Refugees and migrants arriving in Europe could be immune to the very drugs deployed to help them recover from war trauma and journeys across continents, medics fear.
As well as annual cross-border travel and tourism by millions worldwide, nearly one million refugees and migrants arrived by sea into the European Union in 2015, half of them fleeing Syria and another 20 per cent from Afghanistan.1
The spread of bugs resistant to antibiotics is regarded as a threat as serious as climate change, according to European health officials.
But how it may affect refugees and migrants – many of whom come and are passing through countries where antibiotics are dispensed frequently without even prescriptions – is largely unknown.
And health experts have told Tomorrow that antimicrobial resistance (AMR) amongst the million new residents of European Union nations will have to be addressed, even as scientists argue it is almost impossible to assess the problem.
Michael Scannell, director of the food and veterinary office at the Health and Food Safety Directorate of the European Commission,2 admitted AMR for refugees was an “evolving area” and many risks were replicated in normal tourism.
“We know that the pattern of antibiotic prescription varies enormously from one member state to another,” he told Tomorrow. “That’s even without with this particular migration crisis. The extent to which that might be replicated in how incoming migrants themselves are treated, frankly offhand I don’t have an answer.
“But I’d be surprised if any competent physician, if his immediate reaction when confronted by a large number of refugees, migrants, is, ‘Oh let’s give them all a prescription for a particular antibiotic’. Hopefully he would have the competence and the professionalism to deal with them on a case-by-case basis.
“If you’ve arrived in Europe having trekked through various deserts, in very cramped conditions, with poor nutrition and healthcare and then you have to make a dangerous sea crossing, fatigue alone is going to leave you very vulnerable to illness and ill health. And that is the case.
“We are providing a lot of assistance to equip member states to deal with the immediate healthcare needs of migrants. But it’s a very formidable challenge, as is finding accommodation, as is processing their asylum claims, as is deciding to which member states they should be assigned. This is, by any definition, an absolutely enormous challenge of which healthcare is a very important but not the only challenge.”
On the main front line in Greece, where more than 800,000 people have arrived by sea from Turkey in 2015, Hellenic Rescue Team put out a appeal in November for medicine including antibiotics for children as they work on the island of Lesbos and elsewhere.3 They provide first aid during search and rescue missions and are working with other agencies to meet healthcare needs.
“It has been confirmed that the refugees that arrive in this camp are suffering from several kinds of infections, mostly due to the weariness of the long trip, and there are also thousands of them that are injured from war conflicts,” Μeni Kourkouta of HRT told Tomorrow by email.
The International Organisation for Migration (IOM) said there was no “inherent” public health risk from migration.
“The conditions in which migration takes place expose migrants to health risks during their journey,” explained IOM’s director of migration health department, Dr Davide Mosca.4 “The most obvious of these in Europe is death at sea. But they can also result in aggravation of pre-existing health conditions, and a break in continuity and quality of care.
“Both are pre-conditions for avoiding microbes resistant to drugs in the course of treatment. This is particularly true for migrants coming from countries where health systems have collapsed or where they are unable to access quality care during their journey and at their destination.”
Dr Andrea Ammon, acting director of the European Centre for Disease Prevention and Control (ECDC),5 said antibiotics resistance of arriving refugees and migrants was an issue to “keep in mind and monitor”.
“We are right now developing the plans how to deal with the infectious disease health issues of the migrants and that is one of the issues that need to be taken into account,” she told Tomorrow at a briefing for journalists in Brussels in November.
A science primer
microbes: Bacteria are a type of microbe so when you hear antimicrobial resistance and antibiotic resistance, they are referring to the same issue, i.e. germs, bugs or pathogens that have become resistant to drugs used against them. Antimicrobials also include antivirals, antifungals and antiparasitics. The human body caries around 10-100 billion microbes, described as your “normal flora”. That flora can be naturally resistant, but you might never know if you don’t become ill.
antibiotics: With penicillin’s discovery in 1928, it began being used in the World War II and spread to the general public in 1943. But by then, the first resistance had already been discovered. Resistant strains of diseases have sometimes been found as soon as months after the antibiotics were introduced.
superbug: This isn’t the same as super-resistance. An organism might be resistant to multiple drugs (multi-drug resistant, or MDR), or extensively-drug resistant (XDR) or even pan-drug resistant (PDR). But if the resistant organism also causes an infection, and one that frequently causes death, then it’s a superbug. Some of the most series superbugs include C.diff, MRSA and ESBL.6
ESBLs (extended-spectrum beta-lactamases): This is an enzyme produced by a bacteria that are resistant to many types of antibiotics. E. coli bacteria, for example, can produce ESBLs and then become harder to treat.7
gram-positive/gram-negative: This describes how some bacteria can be identified by “staining” them with a violet dye. Identified in 1884, and later named after discoverer Hans Christian Gram, “negative” bacteria have thicker membrane walls more resistant to antibiotics than “positive” ones.
Professor Timothy Walsh, of Cardiff University’s school of medicine,8 works with Médecins Sans Frontières (MSF) and others on the nature of antimicrobial resistance.
He said resistance to drugs can be widespread, particularly in countries where antibiotics have been easily available to humans and overused in agriculture. New research in Pakistan, he said, found about 95 per cent of the population has ESBLs as part of the normal flora and another 40-50 per cent were resistant to a type of antibiotics typically only used for hospital infections, carbapenems. They’re used when someone is already multi-drug resistant, so resistance to them as well is serious.
Another antibiotic, colistin, is old and until recently rarely used as it now becomes a last resort. Colistin is one of a type of drugs called polymyxins and Prof Walsh and a team of researchers discovered a gene, MCR-1, that is resistant to polymyxins. The gene means bacteria invincible to antibiotics and infections such as pneumonia, previously easily treated, can once again be deadly. And MCR-1 has been found in China, Malaysia, Laos, is believed to be in north Thailand and Vietnam, and has been detected in Denmark and the UK, explained Prof Walsh.
Another gene, NDM-1, resists multiple antibiotics including carbapenems and was first found in India and Pakistan. It has seen been found in the UK, Canada, Sweden, Australia, Japan, and the United States, all within the past six years. The gene might be common in bacteria, but it’s only when attached to a serious infection, such as e.coli, that it becomes deadly.
Even beyond ethical research concerns and access to refugee camps for study, it is “virtually impossible” to track the use of antibiotics in conflict zones and medical history of refugees, said Prof Walsh.
“These days because of economic globalisation, quite frankly what happens in one country spreads rapidly throughout the others,” Prof Walsh told Tomorrow by phone.
“Understanding why these countries generate resistance in clinical strains and how they spread is really important, because obviously forewarned is forearmed. The other important thing is to help those countries, if they’re willing to be helped of course, to try and mitigate the spread of resistance within their countries. Obviously once it spreads out of the country, it affects health services in other countries – it becomes a clinical and financial burden.
“Where you have thousands, tens of thousands, hundreds of thousands of people, moving, very quickly from one country to another, from an area where antibiotics have been used very freely, there’s been a lack of sanitation, all those sorts of things and so their normal flora is very MDR if not XDR, then those bacteria will be carried into that new country. And invariably it will spread.
“If they are going to be admitted into the western healthcare system, then there’s going to have to be good infectious disease measures and screening of patients, or trying to get an accurate estimate of [medical] history. So I think that’s actually very important. How stable this resistance is, as people’s normal flora, whether those same bugs go on and cause disease, it’s very very difficult to say. These are the sort of factors that are unknown but nonetheless they are various groups are working on that trying to understand the importance of that.”
Prof Walsh added: “Trying to understand the medium to long-term impact of human travel, whether it be through economic globalisation, whether it be through economic migrants, whether it be through refugees, whether it be just through people jumping on airplanes and travelling, I think it’s massive and I think it’s poorly understood.”
And that ignorance may not just be a threat to the long-term health of arriving refugees and migrants, but even to immediate aid.
Amidst rising anti-immigration and specifically anti-Muslim political rhetoric and actions in some European countries, Mr Scannell emphasised the “real humanitarian issue” beyond just healthcare.
Dr Mosca, of the IOM, added: “The greatest public health risk is that the health needs of refugees and migrants will go unmet, due to stigma, discrimination or xenophobia, in the countries they transit and at their destination.”
This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International Licence.
- UNHCR data on those crossing into Europe, quoting as of December 16, 2015. ↩
- Organisation chart showing Mr Scannell’s place in the EC. ↩
- HRT appeal page, in Greek. ↩
- Biography of Dr Mosca. ↩
- Dr Andrea Ammon profile page. ↩
- More US-based background on the threats. ↩
- UK background on ESBLs. ↩
- Prof Walsh profile page. ↩