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Table 2

A brief summary of discussed questions and the suggested research directions

Discussion pointsSuggestions
Group 1: Surveillance – the WHO extended-spectrum beta-lactamase (ESBL) E. coli tricycle project – status, lessons learned from piloting and next steps 
AMR surveillance in humans, animals and the environment. What are the suitable surveillance targets as AMR reservoirs? • Areas with high population densities, and people live in close proximity with animals and share water systems 
• Measurements in socially deprived areas 
• Human wastewater 
• Surface water (baseline concentrations) 
• Hospital wastewater 
• Animal abattoir/slaughterhouse wastewater 
What are the necessary sample metadata to make good use of AMR surveillance data? • Climate information 
• Water quality 
• Geographical information 
• Operational information from WWTPs 
• Watershed information 
• Sampling strategy 
Group 2: Wastewater treatment technologies – practical implementation of the precautionary principle 
Which kind of wastewater treatment systems should be developed/implemented to remove antibiotic resistance genes (ARGs) and antibiotic-resistant bacteria (ARB)? • For low- and middle-income countries (LMICs), basic sanitation systems such as pit latrines are better than open defecation in terms of the reduction of ARB/ARGs emission to environments 
• It is important to understand the extent to which systems applicable in LMICs would reduce ARB/ARGs with the potential use of high pH lime 
• Importance in developing standardized protocols for quantification of ARGs 
• Importance of having a balance between improving sanitation and removal/transformation of micropollutants 
• Evaluating the contribution of decentralized systems in the removal and release of ARB/ARGs in the aquatic environments 
• The necessity for data sharing and collaboration 
Group 3: Environmental pathways for AMR – decision tree for country prioritizing WASH and environment actions 
Are there potentially important transmission routes other than commonly recognized ones? • Indoor airborne transmission, and fecal sludge 
• The potential transmission routes of antimicrobial fungi including agricultural settings, ice machines, and shower water 
• Livestock have been focused as one of the possible drivers of AMR, but the infection from produce items are often overlooked 
How to prioritize WASH and environmental interventions? • Importance of better communication and coordination between clinical researchers and water engineers 
• Linking dissemination of AMR to specific behavioral factors (e.g. swimming in surface water vs. fountain mist exposure 
• Quantitative microbial risk assessment (QMRA) can aid in prioritization 
Discussion pointsSuggestions
Group 1: Surveillance – the WHO extended-spectrum beta-lactamase (ESBL) E. coli tricycle project – status, lessons learned from piloting and next steps 
AMR surveillance in humans, animals and the environment. What are the suitable surveillance targets as AMR reservoirs? • Areas with high population densities, and people live in close proximity with animals and share water systems 
• Measurements in socially deprived areas 
• Human wastewater 
• Surface water (baseline concentrations) 
• Hospital wastewater 
• Animal abattoir/slaughterhouse wastewater 
What are the necessary sample metadata to make good use of AMR surveillance data? • Climate information 
• Water quality 
• Geographical information 
• Operational information from WWTPs 
• Watershed information 
• Sampling strategy 
Group 2: Wastewater treatment technologies – practical implementation of the precautionary principle 
Which kind of wastewater treatment systems should be developed/implemented to remove antibiotic resistance genes (ARGs) and antibiotic-resistant bacteria (ARB)? • For low- and middle-income countries (LMICs), basic sanitation systems such as pit latrines are better than open defecation in terms of the reduction of ARB/ARGs emission to environments 
• It is important to understand the extent to which systems applicable in LMICs would reduce ARB/ARGs with the potential use of high pH lime 
• Importance in developing standardized protocols for quantification of ARGs 
• Importance of having a balance between improving sanitation and removal/transformation of micropollutants 
• Evaluating the contribution of decentralized systems in the removal and release of ARB/ARGs in the aquatic environments 
• The necessity for data sharing and collaboration 
Group 3: Environmental pathways for AMR – decision tree for country prioritizing WASH and environment actions 
Are there potentially important transmission routes other than commonly recognized ones? • Indoor airborne transmission, and fecal sludge 
• The potential transmission routes of antimicrobial fungi including agricultural settings, ice machines, and shower water 
• Livestock have been focused as one of the possible drivers of AMR, but the infection from produce items are often overlooked 
How to prioritize WASH and environmental interventions? • Importance of better communication and coordination between clinical researchers and water engineers 
• Linking dissemination of AMR to specific behavioral factors (e.g. swimming in surface water vs. fountain mist exposure 
• Quantitative microbial risk assessment (QMRA) can aid in prioritization 
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