Antimicrobial resistance and the current refugee crisis

Seasonal patterns of communicable disease incidence and antibiotic prescribing in Moria refugee camp, Greece

BACKGROUND

Infectious diseases remain a major risk for refugees living in camps. Limited research has been undertaken into the burden and impact of infections in the current refugee crisis around the Mediterranean.This analysis examines the frequency and incidence rates of common infections, and use of antibiotics at a healthcare facility inside Moria refugee camp on the island of Lesvos, Greece, during the winter and summer seasons of 2019.

METHODS

This is a retrospective analysis of routinely, prospectively collected service data from the main acute healthcare facility inside Moria camp.

RESULTS

Of a total of 9601 consultations, 25.16% were for infections (winter: 31.53%, summer: 19.45%). Respiratory, skin and gastrointestinal infections were the most frequent, with incidence rates up to 3.5 times, 50 times and twice as high as those in Western Europe, respectively. Antibiotic prescribing was high (27.7% of all respiratory infections) with high use of broad-spectrum antibiotics (40.2%), raising concerns about induction of antimicrobial resistance.

CONCLUSIONS

The burden of infectious diseases in refugee camps remains high throughout all seasons. Antimicrobial stewardship programmes should be adapted to refugee camp settings to prevent the development of unnecessary antimicrobial resistance. Improving living conditions and access to healthcare in refugee camps is likely to reduce infection rates and antimicrobial resistance among refugees.

Who should be screened for carbapenemase-producing Enterobacterales and when? A systematic review

Carbapenemase-producing Enterobacterales (CPE) cases increases every year in Denmark and the proportion of CPE-positive cases with a travel history decreases. Several epidemiological links show transmission in Danish healthcare setting indicating infection prevention and control challenges and raising questions about the Danish CPE screening protocol. The aim of this review was to identify additional risk factors to those described in the Danish CPE-screening protocol in order to detect the Danish CPE-positive patients and thereby reduce the risk of transmission and outbreaks. A systematic literature search was conducted in PubMed, Embase and Cochrane Library during March 2022. A total of 1487 articles were screened, and 19 studies were included. Retrieved studies dealt with patients with laboratory-confirmed CPE (colonization and/or infection) and associated risk factors. Antimicrobial therapy, especially broad-spectrum antimicrobial agents, prior or current hospitalization of approximately one week in ICU and 20-28 days in other wards and travel history with or without hospitalization abroad were significant risk factors associated with CPE acquisition. Comorbidities and invasive procedures were identified as risk factors, but without identifying specific comorbidities or invasive procedures associated with risk for CPE-acquisition. This study suggests the need to develop an additional algorithm for CPE-screening in Denmark. In addition to risk-based screening on admission, screening of inpatients should be considered. The screening protocol might include screening of inpatients with comorbidities who are hospitalized >1 week in ICU or >3 weeks in other wards and who have previously received or currently are receiving antibiotic treatment. Further research is needed to develop a new CPE-screening algorithm.

Health Problems of Increasing Man-Made and Climate-Related Disasters on Forcibly Displaced populations: A Scoping Review on Global Evidence

Forcibly displaced populations are among the most vulnerable groups in disasters. They experience poorer health conditions compared with nondisplaced individuals. However, a clear picture is lacking regarding the overall health problems encountered by disaster-induced mid- to long-term displaced people. This study investigated these disorders prevalence and identified their correlates among long-settled displaced populations worldwide. The current scoping review follows the PRISMA-ScR guidelines; a systematic search was conducted on PubMed, Web of Science, and CINAHL and included original peer-reviewed studies, commentary, reviews, and grey literature published in English between January 1990 to June 2022. In the thematic and content analysis, the authors applied the narrative review approach to identify themes and sub-themes. Forty-eight documents were identified as fully relevant to this study. The largest number of published papers were from Asia, followed by the Middle East, the United States, and Europe. IDPs in developed countries were the most researched populations. Human-made disasters were addressed by 89% of the included studies. The four main thematic categories included were "physical health," "mental health," "inadequate facilities," and "lack of healthy behaviour." The worsening of noncommunicable diseases had the highest prevalence, followed by communicable diseases. Due to their condition, forcibly displaced migrants face a triple burden of communicable diseases and noncommunicable diseases such as mental health issues. Health-related research and policy need to consider the links among disasters, health problems, and forced migration as a determinant of health in the new era of climate change-driven displacements.

Understanding refugee and immigrant health literacy and beliefs toward antimicrobial resistance

Refugee and migrant populations have increased vulnerability to antimicrobial resistance, yet stewardship guidance is lacking. We addressed this gap through a cross-sectional survey, finding that these populations and immigrants from low and middle-income countries had lower health literacy on the issue compared to native-born Americans and those from high-income countries.

Community-acquired antimicrobial resistance among Syrian refugees and the local population in Türkiye

BACKGROUND

The long-standing antimicrobial resistance (AMR) pandemic has proven difficult to resolve and is becoming more complex, especially in the context of increasing forced migration, with little evidence around patterns of AMR in migrant communities. This study aimed to determine the frequency in the carriage of common types of antimicrobial-resistant bacteria between Syrian refugees and the local communities in Türkiye: extended-spectrum β-lactamase (ESBL), methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE).

METHODS

We collected nasal swabs and stool samples from the study participants, the local community members, and refugees, between September 2020 and March 2021. We screened clinical samples for the presence of ESBL, MRSA and VRE. Antimicrobial-resistant bacterial isolates were tested by phenotypic analysis to determine the AMR status.

RESULTS

The study included a total of 3960 participants: 1453 individuals in the local community (36.2%) and 2525 Syrian refugees (63.8%). Overall, a significantly greater proportion of refugees (6.7%) carried MRSA compared to the local community (3.2%) (P < 0.001). The ESBL-positivity rate was 17.9% in Syrian refugees and 14.3% in the local community (P = 0.041). Carbapenemase activity was detected in three isolates from Syrian refugees. No VRE was detected in Syrian refugees or the local community.

CONCLUSIONS

This large, community-based study on the frequency and the distribution of AMR among Syrian refugees and the local population is the first study in Türkiye.

Prevalence of Antimicrobial Resistance and Infectious Diseases in a Hospitalised Migrant Population in Paris, France, a Retrospective Study

Objectives: The aim of this study was to estimate the prevalence of anti-microbial resistance (AMR) carriage and its risk factors in hospitalized migrants. Additionally, the prevalence of infectious diseases was evaluated, as well as symptoms of psychological trauma. Methods: We conducted a retrospective monocentric cross-sectional study including all migrant patients recently arrived and hospitalised over a one-year period. Results: Among 101 patients, seventy-nine percent originated from Sub-Saharan Africa. The overall AMR carriage rate was 20.7% [95% CI: 12.4; 28.9%]. We isolated 5/92 methicillin-resistant Staphylococcus aureus strains (5.4%) and 15/92 extended-spectrum beta-lactamase-producing Enterobacteriaceae (16.4%). AMR carriage was associated with older age, region of origin and length of migration. Rates of HIV, HBV, and HCV infection were 39.6%, 32.7%, and 5%, reflecting sampling bias linked to reasons for hospitalization. Eleven percent had serological evidence of treponemasis and 7.8% had Chlamydia trachomatis infection. Symptoms of depression or post-traumatic stress disorder were observed for more than half the patients. Conclusion: It appears essential to offer a systematic and comprehensive post-arrival screening of AMR carriage, infectious diseases and psychological trauma to subjects who experienced migration.

A Survey Assessing Antimicrobial Prescribing at United Nations Relief and Works Agency Primary Health Care Centers in Jordan

Antimicrobial resistance (AMR) is a public health emergency. There is insufficient information on AMR in the context of humanitarian settings. An understanding of behavioral and institutional-level factors can strengthen antimicrobial stewardship. This study used a semistructured questionnaire to assess both knowledge, attitudes, and practices (KAP) on antimicrobial use, resistance and stewardship, and options to improving prescribing, among prescribers at the Primary Healthcare facilities of the United Nations' Relief and Works Agency Jordan field office. Responses to the KAP questions were evaluated using the Capability, Opportunity, Motivation, Behavior (COM-B) framework and Bloom's cutoffs. For each framework component, Bloom's cutoffs and interpretations were as follows: ≥ 80%, "good"; 60-79%, "moderate"; and < 60%, "poor." Fourteen options to improve prescribing were each assessed using 5-point Likert scales from very unhelpful to very helpful, aggregated by helpful and very helpful and ranked as follows: > 90%, best/most acceptable; > 80-90%, acceptable; and 70-80% as maybe acceptable/good. The questionnaire response rate was 59% (37/63) with a completion rate of 92% (34/37). Aggregate scores for real knowledge on AMR was 97%; opportunity to improve prescribing 88%; and motivation 16%-participants did not believe that there was a connection between their prescribing and AMR or that they had a key role in helping control AMR. Good options (74% aggregate score) to improving prescribing were the availability of guidelines and resistance data. There was good knowledge of AMR and good opportunities, but poor motivation for rational prescribing or behavioral change. There is a clinical need for AMR data to promote rational antibiotic prescribing.

Pediatric Care for Immigrant, Refugee, and Internationally Adopted Children

Immigrant children are a diverse group and include refugees, asylees, and internationally adopted children. They have various infectious disease risk factors, depending on conditions within their country of origin, journey, and current living conditions. Infectious disease screening should take place within the framework of a comprehensive medical evaluation in the medical home. Some screening is recommended for all immigrant children including hepatitis B, syphilis, HIV, tuberculosis, and intestinal parasites; other diseases can be tested for based on individual risks. Although guidelines and resources are available, there is limited evidence supporting much of the care of immigrant children and youth.

An opportunity for global antimicrobial stewardship research: Refugee populations

Antimicrobial resistance is a well-known global health threat that has higher prevalence in the refugee population. Although guidance has been provided by the World Health Organization and Centers for Disease Control and Prevention on implementing antimicrobial stewardship in lower- and middle-income countries, as well as by the United Nations Refugee Agency on other infection prevention and control efforts, no specific guidance exists for implementation of stewardship in this population. We highlight challenges specific to this population, review recent studies of interest within this space, and propose a research agenda to help move stewardship forward in the refugee population. We advocate for the importance of this issue, particularly given recent current events of geopolitical volatility that render this population more vulnerable, in the setting of its already well-known numerous health challenges.

Antimicrobial resistance among GLASS pathogens in conflict and non-conflict affected settings in the Middle East: a systematic review

BACKGROUND

In spite of the evident general negative effects of armed conflict on countries' health systems and populations' health outcomes, little is known about similar impacts of conflicts on the spread of antimicrobial resistances (AMR). This review was to address this evidence gap and describe: 1. Patterns of AMR in the Middle East (ME) and resistance profiles of pathogens included in the Global AMR Surveillance System (GLASS) supported by the World Health Organization; 2. Differences in proportions of AMR isolates between conflict and non-conflict countries.

METHODS

A systematic literature review was conducted following PRISMA guidelines and searching five electronic databases. Subject heading and free text were searched for "antimicrobial resistances" and "Middle East", to identify observational studies on AMR published from January 2011 to June 2018. Data were extracted from included articles on a predefined set of variables. Percentages of AMR were analysed as median and interquartile ranges. Risk of bias was assessed using the Newcastle-Ottawa Scale.

RESULTS

A total of 132 articles met the inclusion criteria. Included studies showed heterogeneity in study design, laboratory methods and standards for interpretation of results, and an overall high risk of bias. Main findings were the following: 1. High proportions of carbapenem resistance in Acinetobacter spp. (median 74.2%), and both carbapenem resistance (median 8.1 and 15.4% for E. coli and K. pneumoniae respectively) and ESBL-production (median 32.3 and 27.9% for E. coli and K. pneumoniae respectively) amongst Enterobacteriaceae. S. aureus isolates showed a median methicillin resistance percentage of 45.1%, while vancomycin resistance was almost absent. A median of 50% of the strains of S. pneumoniae showed non-susceptibility to penicillin. 2. Similar trends were observed in conflict and non-conflict affected countries.

CONCLUSIONS

There is a lack of standardization in the methodological approach to AMR research in the Middle East. The proportion of antibiotic resistances among specific GLASS pathogens is high, particularly among Acinetobacter spp.

Antimicrobial overuse in India: A symptom of broader societal issues including resource limitations and financial pressures

India and the global community are facing a critical crisis of antimicrobial resistance (AMR), significantly contributed to by on-going and increasing antimicrobial misuse. Information as to what drives misuse of antimicrobials within India is essential to inform strategies to address the crisis. This papers aims to identify perceived influences on antimicrobial use in Hyderabad, India. We conducted semi-structured qualitative interviews conducted with thirty participants (15 doctors, 15 pharmacists) around their experiences of antimicrobials in Hyderabad, India. Thematic analysis was performed and four themes identified around (1) Perceptions of the problem of resistance and antimicrobial use; (2) Social pressures to prescribe/dispense; (3) Financial pressures driving antimicrobial over-use; and (4) Lack of regulation around training and qualifications. We conclude that antimicrobial use within India is embedded with, and occurs as a result of, complex social and economic factors including issues of resource limitation, structural/governance limitations and social relationships. Strategies to address misuse without acknowledging and addressing the critical driving forces of use will be unlikely to induce significant change.

Management of infections caused by WHO critical priority Gram-negative pathogens in Arab countries of the Middle East: a consensus paper

Antimicrobial resistance is an important global issue that impacts the efficacy of established antimicrobial therapy. This is true globally and within the Arab countries of the Middle East, where a range of key Gram-negative pathogens pose challenges to effective therapy. There is a need to establish effective treatment recommendations for this region given specific challenges to antimicrobial therapy, including variations in the availability of antimicrobials, infrastructure and specialist expertise. This consensus provides regional recommendations for the first-line treatment of hospitalized patients with serious infections caused by World Health Organization critical priority Gram-negative pathogens Acinetobacter baumannii and Pseudomonas aeruginosa resistant to carbapenems, and Enterobacteriaceae resistant to carbapenems and third-generation cephalosporins. A working group comprising experts in infectious disease across the region was assembled to review contemporary literature and provide additional consensus on the treatment of key pathogens. Detailed therapeutic recommendations are formulated for these pathogens with a focus on bacteraemia, nosocomial pneumonia, urinary tract infections, skin and soft tissue infections, and intra-abdominal infections. First-line treatment options are provided, along with alternative agents that may be used where variations in antimicrobial availability exist or where local preferences and resistance patterns should be considered. These recommendations take into consideration the diverse social and healthcare structures of the Arab countries of the Middle East, meeting a need that is not filled by international guidelines. There is a need for these recommendations to be updated continually to reflect changes in antimicrobial resistance in the region, as well as drug availability and emerging data from clinical trials.

Using a mobile application to detect health needs among children and adolescents who are newly arrived migrants in Europe

BACKGROUND

Unprecedented numbers of migrants have arrived in Europe, including children and adolescents. Little is known about their unique health needs. Prospective data collection has been sparse. Mobile applications may help to facilitate global health surveillance.

METHODS

A pre-validated survey instrument was converted into a mobile application covering self-reported exposures and disruptions of healthcare before/during migration, communicable and non-communicable diseases. Participation was voluntary, anonymous and confidential.

RESULTS

Data were obtained from 405 migrant children and adolescents in Berlin, Germany, between 7 October 2015 and 15 March 2016 (median age 19 years, range: 1-24; 80.7% males) with the majority from Syria (62.5%), Afghanistan (9.1%) and Iraq (8.2%). In total, 55% were without family, 64% registered asylum-seekers with access to healthcare; 54% had seen a doctor since arrival, with colds or respiratory complaints (37.5 and 13.6%), followed by pain (26.7%) gastrointestinal (12.4%) and skin problems (11.1%). Underlying conditions were reported in 15.6%, predominantly asthma. Overall, 73% reported being up-to date on immunizations, but only 22% held a vaccination record with 46.4% having lost it during migration.

CONCLUSIONS

The lack of medical and immunization records among newly arrived migrants provides a challenge to healthcare systems. Mobile applications offer rapid screening tools in times of crisis, helping stakeholders with timely information.

Increasing Globalization and the Movement of Antimicrobial Resistance between Countries

Background: The threat of antimicrobial resistance continues to grow worldwide, exacerbated by poor antibiotic stewardship practices, limited development of new antimicrobial agents, and increasing globalization. Methods: This review covers previously published studies examining how human movement contributes to the global spread of antimicrobial resistance, including between low- and middle-income and high-income countries. Results: The emergence of resistance in one country or part of the world can become a worldwide event quickly. Human movement, including travel, medical tourism, military service, and migration, results in the globalization of resistant bacterial strains. Conclusions: Increased surveillance, whole-genome sequencing, focused infection control, and effective stewardship practices are needed to maintain the efficacy of antibiotics.

Migrants and imported disease: Trends of admission in an Italian infectious disease ward during the migration crisis of 2015-2017

Background

Since 2014, the migrant population residing in Europe has dramatically increased. Migrants’ unmet health needs represent a barrier to integration and should be promptly addressed, without stigma, in order to favour resettlement.

Methods

All-cause of admissions in the migrant population at the Infectious Disease Clinic of Policlinico San Martino Hospital in Genoa between 2015 and 2017 were analysed. Patients were classified by duration of residence in Italy according to the Recommendation on Statistics of International Migration, cause of hospitalization, and region of origin. All data were evaluated with SPSS Statistics.

Results

Two hundred thirty-five people were admitted, 86 (36.5%) of them residing in Italy for less than 1 year. Except for a significant increase in migrants from Africa, there was no change considering the area of origin, hospitalization reason or by comparing residency in Italy for more or less than 1 year. A considerable number of hospitalizations were related to non-communicable pathologies and latent tuberculosis infection. Residents in Italy for less than 1 year or with active tuberculosis had prolonged hospitalizations, while HIV-infected had shorter hospital stays.

Conclusions

No difference in terms of diagnosis were found between migrants with longer or shorter period of residence in Italy. Adequate outpatient services for the management of communicable diseases could significantly reduce the length of hospitalizations in the migrant population.

Twelve formyl phloroglucinol meroterpenoids from the leaves of Eucalyptus robusta

Twelve formyl phloroglucinol meroterpenoids (FPMs) were isolated from the leaves of Eucalyptus robusta Smith. Their structures were elucidated via spectroscopic data analysis, the circular dichroism (CD) exciton chirality method, Rh₂(OCOCF₃)₄-induced CD experiments, and application of the Snatzke chirality rules. Eucalrobusones Q, S, and X are the first FPMs that have been identified in which the C-7' of phloroglucinol is linked to the C-15 of cadinane, the C-4 of cubebane, and the C-8 of menthane, respectively. (+)-Eucalrobusone X exhibited the most potent antifungal ability against Candida albicans with a MIC₅₀ value of 10.78 μg/mL, and eucalrobusone U exhibited the greatest anti-C. glabrata activity with MIC₅₀ value of 1.53 μg/mL.

Migration Medicine

Migration is increasing and practitioners need to be aware of the unique health needs of this population. The prevalence of infectious diseases among migrants varies and generally mirrors that of their countries of origin, but is modified by the circumstance of migration, the presence of pre-arrival screening programs and post arrival access to health care. To optimize the health of migrants practitioners; (1) should take all opportunities to screen migrants at risk for latent infections such as tuberculosis, chronic hepatitis B and C, HIV, strongyloidiasis, schistosomiasis and Chagas disease, (2) update routine vaccines in all age groups and, (3) be aware of "rare and tropical infections" related to migration and return travel.

Exploring community healthcare providers' perceptions on antimicrobial resistance

OBJECTIVES

Antimicrobial resistance (AMR) is a threat to global health, making previously curable diseases disabling or incurable. Human misuse of antimicrobials exacerbates the issue. As stewards to the public and prescribers of antimicrobials, healthcare providers are vital to reducing AMR, thus their perceptions and experiences around the issue must be explored. This study aimed to understand the perceptions of community nurses and physicians regarding the causes of AMR as well as barriers and facilitators to addressing it.

METHODS

In-depth, semi-structured interviews were conducted to understand the perceptions of nurses and physicians on these issues.

RESULTS

Overall, participants expressed that both environmental and human causes at various levels contribute to AMR. Whilst most themes were discussed by both healthcare practitioner groups, nurses more frequently mentioned patient causes and patient education compared with physicians. Participants also reflected on facilitators to reduce AMR, including guidelines, patient and provider education, and top-down and bottom-up initiatives. Identified barriers included patient demands, physician pressures and fears, and systemic overworking of physicians.

CONCLUSION

This study demonstrated numerous factors underpinning AMR and many barriers to addressing it, hence a multifaceted approach is required. This work also offers insight on how different groups can be utilised or will react to interventions.

Infectious diseases at different stages of migration: an expert review

BACKGROUND

Human migration is increasing in magnitude and scope. The majority of migrants arriving in high-income countries originate from countries with a high prevalence of infectious diseases. The risk and burden of infectious diseases are not equally distributed among migrant groups and vary with migration stage.

METHODS

A broad literature review was conducted on the drivers for infectious diseases and associated health outcomes among migrants across different stages of migration. The aim was to provide practitioners with an overview of the key infectious disease risks at each stage to guide health promotion strategies.

RESULTS

A complex interaction of factors leads to infectious diseases and associated poor health outcomes among migrants. The most important drivers are the epidemiology of infectious diseases in their countries of origin, the circumstances and conditions of the migration journey and barriers accessing healthcare post-arrival. During the recent large waves of forced migration into Europe, the primary health concerns on arrival were psychological, traumatic and chronic non-communicable diseases. In the early settlement period, crowded and unhygienic living conditions in reception camps facilitated outbreaks of respiratory, gastrointestinal, skin infections and vaccine preventable diseases. After re-settlement, undetected and untreated latent infections due to tuberculosis, viral hepatitis, HIV, chronic helminthiasis and Chagas' disease led to poor health outcomes. Migrants are disproportionally affected by preventable travel-related diseases such as malaria, typhoid and hepatitis due to poor uptake of pre-travel prophylaxis and vaccination. Infectious diseases among migrants can be decreased at all migration stages with health promotion strategies adapted to their specific needs and delivered in a linguistically and culturally sensitive manner.

CONCLUSIONS

Tailored health promotion and screening approaches and accessible and responsive health systems, regardless of legal status, will be needed at all migration stages to limit the burden and transmission of infectious diseases in the migrant population.

On-Chip Isoniazid Exposure of Mycobacterium smegmatis Penicillin-Binding Protein (PBP) Mutant Using Time-Lapse Fluorescent Microscopy

Antibiotic resistance has been one of the biggest threats to global health. Despite the available prevention and control strategies and efforts in developing new antibiotics, the need remains for effective approaches against antibiotic resistance. Efficient strategies to cope with antimicrobial resistance require a quantitative and deeper understanding of microbial behavior, which can be obtained using different techniques to provide the missing pieces of the current antibiotic-resistance puzzle. Microfluidic-microscopy techniques are among the most promising methods that contribute modernization of traditional assays in microbiology. They provide monitoring and manipulation of cells at micro-scale volumes. Here, we combined population-level, culture-based assays with single-cell resolution, microfluidic-microscopy systems to investigate isoniazid response of Mycobacterium smegmatis penicillin-binding protein (PBP) mutant. This mutant exhibited normal growth in plain medium and sensitivity to stress responses when treated with thermal stress (45 °C), detergent stress (0.1% sodium dodecyl sulfate), acid stress (pH 4.5), and nutrient starvation (1XPBS). The impact of msm0031 transposon insertion on drug-mediated killing was determined for isoniazid (INH, 50 µg/mL), rifampicin (RIF, 200 µg/mL), ethionamide (ETH, 200 µg/mL), and ethambutol (EMB, 5 µg/mL). The PBP mutant demonstrated remarkable isoniazid-killing phenotype in batch culture. Therefore, we hypothesized that single-cell analysis will show increased lysis kinetics and fewer intact cells after drug treatment. However, the single-cell analysis data showed that upon isoniazid exposure, the percentage of the intact PBP mutant cells was 24%, while the percentage of the intact wild-type cells was 4.6%. The PBP mutant cells exhibited decreased cell-lysis profile. Therefore, the traditional culture-based assays were not sufficient to provide insights about the subpopulation of viable but non-culture cells. Consequently, we need more adequate tools to be able to comprehend and fight the antibiotic resistance of bacteria.

Complex narratives of health, stigma and control: Antimicrobial resistance screening among non-hospitalized refugees

Antimicrobial resistance (AMR) is often presented as a major public health problem globally. Screening for AMR usually takes place in clinical settings. Recent developments in microbiology stimulated a series of studies focusing on AMR in communities, and particularly in travelers (any mobile individual), which was argued to be important for identifying potential public health risks. Against this background, microbiologists have become interested in non-hospitalized refugees as one of the traveler groups. However, this attention to refugees has provoked some professional debates on potential stigmatization of refugees as dangerous "others". To contribute to these debates, and to explore the idea of AMR screening of non-hospitalized refugees from different perspectives, we conducted a qualitative study among four groups of stakeholders who were chosen because of their associations with potential microbiological screening: microbiologists, public health physicians, public health nurses, and refugees. The study took place in a Dutch city from June to August 2016 and had 17 participants: five microbiologists, two public health nurses, four public health physicians, and six refugees. While microbiologists and public health physicians demonstrated a de-contextualized biomedical narrative in arguing that AMR screening among non-hospitalized refugees could be important for scientific research as well as for AMR prevention in communities, public health nurses displayed a more contextualized narrative bringing the benefits for individuals at the center and indicating that screening exclusively among refugees may provoke fear and stigmatization. Refugees were rather positive about AMR screening but stressed that it should particularly contribute to their individual health. We conclude that to design AMR prevention strategies, it is important to consider the complex meanings of AMR screening, and to design these strategies as a process of co-production by diverse stakeholders, including the target populations.

Antibiotics use among Palestine refugees attending UNRWA primary health care centers in Jordan - A cross-sectional study

The irrational use of antibiotics is increasing in Jordanian refugee camps and consequently so too is bacterial resistance. About one-third of health expenditures at UNRWA health centers in Jordan are attributed to antibiotics.

OBJECTIVE

We studied knowledge, attitude and behaviour of Palestine refugees attending UNRWA health centers in Jordan regarding antibiotic use in order to plan public health interventions accordingly.

METHODS

A cross-sectional, interviewer-administered survey among 250 adult Palestine refugees at four different health centers was conducted.

RESULTS

Irrational antibiotic use was widespread: 63% of patients share antibiotics at home, 38% use left-over antibiotics and 60% purchase antibiotics directly from the pharmacy without prescription (OTC) .¹ At the same time, knowledge about antibiotics side effects, resistance, and target agent was low. 90% of patients trust their doctor, however long waiting hours prevent them from seeking medical advice, which significantly increased self-medication.

CONCLUSIONS

Our findings suggest a strong need for public education about antibiotics. In addition, health institutional level improvements such as shorter waiting hours and strict regulations prohibiting dispensing without prescription are necessary to combat growing bacterial resistance.

Pulmonary Diseases in Refugees and Migrants in Europe

More than 2 million people fleeing conflict, persecution, and poverty applied for asylum between 2015 and 2016 in the European Union. Due to this, medical practitioners in recipient countries may be facing a broader spectrum of conditions and unusual presentations not previously encountered, including a wide range of infections with pulmonary involvement. Tuberculosis is known to be more common in migrants and has been covered broadly in other publications. The scope of this review was to provide an overview of exotic infections with pulmonary involvement that could be encountered in refugees and migrants and to briefly describe their epidemiology, diagnosis, and management. As refugees and migrants travel from numerous countries and continents, it is important to be aware of the various organisms that might cause disease according to the country of origin. Some of these diseases are very rare and geographically restricted to certain regions, while others have a more cosmopolitan distribution. Also, the spectrum of severity of these infections can vary from very benign to severe and even life-threatening. We will also describe infectious and noninfectious complications that can be associated with HIV infection as some migrants might originate from high HIV prevalence countries in sub-Saharan Africa. As the diagnosis and treatment of these diseases can be challenging in certain situations, patients with suspected infection might require referral to specialized centers with experience in their management. Additionally, a brief description of noncommunicable pulmonary diseases will be provided.