Pharmaceutical Release into the Environment during Pandemics and Regional Epidemics

政府间气候变化专门委员会指出，人口增长和气候变化可能加剧未来流行病和大流行病的风险。鉴于这些新的社会压力，国家和国际组织在制定药品防范计划方面都作出了重大努力。流行病和大流行药物的使用与常规使用不同，因为35%以上的人口将受到感染，并可能使用一种或多种药物进行治疗。大流行期间的“大剂量”药物对污水处理厂的运行、河流水生系统和人类健康造成了前所未有的、基本上没有特征的风险。目前的药品法规是基于常规条件下预期的预测使用模式，而不是基于大流行或流行病期间。在目前的流感大流行风险出现之前，常规使用和大规模使用之间的区别并没有引起关注，为此正在储存大量的“季节性流感”抗病毒药物（即达菲）。在发生大流行性流感的情况下，预计将使用空前数量的一套药品来治疗感染者并限制大流行性流感在未感染者中的传播。每种药物都有一系列独特的潜在生态目标，包括人类。此外，混合废物流所带来的风险不能通过其组成部分的生态毒理学知识来预测。可以说，最重要的服务可能被高浓度生物活性化学品的涌入所破坏，这就是污水处理厂。关于高浓度抗生素对STW的操作和完整性的影响，我们知之甚少。同样，也没有关于抗病毒药物对STW或环境影响的同行评议研究。目前H5N1病毒无法在人与人之间传播，英国皇家学会和世界上大多数专家认为这是不可避免的，这为我们提供了一个宝贵的、可能短暂的机会窗口，以评估我们目前的药物准备计划的风险，并相应地进行调整。拟议的倡议将为科学理解大流行和流行病期间广泛使用药物的命运和影响奠定基础，并为成员组成的多学科网络不仅能够应对和适应流感大流行，而且能够应对在不久的将来可能出现的其他流行病和大流行提供基础。在其头三年，准备行动将：-开发和发布一个在线知识和网络工具，以整合现有信息来源，帮助评估大流行病和流行病条件下环境中与药品有关的风险。这将为寻求这类信息的人提供一种机制，使他们能够迅速找到最佳资源，并帮助解释现有的知识。-举办五次查明知识差距讲习班，讨论在大流行病和流行病条件下评估药物向环境释放的关键专题。-为同行评审的期刊和相关专业机构的内部刊物撰写文章，描述“预备计划”正在处理的问题，解释网上资源，并报告初步调查结果。将创刊一期特刊。-举办会议，报告“预备计划”头三年的成果，以促进进一步的知识转移，并就该计划的长期运作达成共识。-确定在政策制定和监管中使用科学知识可以吸取的教训，并就此发表一份报告。

The Intergovernmental Panel on Climate Change states that population growth and climate change are likely to intensify the risk of future epidemics and pandemics. In light of these new societal pressures, there has been a significant push from both national and international organizations in the establishment of pharmaceutical preparedness plans. Epidemic and pandemic pharmaceutical usage differs from conventional usage in that upwards of 35% of the population will be infected and potentially treated with one or more pharmaceuticals. The 'bolus' of pharmaceuticals during a pandemic creates unprecedented and largely uncharacterised risks to the operation of sewage treatment plants, riverine aquatic systems and human health. Current regulations on pharmaceuticals are based on intended predicted use patterns under conventional conditions, rather than during a pandemic or epidemic. The distinction between conventional and large scale usage has not been of concern prior to the emergence of the current risk of pandemic influenza, for which large quantities of 'seasonal influenza' antivirals (i.e. Tamiflu) are being stockpiled. In the event of pandemic influenza, unprecedented quantities of a suite of pharmaceutical products are expected to be used to treat the infected and limit the spread of pandemic influenza among the uninfected. With each pharmaceutical comes a unique array of potential ecological targets, including humans. Moreover, the risks posed by a mixed waste stream can not be predicted by knowledge of the ecotoxicology of its constituent parts. Arguably the most critical service that could be disrupted by the influx of high concentrations of biologically-active chemicals is sewage treatment works (STW). Little is known regarding the effect of high concentrations of antibiotics on the operation and integrity of STW. Similarly, there is no peer-reviewed research on the effect of antivirals on STW or the environment. The current inability of the H5N1 virus to transmit from human-to-human, which is considered inevitabile by The Royal Society as well as most of the world experts, provides us with a valuable and possibly brief window of opportunity to assess the risks of our current pharmaceutical preparedness plan and adapt it accordingly. The proposed Initiative will provide a foundation of scientific understanding of the fate and effect of widespread pharmaceutical use during a pandemic and epidemic and a multi-disciplinary network of members capable of responding and adapting to not only an influenza pandemic, but the likely emergence of other epidemics and pandemics in our immediate future. During its first three years the PREPARE Initiative will: - develop and publish an on-line knowledge and networking tool to integrate existing information sources that help in the assessment of risks associated with pharmaceuticals in the environment under pandemic and epidemic conditions. This will provide a mechanism for those seeking such information to be rapidly guided to the best resource and help in interpretation of available knowledge. - run five knowledge gap identification workshops, for the discussion of key specialist topics in the assessment of pharmaceutical release into the environment under pandemic and epidemic conditions. - prepare articles for both peer-reviewed journals as well as the house publications of relevant professional organisations, describing the issue being addressed by the PREPARE Initiative, explaining the on-line resource and reporting on preliminary findings. A special journal issue will be initiated. - run a conference to report on outputs of the PREPARE Initiative during its first three years, to facilitate further knowledge transfer and gather consensus on the longer-term life of the initiative. - identify the lessons that can be learned on the use of scientific knowledge in policy making and regulation and publish a report on this.