Thyroid disease in Ukrainians’ lives

When we think of the many challenges Ukrainians are facing with courage today, we should remember that they lived through Chernobyl, and that they are a people living with thyroid diseases.

Partly because of the Chernobyl nuclear meltdown disaster in 1986, thyroid disease and lifelong thyroid therapy has become an important part of Ukrainians’ past and present.

Within 13 years after the disaster, the Chernobyl region’s thyroid cancer incidence rose more than 500-fold higher than the pre-disaster rate (Mitchell, 1999).

The effect of radioactive iodine on thyroid health has raised awareness of the protection offered by a well-timed dose of potassium iodide in nuclear emergencies.

Total thyroidectomy after thyroid cancer leads to a lifelong dependence on hormone doses that must be carefully fine tuned to the individual.

But it’s not just thyroid cancer.

The number of people with all types of thyroiditis, hypothyroidism, and hyperthyroidism far outnumber the patients who have or have survived thyroid cancer.

In fact, “The frequency of thyroid pathology among adults has changed from 17 to 53% over the past 30 years, and its greatest increase was determined 10-15 years after exposure to radiation” (Tkachenko et al, 2018).

The rates are much higher today than they were before, in regions far outside the contaminated region around Chernobyl.

Hospitalizations for people who were undertreated on thyroid medication were alarmingly high for the calendar year of 2012 at a single Ukrainian hospital, where 23 men and 58 women were admitted for an average hospital stay of 10.77 days. The cost of treating complications of thyroid hormone underdose is much higher than the cost of medicating hypothyroidism itself (Vadziuk, 2015).

Thyroid hormones support the healthy function of every tissue and organ in the human body. Too much or too little thyroid hormone can hinder brain function, and it can worsen mortality rates in cardiovascular diseases, diabetes, kidney and liver disorders, and many other chronic conditions (Sohn et al, 2021; Rhee et al, 2018).

Ukrainian and Belarusian thyroid cancer rates greatly increased since Chernobyl

History.com’s article (Plohky, 2018) “The Chernobyl Cover-Up: How Officials Botched Evacuating an Irradiated City” vividly retells the tale of a population in crisis, and its aftermath:

• “With Chernobyl’s nuclear radiation raining down, Communist party officials dithered, delayed and hid the truth. Then they gave residents of nearby Prypiat 50 minutes to evacuate.”
• “Children were affected the most by Chernobyl radioactive fallout, with 3,000 cases of thyroid cancer registered in the 1990s in Belarus, Russia and Ukraine in the population under 14 years of age. 

Back in 1999 the medical journal The Lancet published a short news update that summarized what had happened by then.

Here is the full text of the short article:

“Thyroid cancers have increased tenfold among Ukrainian children since the 1986 Chernobyl nuclear power station disaster. And most of the malignancies are unusually aggressive and rapidly metastasise to nearby lymph nodes, reports a new epidemiological study (Cancer 1999; 86: 148–55).

Researchers at the Ukraine Academy of Medical Sciences in Kiev found that the number of paediatric thyroid carcinomas had increased

• from 12 per year before the accident
• to 73 per year in 1997.

In the immediate Chernobyl area, the incidence of thyroid cancer has now reached 1 in 3700 of the population, more than 500-fold higher than the pre-disaster rate.

Even higher rates have been recorded in nearby Belarus, which received more iodine-131 fallout than Ukraine.

Children who were younger than 4-years old or were in utero at the time of the accident are at the highest risk, accounting for 42% of the cases.

“Children constitute the most vulnerable group of exposed individuals because their thyroid sensitivity to radiation is high, and there is a longer life span to manifest its effects”, says Virginia LiVolsi (University of Pennsylvania Medical Center, Philadelphia, PA, USA), a co-author on the study.

Children who developed thyroid cancer probably ingested 131-I mainly from cow’s milk, says John Harrison, head of WHO’s collaborating centre on radiation.

Iodine deficiency among the local population and their reliance on subsistence farming also contributed to the increased cancer rates, he says, and “the disaster was made worse by

• the absence of contingency plans to substitute contaminated food with safe food from elsewhere and
• inadequate stocks of stable iodine for prophylaxis”.

Most of the children with thyroid cancer have had a thyroidectomy.

More than 60% of them needed lymph-node dissection to remove metastases—a much higher rate than is usual in paediatric thyroid carcinomas.

The survival rate is very high, but patients will need thyroxine for the rest of their lives, a long-term and expensive health problem for the region.”

Prevalence and incidence of thyroid diseases in Ukraine, 2007-2017

Now let’s look beyond thyroid cancer.

Kravchenko reported in 2021 that among all endocrine disease diagnoses in the Ukraine, after diabetes took the lion’s share of 63%, and “other” conditions 18%,

• Nodular goiter accounted for 8%,
• Thyroiditis 5%,
• Hypothyroidism 3%,
• Thyrotoxicosis 2%, and
• Thyroid cancer 1%

Thyroid diseases account for 19% of the endocrine pie chart in the Ukraine.

Tkachenko and colleagues published an article in 2018 revealing the prevalence and subtypes of thyroid diseases that many Ukrainians live with.

Rates have been increasing.

In Tkachenko’s study, category definitions were as follows:

• “Thyroiditis” includes “all possible types of thyroiditis (acute, subacute, autoimmune, postpartum and chronic specific)”
• “Hypothyroidism … combines congenital hypothyroidism and all forms of acquired,”
• “Hyperthyroidism” includes many causes, “80% of which are diffuse toxic goiter, nodular toxic goiter and hyperthyroid phase of autoimmune thyroiditis.”

“As for the general Ukrainian structure, today

• thyroiditis accounts for 13.8% of all thyroid pathology,
• hypothyroidism – 7.5%,
• hyperthyroidism – 4.1%.”

“Among the population of Kyiv region in 2017,

• “thyroiditis was 11.2 %,
• hypothyroidism — 4.6 %,
• hyperthyroidism — 2.1 %.”

“In 2007-2017, in Kyiv,

thyroiditis increased from 8.2 to 11.2% (increase +36.6%),

hypothyroidism – from 3.1 to 4.6% (increase +48.45%),

hyperthyroidism – from 1.8 to 2.1% (increase +16.7%).”

“In Kyiv region women,

• thyroiditis occurred 9.7 times more often than in men,
• hypothyroidism — 8.3 times and
• hyperthyroidism — 5.3 times.”

“Reliable data on increased prevalence of thyroiditis were found
in the Kyiv region:

• thyroiditis — by 1.9 times (p < 0.01),
• hypothyroidism — 2.1 times (p < 0.01),
• hyperthyroidism — 1.7 times (p < 0.01)

and in Ukraine

• (thyroiditis — by 2.5 times (p < 0.01),
• hypothyroidism — 1.7 times (p < 0.01),
• hyperthyroidism — 1.5 times (p < 0.01)).”

Understanding prevalence rates helps us calculate the individual, social and economic cost of thyroid diseases.

The cost of hospitalizations for thyroid undermedication in Ukraine

A conference abstract was published in 2015 that gave a shocking cost-estimate and of hospitalization of hypothyroid Ukrainians at a single hospital. (Vadziuk, 2015).

Although these patients also likely had comorbidities complicating their health crisis, they were found to be undertreated: “All patients have got to the hospital in stage of medication subcompensation.”

From the abstract:

METHODS

We made the retrospective analysis of 81 patients’s medical records with hypothyroidism that were hospitalized to the endocrinology department of Ternopil University Hospital (Jan-Dec 2012).

The method of pharmacoeconomic analysis “cost of illness” was used to estimate the cost of health care for patients with hypothyroidism. We have made calculations of costs: the cost of laboratory analysis, the cost of instrumental analysis, the cost of drug treatment, doctor’s consultations, costs of patient’s stay in hospital. While determining the direct costs of medical services in monetary terms we used the rates for medical services that were in Ternopil University Hospital.

RESULTS

• The study found that among the patients there were 23 (28.4%) men and 58 (71.6%) women aged 19 to 77 years (46.86±10.03).
• All patients have got to the hospital in stage of medication subcompensation.
• The average duration of stay in hospital for patients was 10.77±1.95 days.
• The total cost of laboratory tests was USD 4,231.95. [more than just TSH and thyroid hormones, but other tests as well]
• The costs of instrumental methods of patients examination amounted USD 576.90.
• The cost of consultations by specialists was USD 769.36.
• In determining the amount of direct costs for medicines we found that the cost of drug treatment of the underlying disease was USD 52.40, the cost of drug therapy of hypothyroidism complications was USD 3,932.21.
• Total cost of patients stay in hospital was USD 9,411.80.
• After calculation of all direct costs we determined that the total cost of hypothyroidism per patient is USD 234.26 per course of treatment.

CONCLUSIONS

In the cost structure of health care provision for patients with hypothyroidism, the most significant costs were spent for laboratory tests and for patient’s stay in hospital.

The presence of underlying disease complications significantly increases cost of drugs.“

And that’s all that Vadziuk had to say.

Many more patients are undertreated than the hospitals and Vadziuk know, because of medicine’s obsession with the thyroid stimulating hormone (TSH) reference range. It’s likely that in this hospital, “medication subcompensation” only meant “high TSH” during thyroid therapy.

High and low TSH is not where the highest chronic disease prevalence rates are.

Higher disease prevalence often lies within the upper half of the TSH and FT4 ranges, and most of all, below the FT3 range. See “Prevalence rates for 10 chronic disorders at various FT4, TSH and FT3 levels.”

Looking to the future

Thyroid disease will continue to be a major issue in human health as Ukraine and the region undergoes the horror of conflict and its aftermath.

In addition to fleeing and fighting for their lives and worrying about their future, patients with chronic thyroid disease in this region may be feeling quite anxious about maintaining access to their pharmaceuticals.

Some might be forgetting their doses. Some may have had to leave their vital medicine behind. Pharmaceutical supply chains may be disrupted.

For refugees, there is a real possibility of having to switch to a different thyroid medication brand, which often requires readjustment of doses.

We can only hope that Ukrainian people dependent on thyroid medication will have access to prompt pharmaceutical refills both inside their war-torn country and in the countries where they are fleeing.

Uncalculated costs, risks

What’s it like to live with a thyroid disease? Well, it’s not that easy to compensate for a living thyroid gland with a static daily dose. But most medical systems want to check your dose with a single hormone test once a year.

Thyroid hormone treatment “sub-vigilance” is like not distributing enough potassium iodide to people living close to a nuclear reactor like Chernobyl.

I believe 90% of mismanaged thyroid treatment cases lie under the surface, like an iceberg waiting to be hit by an ocean liner. Medical systems haven’t learned how to sound the depths and look under the surface of TSH during thyroid treatment.

Individual biochemical setpoints for TSH and thyroid hormones are much narrower than the population ranges, but the latter are often misused as treatment targets in isolation from chronic symptoms and overall health outcomes.

When a health crisis or war comes, will a barely-treated yet “TSH-normalized” patient pull through? Last time I checked, TSH hormone receptors aren’t installed on any thyroid hormone pills. TSH can’t regulate doses. Intelligent physicians can.

What about Canada, a land of many immigrants, and a place of refuge?

The Red Cross is providing humanitarian aid and medication support in Europe, but it may soon be the responsibility of many host countries, including Canada, to treat Ukrainian refugees’ thyroid diseases along with our own citizens.

How do Ukrainian thyroid disease rates compare to various regions in Canada?

How are Canadian rates changing?

We don’t know.

We know much more about thyroid diseases in Ukraine than we do about these same diseases in Canada.

In fact, the omission of thyroid diseases from our national surveillance program recently spurred us at Thyroid Patients Canada to start a social media petition to add it to the list of 20 chronic diseases we monitor in Canada. Please sign.

Don’t let societies abandon thyroid patients of any nationality.

References

Кravchenko, V. I., Тоvkay, О. А., Rakov, О. V., & Тronko, М. D. (2021). Epidemiology of autoimmune thyroiditis / Епідеміологія автоімунного тиреоїдиту. INTERNATIONAL JOURNAL OF ENDOCRINOLOGY (Ukraine), 17(2), 136–144. https://doi.org/10.22141/2224-0721.17.2.2021.230568

Mitchell, P. (1999). Ukrainian thyroid-cancer rates greatly increased since Chernobyl. The Lancet, 354(9172), 51. https://doi.org/10.1016/S0140-6736(05)75320-4

Plokhy, S. (2018, May 10). The Chernobyl Cover-Up: How Officials Botched Evacuating an Irradiated City. HISTORY. https://www.history.com/news/chernobyl-disaster-coverup

Rhee, C. M., Kalantar-Zadeh, K., Ravel, V., Streja, E., You, A. S., Brunelli, S. M., Nguyen, D. V., Brent, G. A., & Kovesdy, C. P. (2018). Thyroid Status and Death Risk in US Veterans With Chronic Kidney Disease. Mayo Clinic Proceedings, 93(5), 573–585. https://doi.org/10.1016/j.mayocp.2018.01.024

Sohn, S. Y., Seo, G. H., & Chung, J. H. (2021). Risk of All-Cause Mortality in Levothyroxine-Treated Hypothyroid Patients: A Nationwide Korean Cohort Study. Frontiers in Endocrinology, 12. https://www.frontiersin.org/article/10.3389/fendo.2021.680647

Tkachenko, V. I., Maksymets, Y. A., Vydyborets, N. V., & Kovalenko, O. F. (2018). Analysis of the prevalence and morbidity of thyroid pathology among the population of Kyiv region and Ukraine for 2007–2017 / Аналіз поширеності тиреоїдної патології та захворюваності на неї серед населення Київської області та України за 2007–2017 рр. INTERNATIONAL JOURNAL OF ENDOCRINOLOGY (Ukraine), 14(3), 272–277. https://doi.org/10.22141/2224-0721.14.3.2018.136426

Vadziuk, I. (2015). Direct cost of Hypothyroidism and its complications in Ukraine. Value in Health, 18(3), A255. https://doi.org/10.1016/j.jval.2015.03.1484