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 dro p in caloric intake, disruption of housing, and a diminution in availa bility of medical services. These disturbances might be expected to re sult in increased reactivation of tuberculosis, which may result in in creased transmission. Such privations occurred in El Salvador during i ts 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 expe rience in the literature. Design: (1) A tuberculin survey was conducte d in El Salvador in July 1992 among all residents aged 1-30 years in 1 2 communities of formerly displaced persons. (2) The English language literature on tuberculosis during wartime was reviewed. Results: (1) O verall, 21.2% of the non-BCG vaccinated had significant tuberculin rea ctions, equivalent to an annual risk of infection of 2.3%. The trend i n the annual risk of infection was upward over the latter 6 years of t he war, stable over the first 6 years, and was downward prior to the w ar years. The estimated incidence of smear positive pulmonary tubercul osis was 125 per 100 000 or 3 times the reported rate for El Salvador. (2) A review of the literature showed consistent evidence for increas ed morbidity and mortality from tuberculosis during wartime. Increased transmission was suggested by those studies showing a rise in both in cidence of tuberculous meningitis during war years and excess morbidit y and mortality many years after a war. Two major population-based stu dies found no evidence of increased transmission based on the calculat ed annual risk of infection; however other studies examining younger o r more severely affected populations, or following more prolonged wars , detected an apparent increase in the transmission of tuberculosis. C onclusions: 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 m ortality for many years, underscoring the need for improved tuberculos is control in the post-war period in countries such as El Salvador tha t have been devastated by war.