BACKGROUND
While the relationship between conflict-associated injuries and antimicrobial resistance is increasingly being elucidated, data concerning civilian casualties is sparse. This systematic review assesses literature focused on Global Antimicrobial Resistance Surveillance System (GLASS) Priority Pathogens causing infections in civilian wounds and burns in conflict-affected countries within the World Health Organisation's Eastern Mediterranean Region Office (EMRO)
METHODS
A systematic literature review was conducted following Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Five databases and grey literature were searched, identifying studies published from January 2010 to June 2024. Search terms included "wounds", "burns," "antimicrobial resistance", and the twelve countries of interest. Included studies reported resistance of GLASS pathogens. Two reviewers used Covidence to assess papers for inclusion. Data were extracted into a spreadsheet for analysis. Where quantitative data were available, medians, interquartile ranges and percentages were calculated by pathogen and country.
RESULTS
621 records were identified; 19 studies met inclusion criteria. Nine of the papers were from Iraq, three from Libya, three from Lebanon, one each from Yemen and Gaza; two reported on conflict affected refugees in Jordan. A total of 1,942 distinct microbiological isolates were reported, representing all four critical and high priority GLASS pathogen categories. Among the isolates, Staphylococcus aureus was the most prevalent (36.3%). Median resistances identified: Methicillin resistant Staphylococcus aureus (n = 680): 55.6% (IQR:49.65-90.3%); carbapenem resistant Pseudomonas aeruginosa (n = 372): 22.14% (7.43-52.22%); carbapenem resistant Acinetobacter baumannii (n = 366): 60.3% (32.1-85%); carbapenem resistant Klebsiella pneumoniae (n = 75): 12.65% (9.73-34.25%); ceftriaxone resistant Escherichia coli (n = 63): 76% (69-84.65%); ceftriaxone resistant Klebsiella pneumoniae (n = 40): 81.45% (76.73-86.18%). Only three studies had a low risk of bias.
DISCUSSION
Findings imply high rates of GLASS priority pathogens among wounded civilians in conflict-affected EMRO countries. However, evidence was heterogeneous, low quality and sparse in certain countries, highlighting the necessity of effective surveillance including standardised data collection. Improving primary data will facilitate the production of large, high-quality studies throughout the EMRO, including under-represented countries.
Conclusion: Laboratory diagnostic capacity building and improved surveillance in conflict-affected settings in the Eastern Mediterranean Region are required to assess the burden of GLASS priority pathogens in vulnerable non-combatant populations.
In refugee and internally displaced person settlements, hygienic water handling and free residual chlorine (FRC) are crucial for protecting water against recontamination after distribution up to the household point-of-consumption. We conducted a secondary analysis of water quality and water handling data collected in refugee camps in South Sudan, Jordan, and Rwanda using statistical and process-based modeling to explore how water handling practices affect FRC decay and household FRC outcomes. The two practices that consistently produced a significant effect on FRC decay and household FRC were storing water in direct sunlight and transferring water between containers during household storage. Samples stored in direct sunlight had 0.22–0.31 mg/L lower household FRC and had FRC decay rates between 2 and 3.7 times higher than samples stored in the shade, and samples that were transferred between containers had 0.031–0.51 mg/L lower household FRC and decay rates 1.65–3 times higher than non-transferred samples in sites in which the effect was significant, suggesting that humanitarian responders should aim to provide additional water storage containers to prevent water transferring in households and encourage water-users not to store water in direct sunlight. By contrast, the effect of the three recommended hygienic water handling behaviors (clean, covered containers and drawing by tap or pouring) was mixed or inconclusive. These inconclusive results were likely due to imbalanced or unreliable approaches to gathering the data, and we recommend that hygienic water handling practices that mechanistically provide a physical barrier against recontamination should always be promoted in humanitarian settings.