Water Currents: WASH and Antimicrobial Resistance

Antimicrobial resistance (AMR) occurs when microorganisms such as bacteria or virus change to resist the action of antimicrobials (e.g., antibiotics). Currently, it is estimated that at least 700,000 people die each year due to drug-resistant diseases. Each year, more and more common diseases are becoming untreatable and lifesaving medical procedures are becoming much riskier due to AMR. A recent UN report on AMR (“No Time to Wait,” listed below) states that drug-resistant diseases could cause 10 million deaths each year by 2050, and that by 2030, AMR could force up to 24 million people into extreme poverty.

This issue of Water Currents contains recent studies on the connection between AMR and water and sanitation, the One Health approach to tackling AMR, country situation reports, and other AMR–related topics.

USAID’s priorities under the U.S. Government Global Water Strategy—improving good governance, water access, and sanitation and hygiene—are considered essential to prevent and counteract the spread of global microbial resistance. In addition, USAID’s Bureau for Global Health works with international organizations and local governments, academia, and private sector partners across Asia and Africa to promote prudent use of antimicrobials in the livestock, aquaculture, and crop production sectors to minimize the likelihood of AMR development and spread.

We would like to thank staff from the Sanitation and Hygiene Applied Research for Equity (SHARE) project, Emory University’s Center for Global Safe Water, Sanitation, and Hygiene, and Global Water 2020 for suggesting AMR as a topic and for contributing content to this issue.


Antimicrobial Resistance: An Emerging Water, Sanitation and Hygiene Issue. World Health Organization (WHO), 2015. This briefing note provides an overview on the role of water and waste in combating AMR and identifies key areas to explore related to risk assessment management, policy, and research.

No Time to Wait: Securing the Future from Drug-Resistant Infections. WHO, April 2019. AMR is a global crisis that threatens a century of progress in health and achievement of the Sustainable Development Goals. Because the drivers of AMR lie in humans, animals, plants, food, and the environment, a sustained One Health response is essential to engage and unite all stakeholders around a shared vision and goals.

Differential Drivers of Antimicrobial Resistance Across the World. Accounts of Chemical Research, March 2019. Researchers show that high population densities in cities that suffer from poor sanitation and solid-waste disposal can potentially impact the dissemination of resistance.

Global Antimicrobial Resistance: A Complex and Dire Threat with Few Definite Answers. Tropical Medicine and International Health, March 2019. Global AMR data and projections are simply alarming. Despite widespread recognition of the issue's magnitude and urgency, the key drivers of global AMR dissemination, and how best to contain it, remain poorly defined.

The Economics of Antimicrobial Resistance and the Role of Water and Sanitation Services. WASHeconomics, January 2019. Water, wastewater, and feces play a key role in the carriage of microorganisms and their genetic material. For example, water can act as a reservoir of antimicrobial-resistant bacteria and exposure route to humans (and animals).

Anthropological and Socioeconomic Factors Contributing to Global Antimicrobial Resistance: A Univariate and Multivariable Analysis. Lancet Planetary Health, September 2018. This study explored the factors contributing to the rise in AMR. The study determined that cutting back on antibiotic use is not enough to counteract the problem, and instead identified improvements in sanitation, access to clean water, and good governance, as well as increased public health care expenditures and better regulation of the private health sector as necessary to reduce global AMR.

Infection Prevention, Control and Surveillance: Limiting the Development and Spread of Drug Resistance. Review on Antimicrobial Resistance, March 2016. This review examines the role of clean water and effective sanitation in preventing the spread of infections in the community and reducing AMR. It also discusses ways to prevent and control infections in health care facilities.

Health Care Facilities/Hygiene Issues 
Quick Fix for Care, Productivity, Hygiene and Inequality: Reframing the Entrenched Problem of Antibiotic Overuse. BMJ Global Health, August 2019. Individuals, caregivers, and health workers in low- and middle-income countries often find themselves using and prescribing antibiotics because of infections caught due to unsanitary conditions in health care settings and at home, as well as in anticipation of such infections.

Fecal Pollution Can Explain Antibiotic Resistance Gene Abundances in Anthropogenically Impacted Environments. Nature Communications, January 2019. Discharge of treated sewage leads to release of antibiotic-resistant bacteria, resistance genes, and antibiotic residues to the environment.

Prevention First: Tackling AMR through Water, Sanitation and Hygiene. One Health, July 2017. This article focuses on three neglected elements of WASH and AMR in health care facilities and the environment. It highlights the importance of WASH for mothers and newborns, and on synergizing WASH policies and approaches to support the continuum of care from health care settings to the home.

The Role of Water, Sanitation and Hygiene (WASH) in Healthcare Settings to Reduce Transmission of Antimicrobial Resistance. Infection Prevention and Control, July 2016. Hand hygiene has been cited as the single most important practice to reduce health facility–acquired infections, and improved hand hygiene practices have been associated with a sustained decrease in the incidence of AMR infections in health care settings. WASH also plays a role; cleaning surfaces and bedding helps prevent transmission of health care–associated infections.

One Health Studies 
Critical Importance of a One Health Approach to Antimicrobial Resistance. EcoHealth, June 2019. This article advocates for a comprehensive One Health research agenda to address AMR that incorporates human, animal, environmental, ecosystem, and wildlife perspectives and identifies key priorities for research.

Global Trends in Antimicrobial Resistance in Animals in Low- and Middle-Income Countries. Science, September 2019. Regions affected by the highest levels of AMR should take immediate actions to preserve the efficacy of antimicrobials that are essential in human medicine by restricting their use in animal production.

One Health—Its Importance in Helping to Better Control Antimicrobial Resistance. Tropical Medicine and Infectious Disease, January 2019. Numerous countries and several international agencies have now included a One Health approach within their action plans to address AMR. Necessary actions include: improvements in antimicrobial use; identifying alternatives to antimicrobials; better regulation and policy; and improving surveillance, stewardship, infection control, sanitation, and animal husbandry.

Evidence Needed for Antimicrobial Resistance Surveillance Systems. WHO Bulletin, January 2019. Evaluating the added value of One Health approaches for antimicrobial resistance surveillance is not a simple task, but it should not be set aside because of its complexity.

Water/Wastewater-Related Aspects 
State of the Art on the Contribution of Water to Antimicrobial Resistance. European Commission, January 2019. The aim of this report is to discuss the mechanisms of antibiotic action and antibiotic resistance focusing on potential effects in water, which researchers recognize as a significant reservoir of antibiotics and antibiotic-resistance genes.

Persistence of Antibiotic Resistance Genes and Bacterial Community Changes in a Drinking Water Treatment System: From Drinking Water Source to Tap Water. Science of The Total Environment, March 2018. Antibiotic resistance genes (ARGs) are emerging contaminants that have become a public concern. This study aimed to investigate the occurrence and diversity of ARGs, and variation in the composition of bacterial communities in source water, drinking water treatment plants, and tap water in the Pearl River Delta region, South China.

Bogotá River Anthropogenic Contamination Alters Microbial Communities and Promotes Spread of Antibiotic Resistance Genes. Nature Scientific Reports, August 2019. In this work, researchers characterized aquatic microbial communities samples collected at three sites along the Bogotá River and from wastewater at three city hospitals, and investigated community profiles and ARGs as a function of anthropogenic contamination.

Identification of Risk Factors Associated with Carriage of Resistant Escherichia coli in Three Culturally Diverse Ethnic Groups in Tanzania: A Biological and Socioeconomic Analysis. The Lancet Planetary Health, November 2018. Households that shared water sources with larger livestock herds and wildlife showed increased odds of carrying resistant E. coli, which probably reflects both contact and water-mediated transmission to people. The mechanism underlying the association between milk and AMR appears to be related to basic transmission.

Molecular Characterization and Antimicrobial Resistance Pattern of Escherichia coli Recovered from Wastewater Treatment Plants in Eastern Cape South Africa. International Journal of Environmental Research and Public Health, June 2018. The study reveals that water samples recovered from the final effluents of wastewater treatment plants may likely be one of the major sources of antibiotic resistance in E. coli.

Wastewater Used for Urban Agriculture in West Africa as a Reservoir for Antibacterial Resistance Dissemination. Environmental Research, September 2018. Wastewater in West Africa harbors a wide diversity of common and specific virulence factors, and studies show that urban agriculture is likely to promote dissemination of bacterial resistance.

Other Water Pollutants: Antimicrobial Resistance. 2018. This chapter in Water and Sanitation‐Related Diseases and the Changing Environment: Challenges, Interventions, and Preventive Measures discusses sources of antibiotic‐resistant bacteria in the environment, specifically in wastewater; the types of wastewater treatment ;and their effect on reducing antibiotics and resistant organisms.

Other Studies 
Towards a Research Agenda for Water, Sanitation and Antimicrobial Resistance. Journal of Water and Health, January 2017. This article discusses the conclusions of a WHO workshop to develop a strategic research agenda on WASH and AMR.

Critical Knowledge Gaps and Research Needs Related to the Environmental Dimensions of Antibiotic Resistance. Environment International, May 2018. The environment plays important roles in the development of antibiotic resistance. This article discusses critical knowledge gaps and research needs on aspects of evolution, transmission, and interventions.

Complexities in Understanding Antimicrobial Resistance Across Domesticated Animal, Human, and Environmental Systems. Annals of the New York Academy of Sciences, March 2019. In this article, the authors review research on the non-foodborne spread of AMR, with a focus on domesticated animals and the environment and possible exposures to humans.

Population-Level Mathematical Modeling of Antimicrobial Resistance: A Systematic Review. BMC Medicine, April 2019. Few ecological studies explore the transmission of AMR from the environment (water, soil, etc.) to potential hosts, despite the increasing evidence of a link between antimicrobial contamination of the environment, and the development and transfer of resistance to human pathogens.

Urban Slums: A Supportive Ecosystem for Typhoidal Salmonellae. Journal of Infectious Diseases, July 2018. Typhoid fever continues to kill thousands of people each week. With worsening AMR, this mortality burden could suddenly increase.

World Health Organization: Antimicrobial Resistance – This website contains fact sheets, WHO’s Global Action Plan, and other resources on AMR.

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