War and antimicrobial resistance: coexisting threats in Ukraine

Richard Armitage is a GP and Public Health Specialty Registrar, and Honorary Assistant Professor at the University of Nottingham’s Academic Unit of Population and Lifespan Sciences. At time of writing he was providing primary care to internally displaced people in the east of Ukraine. He is on twitter: @drricharmitage

Antimicrobial resistance (AMR) is a significant and well-recognised threat to human health in Ukraine. In 2020 in Ukraine, 84.2% of K. pneumonia isolates had third-generation cephalosporin resistance, 77.1% of Acinetobacter spp. isolates had carbapenem resistance, and 18.1% of S. aureus isolates were classified as MRSA, while the corresponding figures in France and the UK were 27.8%, 3.3% and 12.1%, and 13.5%, 1.8% and 5.6%, respectively.¹  Suggested explanations for the scale and severity of this problem include widespread over-the-counter sale and subsequent misuse of antimicrobials without medical guidance or a doctor’s prescription, unwillingness to consult medical professionals for healthcare and advice,² the country’s incomplete and disjointed national surveillance system for AMR in both humans and animals, and under-resourced laboratory facilities, clinical microbiology services, and public health infrastructure.³

Russia’s invasion of Ukraine has triggered a humanitarian crisis of enormous scale.  Many civilian combatants have sustained traumatic injuries in battle, while tens of thousands have and continue to shelter from Russian shelling in damp and overcrowded basements for extensive periods, thereby generating a significant burden of acute illness, uncontrolled chronic disease, poor sanitation and hygiene, dehydration and malnutrition, psychological injury, and mental health deterioration.  To escape the hostilities, over 7.9 million people have left Ukraine to seek safety in neighbouring European countries as refugees. Another 8 million people have fled their homes and are now internally displaced within their home country, many of whom now reside in temporary evacuee centres fashioned from repurposed school buildings, kindergartens and gymnasiums.⁴  These facilities are often grossly over-crowded, house populations with disproportionate burdens of existing disease.⁵

They accommodate those with significant risk factors for infectious disease transmission including malnutrition, extremes of age, and uncontrolled chronic disease.⁶  Under such conditions, infectious disease outbreaks are increasingly probable. Meanwhile the additional strain of mass migration on publicly-funded health services – which were substantially over-stretched and under significant reform even prior to war⁷ – creates additional barriers to accessing care.

Accordingly, the burden of both infective and non-infective disease in Ukraine will continue to escalate due to Russian aggression.  The unwillingness to consult, and inability to access, medical professionals within Ukraine, combined with uncontrolled access to over-the-counter antimicrobials without medical gatekeeping, will complicate widespread acquisition and inappropriate use of antimicrobials by Ukrainian citizens displaced from their homes. This will consequently exacerbate the country’s concerning rates of AMR.  To prevent the threat of Russian hostilities compounding that of AMR, urgent public health messages must be communicated to frontline clinicians and Ukrainian citizens to positively influence health behaviour and promote the safe, appropriate and sustainable use of antimicrobials.

References

1. World Health Organization and the European Centre for Disease Prevention and Control. Antimicrobial resistance surveillance in Europe 2022: 2020 data. 2022. https://www.ecdc.europa.eu/sites/default/files/documents/ECDC-WHO-AMR-report.pdf [accessed 18 May 2022]
2. World Health Organization Europe. “Consult your doctor about antibiotics first”: using digital marketing to tackle antimicrobial resistance in Ukraine. 18 November 2021. https://www.euro.who.int/en/countries/ukraine/news/news/2021/11/consult-your-doctor-about-antibiotics-first-using-digital-marketing-to-tackle-antimicrobial-resistance-in-ukraine [accessed 18 May 2022]
3. A Salmanov, L Iakovlieva, O Golubovska, et al. Ukraine: Antimicrobial Resistance Update. February 2015. http://infectioncontrol.org.ua/wp-content/docs/Ukraine%20poster+2015.pdf [accessed 18 May 2022]
4. International Organization for Migration. Migration Data Portal: Ukraine. https://www.migrationdataportal.org/ukraine/crisis-movements [accessed 18 May 2022]
5. R Armitage. War in Ukraine and the inverse care law. The Lancet European Health Europe 30 April 2022; 100401. DOI: 10.1016/j. lanepe.2022.100401
6. B Armocida et al. Older people: forgotten victims amid the Ukrainian humanitarian disaster. The Lancet Public Health 06 April 2022. DOI: 10.1016/S2468-2667(22)00087-1
7. P Romaniuk and T Semigina. Ukrainian health care system and its chances for successful transition from Soviet legacies. Globalization and Health 2018; 14(116). DOI: 10.1186/s12992-018-0439-5

Featured image by Olga Subach on Unsplash