Hospital Wastewater Treatments Adopted in Asia, Africa, and Australia

Hospital wastewater treatment methods and its impact on human health and environments

The scientific development and economic advances have led to the identification of many pathogenic agents in hospital effluents. Hospital wastewaters are qualitatively similar to municipal wastewaters, with the difference that these wastewaters contain toxic and infectious substances and compounds that can be dangerous for the health of the environment, employees of these centers, and the entire community. Therefore, in the last few years, it has been emphasized that all hospitals and medical and health centers should have a treatment facility for their produced wastewater so that the health of the society and people is not threatened. An issue that is not paid attention to has become one of the environmental problems and concerns of the world today. The present study focused on the investigate hospital wastewater treatment methods and its impact on human health and the environment. In this narrative study, the first literature search was performed with four hundred and twenty-three articles were retrieved based on PubMed, Elsevier, Web of science, Spring, and Google Scholar databases. The results of this study showed that wastewater from hospitals and medical centers can play a significant impress in polluting soil and aquatic environments and spreading infectious diseases. According to the mentioned contents, collection and treatment of hospital wastewater is essential. In addition, if hospital wastewater enters the wastewater collection network without knowing its characteristics or with incomplete treatment and finally enters the municipal wastewater treatment plant. It causes many problems, including disturbing the balance of the biological system of the treatment plant. Purification and disposal of hospital wastewater is considered a vital action based on environmental standards. The results of this study also showed that the treatment methods of this type of hospital wastewater can play a significant role in reducing the spread of diseases caused by hospital wastewater treatment, including infectious diseases. The results of this study can be very useful for politicians, the managers of the Ministry of Energy and Health and the Environmental Organization in choosing the appropriate methods and process to reduce hospital wastewater and increase the efficiency of hospital wastewater treatment plants.

A review on hazards and treatment methods of released antibiotics in hospitals wastewater during the COVID-19 pandemic

Drugs and related goods are widely used in order to promote public health and the quality of life. One of the most serious environmental challenges affecting public health is the ongoing presence of antibiotics in the effluents generated by pharmaceutical industries and hospitals. Antibiotics cannot be entirely removed from wastewater using the traditional wastewater treatment methods. Unmetabolized antibiotics generated by humans can be found in urban and livestock effluent. The antibiotic present in effluent contributes to issues with resistance to antibiotics and the creation of superbugs. Over the recent 2 years, the coronavirus disease 2019 pandemic has substantially boosted hospital waste volume. In this situation, a detailed literature review was conducted to highlight the harmful effects of untreated hospital waste and outline the best approaches to manage it. Approximately 50 to 70% of the emerging contaminants prevalent in the hospital wastewater can be removed using traditional treatment strategies. This paper emphasizes the numerous treatment approaches for effectively eliminating emerging contaminants and antibiotics from hospital wastewater and provides an overview of global hospital wastewater legislation and guidelines on hospital wastewater administration. Around 90% of ECs might be eliminated by biological or physical treatment techniques when used in conjunction with modern oxidation techniques. According to this research, hybrid methods are the best approach for removing antibiotics and ECs from hospital wastewater. The document outlines the many features of effective hospital waste management and might be helpful during and after the coronavirus disease 2019 outbreak, when waste creation on all hospitals throughout the globe has considerably increased.

Application of wastewater-based epidemiology for monitoring COVID-19 in hospital and housing wastewaters

An alternative and complementary diagnostic method of surveillance is provided by wastewater-based surveillance (WBS), particularly in low-income nations like Nepal with scant wastewater treatment facilities and clinical testing infrastructure. In this study, a total of 146 water samples collected from two hospitals (n = 63) and three housing wastewaters (n = 83) from the Kathmandu Valley over the period of March 2021-Febraury 2022 were investigated for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) using quantitative reverse transcription TaqMan PCR assays targeting the N and E genes. Of the total, 67 % (98/146) samples were positive for SARS-CoV-2 RNA either by using N- or E-gene assay, with concentrations ranging from 3.6 to 9.1 log10 copies/L. There was a significant difference found between positive ratio (Chi-square test, p < 0.05) and concentration (t-test, p = 0.009) of SARS-CoV-2 RNA detected from hospital wastewater and housing waters. Wastewater data are correlated with COVID-19 active cases, indicating significance in specific areas like the Hospital (APFH) (p < 0.05). According to the application of a bivariate linear regression model (p < 0.05), the concentrations of N gene may be used to predict the COVID-19 cases in the APFH. Remarkably, SARS-CoV-2 RNA was detected prior to, during, and following clinical case surges, implying that wastewater surveillance could serve as an early warning system for public health decisions. The significance of WBS in tracking and managing pandemics is emphasized by this study, especially in resource-constrained settings.

Ranking the risk of antibiotic resistance genes by metagenomic and multifactorial analysis in hospital wastewater systems

Antimicrobial resistance poses a serious threat to human health. Hospital wastewater system (HWS) is an important source of antibiotic resistance genes (ARGs). The risk of ARGs in HWS is still an under-researched area. In this study, we collected publicly metagenomic datasets of 71 hospital wastewater samples from 18 hospitals in 13 cities. A total of 9838 contigs were identified to carry 383 unique ARGs across all samples, of which 2946 contigs were plasmid-like sequences. Concurrently, the primary hosts of ARGs within HWS were found to be Escherichia coli and Klebsiella pneumoniae. To further evaluate the risk of each ARG subtype, we proposed a risk assessment framework based on the importance of corresponding antibiotics as defined by the WHO and three other indicators - ARG abundance (A), mobility (M), and host pathogenicity (P). Ninety ARGs were identified as R1 ARGs having high-risk scores, which meant having a high abundance, high mobility, and carried by pathogens in HWS. Furthermore, 25% to 49% of genomes from critically important pathogens accessed from NCBI carried R1 ARGs. A significantly higher number of R1 ARGs was carried by pathogens in the effluents of municipal wastewater treatment plants from NCBI, highlighting the role of R1 ARGS in accelerating health and environmental risks.

Removal of pharmaceutical contaminants from hospital wastewater using constructed wetlands: a review

AbstractPharmaceutical compounds are a significant source of environmental pollution, particularly in hospital wastewater, which contains high concentrations of such compounds. Constructed wetlands have emerged as a promising approach to removing pharmaceutical compounds from wastewater. This paper aims to review the current state of knowledge on the removal of pharmaceutical compounds from hospital wastewater using constructed wetlands, including the mechanism of removal, removal efficiency, and future prospects. Pharmaceutical contaminants have been considered to be one of the most emerging pollutants in recent years. In this review article, various studies on constructed wetlands are incorporated in order to remove the pharmaceutical contaminants. The nature of constructed wetland can be explained by understanding the types of constructed wetland, characteristics of hospital wastewater, removal mechanism, and removal efficiency. The results of the review indicate that constructed wetlands are effective in removing pharmaceutical compounds from hospital wastewater. The removal mechanism of these compounds involves a combination of physical, chemical, and biological processes, including adsorption, degradation, and uptake by wetland plants. The removal efficiency of constructed wetlands varies depending on several factors, including the type and concentration of pharmaceutical compounds, the design of the wetland system, and the environmental conditions. Further research is necessary to optimize the performance of these systems, particularly in the removal of emerging contaminants, to ensure their effectiveness and long-term sustainability.

Distribution, fate and removal efficiency of anthelmintic drugs in wastewater treatment plants

The distribution and fate of 19 anthelmintic drugs (ADs) were investigated in two wastewater treatment plants (WWTPs) using different wastewater treatment technologies, including anaerobic-anoxic-aerobic (A2/O) biological process and cyclic activated sludge system (CASS) process. All the 19 ADs were found in the two WWTPs, with concentrations ranging from N.D. to 324.6 ng/L in the influent and from N.D. to 1579.2 ng/L in the effluent. Benzimidazoles were the primary pollutants in the wastewater and suspended particulate matter, accounting for more than half of the total concentration. The concentrations of macrocyclic lactones in the sludge were significantly higher than that of other two media. The ADs removal efficiency of A2/O ranged from -330 % (albendazole sulfoxide) to 100 % (fenbendazole, mebendazole and pyrantel). While the ADs removal efficiency of CASS process ranged from -425 % (albendazole sulfoxide) to 100 % (abamectin, moxidectin and ivermectin). There was no significant difference in the average removal efficiency of the ADs between the two processes (64 % and 63 %, except albendazole sulfoxide). The removal efficiencies of the ADs in the biodegradation stage were better than them in the sedimentation stage. The load per capita of the 19 ADs in two WWTPs ranged from 0 (moxidectin) to 36 μg.d-1.p-1 (albendazole), and the emission in the effluent ranged from 0 (moxidectin) to 163 μg.d-1.p-1 (albendazole sulfoxide). This study provided the first comprehensive data on the occurrence and fate of the 19 ADs and evaluated the removal efficiencies of the 19 ADs in two WWTPs using A2O process and CASS process in the city.

Wastewater from healthcare centers in Burkina Faso is a source of ESBL, AmpC-β-lactamase and carbapenemase-producing Escherichia coli and Klebsiella pneumoniae

BACKGROUND

Extended-spectrum β-lactamase (ESBL), plasmid-mediated AmpC-β-lactamase and carbapenemase-producing Escherichia coli and Klebsiella pneumoniae have spread into the environment worldwide posing a potential public health threat. However, the prevalence data for low- and middle-income countries are still scarce. The aim of this study was to evaluate the presence of ESBL, AmpC-β-lactamase and carbapenemase-producing and multidrug-resistant E. coli and K. pneumoniae in wastewaters from healthcare centers in Burkina Faso.

RESULTS

Eighty-four (84) wastewater samples were collected from five healthcare centers and plated on selective ESBL ChromAgar. E. coli and Klebsiella pneumoniae isolates were identified using API20E. ESBL-producing bacteria were detected in 97.6% of the samples and their average concentration per hospital ranged from 1.10 × 105 to 5.23 × 106 CFU/mL. Out of 170 putative ESBL-producing isolates (64% of them were E. coli) and 51 putative AmpC-β-lactamase-producing isolates, 95% and 45% were confirmed, respectively. Carbapenemase production was detected in 10 isolates, of which 6 were NDM producers, 3 were OXA-48 producers and 1 was NDM and OXA-48 producer. All isolates were multidrug resistant and, moreover, all of them were resistant to all tested β-lactams. Resistance to ESBL inhibitors was also common, up to 66% in E. coli and 62% in K. pneumoniae. Amikacin, fosfomycin and nitrofurantoin were the antibiotics to which the least resistance was detected.

CONCLUSIONS

This study showed that wastewater from healthcare centers constitutes a reservoir of multidrug-resistant bacteria in Burkina Faso, including carbapenemase producers. Untreated healthcare wastewater entering the environment exposes people and animals to infections caused by these multi-resistant bacteria, which are difficult to treat, especially in the resource-poor settings.

Are hospital wastewater treatment plants a source of new resistant bacterial strains?

To understand which type of hospital waste may contain the highest amount of antibiotic resistant microorganisms that could be released into the environment, the bacterial strains entering and leaving a hospital wastewater treatment plant (HWTP) were identified and tested for their antibiotic susceptibility. To achieve this goal, samples were collected from three separate sites, inlet and outlet wastewater positions, and sludge generated in a septic tank. After microbiological characterization according to APHA, AWWA, and WEF protocols, the relative susceptibility of the bacterial strains to various antibiotic agents was assessed according to the Clinical and Laboratory Standards Institute guidelines, to determine whether there were higher numbers of resistant bacterial strains in the inlet wastewater sample than in the outlet wastewater and sludge samples. The results showed more antibiotic resistant bacteria in the sludge than in the inlet wastewater, and that the Enterobacteriaceae family was the predominant species in the collected samples. The most antibiotic-resistant families were found to be Streptococcacea and non-Enterobacteriaceae. Some bacterial strains were resistant to all the tested antibiotics. We conclude that the studied HWTP can be considered a source of resistant bacterial strains. It is suggested that outlet water and sludge generated in HWTPs should be monitored, and that efficient treatment to eliminate all bacteria from the different types of hospital waste released into the environment is adopted.

Metagenomic Insight into Microbiome and Antibiotic Resistance Genes of High Clinical Concern in Urban and Rural Hospital Wastewater of Northern India Origin: a Major Reservoir of Antimicrobial Resistance

India is one of the largest consumers and producers of antibiotics and a hot spot for the emergence and proliferation of antimicrobial resistance genes (ARGs). Indian hospital wastewater (HWW) accumulates ARGs from source hospitals and often merges with urban wastewater, with the potential for environmental and human contamination. Despite its putative clinical importance, there is a lack of high-resolution resistome profiling of Indian hospital wastewater, with most studies either relying on conventional PCR-biased techniques or being limited to one city. In this study, we comprehensively analyzed antibiotic resistomes of wastewater from six Indian hospitals distributed in rural and urban areas of northern India through shotgun metagenomics. Our study revealed the predominance of ARGs against aminoglycoside, macrolide, carbapenem, trimethoprim, and sulfonamide antibiotics in all the samples through both read-based analysis and assembly-based analysis. We detected the mobile colistin resistance gene mcr-5.1 for the first time in Indian hospital sewage. blaNDM-1 was present in 4 out of 6 samples and was carried by Pseudomonas aeruginosa in HWW-2, Klebsiella pneumoniae in HWW-4 and HWW-6, and Acinetobacter baumanii in HWW-5. Most ARGs were plasmid-mediated and hosted by Proteobacteria. We identified virulence factors and transposable elements flanking the ARGs, highlighting the role of horizontal gene transmission of ARGs. IMPORTANCE There is a paucity of research on detailed antibiotic resistome and microbiome diversity of Indian hospital wastewater. This study reports the predominance of clinically concerning ARGs such as the beta-lactamases blaNDM and blaOXA and the colistin resistance gene mcr and their association with the microbiome in six different Indian hospital wastewaters of both urban and rural origin. The abundance of plasmid-mediated ARGs and virulence factors calls for urgent AMR crisis management. The lack of proper wastewater management strategies meeting international standards and open drainage systems further complicates the problem of containing the ARGs at these hospitals. This metagenomic study presents the current AMR profile propagating in hospital settings in India and can be used as a reference for future surveillance and risk management of ARGs in Indian hospitals.

Antibiotic-resistant bacteria in hospital wastewater treatment plant effluent and the possible consequences of its reuse in agricultural irrigation

Wastewater from hospitals should be monitored precisely and treated properly before discharge and reuse to avoid epidemic and pandemic complications, as it contains hazardous pollutants for the ecosystem. Antibiotic residues in treated hospital wastewater effluents constitute a major environmental concern since they resist various wastewater treatment processes. The emergence and spread of multi-drug-resistant bacteria, that cause public health problems, are therefore always a major concern. The aims and objectives of this study were mainly to characterize the chemical and microbial properties of the hospital effluent of wastewater treatment plant (WWTP) before discharge to the environment. Special attention was paid to the presence of multiple resistant bacteria and the effects of hospital effluent reuse in irrigation on zucchini as an economically important plant. The risk of cell-free DNA carrying antibiotic resistance genes contained in the hospital effluent as a long-lasting hazard had been discussed. In this study, 21 bacterial strains were isolated from the effluent of a hospital WWTP. Isolated bacteria were evaluated for multi-drug resistance ability against 5 antibiotics (Tetracycline, Ampicillin, Amoxicillin, Chloramphenicol, and Erythromycin) at a concentration of 25 ppm. Out of them, three isolates (AH-03, AH-07, and AH-13) were selected because they recorded the highest growth in presence of tested antibiotics. Selected isolates were identified using 16S rRNA gene sequence homology as Staphylococcus haemolyticus (AH-03), Enterococcus faecalis (AH-07), and Escherichia coli (AH-13). Their susceptibility to ascending concentrations of tested antibiotics indicated that they were all susceptible at a concentration above 50 ppm. Results of the greenhouse experiment regarding the effect of hospital WWTP effluent reuse on zucchini plant fresh weights compared to that irrigated with fresh water indicated that the former recorded a limited increase in total fresh weights (6.2 g and 5.3 g/plant, respectively). Our results demonstrated the low impact of the reuse of Hospital WWTP effluent in agriculture irrigation compared to its greater risk in transferring multiple antibiotic bacteria and antibiotic resistance genes to soil bacteria through natural transformation.

Antibiotic degradation and mineralization: efficiency increase on combining different chemical treatment processes

The goal of this study was to assess the efficiency of antibiotic degradation applying different chemical treatment methods and their combinations. Thus, improvement in the efficiency of these methods when combined was quantified. The methods tested to degrade/mineralize the antibiotics amoxicillin (AMX) and ciprofloxacin (CIP) under different pH conditions (4, 7 and 10) were ultra-violet irradiation (UV_254 nm), ultrasound (US), hydrogen peroxide (H₂O₂) and ozone (O₃) alone and in combination. The results showed that individual methods were only partially efficient in the degradation/mineralization of antibiotics, except for ozonation at alkaline pH. In the combined methods, the best performance was obtained with US/UV/H₂O₂/O₃ (pH 10, 20-min treatment), where the degradation rates for the antibiotics were 99.8% for CIP and 99.9% for AMX. For the mineralization efficiency the values obtained were 71.3% for CIP and 79.2% for AMX. The results of this study could contribute to the development and improvement of wastewater treatment aimed at avoiding the presence of residual antibiotics in the environment.

An assessment of hospital wastewater and biomedical waste generation, existing legislations, risk assessment, treatment processes, and scenario during COVID-19

Hospitals release significant quantities of wastewater (HWW) and biomedical waste (BMW), which hosts a wide range of contaminants that can adversely affect the environment if left untreated. The COVID-19 outbreak has further increased hospital waste generation over the past two years. In this context, a thorough literature study was carried out to reveal the negative implications of untreated hospital waste and delineate the proper ways to handle them. Conventional treatment methods can remove only 50%-70% of the emerging contaminants (ECs) present in the HWW. Still, many countries have not implemented suitable treatment methods to treat the HWW in-situ. This review presents an overview of worldwide HWW generation, regulations, and guidelines on HWW management and highlights the various treatment techniques for efficiently removing ECs from HWW. When combined with advanced oxidation processes, biological or physical treatment processes could remove around 90% of ECs. Analgesics were found to be more easily removed than antibiotics, β-blockers, and X-ray contrast media. The different environmental implications of BMW have also been highlighted. Mishandling of BMW can spread infections, deadly diseases, and hazardous waste into the environment. Hence, the different steps associated with collection to final disposal of BMW have been delineated to minimize the associated health risks. The paper circumscribes the multiple aspects of efficient hospital waste management and may be instrumental during the COVID-19 pandemic when the waste generation from all hospitals worldwide has increased significantly.

Machine Learning Approach to Predict Quality Parameters for Bacterial Consortium-Treated Hospital Wastewater and Phytotoxicity Assessment on Radish, Cauliflower, Hot Pepper, Rice and Wheat Crops

Raw hospital wastewater is a source of excessive heavy metals and pharmaceutical pollutants. In water-stressed countries such as Pakistan, the practice of unsafe reuse by local farmers for crop irrigation is of major concern. In our previous work, we developed a low-cost bacterial consortium wastewater treatment method. Here, in a two-part study, we first aimed to find what physico-chemical parameters were the most important for differentiating consortium-treated and untreated wastewater for its safe reuse. This was achieved using a Kruskal–Wallis test on a suite of physico-chemical measurements to find those parameters which were differentially abundant between consortium-treated and untreated wastewater. The differentially abundant parameters were then input to a Random Forest classifier. The classifier showed that ‘turbidity’ was the most influential parameter for predicting biotreatment. In the second part of our study, we wanted to know if the consortium-treated wastewater was safe for crop irrigation. We therefore carried out a plant growth experiment using a range of popular crop plants in Pakistan (Radish, Cauliflower, Hot pepper, Rice and Wheat), which were grown using irrigation from consortium-treated and untreated hospital wastewater at a range of dilutions (turbidity levels) and performed a phytotoxicity assessment. Our results showed an increasing trend in germination indices and a decreasing one in phytotoxicity indices in plants after irrigation with consortium-treated hospital wastewater (at each dilution/turbidity measure). The comparative study of growth between plants showed the following trend: Cauliflower > Radish > Wheat > Rice > Hot pepper. Cauliflower was the most adaptive plant (PI: −0.28, −0.13, −0.16, −0.06) for the treated hospital wastewater, while hot pepper was susceptible for reuse; hence, we conclude that bacterial consortium-treated hospital wastewater is safe for reuse for the irrigation of cauliflower, radish, wheat and rice. We further conclude that turbidity is the most influential parameter for predicting bio-treatment efficiency prior to water reuse. This method, therefore, could represent a low-cost, low-tech and safe means for farmers to grow crops in water stressed areas.

Emergency Management of Medical Wastewater in Hospitals Specializing in Infectious Diseases: A Case Study of Huoshenshan Hospital, Wuhan, China

Medical wastewater originating from hospitals specializing in infectious diseases pose a major risk to human and environmental health during pandemics. However, there have been few systematic studies on the management of this type of wastewater management. The function of the Huoshenshan Hospital as a designated emergency field hospital for the treatment of COVID-19 has provided lessons for the management measures of medical wastewater, mainly including: (1) Modern information technology, management schemes, and related standard systems provided the legislative foundation for emergency management of medical wastewater. (2) The three-tier prevention and control medical wastewater management system ensured the discharged wastewater met water quality standards, especially for the leak-proof sealed collection system of the first tier, and the biological and chemical treatment technology of the second tier. (3) The establishment of an effective three-tier medical wastewater quality monitoring accountability system. This system was particularly relevant for ensuring continuous data monitoring and dynamic analysis of characteristic indicators. (4) Information disclosure by government and public supervision promoted successful implementation of medical wastewater management and control measures. Public questionnaires (n = 212) further confirmed the effectiveness of information disclosure. The results of this study can act as methodological reference for the emergency management of wastewater in designated infectious disease hospitals under similar situations.

A review on hospital wastewater treatment: A special emphasis on occurrence and removal of pharmaceutically active compounds, resistant microorganisms, and SARS-CoV-2

The hospital wastewater imposes a potent threat to the security of human health concerning its high vulnerability towards the outbreak of several diseases. Furthermore, the outbreak of COVID-19 pandemic demanded a global attention towards monitoring viruses and other infectious pathogens in hospital wastewater and their removal. Apart from that, the presence of various recalcitrant organics, pharmaceutically active compounds (PhACs), etc. imparts a complex pollution load to water resources and ecosystem. In this review, an insight into the occurrence, persistence and removal of drug-resistant microorganisms and infectious viruses as well as other micro-pollutants have been documented. The performance of various pilot/full-scale studies have been evaluated in terms of removal of biochemical oxygen demand (BOD), chemical oxygen demand (COD), total suspended solids (TSS), PhACs, pathogens, etc. It was found that many biological processes, such as membrane bioreactor, activated sludge process, constructed wetlands, etc. provided more than 80% removal of BOD, COD, TSS, etc. However, the removal of several recalcitrant organic pollutants are less responsive to those processes and demands the application of tertiary treatments, such as adsorption, ozone treatment, UV treatment, etc. Antibiotic-resistant microorganisms, viruses were found to be persistent even after the treatment of hospital wastewater, and high dose of chlorination or UV treatment was required to inactivate them. This article circumscribes the various emerging technologies, which have been used to treat PhACs and pathogens. The present review also emphasized the global concern of the presence of SARS-CoV-2 RNA in hospital wastewater and its removal by the existing treatment facilities.

SARS-CoV-2 in hospital wastewater during outbreak of COVID-19: A review on detection, survival and disinfection technologies

Currently, the apparition of new SARS-CoV, known as SARS-CoV-2, affected more than 34 million people and causing high death rates worldwide. Recently, several studies reported SARS-CoV-2 ribonucleic acid (RNA) in hospital wastewater. SARS-CoV-2 can be transmitted between humans via respiratory droplets, close contact and fomites. Fecal-oral transmission is considered also as a potential route of transmission since several scientists confirmed the presence of SARS-CoV-2 RNA in feces of infected patients, therefore its transmission via feces in aquatic environment, particularly hospital wastewater. Hospitals are one of the important classes of polluting sectors around the world. It was identified that hospital wastewater contains hazardous elements and a wide variety of microbial pathogens and viruses. Therefore, this may potentially pose a significant risk of public health and environment infection. This study reported an introduction about the Physical-chemical and microbiological characterization of hospital wastewater, which can be a route to identify potential technology to reduce the impact of hospital contaminants before evacuation. The presence of SARS-CoV-2 in aqueous environment was reviewed. The knowledge of the detection and survival of SARS-CoV-2 in wastewater and hospital wastewater were described to understand the different routes of SARS-CoV-2 transmission, which is also useful to avoid the outbreak of CoV-19. In addition, disinfection technologies used commonly for deactivation of SARS-CoV-2 were highlighted. It was revealed that, chlorine-containing disinfectants are the most commonly used disinfectants in this field of research. Meanwhile, other efficient technologies must be developed and improved to avoid another wave of the pandemic of COVID-19 infections.

Hospital Wastewater as a Reservoir for Antibiotic Resistance Genes: A Meta-Analysis

Background: The emergence and dissemination of antibiotic resistance genes (ARGs) in the environment poses a huge global health hazard. Hospital wastewater (HWW), in which a high density of antibiotic residues and antibiotic-resistant bacteria are present, may be a reservoir of ARGs dissemination into the environment. Our meta-analysis comprehensively analyzes the prevalence of ARGs in HWW, as well as the influencing factors in ARGs distribution.

Methods: Online databases were used to search for literature using the subject terms: “Drug Resistance” AND “Genes” AND “Hospitals” AND “Wastewater.” Two reviewers independently applied predefined criteria to assess the literature and extract data including “relative abundance of ARGs,” “title,” “authors,” “country,” “location,” “sampling year,” and “sampling seasons.” The median values and 95% confidence intervals of ARGs abundance were calculated by Wilcox.test function in R. Temporal trends, spatial differences, seasonal variations and removal efficiency of ARGs were analyzed by Pearson correlation analysis and Kruskal-Wallis H test.

Results: Resistance genes to carbapenems, sulfonamides, tetracyclines and mobile genetic elements were found at high relative abundance (>10⁻⁴ gene copies/16S rRNA gene copies) in HWW. The abundance of resistance genes to extended-spectrum β-lactams, carbapenems, sulfonamides and glycopeptide significantly decreased, while tetracycline resistance genes abundance increased from 2014 to 2018. The abundance of ARGs was significantly different by country but not by season. ARGs could not be completely removed by on-site HWW treatments and the removal efficiency varies for different ARGs.

Conclusions: HWW presents more types of ARGs, and their abundance is higher than those in most wastewater systems. HWW may be a reservoir of ARGs and play an important role in the dissemination of ARGs.

Treatment of hospital wastewater by supercritical water oxidation process

Hospital wastewater contains several micro and macro pollutants that cannot be removed efficiently by conventional treatment processes. Thus, generally hybrid and multistage treatment methods are suggested for the treatment of hospital wastewater. Supercritical water oxidation (SCWO) is a promising method for the removal of emerging organic pollutants from hospital wastewater in one step and a very short reaction time. In this study, supercritical water oxidation (SCWO) process was used for the removal of pharmaceuticals in addition to conventional pollutants from real hospital wastewater. As a result of a series of preliminary studies, the optimum conditions were selected as 450 °C, 60 s, and 1:1 for temperature, reaction time, and oxidant ratio (H₂O₂/COD), respectively, for the treatment of hospital wastewater at 25 ± 1 MPa. The removal rates were determined above 90% for COD, BOD, TOC, TN, and SS from hospital wastewater. Phosphorus removal was greater than 90%, while the removal rates were around 80% for phenol, AOX, and surfactants in hospital wastewater. A total of 9 pharmaceuticals were observed in the real hospital wastewater samples. The highest removal rate was obtained for Paracetamol as 99.9%, while the lowest removal rate was obtained for Warfarin as 72% after SCWO treatment of hospital wastewater. As a result, it can be concluded that SCWO process is sufficient for the treatment of hospital wastewater without the need of additional treatment steps, with high removal rates in a short reaction time.

Three-dimensional batch electrochemical coagulation (ECC) of health care facility wastewater-clean water reclamation

Three-dimensional (3D) batch ECC of raw health care facility wastewater (HCFWW) was adopted using stainless steel (SS) and aluminum (Al) scrap metal particle electrodes. ECC treatment was focused on priority quality parameters viz., chemical oxygen demand (COD), color, and other important water quality parameters. Sludge settling and filterability for post-ECC slurry were investigated after ECC. COD removals of 87.56 and 87.2% were achieved for current densities (CD) 83.33 and 125 A/m² using SS-3D electrodes, and similarly, 86.99 and 86.23% COD removal for Al-3D electrodes. Simultaneously, color removals were 88.50 and 87.60% for CD 166.66 A/m² (4A) using SS and Al-3D electrodes. Water quality parameters viz., nitrate, phosphates, and sulfate were also removed by 93.18%, 96.83%, and 41.07% for SS-3D electrodes, while Al-3D electrodes showed 93.15%, 96.72%, and 25.94% removal. Post-ECC slurry settling was good for all the applied CD using SS-3D electrodes generating dense and sturdy flocs. Al-3D electrodes showed excellent floc settling properties. SS-3D electrode flocs displayed good filterability at 1A with α: 2.497 × 10¹¹ m kg^-1 and R_m 1.946 × 10¹⁰ m^-1. Post-ECC slurry using Al-3D electrodes were viscous causing delayed filterability giving α: 1.1760 × 10¹¹ m kg^-1 and R_m 1.504 × 10⁹ m^-1 for 3A. E. coli was destroyed by 97 and 98% for 2A and 3A respectively. Clear water reclamation of 85-90% and pollutants/contaminants removed within a short HRT of 75 min proved the effectiveness of adopting 3D-ECC for treating raw HCFWW.