The heat map (Fig. 1) shows regional TB incidence (cases per 100,000 population) using a uniform color scale from 0 (green) to 116 (red) according to the lowest and highest annual regional incidence rates recorded during the study period.

Heat maps of TB incidence in Ukraine, 2013–2023. The color scale shows annual regional incidence from green (the lowest) to red (the highest) rates.

The southeastern regions of Ukraine, including the Odesa region, have preserved a considerable number of TB cases throughout the entire study period. Regions of Southern Ukraine (Kherson and Mykolaiv) and Eastern Ukraine (Donetsk, Zaporizhzhia, Luhansk) experienced a noticeable decrease in incidence in 2022. Central Ukraine’s Dnipro and Kirovohrad regions showed increased incidences in 2022–2023.

Figure 2 illustrates the problem of MDR TB in Ukraine. Throughout the study period, a consistently high detection rate of MDR TB remained in the Southeastern and Central parts of Ukraine.

Heat maps of MDR TB incidence in Ukraine, 2013–2022. The color scale shows annual regional incidence from green (the lowest) to red (the highest) rates.

Although there was a considerable decrease in MDR TB in 2022, the Dnipro region still had a high incidence.

Figure 3 show TB and MDR TB incidence and mortality in the five conventional territorial regions of Ukraine from 2013 to 2023. The incidence and mortality rates are calculated per 100,000 population. The graph of each region along the Y-axis shows the range of lowest to highest TB (left) and MDR TB (right) incidence rates. The mortality rates in 2022–2023 were not available. According to the figures, before 2020, the pattern of both incidence and mortality decreases remained in all regions except Eastern Ukraine. The COVID-19 pandemic in 2020 was associated with a decreased incidence in all five regions of Ukraine.

TB and MDR TB incidence and mortality by region of Ukraine, 2013–2023. The vertical axis shows the range of lowest to highest TB (left) and MDR TB (right) incidence rates. The horizontal axis shows the years.

Since 2014, the eastern part of the country’s morbidity and mortality rates have dropped sharply, which is due to the difficulty of obtaining data from the invaded territories. In addition, in 2016–2020, the incidence of MDR TB exceeded the incidence of conventional forms of TB, and there was also a significant gap in incidence and mortality data, which also indicates an underestimation of TB cases in this region.

Southern Ukraine has been consistently highly endemic for TB throughout 2013–2023 with the gradual decrease in TB incidence and mortality, these indicators are still higher than the average for Ukraine. In 2022, in Eastern Ukraine, the southern regions showed a substantial drop in incidence even compared with the coronavirus epidemic. However, in 2023, the incidence increased again.

The incidence in Northern and Western Ukraine in 2022–2023 showed a gradual increase compared with the 2020–2021 period. In 2022–2023, the incidence in Central Ukraine showed a sharp increase.

The map showing the conventional division of Ukraine’s territory into five regions is placed in the Supplementary Materials (Supp. 1).

Table 2 presents the results of the statistical analysis of TB incidence data across Eastern and Central Ukraine. Initially, a Shapiro-Wilk test was performed to assess the normality of the data’s distribution in the five Ukrainian regions. Normally distributed data were evaluated by ANOVA and Tukey’s post hoc test.

The average incidence of TB in Eastern Ukraine was 50.36 per 100,000 population during phase 1 (2013–2019), 37 per 100,000 population during phase 2 (2020–2021), and 14.95 per 100,000 population during phase 3 (2022–2023) (p < 0.01). There was a significant decrease in incidence during phase 3 compared with phase 2 (Tukey’s post hoc test, p = 0.04).

The average incidence of TB in Central Ukraine was 59.13 per 100,000 population during phase 1 (2013–2019), 36.55 per 100,000 population during phase 2 (2020–2021), and 62.75 per 100,000 population during phase 3 (2022–2023) (p = 0.01). The incidence increased significantly during phase 3 compared with phase 2 (Tukey’s post hoc test p = 0.01).

Table 3 shows TB incidence rates in the regions of Central Ukraine in 2013–2023. The incidence in all regions of Central Ukraine in 2022–2023 increased compared with the coronavirus period of 2020–2021 and also exceeded the indicators in 2014–2019. The number of cases increased especially in the Dnipro region (92.60 per 100,000 population in 2022 and 86.1 per 100,000 population in 2023) and the Kirovohrad region (66.20 per 100,000 population in 2022 and 92.1 per 100,000 population in 2023).

Subsequently, a statistical analysis of the incidence within Central Ukraine was performed. The Shapiro-Wilk test showed that the data for all five regions were normally distributed. The mean incidence for the Dnipro region was 71.8 per 100,000 population in phase 1, 53.5 per 100,000 population in phase 2, and 89.35 per 100,000 population in phase 3 (ANOVA, p = 0.02). There was a significant difference between phases 2 and 3 (Tukey’s post hoc test, p = 0.02).

For the Kirovograd region, the average incidence rate was 71.9 per 100,000 population in phase 1, 43.5 per 100,000 population in phase 2, and 79.2 per 100,000 population in phase 3 (ANOVA, p < 0.01). There were significant differences between phases 1 and 2 (Tukey’s post hoc test, p < 0.01) and between phases 2 and 3 (Tukey’s post hoc test, p < 0.01).

For the Cherkasy region, the average incidence was 52.9 per 100,000 population in phase 1, 32.9 per 100,000 population in phase 2, and 49.45 per 100,000 population in phase 3 (ANOVA, p = 0.02). There was a significant difference between phases 1 and 2 (Tukey’s post hoc test, p = 0.02). Poltava’s mean incidence was 52.61 per 100,000 population in phase 1, 28.5 per 100,000 population in phase 2, and 50.95 per 100,000 population in phase 3 (ANOVA, p = 0.01). There were significant differences between phases 1 and 2 (Tukey’s post hoc test, p < 0.01) and between phases 2 and 3 (Tukey’s post hoc test, p = 0.02).

Vinnytsia’s mean incidence was 46.61 per 100,000 population in phase 1, 24.35 per 100,000 population in phase 2, and 45.05 per 100,000 population in phase 3 (ANOVA, p < 0.01). There were significant differences between phases 1 and 2 (Tukey’s post hoc test, p < 0.01) and between phases 2 and 3 (Tukey’s post hoc test, p = 0.03).