# Beyond borders: Europe's leadership role in tackling transboundary antimicrobial resistance

Benjamin Davido, Delphine Merillon, Marie Fuentes-Braesch

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Benjamin Davido, Delphine Merillon, Marie Fuentes-Braesch. Beyond borders: Europe's leadership role in tackling transboundary antimicrobial resistance. JAC-Antimicrobial Resistance, 2026, 8 (1), 10.1093/jacamr/dlag010. hal-05502849

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# Beyond borders: Europe's leadership role in tackling transboundary antimicrobial resistance

Benjamin Davido ID ¹,²,³*, Delphine Merillon³ and Marie Fuentes-Braesch³

¹Maladies Infectieuses, Hôpital Raymond-Poincaré, Université Paris Saclay, AP-HP, Garches 92380, France; ²UMR1173, Université Versailles Saint-Quentin, Montigny-Le-Bretonneux 78180, France; ³Mission Ministérielle de la Prévention des Infections et de L'antibiorésistance, Direction Générale de la Santé, Paris 75007, France

*Corresponding author. E-mail: benjamin.davido@aphp.fr

Antimicrobial resistance (AMR) remains one of the gravest global health threats, responsible for over 35 000 deaths annually in the EU/EEA and projected to cause nearly 2 million deaths worldwide each year by 2050. While Europe has long positioned itself as a frontrunner in the fight against AMR, growing international mobility and fragmented policy implementation continue to undermine progress. This viewpoint argues that strengthening a coordinated One Health response is essential to address the transboundary nature of antimicrobial resistance. The European response must now evolve beyond national and regional frameworks, with strengthened surveillance at borders, stronger political commitment at the continental level, to curb imported and emerging resistant infections. Only a unified, globally connected Europe can lead an effective and sustainable response to this silent pandemic.

## A growing threat without borders

AMR knows no borders, income levels, or political systems. In 2022, over 865 000 infections and 35 000 deaths in the EU/EEA were linked to resistant bacteria, according to the ECDC.¹ Across Member States, multidrug-resistant organisms (MDROs) account for approximately 71% of healthcare-associated infections.² Globally AMR could cause 39 million cumulative deaths between 2025 and 2050.³ Beyond the human toll, resistant infections threaten food security, animal welfare, and economic stability, with productivity losses and healthcare expenditures estimated at €1.5 billion per year including more than 569 million additional hospital days projected by 2050.⁴

## Europe's unfinished agenda

Nearly all EU/EEA countries have developed One Health (OH) National Action Plans (NAPs), following the 2023 EU Council Recommendation on AMR (2023/C 220/01).⁵ Yet implementation remains uneven and requires collective impetus. A 2024 European Joint Action on Antimicrobial Resistance and Healthcare-Associated Infections 2 (EU-JAMRAI-2) involving 30 European Member States has conducted a needs-assessment survey. Data revealed that merely 18% of Member States (n=5/28) have fully comprehensive OH NAPs, while one-third

lack updated or adequately funded plans. Key obstacles include insufficient human resources (36%), weak interministerial coordination (29%), and fragmented funding (29%). These gaps are particularly concerning given the significant association between poor NAP implementation and higher AMR-related mortality in countries lacking robust plans.⁶

This pattern mirrors broader experience from emergency preparedness research, where fragmented coordination structures and unclear mandates systematically weaken preparedness and increase mortality risk.⁷

Despite EU-level frameworks such as EU4Health, the Health Emergency Preparedness and Response Authority (HERA) and the One Health Priority Research Agenda for AMR,⁸ governance of AMR in Europe still operates in silos.

## The one health approach: from concept to operational reality

One Health remains the cornerstone for understanding and combating AMR,⁹,¹⁰ yet its application often remains rhetorical. Effective implementation requires harmonized surveillance, coordinated legislation, and cross-sectoral investment.

For instance, the WHO *Tricycle* project¹¹—linking human, animal and environmental surveillance in Madagascar, Nepal and Indonesia—shows that integrated surveillance can succeed
even in resource-limited settings. In Europe, initiatives such as European Antimicrobial Resistance Surveillance network in Veterinary medicine (EARS-Vet) and the Joint Inter-Agency Antimicrobial Consumption and Resistance Analysis (JIACRA) reports¹² have laid essential groundwork. These advances, though substantial, remain hindered by persistent data silos across sectors and surveillance systems, resulting in heterogeneous data formats and an incomplete European overview. To move from concept to practice, Europe must invest in data interoperability and joint risk assessment—transforming these stand-alone efforts into a cohesive One Health system.

## Travel, trade and transmission: the hidden accelerators

Globalization accelerates the movement not only of goods and people but also of resistant genes. Beyond trade and food imports, human mobility through tourism, migration, and medical travel represents a major but under-recognised accelerator of AMR dissemination.

In today's interconnected world—including tourism, migration, and medical travel—human mobility has become a major driver of dissemination. Over 70% of travellers returning from South Asia carry ESBL-producing Enterobacterales, representing a 14-fold higher risk than non-travellers,¹³ and medical tourists are twice as likely to acquire resistant bacteria.¹⁴ Yet travel-related AMR carriage is largely overlooked,¹⁵ and integrating travel history into diagnostic and stewardship protocols would help close this blind spot.

Trade in livestock, food, and pharmaceuticals creates complex feedback loops between continents⁴—Europe imports both products and pathogens. International travel and cross-border trade therefore represent key pathways for the introduction and dissemination of resistant bacteria, as shown, for example, by microbiological analyses of food products confiscated from air passengers entering the EU that revealed MDROs including methicillin-resistant Staphylococcus aureus and ESBL-producing Enterobacterales in imported food, primarily from South-Eastern third countries.¹⁶

The COVID-19 pandemic further demonstrated how quickly pathogens can cross borders when governance lags behind biology.¹⁷ In this context, AMR fits squarely within the European Union's framework for serious cross-border threats to health, as defined by Regulation (EU) 2022/2371,¹⁸ calling for permanent and coordinated border-health surveillance and response mechanisms. Such measures should therefore become core elements of preparedness, rather than temporary crisis-driven tools.

## From coordination to commitment

Policy declarations alone will not halt resistance. The 2024 UN General Assembly Political Declaration on AMR¹⁹ reaffirmed global consensus, yet implementation requires dedicated political accountability. Europe must encourage interministerial governance, promoting empowered One Health taskforces with stable mandates and budgets, as previously showed to be of interest for national climate change adoption in Europe.²⁰

Indeed, allocating USD 4 purchasing power parity per person annually to One Health interventions could avert 17000 deaths and save €9.4 billion in healthcare costs across OECD and EU/EEA countries.⁴ Such returns demonstrate that AMR control is not only a moral imperative but also an economic opportunity.

## Building societal ownership

No AMR strategy can succeed without public engagement. Education on antibiotic use and stewardship remains insufficient across disciplines. Surveys in 29 European countries show that many medical students felt unprepared to prescribe antibiotics responsibly.²¹ The UK has similarly reported poor coverage of AMS/AMR in postgraduate training,²² while India and other high-burden countries advocate for standardized AMR education.²³ A recent global review found comparable gaps across medical, pharmacy, nursing, and veterinary curricula.²⁴

Public initiatives such as AMR symbol and awareness campaigns have raised visibility, but broader adoption as a European marker of responsibility could be transformative.

## A vision for global health leadership

Building on recent calls for strengthened European leadership on AMR,²⁵ the present viewpoint provides new operational insights from the EU-JAMRAI-2 needs-assessment survey, with a specific focus on cross-border preparedness, mobility-related AMR risks, and implementation gaps across EU/EEA Member States. This highlights the importance of cross-border collaboration and intercontinental coordination to address transboundary AMR threats.

Europe's global AMR engagement includes support for capacity building, surveillance strengthening, and technical assistance in low- and middle-income regions, including Africa and South-East Asia, where implementation of the WHO Global Action Plan on AMR remains uneven and under-resourced (e.g. low thematic implementation scores across One Health dimensions in several African countries).²⁶

In this context, the European Union has a dual responsibility: to protect its own population through coordinated internal action, and to act as a global AMR partner through multilateral engagement and capacity building at the international level.

The EU-JAMRAI-2 initiative illustrates how continental coordination, aligned with other EU-level initiatives, can contribute to wider international efforts when supported by a clear political mandate. To sustain momentum, Europe should build on the three synergistic pillars of action outlined by the quadripartite (WHO, FAO, WOAH, UNEP):

* **Policy harmonisation**—Align Member-State legislation through the One Health Priority Research Agenda for AMR (2026–2030) and synchronize surveillance requirements to better address transboundary risks.

* **Research and innovation**—Strengthen support for the European Partnership on One Health AMR and the European Partnership on Animal Health and Welfare to accelerate the
<table><caption>**Table 1.** From fragmented national actions to a unified European response</caption><thead><tr><td>Current challenge</td><td>Previous EU/EEA efforts</td><td>Illustrative evidence</td><td>Current EU/EEA efforts</td><td>Proposed EU-level transboundary actions</td></tr></thead><tbody><tr><td>Fragmented national AMR policies</td><td>Early EU guidance Action plan against the rising threats from AMR (2011)</td><td>Only ≈18 % of EU/EEA countries have fully comprehensive One Health NAPs; 35 % lack monitoring &amp; evaluation (EU-JAMRAI 2 Survey, 2024)</td><td>EU4Health, EU-JAMRAI-2, council recommendation (2023)<sup>8</sup></td><td>Harmonized legislation and permanent interministerial One Health taskforces</td></tr><tr><td>Uneven surveillance integration</td><td>Initial EU surveillance networks: EARS-Net, pilot testing of EARS-Vet</td><td>Data remain siloed between EARS-Net, JIACRA, and EARS-Vet networks (Mader et al., 2021<sup>15</sup>)</td><td>EARS-Vet, JIACRA, EU-JAMRAI-2</td><td>Invest in data interoperability and cross-sector analysis</td></tr><tr><td>Limited cross-border preparedness</td><td>Early Warning and Response System (EWRS), (2006) Early cross-border guidance and international agreements with HERA (2020)</td><td>>70 % of travellers returning from South Asia carry ESBL-producing Enterobacterales (Voor in 't Holt et al., 2020<sup>5</sup>); imported food may carry resistant bacteria (Rinn et al., 2025<sup>16</sup>)</td><td>EU-JAMRAI-2 surveillance networks reinforcement, Serious cross-border threats to health (2022)<sup>18</sup></td><td>Embed travel and trade data within AMR surveillance and stewardship programmes</td></tr><tr><td>Under-investment in prevention</td><td>Previous EU funding initiatives for AMR prevention such as EU-JAMRAI 1</td><td>AMR costs ≈ €1.5 billion/year + >569 million extra hospital days projected by 2050 (OECD, 2019<sup>4</sup>)</td><td>EU4Health funding, Horizon Europe programme (2021-2027)</td><td>Stable EU funding ≈ USD 4 PPP per person → ≈17 000 deaths averted (OECD, 2019<sup>4</sup>)</td></tr><tr><td>Weak societal awareness</td><td>European Antibiotic Awareness Day (EEAD) since 2007</td><td>Only 39 % of final-year medical students felt adequately trained; ≈60 % felt unprepared (Dyar et al., 2018<sup>21</sup>)</td><td>EU-JAMRAI-2 awareness campaigns, AMR symbol initiatives, EEAD, the EU platform on AMR</td><td>Mandate AMR education in health curricula and expand public stewardship campaigns</td></tr></tbody></table>

Key evidence from EU-JAMRAI 2, ECDC, OECD, and published studies highlights persistent gaps in AMR policy implementation; the right-hand column outlines proposed transboundary actions tracks to strengthen European policies.

development of novel antimicrobials, diagnostics, and vaccines, ensuring equitable global access.

* **Societal engagement**—Expand education and communication initiatives targeting both health professionals and the public to embed AMR awareness within broader citizenship and sustainability narratives.

These international and national challenges inform the proposed 'Beyond Borders' actions, summarized in Table 1, which highlight coordinated EU-level efforts in capacity building, harmonized surveillance, and cross-sector policy alignment to strengthen Europe's collective response to AMR.

## Conclusion

Antimicrobial resistance is not an isolated European problem—it is a global pandemic unfolding in slow motion. To safeguard future generations, Europe through EU-JAMRAI-2 must move from coordination to commitment—harmonising surveillance, aligning governance, investing in innovation within a One Health framework. By addressing the transboundary drivers of AMR, Europe can both better protect its own population and play a leading role in contributing to global efforts to mitigate the projected burden by 2050.

## Acknowledgements

The authors thank the EU-JAMRAI-2 network and participating Member-State focal points for sharing their national AMR action-plan data and policy insights that informed this commentary.

## Funding

101127787/EU-JAMRAI 2 receives funding from the European Union's EU4Health programme under grant agreement no 101127787. Views and opinions expressed are however those of the author(s) only and do not necessarily reflect those of the European Union or the European Health and Digital Executive Agency (HADEA). Neither the European Union nor the granting authority can be held responsible for them.

## Transparency declarations

B. D. received travel support from Pfizer to attend international meetings (no fees or honoraria received). All other authors: none to declare.

## Author contributions

All authors meet the ICMJE criteria for authorship. B. D.: Conceptualization, drafting, critical revision of the manuscript. D. M.: Literature review, policy analysis, drafting of selected sections. M. F. -B.:
Review of EU policy frameworks, editing, final approval of the version to be published. All authors have read and approved the final version of the manuscript.

## Ethical statement

No ethical approval was required for this commentary, as it does not involve individual patient data or human participants. The analysis draws exclusively on publicly available aggregated information and official European data sources.

## Informed consent

Not applicable. The article contains no identifiable human data. I confirm that all listed authors have contributed to this work and approved the paper.

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