Drug Resistant Microbes Under Siege

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It’s a perfect storm: horrific bone and tissue-pulverizing wounds from high velocity sniper rounds, a health care system crushed by twelve years of military siege, and traumatic wound infections resistant to all but the most powerful and costly antibiotics.

Such is the tempest sweeping tiny Gaza, fifteen months after the launch of protests along the militarized perimeter of what gets called, alternatively, an open-air prison or ghetto.

Great March of Return (Peter Larson)

Great March of Return protesters are calling for the right to return to homes they were driven from in 1948 and 1967. 

According to a World Health Organization report published at the end of May,  277 Gazans were shot dead by Israeli snipers between March 30 2018 and 2019, and over 28,000 injured, in the course of the largely peaceful protests.

“Although any health system in the world would be overwhelmed if it had to manage such a high influx of trauma casualties,” says the WHO report, “the most pressing concern is the staggering number of gunshot wounds.”

According to the WHO report, 6872 Gazans have suffered gunshot wounds in the course of the protests, 172 have been permanently disabled — among them 36 children — and 121 have had limbs amputated. In the absence of specialized tertiary treatment, as many as 1700 more will lose limbs due to extensive bone and soft tissue damage by “high-energy” Israeli munitions, the WHO report states.

Adding infectious insult to injury, a troubling spike has been observed in the incidence of multi-drug-resistant osteomyelitis and other sniper wound infections, impervious to ‘third generation’ carbapenems and imipenems, with nothing but colistin— the antibiotic of last resort — to turn to.

Dina Nasser

Dina Nasser is the senior infection prevention nurse at Augusta Victoria Hospital, in Israeli-occupied East Jerusalem, and a technical advisor on infection control for the Palestinian NGO Juzoor for Health and Social Development.

In response to the rising incidence of multi-drug resistant microbial infections — a serious problem in Palestine/Israel, as it is globally — Nasser has been working with a team of colleagues on a national stewardship program to promote the rational use of antibiotics.

Nasser and her colleagues treat patients from throughout the occupied West Bank and Gaza, as well as Israeli Palestinians with local health insurance. Antibiotic abuse and inadequate resources and skills for drug sensitivity and resistance testing pose a major problem, she says.

Of particular concern to Nasser and her colleagues is the recent emergence of members of the microbial group Enterobacteriaceae that are resistant to both third-generation, carbapenem-class antibiotics (CRE) and the antibiotic of last resort, colistin.  Following the first appearance of CREs a decade ago, Israel established a task force to monitor the strain and mandated its reporting. This past year, Nasser and her group observed twenty-four cases of colistin-resistant infection.

In recent years, Nasser and her colleagues have also been observing cases of drug-resistant Acinetobacter and Pseudomonas infections.

In response to the drug resistance menace, Nasser and her colleagues are engaged in a   collaborative, quality improvement project involving 22 hospitals throughout the Palestinian territories, in cooperation with the Palestinian Ministry of Health. The project promotes the rational use of antibiotics, alongside basic infection control procedures, such as simple handwashing.

They are also promoting the introduction of standardized microbiological testing, so that clinicians can determine the drug resistance and sensitivity patterns of infections they’re trying to treat.

Nothing troubles Nasser and her colleagues more than the health situation in Gaza. A dozen years of Israeli siege and three brutal bombing campaigns have all but destroyed the enclave’s health care system.

The 28,000 injuries inflicted by Israeli forces, in response to the Great March of Return, have pushed Gaza hospitals and clinics to the breaking point. Materials are scarce, particularly specialized microbiological equipment for assessing antibiotic sensitivity and resistance. So are clean water and reliable power.

Examining 2018 data, Nasser and her team of infection-control experts have observed a higher number of carbapenem-resistant infections in Gaza than in the West Bank. Although the evidence is anecdotal, it makes sense: Injured Gazans have been spending more time in critical care units, and appear to be colonized by more drug-resistant microbial strains.

Further, retrospective analysis will be undertaken to see if the incidence of drug-resistant infection in Gaza is indeed greater than elsewhere in the Palestinian territories.

One thing is clear: Multi-drug resistant microbes spawned, in part, by Israel’s siege of Gaza, and by a year of crippling sniper violence, will not honor its blockade. They pose a major threat to Israeli security, which the blockade is ostensibly supposed to bolster. Drug-resistant bugs will sweep up Israel’s shores, along with Gaza’s untreated sewage. They will waft over its militarized perimeter, and be carried by birds and people.

Drug resistant microbes are a global threat. In Gaza’s case, the solution to the drug-resistant infection menace is largely political.

Listen to my conversation with Dina Nasser here:

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