Conflict and humanitarian crises are potentially exposing millions of displaced people to the threat of antimicrobial resistance (AMR), according to a new study and a report published today by international humanitarian group Medecins Sans Frontiers (MSF).
The study, published last week in The Lancet Infectious Diseases, found that refugees and asylum seekers are nearly three times as likely to be colonized or infected with drug-resistant bacteria as the host-country population. The MSF report examines case studies from nine current humanitarian settings to understands what drives AMR in these settings, and how it might be mitigated.
High prevalence of AMR carriage, infection
According to the United Nations High Commissioner for Refugees, an estimated 110 million people worldwide, including 36.4 million refugees and 6.1 million asylum seekers, were forcibly displaced from their homes in 2023. Seventy-five percent were hosted in low- and middle-income countries (LMICs), in substandard living conditions where access to clean water and quality healthcare is limited.
To assess the prevalence of antimicrobial resistance (AMR) among refugees or asylum seekers, researchers from Pfizer and the Migrant Health Research Group at the University of London identified 41 studies published from 2015 through October 2023 that reported on carriage or infection with laboratory-confirmed drug-resistant organisms in 16,970 refugees and asylum seekers. Most studies (32) were conducted in Europe among refugees and asylum seekers from Syria, Afghanistan, and Iraq. Of the 10 studies that reported the reason for displacement, war was the most common reason.
The most common AMR phenotypes reported were multidrug-resistant gram-negative bacteria (26 studies, prevalence ranging from 4.2% to 60.8%), methicillin-resistant Staphylococcus aureus (24 studies, prevalence ranging from 0.92% to 73%), and extended-spectrum beta-lactamase–producing gram-negative bacteria (20 studies, prevalence ranging from 1.6% to 61.1%). Analysis of 10 studies that compared prevalence of AMR carriage or infection among refugees and asylum seekers and the host-country population found refugees or asylum seekers were 2.88 times (95% confidence interval, 2.61 to 3.18) more likely to carry or be infected with a drug-resistant pathogen.
The study authors say healthcare providers who are tasked with caring for refugees and asylum seekers need to be aware of these risks.
“Increased efforts are required to drive improvements in infection prevention and control, antimicrobial stewardship, and access to quality health care to be better tailored for groups at risk, as well as addressing poor living conditions and transit conditions that could be exposing them to increased risk,” they wrote.
Critical drivers of AMR in refugees
The MSF report, meanwhile, draws both on published literature, interviews with stakeholders, and the group’s own work in nine current humanitarian settings where people are being displaced—Gaza, Afghanistan, Mozambique, north Syria, Ukraine, Sierra Leone, South Sudan, and Bangladesh—to highlight that factors that contribute to the high prevalence of AMR in refugees and migrants documented in the Lancet study.
“These case studies illustrate the critical drivers, challenges and consequences of AMR in a range of contexts where MSF works—conflict-affected regions, areas disproportionately impacted by climate change, countries with underfunded health systems, and displaced populations,” the report states.
The critical drivers of AMR in these settings include overwhelmed and crowded refugee camps where bacteria and bacterial infections can easily spread; very limited access to quality healthcare, including lack of diagnostics and antibiotics; critical shortages of trained healthcare workers; healthcare facilities with compromised water, sanitation, and hygiene (WASH) and poor infection prevention and control (IPC) practices; low levels of vaccination; and inadequate stewardship frameworks that can result in inappropriate antibiotic use that promotes resistance.
Often, these settings are in unstable countries with underfunded health systems that are already grappling with high rates of AMR. AMR in these settings is also frequently overshadowed by more urgent needs, such as providing food and immediate medical care for wounded people.
“The breakdown of these systems accelerates the spread of AMR, making it increasingly difficult to manage in already fragile environments,” MSF said, adding that pregnant women, newborns, children under 5, and people with traumatic injuries are among those who are at greatest risk.
MSF, which has integrated AMR reduction into its broader medical humanitarian efforts in the 70 countries where it currently operates, also notes that the scarcity of reliable AMR data in humanitarian settings further exacerbates the problem and hinders context-adapted interventions. The group says that if world leaders truly want to translate the commitments made at the recent United Nations High-Level Meeting on AMR into action, they need to take concrete steps to mitigate the problem in these settings.
The breakdown of these systems accelerates the spread of AMR, making it increasingly difficult to manage in already fragile environments.
Immediate steps include improving the quality of healthcare in these settings, strengthening IPC and WASH, providing access to antibiotics and diagnostics, and promoting antimicrobial stewardship. Long-term, the report concluded that countries must do more to build resilient health systems.
“To combat AMR effectively, global efforts must prioritize the most at-risk populations, ensuring that prevention and response in humanitarian settings are integrated into AMR strategies,” MSF said.
