Access to and utilisation of antimicrobials among forcibly displaced …

The Global Challenge of Antimicrobial Resistance and Forced Displacement

Antimicrobial resistance (AMR) poses a significant threat to global health, with an estimated 4.95 million deaths associated with bacterial AMR in 2019. This challenge is projected to grow, potentially reaching 10 million AMR-related deaths annually by 2050. Concerted efforts are needed to improve surveillance, stewardship, and access to quality antimicrobials, particularly among vulnerable populations like forcibly displaced persons (FDPs).

The number of FDPs worldwide has reached unprecedented levels, with over 90 million people forcibly displaced due to conflict, violence, and natural disasters. Internally displaced people, refugees, and asylum seekers account for the majority of this population, with 83% hosted in low- and middle-income countries (LMICs) where disease surveillance and healthcare infrastructure are often limited.

Factors contributing to the AMR burden among FDPs include:

1. Baseline Endemicity in Countries of Origin: Many FDPs originate from LMICs where antimicrobial stewardship programs are inadequately implemented, leading to high rates of antibiotic misuse and overuse.

2. Inadequate Living Conditions: FDPs often live in overcrowded camps or settlements with poor sanitation, limited access to clean water, and malnutrition – all of which create an optimal environment for AMR transmission.

3. Restricted Access to Healthcare: Barriers such as financial constraints, legal status, and language differences can limit FDPs’ access to quality healthcare and appropriate antimicrobial treatment.

4. Knowledge Gaps on AMR: Low awareness about AMR and appropriate antibiotic use among FDPs can contribute to the misuse and spread of antimicrobials.

Assessing Barriers to Quality Antimicrobial Access and Utilisation Patterns

To better understand the challenges faced by FDPs in accessing quality-assured and affordable antimicrobials, a pilot cross-sectional study was conducted in Uganda, Yemen, and Colombia – countries hosting some of the largest displaced populations globally.

The study aimed to:

1. Identify key barriers to accessing quality-assured and affordable antimicrobials among FDPs.
2. Investigate FDPs’ utilisation patterns of antibiotics.
3. Assess their knowledge about antimicrobial resistance (AMR).
4. Understand their perceptions of the quality of antimicrobials received.

Methodology

The research team used a semi-structured questionnaire to collect data from 136 participants across the three countries, including South Sudanese refugees in Uganda, internally displaced persons (IDPs) in Yemen, and Venezuelan migrants in Colombia. Data was collected between February and May 2021.

Key Findings

Accessing Antimicrobials:
– Obtaining antimicrobials through informal pathways, such as without a prescription or through family/friends, was common in Yemen (54%) and Colombia (68%).
– Barriers to access included financial constraints in Colombia and Uganda, prescription requirements in Yemen and Colombia, and non-availability of drugs in Uganda and Yemen.

Utilisation Patterns:
– In Yemen and Uganda, respondents used antibiotics to treat (67.4%) and prevent (45.3%) common colds.
– In Colombia, only 32% used antibiotics to treat a cold, and 10% used them to prevent a cold.

Knowledge of AMR:
– Knowledge about AMR was generally low across all three study sites (17.6% of participants).

Perceptions of Antimicrobial Quality:
– Most participants in Colombia (82%) were satisfied with the quality of antimicrobials used, followed by Uganda (62.86%) and Yemen (52%).
– In Colombia, 14.7% of participants had received expired antimicrobials within the last year.

Barriers to Accessing Quality Antimicrobials

The study identified several common barriers faced by FDPs in accessing quality-assured and affordable antimicrobials:

Financial Constraints

In Colombia and Uganda, the high cost of antimicrobials was a significant barrier, with 72% of Venezuelan migrants and 88% of Ugandan refugees paying out of pocket for their medicines.

Prescription Requirements

In Yemen and Colombia, the need for a prescription to obtain certain antimicrobials was a major challenge, limiting access for FDPs.

Non-Availability of Drugs

Participants in Uganda and Yemen frequently reported the unavailability of certain antimicrobials at healthcare facilities, forcing them to seek alternative, potentially unregulated, sources.

Utilisation of Informal Pathways

Many FDPs, particularly in Yemen (54%) and Colombia (68%), obtained antimicrobials through informal channels, such as without a prescription or from family/friends, which raises concerns about potential misuse and the quality of the medicines.

Addressing the Knowledge Gap on Antimicrobial Resistance

The low levels of AMR awareness among FDPs across all three study sites suggest a critical need to improve education and understanding about this global health threat.

Antibiotic Misuse and Overuse:
– In Yemen and Uganda, a significant proportion of respondents used antibiotics to treat (67.4%) and prevent (45.3%) common colds, despite the ineffectiveness of antibiotics against viral infections.
– In Colombia, 69.4% of participants reported stopping their antibiotic course when they felt better, rather than completing the full prescribed treatment.

These findings indicate a lack of knowledge about appropriate antibiotic use and the importance of completing prescribed courses, which can contribute to the development and spread of AMR.

Strengthening Antimicrobial Resistance Surveillance Among FDPs

Robust AMR surveillance is essential for understanding the burden and informing evidence-based policies and interventions. However, AMR surveillance among FDPs remains limited, particularly in low-resource settings.

Gaps in Regional Surveillance Networks:
– In sub-Saharan Africa, the lack of a dedicated regional AMR surveillance network, coupled with paper-based data collection, has hindered the collection and sharing of comprehensive AMR data.
– Similarly, while Europe has established surveillance systems like EARS-Net and CAESAR, these networks have not yet incorporated dedicated monitoring of AMR among FDPs.

Limitations of Global Surveillance Efforts:
– The Global Antimicrobial Resistance and Use Surveillance System (GLASS) relies on data approved by individual countries, which may not accurately represent the full AMR landscape, especially among marginalized populations like FDPs.

Recommendations for Improving Access and Utilisation of Quality Antimicrobials

To address the multifaceted challenges faced by FDPs in accessing quality-assured and affordable antimicrobials, a comprehensive, multi-pronged approach is needed. Key recommendations include:

1. Strengthen AMR Surveillance Globally, Especially in Low-Income Countries:
2. Establish regional AMR surveillance networks, particularly in sub-Saharan Africa, to collect and share data on AMR trends among FDPs.

3. Improve coordination and data-sharing between existing global surveillance systems, such as GLASS, to better capture AMR burdens among marginalized populations.

4. Incorporate FDP-Specific Strategies into National Action Plans on AMR:

5. Revise national AMR action plans to include targeted interventions and monitoring for FDP communities, addressing barriers to access and promoting appropriate antibiotic use.

6. Advocate for increased funding and political commitment to implement these FDP-focused AMR strategies.

7. Improve Access to Quality Antimicrobials and Healthcare for FDPs:

8. Ensure that essential antimicrobials are provided free of charge and dispensed through regulated healthcare facilities to FDPs.

9. Implement mobile health clinics and outreach programs to improve accessibility and monitoring of antimicrobial use in refugee/IDP camps and settlements.

10. Enhance AMR Education and Awareness Among FDPs:

11. Develop and disseminate targeted educational campaigns to improve FDPs’ understanding of AMR, appropriate antibiotic use, and the importance of completing prescribed treatment courses.
12. Leverage digital tools, such as mobile applications, to provide FDPs with information and guidance on accessing quality healthcare and using antimicrobials responsibly.

By addressing the key barriers identified in this study and strengthening AMR surveillance and control efforts among FDPs, the global community can take vital steps towards mitigating the spread of antimicrobial resistance and protecting the health of some of the world’s most vulnerable populations.

For more information and resources on improving water, sanitation, and health services for forcibly displaced communities, please visit https://jointactionforwater.org/.