Impact of war on infectious disease in Bosnia-Hercegovina

BMJ 1994; 309 doi: (Published 05 November 1994) Cite this as: BMJ 1994;309:1207
  1. Z Puvacic,
  2. J Weinberg
  1. Department of Epidemiology, Republic Institute of Public Health, Sarajevo, Bosnia-Hercegovina Health Monitoring Unit, World Health Organisation, Zagreb Area Office, Zagreb, Croatia
  1. Correspondence to: Dr J Weinberg, Buckinghamshire Health Authority, Wycombe Locality Team, Prospect House, 38 Crendon Street, High Wycombe, Bucks HP13 6LU.
  • Accepted 12 June 1994

The war that broke out in Bosnia-Hercegovina in April 1992 resulted in the collapse of surveillance of infectious diseases in many areas. The Bosnian authorities recognised the importance of surveillance in managing outbreaks of communicable diseases and the management and evaluation of the humanitarian aid programme, and they have rebuilt the notification system during the conflict with the help of the World Health Organisation. We compared the rates of notification of infectious diseases during 1993 with those during 1987-91.

Methods and results

The surviving elements of the pre-existing surveillance system were used to report to the Republic Institute of Public Health in Sarajevo. Notification was carried out by experienced local staff, often those responsible for notification before the conflict. Various methods were used to overcome difficulties in transmitting notifications. Telephone lines worked occasionally, even across front lines; international humanitarian aid staff visited isolated locations and collected forms. For some enclaves the only method available was amateur radio.

The population figure that we used to calculate incidence of disease was the official estimate of beneficiaries of aid. The figures do not cover tuberculosis, which was reported separately.

During 1993, 45 200 reports were received, covering an estimated population of 1 608 000. The table shows the major conditions notified per 100 000 population for 1987 to 1993. No data were available for 1992.

In the years before the conflict the number of notifications had declined steadily; this decline was reversed for many conditions in 1993. Almost two thirds of disease reported was enteric - mainly, enterocolitis and hepatitis A, and toxinfectio alimentaris (severe diarrhoeal disease with systemic manifestations of confusion and fever for which no clear definition differentiates it from enterocolitis). The other condition with a notable rise was mycosis (skin fungal infection). There was a fall in the notification of influenza, salmonellosis, and the common childhood disease (mumps, measles, whooping cough, and scarlet fever).

Notifications of major diseases per 100 000 in Bosnia-Hercegovina, 1987-93*

View this table:


The impact of the war in Bosnia on the morbidity of the civilian population and the lack of accurate data have been noted.1,2 The data presented here were obtained during a war, from areas of conflict; the data are flawed yet have provided objective information for guiding public health interventions. The prewar reporting categories were retained for comparative purposes, but the absence of confirmation by laboratories of most conditions means that the data must be interpreted with caution. The apparent rise in enterocolitis, hepatitis A, and scabies may be spurious. Increased finding or reporting of cases seems unlikely during a war. Furthermore, the decline in the reporting of conditions such as measles, mumps, and scarlet fever suggests underreporting rather than overreporting Preferential reporting of diarrhoeal disease and hepatitis over respiratory disease may have occurred. Inadequate or destroyed laboratory facilities have probably resulted in a bias towards conditions that do not require confirmation by a laboratory. Reporting was performed, however, by experienced staff, which should maintain consistency. The increased rate of notification reported here is probably an underestimate of the true figure because of underreporting and inflated population estimates - population estimates are the basis for calculating humanitarian aid so they tend to be overestimated.

The importance of epidemiological data in guiding the planning and allocating of resources for emergency assistance has been emphasised repeatedly.3,4 It has been suggested, however, that in wartime the traditional epidemiologists can do little.5 The ability to collect data in a time of conflict is severely limited by lack of access, danger, and the destruction of infrastructures. The present study shows, however, that support for epidemiologists in wartime is worth-while and that useful data, both for detecting outbreaks of infectious disease and for informing humanitarian aid, can be obtained.

We thank all the doctors in Bosnia-Hercegovina who have continued to collect data and plan for the public health despite extremely adverse circumstances and the staff of the World Health Organisation's field offices and health monitoring unit in the former Yugoslavia.


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