Specific Event Identifiers:

• Event Type: Humanitarian Crisis/Armed Conflict

• Onset Date: February 24, 2022

• Location of Event: Chişinău, Republic of Moldova

• Geographic Coordinates: Latitude 47.003670, Longitude 28.907089

• Date of Observations Reported: June-December 2022

• Response Type: Medical Relief (CUAMM Emergency Medical Team)

Sources

Data were collected during the time of CUAMM EMT deployment in the Republic of Moldova. Data analyzed in this report covered the period from June 1 through December 19, 2022. The patients admitted to CUAMM EMT were registered with age, gender, and final diagnosis using the CUAMM EMT Clinical Record that responds also to the Minimum Data Set (MDS) record defined by the WHO. Data used for this report did not include patient personal identifiers or confidential information. In the light of these reasons, the Ethics Committee of Azienda Ospedale-Università of Padua (Italy) provided exemption and a notice for publication purposes was registered and approved (Registration number 0079213).

Observations

From the 1,173 patients admitted to CUAMM team during the period of observation (from June through December 2022), the majority were adults (70.8%) with an average age of 51.9 years. Among adult patients, 569 (68.5%) were females and 258 (31.0%) were males. Patients aged less than 18 years were 336 (28.6%); Table 1. The health issues encountered were distinguished into “diagnosis directly related” to the conflict (health issues caused directly by the conflict, such as traumatic injuries), “diagnosis indirectly related” (health issues caused by the consequences of the conflict, such as malnutrition, spread of infectious diseases, increase of mental health issues), and “diagnosis not related” to the conflict (any health issues that did not show direct or indirect relationship with the conflict). The majority of patients (88.7%; n = 1,040) had health problems not directly related to the conflict, while only 3.2% (n = 38) of patients presented diseases directly related to the event (Table 1).

Table 1.

Demographic and Clinical Characteristics of Patients Presented to the CUAMM EMT in the Period from June to December 2022

Note: Diagnosis not related to conflict: diagnosis referring to a medical condition that did not show any direct or indirect relationship with the conflict; Indirectly related to conflict: diagnosis referring to a medical condition caused by the consequences of the conflict, such as malnutrition, mental health issues; and Directly related to conflict: diagnosis referring to a medical condition caused directly by the conflict, such as traumatic injuries.

The average number of patients admitted per month was 167.6, showing a peak in August (230 patients per month) and a regular decrease in the following months (Figure 2).

Figure 2.

Time Course of CUAMM EMT Registered Patients, Expressed in Number of Patients per Month.

Abbreviation: EMT, Emergency Medical Team

According to the framework defined by the MDS, 56 patients (4.8%) were classified as moderate or minor injury (Code 7 and 8) and 1,117 (95.2%) as non-trauma patients. The five most prevalent diagnosis (Table 2) referred to “other diagnosis, not specified above” (Code 29 and Code 22; 66.8%, n = 783), “suspected COVID-19” (Code 19; 16.3%, n = 191), “acute respiratory infections” (not COVID-19 related - Code 9; 4.2%, n = 49), “skin diseases” (Code 25; 2.9%, n = 34), and “acute mental health problems” (Code 26; 2.3%, n = 27); Table 2.

Table 2.

Diagnosis of Admitted Patients Defined in Accordance with the Minimum Data Set (MDS) Record

Regarding the “other diseases, not specified above” group, a more specific additional diagnosis was reported in 467 (59.6%) patients. Among them, the most prevalent conditions were related to cardiovascular diseases (37.9%; n = 177), gastrointestinal diseases (11.9%; n = 56), chronic musculoskeletal diseases (9.8%; n = 46), cancer (7.7%; n = 36), headache (5.8%; n = 27), dental diseases (5.8%; n = 27), ocular diseases (3.4%; n = 16), and chronic obstructive pulmonary disease (2.4%; n = 11); Figure 3.

Figure 3.

Diagnoses Registered in the “Other Diseases” Group, Namely Code 29, According to the Minimum Data Set (MDS) Record.

Abbreviation: COPD, Chronic Obstructive Pulmonary Diseases

Regarding discharge, 49.9% (n = 586) of patients were discharged permanently, 44.8% (n = 526) were identified for follow-up, 0.4% (n = 5) were discharged against medical follow-up, and 3.1% (n = 36) were transferred to Moldovan hospitals.

Analysis

During the time of its deployment, CUAMM EMT targeted mainly an adult population with health issues not directly related to the Ukrainian conflict. The increase of non-disaster related diseases as time passed after disasters is largely described in scientific literature. ^{Reference Sacchetto, Raviolo, Lovesio, Salio, Hubloue and Ragazzoni18–Reference Ladeira, Cardoso and Ribeiro20} According to the MDS, most of the diagnosis referred to “other diseases, not specified above,” namely Code 29. The high prevalence of diseases that are not included in the MDS specific diagnosis codes, such as “trauma” (Codes 1-8), “infectious diseases” (Codes 9 -18), “additional diagnosis” (Codes 19-22), “emergency” conditions (Code 23-24), or “other diseases” (Codes 25-28), suggested that the Code 29 needs to be better specified to allow an adequate analysis of EMTs clinical activity. The Portuguese EMT Type 1 pointed out the same issue in the report describing its clinical activities during the Idai Cyclone in Mozambique. ^{Reference Ladeira, Cardoso and Ribeiro20}

The diagnoses registered by CUAMM EMT as Code 29 were mainly attributable to non-communicable diseases (NCDs), such as cardiovascular diseases, non-infectious gastrointestinal diseases, chronic musculoskeletal diseases, and cancer. This result, considered together with the registered cases (10 patients; 0.9%) of diabetes (Code 21), showed a high prevalence of NCDs among the refugees.

Recent scientific literature has largely highlighted the impact of NCDs in the aftermath of disasters. ^{Reference Ladeira, Cardoso and Ribeiro20–Reference Bausch, Beran and Hering25} Although NCDs represent an increasing global challenge during disasters and humanitarian emergencies, there is a lack of a standardized response during EMTs operations. ^{Reference Bausch, Beran and Hering25,26} In the past few decades, EMTs have traditionally been employed to manage acute conditions such as trauma and infectious diseases in order to mitigate the immediate impact of the disaster on the health and safety of the affected community. ^{Reference Brandrud, Bretthauer and Brattebø27–Reference McPherson, Counahan and Hall29} At the time of writing this report, the current scientific literature reports poor information regarding the role of EMTs in managing chronic health needs related to NCDs. To the best of the authors’ knowledge, the majority of manuscripts concerning EMTs and NCD treatment are focused on specific conditions, such as diabetes, ^{Reference McDermott, Hardstaff, Alpen, Read and Coatsworth30} chronic ophthalmic diseases, ^{Reference McMaster and Clare31} medical rehabilitation, ^{Reference Amatya, Galea, Li and Khan32} or mental-health issues. ^{Reference Yumiya, Chimed-Ochir and Taji33}

The need to ensure a more comprehensive approach to chronic health needs of vulnerable people in humanitarian emergencies has recently been highlighted in the WHO work on NCDs in emergencies. ³⁴ Since 2022, a joint program of work has been established between WHO’s Department of Noncommunicable Diseases, Rehabilitation, and Disability (NCD) and the World Health Emergencies Program (WHE; Geneva, Switzerland). Specific outputs of this program are aimed at strengthening policies for NCD integration across the emergency cycle and providing normative tools aimed to enhance NCD management in emergency preparedness and response. ³⁴ Many scientific reports focused on disaster response have shed a light on the need to develop plans aimed to expand the ability of health systems in ensuring continuity of care for chronic health conditions. ^{Reference Runkle, Brock-Martin, Karmaus and Svendsen35–Reference Armocida, Ussai and Pavlovych39}

The recent escalation of the armed conflict in Ukraine reflects these observations, having caused massive civilian displacement and casualties with a heavy impact on the health system and on the population’s health. Since chronic NCDs are the leading cause of morbidity and mortality in Ukraine, accounting for 91% of total deaths, it appears fundamental to address the needs of disaster-affected populations with such pre-existing conditions. ^{Reference Armocida, Ussai and Pavlovych39,Reference Van Hemelrijck, Fox and Beyer40}

During its activities, CUAMM EMT operated as a semi-permanent cell composed of two members, including one Italian medical doctor and one local nurse per each daily shift. This team composition had multiple advantageous implications. The support from a local nurse allowed to limit the number of health professionals coming from Italy, facilitating the process of medical doctor recruitment. Moreover, working in integration with the local staff improved the positive impact of the CUAMM team on refugee health needs. The presence of a local nurse speaking Italian, Ukrainian, and Russian allowed to overcome any linguistic barriers between Italian physicians and Ukrainian refugees, facilitating the development of closer relationships with the refugees. Recent scientific literature focused on EMT missions has largely highlighted the importance of the integration of local staff members in the team composition, useful both to promote professional training and population health education, and to plan successful exit strategies. ^{Reference Sacchetto, Raviolo, Lovesio, Salio, Hubloue and Ragazzoni18–Reference Ladeira, Cardoso and Ribeiro20,Reference McDermott, Hardstaff, Alpen, Read and Coatsworth30} The need to provide a semi-permanent service able to provide assistance between the initial emergency response and the re-establishment of local health service delivery was discussed by McMaster, et al in their recent study, focused on designing a mobile eye hospital to support health systems in disaster settings. ^{Reference McMaster and Clare41}

This report provided useful insight regarding the incidence of NCDs among Ukrainian refugees, shedding light on the need for a more precise identification of chronic health needs of vulnerable populations in disaster aftermath. However, it should be underlined that this document presented some limitations. The descriptive picture illustrated in this report might not necessarily provide a complete scenario of health needs in this population, due to the fact the population assisted by the CUAMM EMT targeted other facilities in the area when dealing with other diseases, such as acute life-threatening conditions in need of advanced medical care.