{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,4]],"date-time":"2026-05-04T14:32:04Z","timestamp":1777905124699,"version":"3.51.4"},"reference-count":54,"publisher":"Public Library of Science (PLoS)","issue":"12","license":[{"start":{"date-parts":[[2023,12,27]],"date-time":"2023-12-27T00:00:00Z","timestamp":1703635200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Research for Health in Humanitarian Crises (R2HC) at ELRHA","award":["Grant #38189"],"award-info":[{"award-number":["Grant #38189"]}]},{"name":"Research for Health in Humanitarian Crises (R2HC) at ELRHA","award":["Grant #38189"],"award-info":[{"award-number":["Grant #38189"]}]},{"name":"Research for Health in Humanitarian Crises (R2HC) at ELRHA","award":["Grant #38189"],"award-info":[{"award-number":["Grant #38189"]}]},{"name":"Research for Health in Humanitarian Crises (R2HC) at ELRHA","award":["Grant #38189"],"award-info":[{"award-number":["Grant #38189"]}]},{"name":"Research for Health in Humanitarian Crises (R2HC) at ELRHA","award":["Grant #38189"],"award-info":[{"award-number":["Grant #38189"]}]},{"name":"Research for Health in Humanitarian Crises (R2HC) at ELRHA","award":["Grant #38189"],"award-info":[{"award-number":["Grant #38189"]}]},{"name":"Research for Health in Humanitarian Crises (R2HC) at ELRHA","award":["Grant #38189"],"award-info":[{"award-number":["Grant #38189"]}]}],"content-domain":{"domain":["www.plosglobalpublichealth.org"],"crossmark-restriction":false},"short-container-title":["PLOS Glob Public Health"],"abstract":"<jats:p>Since 2011, Syria has been engulfed in a complex conflict marked by both targeted and indiscriminate attacks on civilians and civilian infrastructure. Water infrastructure has been continuously targeted, exacerbating problems with contamination of and access to clean adequate drinking water, and increasing the risk of waterborne diseases. We aimed to determine whether having access to more functional and chlorinated water stations is associated with a reduced risk of waterborne disease in northwest Syria. We examined the effect of functioning chlorinated water stations on the incidence of waterborne disease in 10 districts of Northwest Syria between January 1, 2017, and June 30, 2021, using weekly reported disease surveillance data and data from a water, sanitation, and hygiene (WASH) system evaluation program of the Assistance Coordination Unit (ACU). We ran eight negative binomial models to examine the association between functioning chlorinated water stations and the incidence of four of the five waterborne diseases: acute bloody diarrhea (ABD), acute other diarrhea (AOD), acute jaundice syndrome (AJS), and severe typhoid fever (STF). Dose-response models were used to investigate how the incidence of disease can theoretically be reduced as functioning and chlorinated water stations strategically increase. Compared to areas with lower quintiles of functioning and chlorinated water stations, the rates of the four waterborne diseases were lower in areas with higher quintiles of functioning and chlorinated water stations. Exposure to functioning water stations had a stronger association with lower rates of waterborne diseases than exposure to chlorinated water stations. Dose-response models demonstrate a potential for curbing the incidence of acute diarrhea and acute jaundice syndrome. The results of this study provide an understanding of the effects of water station functionality and chlorination in conflict settings. These findings support greater prioritization of WASH activities in countries experiencing violence against civilian infrastructure.<\/jats:p>","DOI":"10.1371\/journal.pgph.0002696","type":"journal-article","created":{"date-parts":[[2023,12,27]],"date-time":"2023-12-27T18:22:25Z","timestamp":1703701345000},"page":"e0002696","update-policy":"https:\/\/doi.org\/10.1371\/journal.pgph.corrections_policy","source":"Crossref","is-referenced-by-count":2,"title":["Water and war: The effect of functioning chlorinated water stations in reducing waterborne diseases during conflict in northwest Syria, 2017\u20132021"],"prefix":"10.1371","volume":"3","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9049-984X","authenticated-orcid":true,"given":"Rohini","family":"Haar","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sarah","family":"Abdelrahman","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Evan","family":"Muzzall","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5314-9069","authenticated-orcid":true,"given":"Ibrahim","family":"Aladhan","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4699-2848","authenticated-orcid":true,"given":"Kasim","family":"Shobak","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mohamad Rami","family":"Kawas","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3925-3681","authenticated-orcid":true,"given":"Aya","family":"Aksh","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3901-3656","authenticated-orcid":true,"given":"Alden Hooper","family":"Blair","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Arthur","family":"Reingold","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Naser","family":"AlMhawish","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"340","published-online":{"date-parts":[[2023,12,27]]},"reference":[{"key":"pgph.0002696.ref001","volume-title":"Humanitarian Response Plan Dashboard [Internet];","author":"Global Wash Cluster"},{"key":"pgph.0002696.ref002","volume-title":"UNICEF Strategy for Water, Sanitation and Hygiene 2016\u20132030 [Internet];","author":"UNICEF"},{"key":"pgph.0002696.ref003","first-page":"88","author":"T Yates","year":"2017"},{"key":"pgph.0002696.ref004","unstructured":"Sphere. The Sphere Handbook: Humanitarian Charter and Minimum Standards in Humanitarian Response [Internet]. 2018 [cited 2023 Jun 12]. Available from: https:\/\/handbook.spherestandards.org\/"},{"key":"pgph.0002696.ref005","unstructured":"Rohwerder B. Water, Sanitation and Hygeine (WASH) Syria. In: Syria [Internet]. Institute of Development Studies; 2017. p. 13. (K4D Helpdesk Report). Available from: https:\/\/www.gov.uk\/research-for-development-outputs\/water-sanitation-and-hygiene-wash-in-syria"},{"issue":"1","key":"pgph.0002696.ref006","article-title":"Delivering water, sanitation and hygiene interventions to women and children in conflict settings: a systematic review","volume":"5","author":"D Als","year":"2020","journal-title":"BMJ Glob Health"},{"issue":"1","key":"pgph.0002696.ref007","article-title":"The WASH Approach: Fighting Waterborne Diseases in Emergency Situations.","volume":"123","author":"W. Nicole","year":"2015","journal-title":"Env Health Perspect [Internet]"},{"issue":"10","key":"pgph.0002696.ref008","doi-asserted-by":"crossref","first-page":"e006384","DOI":"10.1136\/bmjgh-2021-006384","article-title":"Overview of attacks against civilian infrastructure during the Syrian civil war, 2012\u20132018","volume":"6","author":"E Muzzall","year":"2021","journal-title":"BMJ Glob Health [Internet]"},{"key":"pgph.0002696.ref009","volume-title":"Humanitarian Needs Overview: Syrian Arab Republic [Internet]","author":"OCHA","year":"2021"},{"key":"pgph.0002696.ref010","volume-title":"Situation Syria Regional Refugee Response [Internet]","author":"UNHCR"},{"issue":"4","key":"pgph.0002696.ref011","doi-asserted-by":"crossref","first-page":"e1002559","DOI":"10.1371\/journal.pmed.1002559","article-title":"Determining the scope of attacks on health in four governorates of Syria in 2016: Results of a field surveillance program. Tsai AC, editor","volume":"15","author":"RJ Haar","year":"2018","journal-title":"PLOS Med [Internet]"},{"issue":"6","key":"pgph.0002696.ref012","doi-asserted-by":"crossref","first-page":"e0217905","DOI":"10.1371\/journal.pone.0217905","article-title":"Attacks on healthcare facilities as an indicator of violence against civilians in Syria: An exploratory analysis of open-source data","volume":"14","author":"S Ri","year":"2019","journal-title":"PloS One"},{"key":"pgph.0002696.ref013","unstructured":"Action against hunger. 9 years of conflict: 15.5 million Syrians lack clean water [Internet]. Reliefweb. 2020. Available from: https:\/\/reliefweb.int\/report\/syrian-arab-republic\/9-years-conflict-155-million-syrians-lack-clean-water"},{"key":"pgph.0002696.ref014","unstructured":"International Committee of the Red Cross. Syria: Water used as weapon of war. ICRC [Internet]. 2015 Sep 2; Available from: https:\/\/www.icrc.org\/en\/document\/syria-water-used-weapon-war"},{"key":"pgph.0002696.ref015","doi-asserted-by":"crossref","first-page":"202","DOI":"10.1016\/j.ijid.2021.05.030","article-title":"Weaponizing water as an instrument of war in Syria: Impact on diarrhoeal disease in Idlib and Aleppo governorates, 2011\u20132019","volume":"108","author":"A Abbara","year":"2021","journal-title":"Int J Infect Dis"},{"issue":"1","key":"pgph.0002696.ref016","first-page":"1","article-title":"Violence against healthcare in conflict: a systematic review of the literature and agenda for future research.","volume":"15","author":"RJ Haar","year":"2021","journal-title":"Confl Health [Internet]"},{"issue":"1","key":"pgph.0002696.ref017","doi-asserted-by":"crossref","DOI":"10.1186\/s13031-018-0151-3","article-title":"Water, sanitation, and hygiene access in southern Syria: analysis of survey data and recommendations for response","volume":"12","author":"M Sikder","year":"2018","journal-title":"Confl Health"},{"key":"pgph.0002696.ref018","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/s13031-023-00502-3","article-title":"Disruption to water supply and waterborne communicable diseases in northeast Syria: a spatiotemporal analysis","volume":"17","author":"R Tabor","year":"2023","journal-title":"Confl Health"},{"key":"pgph.0002696.ref019","unstructured":"ACU. Assistance Coordination Unit- About Us [Internet]. [cited 2023 Jun 12]. Available from: https:\/\/acu-sy.org\/about-us\/"},{"key":"pgph.0002696.ref020","unstructured":"EWARN Staff. Personal Communication from EWARN Staff to Rohini Haar. 2023."},{"key":"pgph.0002696.ref021","article-title":"What Trump just triggered in Syria, visualized.","author":"R Noack","year":"2019","journal-title":"Washington Post [Internet]"},{"key":"pgph.0002696.ref022","unstructured":"Assistance Coordination Unit. Early Warning Alert and Response Network (EWARN) [Internet]. 2016. Available from: https:\/\/acu-sy.org\/ewarn\/"},{"key":"pgph.0002696.ref023","volume-title":"Surveillance standards for vaccine-preventable diseases [Internet]","author":"World Health Organization","year":"2018","edition":"2"},{"key":"pgph.0002696.ref024","unstructured":"EWARN\/ACU. Water-borne Diseases and Water Stations\u2019 Status [Internet]. [cited 2023 Mar 27]. Available from: https:\/\/app.powerbi.com\/view?r=eyJrIjoiNTAwMWRiZDctNzE2MS00NmZkLTg5NTMtZTFkYTk1OTkzMWI3IiwidCI6ImZiMTU5MTQzLTlhNTYtNDRlYS04MWMzLTNiM2NkNGJkMmQ2NyIsImMiOjl9&pageName=ReportSectione00e65459024b1308814"},{"key":"pgph.0002696.ref025","unstructured":"Assistance Coordination Unit. WASH Water Sanitation Hygiene [Internet]. Available from: https:\/\/acu-sy.org\/wash\/"},{"key":"pgph.0002696.ref026","unstructured":"Assistance Coordination Unit. Water Stations\u2019 Status Report [Internet]. 2023 [cited 2023 Oct 30]. Available from: https:\/\/app.powerbi.com\/view?r=eyJrIjoiZDQzMDZiNTktMzlkNy00YmQ5LWE0NDctZjg0ODM5ZDllNDc2IiwidCI6ImZiMTU5MTQzLTlhNTYtNDRlYS04MWMzLTNiM2NkNGJkMmQ2NyIsImMiOjl9&pageName=ReportSectione00e65459024b1308814"},{"key":"pgph.0002696.ref027","unstructured":"Direct communication with ACU staff and authors. 2023."},{"key":"pgph.0002696.ref028","unstructured":"OCHA. Humanitarian Needs Assessment Programme (HNAP) Syria (archived) [Internet]. Available from: https:\/\/www.humanitarianresponse.info\/en\/operations\/syria.%20Accessed"},{"key":"pgph.0002696.ref029","unstructured":"OCHA AOCHAS. Published February 6, 2018 [Internet]. Available from: https:\/\/www.unocha.org\/syrian-arab-republic\/about-ocha-syria"},{"key":"pgph.0002696.ref030","article-title":"R. 8.6 Should I Convert a Continuous Variable to a Categorical Variable? |","author":"P EH","journal-title":"R for Health Data Science [Internet]"},{"key":"pgph.0002696.ref031","unstructured":"Negative Binomial Regression | Stata Data Analysis Examples [Internet]. Available from: https:\/\/stats.idre.ucla.edu\/stata\/dae\/negative-binomial-regression\/"},{"key":"pgph.0002696.ref032","doi-asserted-by":"crossref","DOI":"10.1017\/CBO9780511973420","volume-title":"Negative Binomial Regression.","author":"JM Hilbe","year":"2011"},{"key":"pgph.0002696.ref033","unstructured":"Centre for Health Protection, Department of Health\u2014Acute Diarrhoeal Diseases [Internet]. Available from: https:\/\/www.chp.gov.hk\/en\/healthtopics\/content\/24\/10.html"},{"key":"pgph.0002696.ref034","volume-title":"Hepatitis E [Internet];","author":"World Health Organization"},{"key":"pgph.0002696.ref035","unstructured":"Viral Hepatitis and Hepatitis A Outbreak | University Health Service [Internet]. Available from: https:\/\/uhs.umich.edu\/hepatitis#hepa"},{"key":"pgph.0002696.ref036","unstructured":"Health. Victoria A D. Typhoid and paratyphoid [Internet]. Available from: http:\/\/www.health.vic.gov.au\/infectious-diseases\/typhoid-and-paratyphoid"},{"issue":"19","key":"pgph.0002696.ref037","first-page":"335","article-title":"Confidence Interval or P-Value?","volume":"106","author":"JB du Prel","year":"2009","journal-title":"Dtsch Arztebl Int"},{"key":"pgph.0002696.ref038","unstructured":"ESRI. ArcGIS Online [Internet]. [cited 2023 Mar 27]. Available from: https:\/\/www.arcgis.com\/index.html"},{"issue":"12","key":"pgph.0002696.ref039","doi-asserted-by":"crossref","first-page":"e0146021","DOI":"10.1371\/journal.pone.0146021","article-title":"Dose-Response Analysis Using R.","volume":"10","author":"C Ritz","year":"2015","journal-title":"PLOS ONE [Internet]"},{"key":"pgph.0002696.ref040","unstructured":"R Core team. R: The R Project for Statistical Computing [Internet]. [cited 2021 May 28]. Available from: https:\/\/www.r-project.org\/"},{"issue":"11","key":"pgph.0002696.ref041","doi-asserted-by":"crossref","first-page":"1211","DOI":"10.1016\/S1473-3099(18)30362-1","article-title":"Estimates of the global, regional, and national morbidity, mortality, and aetiologies of diarrhoea in 195 countries: a systematic analysis for the Global Burden of Disease Study 2016","volume":"18","author":"C Troeger","year":"2018","journal-title":"Lancet Infect Dis"},{"key":"pgph.0002696.ref042","article-title":"Syria war: Rebel-held Idlib \u201chit by 200 air strikes in three days","author":"BBW News","year":"2020","journal-title":"BBC News [Internet]"},{"issue":"2","key":"pgph.0002696.ref043","doi-asserted-by":"crossref","first-page":"11","DOI":"10.2307\/1602354","article-title":"Environmental Health Hazards: How Children Are Different from Adults.","volume":"5","author":"CF Bearer","year":"1995","journal-title":"Future Child [Internet]"},{"key":"pgph.0002696.ref044","article-title":"A Systematic Review of Water and Gender Interlinkages: Assessing the Intersection With Health.","author":"P Pouramin","year":"2020","journal-title":"Front Water [Internet]"},{"issue":"2","key":"pgph.0002696.ref045","doi-asserted-by":"crossref","first-page":"249","DOI":"10.1128\/aem.40.2.249-256.1980","article-title":"Comparative inactivation of viruses by chlorine","volume":"40","author":"RS Engelbrecht","year":"1980","journal-title":"Appl Environ Microbiol"},{"issue":"10357","key":"pgph.0002696.ref046","doi-asserted-by":"crossref","first-page":"986","DOI":"10.1016\/S0140-6736(22)01836-0","article-title":"War driving cholera in Syria","volume":"400","author":"S. Devi","year":"2022","journal-title":"The Lancet [Internet]"},{"issue":"10367","key":"pgph.0002696.ref047","doi-asserted-by":"crossref","first-page":"1925","DOI":"10.1016\/S0140-6736(22)02320-0","article-title":"Weaponisation of water","volume":"400","author":"A Abbara","year":"2022","journal-title":"The Lancet [Internet]"},{"key":"pgph.0002696.ref048","article-title":"Exclusive: The day the data died in Syria.","author":"C Lynch","year":"2023","journal-title":"Devex [Internet]"},{"key":"pgph.0002696.ref049","unstructured":"Inside Syria\u2019s water crisis: A cholera outbreak in the making\u2014Syrian Arab Republic | ReliefWeb [Internet]. 2023 [cited 2023 Jun 12]. Available from: https:\/\/reliefweb.int\/report\/syrian-arab-republic\/inside-syrias-water-crisis-cholera-outbreak-making"},{"key":"pgph.0002696.ref050","volume-title":"And it\u2019s not going away. [Internet]","author":"H. Dagres","year":"2022"},{"key":"pgph.0002696.ref051","volume-title":"Providing safe water to 16,000 people in northern Syria [Internet].","author":"ACTED","year":"2021"},{"key":"pgph.0002696.ref052","volume-title":"We must demand justice for atrocities against health care [Internet]","author":"L. Rubenstein","year":"2023"},{"key":"pgph.0002696.ref053","volume-title":"Strengthening Data to Protect Healthcare in Conflict Zones [Internet]","author":"R Haar","year":"2022"},{"key":"pgph.0002696.ref054","volume-title":"Surveillance system for attacks on health care (\u200eSSA) Methodology [Internet].","author":"WHO","year":"2019"}],"container-title":["PLOS Global Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pgph.0002696","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,12,27]],"date-time":"2023-12-27T18:23:06Z","timestamp":1703701386000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pgph.0002696"}},"subtitle":[],"editor":[{"given":"Rajiv","family":"Sarkar","sequence":"first","affiliation":[],"role":[{"role":"editor","vocabulary":"crossref"}]}],"short-title":[],"issued":{"date-parts":[[2023,12,27]]},"references-count":54,"journal-issue":{"issue":"12","published-online":{"date-parts":[[2023,12,27]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pgph.0002696","relation":{},"ISSN":["2767-3375"],"issn-type":[{"value":"2767-3375","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,12,27]]}}}