Table 2 Evidence assessment and the identified research gaps regarding the antimicrobial resistance (AMR) in the environment in the context of mass drug administration (MDA) programs
Research area | Strength of evidence | Remaining gaps |
|---|---|---|
AMR produced by MDA | Moderate | Â AMR impacts of MDA with antimicrobials other than azithromycin |
Environmental introduction of AMR and antimicrobials | Strong |  The role of inadequate sanitation in AMR emergence in settings with poor antibiotic stewardship and sanitation infrastructure  Pharmacokinetics of non-antibiotic antimicrobials in MDA studies  Persistence of antimicrobials in environmental settings |
Environmental persistence of AMR | Moderate |  The likelihood of AMR dissemination via HGT in environmental settings  Differences between ARGs and genes for resistance to other antimicrobials |
Ecotoxicology | Limited |  Ecotoxicological effects of MDA-relevant antimicrobials other than azithromycin and ivermectin  Ecotoxicological effects in response to MDA |
Transmission of AMR from the environment to humans | Limited | Â Quantitative understanding of the risk posed by environmental ARGs |