戰爭與傳染病：難兄難弟
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
圖片來源：Flickr/Mirek Pruchnicki
2022年2月24日，俄羅斯入侵烏克蘭。入侵導致人員死亡、受傷和流離失所。即使正在進行的和平談判使敵對行動停止，烏克蘭也可能在未來幾年繼續遭受苦難。戰爭總是伴隨著傳染病的爆發，烏克蘭也不例外。
俄羅斯的入侵嚴重破壞了烏克蘭的醫療保健基礎設施，世衛組織證實至少有 70 起俄羅斯襲擊了烏克蘭各地的醫療保健設施。此類襲擊，伴隨著道路、橋樑和公共交通網絡的破壞，使公民無法獲得醫療幫助，增加了長期受傷和感染的風險。而且，一旦戰鬥停止，獲得醫療保健的機會減少將阻礙試圖重建的人群。
專業服務也受到干擾。俄羅斯的軍事襲擊迫使愛滋病保健基金會在哈爾科夫和馬里烏波爾的愛滋病毒診所關閉，增加了這些城市愛滋病毒感染者治療中斷的風險。治療中斷與發展為耐藥性 HIV 的風險增加、治療選擇範圍的縮小和疾病傳播增加有關。結核病控制工作也受到了類似的影響。那些逃離衝突地區前往烏克蘭更安全地區的肺結核患者也面臨著治療中斷、死亡、傳播和出現耐藥性等風險增加的情況。 SARS-CoV-2 也將傳播，因為在地下避難所中難以保持物理距離，並且疫苗接種工作因戰爭而中斷。在入侵之前，疫苗接種工作已經很低，只有 35% 的烏克蘭居民完全接種了 SARS-CoV-2 疫苗。這種低疫苗接種率亦只是歡迎逃離烏克蘭難民的國家所需要考慮的健康問題之一。鑑於烏克蘭難民在逃亡期間的生活條件，他們也可能會更容易受到感染。
這些是當前的傳染病問題，遺憾的是，透過其他衝突我們更可以確定其可能的長期後果。自 2011 年以來，敘利亞一直陷入內戰。2016 年，在為期 6 個月的阿勒頗圍城戰中，親政府軍切斷了補給線，襲擊了醫療設施，使這座 25 萬人口的城市缺乏藥品和食物。內戰和圍困的結果之一是，在 2017 年和 2018 年，包括阿勒頗在內的敘利亞北部爆發了麻疹疫情，此前該國自 1999 年以來一直沒有麻疹。類似的故事可能在烏克蘭上演。 2021 年 10 月，烏克蘭報告了一例麻痺性脊髓灰質炎病例，促使政府開始為 10 萬未受保護的兒童接種疫苗，但卻因被入侵而停止。
烏克蘭的戰爭希望不會成為一場曠日持久的衝突。與敘利亞一樣，衝突持續的時間越長，從衛生部門轉移到戰爭的資源就越多。在阿富汗，美國（及其盟友）在該國軍事存在 20 年後，有 200 萬兒童營養不良。缺乏食物會削弱免疫系統，這也是阿富汗目前試圖迅速為其人口接種疫苗以阻止麻疹爆發的部分原因。自 2014 年以來遭受內戰的葉門也出現了類似的資源重新分配。 400 萬葉門人在國內流離失所因而無法獲得適當的水和衛生服務，從而增加了罹患腹瀉疾病的風險。 2017 年霍亂爆發，疑似病例為 250 萬例，造成 3,868 人死亡。戰前，葉門並沒有霍亂。
烏克蘭難民的長期健康也應該受到關注，特別是如果他們長期被安置在難民營中。 2017 年 8 月，數十萬穆斯林羅興亞人因緬甸軍方實施的暴力，逃離緬甸。截至 2021 年 2 月，孟加拉國已為超過 870,000 名羅興亞人提供了避難所，庫圖帕隆難民營（及相關擴展營地）的人數達到驚人的 719,000 人。擁擠在這樣一個地方，衛生條件不當，人們罹患瘧疾和登革熱等疾病的風險增加，孟加拉國從 6 月到 10 月的季風季節將使這種情況更惡化。
其他衝突凸顯了烏克蘭人民面臨的風險，惟鑑於國際社會對烏克蘭的支持，希望能夠避免其中的大量衝突。然而，如果在烏克蘭它們應該被避免，我們還應該反思西方對於上述非西方國家和主要非白人國家其傳染病和戰爭的容忍度。 ■ 刺胳針傳染病
War and infectious diseases: brothers in arms
On Feb 24, 2022, Russia invaded Ukraine. The invasion has resulted in death, injury, and the displacement of people. Even if ongoing peace talks bring a cessation to hostilities, Ukraine will likely continue to suffer for years to come. War is always accompanied by infectious disease outbreaks, and Ukraine will likely be no exception.
The Russian invasion has severely damaged Ukraine’s health-care infrastructure, with WHO confirming at least 70 Russian attacks on health-care facilities across Ukraine. Such attacks, combined with the destruction of roads, bridges, and public transportation networks, prevent citizens from receiving medical help, increasing the risk of long-term injury and infection. And, once the fighting has stopped, reduced access to healthcare will hamper a population trying to rebuild.
Specialist services have also been disrupted. Russian military assaults have forced the closure of the AIDS Healthcare Foundation’s HIV clinics in Kharkiv and Mariupol, raising the risk of treatment interruption in people with HIV in these cities. Interruption is associated with an increased risk of developing drug-resistant HIV, narrowing treatment options and increasing transmission. Tuberculosis control efforts have been similarly impacted. Those suffering from tuberculosis, who have been fleeing conflict zones to reach safer regions of Ukraine, risk discontinuity of treatment, increasing risk of death, transmission, and emergence of drug resistance. SARS-CoV-2 will also spread as physical distancing is made difficult in underground shelters and vaccination efforts are disrupted by the war. Vaccination efforts were already low before the invasion, with only 35% of Ukraine residents fully vaccinated against SARS-CoV-2. This low vaccination rate is just one of the health concerns that countries welcoming fleeing Ukrainians need to consider. Ukrainian refugees are also likely to be more vulnerable to infection given their living conditions during their escape.
These are current infectious disease concerns, and we can, sadly, look to other conflicts to identify possible long-term consequences. Syria has been gripped by civil war since 2011. In 2016, during the 6-month Siege of Aleppo, pro-government forces cut supply lines and attacked medical facilities, leaving a city of 250000 short of medicine and food. One of the outcomes of the civil war and the siege has been, in 2017 and 2018, a measles outbreak across northern Syria, including Aleppo, after the disease had been absent in the country since 1999. A similar story could play out in Ukraine. In October 2021, Ukraine reported a case of paralytic polio prompting the government to begin vaccinating 100000 unprotected children, a rollout halted by the invasion.
The war in Ukraine hopefully will not become a protracted conflict. As with Syria, the longer a conflict goes on, the more resources are diverted from health towards warfare. In Afghanistan, after 20 years of US (and their allies) military presence in the country, 2 million children are malnourished. Lack of food weakens the immune system and is part of the reason Afghanistan is currently trying to rapidly vaccinate its population to halt their own measles outbreak. Yemen, suffering from a civil war since 2014, has also seen a similar redistribution of resources. 4 million Yemenis have been internally displaced with reduced access to suitable water and sanitation services, increasing the risk of diarrhoeal diseases. In 2017, a cholera outbreak with a suspected 2·5 million cases was responsible for 3868 deaths. Before the war, cholera had been absent from Yemen.
The long-term health of Ukraine refugees should also be of concern, escpecially if they are housed in refugee camps for prolonged periods. In August 2017, fleeing violence perpetrated by the Burmese military, hundreds of thousands of Muslim Rohingya people fled Burma. As of Feb 2021, over 870000 Rohingya have been provided shelter in Bangladesh, a staggering 719000 in the Kutupalong Refugee Camp (and associated extension camps). Individuals crowded in such a location, with improper sanitation, are at increased risk of diseases such as malaria and dengue, a situation worsened by Bangladesh’s monsoon season that runs from June to October.
Other conflicts highlight the risks that the Ukrainian people face but given the international response in support of Ukraine hopefully a large number of them can be avoided. But, should they be avoided in Ukraine, we should also reflect on the West’s tolerance of infectious diseases and war in the above, nonWestern, and predominantly non-white countries. ■ The Lancet Infectious Diseases
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