News and Opinions  –  2023

3 questions to MSF: Antimicrobial resistance in the ongoing Gaza war

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In the ongoing conflict in Gaza, the health care system has taken a very heavy toll, hospitals have been damaged or destroyed and remaining structures are operating far beyond capacity and with a big shortage of supply and staff. As in several other armed conflicts in the world, on top of already huge humanitarian needs, antimicrobial resistance (AMR) is making the situation even more severe and complex.

Krystel Moussally, epidemiologist for MSF Lebanon and Anna Farra, Infectious Diseases Specialist for MSF. Photo: MSF.

In this short interview with Krystel Moussally, Epidemiologist for Médecins Sans Frontières (MSF) Lebanon and Anna Farra, Infectious Diseases Specialist for MSF, authors of a commentary recently published in The Lancet, they address the situation in Gaza when it comes to development and spread of antibiotic resistant bacteria.

Krystel Moussally, Epidemiologist for MSF Lebanon and Anna Farra, Infectious Diseases Specialist, MSF:

“What is happening to Gaza now is beyond words, and it almost feels futile and unethical to mention antibiotic resistance, when a whole population is being systematically shelled and killed. But resistant bacteria will stay after the war, be present in soil and water, and cause difficult to treat infections”

ReAct: What has the situation been in terms of antimicrobial resistance in Gaza before the conflict, and how is it now?

Palestinians inspect their house after it was destroyed by an Israeli air strike on the city of Rafah in the southern Gaza Strip, on November 10, 2023. Photo: Shutterstock.

Krystel Moussally, MSF Lebanon says:

–  Gaza is a region that has been in total blockade for almost 16 years and has been prone to recurrent wars which have severely impacted its economy and healthcare, the latter relying mainly on international aid and donations. This has, over time, led to: limited resources, increased acute and chronic wounds prone to infections, inadequate infection prevention and control measures and limited accessibility to antibiotics. All those factors meant that before October 7th, the challenge of antimicrobial resistance in Gaza was already worrisome.

Extended-spectrum beta-lactamase (ESBL) carriage in the community was above 30% (1), as in many countries in the region (2).

– And as mentioned in the article in the Lancet (3), around 70% of isolates collected from bone and tissue samples from May, 2018, to December, 2022, at Al-Awda Hospital’s reconstructive surgical project in Gaza (supported by Médecins Sans Frontières), were multi-drug resistant. In 2022 alone, around 65% of Staphylococcus aureus isolates were methicillin resistant, and around 35% of Pseudomonas aeruginosa isolates were resistant to ceftazidime and imipenem. Almost 25% of Enterobacteriaceae being resistant to carbapenems.

–  As for the answer about what is happening now with respect to antimicrobial resistance it is impossible to know, as the situation is beyond words with remaining healthcare facilities barely functioning and surveillance systems totally down, but one could only assume that there will be a detrimental impact on antimicrobial resistance (4).

ReAct: Why is armed conflicts often a driver to the development and spread of antimicrobial resistance?

Lack of water and sanitation, leading to lack of basic hygiene with ensuing contamination by pathogens. Photo: Shutterstock.

Anna Farra points to the fact that in armed conflicts, several things could be drivers of resistance. She says:

– In the community, destruction of basic infrastructures has a major impact: Disruption of sewage water treatment, and containment, interruption of garbage disposal, lead to biologic waste being directly dumped into the environment carrying resistant bacteria that can further spread. Lack of water and sanitation, leading to lack of basic hygiene with ensuing contamination by pathogens. In the specific example of Gaza, water has become almost unavailable. This becomes particularly prevalent when people affected by conflict become internally displaced, living in shelters and very crowded settings, increasing person to person spread of infections that can be resistant (5). Lack of hygiene also leads to infestations (lice, scabies) and outbreaks (waterborne diarrheal diseases).

She continues:

– Lack of food, water and heating, high levels of fear and stress, as well as trauma lead to weakened immune systems and increase in disease, leading to bacterial superinfections that are difficult to treat.

Krystel Moussally, MSF Lebanon adds on:

–  The impact of war on the healthcare system is also of importance: Destruction of hospital infrastructure, leading to disruption of workflow and crowding, suboptimal possibilities for keeping local sanitation, distances required for proper infection control, and isolation of infected patients, leading to increase in contamination and spread of infections.

– Lack of material and medication, leading to inappropriate disinfection and treatment of infected wounds and diseases.

– No possibility or time for proper diagnostic workup, leading to broad empirical and “blind” therapy.

– Under-resourced system due to direct targeting of healthcare professionals (such as what we are seeing in Gaza), or due to human resources fleeing the war and leaving the country (which was particularly impactful in Iraq during the gulf war). This leads, along with high mass casualty incidents overloading the hospitals, to decreased quality of care, with for instance less optimal surgery leading to increased risk of infection and decreased post-operative care leading to higher likelihood of on infected wounds.

Anna Farra continues:

– Traumatic deep wounds are also easily contaminated with environmental bacteria (for example: Pseudomonas, Acinetobacter, etc) that are often naturally resistant to many antimicrobials, leading to complicated deep-seated infections that need long treatments with broad antibiotics. Wound exposure to heavy metals from the destruction of the infrastructure and from the weaponry used also leads to increase in antimicrobial resistance.

Many examples around war and conflicts as drivers of antimicrobial resistance have been recently published from the Syria and the Ukraine wars (5, 6).

ReAct: What needs to be done to prevent a further deterioration when it comes to antibiotic resistance in Gaza? And in armed conflict settings in general?

Krystel Moussally says:

–  What needs to be done first in Gaza today to prevent further negative impact on antibiotic resistance is obviously to stop the war and stop the targeting and destruction of healthcare facilities, to allow not only basic resources like food, water and shelter, but also enough medical supplies and equipment to enter Gaza, and to open humanitarian and safe corridors for the management of complex cases outside of Gaza.

– In armed conflicts, in general, to avoid further deterioration, prevention and emergency preparedness is key. For hospitals, training the personnel for mass casualty incidents, prepare and safely stock consumables and medications for emergency use, secure electricity, water, oxygen resources for an appropriate amount of time, have appropriate locally adjusted guidelines for antimicrobials use among other things.

Anna Farra concludes: 

– For the general population also, preserve basic rights by providing basic hygiene kits including soap and water. But also prepare for what comes after the war: Knowing the epidemiology of AMR pre-conflict by conducting proper AMR surveillance and centralizing it outside local servers, could be very useful for guiding therapeutic decisions on empirical antimicrobial guidelines for instance.


(1). El Aila NA, Laham NAA, Ayesh BM, Naas T. Fecal carriage of extended-spectrum β-lactamase-producing enterobacterales from hospitals and community settings in Gaza Strip, Palestine. BMC Microbiol. 2023;23(1):376. doi:10.1186/s12866-023-03102-6

(2). Moghnieh RA, Kanafani ZA, Tabaja HZ, Sharara SL, Awad LS, Kanj SS. Epidemiology of common resistant bacterial pathogens in the countries of the Arab League. The Lancet Infectious Diseases. 2018;18(12):e379-e394. doi:10.1016/S1473-3099(18)30414-6

(3) Moussally K, Abu-Sittah G, Gomez FG, Fayad AA, Farra A. Antimicrobial resistance in the ongoing Gaza war: a silent threat. The Lancet. 2023;402(10416):P1972-1973. doi:

(4). Five ways the war in Gaza is impacting Palestinians’ health – occupied Palestinian territory | ReliefWeb. Published October 20, 2023. Accessed December 13, 2023.

(5). Pallett SJC, Boyd SE, O’Shea MK, Martin J, Jenkins DR, Hutley EJ. The contribution of human conflict to the development of antimicrobial resistance. Commun Med. 2023;3(1):1-4. doi:10.1038/s43856-023-00386-7

(6). Bazzi W, Abou Fayad AG, Nasser A, et al. Heavy Metal Toxicity in Armed Conflicts Potentiates AMR in A. baumannii by Selecting for Antibiotic and Heavy Metal Co-resistance Mechanisms. Front Microbiol. 2020;11:68. doi:10.3389/fmicb.2020.00068

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