Review
Antimicrobial resistance and the current refugee crisis

https://doi.org/10.1016/j.jgar.2017.03.013Get rights and content

Highlights

  • Recently, Europe has experienced an enormous influx of refugees and migrants.

  • Data suggest that refugees carry an important burden of multidrug-resistant organisms.

  • This is attributed to the rising antimicrobial resistance rates in their countries of origin.

  • Transmission is facilitated by collapsed infrastructures and poor hygiene.

  • Routine screening and infection control measures should be considered at admission.

Abstract

In the past few years, Europe has experienced an enormous influx of refugees and migrants owing to the ongoing civil war in Syria as well as conflicts, violence and instability in other Asian and African countries. Available data suggest that refugees carry a significant burden of multidrug-resistant (MDR) organisms, which is attributed to the rising antimicrobial resistance (AMR) rates in their countries of origin, both in healthcare settings and in the community. Transmission of MDR pathogens among refugees is facilitated by the collapsed housing, hygiene and healthcare infrastructures in several communities as well as poor hygiene conditions during their trip to destination countries. These findings highlight the fact that refugees may serve as vehicles of AMR mechanisms from their countries of origin along the immigration route. Following risk assessment, routine microbiological screening for MDR organism carriage of refugees and migrants as well as effective infection control measures should be considered upon admission. This will on the one hand address the possibility of dissemination of novel AMR mechanisms in non- or low-endemic countries and on the other will ensure safety for all patients.

Introduction

The ongoing civil war in Syria as well as other conflicts, violence, persecutions and overall instability in areas of the Middle East, Asia and Africa have resulted in millions of refugees and migrants. From the end of 2011, more than 4.8 million Syrians have been registered as refugees seeking safety in other countries. In this context, southeastern Europe has witnessed an unprecedented influx of refugees and migrants over the past years. During 2015 alone, more than 1 million refugees have reached Europe via the sea, including 3771 dead or missing refugees. In 2016, 362 376 refugees reached Europe via the sea, including 5096 dead or missing refugees [1].

Historically, human mobility across borders has played a critical role in the dissemination and subsequent importation of novel multidrug resistance mechanisms of public health importance from one region to another [2]. Immigrants, displaced refugees, tourists and travellers visiting friends and relatives have contributed to the importation and dissemination of pathogens/infections such as multidrug-resistant (MDR) Plasmodium falciparum malaria, MDR and extensively-drug resistant (XDR) tuberculosis, MDR gonorrhoea and MDR enteric pathogens [3], [4], [5], [6], [7]. Over the past decade, the growth of international travel and medical tourism has been closely associated with the importation of Klebsiella pneumoniae carbapenemase (KPC), new Delhi metallo-β-lactamase (NDM)-producing Gram-negative bacteria, and other new antimicrobial resistance (AMR) mechanisms in several countries globally. These AMR mechanisms have been associated with a negative impact on morbidity and mortality of affected hospitalised patients and on healthcare costs [8], [9]. Recent articles indicate that refugees and migrants from Syria and other Asian and African countries may carry MDR organisms and thus may contribute on the dissemination of AMR across borders [10], [11]. Our aim was to review the available data on AMR in refugees and migrants as well as the relevant public health implications in the context of the current refugee crisis in Europe.

Section snippets

Search strategy

A search of the PubMed database from 2011 through January 2017 was conducted using a combination of the words ‘refugees’, ‘migrants’, ‘resistance’, ‘multi-drug resistant’, ‘antimicrobial’, ‘Syria’, ‘Afghanistan’, ‘Iraq’, ‘Iran’ and ‘Libya’. The identified articles were screened for their relevance. A total of 13 articles presenting original data regarding AMR carriage in refugees were identified and were included in the analysis (Table 1). Review articles and data from the United Nations High

Antimicrobial resistance in countries of origin

Available data suggest that several countries of origin of refugees and migrants face rising AMR rates. Recent studies show alarmingly high prevalence of MDR Acinetobacter baumannii, Escherichia coli and Pseudomonas aeruginosa clinical isolates from hospitalised patients in Syria, at the higher end of globally reported levels [12], [13], [14]. An increased prevalence of MDR P. aeruginosa clinical samples was also detected in hospitals in Iraq, and the blaIMP gene predominated among the

Antimicrobial resistance and refugees: what is the evidence?

Data regarding carriage of MDR strains by refugees and migrants in the current refugee crisis are scarce and fragmentary. However, the available data indicate that refugees often are colonised with MDR strains (Table 1). In a preliminary report from an Israeli hospital, 28 (47%) of 60 adults wounded during the Syrian civil war carried at least one MDR pathogen [21]. In particular, the following isolates were found: carbapenem-resistant Enterobacteriaceae (CRE) in 5 cases (NDM in 2 cases);

Preparedness and infection control in host countries

For non-endemic or low-endemic countries for MDR pathogens, the possibility of high prevalence rates of MDR strains among refugees represents a public health emergency. Routine microbiological screening for MDR carriage of refugees and migrants at the time of admission to a healthcare facility could be considered, and healthcare services should be provided under contact precautions until refugees test negative. Yet a policy of testing all refugees upon admission to a healthcare facility can

Conclusions

The current refugee crisis in Europe represents a public health emergency. Carriage of MDR pathogens is frequent in refugees and migrants requiring health care. This is attributed to the significant prevalence of AMR in their countries of origin and the ease of human–human dissemination during war and travel to destination countries. These findings indicate a public health risk for non-endemic or low-endemic host countries for MDR strains. Prompt preparation of healthcare systems at the local

Funding

None.

Ethical approval

Not required.

Competing interests

None declared.

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