The environmental dimension of antimicrobial resistance: the transition from policy formation to implementation

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Prof Dame Sally Davies, the previous Chief medical officer and current UK Special Envoy on Antimicrobial Resistance (AMR) said that if antimicrobial drugs lose their effectiveness it would spell "the end of modern medicine". It has been estimated that by 2050, 10 million deaths a year will be attributable to AMR, more than seven times the current mortality caused by the COVID-19 pandemic. The global economic cost of AMR infections is estimated at a trillion US dollars by 2050. There is a growing consensus that AMR must be tackled using a One Health approach, ie. that human and animal health must be considered in relation to the environment. We know that resistance mechanisms bacterial pathogens acquire can originate in environmental bacteria that have evolved resistance over evolutionary time. Bacteria are unusual in that they can pass on genetic material (genes) horizontally, including to different species, rather than the vertical transfer of genes from parents to offspring that occurs in most animals and plants. It should also be remembered that many antimicrobials used as drugs are produced naturally by bacteria and fungi, so predate human antimicrobial usage. It is therefore not surprising that there is a vast reservoir of AMR genes present in environmental bacteria. In addition to this "natural" reservoir of AMR bacteria and genes, human and animal waste also introduces AMR bacteria and antimicrobials to the environment, where further evolution of resistance can take place with associated risks of environmental transmission to humans. This Knowledge Exchange (KE) Fellowship will build on previous work by Professor Will Gaze and colleagues that has informed international, EU and UK policy on AMR. It will focus on informing planning and implementation of environmental AMR surveillance with the Department for Environment, Food and Rural Affairs (Defra) and the Environment Agency (EA). In addition, KE will take place with the water industry who are focusing on this subject, due to efforts to reduce risk associated with AMR bacteria and antimicrobial residues in human waste which can reach aquatic environments with associated transmission risk to humans. The European Union Water Framework Directive is focusing on risks posed by aquatic residues of certain antimicrobials, and this may translate into regulation of discharge to rivers and coastal areas. KE will also take place with the pharmaceutical industry who are keen to ensure that their drugs do not pose an environmental risk in terms of driving further increases in AMR. This is also important in safeguarding the activity of our remaining useful antimicrobial drugs. The combination of KE with Defra, EA water and pharmaceutical industries provides opportunities for cross-sectoral development of ideas, and in this phase of KE, moving towards implementation of new strategy and policy.