THE EFFECT OF WAR ON TUBERCULOSIS - RESULTS OF A TUBERCULIN SURVEY AMONG DISPLACED PERSONS IN EL-SALVADOR AND A REVIEW OF THE LITERATURE

Setting: During wartime, civilian populations usually experience a drop in caloric intake, disruption of housing, and a diminution in availability of medical services. These disturbances might be expected to result in increased reactivation of tuberculosis, which may result in increased transmission. Such privations occurred in El Salvador during its 1980-92 civil war, particularly among the 20% of the population, or over 1 million people, who were displaced. Objective: (1) To estimate the rate of transmission of tuberculosis among displaced Salvadorians prior to and during the war, and (2) to compare this result with experience in the literature. Design: (1) A tuberculin survey was conducted in El Salvador in July 1992 among all residents aged 1-30 years in 12 communities of formerly displaced persons. (2) The English language literature on tuberculosis during wartime was reviewed. Results: (1) Overall, 21.2% of the non-BCG vaccinated had significant tuberculin reactions, equivalent to an annual risk of infection of 2.3%. The trend in the annual risk of infection was upward over the latter 6 years of the war, stable over the first 6 years, and was downward prior to the war years. The estimated incidence of smear positive pulmonary tuberculosis was 125 per 100 000 or 3 times the reported rate for El Salvador. (2) A review of the literature showed consistent evidence for increased morbidity and mortality from tuberculosis during wartime. Increased transmission was suggested by those studies showing a rise in both incidence of tuberculous meningitis during war years and excess morbidity and mortality many years after a war. Two major population-based studies found no evidence of increased transmission based on the calculated annual risk of infection; however other studies examining younger or more severely affected populations, or following more prolonged wars, detected an apparent increase in the transmission of tuberculosis. Conclusions: Conditions of war are associated with a rapid increase in morbidity and mortality from tuberculosis, which appears to result in increased transmission among populations most severely affected by war. This increased transmission will result in increased morbidity and mortality for many years, underscoring the need for improved tuberculosis control in the post-war period in countries such as El Salvador that have been devastated by war.