Initially published in The Lancet on May 10, 2018 (as part of Volume 6, Issue 7, E34, published on July 1, 2018) and written by Aula Abbara, Hussam AlKabbani, Ibrahim Al-Masri, Zaher Sahloul, Annie Sparrow.

In The Lancet Respiratory Medicine, Ghada Muhjazi and colleagues highlight the challenges of diagnosing and managing tuberculosis in the protracted conflict in Syria. Other notable challenges to Syria’s national tuberculosis programme are the intentional nature of attacks on health-care facilities and deliberate impairment of aid delivery, as well as limited access to hard to reach or besieged areas and prisons. These challenges were described recently as the “weaponisation of health care” by the Lancet Commission on Syria.

There is no mention of prisoners in this Muhjazi and colleagues’ Spotlight, although the association between prisons and tuberculosis is long established and there are more than 118 000 prisoners and detainees in Syria. Harsh conditions including severe overcrowding, torture, and malnutrition have been described. Tuberculosis is reported to be among the leading causes of mortality in Aleppo Central Prison, accounting for more than 25% of 400 fatalities between April, 2012, and October, 2013. Medications, including antituberculosis therapy, often do not reach prisoners; of greater concern is the possibility that intermittent or suboptimal dosing does reach prisoners, increasing the risk of drug-resistant tuberculosis. There are similar concerns in besieged areas. In Eastern Ghouta (an area under siege since October, 2013), according to documents shared by WHO Syria and the Syrian Arab Red Crescent Douma branch, antituberculosis therapy has not been permitted in aid convoys since May, 2015, while the recorded number of patients with tuberculosis has more than doubled, from 114 in May, 2015, to 265 in July, 2017. In 4 months alone, between December, 2017, and March, 2018, three patients with tuberculosis have died, including two children in Douma.

Muhjazi and colleagues report that the Syrian national tuberculosis programme is performing effectively; however, the Global Fund grant rating for 2015–16 was B1-B2 with concerns noted about the accuracy of reporting from Syria’s official surveillance system. The reported incidence of tuberculosis is likely to be only the tip of the iceberg given the inadequate laboratory capacity and diagnostics, particularly in non-government controlled areas where there is over-reliance on smear microscopy rather than culture, which is limited to two central laboratories. Syria’s destroyed health-care system and infrastructure provide ideal conditions for the spread of tuberculosis. As such, investing in cost-effective strategies that rapidly diagnose tuberculosis—eg, Cepheid GeneXpert—including drug-resistant strains are key to implementing an effective national tuberculosis programme. Addressing tuberculosis among besieged and imprisoned populations, using improved diagnostic strategies, and ensuring the availability of antituberculosis therapy for the whole population are key actions required for the future success of Syria’s national tuberculosis programme.

We declare no competing interests.

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