The effective management of health systems depends to a large extent on fundamental elements necessary to safeguard patient safety. Harm can be caused by different factors, inter alia by medical errors, unsound equipment, poor healthcare standards, and healthcare-associated infections (HCAIs, also known as nosocomial infections), which are the most frequent adverse effects in healthcare delivery.1
The term HCAI describes infections developing in a patient during a hospital stay and that were not present or incubating at time of admission. One of the main reasons for HCAIs to emerge is the insufficient application of hygiene standards and isolation precautions.2 For this reason, the World Health Organization (WHO) regards proper hygiene and sanitation as essential in preventing infections in healthcare facilities, and its precautionary standard practices comprise of hand hygiene, protective equipment, cough etiquette, environmental cleaning and waste disposal.3
This article discusses how negligence in the area of waste disposal and handling of pharmaceuticals, especially in settings where antibiotics are widely used (healthcare facilities, animal husbandry) and throughout their lifecycle (from production to disposal), can have serious consequences for public health, in particular by contributing to the global spread of antibiotic and, by extension, antimicrobial resistance (AMR), for example, via contaminated water, food, and excretion.
On average 15–25% of waste generated within healthcare facilities is classified as hazardous,4 meaning that their erratic handling and disposal can easily lead to the spread of infections. As the amount of waste produced globally is growing faster than the infrastructure to cope with it, half of the world’s population is at risk from exposure to poor healthcare waste management.5 Moreover, since waste is a reservoir of pathogenic microorganisms, it contributes to the development of novel, multidrug-resistant ‘superbugs’ that are difficult to inactivate.
The list of pharmaceutical products and hospital derived by-products ending up in the physical environment is increasing. Poor waste disposal coupled with inadequate infection control stimulates the spread of AMR, which can become endemic in the community. One effective way to deal with the emergence of resistant bacteria is avoiding bad sewage and water waste treatments. Antimicrobial stewardship programmes should thus embrace the principles of safe waste management.
The environmental dimension of AMR
In June 2015, the G7 health ministers committed to a full engagement in tackling AMR as it undermines the fundamental right to health for every human being.6
In order to implement the objectives of the WHO Global Action Plan on AMR,7 it is crucial to understand how resistance develops, spreads and circulates in order to draw up coherent policy responses.8 AMR is occurring worldwide for a broad range of factors and circumstances.
The environmental dimension deserves more attention for at least two reasons: firstly, the environment plays a key role as a vector of transmission; secondly, it functions itself as a reservoir for resistance development.9
Since almost all classes of antibiotics are of natural origin, it is normal that resistance also develops in the surrounding environment. Anthropogenic actions can significantly accelerate the Darwinian evolution of resistant bacteria. Hotspots like waste water treatment plants, pharmaceutical manufacturing discharges, and sewages of healthcare and animal husbandry facilities, make ideal settings for their acquisition and spread into terrestrial and aquatic ecosystems where antibiotic residual compounds contribute to the development of resistant pathogens.
There is a growing interest in exploring the links between AMR and the environment. For example, the release of antibiotic compounds into the environment through specific hotspots can severely affect receiving rivers.10
Medical settings and their effluents are characterised by a high prevalence of resistance.11 As noted by WHO, not all hospitals are connected to efficient working sewage treatment plants and discharges sometimes only receive partial treatments.12
Moreover, careless ‘dumping’ of antibiotic manufacturing waste creates a fertile breeding ground for drug-resistant bacteria, and multinational pharmaceutical companies should pay more attention to their global supply chains.13
In addition, the persistent overuse of antibiotics in animal husbandry also releases antibiotic waste into the environment.
As a consequence of the continuous pollution deriving from human activity, there is an increasing prevalence of resistant genes in the bacterial community. The link between bad sanitation and AMR is particularly strong due to poor water discharges14 and contaminated sewage entering the ecosystem.
Knowing that genes are capable of evolving and developing resistance in these hotspots, the control, prevention and management of antibiotic waste must be a strategic policy priority.
The need to scale up action for a safer environment
AMR is a complex problem mainly driven by interconnected factors. Environmental pathways, including waste water treatment plants, urban and hospital sewage and pharmaceutical discharges play a key role.15 Yet despite the compelling evidence that the presence of resistant genes in the environment depends mostly on contamination from anthropogenic activities, a comparatively limited focus is placed on the environmental dimension of the ‘one health’ approach envisioned by the European Commission, which is meant to stress the interconnections between human and animal health and the environment.
There are several biologically plausible reasons why contaminated waste water plays a major role in the development and spread of AMR. Specifically, poor water sanitation contributes to the transmission of infectious resistant genes, giving them the capacity to recombine and evolve more strongly.16 Policy-makers should thus strive to understand why infection control measures often overlook waste treatment, especially when it comes to contaminated effluents released by hospitals and drug manufacturing sites.17
In the case of hospitals, it has been argued that the main problem is a lack of legal requirements for effluent treatments prior to discharge into municipal collectors.18 The same concern applies to the quantity of active pharmaceutical ingredients present in water,19 which essentially are not neutralised by waste water treatment plants. The latter are not designed to prevent resistant genes from being released into the environment20 but mainly to remove organic compounds.
The evidence is sufficient to state that prevention of microbial infections must take into account the environmental dimension. Thinking globally, there is another important reason to address the problem of water sanitation and proper treatment: wherever contaminated water is reutilised, for example, with the objective of increasing the sustainability of global water supplies, there is an increased risk of resistance spreading.
That is why the ‘one health’ approach should address more thoroughly the environmental dimension of infection control through water sanitation and safe waste disposal in healthcare, animal husbandry and pharmaceutical manufacturing settings.
In addition to annual epidemiological reports, the ECDC have published a repository of guidance documents to prevent AMR and foster the exchange of best practices. The increasing emergence of resistant bacteria and microbes that can survive to first-line medicines and treatments is a particularly urgent concern.
Tackling AMR is a global challenge that cannot be managed by a single Member State or by Europe alone. AMR is related to a broad series of determinants including environmental, and international travel and trade accelerate its proliferation.
Measures to reduce the risks posed by resistant genes include identifying critical points of control, reliable surveillance and risk assessment, and technological solutions that can prevent environmental contamination.21 Particular attention should be placed on water hygiene in order to correctly prevent microbial infections at its source. Alongside other sites, hospitals and other healthcare settings are critical hotspots for resistance development, and proper waste disposal, hygiene and water treatment practices must be implemented.
The European Commission is currently in the process of evaluating whether the actions of its expiring Action Plan against AMR22 are still relevant and comprehensive enough. A strategy on pharmaceuticals in the environment (PIE) is still outstanding; policy coherence with the European Water Framework Directive and other environmental policies will be crucial. Moreover, environmental criteria should be an integral part of Good Manufacturing Practices (GMP) for antibiotics, and safe discharge standards should be developed and applied globally.
Apart from the principles of prevention and infection control, it remains vital to educate patients, health professionals, veterinarians and industry about prudent use of antibiotics (for example, problems remain regarding prescription-free availability of antibiotics and Internet sales, and their use as growth promoters in animal breeding) and AMR’s various dimensions including the physical environment.
High level political commitment is indispensable. In November 2015, WHO launched the first World Antibiotic Awareness Week to put emphasis on the Global Action Plan on AMR. For their part, the G7 health ministers committed to strengthening the quality of health systems, including the development of appropriate sanitation and hygiene plants. At a national level, the UK Review on AMR continues to publish relevant findings, with a report on agriculture and the environment from December 2015. Finally, the Uppsala Health Summit offers a multisectoral, collaborative platform for global dialogue.
As European Commissioner for Health and Food Safety, Vytenis Andriukaitis recalled, “AMR is mainly an issue of collaboration: people like coordination if it creates the broadest possible coalition, which is tough at the same time, since only few of them like to be coordinated”.23