Analysis of the impact of crises tuberculosis incidence in Ukraine amid pandemics and war

Abstract

Ukraine has a historically high burden of tuberculosis (TB). As a result of many years of the healthcare system’s reformation, the epidemiological situation has improved. However, under the influence of the COVID-19 pandemic and the illegal invasion by Russia, fluctuations in incidence occur. Through a retrospective, observational analysis using data from the Public Health Center of the Ministry of Health of Ukraine, this study tracked the incidence of TB and multidrug-resistant tuberculosis (MDR TB) and highlights changes caused by crises. The region that maintained a consistently high level of TB and MDR TB throughout the entire study period was Southeastern Ukraine. Data analysis showed a significantly increased TB incidence in Central Ukraine in 2022–2023 (62.75 per 100,000 population) versus 36.55 per 100,000 population in the 2013–2019 period. In Eastern Ukraine, TB incidence decreased markedly (14.95 per 100,000 population) after the beginning of the war in 2022 compared with the pre-COVID-19 pandemic 2013–2019 period (50.36 per 100,000 population). These results indicate a changing pattern of TB incidence throughout Ukraine during the conflict, with lower rates in conflict-affected areas and higher rates in host regions. This reflects the importance of strengthening TB surveillance and control strategies adapted to areas experiencing population influx.

Supplementary Information

The online version contains supplementary material available at 10.1038/s41598-025-01723-7.

Introduction

Crises, such as pandemics and paramilitary conflicts, have a critical impact on the epidemiology of infectious diseases in the context of deteriorating public health services¹. Ukraine is an Eastern European country with a historically high burden of tuberculosis (TB). After the collapse of the Soviet Union, the country experienced a protracted economic crisis that led to population impoverishment and deterioration in funding for public health services. As a result, severe growth and spread of TB with a wide prevalence of multidrug-resistant (MDR TB) forms of disease occurred². Health system reforms launched in 2002 have led to a gradual decrease in TB incidence until 2019. Moreover, Russia’s illegal occupation of Crimea and part of eastern Ukraine in 2014 led to a sharp decrease in the reported incidence due to the impossibility of obtaining data from these regions³. However, the number of TB cases has remained consistently high in Ukraine.

The COVID-19 pandemic has complicated the situation with TB, which has led to fluctuations in detection rates around the world, including in Ukraine⁴. Despite a notable decrease in the number of new TB cases in 2020, subsequent data suggest a resurgence, showing that the global TB incidence trend has increased rapidly and surpassed pre-coronavirus period levels⁵. In this context, an increase in the incidence rate of TB in Ukraine as a burdened country is expected.

The outbreak of war in 2022 inevitably led to a deterioration in quality of life, contributing to the risk of an increase in the incidence of TB. Although several studies showed an increased TB incidence during armed conflicts, the relationship remains complex⁶. Factors such as socioeconomic conditions or the health system’s resilience play an important role⁷. Given the ongoing conflict in Ukraine, further research is needed to understand regional TB dynamics. The military situation in the country is geographically heterogeneous. The main military actions are taking place in Southeastern Ukraine. At the same time, there is a massive displacement of the population across the country, which may provoke a shift in TB incidence and an increase in the proportion of MDR TB forms. In addition, previous related studies paid attention to the risk of active spread of TB not only in the affected area, but also in border countries⁸. The large influx of refugees abroad threatens the spread of morbidity within Europe, particularly in the Eastern European countries bordering Ukraine, e.g., Moldova and Romania, which have a moderate to high burden of TB.

The impact of the war and the COVID-19 pandemic on the incidence of TB in Ukraine remains unstudied. Given the burden of TB in Ukraine, mass population movements may contribute to an uncontrolled increase in the incidence of TB and MDR TB not only in Ukraine, but also in Europe. In this regard, this study analyzed the changes in the incidence of TB in Ukraine against the background of crises and examined the geographical distribution of TB cases within the country against the background of population migration.

Materials and methods

This was a retrospective, observational study. The official annual reports from the Center for Public Health of the Ministry of Health of Ukraine (CPH) for 2013–2023 were analyzed⁹. The CPH is the subdivision that is responsible for disease monitoring and epidemiological surveillance of the Ukrainian population. The CPH permits the quotation, copying of individual parts of texts, images, or videos, reprinting, or any other distribution of information with the mandatory provision of the hyperlink according to its homepage. This study used the following indicators provided by CPH: the number of new TB and MDR TB cases, the annual incidence of TB and MDR TB cases per 100,000 population, and annual TB and MDR TB mortality rates. At the time of the study, MDR TB data for 2023 were unavailable. The CPH defines MDR TB as a form of TB that is resistant to at least two antituberculosis drugs (isoniazid and rifampicin)¹⁰. Using the CPH incidence of TB and MDR TB data, geographic heat maps were created to show the distribution of TB in different regions of Ukraine. All geographic heatmaps were created in Excel for Mac version 16.78 (Microsoft Corporation, Redmond, WA, https://www.microsoft.com/en-us/microsoft-365/excel) with built-in Bing (GeoNames, Microsoft, TomTom). A map showing the territorial division of Ukraine into five regions (Northern, Southern, Central, Western, and Eastern) was also created in Excel for Mac version 16.78 (Microsoft Corporation, Redmond, WA, https://www.microsoft.com/en-us/microsoft-365/excel) with built-in Bing (GeoNames, Microsoft, TomTom). This map also shows the approximate areas of Ukraine that are under Russian control, which also coincides with the regions where active military actions are taking place (Supp. 1). The data on occupied territories was based on DeepStateMap (https://deepstatemap.live/) accessed on April 5, 2025¹¹.

Statistical analysis was performed using the Shapiro-Wilk test to determine the normality of the data. The dataset includes three phases: pre-coronavirus baseline TB burden phase 1 (2013–2019); phase 2 of the COVID-19 pandemic (2020–2021); and phase 3 of the war in Ukraine (2022–2023). Analysis of variance (ANOVA) with Tukey’s multiple comparison test was performed for different phases in the Eastern and Central regions of Ukraine. All significance tests were two-tailed, and P < 0.05 was considered significant. All statistical analyses were performed using R software version 4.3.1. (The R Foundation for Statistical Computing, Vienna, Austria). This article contains Supplementary Materials with two figures.

Results

Changes in incidence and number of new cases of TB and MDR TB in Ukraine in 2013–2023

The study included data on Ukraine’s administrative regions from 2013 to 2023. The total population varied from about 45 million to 41 million, with the structure altering due to natural demographic changes, the effects of the COVID-19 pandemic, and internal displacement resulting from the war. New cases ranged from 30,819 in 2013 to 19,851 in 2023. The dominant group of patients is consistently men aged 35–44 years.

Table 1 presents the incidence per 100,000 population and new case numbers of TB and MDR TB in Ukraine in 2013–2022. The incidence of tuberculosis showed a decreasing trend from 2013 to 2020, but it increased again from 2021 to 2023. In the period from 2013 to 2019, the largest drop in TB cases was observed in 2014 (−17%), with an incidence rate of 71.2 per 100,000 population. Subsequently, a record decline was observed in 2020 (−31%), with an incidence of 42.2 per 100,000 population compared with 2019 (incidence of 60.1 per 100,000 population). In 2021–2023, there was a gradual increase in TB cases, which is especially noticeable in 2022 (26%). In 2023, the increase in incidence was 7%.

Table 1.

Incidence and new cases of TB and MDR TB in Ukraine in 2013–2023 according to the CPH database.

	2013	2014	2015	2016	2017	2018	2019	2020	2021	2022	2023
TB incidence (per 100,000 population)	77.5	71.2	70.5	67.6	63.9	62.3	60.1	42.2	44	45.1	48.4
TB new case number (absolute number)	30,819	25,543	23,896	23 292	21 995	21 314	20 643	14,298	14 688	18 510	19,851
Percentage changes of TB cases in each subsequent year		−17%	−6%	−3%	−6%	−3%	−3%	−31%	3%	26%	7%
MDR TB incidence (per 100,000 population)	21.3	19.7	19.7	18.3	15.9	15	14.1	9.8	9.4	9.5
MDR TB (absolute number)	9650	8432	8440	7778	6757	6336	5908	4083	3884	3909
Percentage changes of MDR TB cases in each subsequent year		−13%	0.1%	−8%	−13%	−6%	−7%	−31%	−5%	1%

Regarding MDR TB, noteworthy is the drop in incidence by 13% in 2014 (incidence 19.7 per 100,000 population) compared with 2013 (incidence 21.3 per 100,000 population). The next peak decline in the indicator by 13% was observed in 2017 (incidence 15.9 per 100,000 population) compared with 2016 (incidence 18.3 per 100,000 population). A sharp decrease of 31% was found in 2020 (incidence 9.8 per 100,000 population) compared with 2019 (incidence 14.1 per 100,000 population), which was associated with the COVID-19 pandemic. An increase in the incidence rate of 1% was recorded in 2022.

Distribution of TB and MDR TB within the territory of Ukraine

The heat map (Fig. 1) shows regional TB incidence (cases per 100,000 population) using a uniform color scale from 0 (green) to 116 (red) according to the lowest and highest annual regional incidence rates recorded during the study period.

Fig. 1.

Heat maps of TB incidence in Ukraine, 2013–2023. The color scale shows annual regional incidence from green (the lowest) to red (the highest) rates.

The southeastern regions of Ukraine, including the Odesa region, have preserved a considerable number of TB cases throughout the entire study period. Regions of Southern Ukraine (Kherson and Mykolaiv) and Eastern Ukraine (Donetsk, Zaporizhzhia, Luhansk) experienced a noticeable decrease in incidence in 2022. Central Ukraine’s Dnipro and Kirovohrad regions showed increased incidences in 2022–2023.

Figure 2 illustrates the problem of MDR TB in Ukraine. Throughout the study period, a consistently high detection rate of MDR TB remained in the Southeastern and Central parts of Ukraine.

Fig. 2.

Heat maps of MDR TB incidence in Ukraine, 2013–2022. The color scale shows annual regional incidence from green (the lowest) to red (the highest) rates.

Although there was a considerable decrease in MDR TB in 2022, the Dnipro region still had a high incidence.

Figure 3 show TB and MDR TB incidence and mortality in the five conventional territorial regions of Ukraine from 2013 to 2023. The incidence and mortality rates are calculated per 100,000 population. The graph of each region along the Y-axis shows the range of lowest to highest TB (left) and MDR TB (right) incidence rates. The mortality rates in 2022–2023 were not available. According to the figures, before 2020, the pattern of both incidence and mortality decreases remained in all regions except Eastern Ukraine. The COVID-19 pandemic in 2020 was associated with a decreased incidence in all five regions of Ukraine.

Fig. 3.

TB and MDR TB incidence and mortality by region of Ukraine, 2013–2023. The vertical axis shows the range of lowest to highest TB (left) and MDR TB (right) incidence rates. The horizontal axis shows the years.

Since 2014, the eastern part of the country’s morbidity and mortality rates have dropped sharply, which is due to the difficulty of obtaining data from the invaded territories. In addition, in 2016–2020, the incidence of MDR TB exceeded the incidence of conventional forms of TB, and there was also a significant gap in incidence and mortality data, which also indicates an underestimation of TB cases in this region.

Southern Ukraine has been consistently highly endemic for TB throughout 2013–2023 with the gradual decrease in TB incidence and mortality, these indicators are still higher than the average for Ukraine. In 2022, in Eastern Ukraine, the southern regions showed a substantial drop in incidence even compared with the coronavirus epidemic. However, in 2023, the incidence increased again.

The incidence in Northern and Western Ukraine in 2022–2023 showed a gradual increase compared with the 2020–2021 period. In 2022–2023, the incidence in Central Ukraine showed a sharp increase.

The map showing the conventional division of Ukraine’s territory into five regions is placed in the Supplementary Materials (Supp. 1).

Table 2 presents the results of the statistical analysis of TB incidence data across Eastern and Central Ukraine. Initially, a Shapiro-Wilk test was performed to assess the normality of the data’s distribution in the five Ukrainian regions. Normally distributed data were evaluated by ANOVA and Tukey’s post hoc test.

Table 2.

TB incidence characteristics by phase in Eastern and central Ukraine.

TB incidence	Phase 1 (2013–2019)		Phase 2 (2020–2021)		Phase 3 (2022–2023)
	Mean	Standard deviation	Mean	Standard deviation	Mean	Standard deviation
Eastern Ukraine	50.36	2.77	37	5.18	14.95	5.18
Central Ukraine	59.17	2.55	36.55	4.59	62.75	4.59

The average incidence of TB in Eastern Ukraine was 50.36 per 100,000 population during phase 1 (2013–2019), 37 per 100,000 population during phase 2 (2020–2021), and 14.95 per 100,000 population during phase 3 (2022–2023) (p < 0.01). There was a significant decrease in incidence during phase 3 compared with phase 2 (Tukey’s post hoc test, p = 0.04).

The average incidence of TB in Central Ukraine was 59.13 per 100,000 population during phase 1 (2013–2019), 36.55 per 100,000 population during phase 2 (2020–2021), and 62.75 per 100,000 population during phase 3 (2022–2023) (p = 0.01). The incidence increased significantly during phase 3 compared with phase 2 (Tukey’s post hoc test p = 0.01).

Table 3 shows TB incidence rates in the regions of Central Ukraine in 2013–2023. The incidence in all regions of Central Ukraine in 2022–2023 increased compared with the coronavirus period of 2020–2021 and also exceeded the indicators in 2014–2019. The number of cases increased especially in the Dnipro region (92.60 per 100,000 population in 2022 and 86.1 per 100,000 population in 2023) and the Kirovohrad region (66.20 per 100,000 population in 2022 and 92.1 per 100,000 population in 2023).

Table 3.

TB incidence rates in central Ukraine in 2013–2023.

	2013	2014	2015	2016	2017	2018	2019	2020	2021	2022	2023
Dnipro region	91	79	78.4	64.7	64.5	61.1	63.9	50.5	56.5	92.60	86.1
Kirovohrad region	77.2	78.9	76.7	67	70.3	65.7	68	45.8	41.2	66.2	92.1
Cherkasy region	61.3	57.2	57.4	52.8	50.3	46.2	45.1	32.3	33.5	40.5	58.4
Poltava region	60.1	54.9	54.7	55.8	52.8	48.6	41.4	30.2	26.8	42.8	59.1
Vinnytsia region	55.9	50.2	47.3	48.2	39.2	40.9	44.6	27.6	21.1	37.1	53
Average Incidence	69.1	64	62.9	57.7	55.4	52.5	52.6	37.3	35.8	55.8	69.7

Subsequently, a statistical analysis of the incidence within Central Ukraine was performed. The Shapiro-Wilk test showed that the data for all five regions were normally distributed. The mean incidence for the Dnipro region was 71.8 per 100,000 population in phase 1, 53.5 per 100,000 population in phase 2, and 89.35 per 100,000 population in phase 3 (ANOVA, p = 0.02). There was a significant difference between phases 2 and 3 (Tukey’s post hoc test, p = 0.02).

For the Kirovograd region, the average incidence rate was 71.9 per 100,000 population in phase 1, 43.5 per 100,000 population in phase 2, and 79.2 per 100,000 population in phase 3 (ANOVA, p < 0.01). There were significant differences between phases 1 and 2 (Tukey’s post hoc test, p < 0.01) and between phases 2 and 3 (Tukey’s post hoc test, p < 0.01).

For the Cherkasy region, the average incidence was 52.9 per 100,000 population in phase 1, 32.9 per 100,000 population in phase 2, and 49.45 per 100,000 population in phase 3 (ANOVA, p = 0.02). There was a significant difference between phases 1 and 2 (Tukey’s post hoc test, p = 0.02). Poltava’s mean incidence was 52.61 per 100,000 population in phase 1, 28.5 per 100,000 population in phase 2, and 50.95 per 100,000 population in phase 3 (ANOVA, p = 0.01). There were significant differences between phases 1 and 2 (Tukey’s post hoc test, p < 0.01) and between phases 2 and 3 (Tukey’s post hoc test, p = 0.02).

Vinnytsia’s mean incidence was 46.61 per 100,000 population in phase 1, 24.35 per 100,000 population in phase 2, and 45.05 per 100,000 population in phase 3 (ANOVA, p < 0.01). There were significant differences between phases 1 and 2 (Tukey’s post hoc test, p < 0.01) and between phases 2 and 3 (Tukey’s post hoc test, p = 0.03).

Discussion

In this study, changes in the incidence of TB and MDR TB under conditions of crises such as a pandemic and war were analyzed using Ukraine as an example. The analysis revealed divergent trends across regions, with a notable increase in TB incidence in Central Ukraine and a marked decrease in reported cases in Eastern Ukraine during the war phase.

After the Soviet Union’s collapse, Ukraine faced a severe TB problem amid an economic crisis. Despite funding shortages and low treatment adherence, it implemented the DOTS strategy and aligned its TB treatment protocols with WHO recommendations^2,9. TB incidence decreased steadily until the first Russian invasion in 2014, which hindered obtaining data from Donetsk, Luhansk, and Crimea. Additionally, Ukraine has reported low treatment success rates for MDR TB despite the implementation of DOTS and the latest BPaL/BPaLM regimens^12,13. Starting in 2014, it has been listed among the WHO’s top countries with MDR TB burden, ranking second in the European region after Kazakhstan, Russia, and Moldova^4,14,15.

TB and MDR TB incidence in Ukraine is heterogeneous, with the Southern, Eastern, and Central regions consistently showing the highest rates ⁹. Particularly, high levels of tuberculosis incidence persisted in Southern Ukraine throughout the study, despite a decline in incidence nationwide. Several factors explain these results. First, the Ukrainian economy weakened, and domestic financial support for antituberculosis programs was reduced due to the armed conflict 2014^16,17. Second, large internal population displacement to safer territories occurred, particularly in Southeastern and Central Ukraine^18,19. In addition, some regions in Southeastern Ukraine describe their social environment as critical and tense based on crime and drug use, belonging to TB risk group^20–22. The Odesa region, with many TB cases, attracts migrants as it is one of Ukraine’s largest seaports, potentially contributing to the spread of TB and HIV²³. These elements have caused regional disparities in the TB burden, as conflict, socioeconomic instability, and population shifts heighten the risk of transmission in Southern and Central Ukraine.

Based on our statistical analysis, the most significant changes in incidence were observed in Eastern and Central Ukraine. In Eastern Ukraine, the decline in TB cases is probably related to the military conflicts of 2014 and 2022 rather than an actual reduction in TB burden. The loss of access to the occupied territories, systematic disrupted surveillance, and mass displacement of the population led to a repeated decrease in the detection of disease cases, as similarly reported in other crisis-affected areas^24–26. On the contrary, MDR TB cases have increased noticeably, reflecting the ongoing effects of extended interruptions in TB control initiatives since 2014.

In the case of Central Ukraine, a significant increase in TB cases was seen in the period 2022–2023 compared with the pandemic period. Several regions, e.g., Poltava and Cherkasy, experienced a decrease in incidence during 2020–2021, showing the impact of the COVID-19 pandemic. However, the war caused a sharp relapse in TB cases, especially in the Dnipro region, which has become one of the areas with the highest number of internally displaced persons since hostilities began in 2022²⁷. These findings suggest a potential association between the war and rising TB incidence in Central Ukraine. Considering the high prevalence of MDR TB forms in Ukraine, forced migration may increase MDR TB in the Ukrainian population²⁸. In the ongoing unstable conditions, it is necessary to strengthen epidemiological alertness and control in regions hosting refugees.

War is associated with deterioration of living standards and medical care due to the high risk of spread of TB²⁹. Previous research reported a 20-fold increase in TB risk associated with the crisis⁶. The authors identified such characteristics of TB during the war as an increased burden of the disease among displaced populations, time delay in seeking medical care in affected regions, and the reduction of the notification rate at the state level. However, the relationship between armed conflict and TB incidence is complex and context-dependent. The systematic review by Gebreyohannes et al.⁷ stated that conflicts are not always related to an increased incidence, and this tendency is influenced by factors such as internal displacement, socioeconomic collapse, and breakdown of prevention programs. The authors mention that active interventions (e.g., DOTS expansion or strengthening national TB control programs) improve outcomes despite conflict. In the case of Ukraine, the national database recorded an increased overall incidence in 2022–2033, with declining TB in conflict-affected areas⁹.

A similar tendency to Ukraine’s incidence was observed in Syrian data due to the conflict that began in 2011⁸. However, countries bordering Syria reported an increased incidence of TB³⁰. Due to active hostilities in Ukraine, around 7.9 million people had left Ukraine to find protection in European countries by the end of 2022³¹. The exact number of TB cases among displaced persons is unknown because there is no mass routine screening of Ukrainians in Europe, and the TB strategy is a local government initiative^32,33. Ukraine’s national epidemiological surveillance system does not provide the number of TB patients who have lost follow-up, particularly from high-displacement regions. Monitoring these cases is critical to assessing the epidemiological burden and adapting control strategies.

The COVID-19 pandemic disrupted TB surveillance worldwide, including Ukraine, which experienced a 31% decline in new TB cases compared to 2019⁹. However, in 2022, the WHO reported that newly diagnosed TB cases increased significantly, surpassing pre-COVID levels⁵. Although Europe is not following this trend, attention is required regarding the influx of Ukrainian refugees, especially in countries bordering Ukraine. A recent study found that Poland, Slovakia, the Czech Republic, and Germany experienced an increase in foreigners contracting TB in 2022, possibly linked to Ukrainian migration³⁴. Furthermore, another study suggested that the Ukrainian conflict with migration will lead to a rapid increase in the incidence of TB throughout Europe³⁵. That is why it is necessary to strengthen epidemiological control over TB in all countries that face a large number of Ukrainian refugees.

Another important aspect is that 32% of Ukrainian refugees returned to Ukraine at least once after initially leaving the country for evacuation³⁶. In this regard, the risk of the disease spreading among the population of Ukraine also increases due to imported cases of TB from other countries with a high burden. Strengthening surveillance in countries hosting large numbers of refugees can prevent the spread of TB. Dense accommodation of refugees in temporary settlement places should not be allowed³⁷. It is also necessary to create alertness regarding TB among medical personnel working with displaced Ukrainians.

The reliability of the data is a significant limitation. In temporarily occupied territories and territories with active hostilities, new cases of TB may be undetected or, even if diagnosed, may be unreported. However, data from other regions remain a reliable source that shows the dynamics of changes in the epidemiological situation of TB within the country. That is why it might be beneficial to emphasize the importance of this research while considering the uncertainty of the data in terms of the ongoing war.

This article examined geographic changes in TB incidence in Ukraine at three time points: before COVID-19 (2013–2019), during the COVID-19 pandemic (2020–2021), and during war (2022–2023). A high incidence of all forms of TB throughout the entire study period was seen in Southern Ukraine. The East showed decreased TB during the war phase, likely associated with reduced case detection and underreporting. The central regions showed increased TB incidence in 2022–2023 compared with the COVID-19 pandemic period, possibly related to migration of the affected population. Given the ongoing cross-border displacement of Ukrainians, the coordination of regional strategies is vital to combat a possible outbreak of TB and MDR TB in Ukraine and Europe.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

K.D. conceived and designed this study, interpreted the data, drafted the manuscript, and revised the manuscript for important intellectual content. V.S. designed this study, interpreted the data, and revised the manuscript for important intellectual content. R.D. interpreted the data and revised the manuscript for important intellectual content. H.M. conceived and designed this study, interpreted the data, and revised the manuscript for important intellectual content. H.Y. conceived this study and revised the manuscript for important intellectual content. T.N. conceived this study and revised the manuscript for important intellectual content. All authors contributed to data acquisition and reviewed, discussed, and approved the final manuscript.

Data availability

All data used in this manuscript are available online. https://phc.org.ua/kontrol-zakhvoryuvan/tuberkuloz/statistika-z-tb/analitichno-statistichni-materiali-z-tb.

Declarations

Competing interests

The authors declare no competing interests.