Improving the regulatory environmental risk assessment of human pharmaceuticals: Required changes in the new legislation

Pollution by antimicrobials and antibiotic resistance genes in East Africa: Occurrence, sources, and potential environmental implications

The escalating burden of antimicrobial pollution in East Africa poses severe threats to public health, environmental integrity, and economic stability. Environmental compartments such as soil and water serve as reservoirs for these pollutants such as antimicrobials and antibiotic resistance genes, creating selective pressure that accelerates the emergence of antimicrobial resistance (AMR). These dynamic fosters the proliferation of multidrug-resistant pathogens, or "superbugs," complicating infection management and amplifying health risks in a region already challenged by inadequate healthcare and sanitation infrastructure. Furthermore, pollution by antimicrobials and antibiotic resistance genes critically disrupts ecological processes, such as nutrient cycling and organic matter degradation, diminishing soil fertility, water quality, and agricultural productivity, thereby threatening food security and overall ecological health. Current surveillance efforts, including the Global Antimicrobial Resistance and Use Surveillance System (GLASS) and the East Africa Public Health Laboratory Networking Project (EAPHLNP), have made strides in tracking AMR trends and guiding policy decisions. However, these efforts remain insufficient to address the growing crisis. This study highlights the urgent need for integrated strategies, including stringent antibiotic usage regulations, advanced wastewater treatment technologies, and comprehensive environmental surveillance. Therefore, there is a need to address the intersections of health, agriculture, and environment, to mitigate AMR and its far-reaching consequences to ensure public health safety and sustainability.

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.

Do you think medicines can be prescribed in a more eco-directed, greener way? A qualitative study based on public and prescriber focus groups on the impact of pharmaceuticals in Scotland's water environment

OBJECTIVES

This qualitative study explored public and prescriber awareness of pharmaceutical pollution in the water environment and eco-directed sustainable prescribing (EDSP) as a mitigation strategy to reduce the environmental impact of prescribing in Scotland.

DESIGN

Focus groups explored prescriber and public perceptions of the topic. Common questions were asked through semistructured facilitation. Focus groups were digitally recorded and transcribed verbatim using an artificial intelligence system, then anonymised and thematically analysed using NVivo software. Data were iteratively analysed using the one sheet of paper technique.

SETTING

Public focus groups were held in-person (Inverness, Scotland, April 2023), and prescriber focus groups were held virtually (MS Teams, August 2023).

PARTICIPANTS

Nine public representatives and 17 NHS Scotland prescribers participated in one of four focus groups. Purposive and opportunistic sampling approaches were used to recruit participants through social media and other channels (ie, community groups, professional emails, general practitioner and hospital flyers). Prescriber representatives registered interest through an online survey to gather information about their professional background. Responses were reviewed to ensure representation of a mixture of medical backgrounds, experience, sectors and health boards.

RESULTS

There is growing awareness among the public and healthcare professionals of pharmaceutical pollution in the environment, but further education is required on the drivers, potential effects and possible interventions. Suggestions for more sustainable healthcare included public health awareness campaigns, better provision for pharmacy take-back schemes, clear medicine/packaging labelling, regular medicines reviews and more considered patient-centred care. From the prescriber perspective, EDSP resonated well with current sustainability initiatives (eg, Realistic Medicine, switching to dry-powder inhalers), but barriers to EDSP included lack of knowledge, confidence, time and resources to implement changes. Although the public representatives were generally open to the concept of EDSP, this decision required weighing pros/cons considering personal health choices, information accessibility and transparency, and trust in and time with prescribers.

CONCLUSIONS

This study identified new insights from prescribers and the public related to the concept of, and barriers to, EDSP in Scotland, as well as perspectives regarding knowledge support tools and information communication. Cross-sector and transdisciplinary collaborative approaches are needed to address the challenges identified here. Nonetheless, EDSP merits further exploration in developing more sustainable, appropriate and effective healthcare which contributes to improved public and planetary health.

Emerging organic micropollutants as serious environmental problem: A comprehensive review

The escalating problem of environmental pollution can be attributed to the accelerated pace of global development, which often prioritizes human needs over planetary health. Despite huge global attempts endeavours to mitigate legacy pollutants, the uninterrupted introduction of novel substances such as the emerging organic micropollutants (EOMs) represents a significant menace to the natural environment and all forms of life on the earth. The widespread occurrence of EOMs in water and wastewater is a consequence of both their growing consumption as well as the limitations of the conventional wastewater treatment methods containing such pollutants resulting in deterioration of water quality and its supplies as well as this is a significant challenge for researchers and the scientific community alike. EOMs possibility to bioaccumulate, their toxic properties, resistance to degradation, and the limitations of conventional wastewater treatment methods for quantitative removal of EOMs at low concentrations give a significant environmental risk. These compounds are not commonly monitored, which exacerbates further the problem. Therefore the wide knowledge concerning EOMs properties, their occurrence as well as awareness about their migration in the environment and harmful effects is also extremely important. Therefore the EOMs characterization of various types, their classification and sources, concentrations in the aquatic systems and wastewaters, existing regulatory guidelines and their impacts on the environment and human health are thoroughly vetted in this review. Although the full extent of EOMs' effects on aquatic ecosystems and human health is still in the process of investigations, there are evident indications of their potential acute and chronic impacts, which warrant urgent attention. In practical terms the results of the research presented in this paper will help to fill the knowledge gaps concerning EOMs as a serious problem and to raise public awareness of actions to move to sustainable pollution management practices to protect our planet for future generations are vital.

Environmental risk assessment in the EU regulation of medicines for human use: an analysis of stakeholder perspectives on its current and future role

An environmental risk assessment (ERA) is mandatory for all applications for marketing authorisation of medicines in the European Union (EU). We investigated stakeholder perspectives on the role of the ERA in EU regulation of medicines for human use. We discuss the current position of the ERA and the current conduct and assessment of the ERA, such as the required expertise, data, and studies, its applicability to generic drugs, and its use in regulatory decision-making. We also discuss future perspectives, including extension of the ERA to cover antimicrobial resistance, improved risk mitigation, impact on 'over-the-counter' (OTC) status, and incorporation into reimbursement considerations.

Tackling Pharmaceutical Pollution Along the Product Lifecycle: Roles and Responsibilities for Producers, Regulators and Prescribers

Pharmaceuticals produce considerable environmental harm. The industry's resource-intensive nature, coupled with high energy costs for manufacturing and transportation, contribute to the "upstream" harms from greenhouse gas emissions and ecosystem pollution, while factors such as overprescription, overuse, and pharmaceutical waste contribute to the "downstream" harms. Effectively addressing pharmaceutical pollution requires an understanding of the key roles and responsibilities along the product lifecycle. In this commentary, we argue that three actors-producers, regulators, and prescribers-have unique and interdependent responsibilities to address these issues. Producers and market access regulators are upstream actors who can manage and mitigate harms by both shifting manufacturing, business practices, and regulatory requirements and producing transparent, robust data on environmental harms. By contrast, prescribers are downstream actors whose capacity to reduce environmental harms arises principally as a "co-benefit" of reducing inappropriate prescribing and overuse. Potentially complicating the prescriber's role are the calls for prescribers to recommend "environmentally preferable medicines". These calls continue to increase, even with the sparsity of transparent and robust data on the impact of pharmaceuticals on the environment. Recognizing the interdependencies among actors, we argue that, rather than being ineffectual, these calls draw needed attention to the critical responsibility for upstream actors to prioritize data production, reporting standards and public transparency to facilitate future downstream efforts to tackle pharmaceutical pollution.

Assessing Environmental Risks during the Drug Development Process for Parasitic Vector-Borne Diseases: A Critical Reflection

Parasitic vector-borne diseases (VBDs) represent nearly 20% of the global burden of infectious diseases. Moreover, the spread of VBDs is enhanced by global travel, urbanization, and climate change. Treatment of VBDs faces challenges due to limitations of existing drugs, as the potential for side effects in nontarget species raises significant environmental concerns. Consequently, considering environmental risks early in drug development processes is critically important. Here, we examine the environmental risk assessment process for veterinary medicinal products in the European Union and identify major gaps in the ecotoxicity data of these drugs. By highlighting the scarcity of ecotoxicological data for commonly used antiparasitic drugs, we stress the urgent need for considering the One Health concept. We advocate for employing predictive tools and nonanimal methodologies such as New Approach Methodologies at early stages of antiparasitic drug research and development. Furthermore, adopting progressive approaches to mitigate ecological risks requires the integration of nonstandard tests that account for real-world complexities and use environmentally relevant exposure scenarios. Such a strategy is vital for a sustainable drug development process as it adheres to the principles of One Health, ultimately contributing to a healthier and more sustainable world.