Antimicrobial Resistance in the Protracted Syrian Conflict: Halting a War in the War

Abstract

The Syrian conflict has damaged key infrastructure and indirectly affected almost all parts of the Middle East and Europe, with no end in sight. Exhausting conditions created by the Syrian crisis and related massive displacement promote the emergence of numerous public health problems that fuel antimicrobial resistance (AMR) development. Here, we explore the current situation of the Syrian displaced population, and AMR inside Syria and among refugees in host countries. We then suggest a roadmap of selected key interventions and strategies to address the threat of AMR in the context of the Syrian crisis. These recommendations are intended to urge health policy-makers in governments and international health organizations to optimize and push for implementing an effective policy taking into consideration the current obstacles.

Catch-22: War, Refugees, COVID-19, and the Scourge of Antimicrobial Resistance

“…Similarly, the Turkish Ministry of Health observed a noticeable increase in the percentage of imported tuberculosis cases, reaching approximately 7% in 2015 compared to 1.3% in 2011 (36). It is worth mentioning that the official data provided by the NTPs in Middle Eastern countries likely underestimate the actual rates of tuberculosis, particularly in areas experiencing economic and political collapse (11,37). Taken together, these observations confirm that the prevailing conditions for large numbers of refugees are conducive for the acquisition of infectious diseases, especially in hosting countries that lack resources and face their own challenges.…”

“…For example, refugees are at high risk of susceptibility and/or exposure to life-threatening infectious diseases such as COVID-19 (6,7), tuberculosis (8), hepatitis A (1), measles (3), and poliomyelitis (4). In many instances, the vulnerable and potentially immunocompromised refugees are exposed to conditions that favor the selection and acquisition of multidrug-resistant (MDR) infections, which also pose a heightened risk for a population with limited access to healthcare, immunizations, and essential medications (9)(10)(11).…”

“…Factors that favor the emergence of antimicrobial resistance (AMR) already existed in Syria before the conflict (11,12). Although there are laws in Syria (number 2/T) that prohibit overthe-counter sale of antimicrobials and date back to 1988, Syria still experienced undeveloped and weakly enforced regulations and laws associated with the prudent use of antimicrobials (11).…”

“…Factors that favor the emergence of antimicrobial resistance (AMR) already existed in Syria before the conflict (11,12). Although there are laws in Syria (number 2/T) that prohibit overthe-counter sale of antimicrobials and date back to 1988, Syria still experienced undeveloped and weakly enforced regulations and laws associated with the prudent use of antimicrobials (11). For example, concerns over losing clients were considered a primary driver that rendered antimicrobials readily accessible for purchase from pharmacies and agriculture drug stores without the need for a medical prescription (13).…”

“…For example, concerns over losing clients were considered a primary driver that rendered antimicrobials readily accessible for purchase from pharmacies and agriculture drug stores without the need for a medical prescription (13). However, the ongoing Syrian conflict has created more favorable conditions for the selection and dissemination of AMR (11,12). Indeed, existing reports on AMR in displaced Syrian populations have described increasing trends of MDR Enterobacterales, methicillin-resistant Staphylococcus aureus (MRSA), and drug-resistant tuberculosis (14)(15)(16)(17)(18)(19)(20)(21)(22).…”