Out of the frying pan and into the fire
Authors: Marc Mendelson, Davidson H Hamer
Journal: The Lancet Infectious Diseases (2018)

In 2017, the total number of international migrants worldwide reached about a quarter of a billion people.1UNDepartment of Economic and Social AffairsPopulation DivisionInternational migration report 2017: highlights.https://www.un.org/development/desa/publications/international-migration-report-2017.htmlDate: Dec 18, 2017Date accessed: March 25, 2018Google Scholar Over the past 2 years, all eyes have focused on Europe, with more than 1 million new immigrants estimated to have arrived, including about 7500 migrants and refugees entering by sea alone in the first 5 weeks of 2018.2International Organization for MigrationMediterranean migrant arrivals reach 7511 in 2018; deaths reach 390.https://www.iom.int/news/mediterranean-migrant-arrivals-reach-7511-2018-deaths-reach-390Date: 2018Date accessed: March 25, 2018Google Scholar The main ports of entry of these migrants were Italy, Greece, and Spain; three countries with high rates of antibiotic resistance to common bacterial infections.3ECDCSurveillance of antimicrobial resistance in Europe 2016. Annual Report of the European Antimicrobial Resistance Surveillance Network (EARS-Net). European Centre for Disease Prevention and Control, Stockholm2017Google Scholar In their systematic review and meta-analysis published in The Lancet Infectious Diseases, Laura B Nellums and colleagues4Nellums LB Thompson H Holmes A et al.Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis.Lancet Infect Dis. 2018; (published online May 17.)http://dx.doi.org/10.1016/S1473-3099(18)30219-6Summary Full Text Full Text PDF Scopus (79) Google Scholar show that, although pooled prevalence rates for antibiotic resistant bacteria (meticillin-resistant Staphylococcus aureus and multidrug-resistant Gram-negative bacteria) were high, resistance was mostly acquired during transit or in high-migrant community settings in Europe, rather than from the migrants' countries of origin. There is growing evidence that travel results in an increased risk of a person being colonised with an antibiotic-resistant bacterium.5Hassing RJ Alsma J Arcilla M van Genderen P Stricker B Verbon A International travel and acquisition of multidrug-resistant Enterobacteriaceae: a systematic review.Euro Surveill. 2015; 20: 30074Google Scholar, 6Arcilla MS van Hattem JM Haverkate MR et al.Import and spread of extended spectrum β-lactamase-producing Enterobacteriaceae by international travellers (COMBAT study): a prospective, multicentre cohort study.Lancet Infect Dis. 2017; 17: 76-85Summary Full Text Full Text PDF Scopus (260) Google Scholar For non-migrant travellers, the risk is greatest in countries with the highest rates of antibiotic resistance, predominantly India and other countries in south and southeast Asia. Nellums and colleagues4Nellums LB Thompson H Holmes A et al.Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis.Lancet Infect Dis. 2018; (published online May 17.)http://dx.doi.org/10.1016/S1473-3099(18)30219-6Summary Full Text Full Text PDF Scopus (79) Google Scholar suggest that, for migrants, their migration route or final destination might confer an equal risk. In a world of blame, migrants have been targets for everything from the economic instability of their host country or region to the health of those populations. However, this systematic review showed that there was no significant dissemination of resistance from migrants to local populations; the reasons for which might be multifactorial. Major factors are likely to be the short duration of colonisation once an antibiotic-resistant bacterium has been acquired6Arcilla MS van Hattem JM Haverkate MR et al.Import and spread of extended spectrum β-lactamase-producing Enterobacteriaceae by international travellers (COMBAT study): a prospective, multicentre cohort study.Lancet Infect Dis. 2017; 17: 76-85Summary Full Text Full Text PDF Scopus (260) Google Scholar and segregation of migrants from the local population in high-density community settings, such as camps, transit centres, or detention facilities. How should we protect migrants to any country from acquiring and becoming infected with a multidrug-resistant bacterium? Admirable national action plans to reduce antibiotic resistance need to be converted into concrete actions with even more solid funding behind them. Only then will society begin to benefit from infection prevention and antibiotic stewardship interventions in humans and animals that can reduce the use of antibiotics, the major driver of resistance, and make our countries safer for all. Notably, this systematic review highlights the need to continue to expand our focus from interventions implemented through health-care settings (such as hospitals) to those that will have a major effect on communities, including migrants in community settings (such as refugee camps). If high-migrant communities are a risk factor for the spread of antibiotic-resistant bacteria, proper hand hygiene and other measures that prevent infection should be implemented, and those involved in planning for migrant services need to shorten the period of stay in such settings. Nellums and colleagues4Nellums LB Thompson H Holmes A et al.Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis.Lancet Infect Dis. 2018; (published online May 17.)http://dx.doi.org/10.1016/S1473-3099(18)30219-6Summary Full Text Full Text PDF Scopus (79) Google Scholar showed that refugees and asylum seekers were more likely to be colonised by antibiotic-resistant bacteria than those who migrated for economic, family, and other reasons. Although their systematic review and meta-analysis did not evaluate the duration of stay of different categories of migrants, asylum seekers are often kept in such settings for prolonged periods while they await integration into their host country or resettlement in a third-party country. In 2016, less than 1% of the 17·2 million worldwide refugees of concern to the UN High Commissioner for Refugees, were resettled.7UN High Commissioner for RefugeesResettlement.http://www.unhcr.org/uk/resettlement.htmlDate: 2016Date accessed: March 25, 2018Google Scholar The reduction of waiting times to settlement might be an important factor not only in how successfully asylum seekers and refugees integrate economically into their host country,8Hainmueller J Hangartner D Lawrence D When lives are put on hold: lengthy asylum processes decrease employment among refugees.Sci Adv. 2016; 2: e1600432Crossref PubMed Scopus (123) Google Scholar but also on the wider health issues of migrants, including the threat of acquiring multidrug-resistant infections. All travellers, including migrants, are sentinels for infectious diseases and hence, surveillance of these important populations plays a crucial role in understanding and intervening in emerging and re-emerging infections. Antibiotic resistance is at epidemic proportions, and the identification of new resistance mechanisms9Kumarasamy KK Toleman MA Walsh TR et al.Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: a molecular, biological, and epidemiological study.Lancet Infect Dis. 2010; 10: 597-602Summary Full Text Full Text PDF PubMed Scopus (2264) Google Scholar, 10Liu YY Wang Y Walsh TR et al.Emergence of plasmid-mediated colistin resistance mechanism MCR-1 in animals and human beings in China: a microbiological and molecular biological study.Lancet Infect Dis. 2016; 16: 161-168Summary Full Text Full Text PDF PubMed Scopus (3334) Google Scholar has changed our understanding of the global spread of resistance. An international network tasked with surveillance of antibiotic resistance in migrants could increase such understanding and be an important addition to the current efforts of surveillance programmes that support the WHO global action plan on antimicrobial resistance. We declare no competing interests. Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysisMigrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Full-Text PDF Open Access