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COVID-19 Resurgence, Other Infections and the Loss of Healthcare for 3 Million People
Casualties of War COVID-19 Resurgence, Other Infections and the Loss of Healthcare for 3 Million People
BY MARIE ROSENTHAL, MS
Just as the world was taking baby steps toward a return to normal after two years of the COVID-19 pandemic, Russia invaded Ukraine, forcing a tidal wave of more than 3 million refugees into neighboring countries. Along with this humanitarian crisis comes another casualty of war: a possible resurgence of COVID-19 and other infections.
“Even if the pandemic hadn’t happened, it is well known that whenever you get mass migration, this favors infectious disease transmission,” said Mark Wilcox, MD, FRCPath, a professor of medical microbiology and the Sir Edward Brotherton Chair of Bacteriology at the University of Leeds, in England, who is also a member of the editorial advisory board of Infectious Disease Special Edition (IDSE). “So, if you look at the history of influenza or the history of meningococcal disease, you get peaks whenever you have mass migration. Unfortunately, it’s very predictable, and this is a mass migration where we will almost certainly see a resurgence of COVID-19,” he said.
The Threats
After weeks of decline, COVID-19 has started inching back up in Europe. In fact, cases around the world increased 8% by March 14, a reminder that COVID-19 is not over, according to Tedros Adhanom Ghebreyesus, MS, PhD, the director-general of the World Health Organization.
“Although reported [COVID-19] cases and deaths are declining globally, and several countries have lifted restrictions, the pandemic is far from over, and it will not be over ‘anywhere’ until it’s over ‘everywhere,’” Dr. Tedros said at a media update.
The big unknown is the effect the war in Ukraine will have on the pandemic. Will there be another surge, a new variant of concern, or will this mass migration just allow for efficient
transmission of omicron among a largely unvaccinated population and/or among older people with waning immunity? Only 34.5% of Ukraine’s population is fully vaccinated against COVID-19.
“I have been fretting about this now for weeks, and I am concerned that the Eastern European countries are under-vaccinated both against influenza and COVID-19,” said William Schaffner, MD, a professor of health policy and preventive medicine in the Department of Health Policy at Vanderbilt University, in Nashville, Tenn.
“I am very concerned that the conditions we are seeing— mass refugees, people crowded together—are ideal for the transmission of respiratory viruses and other infections,” he added.
Influenza, rhinoviruses and human metapneumovirus are additional threats, Dr. Schaffner noted. Although most of these are relatively minor illnesses, they can be more severe in certain populations, such as those fleeing Ukraine. “We worry most about the very young and the very old, and this refugee population is enriched with these parts of the demographic spectrum,” Dr. Schaffner said.
Testing and surveillance for COVID-19 has decreased worldwide, according to the WHO, which is another issue. As the humanitarian crisis continues, it will be harder and harder to do among the refugees.
“The likelihood that they will be able to do surveillance for COVID is not great,” admitted Stuart Campbell Ray, MD, a professor of medicine at the Johns Hopkins University, in Baltimore, and a member of the IDSE editorial advisory board. “It would be smart to do some statistical sampling, at least, to detect if an outbreak started to occur because it could be a real challenge. But then whose lab is going handle all that volume? There are a bunch of logistical problems,” Dr. Ray said.
Worsening Situation
The untenable situation was exacerbated by Russia’s targeting of hospitals and other medical establishments, according to the WHO. As of March 13, the WHO verified 31 reports of attacks on healthcare facilities in Ukraine since Feb. 24.
“I worry about healthcare systems buckling [in Ukraine and receiving countries],” said Rajesh T. Gandhi, MD, a professor of medicine at Harvard Medical School, in Boston. “Obviously, it’s a complicated situation because the war itself is decimating the ability to provide healthcare, and then if you add to that the potential for increasing rates of severe COVID-19, I think it’s a perfect storm of potential problems.”
Most healthcare systems are already stretched because of COVID-19, Dr. Wilcox reminded, who is also a consultant and the head of microbiology research and development at Leeds Teaching Hospitals NHS Trust. “In a small country like Poland, I just can image what a [serious] outbreak would do to their healthcare system,” he said.
The humanitarian emergency is affecting Ukraine, Slovakia, Hungary, Moldova and the rest of Europe, according to the WHO, but the country most affected besides Ukraine has to be Poland, which has taken in most of the refugees. More than 1.4 million people fled to Poland, a country of about 38 million people, between Feb. 24 and March 9, and the numbers are expected to grow exponentially. The United Nations High Commissioner for Refugees estimates that by July 2022, 4 million refugees will leave Ukraine.
“We have the health risks of people on the move, mainly women and children,” said Mike Ryan, MPH, MB, BCh BAO, the executive director of the WHO Health Emergencies Programme, an epidemiologist and trauma surgeon, who has been managing acute health risks around the globe for nearly 25 years.
“We also have a complex situation with many, many older persons with complex health needs who may not be able to move or cannot move so easily, and getting aid and assistance to them is very important.
“We have had circulating vaccine-derived polio, COVID and other diseases previously and currently there. There have been previous epidemics of cholera in Ukraine. All of these risks remain,” Dr. Ryan reminded at the briefing.
1.5M Poland 1,412,503
1.2M
900K
600K
300K
0
Other European Countries 258,844 Hungary 214,160 Slovakia 165,199 Russian Federation 97,098
Romania 84,671 Moldova 82,762 Belarus 765
Figure. Population movement and displacement of refugees from Ukraine to surrounding countries as of March 9, 2022. Source: WHO
So Many Levels of Complexity
There are numerous levels of complexity when it comes to infectious disease threats and helping the refugees, according
to Dr. Ray, who is also the vice chair of medicine for data integrity and analytics in the Department of Medicine at Hopkins. “For one thing, just the human movement; we could digress and talk about a bunch of infectious diseases that have been seen when there’s large human movements. This sort of crisis is a breeding ground for both endemic and epidemic disease.
“Another dimension, of course, is the healthcare system in the arriving site, which is going to be overwhelmed simply by the number of people arriving,” he said.
Finally, all refugees with chronic conditions from cardiovascular disease and diabetes to cancer and HIV, who need immediate care and possibly medication and who probably will not have medical records will further increase the healthcare burden, Dr. Ray explained.
“We’ve all heard about some of the kids with cancer who are arriving in some neighboring countries and needing care with very few records. That just illustrates the kind of disruption of usual care this kind of migration creates, and then you add to that the possibility of epidemic disease, and it is a very difficult situation,” he added.
Dr. Gandhi, who is also the co-director and principal investigator at the Harvard Center for AIDS Research, as well as an immediate past president of the HIV Medicine Association, is particularly concerned about HIV. According to UNAIDS, Ukraine has the second-largest HIV epidemic in Eastern Europe and Central Asia, with an estimated 250,777 people living with HIV in 2019.
“One of the key things about infectious diseases that distinguishes them from other diseases is disruptions in care carry the prospect of resulting drug resistance,” said Dr. Gandhi, who is also a member of the IDSE editorial advisory board. “We don’t want people with HIV to run out of medicines or to not have access to medicine, so that is just one aspect of the situation that I worry a lot about.”
Another endemic disease of concern in Ukraine is tuberculosis. “Ukraine has a relatively high rate of drug-resistant tuberculosis,” Dr. Ray said. “And so, one of the concerns would be how to manage the risk that in crowded conditions, if people are stressed and possibly malnourished during transit, things like TB could crop up.”
Although TB incidence rates have dropped significantly in Ukraine, from 127 cases per 100,000 people in 2005 to 42.2 cases per 100,000 in 2020, the prevalence of the disease is still high, according to the WHO, which estimates that in 2018, much of TB in the Ukraine was resistant: 29% of new patients and 46% of previously treated patients have resistant TB.
Dr. Gandhi said, “Drug-resistant TB is very hard to treat under the best of circumstances, and this is now the worst of situations.”
Tuberculosis is a disease that countries accepting refugees will probably want to screen for, Dr. Wilcox suggested. The United Kingdom faced a similar concern among Afghan refugees. “At the moment, we haven’t had many [Ukrainian] migrants to the U.K., but we will, and we did this for Afghanistan. We had an active TB screening program for them,” which enabled better treatment, Dr. Wilcox said. “It’s easier to manage if you can screen for it.”
Meningococcal disease, as mentioned earlier, is also a concern. Although Ukraine does not have a lot of meningococcal disease, “they aren’t highly vaccinated, and so that would be something that could run through a population pretty quickly and in a devastating way,” Dr. Ray said.
Norovirus and other diarrheal diseases are always a concern, according to Vanderbilt’s Dr. Schaffner. “Norovirus is extraordinarily transmissible,” he said. “You wish you were dead for three days and then you recover, but then of course, with dehydration, once again [it disproportionately] affects the very young and very old.”
And looming over all of them is the pandemic. Between March 3 and 9, a total of 791,021 new cases of COVID-19 and 8,012 new deaths were reported from Ukraine and the surrounding countries, according to the WHO.
However, suboptimal vaccination coverage is not just an issue for COVID-19, according to the WHO situation report. Ukraine has seen recent outbreaks of polio and measles, which could spread. The WHO called for enhanced surveillance for all of these diseases, and recommended that countries plan vaccination campaigns for COVID-19, polio and measles, and other vaccine-preventable diseases, including tetanus. But the ability to deliver these vaccines might be difficult with all that is happening.
“Obviously, there is such a fluid situation on the ground right now, that it’s hard to predict a day in advance, much less weeks or months in advance,” Dr. Gandhi said. “I think war and infectious diseases sadly have gone closely together throughout history. We don’t want to see that repeat itself.” ■
A small respite for women and children above the central train station tracks in Lviv, Ukraine.
The sources reported no relevant financial disclosures. Photos: WHO / Marta Soszynska
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