An Emerging Health Crisis in Turkey and Syria after the Earthquake Disaster on 6 February 2023: Risk Factors, Prevention and Management of Infectious Diseases

On 6 February 2023, two major earthquakes (Mw 7.8 and Mw 7.5) struck southeastern Turkey and northern Syria along the East Anatolian Fault Zone, causing catastrophic destruction of buildings and infrastructure and very high casualties. As of 13 February 2023, Turkey reported 31,643 deaths and 158,165 evacuees, while Syria reported over 5,000 deaths. WHO estimated 15 million people affected in Turkey and 10.87 million in Syria, with nearly 26 million people exposed and over 5 million considered vulnerable. Beyond the immediate trauma burden, the authors warn of an emerging public health threat from sporadic cases, outbreaks, and epidemics of infectious diseases in affected populations and responders. The study aims to identify risk factors for infectious diseases in the impacted areas, using field data from post-event surveys and experience in disaster management, and to propose preventive and control measures within a multi-hazard framework informed by lessons from past events and the ongoing COVID-19 pandemic.

Past Turkish earthquakes (1999 Izmit Mw 7.6; 2011 Van Mw 7.1) led to increases in gastrointestinal infections (e.g., Shigella, Salmonella, Giardia) due to hot weather, infrastructure damage, and unsafe water. After Izmit, diarrheal diseases rose until mid-September 1999, with Shigella predominant. Inconsistent water supply and sanitation in shelters increased Hepatitis A and E among children; faster preventive actions after the Düzce quake reduced HAV/HEV prevalence compared to Izmit, though HAV remained prevalent years later. Prolonged residence in temporary settlements correlated with higher giardiasis and enterobiasis among children versus peers in normal conditions. Dermatologic issues (infections/infestations, eczemas, neurocutaneous dermatoses) were linked to damaged infrastructure, poor hygiene, and psycho-emotional stress. Wound infections after Izmit and Van were often hospital-acquired, mainly due to resistant Gram-negative bacteria, particularly Acinetobacter baumannii, contributing to sepsis risk in crush injuries. Evidence from Japan (2011 earthquake/tsunami) showed crowded shelters, malnutrition, aspiration, and cold temperatures increasing pneumonia among evacuees, especially elders.

The authors conducted rapid post-event field surveys in the most affected urban centers (Kahramanmaraş, Nurdağı, Gaziantep, Osmaniye, Adana, İskenderun, Antakya) shortly after the earthquakes. E. Lekkas joined the Greek search and rescue mission (EMAK units, Hellenic Fire Service, EKAB, EPPO) operating in Hatay province, while S. Mavroulis participated as part of a scientific mission, collecting disaster-related data for five consecutive days. Data collected included: structural damage to buildings and health facilities; impacts on roads and lifelines (drinking water, electricity); functionality of product distribution networks; and emergency response actions (provision of essentials, adequacy and siting of temporary shelters). The team evaluated field observations to identify prevailing risk factors for infectious disease emergence and to select preventive and management measures. Complementarily, they reviewed examples of infectious disease outbreaks following past Turkish earthquakes to contextualize current risks.

- Extensive damage to healthcare infrastructure: at least 15 hospitals in Turkey suffered partial/heavy damage and 48 health facilities were affected in northwest Syria; evacuations and staff casualties reduced care capacity and delayed treatment. - Lifeline disruption: destroyed water supply and sewerage systems led to interruptions in safe drinking water and contamination risks, increasing the likelihood of water- and food-borne diseases; electricity/telecom failures and disrupted distribution chains hindered access to food, hygiene items, and medical supplies. - Shelter-related risks: massive displacement to emergency shelters and camps created overcrowding, poor ventilation/heating, inadequate hygiene and sanitation, unsafe water, malnutrition, and cold exposure, increasing risks of respiratory infections (influenza, pneumonia, COVID-19), gastrointestinal illnesses, and skin/wound infections. - Environmental and vector/rodent risks: altered human–pathogen–environment interactions, garbage accumulation, poor waste management, and rodent infestations heighten risks for leptospirosis and other rodent-borne diseases; vector-borne risks may rise if control programs are disrupted. - Compounding crises: in northwest Syria, prolonged conflict, fragile health systems, economic instability, COVID-19, and an ongoing cholera epidemic (linked to contaminated Euphrates water) exacerbate outbreak risks. - Immunization and treatment disruptions: interruptions to vaccination programs (e.g., MMR) and TB treatments may increase vaccine-preventable diseases and transmission; Turkey recorded over 1,050,000 measles cases (1960–2019), with recent vulnerabilities among unvaccinated populations and in conflict-affected Syrian communities. - Epidemiologic context: nearly 26 million people exposed, with 5.08 million vulnerable (including >345,000 elderly and >1.4 million children), suggesting high susceptibility to outbreaks if preventive measures lag.

A robust, rapid infectious disease surveillance system is critical to detect sporadic cases, monitor trends, and issue early warnings for epidemic-prone diseases. Surveillance objectives include describing disease burden/epidemiology, tracking trends and causative agents, and detecting outbreaks/new pathogens. Tailored surveillance approaches should match disease epidemiology and clinical presentations. To reduce transmission in shelters, authorities should provide safe bottled water, shelf-stable food, adequate heating/ventilation, PPE (masks, gloves, disinfectants), sufficient medical supplies and vaccines, and implement hygiene promotion and sanitation measures (education, signage, individual toilets/trench latrines, handwashing with soap). Overcrowding can be mitigated by diversifying shelter types (e.g., campervans, containers, hotel rooms, host families) and ensuring warmth to prevent hypothermia-associated respiratory infections. Vaccination (MMR, influenza, Hib, pneumococcal, polio) should begin promptly upon camp assembly; WHO/UNICEF initiated a cholera vaccination campaign in Northwest Syria. Water and sanitation systems require inspection for structural/non-structural failures, with chlorination, alternative sourcing, and disinfection as needed, and WASH safety ensured in shelters and camps. Rodent-borne disease risk reduction demands rapid identification of local rodent species, breeding habitats, and environmental drivers, alongside avoidance of exposure-prone areas (uncontrolled waste sites, stagnant water) and improved waste management. Community and responder education on transmission modes, symptoms, and early care-seeking can reduce morbidity/mortality. Disasters do not introduce new diseases; they foster transmission of endemic or imported pathogens when conditions allow. Rapid risk assessments in the initial weeks should quantify population displacement, infrastructure disruptions, and specific infectious risk profiles to guide targeted interventions.

Post-earthquake conditions in southeastern Turkey and northern Syria created a convergence of risk factors for infectious disease emergence and spread, including healthcare infrastructure damage, lifeline failures, overcrowded shelters, unsafe water, poor sanitation, cold exposure, and disrupted public health programs. Compounded by conflict, COVID-19, and cholera in Syria, the humanitarian situation heightens outbreak risk. Effective disease surveillance at local and regional levels is essential for early warning and response. Prevention and control should follow a multi-hazard approach applying lessons from past disasters: rapid provision of essentials and temporary housing, adequate medical supplies, vaccination campaigns, WASH measures and hygiene promotion, inspection and disinfection of water systems, rodent/vector control, and public education. Implementing these measures can mitigate potentially uncontrollable transmission of water-borne, rodent-borne, respiratory, and skin infections in the affected areas.