Senior Scientist Dr Andrew Singer, who contributed to today’s Annual Report from the Chief Medical Officer for England, gives his reaction to the report's recommendations.
Today Dame Sally Davies, the Chief Medical Officer for England, published the "Annual Report of the Chief Medical Officer 2017, Health Impacts of All Pollution - what do we know?" The report focuses on the direct impact of pollution on human health. This is a ground-breaking effort by a Chief Medical Officer to highlight known pollution risks and their causal relationship with human health. This is best evidenced by the discussion on air pollution, which is a current health threat to both city and rural inhabitants in the UK and worldwide. The report highlights 22 Recommendations that offer solid, tractable ways forward for gathering evidence where it is lacking, assigning leadership roles for government (e.g. Public Health England and the Environment Agency), calling on funding bodies (UK Research and Innovation) to support integrated research to fill knowledge gaps, and to provide transparency both in the collection of data as well as its interpretation.
To research scientists such as myself, the collection of new data is just as welcome as the publication of existing pollution and health data. Transparency in government roles and priorities for monitoring can greatly focus and facilitate future research by engaging rapidly with the most appropriate department, ensuring that effort is not wasted collecting data that already exists, while also making it easier to identify knowledge gaps.
Pollution from the Health and Care System
It is particularly noteworthy that the CMO dedicates the better part of Chapter 2 to 'Pollution from the Health and Care System'. I was fortunate to co-author, with Dr Will Gaze of the University of Exeter, the section addressing the challenge of environmental pollution as a driver of antibacterial drug resistance. In this Chapter, the CMO highlights the gains to be made by reducing pharmaceutical pollution. For what is possibly the first time, it has been recognised at the highest level (possibly anywhere in the world), that environmental pollution from antimicrobials and antimicrobial resistant microorganisms represent a significant risk to the generation and spread of antibacterial resistance with implications to the environment and human health.
"For what is possibly the first time, it has been recognised at the highest level (possibly anywhere in the world), that environmental pollution from antimicrobials and antimicrobial resistant microorganisms represent a significant risk to the generation and spread of antibacterial resistance with implications to the environment and human health." Dr Andrew Singer, CEH
Antibiotics chronically enter the environment from wastewater, stemming from the fact that a majority of most antibiotics pass through the body intact. These antibiotics can persist even beyond the point of the sewage works and enter the river, as has been shown thousands of times in the scientific literature. What is exciting about this report is that it acknowledges not only the health risks that antibiotics in the environment play in driving resistance of human relevance, but also highlights the importance of the antibiotic-resistant bacteria that co-occur in wastewater and their role in the spread of resistance in the environment and ultimately back to humans.
The importance of antibiotic resistance GENES as POLLUTANTS is a ground-breaking step forward for policy.
Furthermore, the report highlights the complex issue of ‘co-selection’, which refers to the capacity of chemicals OTHER than antibiotics to ‘select for’ or maintain antibiotic resistance in the absence of antibiotics. The most well studied of these ‘co-selective’ chemicals are: biocides, such as triclosan which is found in toothpaste, handwashes and some plastics, and metals, which are found ubiquitously in our food, water, cosmetics, and throughout daily life.
The report states, "The challenge to the research community will be in providing the evidence base needed to justify appropriate wastewater engineering targets, while also considering the effects of chemical mixtures and the importance of co-selection (i.e. metals and biocides)."
This section proposes radical change to our assessment of risk from wastewater. It means that future efforts to tackle AMR must also acknowledge the wider suite of chemicals present (e.g., mixture effects and co-selection). In short, mixture effects and co-selection can and will counteract the efforts towards lowering antibiotic resistance in wastewater. Hence, future efforts to reduce the load of antibiotic resistance genes entering and leaving sewage works will need to look holistically at the problem and include all possible chemical drivers of resistance genes for a sustainable and cost-effective solution. This is a call for an inter-disciplinary solution to the pollution in our wastewater, which will involve source reduction and recycling as well as innovation in wastewater, all driven by an evidence-based understanding of our environmental targets (i.e. what should be the regulatory levels of chemicals and genes that are most protective).
The CMO has laid down the gauntlet for Defra, EA, the Water Industry and Academics to work together to develop a holistic, sustainable and cost-effective solution to the risks to human health posed by pharmaceutical pollution in wastewater. I welcome this report and am honoured to have provided perspectives and evidence to support its important messages.
The following are an abbreviated summary of the Recommendations provided by the CMO for the report:
- Reduce contribution of pollution to non-communicable diseases (NCDs).
- Publish a chemicals strategy that accounts for human health impacts including mixtures.
- Evaluate the health impact from improved air quality measures in London.
- Local governments must exercise their authority to improve the health of their local population.
- Local authorities must address all forms of pollution, both at low-level and intermittent high level exposure.
- Local authorities must be supported by Public Health England through provision of evidence of health impacts of pollution and toolkits to avoid or ameliorate pollution.
- The risk and impact of all forms of pollution must be considered at all stages of local authority planning.
- National air pollution standards must be stringent and able to protect human health.
- Integrate health data surveillance and road charging schemes across England.
- Support the development, testing and implementation of home air quality monitoring.
- The health service and related industry must: be transparent about polluting activities; strive to reduce pollution; and establish best practice.
- NHS Trusts report on their Sustainable Development Management Plans and provide data. PHE should report on all Trusts in an Annual Report to NHS Improvement, which should recommend remedial action.
- CCGs to publish an assessment of how local air pollution correlates with hospital visits and PHE should aggregate these for a national public report to NHS England.
- Ambulance Trusts must replace diesel with low emission vehicles and PHE should report on this phase out annually for a report to NHS England.
- Ensure health impacts of pollution are taught to clinicians and as part of continuous professional development programmes.
- PHE to synthesise and publish evidence concerning the health impacts of all pollutants.
- UKRI offer a health-related pollution topic for the first national Citizens Science endeavours.
- PHE and EA to compile health impacts of pollution data and pollution surveillance.
- PHE to lead on a programme of surveillance on the health impacts of pollution.
- PHE to create an English health biomonitoring data set, detailing exposure to pollutant and health outcomes.
- UKRI work towards integrating health and pollution data, including health impact, socio-demographic and pollution data.
- Research funding should encourage multi-disciplinary research on the long-term impacts of low-level pollution on human health.
Chapter 2 of the report addresses ‘Pollution from the Health and Care System’ and highlights among other things that there are gains to be made by reducing pharmaceutical pollution. As environmental antimicrobial pollution is a significant contributor to the generation and spread of antibacterial resistant bacteria in the environment.
Chapter 3. Chemical mixtures and ‘legacy’ pollutants, such as metals, need to be considered for their impact on human health, including the genome and epigenome, where intergenerational impacts can occur.
Chapter 4. Noise and light pollution are high priority areas for new research. Nanomaterials should be understood for their adverse human health impacts.
Chapter 5. Health economics of interventions to reduce pollution.
Chapter 6. Pollution and health inequalities.
Chapter 7. Environmental and health service pollution. Environmental health professionals engage in proactive and preventative work.
Chapter 8. Environmental pollution – data, surveillance and health impacts. Discusses the difficulty in studying and monitoring health impacts from pollution.
Chapter 9. Measurement and communication of health risks from pollution. What is the balance in harm between short term exposure to high level and long term exposure to lower levels of pollutants?