One Health strategies for addressing antimicrobial resistance: an exclusive emphasis on Bulgaria

Antimicrobial resistance (AMR) is a public health challenge, primarily driven by the excessive use of antibiotics (ABs). While the European Union (EU) has successfully reduced ABs consumption since 2009, Bulgaria (BG) reports an increase in ABs use in both community and hospital settings. According to the 2021 Eurobarometer, the consumption rate of ABs among Bulgarians is twice as high as that in Germany, with a significant number taking ABs without a prescription. Moreover, only 41% of Bulgarians are aware that ABs do not kill viruses, and 30% took ABs for COVID-19 (as compared to 1% in Finland). This highlights an urgent need for interventions to tackle AMR in BG, using One Health (OH) approaches that consider the complex interplay between human, animal, and environmental health. The data presented aims to alert a wide range of stakeholders that AMR is not just a clinical or national issue but it has cross-border implications. It emphasizes the role that everyone must play in preserving the efficacy of ABs. Strategies for sustainable OH solutions: Researchers and educators should incorporate AMR and OH in their core responsibilities, providing relevant training and raising community awareness regarding prudent ABs use. Encouraging integrative medicine approaches, including traditional practices such as phytotherapy, can help delay the ABs prescriptions. Research is also necessary to support OH legislative changes that restrict ABs sales. Particularly, Bulgaria is among the few EU countries that have not approved an OH Action Plan against AMR or an inter-sectoral OH mechanism between veterinary, food, and health authorities. OH remains relatively unfamiliar in BG. Despite this, there is a political will to develop national OH policies, as demonstrated in the recently adopted National Health Strategy 2030. Urgent actions are needed to address AMR in BG. Using EU's AMR activities as a model, this analysis is a step towards a regional OH project. KEY MESSAGES: • AMR is a pressing public health problem in Bulgaria with cross-border implications. One Health strategies are needed urgently to address it. EU's AMR activities can be a model. • Bulgarian researchers, educators, and policymakers must make AMR their central responsibility. OH Action Plan against AMR and an inter-sectoral collaboration are the keys to success.