Posted on: The Guardian | December 31st, 2018

Medics say antibiotics shortage stops them following protocols to fight drug-resistant bacteria

Doctors in Gaza and the West Bank have said they are battling an epidemic of antibiotic-resistant superbugs, a growing problem in the world’s conflict zones, which could also spill over the Palestinian borders.

The rise and spread of such virulent infections adds to the devastation of war, increasing medical costs, blocking hospital beds because patients need care for longer, and often leaving people whose injuries might once have been healed with life-changing disabilities.

Gaza is a particularly fertile breeding ground for superbugs because its health system has been worn down by years of blockade, and antibiotics are in short supply, the Bureau of Investigative Journalism has found.

“This is a global health security issue because multi-drug-resistant organisms don’t know any boundaries,” said Dina Nasser, lead infection control nurse at Augusta Victoria hospital in East Jerusalem, who has also worked in Gaza. “That’s why the global community, even if it’s not interested in the politics of Gaza, should be interested in this.”

Even though doctors in Gaza knew protocols to prevent the rise of drug-resistant bacteria, persistent shortages of antibiotics meant they could not always follow them, they told reporters. Patients take incomplete courses of antibiotics or are prescribed a mix because the right medicine is not available.

Shortages of water, power and fuel for generators mean doctors cannot always meet even basic hygiene standards, making it easier for any drug-resistant infection to spread. At times doctors are not even able to wash their hands and there are shortages of gloves, gowns and chlorine tablets for disinfecting.

A decade-long Israeli blockade on travel and trade means Gaza is relatively isolated compared with other conflict areas that have proved fertile ground for superbugs.

The US military noted the spread of drug-resistant bacteria from Iraq more than a decade ago; it logged such a huge rise in injured personnel returning with resistant Acinetobacter that the bacteria were eventually nicknamed “Iraqibacter”.

But Gaza is not totally cut off. Small numbers of patients do transfer to other hospitals in Palestine, Israel and nearby countries such as Jordan, Egypt and Lebanon.

Healthy people can carry the bacteria without showing any symptoms, so doctors and aid workers travelling in and out of Gaza could transport superbugs to other countries. The bacteria can also travel without human hosts.

“It will always get out,” said Dr Ghassan Abu Sittah, who studies conflict medicine at the American University of Beirut Medical Center (AUBMC). “The untreated sewage from Gaza containing multi-drug-resistant bacteria goes into the aquifer and that is a shared aquifer [with Egypt and Israel].

“There are papers from Scotland that show actually multi-drug-resistant bacteria can be found in the pellets of migrating birds. The idea anyone could be immune to this phenomenon is absurd.”

The scale of the problem was thrown into relief by an increase in violence in Gaza this year, when more than 200 people were killed and thousands injured, mostly shot in the legs, during protests along the border that culminated in a “Great March of Return” rally in May.

Dr Mahmoud Mattar, an orthopaedic surgeon, said around 2,000 Gazans were currently dealing with serious gunshot injuries to the legs that would typically require multiple reconstruction operations and two years of rehabilitation.

Nearly all of these patients have also contracted superbug infections, meaning surgeons have to delay closing their wounds. That reduces the chances of successful reconstruction, extends hospital stays and increases the risk of amputation.

The first antibiotic, penicillin, was brought into mass production towards the end of the second world war. Since then, antibiotics have saved millions of lives and prevented countless disabilities, particularly among those injured in war, by allowing doctors to avoid amputations.

But no new class of antibiotic has been developed since the 1980s, and as the world’s superbug crisis grows ever more severe, some modern conflict zones are starting to resemble those in pre-penicillin days.

“We are expecting an absolute catastrophe in terms of residual disability in the wounded [in Gaza],” said Abu Sittah, who is head of plastic surgery at AUBMC and travelled to Gaza in May to treat patients at al-Awda hospital.

All the superbugs on the World Health Organization’s (WHO) list of priority bacteria – those which pose the greatest threat to human health – have been reported in Palestine.

But Gaza’s hospitals, like many others in conflict zones, are already in crisis, with a dire lack of equipment and medicine and severe overcrowding. Most also lack the ability to detect superbugs, making things worse.

31 operations after being shot in the leg

One of the Gazans dealing with the double impact of injury and superbug infection is Fahed Zuhud, 29. He was throwing stones near the border in February when a bullet shattered his leg. He was rushed to hospital for surgery, but his wound became infected and he developed osteomyelitis, a serious infection inside the bone which can often lead to amputation.

So far Zuhud has endured 31 operations to reconstruct his leg and try to clear the wound of infection. He can no longer work, and faces years more of treatment. Doctors have not been able to identify the strain but believe it is multi-drug-resistant because he has had every antibiotic available, to no effect.

The medical charity Médecins Sans Frontières is setting up a service with the ministry of health to test bone samples from hospitals all over Gaza for multi-drug-resistant osteomyelitis so they can get targeted antibiotics. It is also running an osteomyelitis clinic, where patients can be followed up and rehabilitated more easily. Zuhud is now being treated there.

He is waiting for a bone implant, but the infection has stalled his treatment. If his infection had been treatable with antibiotics, he might be able to walk by now, says Dr Ahmed Abu Warda, a doctor at the clinic.

Instead, 10 months later, Zuhud is still on crutches and there is concern that the infection could still spread. “Maybe he will lose all the femur bone,” Warda said. “Amputation is still a possibility.”

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