Session 6: Antimicrobial Resistance as a Consequence of War
On April 19, 2024, session 6 of the IANPHI Europe Network Meeting focused on antimicrobial resistance as a consequence of war. This session was moderated by Olga Gvozdetska, Acting Deputy General Director, Public Health Centre of the Ministry of Health of Ukraine.
In the wake of the COVID-19 pandemic, which exposed flaws in Ukraine's medical system, the war against Russia represents a completely new medical challenge. Many Ukrainian soldiers suffer from complicated physical traumas and infected wounds. Hospital services are stumped, including diagnostics, access to antibiotics and other medical products, and treatment capacity. Antimicrobial resistant infections, highlighted during the 2019 pandemic, including multi-drug resistance, are rampant.
Antimicrobial Resistance across Europe: Insights and Comparisons, with a Focus on Ukraine
Dr. Roman Kolesnyk, Head of AMR and IPC department, Public Health Centre of the Ministry of Health of Ukraine
Dr. Roman Kolesnyk began by demonstrating that before 2021 and the start of the pandemic crisis, Ukraine did not have an epidemiological surveillance hospitals. Indeed, before this crisis, cases of bacteriological contamination were rare. However, with the arrival of COVID-19, interest was shown in the detection of healthcare-associated infections (HAI) due to the nature of the virus. In addition, a point prevalence survey of healthcare-associated infection carried out in 2021 on HAI cases showed that the official data were not accurate: HAIs were 600% more prevalent than the official data. In 2023, similar research was carried out, showing that the HAI rate had risen again. Alongside this study, a second study was carried out in 2022 on the personal consumption of antimicrobials in Ukraine. This highlighted the fact that, because of the war, Ukraine had resorted to medicines from humanitarian aid, particularly antibiotics. As a result, authorisation was given for the import of medicines, even though they did not have marketing authorisation. This study has therefore highlighted the fact that controlling the use of medicines in Ukraine is complex: solutions are being proposed to control the entry of medicines into the country (legally imported as well as those supplied as humanitarian aid).
Examining the various groups of antibiotics available in Ukraine reveals an increasing trend in their use over the years from 2015 to 2023. During the COVID-19 pandemic, a significant rise in antimicrobial consumption was observed, a trend common to all European countries. However, certain antimicrobials (Beta-lactam and Cephalosporins) continue to be widely used despite the end of the pandemic. Dr. Kolesnyk believes that current consumption will continue to rise despite the demographic changes taking place in Ukraine (millions of refugees due to war). At the same time, including due to the large number of wounded, the deterioration of sanitary conditions, the quality of life of internally displaced persons because of Russia’s aggression, the need for the use of antibiotics is increasing simultaneously with the spread of antimicrobial resistance. Dr. Kolesnyk also demonstrated that the antimicrobials still in use today are not harmless, and highlight that the antibiotics are less effective against common hospitals herms: ceftriaxone & levofloxacin for instance. Finally, the last part of the presentation by the Head of AMR and IPC department of Public Health of MOH of Ukraine was devoted to the frequency of pathogen strains detection in hospitals of Ukraine during the treatment of war wounded. It was shown that out of 24,584 wounds studied, 18,966 tested positive for pathogens such as Kebsiela Pneumonia or Staphylococcus aureus. This critical situation is associated with the quality of care that hospitals are able to provide in a war context, the number of beds available to accommodate the wounded, a large number of wounded who need comprehensive care with a limited number of well-trained medical personnel and limited resources in hospitals and laboratories. The last example highlighted by the Dr. Kolesnyk is the prevalence of K.pneumoniae strains resistant to antibiotics from 2018 to 2023. Resistance has increased significantly over the five last years, and is a cause for concern, as Ukrainian citizens fleeing the war are likely to carry this prevalence with them.
Strategic goals of the fight against AMR until 2030 year proposed at the end of the meeting:
- Strengthening the system of infection prevention control in health care institutions;.
- Increasing the capacity of bacteriological laboratories;
- Implementation of a surveillance system for pathogens with AMR and consumption of antimicrobials;
- Strengthening of measures to ensure the welfare of animals, veterinary-sanitary and epizootic welfare in terms of countering the spread of pathogens with AMR;
- Raising the awareness of the population, medical and veterinary workers regarding the prevention of infection and countering the spread of AMR pathogens;
- Strengthening of personnel potential and conducting scientific research.
WHO's Collaborative Approach for Ukraine and Mitigating European Spread
Dr. Danilo Lo Fo Wong, Regional Adviser for the Control of Antimicrobial Resistance, WHO Europe
This panel, led by Dr. Danilo Lo Fo Wong, focused on the activities set up by the World Health Organization's Regional and Country Office on antimicrobial resistance in Ukraine. He began by explaining that a surveillance network called EARS (European Antimicrobial Resistance Surveillance System) had existed in Europe since 1998 whiwh turned into EARS-Net when it was taken over by the European Center for Disease Prevention and Control (ECDC) in 2010. In 2012, the WHO Regional Office for Europe and partners initiated the Central Asia and European Surveillance of AMR (CAESAR) network for countries in the WHO region outside of the European Union. Over the years, more and more countries have been added to the network, increasing the amount of data collected. The development of specific surveillance in Ukraine has been very impressive. Dr. Danilo Lo Fo Wong points out that from 2017, with 4 partner laboratories in the project, by 2024 the national surveillance network had grown to more than 100 laboratories providing data. As far as the data recovered is concerned, there has been an upward trend in the number of cases of antimicrobial resistant pathogens (x 10) between 2017 and 2022.
In addition to the quantity of data, WHO also looked at the quality of the data obtained and the methodology used. In Ukraine, the European Committee on Antimicrobial Susceptibility Testing (EUCAST) methodology is taught and applied to generate resistance data: seven 3-day training courses are given on this methodology (over 200 participants in 22 regions of Ukraine) and are compulsory to ensure that the data complies with European standards. Manny countries in the European region con learn from the way in which the quality and the coverage of the national surveillance network was improved in Ukraine. In conclusion, these two European surveillance systems show that the problem in Ukraine is not an isolated one, and that Europe as a whole is experiencing a sharp increase in high levels of antibiotic resistance in general. What is more, the data also shows that the countries with the highest rates of pneumonia and resistance are also those with the weakest healthcare system, which hampers an adequate AMR response. There is therefore a twofold urgency: the overall increase in cases of resistant infections in Europe, and the need to improve European healthcare systems. This is particularly the case now in Ukraine, where soldiers have to be sent to hospitals outside the country because they cannot be treated locally.
The emphasis is on the prevention of AMR to strengthen the Ukrainian health system, as well as in the training of health personnel.
Experiences from Norway on Receiving Patients from Ukraine
Dr. Miriam Sare, Senior Medical Officer, Norwegian Institute of Public Health (FHI)
This presentation by Dr. Miriam Sare described the treatment of Ukrainian war-wounded soldiers evacuated in Norway. Norwegian surveillance data showed a rapid increase in antibiotic-resistant bacteria among Ukrainian patients. At the time, Norwegian hospitals:
- Had limited experience in treating complicated war injuries. Many patients had multiple and complicated traumas, and several concurrent infections;
- Observed complex resistance patterns previously not detected in Norway;
- Needed to use empirical antibiotic treatment strategies with insufficient scientific documentation;
- Had limited or no access to some broadspectrum antibiotics against extensively drug-resistant (XDR) bacteria, and treated patients with multiple co-morbidities (MDR-TB, hepatitis, mental trauma).
Oslo University Hospital organized a "Medevac" hospital ward for the evacuated Ukrainian patients with a multidisciplinary team consisting of orthopedic surgeons, infectious disease specialists, microbiologist and an infection disease consultant. Other specialists, including psychiatric social workers, interpreters, and nutritionists, supported the team. In addition, an infection prevention and control (IPC) protocol, which included patient logistics, isolation and screening procedures, and training of staff, was put in place to prevent hospital transmission. No further spread has been detected so far.
Group and panel discussions
The rapid increase in AMR among Ukrainian soldiers wounded in war, show the urgent need for the Ukrainian hospitals treating the patients, to have access to ample resources to detect, treat and follow up of the patients. Importantly, bacteria with complex resistance patterns from Ukraine can easily spread to other European countries if not adequate attention is given. Oslo University Hospital is interested in establishing contact with other European hospitals through their NPHIs to exchange best practice.