Invited to present evidence to the US Presidential Advisory Council on Combatting Antibiotic-Resistant Bacteria (PACCARB) in Washington DC last month, Graham is one of a handful of world-leading experts who has been asked to help shape the new "One Health" strategy set up to address the threat of antibiotic resistance (AR).

Announced last year by President Obama, the new National Action Plan will identify ways to "prevent and contain outbreaks of antibiotic-resistant infections; maintain the efficacy of current and new antibiotics; and develop and deploy next-generation diagnostics, antibiotics, vaccines, and other therapeutics." Key to this is identifying the gaps in current health strategies.

Highlighting the critical link between regionally inadequate waste management and the spread of AR genes and bacteria, Professor Graham stated at the meeting – which was broadcast online around the world - that current policy underestimates the importance of improving water quality at global scales as key to curtailing AR in health systems around the world.

Global strategies

"Although there is growing information on environmental AR exposures, how such exposures impact human health is still under debate," explains Professor Graham.

"Our research shows that regionally poor water quality is very likely a major driver in the global spread of antibiotic resistance; maybe as important as use of antibiotics. But there is a gap in current health strategies to address this.

"Here in the West we have become complacent because we have excellent waste treatment systems and access to clean water.  But in parts of the world where waste management is limited and-or inadequate for the scale of the problem, AR genes and bacteria are being discharged into the water system and is spread from person to water to person at major scales.

"It's crucial that we stop thinking of this as 'someone else's problem' and instead put clear global strategies in place to improve waste management and water supplies, and also increase international environmental monitoring."

The rise of antibiotic resistance

Antibiotic resistance and the associated spread of untreatable ‘superbugs’ is one of the major public health concerns of the 21st century.

Antibiotics have been a critical public health tool since the discovery of penicillin in 1928, saving the lives of millions of people around the world but the emergence of drug-resistant strains is undermining our ability to treat bacterial infections.

Speaking at the committee hearing, Professor Graham said the spread of antibiotic-resistance to one of the most beautiful and pristine locations in Asia was a clear example of how superbugs can be spread via the environment on a massive scale.

"Every year hundreds of thousands of pilgrims descend on sacred sites along the Upper Ganges River, in the foothills of the Himalayas, to bathe at the water’s edge," explains Professor Graham, who carried out the research with colleagues at IIT Delhi. 

"These huge seasonal human influxes temporarily overload already stretched waste handling systems which results in untreated human wastes being released into the river, exposing visitors and residents to potentially infectious AR bacteria."

Water and sediment samples taken from sacred sites near Rishikesh and Haridwar show antibiotic resistance gene levels, strongly correlated with human wastes, leads to ‘superbug’ levels about 60 times greater per capita when pilgrims are present compared with other times of the year. Once in the water, others using the river can ingest these genes. 

“In the age of international travel, antibiotic resistance genes and organisms in the gut of individuals as a result of inadequate sanitation can be carried anywhere, exposing wider populations to such resistance.

"We know that many locations with elevated antibiotic resistance exist around the world, particularly in densely populated areas, such as urban Africa, the subcontinent and Latin America, and they are almost always associated with inconsistent sanitation and generally poorer water quality.

"If we can stem the spread of such antibiotic resistant genes locally – possibly through improved local sanitation and waste treatment – we have a better chance of limiting its spread on a global scale."