By Marie Rosenthal, MS

The millions of refugees pouring out of Ukraine into Poland and Slovakia were not as prone to infectious diseases as was expected from the size of the humanitarian crisis. However, the host countries saw increases in many diseases, including HIV, according to two physicians who gave situation updates at ECCMID 2023: the European Congress of Clinical Microbiology & Infectious Diseases, held in Copenhagen, Denmark.

“The Russian aggression against Ukraine has caused the worst migration crisis in Europe since the Second World War, and several millions of Ukrainian citizens have been forced to leave their country and seek safer places in neighboring countries including Poland,” explained Dorota Zarebska-Michaluk, MD, PhD, the head of the Department of Infectious Disease and Allergy at Jan Kochanowski University, in Kielce, Poland, and vice president of the Polish Association for the Study of the Liver. 

“According to estimates by Polish border guards during one year of the war, more than 10 million Ukrainians have entered our country.”

Most of them were women and children, Dr. Zarebska-Michaluk said. Many subsequently returned to Ukraine—most to fight for their country—and today, about 2 million Ukrainians remain in Poland, mostly in metropolitan areas. One Polish area saw its population increase by more than 50%, she said.

Although Slovakia is a much smaller country, it too saw a large influx of people, according to Alena Košcálová, MD, the deputy head of the Department of Infectious Diseases at University Hospital Bratislava, in Slovakia, and a consultant to the Ministry of Health for infectious diseases and COVID-19.

“There are some days we remember for life, and 24th of February 2022, will definitely be one of them,” Dr. Košcálová said. “We were all in shock after the Russian invasion into Ukraine that resulted in the largest refugee crisis since World War II. More than 1.3 million Ukrainians have crossed the border to Slovakia since that day, and more than 100,000 asked for temporary protection status. 

“The fleeing population was extremely vulnerable, as women and children represented 78% of all arrivals.”

Dr. Košcálová’s experience at Médecins Sans Frontières, where she worked before her current position in Bratislava, served her well. “We know that in a refugee crisis, the first hours and days matter.”

However, the invasion was such a surprise and, coming out of COVID-19, the state took a little longer to coordinate a full response, but local nongovernmental organizations and others acted as quickly as they could to provide humanitarian assistance. “And actually the humanitarian assistance, even if it was not in a coordinated way, was present since day one,” Dr. Košcálová said.

Addressing the health needs of this influx of people is a huge and ongoing challenge, according to both physicians, made more so by the lack of health documentation carried by many of the Ukrainian people.

“As you know, the best source of data is medical documentation, but taking [those documents] for refugees leaving their home in fear and hurry was the last thing that they thought about. You must also take into account the possibility of falsification of documentation because we faced this phenomenon during the last measles outbreak in Poland in 2018,” Dr. Zarebska-Michaluk said. 

There are many anti-vaxxers in both Ukraine and Poland, according to Dr. Zarebska-Michaluk, so there was concern about the vaccination status of refugees. In addition, the routine vaccination schedules for Ukraine and Poland are different. In Poland, the vaccination program covers children up to 19 years of age, while that of Ukraine ends at 16 years. 

In addition, the number of mandatory vaccinations is lower in Ukraine, which does not include vaccination against pneumococcus and rotavirus. 

Although most countries in Europe use inactivated polio vaccine (IPV) for all doses to limit vaccine-related disease, Ukraine only uses IPV for the first two doses, and the remaining doses are live oral polio vaccines. Ukraine also administers a tuberculosis vaccine between the third and fifth day after birth. Poland, in contrast, gives it immediately after birth. 

The overall vaccination rate was much lower in Ukraine before the war, and the World Health Organization began a nationwide vaccination campaign on Feb. 1, 2022, to increase vaccinations, after there was a serious measles outbreak in 2019. That effort was “quickly interrupted by the Russian aggression,” Dr. Zarebska-Michaluk said.

“Ukraine also has gaps in immunization against measles. In 2016, the level of vaccination was as low as 31%, and due to these gaps, two outbreaks were reported in Ukraine in recent years. The first one was in 2012, and the second one between 2017 to 2019,” she said. 

Between 2018 and 2019, the measles outbreak—which saw 104,442 cases—was affecting many countries in Europe, and both Ukraine and Poland were among the top 10 countries with cases. In 2022, of the 904 measles cases reported, 834 were in 10 countries; Poland with 27 cases was in fifth place, and Ukraine was no longer in the top 10. Dr. Zarebska-Michaluk believes this is because the cases moved from Ukraine to Poland. 

“Ukraine was outside of the top 10 countries, but I think that probably is because reporting of infectious diseases during the war is affected by conditions. And also we do not know how many Polish cases were diagnosed in Ukrainian citizens. I tried to find such data, but I failed,” Dr. Zarebska-Michaluk explained. 

In 2021, Poland saw 50 cases and Ukraine had 19 cases of rubella. In 2022, Poland reported 152 cases whereas Ukraine recorded nine. “Again, we do not know how many Polish cases were reported in Ukrainian children. But I think that in the case of rubella, refugees are at risk for infection coming to our country,” she said. 

A polio outbreak was confirmed in Ukraine on Oct 6, 2021, after circulating vaccine-derived poliovirus type 2 was isolated in a 17-month-old girl with acute flaccid paralysis, with 19 asymptomatic contacts also testing positive. “The isolated viral strain in both symptomatic and asymptomatic cases has been linked to poliovirus in Pakistan, which is one of two endemic polio countries worldwide,” Dr. Zarebska-Michaluk said. (Afghanistan is the second one.)

One goal of the WHO vaccination campaign—vaccinating 140,000 children between 6 months and 6 years with IPV—was disrupted by the war. It is believed that about 70% of the targeted population was reached. 

Tuberculosis is also a problem. Although the incidence has decreased in Ukraine, TB is still 10 times higher than the rest of Europe, she said. “In 2021, Ukraine had the fifth highest incidence of tuberculosis among all countries in the WHO European region,” Dr. Zarebska-Michaluk said, and many multidrug-resistant (MDR) strains. 

And many of the patients with TB are coinfected with HIV, which is a serious problem in Ukraine, particularly among females, according to Dr. Zarebska-Michaluk. “Ukraine has one of the highest [rates of] HIV in the world and the second-highest prevalence of HIV in Europe and Central Asia, with more than 250,000 people living with [the infection],” she said. In 2021, Ukraine reported more than 15,000 new HIV cases. 

“The most common root of HIV transmission in Ukraine is heterosexual intercourse, then intravenous drug use and in third place is sex between men. In Poland, we have a different order. In the first place, we have sex between men, then intravenous drug use and heterosexual intercourse,” she said. 

Women account for approximately 46% of all HIV infections in Ukraine, and only about 62% of the population is on antiretroviral treatment compared with 82% in European Union countries. Approximately 80% of patients treated in Ukraine were on a regimen with dolutegravir-lamivudine-tenofovir, which was not available in Poland, so they had to be switched to another antiretroviral treatment. “The predominant genotype among Ukrainian patients is associated with a risk for resistance to integrase inhibitors. So, that should be kept in mind when switching treatment,” she said. 

Since coming to Poland, about 8% of newly diagnosed HIV cases are from Ukraine and most of them are among women. In addition, 36.5% have AIDS.

Hepatitis A, B and C were also seen among the refugees, as was COVID-19. Luckily, most specimens of SARS-CoV-2 were of the omicron variant, which caused milder disease. However, the COVID-19 vaccination rate was low in Ukraine: at only about 35% coverage. Dr. Zarebska-Michaluk admitted COVID-19 vaccination was low in Poland, too, but was almost twice that of Ukraine at 67%.

As of March 2022, Ukrainian refugees who entered the country after the war began are entitled to healthcare in Poland, which includes vaccinations, although there are restrictions, she said. 

“The very important part of medical care for refugees, especially for children of refugees, is vaccination. The Minister of Health recommends immunization from the day of arrival in Poland for children under 19 years of age,” Dr. Zarebska-Michaluk said. If someone plans to stay for less than three months, vaccination is voluntary, but for anyone planning to stay longer than three months, vaccination is mandatory and should be given according to the Polish vaccination schedule.

Anyone without documentation should be considered unvaccinated and should receive all of their vaccines according to the schedule.

“With the exception of newly diagnosed HIV infections, AIDS, sexually transmitted diseases and tuberculosis diagnosed in non-Polish citizens, a comparison with previous years does not support the conclusion [that increases in infectious diseases were brought on by the refugees],” she said.
“Refugees have faced many limitations and barriers in the host country, including language barriers and lack of access to medical service,” Dr. Zarebska-Michaluk said, adding that the government has been trying to get the word out about where the people can seek care. Several clinics have been set up specifically for Ukrainian refugees and many will receive free care.

Slovakia
Slovakia attempted to survey all the refugees about their health when they arrived, but that quickly proved impractical, according to Dr. Košcálová. Of more than 1,000 people, 81% of parents declared their children were fully vaccinated, but they had no documentation to verify this; 14% did not know their vaccination status; and 5% declared incomplete vaccination. The most commonly reported problems were hypertension and diabetes. 

They were surprised about the number of people who brought their pets, and there was panic when people believed one pet had rabies, which turned out to be a false alert.

“As Dorota already mentioned, our biggest fear was measles because of the number of arriving children [with unknown vaccination status],” she said. 

“Fortunately, we’ve seen no cases of measles, and there was also a low rate of COVID-19. There were no major outbreaks detected,” Dr. Košcálová said. 

She advocated against screening for COVID-19 because the limited capacity to isolate in the temporary shelters just added to the chaos in the early days. Medical care was basic at the borders. However, ambulances were on standby to transport more critical and complex patients to a hospital. In addition to medical care, there was access to psychosocial care at the border.

In less than two months, 27,000 refugees passed through one transit center, and 5% sought medical care. There were 1,400 consultations and 21% were for children, mostly for mild issues such as headaches, hypertension, diabetes and respiratory tract infections, she said. They also saw some cases of hypothermia and abdominal pain. 

Although Slovakia had a rocky start, the integration is working. Barriers to access to care include a lack of clarity about what will be covered by insurance. 

“The clinicians don’t know if they can actually provide the care and then sometimes refuse care, and on the other side, the patient doesn’t know his health problem is covered. And of course, there are other traditional problems, such as language problems,” Dr. Košcálová said. 

One survey found that about 25% of households needed medical care since their arrival, with the needs being higher among the children and older adults. As in Poland, there were several barriers to care. Among them, the refugees were unsure of their rights or where they could find care, and many healthcare providers were not certain they could care for these patients, so they refused care.

“I would like to add—and this is probably true for the whole of Europe—but actually, the health services are very stretched and overwhelmed, even among the local population. So sometimes it’s really difficult to absorb the extra patients,” she said.

Centers were set up specifically to provide Ukrainians primary care, which includes gynecology and obstetrics, as well as mental health care.

“There is also a plan actually to offer a systematic screening of HIV, hepatitis B and C, and syphilis testing.”

One serious problem is a lack of healthcare professionals to treat the influx of people, and although Ukrainian healthcare professionals are among the refugees, they aren’t licensed to practice in Slovakia or Poland. One center in Slovakia is trying to overcome the long process to allow them to practice and help in the clinics.

Drug shortages are also a serious problem. And like Poland, Slovakia is seeing an increase in TB, HIV and other infectious diseases. 

Devastating War Injuries

Another report from ECCMID highlighted the devastating impact of war injuries with complex bone and soft tissue MDR infections. Specialists treated 13 civilians and one soldier who were transferred to Germany because of the complexity needed for their care.

“Casualties of the war in Ukraine often receive suboptimal surgical and antibiotic treatment in often unsterile low-resource conditions and war zone, emergency settings, sometimes for weeks or even months,” said lead author Dr Maria Virginia Dos Santos from the Charité – University Hospital, in Berlin.

“The logistics of treatment in war, extensive injuries and infections, with the added challenge of polymicrobial infections caused by various combinations of bacteria, fungi and parasites with multiresistant pathogens, makes these injuries extremely complex to treat,” she said.

Since the war in Ukraine started in February 2022, injured civilians and soldiers who were initially stabilized in Ukrainian and Polish hospitals have been transported to neighboring countries for further treatment.

Between March and December 2022, 47 patients from Ukraine were treated in the Center for Musculoskeletal Surgery at the Charité – University Hospital, led by the trauma and orthopedic surgeons.

In this analysis, doctors described treating 14 of those patients with highly complex musculoskeletal infections: six from gunshot wounds and eight from bomb and grenade explosions.

Most of the patients were male (10) and four were female; among them there were three children. The youngest was just 14 years old and the oldest 64.

War injuries result in complex and extensive soft tissue damage as well as large bone defects, contaminated by foreign objects and commonly infected with MDR bacteria.

In this analysis, doctors focused on infections of injuries with mostly MDR pathogens that were treated by a multidisciplinary team, requiring a combination of surgical treatment strategies and antimicrobial therapy.

Most infections were bone infections, followed by implant-associated infections, soft tissue infections and septic arthritis. The most common infections were in the lower extremities, but almost half of patients had more than one anatomic area affected. Two patients had multiple sites of infection.

All patients required complex anti-infective treatment strategies due to difficult-to-treat or MDR bacteria detected in tissue samples.

Overall, 13 patients were colonized with MDR gram-negative organisms, mainly Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter baumannii and Escherichia coli, as well as coagulase-negative staphylococci, enterococci and fungal infections.

Of the 25 gram-negative bacterial isolates identified, almost three-fourths (72%) were resistant to carbapenems and the newer cephalosporins (ceftazidime-avibactam, ceftolozane-tazobactam)—the antibiotics of last resort. And 39% of the isolates were resistant to cefiderocol, 20% to colistin and 96% to ciprofloxacin—one of the most commonly prescribed oral antibiotics.

Empiric treatment included the combination of antibiotics colistin, meropenem and vancomycin in addition to radical surgical debridement, soft tissue reconstructions, reconstructive surgery to stabilize and join the ends of a broken bone, and joint replacement surgery, abdominal surgery, oral and maxillofacial surgery, and hardware removal, resulting in lengthy hospital stays.

“We are dealing with a completely new pathogen spectrum than what we would expect to see in Germany,” Dr. Dos Santos said. “In these horrific war injuries, we are seeing a high incidence of multiresistant gram-negative pathogens, and all our cases have been polymicrobial infections. This means we’ve had to adjust our previous antibiotic treatment strategies to cover these multidrug-resistant organisms.”

As of April 2023, two patients have been discharged after treatment and are thought to have returned to Ukraine, two are currently still undergoing treatment, and another two have developed new acute infections at different sites. 

The remaining eight patients have no signs of infection and have been discharged from the hospital but are undergoing an extensive rehabilitation process for their injuries, as well as the social and emotional impact of the trauma.