The hidden TB epidemic in Ukraine

“It wasn’t my choice to become a TB doctor,” says Olha Konstantynovska M.D., Ph.D., TB physician, and Associate Professor in the Department of Infectious Diseases and Clinical Immunology at V.N Karazin Kharkiv National University, one of the largest universities in Ukraine. “But TB doctors were in short supply, as it’s a difficult speciality. Nobody wanted to be a TB specialist in Ukraine.”

This is partly because TB patients still face so much stigma in society, she points out. “I decided to stay because I saw that so many patients needed help. It’s very stigmatised, even among medical specialists. In a general hospital, if a patient with TB comes in for consultation for some other reason, people don’t want to contract it.”

This kind of stigmatization, of course, is not restricted to TB patients. It’s also a major issue – across the world – for people living with HIV or hepatitis C. “About 25% of our TB patients are already HIV infected, so we have triple infections sometimes – HIV, TB and hepatitis C in one person,” she says.

Konstantynovska made TB her specialism, and now carries out extensive research in addition to lecturing her students and acting as a consultant for patients with severe symptoms. She’s also a member of TBnet, the Europe-wide network of TB physicians.

“We need to have knowledge of three different diseases. And we have to do our best to treat our patients – they can’t go to a normal hospital because of the stigma, so we have to have the knowledge to help them in our place.” Her clinic has multiple specialist consultants, including neurologists, gynaecologists and obstetricians, and traumatologists. “So we can send them to that department and the doctor can help the patient here. There’s no need to go somewhere else.”

Extraordinary infection rates

Infection rates in Ukraine are high, she says, and while the numbers had been coming down, the war – with so many people living in incredibly overcrowded conditions in cellars and shelters – has reversed the progress that had been made. “Twenty years ago when I started university our professor said that by the age of 30 the majority of the population were already infected with TB,” she says. “The incidence rate of tuberculosis in our society is quite high.”

Most of these cases, of course, will usually be latent, and the length of time TB can remain latent in the body depends on the person, she says. There’s a one in ten lifetime chance that someone with untreated latent TB will develop into an active case. “I’ve seen elderly people with calcification in the lungs, and they never demonstrated the symptoms of active tuberculosis. Maybe they were infected in early childhood, and all their life they’ve had no active symptoms. It depends on your immune response.”

Aside from living in overcrowded conditions, other reasons why people with latent TB are more likely to become active TB cases include poor nutrition or development of diabetes. Diet is very important, she points out, particularly eating lots of protein. “So if patients eat meat, cheese, eggs, their immune response may be much better.”

“I had a patient who was a ballerina. She had a strict diet in order to stay thin and light to dance, and she got tuberculosis aged 18. She became sick and it was the beginning of 2000s, so we didn’t have many different anti-tuberculosis drugs to treat her.” A new injectable drug meant that she eventually became healthy again, “but she got this infection because of diet,” says Olha.

Clearly, eating well has become more difficult since the beginning of the war, but there were more pressing challenges at the start of the conflict. The relentless bombardment of Kharkiv meant that Olha’s colleagues were wearing bulletproof vests to go from one building to another, while many had become homeless and were living in the hospital – along with their children.

The effect of overcrowding on childrens’ health

Kharkiv Oblast has a population of almost 3 million people, and in the early stages of the war three of its TB services were occupied by Russian troops, meaning all treatment stopped.

“For about nine months citizens went without any diagnostics – not x-ray, not sputum, nothing. Nobody cared about them. Now we’re seeing very severe cases, with big changes in the lungs and active tuberculosis.”

On top of this, the extreme overcrowding made it difficult to find the contacts of anyone with TB, she points out.

“We also saw children becoming sick. We have a small boy with congenital tuberculosis. He was born at the beginning of the war, and unfortunately his mother died. He spent about a month in the cellar of the hospital in Kharkiv. He had tuberculosis of the intestine, lungs and peripheral lymph nodes. At the age of one and a half months he had an operation because of intestinal problems, and he had an ileostomy. He's being treated in our hospital.”

One problem is that his mother wasn’t diagnosed because of the war, she says, “so nobody knows why she died – maybe she died because of tuberculosis. He’s in a very serious condition. So that’s one example of what’s going on in our region – congenital tuberculosis in children, tuberculous meningitis, doctors becoming sick with tuberculosis. We have several healthcare workers in our department with tuberculosis.”

New diagnostics and hidden epidemics

“In our protocols we have both blood and skin tests for TB infection,” she says. “Patients from the occupied territory have to do the tests locally – they can’t travel to us, so we’re sending cars to the regions to collect samples and bring them to the hospital to check. It’s dangerous.”

“A local nurse can take the blood, and the driver will bring it with all the other samples in a car, so we can check around 100 patients per day. There’s no need for a patient to come to the hospital. But if we’re doing TST skin tests patients need to come to us personally and then return after two days to check the result. In the occupied territory we don’t have too many healthcare workers who can do that.”

In a war situation, blood-based tests have a major advantage over skin tests as they only require one visit to the doctor to be administered, whereas TST skin tests require visits to get tested and then to get the results. Blood-based tests are also more advanced in terms of sensitivity and are not affected by BCG vaccinations, which almost everyone in Ukraine has had.

New diagnostics and new drugs meant that TB infection rates worldwide had been falling for a long time, but the most recent WHO TB report shows that they’re now increasing again – in part, of course, because of the war in Ukraine. But it’s still a condition that’s preventable and curable.

Does she think we’ll hopefully see it eradicated at some point in the not-too-distant future?

“I’m not optimistic – I believe there are hidden epidemics in some regions,” she says. “Before the war we had COVID and the local restrictions, so we had difficulties with transportation and logistics for about two years. People were sitting in their houses and nobody cared about the reason for their cough – they were just prescribed antibiotics by local doctors. Nobody cared about TB at all during that period, and now we have war. So right now nobody cares about COVID, but they continue to ignore the tuberculosis problem.

“So I think this hidden epidemic means that after the war we’ll have increases in the incidence rate for several years – especially among children. If you have children with TB it means they’ve caught the infection from an adult, so we have to try to trace the contacts. It’s very difficult to do.”

“I see that mortality is increasing and I see more and more active cases among children, which is a bad prognostic sign. But my aim is for our patients to become healthy, and to reduce mortality – especially among children.”