Tuberculosis Co-infection Research Articles

Disparidades geoprogramáticas do desempenho de indicadores da tuberculose na população em situação de rua no Brasil: uma abordagem ecológica

ABSTRACT Objective: To analyze the performance and spatial distribution of tuberculosis control indicators in the homeless population in Brazil. Methods: Ecological study, which had the regions and federal units of Brazil as the unit of analysis. The indicators considered, referring to the period from 2015 to 2021, were: proportion of HIV testing, proportion of tuberculosis-HIV co-infection, proportion of directly observed treatment, and proportion of outcomes (cure, treatment abandonment and death). The calculation was performed on each ecological unit, as recommended by the Ministry of Health. For the production of geographic figures, the technique of natural breaks was used. Results: It was identified that people living on the streets had: low HIV testing, especially in Pará (71.7%); high proportion of tuberculosis-HIV coinfection, especially in Rio Grande do Sul (39.9%); and unsatisfactory implementation of directly observed treatment, mainly in Paraíba (7.7%). With regard to outcomes, there was a high rate of treatment abandonment, with a higher proportion in Roraima (52.9%), and a high number of deaths, with an emphasis on Mato Grosso do Sul (23.1%), which also recorded the worst cure rate (28.7%). Conclusion: There was evidence of poor performance of tuberculosis control indicators in homeless people, with heterogeneous distribution between states and regions of the country, and it is clear that most of them had insufficient results. These data raise the persistence of difficulties and challenges inherent to the implementation of tuberculosis control strategies for this population in the national territory.

Mobile devices and accessories are reservoir for drug-resistant bacteria among university students a cross-sectional study

One of the most prevalent opportunistic illnesses among Human immunodeficiency virus(HIV) positive people is tuberculosis. Numerous studies have demonstrated that HIV/Acquired immune deficiency syndrome(AIDS) is a significant public health issue in India. The World health organization(WHO) advised using Cartridge based nucleic acid amplification test (CBNAAT) in conjunction with Rifampicin resistance to identify pulmonary tuberculosis (TB).This cross-sectional research had 160 patients who were older than 15 years. The bulk of the patients, or 109 (68.12%), were in the middle age range of 26 to 45 years, with 135 (84.66%) of them being from rural areas. Low education status persons (primary and high school, 35% and 33.75% respectively) constitute the demographic that is most frequently impacted; nevertheless, among females, uneducated groups are more frequently afflicted. The shift in the distribution of HIV/AIDS and tuberculosis co- infection patients in India's Vindhya Region implies that the HIV/TB co-infection epidemic is spreading. CBNAAT reduces TB detection time while increasing sensitivity and positivity in HIV and TB coinfection. There is an urgent need for intervention to reduce dangerous sexual behaviors.

Clinical and demographical profile HIV and tuberculosis infection with special emphasis on the sputum and CBNAAT positivity in vindhya region of India

One of the most prevalent opportunistic illnesses among Human immunodeficiency virus(HIV) positive people is tuberculosis. Numerous studies have demonstrated that HIV/Acquired immune deficiency syndrome(AIDS) is a significant public health issue in India. The World health organization(WHO) advised using Cartridge based nucleic acid amplification test (CBNAAT) in conjunction with Rifampicin resistance to identify pulmonary tuberculosis (TB).This cross-sectional research had 160 patients who were older than 15 years. The bulk of the patients, or 109 (68.12%), were in the middle age range of 26 to 45 years, with 135 (84.66%) of them being from rural areas. Low education status persons (primary and high school, 35% and 33.75% respectively) constitute the demographic that is most frequently impacted; nevertheless, among females, uneducated groups are more frequently afflicted. The shift in the distribution of HIV/AIDS and tuberculosis co- infection patients in India's Vindhya Region implies that the HIV/TB co-infection epidemic is spreading. CBNAAT reduces TB detection time while increasing sensitivity and positivity in HIV and TB coinfection. There is an urgent need for intervention to reduce dangerous sexual behaviors.

Co-infection by Mycobacterium Tuberculosis And Klebsiella Pneumoniae in an Elderly Male With Multiple Co-morbidities: A Rare Entity With High Mortality

Klebsiella pneumoniae and Mycobacterium tuberculosis coinfection is one of the most lethal combinations with high mortality specially if there is delay in diagnosis and proper management. Patients with uncontrolled diabetes mellitus are prone to develop this type of serious infection.There is a considerable overlap in the clinical presentation of these critical pulmonary infections hence there is need for a high index of clinical suspicion, appropriate judicious investigations, and promt management to improve survivality. Here, we have presented Mycobacterium tuberculosis and Klebsiella pneumonia co-infection presenting as cough, chest pain, and shortness of breath in an elderly male with multiple co-morbidities, like uncontrolled diabetes mellitus, hypertension, prosthetic aortic valve in situ (for aortic stenosis)& previous history of ishchaemic stroke. This combination is rare and to the best of our knowledge not reported in the literature from Bangladesh. Bangladesh J Medicine 2022; 33: 52-57

The clinical characteristics and risk factors for severe COVID-19 in patients with COVID-19 and tuberculosis coinfection.

Under the wave of the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) variant Omicron epidemic, the number of infectious cases has increased dramatically in Jilin Province, China since March 2022.The clinical features and severity of SARS-CoV-2 Omicron variant infection in tuberculosis (TB) patients are not yet clear. Data were obtained from 153 patients with the Omicron variant and TB coinfection and 153 non-TB COVID-19 patients who had been hospitalized at Changchun Infectious Disease Hospital from March to June 2022. Among these coinfection patients, 17 patients showed COVID-19-related pneumonia on chest imaging and 11 were diagnosed with severe COVID-19. The median duration of SARS-CoV-2 clearance was 13 days. The negative conversion time was associated with age, COVID-19-related pneumonia and antibody IgG. A higher white blood cell count, a lower lymphocyte percentage, a higher CRP level, and a higher D-dimer level were found in the severe group. Age and increased PCT were individual risk factors for the severity of COVID-19. Compared with the non-TB patients, the coinfection patients had higher severity of COVID-19 and the elder coinfection patients had a longer negative conversion time. This study found an association between age, pneumonia, antibody IgG and RNA negative conversion time in COVID-19 and TB coinfection patients, and age and increased PCT were risk factors for the severity of COVID-19.

Landscape of TB Infection and Prevention among People Living with HIV.

Tuberculosis (TB) is one of the leading causes of mortality in people living with HIV (PLHIV) and contributes to up to a third of deaths in this population. The World Health Organization guidelines aim to target early detection and treatment of TB among PLHIV, particularly in high-prevalence and low-resource settings. Prevention plays a key role in the fight against TB among PLHIV. This review explores TB screening tools available for PLHIV, including symptom-based screening, chest radiography, tuberculin skin tests, interferon gamma release assays, and serum biomarkers. We then review TB Preventive Treatment (TPT), shown to reduce the progression to active TB and mortality among PLHIV, and available TPT regimens. Last, we highlight policy-practice gaps and barriers to implementation as well as ongoing research needs to lower the burden of TB and HIV coinfection through preventive activities, innovative diagnostic tests, and cost-effectiveness studies.

Weight Gain Among Treatment-Naïve Persons With HIV Receiving Dolutegravir in Kenya.

Several recent studies have linked integrase strand transfer inhibitors (INSTI) with increased weight gain. The effects of sex on weight gain with dolutegravir (DTG)-based antiretroviral therapy (ART) among treatment-naïve participants in a lower-income, sub-Saharan population with high rates of pre-ART underweight and tuberculosis (TB) coinfection are unknown. Our analysis included treatment-naïve participants in Kenya and starting their first treatment regimen between January 1, 2015, and September 30, 2018. Participants were grouped into 2 cohorts based on the initial treatment regimen [DTG vs. nonnucleoside reverse transcriptase inhibitors (NNRTI)]. We modelled weight changes over time using a multivariable nonlinear mixed-effect model, with participant as a random effect. Logistic regression models were constructed to evaluate the association between different variables with extreme increase in body mass index (≥10% increase). Seventeen thousand forty-four participants met our inclusion criteria. Sixty-two percent of participants were women, 6% were receiving active TB therapy, and 97% were on NNRTI-based regimens. Participants starting DTG-based regimens were more likely to gain weight when compared with participants starting NNRTI-based regimens. Female participants starting DTG-based regimens experienced the highest weight gain compared with other participants (mean gain of 6.1 kgs at 18 months). Female participants receiving DTG-based regimens, along with participants with lower CD4 cell counts, underweight at baseline, and those receiving active TB therapy were also at higher risk for extreme body mass index increase. Our study in a lower-income sub-Saharan African population confirms higher weight gain with DTG-based regimens compared with traditional ART for treatment-naïve patients.

Quality of Life in Co-Infection of Tuberculosis (Tb) and Human Immune Deficiency Virus/ Acquired Immune Deficie ncy Syndrome HIV/AIDS Positive Patients

OBJECTIVES The objective of our study was to compare the quality of life of HIV/AIDS and TB co-infected patients visiting Family Care Center HMC, Peshawar. METHODOLOGY It was a descriptive cross-sectional study, carried out from 1st october to december 2021 at the Family Care Center department of Hayatabad Medical Complex (HMC), Peshawar.The study sample comprised of 46 participants who were selected by Non probability convenient sampling technique.Out of the total 46 participants 23 were HIV positive with TB co-infected and 23 were HIV positive patients only. Data were collected using World Health Organization Quality of Life WHOQOL-BREF validated structured questionnaires were filled from both male & female participants. RESULT 31 study participants were males participants (67.4%) and 15were females (32.6%). Which included on HIV/AIDS group 13 males (56.5%) and 10 females participants (43.5%) and HIV/AIDS with TB co-infected patients 18 males (78.3%) and 5 females (21.7%).The quality of life was poor in TB Co-infection HIV/AIDS positive patients than in only HIV/AIDS positive patients. The overall quality of life was < 60 % in which 8.6 % find out in HIV/AIDS +ve and 13.1 % in co-infection of Tb with HIV/AID. CONCLUSIONS The difference in the quality of life among the two groups was not significant. Although there was some difference in psychological, social and physical domains in HIV/AIDS with TB co-infection patients as compared to HIV /AIDS. We identified that stigmatization, lack of awareness, and early screening plus treatment were prominent issues.

Treatment outcome and its associated factors among HIV-MTB co-infected patients in Sichuan, China: A retrospective study.

Human immunodeficiency virus (HIV)-Mycobacterium tuberculosis (MTB) co-infection has become a pressing global public health problem. Although tuberculosis (TB) is both treatable and curable, it has been exacerbated by the HIV/acquired immune deficiency syndrome (AIDS) epidemic. HIV-MTB co-infected patients have a variety of disease-specific, and treatment-related factors that can adversely affect their treatment outcomes. This study was conducted to assess the outcomes of TB treatment and its associated factors among HIV-MTB co-infected patients in Sichuan, Southwest China. A retrospective study was performed on HIV-MTB co-infected patients who were diagnosed and registered in TB designated hospitals in Sichuan from January 1, 2016, to December 31, 2020. Data were collected from patients' electronic medical records regarding their demographic, clinical, and social support information, and categorical data, such as sex, were reported using numbers and percentages. χ2 and t-tests were conducted to compare groups in relation to different levels of medical institutions. A binary logistic regression model was used to identify the factors associated with unsuccessful TB treatment outcomes. For logistic regression analysis performed using an α of 0.05, odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were calculated for various risk factors. A total of 3677 registered HIV-MTB co-infected patients were enrolled. After adjusting for other variables, male, advanced age, receiving TB treatment at the municipal medical institution, being diagnosed with external pulmonary TB, referral or tracing, being sputum smear positive, not initiating antiretroviral therapy (ART) and not using fixed-dose combinations were the main risk factors for treatment failure of HIV-MTB co-infected patients in Sichuan province. Sex, age, hospital level, patient source, other diagnostic factors (e.g., sputum smear results, anatomical site of TB), and factors of therapeutic schemes (e.g., antiretroviral therapy, fixed-dose combinations) may serve as risk factors to estimate the likely treatment outcome of HIV-TB co-infection.

Impact of COVID-19 Coinfection on Management of Tuberculosis Patients Registered at DOTS Center in a Tertiary Care Hospital

Introduction: This study was conducted to determine the impact of coronavirus disease 2019 (COVID-19) and the ensuing lockdown on tuberculosis (TB) management undergoing treatment under the National Tuberculosis Elimination Program (NTEP) and vice-versa. Aims: To study (1) the occurrence of COVID-19 and its severity among patients suffering from TB and (2) the impact of a pandemic on TB management under NTEP. Materials and methods: A retrospective observational study was conducted in patients registered at Directly observed therapy short-course (DOTS) center from 1st April 2020 to 31st July 2021 at ESIC Medical College and Hospital, Faridabad, Haryana, India, using a semi-structured predesigned questionnaire administered telephonically. Results: Out of 387 TB patients registered at the DOTS center, 191 participated in the study. The occurrence of COVID-19 in patients with TB was 10 (5.2%), of which five (50%) were symptomatic; four (40%) had pulmonary TB, and six (60%) had extrapulmonary TB. Nine (90%) patients had mild and one (10%) moderately severe disease requiring hospitalization. Amongst 191 patients, 29 (15.2%) missed anti-TB treatment (ATT); 15 (51.7%) could not access the DOTS center due to restrictions, and seven (24.1%) due to personal reasons, eight (27.5%) forgot to take medication, and one (0.34%) migrated elsewhere. Conclusions: The occurrence of COVID-19 in patients with TB was found to be 5.2% in this study. The severity of COVID-19 was mostly mild and the mortality rate in patients with a coinfection of TB and COVID-19 was 10%. The COVID-19 pandemic had a negative impact on TB management under NTEP due to the imposed lockdown. The limitation of this study was the small sample size.

Clinical Profile of Patients with Immune Reconstitution Inflammatory Syndrome in Human Immunodeficiency Virus/Tuberculosis Coinfection and their Outcome: A Prospective Observational Study

Introduction: Antiretroviral therapy (ART) is a life-saving treatment for the human immunodeficiency virus (HIV). However, the starting of ART is often complicated by immune reconstitution inflammatory syndrome (IRIS) in tuberculosis (TB). This study was done to examine the clinical profile of patients with IRIS in HIV-TB coinfection and their outcomes. Materials and methods: A prospective observational study was conducted at the Government Hospital of Thoracic Medicine, Chennai, Tamil Nadu, India, from January to December 2013. Patients diagnosed to have HIV and TB coinfection, those on anti-tuberculosis therapy (ATT) and ART, patients with paradoxical IRIS, and ART-naïve patients were included in the study. A total of 230 patients were studied and followed up for 1 year. Clinical examination and chest X-rays, sputum smear for acid-fast bacillus (AFB), baseline CD4 count, ultrasonogram of the abdomen, routine blood investigations, and other necessary parameters required to determine IRIS TB in HIV/TB coinfected patients were taken. Results: Among the 230 HIV patients studied, 74.3% were males, and the mean age was 39.01 ± 9.60 years. The incidence of IRIS was 20.9%, and the mortality rate was 25% among them. Oral candidiasis was the most common opportunistic infection (37.8%). Among IRIS patients, 62.5% had stage III clinical disease. Conclusion: The time of starting ART is critical to reducing IRIS-associated morbidity. Improved knowledge of the pathophysiology of IRIS will enable better diagnostic modalities and targeted treatments to be developed.

Tuberculosis and COVID-19 co-infection in Serbia: Pandemic challenge in a low-burden country.

COVID-19 and tuberculosis (TB) represent global threats to the public health system. The impact of COVID-19 on TB results in a reduction in the number of notified TB cases, delayed diagnosis and treatment, and increased case fatality and mortality rates. The aim of the study was to analyze the TB/COVID-19 co-infected cohort in Serbia as a low-burden country and compare it to the global TB/COVID-19 cohort. A retrospective analysis was done on 53 TB and COVID-19 co-infected patients treated in COVID hospital "Batajnica" in Belgrade and Special Hospital for Pulmonary Diseases "Ozren" Sokobanja in the period from 6 March 2020 to 1 April 2022. A comparative analysis with the global cohort published recently was also performed. TB/COVID-19 cohort in Serbia included significantly fewer migrants and diabetes cases, but more cases with chronic respiratory diseases compared to the global. Descriptive analysis of TB cases in the Serbian TB/COVID-19 cohort showed fewer cases diagnosed with sputum smear and Gene Xpert/HAIN, fewer EPTB and mono-resistant cases, and more cases diagnosed with solid culture, unilateral pulmonary infiltrate (with bilateral cavity lesions), and bilateral pulmonary infiltrate (no cavities) compared to TB/COVID-19 cases worldwide. Nasal congestion and fever were more common COVID-19 symptoms in the global cohort. Radiology was more commonly used for the diagnosis of COVID-19 in Serbia. Typical bilateral ground opacities were less common among Serbian patients. Serbian patients spent fewer days in the hospital and achieved a higher PCR conversion rate and TB treatment success rate. The Serbian TB/COVID-19 cohort achieved a higher treatment success rate compared to the global cohort. Encouraging vaccination against SARS-CoV-2 for people with a current or past TB disease, as well as rapid diagnosis and targeted treatment of TB in highly specialized pulmonology institutions, presents key points to avoid excessive morbidity and mortality.

Tuberculosis Co-infection and Associated Factors among People Living with HIV /AIDS Who are on Antiretroviral Therapy in Pastoral Community, Northeast Ethiopia. A Bayesian Analysis Approach

Tuberculosis Co-infection and Associated Factors among People Living with HIV /AIDS Who are on Antiretroviral Therapy in Pastoral Community, Northeast Ethiopia. A Bayesian Analysis Approach

The Incidence of Osteoarticular Tuberculosis in the Siberian and Far Eastern Federal Districts in 2018-2020

The incidence of osteoarticular tuberculosis in 15 regions of the Siberian and Far Eastern Federal Districts from 2018 to 2020 was assessed. The incidence of osteoarticular tuberculosis and co-infection of osteoarticular tuberculosis with HIV and osteoarticular tuberculosis with hepatitis B/C was analyzed. Variants of osteoarticular tuberculosis with respiratory tuberculosis, variants of tuberculosis sites in the bone articular system and the most typical neurological disorders in those patients were presented.

Global Impact of Tuberculosis and HIV coinfection

Tuberculosis (TB) is ranked second among the casualties caused by infectious diseases and therefore has been a focus of research for decades. Multi Drug resistant (MDR) tuberculosis is a potential threat to eradicate TB globally. HIV coinfection further complicates the situation due to difficulty in the management of the dual disease, resulting in a high rate of mortality in cases of MDR-TB with HIV coinfection globally. In India, the HIV-TB coinfection incidence is at the rate of 3.8 per 100,000 people, which is at a significant standing in the world. Early and prompt diagnosis helps in designing an effective treatment regime which includes antiretroviral therapy for HIV and the use of the second line of drugs for the treatment of MDR-TB. Since the course of action is extensive, designing policies to provide a support system to the patient and the caregiver will ensure better management of the disease.

COVID-19 and Coinfections: A Serious Health Threat Requires Combination of Diagnosis and Therapy.

Since the advent of the COVID-19 pandemic in 2019, a mammoth research activity targeting the etiological features of COVID-19 has commenced. Many aspects of the disease have been studied, and various others are under consideration. The secondary microbial coinfections with COVID-19 have generated some serious concerns across the globe. This review mainly focuses on the notable secondary coinfections. The coinfection of influenza, tuberculosis, and typhoid may mimic the original COVID-19 symptoms. Physicians and clinicians must focus on the secondary coinfections which may aggravate the disease progression towards acute respiratory disorder syndrome (ARDS). Diagnostic strategies must also be redefined to determine the actual underlying secondary coinfection. There is a need for combination therapy and diagnostic approaches to minimize the risks associated with the COVID-19 pandemic effectively.

Exploring swallowing, feeding and communication characteristics of toddlers with severe acute malnutrition.

Severe acute malnutrition (SAM) is associated with cognitive and motor deficits. Little is known about the swallowing, feeding and communication characteristics of hospitalised toddlers with SAM, limiting the abilities of speech-language therapists to provide effective early intervention. To explore the background, swallowing, feeding and communication characteristics of toddlers with SAM during in-patient nutritional rehabilitation. An exploratory, prospective, collective case-study was conducted with three hospitalised toddlers who were 12-18 months old and independently diagnosed with SAM, at least 1 week after transitioning to oral feeding. Detailed case histories were compiled through medical file perusal and parent interviews. Cross-sectional clinical bedside assessments were completed with the Rossetti Infant-Toddler Language Scale and Schedule for Oral-Motor Assessment. All three participants had a history of feeding difficulties before admission. Despite intact pharyngeal swallows, heterogeneous oral-sensorimotor dysfunction and disruptive feeding behaviours were identified. Risk for oropharyngeal dysphagia indicates the need to modify dietary consistencies to prevent prolonging recovery or SAM relapse. Participants had mild-to-moderate language delays, particularly in interaction-attachment, play and language comprehension, with an atypical moderate receptive and mild expressive language delay profile. None of the participants were referred for speech-language therapy. This exploratory research showed the oral-sensorimotor skills, swallowing and communication characteristics of children with SAM. Speech-language therapists could address oral-sensorimotor functioning, feeding difficulties and communication interaction delays before discharge to community-based management for SAM. Further investigation with a larger sample size is recommended.Contribution:Novel description of the oral-sensorimotor skills for feeding and the communication development of three severely malnourished toddlers with HIV and tuberculosis co-infection was presented. The complexity of the three cases is highlighted.

Effect of active tuberculosis on the survival of HIV-infected adult patients who initiated antiretroviral therapy at public hospitals of Eastern Ethiopia: A retrospective cohort study.

In resource-limited countries such as Ethiopia, tuberculosis is the major cause of morbidity and mortality among people living with the human immunodeficiency virus. In the era of antiretroviral therapy, the effect of tuberculosis on the survival of patients who are living with human immunodeficiency virus has been poorly understood in Ethiopia. Therefore, this study aimed to determine the effect of active tuberculosis on the survival of HIV-infected adult patients who initiated antiretroviral therapy in public hospitals in Eastern Ethiopia. An institution-based retrospective cohort study was conducted among 566 participants from January 1, 2014, to June 30, 2018. The collected data were entered into EpiData version 3.1 before being exported to Stata version 14 for analysis. A Cox proportional hazard model was used to determine the effect of active tuberculosis on the survival of HIV-infected adult patients who initiated antiretroviral therapy, and a p-value less than 0.05 and a 95% confidence level were used to declare statistical significance. Of the 566 patients included in the study, 76 died. The mortality rate was 11.04 per 100 person-years in tuberculosis co-infected patients, while it was 2.52 per 100 person-years in non-tuberculosis co-infected patients. The patients with tuberculosis co-infection had a 2.19 times higher hazard of death (AHR: 2.19; 95% CI: 1.17, 4.12) compared to those without tuberculosis. Advanced clinical stage, low CD4+ cell count, and previous episodes of an opportunistic infection other than tuberculosis were found to be independent predictors of mortality. Co-infection with tuberculosis at antiretroviral therapy initiation increases the hazard of death approximately two-fold. Hence, we recommend key organizations to enhance the region's collaborative interventional and preventative strategies for TB and HIV.

Case Report: A case report of multiple co-infections (melioidosis, paragonimiasis, Covid-19 and tuberculosis) in a patient with diabetes mellitus and thalassemia-trait in Myanmar

Burkholderia pseudomallei is a soil-dwelling aerobic bacterium prevalent in tropical and subtropical regions, particularly in Southeast Asia and Northern Australia. It is the causal organism of melioidosis, a severe infection that can manifest as chronic debilitating pneumonia resembling pulmonary tuberculosis. Here, we report a case of melioidosis, pulmonary tuberculosis, covid-19, and paragonimus co-infection in a 50-year-old male with poorly controlled diabetes mellitus and β-thalassemia trait. The patient recovered with intravenous antibiotics and standard anti-tuberculosis treatment.

How the on-going conflict in Ukraine is impacting cardiovascular health.

Following the outbreak of war in Ukraine on 24 February 2022, we are witnessing a conflict that has led to many civilian, military, and volunteer civil defence force casualties. Those civilians living in a theatre of war are directly exposed to combat-attributable trauma and risks from explosive ordnance. The United Nations Office for the High Commissioner for Human Rights (UNHCR) reported that by 4th September, there had been 13 917 confirmed casualties in the non-combatant civilian population with 5718 deaths1; these figures are likely to be significant underestimates. It is believed that ∼18 million people have been directly impacted by the hostilities with more than 8 million internally displaced. Given the widespread destruction of housing and civil infrastructure, including the disconnection of basic utilities, initial activity to aid those affected has focused on ensuring safe shelter with humanitarian support in the form of clean water, nutrition, sanitation, and clothing. Medical services have been badly disrupted. Monitored by the World Health Organization Surveillance System for Attacks on Health Care, as of 6th September, there had been 512 attacks against healthcare facilities, personnel, patients, transportation, and supply depots, with 100 people killed and 129 injured.2 Some of the remaining clinical resources, particularly those in central Ukraine, have been repurposed as trauma centres to receive casualties from the battlefront if staff are available. These professionals inevitably face ethical treatment dilemmas concerning the allocation of increasingly scarce medicines and equipment, a possible source of moral distress. This war is being pursued against the backdrop of the continuing COVID-19 pandemic, with interruption of public health initiatives to immunize a population already vulnerable due to poor vaccine uptake. Barriers arising from the conflict have hampered the treatment of those infected with coronavirus or other communicable diseases such as HIV and tuberculosis—co-infection with the latter two pathogens is relatively common in Ukraine. The conditions endured by people sheltering from the fighting or seeking refuge through humanitarian corridors, if accessible, seem likely to increase the risk of contagion.