Pharmaceuticals and the environment

The Potential Role of Ecotoxicological Data in National Essential Medicine Lists: A Cross-Sectional Analysis

BACKGROUND

Medicines affect the environment throughout their lifecycle, from production and distribution to use and disposal. They contribute to the pollution of air, water, and soil, impacting ecosystems and human health. Recognizing these risks, regulatory bodies and organizations have highlighted pharmaceutical pollution as a global concern, emphasizing the need for environmental risk assessments and sustainable practices.

METHODS

This study reviewed the essential medicines lists (EMLs) from 158 countries and examined the available ecotoxicological data. Medicines with high bioaccumulation, persistence, and toxicity were identified and cross-referenced with their inclusion in EMLs. Additionally, we analyzed the presence of alternative medicines with similar therapeutic effects but potentially lower environmental risks.

RESULTS

Five medicines-ciprofloxacin, ethinylestradiol, levonorgestrel, ibuprofen, and sertraline-were selected as illustrative examples due to their high environmental persistence and toxicity. All were listed in the 2023 WHO model list, with ciprofloxacin appearing in 94.3% of national EMLs.

CONCLUSIONS

This study underscores the limited availability of ecotoxicological data, which hinders environmental risk assessment for medicines. EMLs could serve as a tool to enhance the awareness and data mobilization of pharmaceutical pollution. Incorporating environmental criteria into EMLs could support more sustainable medicine selection and regulatory practices.

The climate emergency for rheumatologists: where do we stand?

Climate change and pollution are a major existential threat. Healthcare contributes a noteworthy 4-6% to the total carbon footprint and 5-7% of the total greenhouse gas (GHG) emissions. Environmental pollution and modern lifestyles are also contributing to the increased prevalence of autoimmune and lifestyle-related rheumatic disease. In this review, we assess both the effects of rheumatological practice on climate change and the potential impact of climate change on rheumatological diseases. Preliminary evidence suggests that climate change is linked with the inception or exacerbation of some of the autoimmune and inflammatory rheumatic diseases (AIRDs) like rheumatoid arthritis, lupus, systemic sclerosis, and reactive arthritis. Furthermore, with rampant industrialization and pollution, emerging infections such as Dengue, Zika virus, and chikungunya have emerged as triggers of inflammatory arthritis. Strategies at different levels are proposed to mitigate the effect of the healthcare industry and the community on the environment. The rheumatology community can acknowledge and begin to address the challenges of climate change and health.

Focus on patient perspectives in climate action policies for healthcare. A German survey analysis on what patients are willing to do

Background

The healthcare sector, while dedicated to improving health, paradoxically contributes significantly to global carbon emissions, accounting for approximately 4.9% of global emissions. Despite growing public concern about climate change, few studies have explored patients' awareness and attitudes toward the environmental impact of healthcare. This study aims to assess patients' perspectives on climate change and the sustainability of healthcare practices.

Methods

A cross-sectional survey was conducted at Ludwig-Maximilians-University (LMU) Hospital in Munich, Germany. Patients were invited to participate in a voluntary, anonymous online survey via strategically placed QR codes throughout the hospital. The survey explored patients' demographic information, environmental awareness, attitudes toward climate-friendly practices in healthcare, and willingness to support sustainable initiatives. Descriptive statistics and regression analyses were used to analyze the data.

Results

A total of 399 patients completed the survey (87% completion rate). The majority of respondents (92.3%) were aware of climate change, and 82.7% reported prioritizing climate-friendly practices in their personal lives. However, 55.9% of respondents were unaware of the healthcare system's contribution to carbon emissions, and only 18.3% knew about hospitals' climate impact. Despite this, 88.2% of respondents supported environmentally friendly initiatives in hospitals, and 86.5% were open to sustainable alternatives, provided that quality standards were maintained. Participants expressed significant interest in knowing the environmental impact of their treatments, with 63.2% in favor of a Nutri-Score-like system that would display the carbon footprint of medical procedures. Among those, 54.4% indicated that such a system would influence their choice of treatment. Similarly, 62.2% of respondents were interested in knowing the environmental impact of their medications, with 65% reporting that this information would affect their medication choices. A notable proportion of patients (66.2%) indicated willingness to support sustainable healthcare through shorter hospital stays and increased follow-up visits, while 35.8% were open to paying a CO2 compensation fee for their treatments. However, 81% were unwilling to pay higher insurance premiums to support environmentally friendly practices in hospitals. Regression analyses revealed that older age groups and having children were positively associated with environmental awareness (p < 0.05). However, factors such as gender, education level, relationship status, and illness severity did not significantly impact environmental attitudes. There was a significant correlation between patients' environmental friendliness and their readiness to take climate-protective actions (p < 0.001).

Conclusion

The study highlights a gap between patients' environmental awareness and their knowledge of healthcare's carbon footprint. While patients are generally supportive of sustainable practices in healthcare, their willingness to act diminishes when personal costs or discomfort are involved. A coordinated approach involving policy changes, patient education, and market innovations is essential to promote sustainable practices in healthcare without compromising patient care quality. Further research is needed to explore strategies for bridging the gap between environmental awareness and action in healthcare settings.

Are pharmaceutical residues in crops a threat to human health?

The application of biosolids, manure, and slurry onto agricultural soils and the growing use of treated wastewater in agriculture result in the introduction of human and veterinary pharmaceuticals to the environment. Once in the soil environment, pharmaceuticals may be taken up by crops, resulting in consequent human exposure to pharmaceutical residues. The potential side effects of pharmaceuticals administered in human medicine are widely documented; however, far less is known regarding the risks that arise from incidental dietary exposure. The aim of this study was to evaluate human exposure to pharmaceutical residues in crops and assess the associated risk to health for a range of pharmaceuticals frequently detected in soils. Estimated concentrations of carbamazepine, oxytetracycline, sulfamethoxazole, trimethoprim, and tetracycline in soil were used in conjunction with plant uptake and crop consumption data to estimate daily exposures to each compound. Exposure concentrations were compared to Acceptable Daily Intakes (ADIs) to determine the level of risk. Generally, exposure concentrations were lower than ADIs. The exceptions were carbamazepine, and trimethoprim and sulfamethoxazole under conservative, worst-case scenarios, where a potential risk to human health was predicted. Future research therefore needs to prioritize investigation into the health effects following exposure to these compounds from consumption of contaminated crops.

How Pharmaceutical Residues Occur, Behave, and Affect the Soil Environment

Many pharmaceuticals (PhMs), compounds for the treatment or prevention of diseases in humans and animals, have been identified as pollutants of emerging concern (PECs) due to their wide environmental distribution and potential adverse impact on nontarget organisms and populations. They are often found at significant levels in soils due to the continuous release of effluent and sludge from wastewater treatment plants (WWTPs), the release of which occurs much faster than the removal of PhMs. Although they are generally present at low environmental concentrations, conventional wastewater treatment cannot successfully remove PhMs from influent streams or biosolids. In addition, the soil application of animal manure can result in the pollution of soil, surface water, and groundwater with PhMs through surface runoff and leaching. In arid and semiarid regions, irrigation with reclaimed wastewater and the soil application of biosolids are usual agricultural practices, resulting in the distribution of a wide number of PhMs in agricultural soils. The ability to accurately study the fate of PhMs in soils is critical for careful risk evaluation associated with wastewater reuse or biosolid return to the environment. The behavior and fate of PhMs in soils are determined by a number of processes, including adsorption/desorption (accumulation) to soil colloids, biotic (biodegradation) and abiotic (chemical and photochemical degradation) degradation, and transfer (movement) through the soil profile. The sorption/desorption of PhMs in soils is the main determinant of the amount of organic chemicals taken up by plant roots. The magnitude of this process depends on several factors, such as crop type, the physicochemical properties of the compound, environmental properties, and soil-plant characteristics. PhMs are assumed to be readily bioavailable in soil solutions for uptake by plants, and such solutions act as carriers to transport PhMs into plants. Determining microbial responses under exposure conditions can assist in elucidating the impact of PhMs on soil microbial activity and community size. For all of the above reasons, soil remediation is critical when soil pollutants threaten the environment.

Challenges to decarbonizing medication prescribing and use practices: A call to action

Climate change undeniably impacts the social and environmental determinants of one's health. The healthcare sector, encompassing medications and the pharmaceutical industry supply chain, accounts for a significant portion of global health care contributions to greenhouse gas (GHG) and waste production. Despite these realities, healthcare professionals - physicians, pharmacists, nurses, and others - may be unaware of GHG emissions and the long-term environmental effects of the medications they prescribe, dispense, and administer daily. In this commentary, we identify existing challenges and explore potential strategies to recognize and reduce the climate change impacts associated with medication use.

Guidance provided by pharmacists to customers regarding to destination of unused household medications: disposal of household medications

BACKGROUND

Discarding pharmaceuticals in the garbage or into the sewage system are still the most common methods in many countries. This study aims to investigate the guidance provided by pharmacists to customers on the disposal of unused and expired household medications in São Paulo State, Brazil.

METHOD

The study population consisted of 630 pharmacists from the State of São Paulo, who work in community pharmacies. They answered an online questionnaire with questions composed in three blocks: demographic, work, and academic information on the pharmacist; guidance about the disposal of household medications; and knowledge regarding the reverse logistics of these medications. An invitation to participate in the questionnaire was made via WhatsApp, individually and collectively. Inferential statistics were performed using the chi-square test and were considered significant when p < 0.05%.

RESULTS

Among the participating pharmacists, the majority were women under 60 years old,56 (8.89%) stated that they never orient the customer regarding the disposal of unused and expired household medications, while 574 (91,12%) indicated that they almost provide guidance. The frequency with which they provided guidance was influenced by the number of years since graduation (p = 0.0047), the time they had worked in pharmacies and drugstores (p = 0.0007), and whether or not they had a graduate degree (p = 0.0181). Regarding the disposal of medications, among the 643 responses provided by the pharmacists,516 (80.25%) indicated that they oriented customers to return them to a pharmacy.

CONCLUSION

A small number of pharmacists always orient customers on the proper disposal that should be followed for unused and expired household medications, prioritizing their return to a pharmacy. In general, these pharmacists have longer periods of work experience and higher academic qualifications. Thus, it is important to increase knowledge through professional training and further education programs.

Experience of the adequacy and appropriateness of pharmaceuticals-related environmental information and preferred information channels among Finns

The normal use of medicines is the major environmental source of pharmaceuticals and a significant contributor to the chemicalization of the environment. Despite the key role of medicine users in contributing to this environmental challenge, little research has been conducted into the current state of lay people's pharmaceuticals-related environmental information, namely the information received, the information needed, the topics included in the information received, topics of interest, and previous and preferred information channels. In this study, these aspects were studied among 2,030 Finnish adults by means of an electronic survey. Of the respondents, 84.5% had received information related to pharmaceuticals in the environment (PiE). Female gender, higher age, high education level, general environmental friendliness, and use of prescription medicines were associated with a greater likelihood that information had been received. Furthermore, 39.8% of the respondents considered the amount of information received to be sufficient. Respondents had most commonly received information on 1 to 3 different topics. Proper disposal of medicines and pharmaceutical residues ending up in the environment in general were the most common topics covered by the information received. Medicines disposal and the effects of environmental pharmaceutical residues on people were the most interesting topics among the respondents. PiE-related information was most commonly obtained from traditional media (80.4%) and websites (40.5%), the least common source of PiE-related information being physicians (1.6%). The respondents were eager to receive such information in the future, preferring traditional media and medicine package leaflets as the most convenient information channels. These findings indicate a need for more diverse PiE-related information via easily accessible information channels that can vary based on sociodemographic characteristics.

Pharmaceutical Pollution in Aquatic Environments: A Concise Review of Environmental Impacts and Bioremediation Systems

The presence of emerging contaminants in the environment, such as pharmaceuticals, is a growing global concern. The excessive use of medication globally, together with the recalcitrance of pharmaceuticals in traditional wastewater treatment systems, has caused these compounds to present a severe environmental problem. In recent years, the increase in their availability, access and use of drugs has caused concentrations in water bodies to rise substantially. Considered as emerging contaminants, pharmaceuticals represent a challenge in the field of environmental remediation; therefore, alternative add-on systems for traditional wastewater treatment plants are continuously being developed to mitigate their impact and reduce their effects on the environment and human health. In this review, we describe the current status and impact of pharmaceutical compounds as emerging contaminants, focusing on their presence in water bodies, and analyzing the development of bioremediation systems, especially mycoremediation, for the removal of these pharmaceutical compounds with a special focus on fungal technologies.