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The request from NFSA and NEA:Antimicrobial agents and microorganisms are introduced to sewage systems by differenthuman activities, from private homes, institutions such as schools and hospitals, officebuildings, industrial and commercial activities, i.e., from everywhere where people work andlive.The Norwegian Food Safety Authority (NFSA) and Norwegian Environment Agency (NEA)asked the Norwegian Scientific Committee for Food and Environment (Vitenskapskomiteenfor mat og miljø, VKM) for an extension of the 2009 VKM report “Risk assessment ofcontaminants in sewage sludge applied on Norwegian soils” regarding the impact ofwastewater (WW)- and sewage sludge treatment methods used in Norway, on the fate andsurvival of antimicrobial resistant bacteria, fate of antimicrobial resistance genes, and maindrivers for resistance (e.g. antibiotics, antifungal agents, heavy metals, disinfectants).The request addressed by VKM:VKM appointed a working group, consisting of three members of the Panel on MicrobialEcology, four external members and VKM staff to prepare a draft Opinion document. ThePanel on Microbial Ecology has reviewed and revised the draft prepared by the workinggroup and approved the Opinion document “Assessment of the impact of wastewater andsewage sludge treatment methods on antimicrobial resistance”.The antimicrobial resistance cycle:Exposure to antimicrobial agents is regarded as the most important driver for developmentand dissemination of AMR in microorganisms. Consequently, an important location for thedevelopment of AMR is the gut of humans or animals receiving antimicrobial drug therapy.As ARB, ARG, resistance genes and antimicrobial agents will end up in the WW system, thissystem could be regarded as a potential hot spot for interactions between differentmicroorganisms, between different antimicrobial agents, and between microorganisms andantimicrobial agents. Hospitals and pharmaceutical companies are regarded as being animportant source for antimicrobial drug residues released in WW.At the wastewater treatment plant (WWTP), bacteria and genes end up either in the effluentwastewater fraction or in the sludge fraction. When ARB and ARG are distributed with theWW sludge, they may reach arable land when the sludge is used as soil improver andfertilising product, and thus be recycled into the food-production chain. When following theeffluent WW fraction, ARB and ARB will be released into WW recipients, such as lakes, riversor fjords, and may, from these environments, also be recycled into food production. In eachstep of these cycles, ARB and ARG will be introduced into new environmental compartmentsto which they must adapt, and to microbial communities with which they must compete for survival and growth. Depending on the bacterial species, these new environmentalcompartments will be more or less hostile, but they will also provide opportunities formicrobial interactions, like dissemination of ARG due to horizontal gene transfer (HGT) withinand between bacterial species.Findings:It is challenging to deliver a general assessment of the nature of as well as the probabilityfor direct discharge of ARB and ARG into effluent WW and applied sludge. This is due to thecombined complexity of resistance carriers, traits, various sources of variation, and the WWsystems. Moreover, there is currently a lack of harmonized methods and protocols tocompare studies from different systems. However, there are no strong indications that thereis a significant enrichment of ARB in WWTP operated under European conditions, which, ona general level, also applies to the Norwegian situation. Although some studies indicate aslight increase in the fraction of ARB, the absolute reduction in bacterial load during WWtreatment (WWT) is significant; removal of between 99 % to 99.9 % of faecal indicatorbacteria is generally achieved by secondary treatment, including biological and physicochemical treatment steps.Effluent WW is often released into water recipients, and there are many mechanisms(physical, mechanical, and chemical) that will limit the extent that ARB of faecal origin aretransferred to the food-production chain. However, there are different views on thesignificance of this release for the development of AMR. Results from single studies indicatethat WWTP effluents contribute little to the total AMR exposure of micro – and macroorganisms in aquatic and marine environments. On the other hand, freshwater environmentsin general are regarded as an important reservoir of novel antibiotic resistance determinants,and in some areas, relative abundance of resistance determinants in effluents has beenobserved to be considerably higher than in pristine natural water sources. Some imprint ofAMR in recipient waters, compared to pristine waters, is unavoidable.During WWT, bacteria largely adhere to particles that are aggregated and precipitated toform a solid sludge. The mandatory hygienisation of sludge kills a large proportion of thesebacteria, notably all thermosensitive faecal bacteria. However, the resulting hygienisedsludge is still rich in bacteria, some of which are carriers of ARGs. The current Norwegianregulations on use of sludge on soil contribute to prevent contamination of food withantimicrobial resistant bacteria and antimicrobial resistance genes from sludge. Yet, soils docontain a pool of both natural and sludge-derived antimicrobial resistance. The contributionof sludge to this antimicrobial resistance pool is probably temporally limited to a period aftersoil amendment with sludge. A recent, comprehensive study from Sweden showed that longterm application of sewage sludge on farmland only resulted in minor changes of soilbacterial community composition. No evidence could be found for enrichment ofantimicrobial resistant bacteria or antimicrobial resistance genes in soil amended withdigested and stored sewage. Hospital WW contains more ARB, ARG, and antibiotic residues than municipal sewage, butthe difference is not large for ARB and the impact may be minimal in large WW systems. Insmaller WW infrastructures, a hospital or similar institution may have a higher impact on theeffluent water from the WWTP, and this might suggest that local treatment of the WW at thehospital could be advantageous. A recent Norwegian study monitored bacterial diversity indifferent WW in the Oslo area, and found the highest concentration of AMR (ARB and/orARG) in hospital WW. But surprisingly, high concentrations were also found in the studiedcommunity wastewater. The relative contribution of hospital effluents seemed low in termsof dissemination of antimicrobial resistant bacteria to the wastewater treatment plant.All measures that can be taken at source to avoid dissemination of antimicrobial agents,ARB, and ARG should be evaluated for their contribution towards combatting AMRemergence. Concentrations of antimicrobial agents, ARB, and ARG are highest in the sewagesystem and at the inlet to WWTPs. Separation of the different fractions of antimicrobials,ARB, and ARG for individual treatment may therefore reduce the total load reaching theWWTPs. Due to the high concentrations of ARB and ARG in the sewage system, risks fromsewage pipe leakages are of concern. Intrusion of contaminated water into the drinkingwater distribution system should also raise concern. Rehabilitation of the sewage anddrinking water networks will considerably mitigate risks. The level of sewage treatment inNorway is rather low, and upgrading will decrease the concentration of bacteria discharged.However, WWTPs are generally not designed for removal of AMR. Membrane processesseem to be the most promising option for increasing such removal rates.Future perspectives:The opinion discusses how the “concept of sensitive recipients” for requirements of the levelof WWT could be revisited. This concept is currently based on controlling nutrient loads tothe environment, rather than on trace contaminants or contaminants such as ARB and ARGthat develop in the stressed environment. In the future, it might be of value to definerequirements for WWT based on the relative increase caused by the discharge to thepollution level. Using such a paradigm, a small load with contaminants to a rather unpollutedenvironment would be rated as being highly critical and the discharge would require furthertreatment. In addition to the amount of ARB, the type of resistance and their level ofhorizontal mobility are also important in this aspect.This opinion also proposes the establishment of a new monitoring programme, parallel to theexisting NORM and NORM-VET monitoring programmes; “NORM-ECO”. There is relativelylittle knowledge on AMR in non-clinical compartments, compared with hospital and otherclinical settings, and parameters that would trigger immediate responses from NFAS or NEAare not yet identified. However, establishment of a “NORM-ECO”-system requires clarificationof that needs further definition.