Table 4 Impact of conflict on Tuberculosis outbreaks

Gele and Bjune, 2010 [32]

Somali Regional State of Ethiopia,

Population from the tuberculosis management units in the Jigjiga and Shinile zones of the Somali Regional State,

June – September 2007

TB Patients in the intensive phase of treatment

• Large number of military conflicts may impact TB control programmes by interfering with the goals of identifying and curing TB patients.

• Armed conflicts may not only fuel TB epidemics by escalating poverty and malnutrition, and thereby increase the number of TB susceptible individuals, but also cause diagnostic delays by deterring infectious TB patients from seeking prompt diagnosis and treatment.

• Access to health care is often limited by the lack of security.

• Armed conflicts hamper TB control efforts not only by disrupting the health system but by diverting economic resources to priorities other than health needs.

Implemented:

Not mentioned

Suggested:

• Improve the access to TB diagnosis and treatment.

• Sustainable political commitment for the implementation of successful TB control programmes.

• Expansion of user-friendly directly observed therapy short-course (DOTS) in the conflict zone.

• Establishment of training programmes for community health workers for early detection of TB patients.

• International organisations providing health services should be given unconditional access to conflict zones.

Boyong et al., 2018 [34]

Wau,

South Sudan,

Wau Teaching Hospital in armed conflict in South Sudan,

January – February 2016

Suspected tuberculosis cases at Wau Teaching Hospital

• The city of Wau had been at the centre of conflict and the Wau Teaching Hospital, the only hospital of this size in a 350-km radius serving approximately 3 million people, had critical shortage of professional health workers (1.5 physicians and two Nurses/Midwifes were available for every 100,000 citizens)

• Patients travelled long distances, which were interrupted by gunfights, to seek TB medical attention

• Interrupted treatments because it was impossible to travel.

• Displacement of people

Implemented:

Not mentioned

Suggested:

Not mentioned

Pembi et al., 2020 [33]

Adamawa State,

North-east

Nigeria,

Adamawa State

2010–2016

Tuberculosis cases

• Adamawa State experienced several years of violence, with a severe disruption of public health activities and a massive population displacement

• TB services are at risk in areas with political disruption and conflict

• Years and places of higher conflict were associated with lower TB notifications.

• Displacement of the populations to other locations that were considered safer

• Refugees and IDPs with limited access to TB health services, or no access due to transport

• Disruption of TB services

• Reduced numbers of health staff

Implemented:

• TB Reach-funded project in all areas during which TB risk messages were broadcasted through jingles in the local radios

• Health workers were re-trained on TB identification, diagnosis, treatment and follow-up

• 402 community volunteers were engaged to boost awareness and reporting of cases

• Introduction of GeneXpert testing increased awareness on TB

Suggested:

Not mentioned

Dahl et al., 2022 [35]

Ukraine and Russia

Population of Ukraine and Russia

• The internal displacement of citizens, especially within Ukraine but also in Russia, and migration of war refugees has large consequences including the dispersal of drug-resistant Mycobacterium tuberculosis in both the affected and neighbouring countries, which are presently facing an un-precedented flow of refugees.

• Initiating and maintaining a course of anti-TB therapy during war, or during migration, is undoubtedly also associated with a higher risk of inappropriate or interrupted treatment and, followingly, an increased likelihood of drug-resistance, treatment failure and death.

Implemented:

Not mentioned

Suggested:

The international health community must be prepared to intensify the capacity of detection and treatment of both drug-susceptible and drug-resistant TB, and to strengthen screening programmes for TB prevention and treatment of active disease among migrants and close contacts of people with TB, ultimately to diminish the impact of the ongoing conflict and its future consequences for global health.

Guthmann et al., 2023 [36]

Ukraine and France

2022–2023

Population of France

• The spread of TB due to the war and the large population movement fleeing Ukraine to reach France among which TB cases

Implemented:

Active CXR screening to detect TB cases among the displaced population

Suggested:

Pre-established well-organised network of TB centres such as the CLAT network in case of sudden mass migration from a high TB incidence country. Increasing effectiveness of the existing strategy may require further well-trained man-power and financial support, both likely not being readily available.