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Policy  –  Implement the plan

Environmental considerations

To curb the development and spread of antibiotic resistance, national and local governments also have to consider actions to limit release and spread of antibiotics and resistant bacteria in the environment.

Antibiotics and antibiotic resistant bacteria reach the environment in several ways (see UNDERSTAND: Antibiotic resistance – Spread of resistant bacteria and How did we end up here? – Antibiotics in the environment), and regulatory as well as other measures are needed to diminish these pathways. Main channels include wastewater from pharmaceutical production facilities, hospitals and sewage treatment plants and manure from intensive livestock facilities. The Global Action Plan on Antimicrobial Resistance highlights the importance of increasing understanding of the impact of resistance and antibiotics in the environment, and calls for measures to control spread of resistant bacteria through the environment.

Emissions through human use

As many antibiotics are excreted in active form through urine and feces, improved sanitation and sewage treatment is a key component to prevent the spread of resistant pathogens. Traditional sewage treatment plants are not designed for the removal of antibiotics or antibiotic resistant bacteria. Instead, the presence of antibiotics together with a high microbial cell density might favour resistance gene transfer between bacteria residing in activated sludge. However, the occurrence of both antibiotics and antibiotic resistant bacteria in sludge can be reduced by good management procedures such as anaerobic digestion and storage before waste solids are spread on arable land. To reduce occurrence in water effluents, waste water treatment options should be considered. Increased attention should be directed to hospital effluents, as it often contains higher concentration of both antibiotics and antibiotic resistant bacteria than effluents from sewage treatment plants.

Lack of access to clean water and sanitation also facilitates the spread of bacterial diseases leading to increased morbidity and mortality, especially in children. The WHO-UNICEF Joint Monitoring Program for Water and Sanitation estimates that 2.4 billion people lack access to an improved sanitation facility.

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Emissions through antibiotic use in animals

Use of antibiotics in the animal sector is more extensive than human usage globally, thus, emission of antibiotics into the environment from agricultural use is substantial. Limiting the use of antibiotics by stopping inadequate and non-medical use is, therefore, a way of also reducing the release of such compounds into the environment. As excreted antibiotics and antibiotic resistant bacteria end up in manure, they will follow the same general pattern of spread and leakage as pathogens and nutrients in manure. Regulatory measures to prevent leakage of nutrients and decrease pathogen levels, both during storage and when spread on agricultural land  also have a beneficial effect on reducing antibiotics and antibiotic resistant bacteria in the environment. The prevention of nutrient leakage is also of economic interest for the farmer, as it increases the value of the manure as fertilizer.

Awareness raising and regulatory measures to promote good practices in this field is therefore of value and recommendations have been formulated for both high- and low-income settings.

Emission from antibiotic production facilities

As pharmaceutical production facilities represent defined sources for environmental emissions of antibiotics, measures can be taken to promote resource-efficient pollution control. For example, environmental risk assessment of antibiotics should include the risk for development of antibiotic resistance in bacteria. Also, by inserting regulations for environmental control within the framework of Good Manufacturing Practice, manufacturers of medicinal products would be required to comply with specific requirements limiting discharges and emissions of active pharmaceutical ingredients into the environment, independently in which country production is localized.

One option for governments that want to address environmental aspects of antibiotic resistance is to use sustainable public procurement. Some countries have started this work, for example by implementing environmental procurement criteria for medicines for hospital use, where emissions from manufacturing are considered. Even though discharge limits have not yet been specified, suppliers and subcontractors have to set up monitoring programs. Also, buyers of generic antibiotics could consider environmental aspects when making procurement decisions. Alternatively, environmental considerations may be included in national generic substitution systems, so that cost reduction is not the only driver in selection of therapeutically interchangeable medicines that will be reimbursed by the state.

Water, Sanitation and Hygiene (WASH) is closely linked to both environmental considerations and infection prevention and control. Some resources of interest may also be found in Infection prevention and control.

Selected Resources

Resource Description
EMBRACE-WATERS statement: Recommendations for reporting of studies on antimicrobial resistance in wastewater and related aquatic environments Journal article proposing guidelines for better standardising antimicrobial resistance studies in the wastewater compartment.
A conceptual framework for the environmental surveillance of antibiotics and antibiotic resistance Journal article proposing a framework for how to use environmental samples for surveillance of antibiotic consumption and antibiotic resistance. The framework contains five objectives of surveillance together with proposed markers and sampling sites.
Management Options for Reducing the Release of Antibiotics and Antibiotic Resistance Genes to the Environment Journal article that discusses different options for reducing the spread of antibiotics and antibiotic resistance through the environment, and especially through agriculture. The authors identify a number of feasible options, including manure and nutrient management, runoff control, and infrastructure upgrades.
Sustainability criteria for medicinal products Procurement criteria can be used to achieve environmental and other public policy goals. The National Agency for Public Procurement in Sweden has developed procurement criteria which encompass medical products intended for human use.
Antimicrobials in agriculture and the environment: reducing unnecessary use and waste (PDF 0,75MB) Report from the UK Review on Antimicrobial Resistance that discusses the use of antibiotics in food animal production and suggests a series of interventions to reduce the use of antibiotics, release into the environment and spread of antibiotic resistance.
The costs and risks of AMR water pollution (PDF 1,54MB) Report developed by the World Economic Forum that provides an overview and a global risk assessment of AMR water pollution. Section 4 outlines possible interventions from the public and private sectors to address the impacts and risks of waterborne AMR.
Sanitation safety planning: Manual for safe use and disposal of wastewater, greywater and excreta Tool to assess risks and guide improvements in sanitation and waste management to protect public health on multiple levels. Contains six modules to guide the assessment process and an example of implementation in a hypothetical middle-income country. Available in English, Farsi, French, Japanese, Portuguese, Russian, Spanish.
Safe management of wastes from health-care activities: a summary Report by the WHO aimed at policymakers, practitioners, and facility managers to improve safe healthcare waste management. It is based on the WHO handbook Safe management of wastes from healthcare activities and considers relevant World Health Assembly (WHA) resolutions, other UN documents, and emerging global and national developments on WASH and IPC.
Reducing the environmental impact of medicines from procurement to disposal Report/Guide. Written from a health management perspective and focused on the stages of the medicines’ lifecycle that can be influenced by health managers. It describes the impact of medicines on the environment, as well as it exhibits case studies and related recommendations and best practices that health managers could put in practice to help reduce it.
Guidelines on sanitation and health Guidance and tools. Evidence-informed recommendations for maximizing health impact of sanitation interventions. Intended to guide international, national and local sanitation policies and programme actions and articulate and support the role of health authorities in this area. WHO has also developed sanitation inspection forms and management advise sheets.
Antimicrobial resistance: An emerging water, sanitation and hygiene issue Policy brief. Water and waste play a major role in combating antimicrobial resistance and is also an important element of the Global Action Plan. This briefing note developed by WHO provides an overview of antimicrobial resistance and WASH and proposes new directions for risk assessment management, policy and research.
Pharmaceuticals in the environment initiatives Database of initiatives and technology pilots in EU Member States to address pharmaceuticals in the environment and pharmaceutical waste (including in wastewater). Searchable by areas of interest (for example AMR), geographic area, country, etc. Curated by Health Care Without Harm Europe (Safer Pharma campaign).
Industrial Wastewater Treatment Technology Database (IWTT) Database of wastewater treatment technologies. Search for pilot and full-scale technologies by industry (such as hospital), treatment technology (such as UV), or pollutant (such as different antibiotics). Curated by the US EPA.