Abstract
The emergence and spread of antimicrobial resistance (AMR), including clinically relevant antimicrobial-resistant bacteria, genetic resistance elements, and antibiotic residues, presents a significant threat to human health. Reducing the incidence of infection by improving water, sanitation, and hygiene (WASH) is one of five objectives in the World Health Organization's (WHO) Global Action Plan on AMR. In September 2019, WHO and the Health-Related Water Microbiology specialist group (HRWM-SG) of the International Water Association (IWA) organized its third workshop on AMR, focusing on the following three main issues: environmental pathways of AMR transmission, environmental surveillance, and removal from human waste. The workshop concluded that despite an increase in scientific evidence that the environment may play a significant role, especially in low-resource settings, the exact relative role of the environment is still unclear. Given many antibiotic-resistant bacteria (ARB) can be part of the normal gut flora, it can be assumed that for environmental transmission, the burden of fecal-oral transmission of AMR in a geographical area follows that of WASH-related infections. There are some uncertainties as to the potential for the propagation of particular resistance genes within wastewater treatment plants (WWTPs), but there is no doubt that the reduction in viable microbes (with or without resistance genes) available for transmission via the environment is one of the goals of human waste management. Although progress has been made in the past years with respect to quantifying environmental AMR transmission potential, still more data on the spread of environmental AMR within human communities is needed. Even though evidence on AMR in WWTPs has increased, the reduction in the emergence and spread of AMR by basic sanitation methods is yet unresolved. In order to contribute to the generation of harmonized One Health surveillance data, WHO has initiated an integrated One Health surveillance strategy that includes the environment. The main challenge lies in rolling it out globally including to the poorest regions.
Highlights
Antimicrobial resistance (AMR) has been raised as an important issue on the international agenda for over a decade
Analysis of environmental samples is based on quantitative determinations of extended-spectrum beta-lactamase (ESBL) E. coli and total E. coli by use of tryptone bile X-glucuronide (TBX) agar plates
Acquired data are the prevalence (% carriage) of ESBL-resistant E. coli in animals and humans, the occurrence of ESBLresistant E. coli and total E. coli per volume of river water, and the ratio of ESBL E. coli to total E. coli
Summary
Antimicrobial resistance (AMR) has been raised as an important issue on the international agenda for over a decade. While the relative role of the environment in AMR transmission is unclear at this stage, an important step is to identify hotspots of AMR spread and human exposure, and explore possible benefits of actions to reduce the load of AMR agents into water environments (Bengtsson-Palme et al ; Amarasiri et al ) This is reflected in the World Health Organization’s (WHO) Global Action Plan on AMR, in which reducing the incidence of infection by improving water, sanitation and hygiene (WASH) is included as one of the five objectives (WHO ), and in the recent WHO, Food and Agriculture Organization of the United Nations (FAO), and World Organization for Animal Health (OIE) publication of a technical brief on WASH and wastewater management to prevent infections and reduce the spread of AMR (WHO et al ). Discussion and conclusions derived from the breakout group discussion are summarized
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