Human-use antibacterial residues in the natural environment of China: implication for ecopharmacovigilance

Future Healthcare Workers and Ecopharmacovigilance: Where Do We Stand?

With the rapid development of the pharmaceutical industry and constant growth of drug usage, ecopharmacovigilance (EPV) has emerged as a way of coping with and minimizing the effects that drugs have on the environment. EPV concerns and describes unwanted effects that the use of a specific drug could have on the environment. The US, EU and Cananda are the improving position of EPV, both in legislation and practice. EPV requires further development as previous studies have shown that neither the general population nor healthcare professionals have enough knowledge about the subject. Improving awareness and knowledge about this topic is a key task for the future of EPV. The main objective was to determine students' level of knowledge about ecopharmacovigilance and to examine ways of storing and disposing of unused and expired drugs. Students' knowledge and habits were examined by a previously published survey. The survey contains twenty questions divided into three parts and the possibility of writing an additional note. There was no difference in the level of knowledge between the students of different studies. Also, students who had a family member working as healthcare professional did not show a higher level of knowledge compared to the others. Pharmacy students had a greater intention to educate their environment about EPV when compared to students of the other studies. This is in the line with a previous study which showed that the general public expects that pharmacists and physicians educate them about EPV. Medicine and dental medicine students will become prescribers after finishing their studies, and as such, they should be informed about eco-directed sustainable prescribing (EDSP) as part of an EPV strategy. More than half of the participants reported good adherence to prescribers' instruction, which decreased the amount of unused drugs. Most of the students found that the drug expiration date was legible, but they did not check it often. In comparison with similar studies, Croatian students had more knowledge and better practices concerning EPV and drug disposal. Structured learning strategies and curriculum implementation for EPV are much needed for further raising awareness about the subject among healthcare professionals and the public.

Land-derived wastewater facilitates antibiotic resistance contamination in marine sediment of semi-closed bay: A case study in Jiaozhou Bay, China

The emergence of antibiotic resistance is a severe threat to public health. There are few studies on the effects of sewage discharge on antibiotics and antibiotic resistance genes (ARGs) contamination in Jiaozhou Bay sediment. Herein, a total of 281 ARG subtypes, 10 mobile genetic elements (MGEs), 10 antibiotics and bacterial communities in marine sediments from Jiaozhou Bay were characterized. Similar bacterial community structures and ARG profiles were identified between the various sampling sites inside the bay, which were both dominated by multidrug and (fluoro)quinolone resistance genes and harbored lower relative abundances of ARGs than those in the sampling sites near the bay exit. Compared with antibiotics and MGEs, bacterial community composition was a more important driver of ARG diversity and geographic distribution. The abundance of pathogens carrying genetic information increased dramatically in southern Jiaozhou Bay is affected by sewage discharge, which indicating that wastewater discharge facilitated ARG contamination of marine sediments. This study highlights the risk of disseminating antibiotic resistance-influencing factors from treated wastewater discharge into marine environment there is an urgent need to optimize or improve wastewater treatment processes to enhance the removal of antibiotics and ARGs. This study has necessary implications for filling the gap in information on antibiotic resistance in Jiaozhou Bay and developing future pollution regulation and control measures.

Medical Household Waste as a Potential Environmental Hazard: An Ecological and Epidemiological Approach

Nowadays, the contamination caused by emerging pollutants is a global concern due to the lack of scientific evidence to demonstrate the risk or toxicity to humans due to the presence of pharmaceutical residues in the environment. This study aimed to identify and describe the disposal practices of unused and unwanted medications, as well as to analyze and identify the most frequent drugs determined on water bodies adjacent to the biggest urban population in Mexico. A two-phase study with an epidemiological and an ecological assessment was performed. The epidemiological phase was carried out with a descriptive cross-sectional study among citizens from Mexico City and the metropolitan area using an electronic survey applied to 719 subjects aimed to assess practices in which pharmaceutical products are disposed. The ecological phase included a review of scientific reports. The results show that nearly 83.5% of those surveyed use inappropriate practices for disposal medicines, the main ones are through the municipal dump or directly in the drain. The ecological approach was carried out by a systematic literature review of original reports published between 2013 to 2023; information about the class of drugs, active substance, environmental compartments, location, and concentration was extracted and presented. Fifty-one different types of pharmaceutical residues were detected in wastewater in Mexico City in the last decade. The results of this study can contribute to the application of public policies for waste management authorities to mitigate the socio-environmental risks due to the inappropriate disposal of medicines.

Domestic Waste and Wastewaters as Potential Sources of Pharmaceuticals in Nestling White Storks (Ciconia ciconia)

Information on the exposure of wild birds to pharmaceuticals from wastewater and urban refuse is scarce despite the enormous amount of drugs consumed and discarded by human populations. We tested for the presence of a battery of antibiotics, NSAIDs, and analgesics in the blood of white stork (Ciconia ciconia) nestlings in the vicinity of urban waste dumps and contaminated rivers in Madrid, central Spain. We also carried out a literature review on the occurrence and concentration of the tested compounds in other wild bird species to further evaluate possible shared exposure routes with white storks. The presence of two pharmaceutical drugs (the analgesic acetaminophen and the antibiotic marbofloxacin) out of fourteen analysed in the blood of nestlings was confirmed in 15% of individuals (n = 20) and in 30% of the nests (n = 10). The apparently low occurrence and concentration (acetaminophen: 9.45 ng mL−1; marbofloxacin: 7.21 ng mL−1) in nestlings from different nests suggests the uptake through food acquired in rubbish dumps rather than through contaminated flowing water provided by parents to offspring. As with other synthetic materials, different administration forms (tablets, capsules, and gels) of acetaminophen discarded in household waste could be accidentally ingested when parent storks forage on rubbish to provide meat scraps to their nestlings. The presence of the fluoroquinolone marbofloxacin, exclusively used in veterinary medicine, suggests exposure via consumption of meat residues of treated animals for human consumption found in rubbish dumps, as documented previously at higher concentrations in vultures consuming entire carcasses of large livestock. Control measures and ecopharmacovigilance frameworks are needed to minimize the release of pharmaceutical compounds from the human population into the environment.

Safe Disposal of Unused Medicine among Health Professions Students at Makerere University: Knowledge, Practices and Barrier

Background

Environmental contamination with antimicrobial agents is one of the leading drivers of antimicrobial resistance (AMR) worldwide. However, scarce data exists concerning the factors fueling unsafe disposal of medicines globally. This study aimed to assess for the knowledge, practices, and barriers concerning safe disposal of unwanted medicines among health professions students (HPS) at Makerere University, Uganda.

Methods

We conducted a cross-sectional study using an online assessment tool sent through WhatsApp groups and E-mail addresses of undergraduate HPS at the College of Health Sciences Makerere University, Uganda between 1stFebruary and 16thMarch 2022.Good knowledge was defined as a score of 80% of the knowledge domain questions on a standardized questionnaire.

Results

We enrolled 205 participants, 135 (65.9%) were male, with a median age of 23 (range: 19 -43) years. Overall, 157 (76%) participants had good Knowledge. The mean knowledge score was 63%. About half (n=102, 49.8%) of the participants had unused medicines kept at their respective residential places, mainly antibiotics (27%, ×/102) and analgesics (21 %, ×/102). The most common method of medicine disposal was dumping into household garbage (n=103, 50.2%). Only 37 (18%) of participants had ever used the take-back method of medicine disposal. The most reported barriers for safe disposal were inadequate knowledge and insufficient advice from the dispensers concerning safe disposal practices. Year of study was the only factor significantly associated with knowledge about safe disposal of medicines, (adjusted Odds Ratio: 9.7, 95%CI 2.3 - 40.5, p= 0.002), with participants in higher academic years having more knowledge than those in lower years.

Conclusion

Despite a good knowledge level among the participants, the practice of safe disposal of unused medicines remains suboptimal in this population. Strategies aimed at enhancing safe disposal practices such as giving proper instructions to medicine buyers by dispensers regarding disposal practices are recommended to abate the growing burden of AMR.

Attitudes and opinions about ecopharmacovigilance from multi-disciplinary perspectives: a cross-sectional survey among academic researchers in China

As a promising upstream strategy to reduce the environmental loads of pharmaceutical emerging contaminants (PECs) through source control, ecopharmacovigilance (EPV) is concerned with the set of activities to identify, evaluate, understand, and prevent against diverse PEC-related problems, and has been accepted as a multi-disciplinary and multi-stakeholder system. This cross-sectional observational survey aimed to assess the attitudes and opinions about EPV from multi-disciplinary perspectives among Chinese academic professors from four main EPV-related disciplines including pharmacy, management, clinical medicine, and environmental and ecological science based on a self-developed questionnaire. Forty-two usable survey instruments were acquired. Results showed that the responding Chinese academic researchers from different disciplines expressed consistently positive attitudes and strong intentions for EPV, in spite of several disparities existing among disciplinary groups showing that pharmacy and medical researchers felt more certain of the environmental adverse effects of PECs, and researchers in pharmacy and environmental and ecological science were more interested in EPV. A multi-disciplinary consensus was achieved in regard to the types of key stakeholders in EPV practices including the pharmaceutical manufacturers, the public, the drug safety authority, hospitals, and the environmental protection agency. The main roles and responsibilities of each stakeholder identity in EPV practices were summarized based on the expert opinions.

A dataset of distribution of antibiotic occurrence in solid environmental matrices in China

While there is growing global concern about the impact of antibiotic residues on emergence and enhancement bacteria’s resistance, toxicity to natural organisms, and, ultimately, public health, a concise picture of measured environmental concentrations of antibiotic occurrence in multiple environmental matrices, particularly in solid matrices (e.g., sludge, soil, and sediments) is still elusive, especially for China. In this paper, we present an up-to-date dataset of the distribution of antibiotic occurrence in solid environmental matrices in China, derived from 210 peer-reviewed literature published between 2000 and 2020. We extracted geographical sampling locations and measured concentration associated with antibiotic occurrence reported in English and Chinese original publications, and applied quality-control procedures to remove duplicates and ensure accuracy. The dataset contains 6929 records of geo-referenced occurrences for 135 antibiotics distributed over 391 locations distinguished at four levels of scale i.e., provincial, prefectural, county, and township or finer. The geographical dataset provides an updated map of antibiotic occurrence in solid environmental matrices in China and can be used for further environmental health risk assessment.

Measurement(s)	Scientific Publication
Technology Type(s)	digital curation
Factor Type(s)	location • matrices • antibiotics
Sample Characteristic - Environment	solid environmental material
Sample Characteristic - Location	China

Management of pharmaceutical micropollutants discharged in urban waters: 30 years of systematic review looking at opportunities for developing countries

Pharmaceutical micropollutants' contamination of urban waters has been studied globally for decades, but the concentration of innovations in management initiatives is still in developed economies. The gap between the locus of innovations in pharmaceuticals and the relative stagnation in less developed economies to manage waste originating in this activity seems fruitful for investigations on innovation in integrated micropollutant management strategies. These tensions allow for advances in current knowledge for environmental management and, particularly, finding solutions for the contamination by pharmaceutical micropollutants of urban water bodies in developing countries. We aim to list the main strategies for managing pharmaceutical micropollutants discussed to point out opportunities for developing countries to advance in this direction. Methodologically, we conducted a systematic literature review from 1990 to 2020, covering 3027 documents on "pharmaceutical micropollutants management." The framework formed by the macro-approach to integrated management operationalized by the dimensional micro-approaches: technical, organizational, community, and governmental allowed us to understand that (1) the management of pharmaceutical micropollutants tends to occur through a technical approach centered on the removal of aquatic matrices, green chemistry, and urine diversion; (2) management with an organizational approach has enabled removing drugs from water bodies by drug take-back program, collaborative projects, drug use reduction, and better organizational practices; (3) the community approach have helped minimize this type of pollution by reducing the consumption of medicines and the proper destination for medicines that are no longer in use. Finally, the government management approach emerges as a source of legal, economic, and informational instruments to reduce pollution by pharmaceutical micropollutants. Furthermore, these management approaches allowed us to identify 15 opportunities for possible adjustments for developing societies. These opportunities can be promising for practices and research and, in the medium term, contribute to minimizing pollution by pharmaceutical micropollutants in urban waters.

Cleaning up China's Medical Cabinet-An Antibiotic Take-Back Programme to Reduce Household Antibiotic Storage for Unsupervised Use in Rural China: A Mixed-Methods Feasibility Study

: Background: Antibiotic misuse and unsafe disposal harm the environment and human health and contribute to the global threat of antimicrobial resistance. Household storage of antibiotics for unsupervised use and careless disposal of medications is a common practice in China and most low- and middle-income countries. Currently, few interventions are available to address this challenge.

OBJECTIVE

This study assesses the feasibility and acceptability of an evidence-based, theory-informed, community-based take-back programme for disposing household's expired, unwanted, or unused antibiotics in rural China.

METHODS

We adopted the RE-AIM framework and the community-based participatory research principles in the development, implementation, and evaluation of the intervention. The RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) and Medical Research Council's frameworks were employed in analysing and reporting evaluation results. A mixed-methods, controlled pre-and post-test design was used for 1) quantitative surveying of a representative community panel of 50 households, and 2) qualitative semi-structured stakeholders' interviews to explore intervention and study design feasibility and acceptability at three phases: pre-intervention, intervention, and post-intervention. Quantitative and qualitative data from a similar village-serving as a control-were also collected.

RESULTS

All a priori feasibility objectives were met: Conversion to consent was 100.0% (100 screened, approached, recruited, and consented). All participants completed the pre-intervention assessment, and 44/50 households in the intervention village completed the post-intervention assessment. The programme, embedded in existing social and physical infrastructure for dissemination, directly reached over 68.2% (30/44) of its target audience. Stakeholders reported the intervention and study design as feasible and acceptable.

CONCLUSIONS

This study illustrates the feasibility, acceptability, and potential efficacy of community-based antibiotic take-back programmes in China to encourage safe disposal and decrease the availability of expired, unwanted, or unused antibiotics in the household for unsupervised use.

Using a targeted ecopharmacovigilance intervention to control antibiotic pollution in a rural aquatic environment

The "targeted ecopharmacovigilance (EPV)" strategy emphasizes the control of environmental pollution by high-priority hazardous pharmaceuticals from principal pollution sources especially in areas that are high risk as a result of drug administration. We conducted a prospective empirical study to explore the possibility of using a targeted EPV intervention as an optimized management tool for the control of aquatic pollution by antibiotics, a common type of pharmaceutical residue, in a rural area in China. Because of the notably high levels of ofloxacin in the studied aquatic environment and the well-accepted environmental risks posed by fluoroquinolone residues, ofloxacin was selected as the targeted high-priority antibiotic pollutant. Based on the main sources of antibiotic pollution in the studied rural aquatic environment, which had been traced previously, a five-step targeted EPV intervention was designed and conducted from Feb 2018 to Jan 2019. The results showed that the residual levels of ofloxacin in the studied Chinese rural aquatic environment significantly decreased during the targeted EPV intervention. Importantly, the EPV measures targeting ofloxacin were found to effectively reduce the environmental pollution by other non-targeted antibiotics. The data from a survey of 45 participants (42 residents and 3 clinicians) and 12 program committee members revealed that the targeted EPV intervention was acceptable to both participants and organizers and could be used as an economical and feasible solution for addressing antibiotic pollution in aquatic environments.

Characterization of plasmid mediated quinolone resistance determinants in ciprofloxacin resistant-Escherichia coli from chicken meat produced by integrated broiler operations in Korea

The purpose of this study was to determine the genetic characterization of ciprofloxacin resistant- Escherichia coli recovered from 7 different integrated broiler operations in Korea. Among the 157 E. coli isolated from chicken meat produced by integrated broiler operations, 75 (47.8%) were observed to be ciprofloxacin resistant-E. coli. However, the prevalence varied from 25.0 to 75.0%, in chicken meat, indicating variation in ciprofloxacin resistant E. coli occurrence among the operations. Among the 75 ciprofloxacin resistant-E. coli isolates, 10 showed plasmid-mediated quinolone resistance (PMQR) genes, aac(6')-Ib-cr, qnrS1 and qnrB4. Among the 10 PMQR-positive E. coli, a double amino-acid exchange in both gyrA and parC with ciprofloxacin minimum inhibitory concentrations of ≥16 μg/mL was noted in 8 isolates, and 4 transconjugants (40.0%) expressed similar antimicrobial resistance patterns and revealed the presence of PMQR genes and β-lactamase genes. Our findings suggest that E. coli with resistance to ciprofloxacin can now be found in association with integrated broiler operations, thus highlighting the need for monitoring and prevention programs in integrated operations.

Attitudes and Practice Regarding Disposal for Unwanted Medications among Young Adults and Elderly People in China from an Ecopharmacovigilance Perspective

Due to the expensive cost and uncertain effectiveness of environmental management options in eliminating pharmaceutical residues, recently, decreasing the emission of pharmaceutical pollutants from a drug administration perspective has been considered a hot area of research. As a kind of drug administration for the environment, ecopharmacovigilance (EPV) emphasizes the source control of pharmaceutical pollutants. Disposal of unwanted medicines has been considered as the easiest target for source control of pharmaceutical contamination. Here, we focused on public attitudes and practice regarding disposal of unwanted medicines from the EPV perspective among 365 Chinese university young adults and 206 elderly retirement home residents. The results showed that the majority of respondents had positive attitudes, but exhibited inadequate awareness and poor practice. In addition, the young-adult respondents were found to pay more attention to the environmental problems posed by pharmaceutical residues, and be more supportive of the EPV intervention predominantly performed by pharmaceutical industries and pharmacists. Therefore, it is urgent to establish the standard medicine disposal protocols and educate the general public on the best way for medication disposal under the principle of EPV in China, and efforts on environmentally-preferred drug disposal under EPV should target for the specific demographics.

Comparison of the occurrence of antibiotic residues in two rural ponds: implication for ecopharmacovigilance

As a well-accepted drug-administration strategy for the minimization of environmental risks posed by pharmaceutical residues, ecopharmacovigilance (EPV) needs to guard against and control the pharmaceutical pollution sources. However, the underlying routes by which pharmaceuticals reach the environment vary significantly under different scenes, so it is necessary to implement different EPV measures in different backgrounds. This study detected the occurrence of antibiotic residues in two ponds within a Chinese rural community; assessed their ecological risks; compared and analyzed the geographic and demographic information, as well as the antibiotic-related anthropogenic behaviors of residents living around ponds, in order to trace the main entrances of antibiotics into the water environment; and then propose the EPV measures according to rural conditions. The results showed that the pollution degree of antibiotic residues was different between two studied ponds, which was manifested by the different antibiotic types and levels in water samples. And the possible main sources of antibiotic pollution in the studied rural water environment might include the application of human excretions and animal manures as fertilizers on the farmland, antibiotic use and inappropriate disposal in the clinic, and the direct disposal of the leftover antibiotics. From the perspective of drug administration, we then identified some suggestions on EPV measures which could be taken under existing rural conditions, including encouraging eco-directed sustainable prescribing of antibiotics in human and animals, improving take-back collection of unused antibiotics, building monitoring mechanism for antibiotic residues in the natural environment, identifying high-priority antibiotic residues, and implementing targeted EPV.

Adapting and applying common methods used in pharmacovigilance to the environment: A possible starting point for the implementation of eco-pharmacovigilance

Now, the occurrence of pharmaceuticals in natural environment has been frequently reported around the world. As a kind of biologically active compounds specially designed to be effective even at very low concentration levels, pharmaceuticals in the environment could have adverse impacts to the health of human beings or other non-targeted organisms due to long-term exposures. To minimize the pharmaceutical pollution from the perspective of drug administration, a new concept called as eco-pharmacovigilance (EPV) has been proposed as a kind of pharmacovigilance(PV) for the environment. However, as a new and comprehensive science, EPV has not sophisticated methods in practice and formalized implementation model up to now. Since EPV is a special kind of PV, it could be feasible to draw on the experience of PV as a possible and reasonable starting point for EPV. In this paper, we discussed the common methods and activities used in PV including spontaneous reporting, intensive monitoring, database studies, and their potential applicability to the environment. And we concluded that these common methods in PV could be adapted and applied to EPV. But there is still the need for organizational, technical and financial supports of the EPV system.

Implementing ecopharmacovigilance (EPV) from a pharmacy perspective: A focus on non-steroidal anti-inflammatory drugs

Environmental experts have made great efforts to control pharmaceutical pollution. However, the control of emerged environmental problems caused by medicines should draw more attention of pharmacy and pharmacovigilance researchers. Ecopharmacovigilance (EPV) as a kind of pharmacovigilance for the environment is recognized worldwide as crucial to minimize the environmental risk of pharmaceutical pollutants. But continuing to treat the pollution of pharmaceuticals as a group of substances instead of targeting individual pharmaceuticals on a prioritized basis will lead to a significant waste of resources. Considering vulture population decline caused by non-steroidal anti-inflammatory drugs (NSAIDs) residues, we presented a global-scale analysis of 139 reports of NSAIDs occurrence across 29 countries, in order to provide a specific context for implementing EPV. We found a heavy regional bias toward research in Europe, Asia and America. The top 5 most frequently studied NSAIDs included ibuprofen, diclofenac, naproxen, acetaminophen and ketoprofen. The profile of NSAIDs was dominated by acetaminophen in wastewater influents and effluents. Ibuprofen was the most abundant NSAID in surface water. Only 9 NSAIDs were reported in groundwater samples. And majority of NSAIDs were detected in solid matrices at below 1μg/g except for ketoprofen, diclofenac and ibuprofen. From a pharmacy perspective, we get some implication and propose some management practice options for EPV implementation. These include: Further popularizing and applying the concept of EPV, together with developing relevant regulatory guidance, is necessary; More attention should be paid to how to implement EPV for the pollution control of older established drugs; Triggering "a dynamic watch-list mechanism" in conjunction with "source control"; Implementing targeted sewage treatment technologies and strengthening multidisciplinary collaboration; Pharmaceutical levels in aquatic organisms as biological indicators for monitoring pharmaceutical pollution within the water environment; Upgrading drinking water treatment plants with the aim of removing pharmaceutical residues; Paying more attention to EPV for pharmaceuticals in solid matrices.

Knowledge, perceptions, and practice of ecopharmacovigilance among pharmacy professionals in China

Ecopharmacovigilance (EPV) is now a well-accepted critical component for the control of potential environmental risk posed by pharmaceutical residues. And improving the knowledge and perceptions about EPV, especially among pharmacy professionals, is the first step towards addressing the environmental impact of pharmaceuticals. This cross-sectional study was conducted to assess the knowledge, perceptions, and practice on EPV using a validated self-administered questionnaire delivered to a sample of 120 pharmacy professionals in Hubei Province, China. And 107 usable survey instruments were acquired. The mean score for knowledge about EPV was 3.85 out of a total of 10. The pharmacy professionals' overall perceptions of EPV and pharmaceutical pollution in environment were positive. But of the 107 respondents, 45 (42%) stated that they had not participated in any EPV measure. In addition, none had received training on EPV, and only 25 (23%) respondents had read the literature on EPV. In response to the question about the major perceived barrier to the effective implementation of EPV in China, 45 (42%) respondents chose the answer "poor awareness of EPV." These data suggests most pharmacy professionals in China had a positive attitude but lack of knowledge and practices towards EPV. Therefore, more should be done to enhance pharmacy professionals' knowledge on EPV.

Eco-pharmacovigilance of non-steroidal anti-inflammatory drugs: Necessity and opportunities

Eco-pharmacovigilance (EPV) is a practical and powerful approach to minimize the potential risks posed by pharmaceutical residues in environment. However, it is impracticable to practise rigorous and unitary EPV process for all the existing and new pharmaceuticals. Here, we focused on non-steroidal anti-inflammatory drugs (NSAIDs), and discussed the necessity and potential opportunities of practising EPV of NSAIDs. We found that the consumption of NSAIDs is huge and ubiquitous across the globe. NSAIDs were worldwidely reported as one of the most dominant and frequently detected groups in environmental matrices including wastewater, surface water, suspended solids, sediments, groundwater, even drinking water. Besides, there is definitive evidence for the adverse impacts of NSAID residues on scavenging birds and aquatic species. These data suggested the necessity of implementing EPV of NSAIDs. From the perspective of drug administration, we identified some things that can be done as management practice options for EPV implementation on NSAIDs.