From botulism to rabies: the unexpected health consequences of conflict in Ukraine

Conflict affects people's lives in many ways, and the health care system is no different. Even before Russia launched its 'special military operation' in Ukraine in February 2022, the country had some of Europe's lowest vaccine coverage rates, and highest rates of HIV and antimicrobial-resistant infections.

The ongoing conflict has wreaked further havoc on Ukraine's health care infrastructure, destroying hospitals and clinics, disrupting vaccination programmes and limiting capacity for diagnostic tests, as well as damaging water supplies and making people homeless.

Sadly, such disruptions make outbreaks of vaccine-preventable and waterborne diseases a common consequence of conflict. However, a recent study has highlighted some less obvious repercussions of the ongoing war in Ukraine on people's health.

Prof Raina MacIntyre at University of New South Wales in Sydney, Australia, and colleagues used an AI-based epidemic early warning system called EPIWATCH® to compare outbreak reports for specific diseases and clinical symptoms before and after the Russian invasion.

Artificial intelligence

The system processes open-source data, such as news and website reports of infectious disease or disease symptoms, to generate signals of potential epidemics.

"The basic 'count' in EPIWATCH® is reports, which provides a useful way of tracking trends," said MacIntyre. "We also have AI methods to extract case counts from these."

Although official case counts will be generated by health departments based on lab confirmed cases of specific diseases, reliance on these figures can be problematic when diagnostic capacity is low.

"Mpox in the Democratic Republic of the Congo is a good example where only a fraction of cases are lab-confirmed," MacIntyre explained. "In that case it is critical to count 'suspected' cases to understand the scale and spread of the epidemic."

In the absence of formal disease surveillance - something that becomes harder to do in war zones - EPIWATCH has the potential to provide early warning signals for disease outbreaks that might otherwise be missed, or to reinforce existing surveillance efforts.

Ukraine conflict

The research, published in Emerging Infectious Diseases, identified an uptick in overall reports of infectious disease in Ukraine between February and July 2022, compared to the same period in 2021 and the three months immediately before the Russian invasion.

Some of these diseases, such as cholera, are frequently reported in war zones - reflecting declining hygiene and sanitation, including reduced access to safe drinking water and toilets. In Ukraine, EPIWATCH identified 10,015 cases of this deadly diarrhoeal disease between February and July 2022

Other patterns detected by EPIWATCH provide less obvious, yet disturbing insights into the toll that conflict can take on people's lives:

1. Rabies

Daily reports of rabies increased from 12 before the conflict to 40 during the first five months of war - presumably exacerbated by an increased number of displaced domestic dogs.

Many people who abandoned their homes at the start of the war left pet animals behind, resulting in packs of dogs scavenging for food - and an increased risk of dog bites for humans who encounter them. Also, whereas previously Ukraine had implemented a successful oral rabies campaign for wild fox populations and regularly vaccinated domestic animals against the disease, these campaigns have been disrupted by the conflict.

The Ministry of Health of Ukraine also reported a significant increase in the number of humans being bitten by domestic and wild animals, and laboratory-confirmed animal cases of rabies, during 2023. Recognising this problem, the World Health Organization and other stakeholders have agreed that improved management of wild and free-roaming domestic animals is an urgent priority.

2. Botulism

Botulism is a rare, but potentially life-threatening illness caused by toxins from Clostridium botulinum bacteria. When botulism does strike, it tends to be associated with eating improperly canned, preserved or fermented foods.

According to EPIWATCH, daily reports of botulism increased from 22 to 122 following the Russian invasion. "This is probably because people resorted to eating badly canned food," MacIntyre said.

3. HIV/AIDS

Before the war, Ukraine had one of the highest rates of HIV/AIDS in eastern Europe and central Asia, with around 1% of the population estimated to have been living with the infection in 2019. However, with more than 14 million people internally displaced or forced to flee to neighbouring countries, many HIV clinics shutting down, and disrupted supplies of antiretroviral drugs and diagnostic services, many patients with HIV have been forced to interrupt their treatment.

EPIWATCH identified an increase in daily reports of HIV and AIDS from six to 61, during the first five months of the war, at a time when no government or other case reporting could be found.

To combat some of these challenges, The Global Fund, the world's largest financier of AIDS, TB, and malaria initiatives, recently announced US$ 27.7 million in emergency funding to support the continuity of prevention, testing and treatment services for HIV and tuberculosis in Ukraine.

Early warning system

Although EPIWATCH provides reports of outbreaks, and case numbers extracted from these reports may be less precise than official figures, for most diseases there was no formal surveillance or case reporting during the conflict, MacIntyre and her colleagues said.

"Weak or absent formal surveillance during wartime hampers timely and targeted interventions such as vaccination programs," they added. "Solely relying on formal surveillance may [also] result in missed early warning signals from other sources, heightening the risk that diseases will spread internationally.

"In that context, open-source epidemic intelligence can provide early warnings of epidemics."

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