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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 June 4, 2021, reaffirmed their war on “superbugs” — microbes responsible for common illnesses that have become resistant to conventional treatments.

Antimicrobial resistance is a growing global threat that, if left unaddressed, will cause 10 million additional deaths per year, globally, by 2050, with a cumulative global economic cost of $100 trillion. The communique underlined the importance of a holistic “One Health” approach that 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 Program (UNEP), the Food & Agriculture Organization (FAO), the World Organization for Animal Health (OIE), and the World Health Organization (WHO) have joined forces to make a One Health approach central to their work. Most people in the field of infectious disease control and prevention are delighted by the commitment, collaboration, and hope provided for the future.

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 harboring 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 transportation to heating, ventilation, and air conditioning (HVAC) systems.

Transportation 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, particularly antimicrobial-resistant bacteria.

One Health: Three levels

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

1. Governance and leadership

1. Governance and leadership

Counter-measures against antimicrobial resistance will be guided by national action plans, which each country will develop and agree upon with the FAO-OIE-WHO-UNEP alliance.

National plans will be focused on the following:

  • Prioritizing and strengthening infrastructure to boost the health of populations (e.g., 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 are now widespread in concentrations that are nonlethal to microbes, allowing them to mutate into resistant strains
  • Legislation and regulation

2. Data and digital systems

2. Data and digital systems

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

Data will reveal the following:

  • 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 (e.g., plastic particulates in wastewater, which harbor and transmit germs)

Better data will enable better-targeted interventions: infrastructure development, investment in research, clinical facilities, health education programs, healthcare capacity building, or lockdowns. However, to achieve this, surveillance of antimicrobial resistance 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. Organizations 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

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 public spaces to encourage active travel such as cycling and walking; widescale tree planting and provision of more parks combined with low or zero-emissions public transportation 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: minimize access, minimize exposure time, minimize contact with shared surfaces, and optimize hygiene and sanitation. Infrastructure epidemiology applies particularly to transportation 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 from 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: Digitalization, including Internet of Things technology, enables wastewater flows to be monitored for antimicrobial-resistant 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 that addresses sewer flooding as well as surface water and fluvial flooding is essential.

      While the need to tackle antimicrobial resistance was already moving up the global agenda, the COVID-19 pandemic has emphasized 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 regulation and legislation affecting the planning, delivery, and operation of existing and new assets.

      Dr. Anthony Huszar, Account Leader, Global Health Security

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