POST 239. March 9, 2022. CORONAVIRUS. “War is an infectious disease’s best friend,” says Michael Osterholm, “It challenges every public health program you can possibly have. It limits the medical care available for those who might be seriously ill, and often fosters transmission when so many people are crowded into bomb shelter locations and on trains. This is going to be the perfect storm of one serious challenge after another.” (E)

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“As Ukrainian cities face a barrage of attacks from Russian forces, casualties mount and more than a million civilians flee their homes, another familiar enemy may be on the horizon: COVID-19. 

The World Health Organization said Wednesday during a briefing that the conflict may cause a surge in infections, straining scarce resources and contributing to more suffering and death.

“Anytime you disrupt society like this, put literally millions of people on the move, an infectious disease will exploit that,” said Dr. Michael Ryan, executive director of the WHO Health Emergencies Program.

“(People are) highly susceptible to the impacts … of being infected themselves, and it’s much more likely that disease will spread,” Ryan said.

A pandemic doesn’t pause for war. In fact, health experts said, war creates prime conditions for infectious diseases to flourish: densely crowded shelters, forced travel across borders and limited access to hospital resources.

Ukraine is coming off one of its worst waves of COVID-19 since the pandemic began, according to WHO data. On Feb. 4, there were a record 43,778 positive cases reported, and although cases have declined, the crisis could result in the virus easily spreading without tests available.

Ukraine received its first 500,000 doses of COVID-19 vaccine in February. The country of more than 40 million is one of the last in the region to begin inoculating its population, and only 34% of residents are fully vaccinated, according to WHO data.

The “low levels of vaccination and very level low levels of getting booster doses and the social disruption is just a perfect storm for seeing the surge in cases,” said Dr. Wafaa El-Sadr, professor of epidemiology and medicine at Columbia University Mailman School of Public Health. “It’s quite worrisome.”

Although health experts agree the conflict is likely to lead to another surge, they said it will be nearly impossible to track as surveillance systems fall apart.”  (A)

““That’s a toxic mix of COVID patients with battle injuries,” Eric Toner, MD, senior scholar at the Johns Hopkins Center for Health Security in Baltimore, Maryland, told Medscape Medical News.

He added that transporting liquid and bottled oxygen is “problematic and dangerous in a war zone.”

According to Reuters, the World Health Organization said on Sunday that Ukraine is running out of oxygen.

“The oxygen supply situation is nearing a very dangerous point in Ukraine. Trucks are unable to transport oxygen supplies from plants to hospitals across the country, including the capital Kyiv,” WHO Director-General Tedros Adhanom Ghebreyesus and WHO Regional Director for Europe Hans Kluge said in a statement.

Before the Russian invasion last week, Toner said, COVID cases in Ukraine had dropped about 30% from their Omicron peak but were still high at 62 cases per 100,000. For comparison, the United States is currently at 20 cases daily per 100,000, according to the New York

“I would have to think there’s going to be an uptick in COVID cases, but no one will know how big or how bad because there will be no data,” he said…

Ron Waldman, MD, MPH. professor emeritus of global health at George Washington University in Washington, DC, told Medscape Medical News that cause for alarm regarding COVID spread may be premature.

Waldman, who currently lives in Portugal, said though COVID is surging in some parts of the world, the number of cases in in Europe, as in the United States, are plunging rapidly.

“The incidence of COVID seems to be declining everywhere regardless of vaccination status,” he said.

He acknowledged that with higher population density infected people may come in contact more easily with people who are not infected and high mobility is also considered to be an increased risk factor for COVID spread.

However, he said, “Refugees are frequently viewed with fear and with suspicion and are frequently tagged with labels they don’t deserve. We’re going to be looking at a lot of people – I think the numbers are about a half million now –who are fleeing an armed conflict out of fear for their lives and the lives of their families. And to tag them with a label of ‘COVID spreaders’ does not have any business in the equation.”

He said given the positive epidemiological trend of decreasing cases and milder infection from the Omicron variant, “I don’t think we can allow fear of COVID from refugees to interfere with our humanity.”” (B)

“As people flee war, there is always a concern that they may bring infectious diseases with them, aiding the spread of illness through no fault of their own.

And history tells us warzones can provide the ideal conditions for infectious diseases to spread. Distracted government institutions, faltering health services, and the congregation of large numbers of vulnerable people, alongside environmental degradation, can create the perfect storm of conditions for an outbreak of a catastrophic infectious disease.

We saw this in the Democratic Republic of the Congo (DRC) during the 2018-2020 Ebola outbreak, particularly in the eastern part which has been engulfed in civil unrest and conflict. It is no coincidence that the DRC had a devastating and prolonged outbreak of Ebola, despite the efforts of government and foreign aid organisations…

In the Middle East and North Africa, years of war in Syria, Iraq, Yemen and Libya – including attacks on hospitals and clinics – left large parts of each country without a workable health infrastructure. And many healthcare professionals have been killed during conflicts, leaving a lack of trained professionals. Syria has seen a resurgence of preventable diseases like measles, polio and tuberculosis, as well as the spread of infectious diseases such as cutaneous leishmaniasis – known in Syria as “Aleppo Evil” – a disease spread by sandflies that causes disfiguring skin lesions…

It is understandable that the primary focus of the people of Ukraine is to escape danger, but the sad reality is that the combination of large crowds and people rammed into train carriages all breathing the same air is the ideal situation for an airborne virus like COVID to spread.

Some people have taken refuge in subway stations to escape the dangers of the war; once again, this will mean large volumes of people in close proximity, many of whom do not have the added protection of the vaccines, leading to an increased risk of infection. As groups of people reach the borders of neighbouring countries, another bottleneck is likely to form – once again increasing the risk of infection.

COVID remains a dangerous infection, particularly for the elderly and clinically vulnerable. Many people fleeing war zones suffer from lack of sleep, no access to their usual medicines, and poor nutrition – all of which can increase the risk of serious infection due to the negative impact these things can have on the immune system.

Beyond the immediate spread of the virus, the longer the war goes on, the more it will impact health systems and disrupt surveillance and response systems.

Attacking infrastructure is a tactic often used in war to disable transport and supplies, aiming to weaken a country into submission, and this will have inevitable consequences for medical supplies in Ukraine. A weakened infrastructure will hinder both civilian and military populations’ access to healthcare and other emergency services.

Russia is reported to have built field hospitals for their own sick and wounded in areas surrounding Ukraine while at the same time, there have been reports of its military shelling maternity units in Ukraine’s Kyiv, and hospitals being forced to move staff and facilities to makeshift locations underground…

As the war rages on, there will be a threat to the supply of electricity and power and even clean water to hospitals.

It is often said that in war there are no winners, but it is clear that disease and illness stand to benefit from human conflict. Coordination amongst international aid organisations will now be key to keeping essential health services going as the crisis deepens.” (C)

“War is a public health crisis

The more significant issue is the holistic nature of war as a public health crisis. Not just for COVID-19, but other infectious and devastating diseases such as polio.

“I have been optimistic that the world will soon see the eradication of polio,” Oladele A. Ogunseitan, PhD, a professor of population health and disease prevention at the University of California Irvine, told Healthline. “But the last vestiges of the devastating disease has always been in the areas of conflict in Nigeria [and] Afghanistan. Now, there is evidence of a small but significant detection of polio in Ukraine and the current war will make it difficult to contain, and perhaps even spread to countries receiving large numbers of refugees such as Poland.”

And while cases and deaths from the Omicron variant may only rise slightly, a new, more vaccine-evasive variant of the disease could throw those predictions out the window.

“There is a long history of war and public health. There is evidence that in many cases, after the gun battle is over, public health impacts continue for years, perhaps decades,” Ogunseitan said. “This is particularly troublesome in the middle of a pandemic that has taken a toll of 2 years and millions of lives lost.”

“The war situation and population migration will make the emergence of new variants more likely, and that is a threat to global health, particularly if the existing vaccines are not effective against new strains or vaccinated people require a fourth booster vaccine to remain protected,” Ogunseitan added.

What the world needs, experts say, is an end to fighting as well as the support of healthcare systems in other countries that are taking in Ukrainian refugees.

“This is exactly the time to take care of refugees leaving Ukraine,” Ogunseitan said. “We cannot afford to leave it to them to find their way to healthcare in the receiving countries. Otherwise, dispersion into the host population will delay an end to the pandemic.”” (D)

“We have warned for years about the potential convergence of conflict and epidemiology—bad things happen when those things converge,” says Dr. Eric Toner, senior scholar at the Johns Hopkins Center for Health Security. “Certainly, in the dire circumstances in which the population is right now, mask-wearing, distancing, and quarantine are not going to be possible. As people flee the affected parts of the country, crowding on buses, trains, and cars and ending up in hotels or living with relatives or in refugee settlements—those are not conditions for good control of a transmissible disease like COVID-19.”

Hospitals will likely be hit hardest by the influx of refugees during the pandemic, say public health experts. War-related injuries will take precedence over COVID-19 care, which will only make it easier for the virus to spread. That disruption will in turn lead to more health care workers who will get infected, and won’t be able to perform their duties.

“There will be runs on hospitals and facilities and resources because of injuries associated with the conflict,” says Shaman. “In the longer term, I imagine it will result in deterioration of the ability to deliver health care at the level that people in the Ukraine are used to having.” And if surges occur in neighboring countries as well, that puts additional pressure on health care services in the entire region. “The world community would be advised to provide supplies and facilities to buffer the displaced Ukrainians and Polish populations from those consequences.”

Shaman and other public health experts are also concerned about longer term effects of the conflict on COVID-19 control. Studies consistently show that vaccine-based immunity starts to wane after about five to six months. Booster shots are essential to maintaining protection against disease so severe that it requires hospital care; if the conflict in Ukraine continues, that would mean even vaccinated citizens will not be able to get boosted as trauma care and war-related injuries will take priority over vaccination efforts.

The situation exposes the weaknesses in the global biodefense network against threats like highly infectious coronaviruses. Even without a military conflict, stark inequities in health resources have led to profound differences in countries’ ability to control COVID-19; developed nations have been able to purchase and distribute vaccines, while poorer countries, mostly in Africa and parts of Asia, still struggle to contain the virus since they lack access to the shots. When a conflict like that occurring in Ukraine right now hits during a pandemic, the lack of global coordination of public health resources becomes more tragically obvious. “I can’t begin to tell you where the solution is,” says Shaman. “The World Health Organization doesn’t have the authority or the resources in terms of money to deal with this. This is a very large issue that involves development, nation sovereignty, and the ability of nation states to get along and support one another in a trusting way rather than in ways that we’ve seen the world devolve into over the last 20 years.” (E)

“A grim scene awaited Dr. Oleksandr Sherbina as he made the rounds of Clinical Hospital No. 7, a medical facility that once specialized in treating strokes but is now suddenly immersed in the atrocities of war. As he passed the operating theater, surgeons were amputating the lower leg of a wounded Ukrainian soldier.

The hospital is near a combat zone in a northwestern suburb of Kyiv, where the booms of incoming artillery can be heard inside the building amid a scramble of activity as triage nurses greet the ambulances arriving every few minutes. In a hallway, an orderly used a rag to wash blood off stretchers.

“The flow of wounded is growing,” said Dr. Sherbina, a surgeon who is the hospital’s director.

In recent days the fighting between Russian and Ukrainian forces has crept from outlying towns to the edge of Kyiv, and closer to his hospital. “We work and we understand that every day it is getting worse and worse,” he added.

This worries Dr. Sherbina deeply. Even as he and fellow doctors treat patients ravaged by the shrapnel that whistles off mortars and artillery shells, they know they are at risk of suffering the same type of wounds.

“This is what I am most afraid of, because we are close to the fighting,” he said. “I am hoping that the walls defend us.”

Around Ukraine, as Russian bombings have grown more indiscriminate and more civilians find themselves in harm’s way, hospitals have become increasingly perilous places to work. They have been hit by heavy artillery, and doctors and nurses have been killed while performing their duties. The Ukrainian Ministry of Health reported that 34 medical facilities had been damaged and that at least 10 doctors had been killed.

Ambulance workers have also been killed. The ministry said seven ambulances had been fired on, killing four emergency medical technicians in separate incidents, and that another two emergency medical technicians were killed while traveling in civilian cars to treat the wounded.

The ministry’s reports could not be independently confirmed.

The most dire conditions are not in Kyiv, the capital, but in cities partially or wholly surrounded, such as Kharkiv in eastern Ukraine, where three medical facilities have been damaged by artillery: the Kharkiv City Hospital, the Regional Children’s Hospital and a blood bank.

A surgeon working in the military hospital in Kharkiv, who said military rules prohibited her from speaking publicly, described a flood of civilian and military casualties. The hospital, she said, receives 60 to 80 wounded people per day.

“It comes in waves,” she said in a telephone interview. Typically, she said, “the first half a day can be calm and then a huge wave of wounded arrive” later in the day, following the rhythm of the fighting, which tends to take place in the afternoon.

Yevheniy Ilin, a surgical oncologist, was working in the city’s oncology hospital on Feb. 28 when a bomb landed nearby, blowing in all the windows on one side of the building, he said in a telephone interview. The heat and electricity went out in the hospital, he said, so he moved to the city’s military hospital. Many other doctors gave up working in the city and joined the flow of displaced people headed west.

“We are coping,” he said. “You just go and sleep any free moment you have. Whether it is 15 or 30 minutes. You never know when the next shelling will be and if you’ll get to sleep at night.”

The World Health Organization on Tuesday said it had confirmed attacks on medical facilities in Ukraine and said it was investigating reports of more attacks, but the group had a different total than the Ukrainian Ministry of Health. The W.H.O. said it had confirmed 16 attacks on hospitals, in which nine people were killed and 16 wounded, Catherine Smallwood, senior emergency officer for W.H.O. Europe, told a news conference.

The group noted that there had been direct attacks on hospitals and that combatants had at times appropriated ambulances or diverted them for nonmedical uses. The number of attacks had increased rapidly in recent days, she said.” (F)

“Russia’s invasion of Ukraine is causing a devastating humanitarian crisis in the country, with at least two million people fleeing into neighboring countries and the World Health Organization (WHO) warning that the deteriorating conditions will make it easier for Covid-19 to spread.

“Anytime you disrupt society like this and put literally millions of people on the move, then infectious diseases will exploit that,” Dr. Mike Ryan, director of WHO’s Health Emergencies Program, said last week. “People are packed together, they’re stressed, and they’re not eating, they’re not sleeping properly. They’re highly susceptible to the impacts… And it’s much more likely that disease will spread.”..

Attacks on health care services, including hospitals and other facilities, have been intensifying since the start of the invasion, with 16 confirmed reports and more currently being verified, Hans Kluge, WHO’S regional director for Europe, said Tuesday. The country is also suffering from a critical oxygen shortage, exacerbated by the closure of at least three major oxygen plants. WHO has sent 500 oxygen concentrators to Ukraine, but Kluge warned that Covid-related deaths “will increase as oxygen shortages continue,” with older people “disproportionately affected as their access to health care is disrupted.”

As refugees move into neighboring countries, public health officials are imploring those nations to serve the complex health needs of fleeing Ukrainians, which range from mental health services to protection from infectious diseases like Covid-19. The health ministries of those neighboring countries “reassured me there is no shortage of Covid-19 vaccines,” Kluge said.” (G)

“A Russian attack severely damaged a children’s hospital and maternity ward in the besieged port city of Mariupol, Ukrainian officials said Wednesday, as citizens trying to escape shelling on the outskirts of Kyiv streamed toward the capital amid warnings from the West that Moscow’s invasion is about to take a more brutal and indiscriminate turn.

“…Authorities said they were trying to establish how many people had been killed or wounded.” (H)