在烏克蘭的戰爭中斷了結核病之服務
在烏克蘭的戰爭威脅到該國結核病患者照護的連續性。埃德.霍爾特報導。
資料來源：http://www.thelancet.com/infection Vol 22 May 2022；財團法人台灣紅絲帶基金會編譯
參與烏克蘭應對結核病的人士警告說，在烏克蘭的戰爭可能會使已經是世界上結核病(TB)最嚴重流行地區之一的該國更惡化。他們說，戰鬥、對醫療設施和醫務人員的直接襲擊、數百萬人流離失所，以及藥物獲得和提供的問題正在擾亂對患者的治療。
世衛組織結核病小組負責人 Askar Yedilbayev 告訴《刺胳針傳染病》雜誌：「對於那些逃到烏克蘭境內或國外之其他地區的人來說，繼續治療存在著風險。對結核病和耐藥結核病的連續治療的中斷將產生嚴重後果，例如擴大對藥物之耐藥性、造成感染之傳播，尤其是耐藥菌株的傳播，以及死亡」。
烏克蘭的結核病發生率在世衛組織歐洲區域中排名第四，而超級耐藥結核病(extensively drugresistant TB, XDR-TB)確診病例的數量更在世界上排名第五。自 2 月 24 日俄羅斯入侵以來，由於俄羅斯軍隊對城市以及醫院和醫護人員為目標的無情轟炸，烏克蘭的醫療保健系統正承受著越來越大的壓力。
在撰寫本文此時，世衛組織表示，結核病和耐藥結核病（DR-TB）的治療「在整個烏克蘭基本上都可以獲得」，藥物供應充足，尤其是耐藥性結核。它承認「外部因素」已經在影響照護的連續性，並引用了一個地區的倉庫被炸毀的例子，已迫使其他地區的藥品難以重新分配。
戰前已經在該國開展結核病照護工作的醫療機構表示，他們將繼續提供服務，包括提供藥物，但由於安全擔憂和交通問題，道路被難民或俄羅斯軍隊堵塞，已越來越困難。
克拉馬托爾斯克市紅十字會負責人柳博夫.別列日納（Lyubov Berezhna）說：「我們正在努力滿足患者的需求，我們都在盡最大努力。情況每天都在惡化，誰也不知道明天會發生什麼」。與此同時，其他組織被迫大幅縮減其業務規模。
參與烏克蘭結核病應對工作的最大非國家組織之一的公共衛生聯盟之葉夫根尼婭.格留赫 (Evgenia Geliukh) 說：「以前，我們和我們的合作夥伴提供廣泛的服務，但現在於某些地方，僅只是檢查結核病患者是否持續堅持在他們的治療方案中，且在一些地方主動去發現活動性結核病例則已經停止」。
在烏克蘭，估計該國內有近 600 萬流離失所的人在獲得藥品上亦是問題。國內流離失所的結核病患者可以在他們能到達的任何醫療機構接受治療，但並不能保證有藥物可用。「有這麼多人離開烏克蘭東部，在更西部之其他地方的需求已見增加，因此[結核病藥物]供應出現問題」，Geliukh 說。
這種情況已經引起了一些專家的可怕警告。葉迪爾巴耶夫說：「戰爭和人道主義危機將對烏克蘭的結核病和耐藥結核病產生負面影響。結核病和耐藥結核病的延遲診斷將會導致開始適當治療時間的延遲，最終導致……治療結果不佳，因未診斷而加鉅，結果未治療個案亦造成社區中感染的持續傳播」。
與此同時，自入侵開始以來已有超過 300 萬人逃離該國，難民中結核病的風險也成為關注焦點。在本月早些時候發布的一份報告中，歐洲疾病預防和控制中心 (ECDC) 敦促烏克蘭的鄰國確保難民能夠獲得醫療保健服務，以幫助及早發現傳染病。
ECDC 移民健康專家 Teymur Noori 表示，該組織「擔心難民中的結核病，尤其是耐多藥結核病」，但強調該機構的建議是針對難民而不是當地人口所提出的。「[建議是]烏克蘭以外的醫療保健系統可以準備去減輕危機對難民本身所造成的健康影響。我們並不擔心當地居民會因為難民而爆發傳染病」。
在所有歐盟國家和英國，烏克蘭難民都獲得了當地醫療保健服務，耶迪爾巴耶夫說，世衛組織正在與鄰國的衛生當局合作，以「確保需要繼續治療的難民以及任何在烏克蘭以外被診斷出患有結核病的人，獲得結核病和耐藥結核病之治療」。
聯合國愛滋病規劃署東歐和中亞特別顧問米歇爾.卡扎奇金說，他相信患有結核病的烏克蘭難民人數將界於 1,000 到 2,000 人之間。 Covid-19 已經對結核病病例的偵測和檢驗產生了巨大影響，而現在最主要的情況是確保現有的治療」，Kazatchkine 補充道。
埃德.霍爾特敖報導。
Tuberculosis services disrupted by war in Ukraine
The war in Ukraine is threatening continuity of care for patients with tuberculosis in the country. Ed Holt reports.
War in Ukraine could worsen what is already one of the world’s most serious tuberculosis (TB) epidemics, those involved in the country’s response to the disease have warned. Fighting, direct attacks on health-care facilities and medics, displacement of millions of people, and problems with access to and delivery of medicines are disrupting treatment for patients, they say.
Askar Yedilbayev, WHO TB team lead, told The Lancet Infectious Diseases: “For those escaping to other regions within Ukraine, or outside the country, continuity of treatment is at risk. Interruption of continuity of treatment for TB and DR-TB will have serious consequences, such as amplification of drug-resistance, transmission of infection, especially with resistant strains, and death”.
Ukraine has the fourth-highest TB incidence in the WHO European Region and the fifth-highest number of confirmed cases of extensively drugresistant TB in the world. Since the Russian invasion on Feb 24, Ukraine’s health-care system has come under increasing pressure amid relentless bombardment of cities and targeting of hospitals and health-care workers by Russian forces.
At the time of writing, WHO said that treatment for TB and drug-resistant TB (DR-TB) was “largely available across Ukraine”, with sufficient supply of medicines, especially for DR-TB. It admitted though that “external factors” were already affecting continuity of care, citing the example of warehouses in one region being bombed, forcing difficult reallocation of drugs from other regions.
Medical organisations already working in the country to deliver TB care before the war have said that they are continuing to provide services, including medicine deliveries, but are finding it increasingly difficult due to security worries and transportation issues, with roads clogged with refugees or Russian troops.
Lyubov Berezhna, the head of the Red Cross in Kramatorsk, said: “We are trying to meet patients’ needs and we are all doing the maximum we can. The situation is getting worse every day, and no one knows what tomorrow will bring”. Meanwhile, other organisations have been forced to drastically cut back the scale of their operations.
Evgenia Geliukh of the Alliance for Public Health, one of the biggest non-state organisations involved in Ukraine’s TB response, said: “Before, we and our partners provided a wide spectrum of services, but now in some places it’s just checking that TB patients are sticking to their regimen, and in some places finding active TB cases has stopped”.
Access to medicines is also problematic for the estimated almost 6 million internally displaced people in Ukraine. Internally displaced patients with TB can receive treatment at any health-care facility they can get to, but there is no guarantee drugs will be available. “With so many people leaving eastern Ukraine, other places further west are seeing higher demand and therefore problems with supply [of TB drugs]”, said Geliukh.
The situation has prompted dire warnings from some experts. Yedilbayev said: “War and humanitarian crisis will have a negative impact on TB and DR-TB in Ukraine. Delayed diagnosis of TB and DR-TB will result in delays to initiation of appropriate treatment, eventually leading to…poor treatment outcomes, which will be aggravated by undiagnosed and, as a result, untreated TB cases, and continuous transmission of infection in communities”.
Meanwhile, with more than 3 million people having fled the country since the start of the invasion, the risk of TB among refugees has also come into focus. In a report released earlier this month, the European Centre for Disease Prevention and Control (ECDC) urged Ukraine’s neighbouring states to ensure refugees had access to health-care services to help in the early detection of infectious diseases.
Teymur Noori, ECDC expert in migrant health, said the organisation was “worried about TB, especially MDR-TB” among refugees but stressed the institution’s recommendations were made with refugees, not local populations, in mind. “[The recommendations are] so healthcare systems outside Ukraine can prepare to mitigate the health impacts of the crisis on refugees themselves. We’re not worried about local populations seeing outbreaks of infectious diseases because of refugees.”
In all EU countries, and in the UK, Ukrainian refugees have been given access to local health care and Yedilbayev said WHO was working with health authorities of neighbouring countries to “ensure access to TB and DR-TB treatment for refugees requiring continuation of treatment and anyone diagnosed with TB outside Ukraine”.
Michel Kazatchkine, UNAIDS special advisor for Eastern Europe and Central Asia, said he believed the numbers of Ukrainian refugees with TB would be between 1000 and 2000. “The war has been a setback for TB efforts in Ukraine. Covid-19 had already had a great effect on testing and detecting TB cases and the situation now is largely one of just safeguarding existing treatment”, Kazatchkine added. Ed Holt