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Keeping Medicines Out of Water We spoke to Erika Brattinga-Róth, project leader of the Interreg NWE–funded PREWAPHARM project, about a transnational effort to reduce pharmaceutical pollution in European waterways. By bridging the healthcare and water sectors, the project develops source-based strategies that address a growing environmental and public health challenge. Pharmaceutical residues are an increasingly important source of water pollution across Europe. After use, a substantial share of some orally administered medicines – including antibiotics and hormones – may be excreted unchanged or as metabolites and ultimately enter wastewater and surface waters. Traditional wastewater treatment plants were not designed to remove these micropollutants; international evidence shows that removal efficiencies vary widely by substance, treatment process, and region (Khasawneh & Palaniandy, 2021; RIVM, 2020). Residues that pass through are discharged into surface waters, where they can affect aquatic ecosystems, contribute to pathways linked to antibiotic resistance, and pose risks to ecosystem health. Demographic and climatic trends compound the problem: as populations age, medicine consumption rises, and during droughts lower water volumes can concentrate pollutants, increasing the likelihood that water bodies will fail to meet revised European quality standards. Evidence suggests environmental impacts. Even in very low concentrations, pharmaceutical residues can disrupt the behaviour and reproductive biology of aquatic organisms. Some psychoactive compounds reduce normal predator-avoidance responses in fish, while endocrine-disrupting substances such as synthetic oestrogens have been associated with feminisation and sex change in amphibians (Arnold et al., 2014; OECD, 2019; Martin et al., 2017). These effects cascade through food chains and contribute to biodiversity loss, undermining the ecological systems on which human health depends. This interdependence is captured by the One Health concept, which holds that without a healthy environment and healthy animals, human health cannot be sustained. “People need to see this system – that every human being is part of it, and you cannot separate yourself from the environment,” explains Erika Brattinga-Róth, the project leader of PREWAPHARM. Addressing this challenge is complicated by the fact that responsibility is distributed across sectors that have traditionally operated in

isolation. Healthcare professionals prescribe and dispense medicines, water authorities manage treatment infrastructure, and policymakers set regulatory frameworks, yet coordinated action between these domains has been limited. The Interreg North-West Europe–funded project PREWAPHARM (Prevention of Water Pollution by Pharmaceuticals) was conceived to bridge this divide. With 18 partners and 38 associated organisations from seven countries – the Netherlands, Belgium, Germany, Luxembourg, France, Switzerland and Ireland – the project brings together expertise from the healthcare and water sectors to develop collaborative, source-based solutions.

Bridging Policy Gaps PREWAPHARM adopts a chain-wide approach, intervening at multiple points from prescription to wastewater discharge. Its first pillar benchmarks existing EU, national, and regional legislation to identify gaps that hinder effective action. Relevant directives – including the Water Framework Directive, the Urban Wastewater Treatment Directive, the Drinking Water Directive, and the recently adopted Soil Monitoring and Resilience Directive – are being examined alongside the reformed EU pharmaceutical legislation, which reached political agreement in December 2025. Until recently, most pharmaceutical substances were not covered by EU-wide binding surfacewater quality standards. This changed with the formal adoption in mid-February 2026 of revised EU water-pollution rules, which now include seven pharmaceutical substances – azithromycin, carbamazepine, clarithromycin, diclofenac, erythromycin, ibuprofen, and permethrin – and three estrogenic hormones:

17-beta estradiol (E2), estrone (E1), and ethinyl estradiol (EE2) (Council of the European Union, 2026; European Commission, 2022). These requirements must now be transposed into national law and incorporated into monitoring programmes. The revised Urban Wastewater Treatment Directive, in force since 1 January 2025, requires producers of human medicinal and cosmetic products to cover at least 80% of the costs of quaternary treatment through extended producer responsibility schemes. However, transposition into national legislation is ongoing and considerable debate surrounds implementation. Additionally, some pharmaceuticals contain fluorinated structures that may fall under certain PFAS definitions – highly persistent chemicals that break down only very slowly in the environment. As they degrade, they can form trifluoroacetic acid (TFA), a mobile substance particularly difficult to remove from water. The intersection of pharmaceutical pollution with the broader PFAS challenge underscores the urgency of coordinated action. PREWAPHARM’s transnational strategy, accompanied by regional action plans for the Netherlands, Belgium, Germany, and Luxembourg, is intended to provide policymakers with a practical framework for closing these gaps.

considerably across the seven participating countries. By comparing the effects of interventions across different systems, we can identify which approaches are most effective in each context,” explains Brattinga-Róth. On the water technology side, four pilot projects are testing treatment methods at high-impact sites, including hospitals in Luxembourg and Belgium, small-scale municipal wastewater treatment plants, and a combined sewer overflow. Partner organisations are evaluating, combining, and optimising technologies including membrane treatment, electrochemical removal, advanced oxidation processes, adsorbent resins, and naturebased solutions, alongside an innovative bioaugmented filtration system. The first hospital

The third pillar of PREWAPHARM is to ensure the long-term sustainability of the project’s outcomes. PREWAPHARM is establishing local communities of practice in each participating region, bringing together stakeholders from healthcare, water management, government, and research to foster collaborative action. These regional communities will be connected through the North-West European Centre of Medicine Residues in Water, a knowledge and advisory hub designed to continue beyond the project’s four-year lifetime. Initially functioning as an online platform providing access to current knowledge and enabling professionals to submit practical questions, the centre is intended to evolve into a dynamic meeting

“Without a healthy environment and healthy animals, we cannot have healthy people. People need to see this system – that every human being is part of it, and you cannot separate yourself from the environment.” pilot in Luxembourg is expected to begin mid2026. In the Belgian hospital pilot, the most promising technologies will be tested on a larger scale, and the potential for water reuse will be assessed. The small-scale wastewater treatment plant pilot will also begin in 2026, testing enhanced treatment wetlands for the removal of active pharmaceutical ingredients. “A lot of technology is already available; we can remove virtually all pharmaceuticals from wastewater. The question is: what is most effective, what is feasible, and where in the chain is the best place to intervene?” notes Brattinga-Róth. Organisations with proven best practices in pharmaceutical mitigation or water technology are invited to share their experience with the consortium.

place for networking and exchange. In parallel, training programmes are being developed for both healthcare professionals on sustainable prescribing and water professionals on treatment technologies. Aligned with the EU Green Deal and the Zero Pollution Action Plan, the project’s findings are intended to inform policymakers at regional, national, and European levels. This complex, cross-sectoral challenge calls for joint action to reduce the impact of medicine use on clean water availability. The project team welcomes perspectives on current policy gaps and ideas for improvement, as well as proven best practices that could be implemented more widely across North-West Europe. Pilot-scale constructed wetland to remove contaminants.

From Prescription to Purification

PREWAPHARM Tackling water pollution by pharmaceuticals at its source

Project Objectives

PREWAPHARM aims to reduce pharmaceutical residues in water across Northwest Europe by developing a joint transnational strategy and regional action plans, piloting upstream solutions from sustainable prescribing to on-site wastewater treatment, and establishing a Northwest European Centre of Excellence for Medicine Residues in Water as a lasting knowledge hub.

Project Funding

This project has received funding from the European Union’s Interreg NWE program under grant no. NWE0400548 (PREWAPHARM).Views and opinions expressed are however those of the author(s) only and do not necessarily reflect those of the European Union nor the granting authority. Neither the European Union nor the granting authority can be held responsible for them.

Project Partners

PREWAPHARM is an Interreg NWE initiative uniting 18 partners across six countries. https://prewapharm.nweurope.eu/partners

Associated Partners

PREWAPHARM is supported by 38 associated partners across six countries, strengthening cross-sector collaboration and impact. https://prewapharm.nweurope.eu/associated-partners

Contact Details

Project Coordinator, Erika Brattinga-Róth E: prewapharm@tcnn.nl W: https://prewapharm.nweurope.eu/

Erika Brattinga-Róth, Eelko Hak, Pieter-Jan De Buyck, and Jimmy Roussel

Erika Brattinga-Róth coordinates PREWAPHARM as project leader and leads the Northern Netherlands Medicine Residues in Water Network, bringing 20+ years’ applied research and project management experience. Eelko Hak is a professor of pharmacoepidemiology from the University of Groningen, leads Pillar 1 and has been leading pharmacy-related environmental research since 2019.

The second pillar translates strategic insights into practical pilot interventions. On the pharmaceutical side, three transnational pilots are testing approaches to sustainable prescribing: a population-level medicine benchmarking tool that compares dispensing practices across participating countries, community-pharmacy and GP-led interventions promoting greener prescription choices, and a transitional healthcare toolkit for patients moving from hospital to home care. Where medicines with equivalent therapeutic efficacy exist, healthcare professionals can be guided toward alternatives with a lower environmental footprint. “The role of pharmacists and their influence on medicine dispensing vary

EU Research

Sustaining the Impact

Pieter-Jan De Buyck, R&D Project Lead at VITO, is responsible for Pillar 2 and has 10+ years’ water- sector experience developing solutions for industry and society. Jimmy Roussel is a Lead R&T Engineer at LIST with over 15 years’ experience in the field of wastewater treatment, oversees Pillar 3.