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. 2025 Dec;15(4):100911.
doi: 10.1016/j.afjem.2025.100911. Epub 2025 Sep 26.

Assessing the relationship between armed conflict and infectious disease incidence in Six Sub-Saharan Countries: Implications for Emergency Departments in conflict areas

Andrew Holzman  1 , Daniel Olinga  2 , Jacob Busingye  2 , Douglas Rappaport  3
Affiliations

Assessing the relationship between armed conflict and infectious disease incidence in Six Sub-Saharan Countries: Implications for Emergency Departments in conflict areas

Andrew Holzman et al. Afr J Emerg Med. 2025 Dec.

Abstract

Introduction: This study aimed to update and expand on prior ecological analyses by examining within-country and cross-national correlations between conflict deaths and infectious disease incidence in six neighboring sub-Saharan African countries.

Methods: We analyzed six countries including Uganda, Rwanda, the Democratic Republic of the Congo, Central African Republic, South Sudan, and Burundi using conflict death data from the Uppsala Conflict Data Program and disease incidence data from the World Health Organization databases. Data were analyzed for the maximum period covered in the UCDP for each country, in general from 1990 to the present. Seven diseases were examined: malaria, tuberculosis, human immunodeficiency virus, tetanus, pertussis, measles, and yellow fever. We assembled matrices of regressions between conflict deaths and disease incidence within and across countries. The approach of this study was hypothesis-generating, with the intent to flag associations worthy of further consideration.

Results: Within-country analyses identified strong positive associations in Burundi (e.g., tuberculosis: R² = 0.81, p<0.001; tetanus: R² = 0.59, p<0.001) and Uganda (e.g., tuberculosis: R² = 0.56, p<0.001; malaria: R² = 0.42, p<0.001). Weaker but statistically significant correlations were also observed with measles in Uganda (R² = 0.13, p = 0.04) and Burundi (R² = 0.29, p = 0.001). Cross-nationally, we observed strong correlations between conflict deaths in Burundi and tuberculosis incidence in Uganda (R² = 0.86, p<0.001) and conflict deaths in South Sudan and malaria in the Democratic Republic of the Congo (R² = 0.64, p<0.001).

Conclusion: We confirm prior reports of malaria incidence association with armed conflict while introducing potential new associations involving tetanus and measles. Our hypothesis-generating approach supports further research. Emergency physicians and health systems in conflict-affected and adjacent regions should anticipate shifts in disease burden and consider preparedness strategies.

Keywords: Conflict; Infectious disease; Measles; Tetanus.

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Conflict of interest statement

The authors declared no conflicts of interest.

Figures

Fig 1:
Fig. 1
Conflict deaths for each country studied over time.
Fig 2:
Fig. 2
Z-score normalized trends over time for conflict deaths and disease incidences for each disease studied in Uganda.
Fig 3:
Fig. 3
Z-score normalized trends over time for conflict deaths and incidence of each disease studied in Burundi.
See this image and copyright information in PMC

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