during the last five years

                 Year           Insecticide          No. canals targeted
                                 quantities
                 2000               400                      24
                 2001              1300                       9
                 2002               700                      14
                 2003               410
                 2004               600                      17
                 2005               675                      30
     Table 11: Insecticide usage for malaria spraying during the last five years

         Year          Insecticide     No. houses sprayed    No. population
                       quantities
                       (L/Kg)
            2000            595               16475               131799
            2001            770                                    25781
            2002            650                3545                45370
            2003            935                                    28025
            2004           1503                9980                77228
            2005           1179                7272                77268


    Table 12: Insecticide usage for leishmanis spraying during the last five years

         Year          Insecticide     No. houses sprayed    No. population
                       quantities
                       (L/Kg)
         2000              18251             162755              1153672
         2001              17657             198772              1342533
         2002              26075             163785              1217126
         2003              88711             170024              1276723
         2004              16424             260666              1385781
         2005              22809             149827              1279350


The focus on chemical methods of vector control appears to be inappropriate due the
reluctance of people for spraying inside houses. More emphasis needs to be on
environmental management to eliminate vector breeding. Also, awareness needs to be
raised regarding new developments that usually result in the creation of new foci for
leishmaniasis, the major health problem in Syria.

Chemical control methods are oversubscribed due to high dependence of other methods;
e.g. environmental management; on intersectoral collaboration which is not yet effective.

Vector densities before and after pesticide spraying and the ratio between the number of
infected people and total population (per administrative unit) are the indicators used for
monitoring and evaluation.

None of the methods has been discontinued. However, insecticide spraying may be
temporarily discontinued when the number of cases decreases or where there are no
logistic support.
3.3       Pesticide management practices, safety and environmental issues

3.3.1     Legislative control of public health pesticides

Public health pesticides are used by MOH and Ministry of Local Administration and
Environment (MOLAE). Public health pesticides are the responsibility of the MOH as
per the governmental authorization number 5655 for 1988.
Both the Permanent Technical Committee for Pesticides and the Technical Committee for
Household Pesticides are responsible for the registration and procurement of public
health pesticides. The Permanent Technical Committee for Pesticides has been re-
formulated in 1985 to include members from the MOH (five members), MOA, MOLGE
(two members), Faculty of Pharmacy, Faculty of Agriculture, and Health Directorate of
Reef Damascus.

Vector control pesticides are registered by the Permanent Technical Committee for
Pesticides after testing the active ingredients and efficacy under both lab and field
conditions.       Household pesticides are registered by the Directorate of
Pharmacology/MOH upon recommendations by the Technical Committee for Household
Pesticides after lab testing in the Ministry of Economics, MOA and Ministry of Defense.
The pesticide is registered for five year periods and may be renewed.

Repackaging is allowed only for those agents who are legally licensed. Pesticides storage
takes place in the MOH and MOLGE at the central level. These stores are generally in
good conditions. Distribution from the central stores to peripheral units is carried out
based on demand. Those peripheral units do not have adequate facilities for safe storage.
Pesticides transportation is carried out by special government or rented trucks. No
information on safe transportation is available at the MOH or the Permanent Technical
Committee for Pesticides.

 Table 13: Legal instruments related to management of public health pesticides and
                              responsible authorities

        Legal instrument        Responsible authority       Management aspect
        Law 50/2002                     MOLAE               Risk assessment
                                                            Disposal
        Law 49/2004                       MOLAE             Hazardous             waste
                                                            treatment
        Decree 1/T/1988                    MOH              Importation & handling
                                                            of      public       health
                                                            pesticides, registration of
                                                            household pesticides
        Decree 8/T/1990                    MOH              Importation              &
                                                            production of household
                                                            pesticides
Vector control pesticides are distributed according to real needs, thus there are no surplus
that would require disposal. Exceptions are those old pesticides that are stored for long
times, where they are waiting to be safely disposed off through a project by the MOA and
FAO. During this project, about 600 tons of obsolete pesticides have been identified and
collected. These include some 1575 kg of DDT. Only 450 tons of these pesticides have
been repacked while the rest is waiting for financial resources. The following step of
such project is to export these materials outside of Syria.

Used containers, on the other hand, are subject to misuse by farmers and the community
where there are no systematic means for their collection and disposal. Some efforts are
exerted to perforate used containers and dumping them in isolated sites away from
underground water. However, there is no means to verify this unless the identification of
such sites is based on scientific evidence.

MOH has no role in monitoring pesticides available in the market. This is the
responsibility of the Ministry of Economy & Trade and MOA. However, such
monitoring is inefficient as many un-registered pesticides are found in the market.

Efficiency of pesticides used by municipalities is not monitored due to lack of trained
personnel. However, MOH carries out long-lasting effect of some pesticide on treated
surfaces. Meanwhile, no insecticide susceptibility tests have been carried out for public
health pesticides for the last ten years due to lack of expertise and facilities.

A pesticide analysis lab exists (Central Pesticide Laboratory) at the Agricultural research
Authority where the active ingredients of pesticides are analyzed. Another lab exists at
the Ministry of Economy and Commerce. Both laboratories carry out pesticide residue
analysis only when necessary or when asked to do that.

Agricultural pesticides are managed according to the law number 18 for 2004 and its
related decrees and stipulations. MOA is responsible for management of agricultural
pesticides including registration, monitoring of local markets, labeling and un-registered
products.

Upon entry, pesticides are stamped with ministerial stamps indicating registration and
entry date. No information on border collaboration relevant to this issue. Also no web
sites are generated for pesticide information distribution purposes.
      Table 14: Role of different ministries in pesticides management in Syria

Ministry               Role
MOH                    - Besides supervising and organizing the importation,
                       exportation and marketing of pharmaceuticals and chemical
                       products, is responsible for licensing individuals who are
                       allowed to deal with chemicals commercially and who
                       should have a University degree in either Chemistry or
                       Pharmacy.
                       - Syrian Poisons Information Centre is part of the Ministry
                       of Health.
MOA                    Organize and supervise the importation, exportation,
                       handling and marketing of all agro-chemicals, such as
                       pesticides and fertilizers.
MOLAE                  Play a main coordinating role with concerned Ministries
                       and Authorities in all environmental matters
Industry               In charge of licensing factories and enterprises, which use
                       chemicals as raw materials and of identifying their
                       requirement capacity for chemicals according to the size of
                       the plant.
Finance                Through the Directory of Customs, monitors the
                       importation and exportation of chemicals, including
                       periodic analysis of imported chemicals.
Ministry of Social and In charge of educating the working population in health and
Labor Affairs          safety matters, and in supervising factories to ensure that
                       they meet safety regulations for the handling of chemicals.
        Table 15: Legislative framework for the management of pesticide other than
                   those used for public health purposes in Syria

      Legal         Responsible               Management             Level        of
      instrument    authority                 aspect                 enforcement
      National           MOLAE                All aspects            Not enforced
      system    for
      hazardous
      waste
      management
      Law 18/2004         MOA                 Handling          of   Enforced
                                              agrochemicals
      Decree                  MOA             Registration      of   Enforced
      98/T/2004                               agrochemicals
      Decree                  MOA             Importation       of   Enforced
      18/T/2002                               agricultural
                                              pesticides
      Decree                  MOA             Importation       &    Enforced
      64/T/1997                               registration      of
                                              agricultural
                                              pesticides
      Decree                  MOA             Prevention       off   Enforced
      110T/1990                               importation of some
                                              pesticides

Public health pesticide products are approved for specific uses however, they are not
registered. The list of such type of pesticides is not gazetted, but is provided upon
request. There is no system currently in place to manage professional pest management
pesticides.

There is no certification scheme for public health pesticide application equipment.

3.3.2 Vector control and public health pest management

Public health pesticides (for MOH & MOLAE) are imported by the General Agency for
External Commerce (which is the sole agent for importation in the country) according to
a detailed plan of needs. While locally manufactured pesticides are ordered directly by
the user. Due to national policies encouraging the use of local products, most pesticides
are procured from local markets based on their competitive lower prices compared to
imported ones. Although the local products might be lower in technical specifications,
they are still procured based on prices.

The quality of products is checked in national laboratories, which only test the active
ingredient and not the impurities.
Statistics on imported or locally manufactured vector control and household insecticides
are available.

Entomological surveillance is not routinely carried out. Insecticide resistance monitoring
is not also carried out. The last data were collected ten years ago. Sometimes limited
insecticide resistance tests are done before spray campaigns.

Bioassay tests are carried out but using any reference strains due to lack of facilities and
experience.

3.3.3 Pesticide poisoning, formulation            and    repackaging,     storage,   waste
      management and disposal

All issues relating to poisoning by man made chemicals and natural toxins are dealt with
through the Syrian Poison Information Center/MOH. The center provides a free of charge
information service. Further, antidotes are imported by the Ministry of Health and are
distributed free of charge to public hospitals through the Center. Recently, the Centre has
improved its technical services and the systematic registration of cases of poisoning
presenting to public hospitals and health centers, using a standardized reporting format.
For 2001, the number of cases reported to the Poison Information Center was 6176, of
which 1606 case as chemical poisoning. Statistical data on poisoning cases are important
for toxicovigilence and the authorities are informed concerning any repeated cases
involving specific products found on the market.

During 2003, 6876 cases of chemical poisoning were reported in Syria. Of these, 590
were due to pesticide poisoning. While for 2004, 3660 cases of chemical poisoning were
reported, of which 407 were due to pesticide poisoning. Detailed data for pesticide
poisoning for 2005 are given in annex I.

Notification of pesticide poisoning is required only through a ministerial decree not a
law. This is enforced only on public hospitals but on private ones.

There are five main formulation and repackaging facilities for public health pesticides as
follows:

   -   Al Tahan for Pesticides and fertilizers, Aleppo
   -   Al Tawfik for Pesticides, Rural Damascus
   -   Syrico for Agriculture chemicals, Aleppo
   -   National Company for Plant Protection, Rural Damascus
   -   Al Sharq Company for Agriculture products

There is a central storage facility for pesticides in Rural Damascus (850 m2) belonging to
MOH. Other storage facilities are found in each governorate. There are no specific
activities undertaken by national and local authorities on proper management of vector
control pesticide stocks. However, there are currently some general upgrading activities
to improve storage conditions. The MOLAE has a central storage facility in Rural
Damascus with an area of 500 m2. It can accommodate only half of the required
quantity, it has no special specification or safety features with contaminated floor. In
addition, the staff working in this facility are not trained or qualified for this job.

No information is available on bulk storage facilities for household and professional pest
management pesticides.

Facilities where obsolete vector control pesticides are stored are not well managed.

3.4      Cost of intervention, program budget and funding levels

      Costs of interventions are only available for chemical control methods. The available
      information is for 2003 and is presented in the following table 16.
                  Table 16: Cost of chemical control methods during 2003

       Intervention No.          No.            Quantity Labor
                    Governorates villages/areas of         cost                Transport
                                 covered        pesticides (S. L.)             cost
                                                                               (S. L.)
       IRS                  3             128          1600 L      725,200      140,070
       Mosquitoes
       Mosquito             8               -          1260 L     1,342,208         -
       larval
       control
       Spraying for        10             554         24480 L     5,638,920    8,149,435
       leishmania
       Bilharzia            6               -             -            -       1,335,872
       snail control

The vector control budget allocated for 2006 is USD 290,000. These include USD
25,000 for IRS-malaria, 230,000 for IRS-leishmania and 35,000 larval control for
malaria. The shortfall is about 46% as the total required is estimated to be USD 545,000.
MOH does not provide money to cover equipment and vehicles rent as it is envisaged
that control centers would use the local government facilities. However, those are
responsible for all activities of their governorates including afforestation, immunization
and waste management, etc.

Vector control products are not currently exempted from taxes.

3.5      Other specific issues

      Syria participates in several international conventions and agreements related to
      pesticide management for vector control and public health. These conventions and
      agreements include:
              o Basel Convention on the Control of Trans-boundary Movements of
                  Hazardous Wastes and their Disposal
              o Stockholm Convention on Persistent Organic Pollutants (POPs)
              o Rotterdam Convention on the Prior Informed Consent Procedure for
                  Certain Hazardous Chemicals and Pesticides in International Trade

The focal point for these conventions is the “Chemical safety Directorate, General
Authority for Environment”.

There are no existing cross-border collaborations on vector control with neighboring
countries. Cross-border meeting with Iraq and Turkey has been held to coordinate
malaria control but the agreement was not executed.
4.     Intersectoral collaboration

During 2006, an intersectoral committee (ISC) was formed by the MOH to carry out the
VCNA and develop a national strategy for integrated vector management (IVM). The
ISC has representatives from different relevant ministries. Its structure is shown in the
following table 17.

                        Table 17: Structure of the ISC in Syria

                     Ministry                 Representative
        MOH                                   Dr Mahmoud Koriem, Head
                                              Dr Atef El Taweel
                                              Eng. Ayman El Khatib
        MOA                                   Eng Mayada Shiek El Hadadeen
        MOLAE                                 Eng Rofayda El Shamat, Local
                                              Government
                                              Eng Saghaf Nahawi, Environment

        MOI                                   Eng Mayada Kodmani
        Army Medical Services                 Eng Mohamed El Zobon

Dr Nasir Ajlan, current Head of Malaria and other Parasitic Diseases will be added to the
committee.

Currently, there is no memorandum of understanding between the members of the ISC.
However, this is planned as a next step during the process of developing a national IVM
strategy.

The ISC has been heavily involved in the preparation and execution of the national
VCNA. It has met several times and collected the available information and data for the
assessment. The ISC members have also visited several agencies, institutions and local
communities during the process. The committee has also prepared a national IVM
strategy and will hold a national consensus workshop to discuss the results with a broader
group of stakeholders.

Constraints facing the ISC include lack of awareness for the role of different stakeholders
in the activities of vector control, lack of clear mechanisms for the participation of each
representative, irrelevant representation from some ministries, solid routine of the
government institutions and lack of awareness of some ministries. Weak political
commitment during times where the diseases incidence declines also contributes to the
constraints facing the proper functioning of the ISC.

These constraints may be overcome through proper planning and liaison with high level
decision makers within the relevant institutions. Demanding participation by MOH from
other stakeholders should clarify the anticipated role in the ISC. More important is
giving the ISC a solid institutional entity through a high level decree with securing
financial resources.

Due to epidemiological significance of leishmaniases in Syria, several intersectoral
committees have been established in the country to deal with this problem. One
committee was established on the central level and several on the lower administrative
levels; i.e. governorate level. The central committee has representatives form the
following ministries:

              MOH (4 members)
              MOA (one member)
              Ministry of Education (one member)
              Ministry of Settlement and Construction (one member)
              MOLGE (two members)

The terms of reference of this central committee include the follow up of implementation
of environmental management measures taken to reduce the spread of leishmaniasis.
This committee could be expanded and its terms of reference updated to coordinate
intersectoral actions for vector control in the country. This, however, would also require
the broadening of its mandate beyond only leishmaniasis and the inclusion of different
other stakeholders. Discussion with the MOH and other stakeholders regarding this action
is necessary to find out what is the best option from the practical point of view.

Municipalities are involved in vector/public health pest control operations. They are
responsible for pest and vector control on the governorate level. The following diagram
shows the linkage between municipalities and the MOH. Municipalities do not have a
pest/vector control plan, but their activities are stimulated by people’s complains or
through their staff’s inspection of their jurisdiction areas. They do not carry out
insecticide susceptibility tests and do not change the type of pesticides used based on
scientific basis. However, it should be mentioned here that municipalities use higher
quantities of pesticides than MOH.
MOLAE                                        MOH


Governorates



Directorate of Health Affairs        Directorate of Health
                                     Affairs



Insecticide
                                     Center for malaria &
Spraying                             leishmania control
Department



Figure 4: Diagram showing linkage between municipalities and MOH’s
                     activities in vector control
5.     Community mobilisation

5.1    Understanding the local population

Local communities are well aware of the threats and nuisance caused by vectors.
However, their awareness of the difference between mosquitoes and sand flies is weak.
They perceive diseases as threats to them and their children. However, their awareness of
the main vector-borne diseases is much less. Exception is leishmaniasis which is wide
spread over large areas of the country.
Poverty in some local communities is the main factor that would work against
compliance to vector control interventions. Due to their economic status, people feel that
they have more pressing day-to-day needs than vector related problems. On the other
hand, it is easy to communicate with them and drive the intended messages quickly
through the community leaders and local government.

On the other hand, other relatively well-off communities refuse to let vector control
operators into their home not to spoil them. So, if allowed; operators may be only able to
spray bathroom an action which hinder the control and protection activities.

The community in Al Domir (where a focus group discussion was carried out) is
composed of many active and influential groups. These include the following: the local
government (represented by the City Council); which is elected by the people; Party
Committees, charity societies, Farmers’ society, Agricultural Society, youth clubs,
schools, mosque imams (religious leaders) and women societies. All of these groups are
actively involved in social life and have strong communication with the different
segments of the community. Each could play a significant role in community
mobilization for vector control.

Municipality leaders, Farmers’ society, Agricultural Society, and school teachers are
considered “trusted” and “credible”. They have provided honest and informative view of
the structure and characteristics of the local community. Therefore, they could definitely
help in understanding local perceptions and in planning strategies to strengthen
community mobilization for vector control interventions.

The most vulnerable group of the society is the poor. They need to be reached as a
priority since their economic status makes them more liable to vector attack and
minimize their abilities to protect themselves against health risks.

In other newly developed urban environs, the new comers are also vulnerable due to their
exposure to leishmania infections for which they are not immune.

Access to media is very high in the community. Almost all people have television sets
and many of them have access to satellite broadcast at home. Radio is no more
considered as one of the popular media tool in local community.
Decision making is considered as a participatory process within the community and
households. The community groups meet and discuss their problems and decisions are
taken after discussion within the community. Women play a major role in the Syrian
communities.

5.2        Planning and coordinating activities

Planning and coordination of community mobilization is carried out according to the
needs of relevant institutions/authorities.

The Center for Preparation of Health Education Resources within MOH plays a major
role in community mobilization and education. It has carried out several programs
covering, among others, vector-borne diseases. It is equipped with the necessary
infrastructure to produce IECs.         Examples of brochures, booklets, posters and
documentary films exist in the department. These are produced for local communities and
are written in local language. Funds allocated to this department are limited, thus, to be
able to participate in this endeavor additional funds should be secured.

Community mobilization could also be facilitated through the Agricultural Societies and
the Farmers Societies which are considered very efficient in involving local people
raising their awareness. They can provide; in collaboration with health directorates; a
well-structured management system for communication and coordination. Schools and
youth clubs are also among the most important focal points for this aspect. Women
societies could also be mobilized to participate in community mobilization in relation to
vector control.

National capacity to carry out rapid and focused socio-behavioral field research to assist
in assessing proposed behavioral objectives exist in Syria, particularly in the academia
and MOH.

IEC materials are present for several diseases including vector-bone ones. The content
varies based on the target groups. These can easily be adapted to suit specific needs.

The above information will allow the preparation of a community mobilization and
communication plan that includes a monitoring and evaluation framework to track
implementation and measure impact of the community mobilization and communication
plan in relation to the control of vector-borne diseases in the country.
II. Vector control program problem analysis, constraints and needs
A. Vector control program problem analysis

This section aims at analyzing the problems facing the vector control program in Syria
based on the information and data collected during the first phase of the VCNA process.
Such analysis allows the identification of the gaps/constraints and the development of an
action plan for a national IVM strategy.

A summary of the vector control problem analysis is depicted in figure 5. It is based on a
systems analysis approach linking inputs, processes and outputs.

Strength and efficiency of vector control programs, in general, are influenced by three
main groups of factors (inputs). These include the policy framework, institutional
framework as well as the scientific and technical base upon which the control program is
formulated. These groups of factors are inherently interconnected to each other with
feedback mechanisms linking their secondary and higher order consequences into
synergies that shape the final outcome of the program.

1. Systems inputs

From the policy framework standpoint, the analysis reveals the presence of political will
within the highest level of the government including the President himself. This has been
translated into the formulation of several central and peripheral committees to coordinate
efforts directed to the control of vector-borne diseases especially leishmaniases.
However, this political will is not adequately reflected on the follow up of the actions of
the committees and their impact on the disease control. Lack of appropriate mechanisms
that would enforce and regulate intersectoral collaboration in the fight against the disease
as well as the lack of a national action plan and lack of scientific knowledge all
undermine the political commitment to disease control. In addition, insufficient financial
resources allocated to vector control operations also reflect the low level of political
commitment.

The low level of political commitment creates no need to develop a separate policy for
vector control on the national level. The overall outcome of this situation is an inadequate
policy framework for vector control programs, a situation that would subsequently affect
the institutional and financial requirements of a strong program.

Although intersectoral committees are already established, their efficiency in dealing
with disease problems is still inadequate. Under epidemic situations these committees
receive strong support due to political stress, but as the situation eases less support is
seen. Consequently, intersectoral collaboration and stakeholders’ involvement still need
to be strengthened with a national plan of action where the role of each stakeholder is
clearly defined with sufficient technical, scientific and financial resources. This situation
affects both the institutional framework and the enabling environment for vector control.
                             Figure 5: Systems analysis for vector control problems in Syria



Epidemiological situation                                                                  Increased cost to




                                           resources for vector control
                                           Inadequate financial
      is alerting                                                                            health sector

                                                                                                                        Increased vector-borne
  Discontinuous political                                                                                               disease transmission risk
                                                                                         Increased mortality &
  commitment to vector
                                                                                               morbidity
     control activities
                                                                                                                        Inadequate vector control

 No national vector policy
                                                                                                                          Inadequate program
                                                                                                                            development &
Vector control not recognized                                                                                               implementation
    as a separate policy                                                                   Inadequate vector
                                                                                            control program
                                                                                             infrastructure

                                                                                                                              Poor scientific basis to
     Ineffective public
                                         Inadequate technical &                                                                guide vector control
   discussion/education
                                            human resources                                                                          policies

      Many ineffective
intersectoral committees for
     leishmania control                                                                Inadequate training       No budget for research in
                                                                                                                      vector control
        Ineffective
       intersectoral
       collaboration                                                                                             Missing scientific disciplines

    Weak stakeholders
      involvement
                                                                                                                        Inadequate national
                                                                          Inadequate enabling
                                                                                                                        research & training
    Weak institutional                                                        environment
                                                                                                                           infrastructure
     arrangements
Inadequate funding levels, on the other hand, negatively impacts the resource base
available for vector control programs. This directly leads to inadequate human resources
and facilities on both the central and peripheral levels. The problem of insufficient human
resources is actually more complicated than that of facilities, which might be solved by
direct spending to fulfill needs. It is evident that there is a great shortage in all categories
of the staff required for vector control operations. This is mainly due to three main
reasons: unavailability of the required specialties on the national level; low salaries
provided for the staff working in this field and better opportunities available for qualified
staff outside of the government health sector.

As the vector control program is mainly built on chemical control methods, with two
spraying campaigns per year, and due to lack of financial resources; the program depends
on temporary/seasonal workforce. As this manpower is seasonal, no continuous training
is provided to them. In addition, as the salaries provided to them are very low, most
workers refuse to cooperate with MOH or municipalities to do this job. The end result is
that the authorities would employ young persons (between 13 and 17 years of age) who
have no experience and awareness towards the use of pesticides. All these factors render
the chemical control activities inefficient while wasting the material and polluting the
environment without any measurable impact of vector populations. Another negative
impact is the exposure of this inexperienced workforce to chemicals as they tend not to
use protective cloths due to hot weather and lack of awareness.

Other underlying causes of vector control program inadequacy are related to the lack of
proper technical expertise. One very important shortage in the staff on both the central
and peripheral levels is the absolute lack of medical entomologists. Both the planning
and implementation of control programs would require solid scientific knowledge about
the vectors and reservoirs. Monitoring and evaluation would also require special
expertise. Finding alternatives to chemical control methods also requires in depth studies
of the ecoepidemiology including entomological factors, which are not adequately
covered.

All of these factors synergistically contribute to insufficient human and technical
resources available to the vector control program, without which any program would be
greatly compromised. In fact, here the third group of factors (scientific and technical
base of vector control) comes into play. Although there are several academic and
research institutions that carry out research in the field of entomology and vector-borne
diseases, the number of publications and available research during the last five years are
very limited (10-15) and covers narrow areas of vector control. There are also very
limited research in the field of vector ecology, biology and bionomics. There is also no
government funding allocated for entomology and vector control research neither within
MOH nor other institutions.

This in addition to the lack of medical entomology specialists, basic research facilities
(insectaries, field sampling gear, etc) and operational research agenda contribute to the
inadequate research infrastructure. The parallel lack of national training institutions in
the area of vector biology and control also underlies this problem. Thus, old retired
    expertise once available to the vector control program could not be replaced by new
    technically qualified staff. The outcome of this situation is the lack of
    training/educational opportunities on the national level as well as the inadequate
    scientific basis and technical guidance that could support the development of sound
    vector control policies and operations on the national level.

    Therefore, it appears that the three main groups of factors influencing the infrastructure
    of the vector control program have resulted in five main inputs, including:

-    Discontinuous political commitment to vector control
-    Inadequate financial resources for vector control
-    Inadequate enabling environment
-    Inadequate technical & human resources
-    Inadequate training
-    Poor scientific basis to guide vector control policies and operations

    These inputs collectively lead to an inadequate vector control program infrastructure,
    which would make the authorities struggle to achieve any desirable aims.

    2. Vector control processes, outputs and outcomes

    The vector control program inputs identified in the previous section would directly
    influence its structure, level of operation (processes), outputs and outcomes.

    The position of the current vector control unit is lower in rank within the institutional
    hierarchy of MOH than other departments. The vector control unit in the MOH is
    replicated on the lower administrative units by 14 peripheral units. MOH has only
    technical supervision role over the peripheral units (including provision of pesticides),
    while their other financial resources are coming from the MOLAE. This works against a
    proper coordination mechanism since the MOH controls only the technical part but have
    no say on how the necessary logistical support (e.g. cars, equipment, etc) could be
    secured.

    From the financial point of view, insufficient funding leads to the appointment of what is
    called “temporary” personnel for vector control field operations, whom are not qualified
    for this technical task. Consequences on the quality of such operations are obvious.
    There is also a shortage in facilities including those for office or field operations leading
    to limited managerial and operational efficiency.

    Lack of funds, facilities and technical expertise also contribute to the inadequate
    monitoring and evaluation protocols for vector control activities, which are apparently
    carried out only through supervisory inspections on the field operations.

    In addition, no routine vector surveillance is carried out in sentinel sites. There is also no
    system for pesticides resistance management. Lack of these operational tools definitely
    influences the overall performance of the control program.
Vector control operations carried out by MOLGE is rather selective, targeted basically to
nuisance mosquitoes and flies and in most cases is carried out in response to complaints.
It is not based on solid knowledge on the mosquito species composition, its distribution
and ecology within the municipality. Again, the reason lies in the lack of specialized staff
and appropriate training.

In fact, fragmentation of vector control activities intersectorally; without appropriate
level of coordination and collaboration; weakens the institutional framework and may
result in redundant activities, cost-ineffectiveness and unsatisfactory program outcomes.
The lower rank of vector control unit within the administrative hierarchy of MOH may
reflect the level of importance given to it, which is further reflected on its financial,
technical and human resources.

All the above mentioned factors coupled with the insufficient level of scientific and
technical support for the vector control program contribute to the systems outputs which
are: the inadequate program development and implementation, inadequate vector control
and finally an expected increase in the vector-borne disease transmission risk.

In case the current vector control program’s inputs, processes and outputs prevails, this
system may lead, on the long term, to increased costs to the health sector as well as to an
expected increase in mortality and morbidity due to vector-borne diseases, especially
under the current state of new urbanization and increased population movement.

3. Framework for IVM

Although certain level of institutional frameworks exist within MOH and the MOLGE
that stress multisectoral involvement in vector and disease control measures, these have
not been translated into national policies and/or strategies for vector control including the
involvement of affected communities and NGOs. Vector control by the MOH is thus
carried out based only on year-by-year plans with no strategic directions.

Policies and regulations for EIA exist and integrate EH dimensions into the assessment
process. However, the vector-borne disease dimensions are not yet fully incorporated into
this system, although the EH directorate within the MOH is the responsible unit for
EHIA. This may show that intra-sectoral collaboration would also need to be
strengthened.

Experience in Syria has shown that new developments, especially urbanization, have
resulted in the formation of new foci for leishmaniasis thus spreading the disease over a
larger area, making it hard for authorities to respond to disease control. This situation is
not unique to Syria, but it is replicated in many other countries due to lack of awareness
which dissociates “environmental” impacts from health impacts of development projects,
where; as the term implies; environmental impacts are stressed and health ones
overlooked. Here again, the role of the ISC is emphasized to formulate a mechanism by
which the environmental health issues could be integrated into existing EIA framework.
4. Pesticides management issues

Pesticide management legislations and policies are currently in place; however, it is not
yet fully implemented and monitored, especially those aspects related to safe use of
pesticides and disposal of used containers. Transport of pesticides is not regulated yet.

Reasons behind this lie in the lack of technical expertise, funds and safe disposal
infrastructure in the country. In addition, evident lack of community and workers’
awareness regarding the environmental and health hazards of pesticides contributes to the
problem. This situation results in exposing public health, agricultural workers and
farmers to the risks associated with the unsafe use of pesticides.

Chemical poisoning data available for Syria revealed that the percentage of pesticide
poisoning cases ranged between 11 and 14.5% and that cases occurred in rural and urban
areas. In addition, unsafe practices currently used to dispose of used containers of
pesticides poses environmental threats related to pollution of soil, water and air.

Most of obsolete pesticides are not properly stored. At the present time, the Syrian
Government does not have the necessary capability and technical equipment to dispose of
these stocks in an environmentally safe manner.

Public health pesticides and related equipment are not exempted from taxes similar to
those for agricultural use, which are subject to lower taxes and tariffs. This reflects a
lower political commitment for vector control in comparison to control of agricultural
pests.

Therefore, there is a pressing need to formulate a plan to overcome current deficiencies in
pesticide management, an effort necessarily demanding intersectoral collaboration.

5. Community mobilization

A good level of awareness towards vector problems prevails among local communities.
Several cultural, societal and behavioral characteristics, however, may work against
vector control operations in target areas. This is mainly due to the nature of agricultural
and animal farming practices exercised in rural areas and perceptions and awareness in
urban ones. Meanwhile, hot weather during summer leads people to sleep outside their
homes with no protection, thus exposing them to increased number of vector bites.

The community structure and nature enable continuous communication with potential
awareness raising if the appropriate mechanisms are used. The local structures actively
involved in the communities, mainly the farmers and agricultural societies, would also
play a vital role in the anticipated community mobilization activities. In addition, MOH
through its Center for Preparation of Health Education Resources is in a good position to
lead these efforts in collaboration with the locals.
B. Gaps facing the vector control program and related needs

Based on the analysis of problems facing the vector control program, a group of gaps
could be identified. The identified constraints fall within the policy, institutional,
financial, intersectorl, technical/training and community perception frameworks. The
following broad set of constraints have been identified and prioritized based on their own
importance and their direct influence on subsequent items.

   -    Discontinuous political commitment to vector control
   -    Inappropriate institutional framework
   -    Insufficient financial resources
   -    Ineffective intersectoral collaboration
   -    Inadequate human resources
   -    Inadequate technical capabilities
   -    Insufficient facilities and infrastructure
   -    Inadequate training and education infrastructure relevant to medical entomology
   -    Poor scientific knowledge on vector-related topics leading to inadequate basis for
        vector control program development and implementation
   -    Insufficient enforcement of pesticide management practices
   -    Inadequate integration of vector-borne disease issues into current environmental
        management systems (e.g. EIA)
   -    Socio-cultural perceptions working against vector control activities

Main constraints are found in the administrative routine within government sector that
usually works against or delay necessary actions. Engagement of vector control staff in
several administrative routines in addition to their original technical responsibilities is
another constraint. Existing legal and institutional frameworks and the time and effort
needed to change them may also pose other constraints.

Needs

Based on the vector control situation and problem analyses and on the identification of
constraints facing the required performance level of program implementation, the
following needs are identified. These are listed in order of their importance and their
consequential impact on subsequent needs.

It is important to draw attention to the fact that some of these needs could only be
fulfilled on a longer term than others. Examples include the completion of required staff,
capacity building and strengthening of training and education infrastructure relevant to
medical entomology.         However, commencement of activities required to their
implementation should start immediately. Action plans to fulfill the needs will be
developed (within the national IVM strategy) in parallel lines and on short, medium and
long-term stages.
The identified needs are listed hereunder:

   -   Increase and maintain a sufficient level of political support to vector control.
   -   Restructuring of the institutional framework
   -   Secure a proper level of financial resources
   -   Strengthen intersectoral collaboration
   -   Bridge the gap in human resources
   -   Upgrade technical capabilities of staff
   -   Upgrade facilities and infrastructure
   -   Strengthen training and education infrastructure relevant to medical entomology
   -   Strengthen and support research on vector-related topics to provide an adequate
       basis for vector control program development and implementation
   -   Strengthen enforcement mechanisms of pesticide management practices
   -   Integrate vector-borne disease issues into current EIA system
   -   Raise community awareness regarding collaboration in vector control activities
   -   Identify control methods suitable for the different socio-cultural situations

A summary of the constraints facing the vector control program, needs and means
necessary to fulfill them is presented in table 18.

C. Opportunities for improving the vector control program

Although several constraints have been identified that might preclude the proper structure
and functioning of the vector control program, several opportunities also exist within the
current national frameworks that would permit improvement and achievement of the
required goals.

In this section, currently available opportunities will be presented and discussed in
relation to their role in promoting a better environment for improving and upgrading of
the vector control program and in formulating a sound IVM strategy on the national level.

C.1. Legislative framework

Existing legal frameworks for public health and vector control are very old. Currently,
the MOH is undertaking steps to review and update these legal bases. Thus, this is a good
opportunity to integrate IVM principles into national policies and legislation where role
and responsibilities of relevant stakeholders and financial burdens could be stipulated.
This is an important step towards the implementation of IVM strategies in the country,
which is also a commitment of the country under WHO resolutions.

A legal requirement for EIA already exists in the country, but it does not yet fully include
the vector-borne disease implications as a clear component of the assessment. To support
its efforts to control and prevent burdens of vector-borne diseases, the MOH in
collaboration with the MOLGE and other stakeholders should work to develop a
framework within which vector-borne disease implications of development programs and
projects are examined before the approval of such activities. This can be achieved
through the integration of vector-borne disease aspects as a separate item within existing
legal EHIA requirements managed by the EH Directorate of the MOH.

A screening process for proposed projects/programs should be developed in order to
identify the ones which have potential vector-borne disease implications. For these,
EHIA component should be requested as part of the EIA to be prepared by proponents. It
must be noted here that both governmental and private sector’s proposed projects should
be subject to such requirement.

To put this requirement on action, MOLGE should issue a new guideline for the
preparation of EIAs in the country indicating that all environmental implications of
developmental projects/programs, including those related to vector-bore diseases, should
be adequately addressed. In order not to demand an EHIA for all proposed
projects/programs, a screening process may be included in the guidelines to help
proponents identify whether their projects would have vector-borne diseases
implications; thus requiring an EHIA; or not.

Here, it should be indicated that no changes in the existing legal basis are required. Only
changes in the procedures and guiding principles of the existing EIA process will be
needed.

C.2. Intra- and intersectoral collaboration

Any form of intersectoral collaboration/coordination requires a solid legal and
institutional framework upon which such complex type of activity may be implemented.
In case of Syria; the seriousness of the leishmania problem has created a good political
will to support the control of the disease. This has been followed by the establishment of
several intersectoral committees where relevant stakeholders are represented. Thus, an
opportunity exists here where experience of these committees may be shared with the
ISC to provide for a better collaboration mechanisms. Alternatively, the existing central
committee for leishmania control may be expanded and upgraded to take over the role of
coordinating the national vector control activities.

The “Control of Environmental Health Hazards Program”, which is currently operational
in the EH Directorate/MOH, provides another opportunity that should be used to promote
environmental practices in dealing with vectors and reservoirs of leishmaniases in Syria.
Management of pesticides and its safe disposal would be another area of common
interest. MOH’s staff from the Malaria and Other Parasitic Diseases Directorate as well
as of the Health Directorates, on different administrative levels, should be included in the
training program instead of replicating a similar activity.

Collaboration and coordination with other stakeholders involved in vector control
(municipalities, MOA and the army) would lead to an efficient and cost-effective control
program since these agencies already have their own budgets and facilities.
The MOA has many farmers’ schools distributed over the country. These can serve as a
vehicle for vector control training and community awareness especially that they have
good relations with the locals.
Collaboration and coordination with other stakeholders involved in vector control
(municipalities, MOA and the army) would lead to an efficient and cost-effective control
program since these agencies already have their own budgets and facilities.

The MOA has many farmers’ schools distributed over the country. These can serve as a
vehicle for vector control training and community awareness especially that they have
good relations with the locals.

C.3. Research in vector control related fields

The MOH maintains a very good relation with the national research/education institutions
which has been indicated in several occasions. MOH could then develop a research
agenda including the priority research questions related to their operational needs and
share it with those institutions. Research activities could thus be directed to answer the
questions providing the MOH, in part, with information and knowledge necessary to plan
sound interventions.

C.4. Supporting tools for vector control program

Currently, many technologies are available to health authorities that could greatly help in
the planning, monitoring and management of control operations. Geographic Information
Systems (GIS) and remote sensing are among such available technologies. The General
Organization of Remote Sensing (GORS) is actively working in Syria to cover a lot of
scientific disciplines and various applications. The agency has a good digital information
system including geology, hydrology, topography, climate, land use/land cover, etc. It
also possesses different satellite data for the country. Discussions with the officials within
the GORS indicated their willingness to cooperate with the MOH to map vectors and
vector-borne diseases, to generate relevant data bases and to train the MOH staff on using
GIS and remote sensing technologies. GORS also have ready-made data for some areas
which may be selected as demonstration sites for the GEF project.
             Table 18: Constraints facing the vector control program, needs and means for fulfilling them


    Constraints                                 Needs                                  Actions for fulfilling needs
Discontinuous political     Increase and maintain a sufficient level of    -   Open channels of communication between
commitment to vector        political support to vector control.               decision-makers and the vector control unit.
control                                                                    -   Discuss specific shortfalls in the program in
                                                                               light of the importance of the presence of such
                                                                               activities as a means of prevention and control
                                                                               of VBD burdens.
                                                                           -   Use the framework of the GEF project to
                                                                               promote the need for more support for the
                                                                               national health benefits.
                                                                           -   Convene national workshops where the
                                                                               problems of VBD are discussed among
                                                                               stakeholders and decision-makers to encourage
                                                                               political support.
                                                                           -   WHO/EMRO can support these actions as
                                                                               appropriate.
                                                                           -   Draft a national vector control policy
                                                                               framework by the ISC.
                                                                           -   Get endorsement of the policy by high level
                                                                               decision-makers.
Inappropriate               Restructuring of the institutional framework   -   The ISC should start drafting an alternate
institutional framework                                                        structure where all vector control activities
                                                                               should be planned, financed and managed by a
                                                                               single body in the country.
                                                                           -   Develop a time schedule and implementation
                                                                               plan.
                                                                           -   Secure political commitment and budget for the
                                                                               plan.
                                                                             -   This may be done on stages according to the
                                                                                 national circumstances.
Insufficient    financial   Need to negotiate means of increasing            -   Identify priorities of financial shortfalls.
resources                   financial resources once the required level of   -   Identify alternative means of overcoming these
                            political support is secured.                        shortfalls though: re-allocation of current
                                                                                 budget items, efficient use of available
                                                                                 resources, increase in government budgets and
                                                                                 identifying other sources of funding (national,
                                                                                 bi-lateral and international).
                                                                             -   In order to ensure high visibility for vector
                                                                                 control and allocation of adequate resources
                                                                                 proportional to VBD risk, vector control needs
                                                                                 to be promoted nationally in poverty reduction
                                                                                 strategy papers, sector-wide approaches and
                                                                                 essential health packages.
                                                                             -   Prepare an action plan and endorse it by high
                                                                                 level decision-makers.
                                                                             -   This may be done on stages according to the
                                                                                 national circumstances.
Ineffective intersectoral   Strengthen      the    existing  intersectoral   -   Develop a national strategy for vector control
collaboration               collaboration      frameworks   to     ensure        with roles and responsibilities of relevant
                            sustainable and effective impact of vector           stakeholders are well identified.
                            control activities and to develop a national     -   Secure high level political and legal support for
                            IVM strategy involving all relevant                  the strategy.
                            stakeholders.                                    -   Sustainable coordination mechanisms should be
                                                                                 put in place between government units involved
                                                                                 in vector control activities.
                                                                             -   Memoranda of understanding (MOU) between
                                                                                 the relevant stakeholders should be prepared.
                                                                                 The MOU should indicate when, where and
                                                                                 how other sectors are called upon to participate
                                                                             in IVM activities including those related to
                                                                             prevention and control.
                                                                          - This could be easily done by the recently formed
                                                                          ISC.
Inadequate           -
                 human - Bridge the gap in staff requirements on the      - Identify priorities in staff requirements.
resources              different levels.                                  - Prepare a staged-plan for filling the gaps in
                     - - Motivate staff                                      human resources.
                     - - Raise salaries and/or develop incentives plans   - Re-allocate existing staff to high priority areas.
                     - - Secure career development plans                  - Use current budgets; if appropriate; to recruit
                                                                             appropriate staff based on priorities.
                                                                          - Allocate part of new budgets to recruit
                                                                             additional staff, if applicable.
                                                                          - Use non-traditional means of involving the
                                                                             required staff; if present outside the MOH; in
                                                                             the program. Staff could be involved on short-
                                                                             term, part-time, voluntary or consultancy basis.
                                                                          - Identify realistic measure to motivate staff.
                                                                          - Implement career development plans and
                                                                             incentives to encourage quality performance.
Inadequate     technical    Upgrade technical capabilities of staff       - Identify priority needs in technical issues.
capabilities                                                              - Prepare an action plan for training the staff on
                                                                             these technical priority issues.
                                                                          - To save time and money, experts form the
                                                                             region could be invited to Syria to train an
                                                                             adequate number of the personnel.
                                                                          - Training of trainers (TOT) approach can also be
                                                                             adopted in order to save money and time and to
                                                                             secure national sustainability.
                                                                          - High technical capabilities can be attained
                                                                             through sending staff to acquire post-graduate
                                                                             certificates in scientific institutions in the
                                                                                          region.
                                                                                    -     WHO/EMRO could assist in this endeavor.
Insufficient    facilities        Secure the minimum level of facilities and        -     Identify priorities of the needed facilities and
and infrastructure                infrastructure on both the central and                  infrastructure.
                                  peripheral levels.                                -     Examine alternate means of fulfilling needs
                                                                                          including: re-allocation of budget items, re-
                                                                                          allocation    of    facilities   within    MOH
                                                                                          departments, establishment of central facilities,
                                                                                          national/international             organizations,
                                                                                          international donation, etc.
                                                                                    -     Once political and financial support is secured,
                                                                                          completion of the requirements could be
                                                                                          facilitated.
Inadequate training and           Strengthen       training    and      education       This requires a long-term action plan with the
education infrastructure          infrastructure relevant to medical entomology         involvement of many stakeholders including:
relevant to medical                                                                     ministries of education, scientific research,
entomology                                                                              finance and planning.
                                                                                        The first step towards the long-term action is to
                                                                                        involve these bodies in the national consensus
                                                                                        workshop where this need is presented and
                                                                                        discussed.
Poor             scientific   -    Encourage research interests and activities      -     MOH should work closely with research and
knowledge on vector-               in the field of vector biology, ecology,               academic institutions to identify research
related topics leading to          bionomics and competence within existing               priorities with direct relevance to the needs of
inadequate basis for               scientific institutions.                               the ministry.
vector control program        -    Strengthen ties between MOH and scientific       -     Such type of operational research could then be
development            and         institutions.                                          applied for funded through the TDR Small
implementation                -    Develop linkage between research priorities            Grant Scheme of the WHO.
                                   of MOH and research agenda in the                -     Other Funding opportunities are available from
                                   scientific institutions.                               several other regional and international
                                                                                          organizations. Identification of these funding
                                                                                    organizations may be easier for research
                                                                                    institutions as it falls within their routine
                                                                                    activities.
                                                                                -   WHO can also play a role in this endeavor.
                                                                                -   Develop a mechanism through which available
                                                                                    research results could be systematically
                                                                                    reviewed to identify aspects that might assist in
                                                                                    the development of policies and practical
                                                                                    approaches to prevention and control of vectors
                                                                                    and vector-borne diseases.
                                                                                -   Involvement of an appropriate member from the
                                                                                    scientific community in the ISC would assit in
                                                                                    this task.
                                                                                -   On another front, MOH should try to allocate a
                                                                                    part of its funds to support research addressing
                                                                                    its priority needs. However, this would require
                                                                                    a high level of political commitment.

Insufficient enforcement    -    Law enforcement                                -Increase capacity for monitoring and inspection
of              pesticide   -    Awareness raising for workers and farmers       of all steps for pesticide management.
management practices        -    Staff training                              - Conduct educational programs appropriate for
                                                                                 the levels of target audience to raise awareness
                                                                                 towards health and environmental risks
                                                                                 associated with unsafe use of pesticides.
                                                                             - The “Control of Environmental Health Hazards
                                                                                 Program”, which is currently operational in the
                                                                                 EH Directorate/MOH, provides a good venue
                                                                                 that should be used to promote good pesticides
                                                                                 management and safe disposal thoughout the
                                                                                 country.
Inadequate    integration       Integrate vector-borne disease issues into - To support its efforts to control and prevent burdens
of vector-borne disease       current EIA system                                 of vector-borne diseases, the MOH in collaboration
issues    into  current                                                          with the MOLGE and other stakeholders should work
environmental                                                                    to include vector-borne disease issues into existing
management     systems                                                           EHIA carried out by EH Directorate of the MOH.
(e.g. EIA)                                                                       - A screening process for proposed projects/programs
                                                                                 should be developed in order to identify the ones
                                                                                 which have potential vector-borne disease
                                                                                 implications. For these, appropriate assessment
                                                                                 should be carried out by the relevant department.
                                                                                 - To put this requirement on action, MOLGE should
                                                                                 issue a new guideline for the preparation of EIAs in
                                                                                 the country indicating that all environmental
                                                                                 implications of developmental projects/programs,
                                                                                 including those related to vector-bore diseases,
                                                                                 should be adequately addressed.
                                                                                 - Here, it should be indicated that no changes in the
                                                                                 existing legal basis are required. Only changes in the
                                                                                 procedures and guiding principles of the existing EIA
                                                                                 process will be needed.
Socio-cultural            -    Manage public perception to develop                 - Educate and raise awareness of target
perceptions    working         positive attitudes towards vector control               communities towards the importance of vector
against vector control         activities and to promote community                     control in reducing disease burdens. Education
activities                     participation in its implementation.                    should involve changing behaviors that increase
                          -    Identify and implement vector control                   the risk of exposure to infection.
                               alternatives suitable to the nature of targeted     - Education programs should involve MOH,
                               communities.                                            MOA, MOI, MOLGE, Ministry of Education
                                                                                       and the media.
                                                                                   - Identify appropriate control methods for urban
                                                                                       and well-off communities that are accepted by
                                                                                       the locals. These alternatives should be based
                                                                                       on environmental management rather than
                                                                             chemical methods.
                                                                         -   Agricultural and farmers’ societies could assist
                                                                             in this task at the local level.
    Constraints                               Needs                                   Actions for fulfilling needs
Discontinuous political   Increase and maintain a sufficient level of    -   Open channels of communication between
commitment to vector      political support to vector control.               decision-makers and the vector control unit.
control                                                                  -   Discuss specific shortfalls in the program in
                                                                             light of the importance of the presence of such
                                                                             activities as a means of prevention and control
                                                                             of VBD burdens.
                                                                         -   Use the framework of the GEF project to
                                                                             promote the need for more support for the
                                                                             national health benefits.
                                                                         -   Convene national workshops where the
                                                                             problems of VBD are discussed among
                                                                             stakeholders and decision-makers to encourage
                                                                             political support.
                                                                         -   WHO/EMRO can support these actions as
                                                                             appropriate.
                                                                         -   Draft a national vector control policy
                                                                             framework by the ISC.
                                                                         -   Get endorsement of the policy by high level
                                                                             decision-makers.
Inappropriate             Restructuring of the institutional framework   -   The ISC should start drafting an alternate
institutional framework                                                      structure where all vector control activities
                                                                             should be planned, financed and managed by a
                                                                             single body in the country.
                                                                         -   Develop a time schedule and implementation
                                                                             plan.
                                                                         -   Secure political commitment and budget for the
                                                                             plan.
                                                                             -   This may be done on stages according to the
                                                                                 national circumstances.
Insufficient    financial   Need to negotiate means of increasing            -   Identify priorities of financial shortfalls.
resources                   financial resources once the required level of   -   Identify alternative means of overcoming these
                            political support is secured.                        shortfalls though: re-allocation of current
                                                                                 budget items, efficient use of available
                                                                                 resources, increase in government budgets and
                                                                                 identifying other sources of funding (national,
                                                                                 bi-lateral and international).
                                                                             -   In order to ensure high visibility for vector
                                                                                 control and allocation of adequate resources
                                                                                 proportional to VBD risk, vector control needs
                                                                                 to be promoted nationally in poverty reduction
                                                                                 strategy papers, sector-wide approaches and
                                                                                 essential health packages.
                                                                             -   Prepare an action plan and endorse it by high
                                                                                 level decision-makers.
                                                                             -   This may be done on stages according to the
                                                                                 national circumstances.
Ineffective intersectoral   Strengthen      the    existing  intersectoral   -   Develop a national strategy for vector control
collaboration               collaboration      frameworks   to     ensure        with roles and responsibilities of relevant
                            sustainable and effective impact of vector           stakeholders are well identified.
                            control activities and to develop a national     -   Secure high level political and legal support for
                            IVM strategy involving all relevant                  the strategy.
                            stakeholders.                                    -   Sustainable coordination mechanisms should be
                                                                                 put in place between government units involved
                                                                                 in vector control activities.
                                                                             -   Memoranda of understanding (MOU) between
                                                                                 the relevant stakeholders should be prepared.
                                                                                 The MOU should indicate when, where and
                                                                                 how other sectors are called upon to participate
                                                                             in IVM activities including those related to
                                                                             prevention and control.
                                                                          - This could be easily done by the recently formed
                                                                          ISC.
Inadequate           -
                 human - Bridge the gap in staff requirements on the      - Identify priorities in staff requirements.
resources              different levels.                                  - Prepare a staged-plan for filling the gaps in
                     - - Motivate staff                                      human resources.
                     - - Raise salaries and/or develop incentives plans   - Re-allocate existing staff to high priority areas.
                     - - Secure career development plans                  - Use current budgets; if appropriate; to recruit
                                                                             appropriate staff based on priorities.
                                                                          - Allocate part of new budgets to recruit
                                                                             additional staff, if applicable.
                                                                          - Use non-traditional means of involving the
                                                                             required staff; if present outside the MOH; in
                                                                             the program. Staff could be involved on short-
                                                                             term, part-time, voluntary or consultancy basis.
                                                                          - Identify realistic measure to motivate staff.
                                                                          - Implement career development plans and
                                                                             incentives to encourage quality performance.
Inadequate     technical    Upgrade technical capabilities of staff       - Identify priority needs in technical issues.
capabilities                                                              - Prepare an action plan for training the staff on
                                                                             these technical priority issues.
                                                                          - To save time and money, experts form the
                                                                             region could be invited to Syria to train an
                                                                             adequate number of the personnel.
                                                                          - Training of trainers (TOT) approach can also be
                                                                             adopted in order to save money and time and to
                                                                             secure national sustainability.
                                                                          - High technical capabilities can be attained
                                                                             through sending staff to acquire post-graduate
                                                                             certificates in scientific institutions in the
                                                                                          region.
                                                                                    -     WHO/EMRO could assist in this endeavor.
Insufficient    facilities        Secure the minimum level of facilities and        -     Identify priorities of the needed facilities and
and infrastructure                infrastructure on both the central and                  infrastructure.
                                  peripheral levels.                                -     Examine alternate means of fulfilling needs
                                                                                          including: re-allocation of budget items, re-
                                                                                          allocation    of    facilities   within    MOH
                                                                                          departments, establishment of central facilities,
                                                                                          national/international             organizations,
                                                                                          international donation, etc.
                                                                                    -     Once political and financial support is secured,
                                                                                          completion of the requirements could be
                                                                                          facilitated.
Inadequate training and           Strengthen       training    and      education       This requires a long-term action plan with the
education infrastructure          infrastructure relevant to medical entomology         involvement of many stakeholders including:
relevant to medical                                                                     ministries of education, scientific research,
entomology                                                                              finance and planning.
                                                                                        The first step towards the long-term action is to
                                                                                        involve these bodies in the national consensus
                                                                                        workshop where this need is presented and
                                                                                        discussed.
Poor             scientific   -    Encourage research interests and activities      -     MOH should work closely with research and
knowledge on vector-               in the field of vector biology, ecology,               academic institutions to identify research
related topics leading to          bionomics and competence within existing               priorities with direct relevance to the needs of
inadequate basis for               scientific institutions.                               the ministry.
vector control program        -    Strengthen ties between MOH and scientific       -     Such type of operational research could then be
development            and         institutions.                                          applied for funded through the TDR Small
implementation                -    Develop linkage between research priorities            Grant Scheme of the WHO.
                                   of MOH and research agenda in the                -     Other Funding opportunities are available from
                                   scientific institutions.                               several other regional and international
                                                                                          organizations. Identification of these funding
                                                                                organizations may be easier for research
                                                                                institutions as it falls within their routine
                                                                                activities.
                                                                            -   WHO can also play a role in this endeavor.
                                                                            -   Develop a mechanism through which available
                                                                                research results could be systematically
                                                                                reviewed to identify aspects that might assist in
                                                                                the development of policies and practical
                                                                                approaches to prevention and control of vectors
                                                                                and vector-borne diseases.
                                                                            -   Involvement of an appropriate member from the
                                                                                scientific community in the ISC would assit in
                                                                                this task.
                                                                            -   On another front, MOH should try to allocate a
                                                                                part of its funds to support research addressing
                                                                                its priority needs. However, this would require
                                                                                a high level of political commitment.

Insufficient enforcement    -   Law enforcement                             -   Increase capacity for monitoring and inspection
of              pesticide   -   Awareness raising for workers and farmers       of all steps for pesticide management.
management practices        -   Staff training                              -   Conduct educational programs appropriate for
                                                                                the levels of target audience to raise awareness
                                                                                towards health and environmental risks
                                                                                associated with unsafe use of pesticides.
                                                                            -   The “Control of Environmental Health Hazards
                                                                                Program”, which is currently operational in the
                                                                                EH Directorate/MOH, provides a good venue
                                                                                that should be used to promote good pesticides
                                                                                management and safe disposal throughout the
                                                                                country.
Inadequate integration     Integrate vector-borne disease issues into - To support its efforts to control and prevent burdens
of vector-borne disease    current EIA system                                of vector-borne diseases, the MOH in collaboration
issues    into  current                                                      with the MOLGE and other stakeholders should work
environmental                                                                to include vector-borne disease issues into existing
management     systems                                                       EHIA carried out by EH Directorate of the MOH.
(e.g. EIA)                                                                   - A screening process for proposed projects/programs
                                                                             should be developed in order to identify the ones
                                                                             which have potential vector-borne disease
                                                                             implications. For these, appropriate assessment
                                                                             should be carried out by the relevant department.
                                                                             - To put this requirement on action, MOLGE should
                                                                             issue a new guideline for the preparation of EIAs in
                                                                             the country indicating that all environmental
                                                                             implications of developmental projects/programs,
                                                                             including those related to vector-bore diseases,
                                                                             should be adequately addressed.
                                                                             - Here, it should be indicated that no changes in the
                                                                             existing legal basis are required. Only changes in the
                                                                             procedures and guiding principles of the existing EIA
                                                                             process will be needed.
Socio-cultural            - Manage public perception to develop                - Educate and raise awareness of target
perceptions    working       positive attitudes towards vector control             communities towards the importance of vector
against vector control       activities and to promote community                   control in reducing disease burdens. Education
activities                   participation in its implementation.                  should involve changing behaviors that increase
                          - Identify and implement vector control                  the risk of exposure to infection.
                             alternatives suitable to the nature of targeted   - Education programs should involve MOH,
                             communities.                                          MOA, MOI, MOLGE, Ministry of Education
                                                                                   and the media.
                                                                               - Identify appropriate control methods for urban
                                                                                   and well-off communities that are accepted by
                                                                                   the locals. These alternatives should be based
    on environmental management rather than
    chemical methods.
-   Agricultural and farmers’ societies could assist
    in this task at the local level.
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Al-Majali O, Routh HB, Abuloham O, et al. A 2-year study of liquid nitrogen therapy in
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Curtis CF, Davies CR. Present use of pesticides for vector and allergen control
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ANNEX I: Pesticide poisoning data in Syria for 2005 by governorate
Governorate      No. pesticide poisoning cases
                              3
    Edleb
   Hasaka                     2

   Al Reqa                    11

 Al Sowaidaa                  14

 Al Kanaitra                  1

    Latika                    18

   Aleppo                    193

   Hammah                     14

    Hems                      81

    Daraa                     22

  Damascus                    31

  Dir Al Zor                  1

Rural Damascus                29

   Tartous                    0

				
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