Antimicrobial resistance and water, sanitation, and hygiene

Water quality has wide ranging implications for human health, as the use and consumption of unsafe water often acts as a route of transmission for many pathogens, including those that express antimicrobial resistant traits. The FAO states that water quality can be safeguarded directly through specific water protection and quality legislation. Adopting water quality policies allow countries to enforce standards that ensure that water being used for consumption and recreation are safe for human use, and that surface and groundwater sources are suitable to support the ecosystem. Thus, knowledge of which countries have legally binding water quality standards is valuable for understanding the role of policy in the relationship between water, human health, and the development of antimicrobial resistant pathogens.

Water contaminants include microorganisms, inorganic and organic chemicals and disinfection byproducts that may be associated with an increased risk of adverse health effects if ingested. Competent environmental authorities empowered to monitor contaminant residue concentrations and microbial contents in water sources may reduce risks of antimicrobial resistance development, as monitoring would allow authorities to identify and rapidly address water pollution with the antimicrobials that create selective pressures on microorganisms in the environment. Intergovernmental bodies, including the World Health Organization (WHO) and UN Water, endeavor to support member state governments in enacting policy for standardized water quality monitoring and reporting systems. The WHO provides health-based drinking-water quality targets with guideline concentration values for substances of concern. Likewise, UN Water provides a global monitoring and reporting dashboard to ensure reliable water quality data and support countries in meeting Sustainable Development Goal 6. Analyzing the global policy landscape that governs environmental monitoring provides insight into _if _and _how _water quality, and, by extension, the presence of conditions favorable to the development of antimicrobial resistance, is assessed and reported across the globe.

Point-source pollution is contamination of a water body due to chemical discharges from a single source. Interventions to reduce point-source pollution, often resulting from industrial and agricultural activities, include limiting hazardous waste disposals and recycling waste receptacles. Policies addressing point-source pollution may act as foundational regulatory frameworks for decision-makers working to take action against AMR in their country. Thus,  identifying each countries’ policies on the disposal of pollutants in water sources will allow for an understanding of global preparedness to address AMR through legal action.

In 2019, a highly regarded paper established a link between untreated domestic sewage, which comes from household and community sources, and the transmission of antimicrobial resistant microorganisms. The study took samples from 60 countries, representative of all WHO regions, and found that microbes with genomes containing AMR genes were found in nearly all samples, though relative abundance varied greatly across countries and continents. Moreover, they concluded that untreated domestic sewage that is improperly disposed of or leached from sewerage systems may act as a route of transmission for antimicrobial resistance (Hendriksen et al., 2019). Thus, adequate sanitation infrastructure and regulation may contribute to lowering the burden of AMR. Knowledge of the global policy environment for sewerage systems facilitates global assessments of the risks of AMR transmission through human sewage, but also provides examples of how countries have taken legislative action to mitigate this threat.

Wastewater has been identified as a significant environmental reservoir for antimicrobial resistant microorganisms (Nguyen et al., 2021). In some instances, wastewater effluent from pharmaceutical manufacturing sites have been found to contain high concentrations of broad-spectrum antibiotics, which, when released into the environment, create the selective pressures that drive the evolution of antimicrobial resistance in the aquatic environment (Larsson et al., 2007).  Identifying policies that regulate the disposal of wastewater from hospitals, medical centers, pharmaceutical production facilities or other establishments where antimicrobials are produced, stored or used is critical to understanding the likelihood of microorganisms in the surrounding environment developing antimicrobial resistance. However, in the majority of countries, wastewater and medical or pharmaceutical waste are regulated under different policies. Therefore, knowing which countries have policies in place to regulate the treatment and disposal of wastewater into water bodies will prove valuable for understanding the substances discharged into a country’s water sources. Likewise, this subtopic will inform broader research on policies regulating effluents from facilities that specifically handle, produce and use antimicrobial substances.

Medical and pharmaceutical waste, which contains both solid and liquid waste from medical care facilities, as well as discarded medical countermeasures, can pose a risk to human and environmental health when improperly disposed of. Infectious solid waste, liquid wastewater from hospitals and unused antibiotics are of particular concern, as these forms of healthcare waste have been identified as drivers of AMR development when their disposal is unregulated. Thus, mapping medical waste management policies will inform the analysis of varied regulatory approaches that affect the relationship between medical waste disposal, the environment, and the development of antimicrobial resistance. More broadly, this subtopic will facilitate research on policies regulating the disposal of solid wastes and liquid discharges from facilities specifically handling, producing, and using antimicrobial substances.