Effect of armed conflict in Donbas on the burden of rifampicin-resistant tuberculosis in Ukraine

Sereda, Yuliia

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Year:: 2023
Contributor:: Sereda, Yuliia (creator); Chiang, Silvia (Advisor); Paul, Alice J (Reader); Brown University. School of Public Health (sponsor)
Genre:: theses
Subject:: causal inference; Tuberculosis; War; drug-resistant tuberculos; Eastern Europe
Extent:: , 81 p.

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Abstract:: Background. Ukraine has one of the highest burdens of rifampicin-resistant tuberculosis (RR-TB) in the world, and since 2014, the country has been involved in an armed conflict followed by infrastructure damage and a large number of internally displaced people (IDP). We used counterfactual methods to examine the impact of the Donbas war on the RR-TB epidemic in Ukraine during its early years. Methods. We conducted a secondary analysis of a nationwide electronic tuberculosis patient-level database. Our study focused on a sample of health facilities that consistently reported over time, encompassing 175,975 TB cases from 350 hospitals. We used a modified difference-in-difference method to assess changes in the probability of laboratory-confirmed or clinically diagnosed RR-TB before (2011-2013) and after (2014-2016) the war. Exposures of interest were the distance between the centroids of a patient's district and the conflict area and indicator variables for regions directly or indirectly affected by the war. We compared three regional groups, namely, "Donbas" (2 regions), "regions bordering Donbas" (3 regions), and "regions distant from Donbas" (3 regions) against control regions with a low IDP population. To ensure balance in patient characteristics across comparison groups and over time, we defined difference-in-difference models as linear probability regressions with regional fixed effects weighted by the propensity score. We derived propensity scores using gradient boosting models and performed robustness checks, including placebo lag and lead tests, and an analysis of effects credibility given violations of parallel trends. Results: During the pre-war period, an increase in the distance to the conflict area by one standard deviation was associated with a decrease in the probability of RR-TB diagnosis by 7.5 percentage points (95% CI: 4.2–10.9). After the war, the distance effect decreased by up to 3.5 percentage points (95% CI: 2.0, 5.0). Control regions with a low IDP population experienced a continuous increase in RR-TB proportion after the war, whereas there was a reduction in RR-TB proportion by up to 6.1 percentage points (95% CI: 2.9–9.4) in Donbas and up to 4.4 percentage points (95% CI: 1.8–7.1) in regions neighboring Donbas. Regions distant from Donbas with a high IDP population and control regions with a low IDP population had comparable RR-TB proportions one year before and three years after the war. Conclusions: The war in Donbas led to a decrease in the spatial disparities in RR-TB, with previously low-burden regions approaching the levels of high-burden regions. The reduction in RR-TB probability in Donbas and neighboring regions disregarding high IDP intensity may indicate underdiagnoses of RR-TB cases and highlights the need for active case-finding interventions.
Notes:: Thesis (M. P. H.)--Brown University, 2023

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Citation

Sereda, Yuliia, "Effect of armed conflict in Donbas on the burden of rifampicin-resistant tuberculosis in Ukraine" (2023). Public Health Theses and Dissertations. Brown Digital Repository. Brown University Library. https://repository.library.brown.edu/studio/item/bdr:p4bxuhht/

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Public Health Theses and Dissertations

Theses and Dissertations for the Public Health department.
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