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Infrastructure: a frontline in the fight against superbugs

Experts agree that a holistic approach encompassing human, animal, plant and environmental health is the only way to effectively fight antimicrobial resistance. Dr Anthony Huszar sees infrastructure as another key battleground.

A communique from the health ministers of the Group of Seven (G7) advanced economies on 4 June 2021 reaffirmed their war on ‘superbugs’ – microbes responsible for common illnesses which have become resistant to conventional treatments. Antimicrobial resistance (AMR) is a growing global threat that, if left unaddressed, will cause 10M additional deaths per year, globally, by 2050, with a cumulative global economic cost of US$100trn. The communique underlined the importance of a holistic ‘One Health’ approach which views human, animal, plant and environmental health as interlinked.

“We encourage close coordination and collaboration including full integration of environmental and ecosystem work,” the G7 health ministers said. “This is crucial in order to improve the international system’s ability to prevent, detect, report and respond to current and future health threats, including by promoting transparency and facilitating the rapid sharing of data, samples and information.”

The United Nations Environment Programme (UNEP), the Food & Agriculture Organization (FAO), the World Organisation for Animal Health (OIE) and the World Health Organization (WHO) have joined forces to make a One Health approach central to their work. Most in the field of infectious disease control and prevention are rightly delighted by the commitment, collaboration, and hope provided for the future.

But in addition to human, animal, plant and environmental health, One Health should also encompass the built environment and infrastructure. From the poorest nations to the richest, pollution and degradation of the natural environment cuts lives short and contributes to a wide swathe of illnesses. Much of that pollution and degradation arises from building, operating and using infrastructure.

Infrastructure also plays a part in harbouring germs and spreading infection, as illustrated by the COVID-19 pandemic, which was spread via everything from escalator handles, the buttons of ATM cash dispensers and grab rails on public transport to heating, ventilation and air conditioning (HVAC) systems. Transport systems circulated the coronavirus around the world in a matter of weeks. While COVID-19 is caused by a virus, similar transmission pathways should be considered for bacterial infections and in particular antimicrobial resistant bacteria.

One Health: three levels

A One Health approach to tackling AMR can be divided into three operational levels, affecting the infrastructure industry in different ways:

1. Governance and leadership

AMR counter-measures will be guided by national action plans, which each country will develop and agree with the FAO-OIE-WHO-UNEP alliance.

National plans will be focused on:

prioritising and strengthening infrastructure to boost the health of populations (eg expanding water and sanitation provision)
surveillance systems for antibiotic resistance and use
tightening the use of antimicrobials in humans, animals and plants
monitoring the environment where these drugs end up and are now widespread, in concentrations that are non-lethal to microbes, allowing them to mutate into resistant strains
legislation and regulation

2. Data and digital systems

Accurate data collection and analysis are key to delivering each country’s AMR national action plan.

Data will reveal:

the role played by infrastructure in disease transmission
disease trends and distributions
the patient and healthcare system outcomes arising from different treatments
how drug use affects infectious disease rates
antimicrobial levels in solid waste and wastewater
the impacts of antimicrobial use in agriculture
correlations with other factors (eg plastic particulates in wastewater, which harbour and transmit germs)

Better data will enable better-targeted interventions: infrastructure development, investment in research, clinical facilities, health education programmes, healthcare capacity building or lockdowns. However, to achieve this, AMR surveillance must be strengthened, with work needed to connect data between sectors, regions and countries for added insight.

More work is also needed to understand the interactions between human, animal and environmental health. There are opportunities for some in our sector to provide the connectivity, digital platforms and tools needed to produce and manage this data. Organisations right across the infrastructure sector will need to produce much better data than they do today, to shine a light on their own contributions to One Health.

3. Asset operation

There are many ways that a One Health approach affects new and existing infrastructure. The most far-reaching involves designing towns and cities to achieve population-wide health improvements.

These involve planning streets and the public realm to encourage active travel such as cycling and walking; widescale tree-planting and provision of more parks combined with low or zero-emissions public transport and reduced private car use to improve air quality; upgrading existing buildings and designing new ones to be thermally efficient, protecting people from extreme heat and cold; eliminating toxic materials from building fittings and furniture. The result: people who will be less likely to become ill and require antibiotics

The COVID-19 pandemic gave rise to a new discipline, infrastructure epidemiology, which applies four core principles to reduce disease transmission: minimise access, minimise exposure time, minimise contact with shared surfaces, and optimise hygiene and sanitation. Infrastructure epidemiology applies particularly to transport and buildings – especially hospitals, schools, universities, transportation terminals and stations, supermarkets and offices. Design, operation, facilities management, asset management and user information all offer opportunities to stop diseases spreading.

Other examples:

Clean water and sanitation: ensuring universal provision delivers a cascade of benefits, with improved hygiene reducing risk of infection, which results in fewer hospital visits and reduced use of antimicrobial drugs.
Wastewater management: digitalisation, including internet of things technology, enable wastewater flows to be monitored for AMR bacteria and antimicrobial compounds. Innovation is needed to find ways of removing antimicrobial drugs from sewage.
Waste management: antimicrobial waste – predominantly unwanted drugs thrown out by households, hospitals, industry and farmers – ends up in the environment. Education and convenient disposal infrastructure are required.
Flood management: infectious disease outbreaks are common after major flooding incidents. Improved protection addressing sewer flooding as well as surface water and fluvial flooding is essential.

While the need to tackle AMR was already moving up the global agenda, the COVID-19 pandemic has emphasised the risk posed by infectious diseases. One Health principles are far-reaching and we should expect to see them permeating many areas of government policy.

Because infrastructure has such a profound impact on human health, we should expect that One Health will impact on regulation and legislation affecting the planning, delivery and operation of existing and new assets.

Dr Anthony Huszar, account leader – global health security

Infrastructure: a frontline in the fight against superbugs

One Health: three levels

This is the future