Public health concerns about Tuberculosis caused by Russia/Ukraine conflict

Abstract According to WHO, Ukraine has the fourth‐highest Tuberculosis (TB) incidence in the WHO European region while globally has the fifth‐highest number of confirmed cases of extensively drug‐resistant TB. Before the Russian invasion in Ukraine several interventions have been employed to mitigate the TB epidemic in the country. However, the ongoing war has demolished meticulous efforts and subsequently worsen the situation. WHO in collaboration with the Ukraine government and other organizations such as EU and UK are required to take up arms against the situation. In this work, implications brought up from the war, efforts, and recommendations to battling TB epidemic due to the war are highlighted.


| INTRODUCTION
In any nation, peace is crucial in ensuring the economy's stability, political endurance, and even the overall public health of its citizens. Upon the conflict, many Ukrainians have been forced to migrate to neighboring countries away from the war that is still going on in their country. Since neither ECDC nor WHO guidelines recommend universal testing of TB infection of refugees fleeing to the European countries, it is an undeniable truth that the progression and transmission of the RR/MDR-TB strains caused by Ukrainian migrants will be at a high rate that can

| TB INFECTION BEFORE AND DURING THE CONFLICT
The burden of TB in Ukraine has been chronically high even before the war; since the invasion of Russia in Ukraine, nearly 400 health facilities have been terribly destroyed, including three TB hospitals, meanwhile leaving the HCWs severely injured or killed. 4,5 The war has increased the burden of TB in Ukraine, which already had the fourth-highest TB incidence in the European region. 6,7 In addition, following the crises in the country's health facilities upon the effects of the war, there is a great risk of an increase in the prevalence of other major health problems such as COVID-19, TB-HIV coinfection, and MDR TB. [7][8][9] The war also has caused and contributed to spreading TB and other diseases to the countries where Ukrainian refugees flee. 8 Before the occurrence of the conflict, cases of TB in the country spiked up to 30,000 annually while among those cases, 29% of all new diagnoses were MDR-TB cases and only 81% of the total TB cases were diagnosed and treated. On the other hand, during early days of the conflict it was revealed that 6837 individuals were diagnosed to have TB. 10 Following the large movement of Ukrainians migrating from their invaded country, it has been difficult for healthcare workers to diagnose and treat TB patients properly.
Significantly, this has led to higher risks of transmission of the TB epidemic and other infectious diseases among the refugees and other hosting countries' citizens. Eventually, leaving no solution to the high incidences and burden of TB infection in Ukraine. 6,8 One of the catastrophic challenges caused by this conflict is the short-time fall of the economy in Ukraine and other countries.
Poverty, as one of the most potent financial determinants, may increase the risks of infection, thus causing a significant TB burden in the community affected. 11  Aligning with that, Medecins Sans Frontieres, an organization that provides medical assistance to people affected by conflicts, epidemics, disasters, or exclusion from healthcare, through its team in collaboration with other hospitals across the country has pressed efforts on providing supplies needed to rescue HIV and TB programs as one of their medical activities. They offered over 170 international and more than 400 Ukrainian medical staff (doctors, nurses, surgeons) working in response to the war in Ukraine. 12

| RECOMMENDATIONS
As statistics show, Ukraine has low immunization records against MDR-TB; there must be a close reform and third eye concern about this problem. To increase the supplies of drugs and efforts to reach the people with concerned problem WHO and other Public Health Organizations, should continue to use the main routes of transportation in Ukraine that are not highly affected by the war especially in frontline parts of war, for example the railway transportation, as Russian troops have not highly targeted the transportation route, by doing this, as many as the medical facilities will be delivered to the area especially to the highly affected parts of Ukraine including Kyiv region.
Since it's very difficult to predict the end days of the war, and for the WHO restrictions, the authorities should critically look into the screening of refugees so as to avoid stigmatization and discrimination cases against refugees. 1 Also, regarding that, Ukraine is the second leading country in the region with the highest cases of MDR-TB, and more than 7 million people have left the country and the threshold is 79 per 100,000 population are estimated to have the MDR-TB, a critical concern by the authorities should be laid for the time being.
WHO should call for the emergency public health concern that the refugees should be allowed to be screened to reduce the prevalence and the number of TB infections among the citizens in host countries and even healthcare workers at the refugee camps. Avoiding the initiation of treatment against TB by only considering the population at risk and vulnerable populations is vital, as the medication may cause side effects to the population given without being diagnosed for the disease. 6 Besides that, the follow-up for Ukrainian citizens that were continuing with the treatment has been destroyed; the communication technology techniques should also be imposed as one of the strategies to get a follow-up with the lost Ukrainian refugees and internal scattered population under treatment, this can be done through social medias like Facebook and WhatsApp provided that the records of patients under follow-up is there, this will help to know the location of some of patients, knowing that will help to pave down the ways that they could be reached and being assisted.