Journal of Cleaner Production 273 (2020) 122851

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Journal of Cleaner Production

journal homepage: www.elsevier.com/locate/jclepro

Review

Hospital laundry wastewaters: A review on treatment alternatives, life

cycle assessment and prognosis scenarios
Carlos Alexandre Lutterbeck*, Gustavo Stolzenberg Colares, Naira Dell’Osbel,
^
Fagner P. da Silva, Lourdes Teresinha Kist, Enio Leandro Machado**
Graduate Program in Environmental Technology, University of Santa Cruz Do Sul d UNISC, Santa Cruz Do Sul, RS, Brazil

a r t i c l e i n f o a b s t r a c t

Article history: Because of the generation of high volumes of wastewaters with known toxicological properties, hospital
Received 26 January 2020 laundry wastewaters constitute an unquestionable source of pollution for water bodies. So, the present
Received in revised form research aimed to summarize, analyze and discuss studies carried out by different work groups that focus
10 June 2020
their researches on the characterization and the treatment of these effluents. An initial section briefly
Accepted 14 June 2020
discussed the integrated management, including treatment alternatives, for hospital wastewaters. In a
Available online 15 July 2020
second step, bibliometric analysis based on the Web of Science database and using the VOSviewer
Handling editor: Prof. Jiri Jaromir Klemes software were carried out. Based on the obtained data, a literature review of characterization studies and
of the main alternatives for the treatment of hospital laundry wastewaters was performed. Finally, five of
Keywords: the discussed treatments were selected and submitted to life cycle assessment (LCA) in order to identify
Hospital laundry wastewaters the main aspects associated with the environmental burdens of the treatments and so help to propose
Bibliometric analysis alternatives that may mitigate these impacts. The results of the bibliometric analysis showed that despite
Advanced oxidation process the threat that hospital laundry wastewaters can pose to human and environmental health, a scare
Life cycle assessment and prognosis
number of studies address the treatment of these effluents. Furthermore, the few researches dedicated to
scenarios
this important topic, evaluate the treatment efficiency based only in reduction/removal of load param-
eters, i.e., disregarding the potential toxic effects of the wastewaters. LCA also showed that most of the
investigated treatments alternatives presented relevant negative impacts, so that, the benefits obtained
by the treatments might be lower than the environmental burdens and even increase the direct and
indirect toxic effects of the effluents. LCA also showed that most of the investigated treatments alter-
natives presented relevant negative impacts, so that, the benefits obtained by the treatments might be
lower than the environmental burdens and even increase the direct and indirect toxic effects of the
effluents. In the vast majority of the analyzed categories, these negative impacts were mainly associated
with the consumption of electricity. Therefore, treatment systems with high energy requirements should
be avoided, even when achieving good pollutant removal rates due to relevant “environmental costs”. So,
LCA results showed that the replacement of fossil fuels by cleaner energy sources, such as solar energy,
may significantly lower the negative environmental impacts.
© 2020 Elsevier Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2. Conception, implementation and analysis for the integrated management of hospital laundry wastewaters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
3. Bibliometric analysis and treatment methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

* Corresponding author. Graduate Program in Environmental Technology, Uni-

versity of Santa Cruz do Sul d UNISC, Santa Cruz do Sul, RS, Brazil.
** Corresponding author. Graduate Program in Environmental Technology, Uni-
versity of Santa Cruz do Sul d UNISC, Santa Cruz do Sul, RS, Brazil.
E-mail addresses: carlosalexandre@unisc.br (C.A. Lutterbeck), enio@unisc.br
^ Machado).
(E.L.

https://doi.org/10.1016/j.jclepro.2020.122851
0959-6526/© 2020 Elsevier Ltd. All rights reserved.
2 C.A. Lutterbeck et al. / Journal of Cleaner Production 273 (2020) 122851

3.1. Bibliometric analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

3.2. Treatment methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
3.2.1. Physicochemical methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
3.2.2. Advanced oxidation processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
3.2.3. Novel treatment technologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
4. Life cycle assessment and prognosis scenarios . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
5. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Declaration of competing interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Supplementary data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

1. Introduction persistent pollutants, such as pharmaceuticals, sanitizers, disin-

fectants, antibiotics, wetting agents, and other surfactants hospital
Hospitals are responsible for the generation of high amounts of laundry wastewaters constitute one of the most significant causes
waste. Depending on the activities developed at the various sectors of environmental harm amongst the various sectors of a typical
of these institutions, different types of waste are produced. In this healthcare unit (Kist et al., 2008; Zotesso et al., 2016). According to
sense, despite the production of solid waste with hazardous fea- the Brazilian Ministry of Health (1986), hospital laundries are
tures, effluents produced at health care units have been the focus of responsible for 50% of hospitals water consumption and require
several researches over the past years, mainly because of the gen- 35e40 L of water to process 1 kg of dried clothes.
eration of considerable volumes. According to Boillot et al. (2008) Hospital laundry is a functional support unit for patient care. In
while the domestic water consumption per inhabitant stays general, the laundering process of these units is divided into
around 100 L, the demand in hospitals generally ranges from 400 to different steps: initial “rinses”, “pre-wash”, “wash” and “softening”
1200 L per bed and day. In developing countries, the water use in (Kist et al., 2008; Lutterbeck et al., 2014; Schwaickhardt et al., 2017).
hospitals is approximately 500 L per bed and day (Lutterbeck et al., Each of these steps has his own specifications such as the amount of
2014). water consumed, water temperature, energy consumption and
Characterization studies have shown that effluents generated at input of chemical compounds. Therefore, the adequate manage-
health care units might present similar values to urban wastewa- ment of hospital laundry wastewaters is an urgent need to mitigate
ters in terms of organic load: BOD5 (biological oxygen demand) the negative environmental impacts that the incorrect disposal of
varying from 50 to 400 mg L
1, COD (chemical oxygen demand) these effluents might cause.
from 150 to 800 mg L
1, TSS (total suspended solids) from 60 to As already mentioned, an increasing number of studies has been
200 mg L
1 and TOC (total organic carbon) from 50 to 300 mg L
1 dedicated to the treatment of hospital effluents. However, few of
(Kist et al., 2008). Nevertheless, several authors state that these them have achieved satisfactory results (Schwaickhardt et al.,
wastewaters present special features and that its release into the 2017). As a matter of fact, most of the hospitals discharge their
municipal sewer system without preliminary treatment pose po- wastewaters without any treatment directly into surface waters or
tential threats to environment and to public health due to the domestic sewer net. Others use conventional methods (i.e. anaer-
discharge of toxic chemical substances affecting several aquatic obic, aerobic systems with membranes, and oxic/anoxic systems)
species (Carraro et al., 2016; Gautam et al., 2007; Kern et al., 2015; which are unable to remove the so called “emerging contami-
Verlicchi et al., 2010). nants”. In this sense, integrated systems combining traditional
In fact, hospital wastewaters differ from domestic wastewaters methods and advanced oxidation processes (AOP’s) as a pre-or
because they might contain a wide range of pollutants, including post-treatment appear as an interesting alternative. However,
the so-called “emerging contaminants”, such as pharmaceutical along with the necessity to implement systems that might, in fact,
compounds, chemical residues, radioelements, antibiotic resistance satisfactory treat hospital wastewaters, the environmental impacts
strains, and pathogens that don’t have a regulatory status but can that these systems might cause must also be evaluated.
represent a risk (Carraro et al., 2016; Verlicchi et al., 2015). These In this sense, Life Cycle Assessment (LCA) is one of the most
characteristics may confer toxic and genotoxic properties to this developed and widely used system analysis tool. It has been cited
kind of effluents and may have potentially negative effects on the by the European Union as a state-of-the-art methodology for the
biological balance of natural environments (Kern et al., 2013; Kist calculation of environmental impacts associated with a product,
et al., 2008). According to Boillot et al. (2008) hospital wastewa- process or service (da Silva et al., 2017; Tagliaferri et al., 2017).
ters may increase the toxicity of urban wastewaters from 5 up to 15 Furthermore, the use of LCA as an environmental tool enables the
times when discharged without a proper treatment. identification of “hot spots” in the system, that are those activities
Along the past decades, some studies addressing the treatment that have the most significant impact and should be improved as
of hospital wastewaters have been published; nevertheless, only a the first priority, thus enabling identification of more environ-
little number of units treat their effluents efficiently (Lutterbeck mentally sustainable options (Clift, 2006).
et al., 2014). Furthermore, few countries have reference standards Therefore, considering the high volumes generated and the
and specific treatment methods to manage these effluents. So, in complex matrix of hospital laundry wastewaters, the presented
many cases, hospital wastewaters are regarded as domestic and study aimed: (i) briefly discuss the possibilities for an integrated
therefore discharged directly into the municipal sewer network management of hospital laundry wastewaters; (ii) conduct a bib-
without any pretreatment or imposed quality limit (Carraro et al., liometric analysis of hospital wastewaters in general, and specif-
2016). ically of hospital laundry wastewaters; (iii) review the current
Due to considerable levels of water consumption as well as the technologies applied to the treatment of these effluents; (iv) apply
presence of high microbial load, high COD, BOD5, and some life cycle assessment for five study cases and; (v) propose
 C.A. Lutterbeck et al. / Journal of Cleaner Production 273 (2020) 122851
alternatives to reduce the environmental impacts of the investi-
gated treatment systems.
2. Conception, implementation and analysis for the
integrated management of hospital laundry wastewaters
Among the different sectors of health care institutions, laundry
can be considered one of the most relevant. Fijan et al. (2008) state
that the laundering process in hospitals is complex since involves
the correct dosage of washing agents and the sustainable use of
water and energy. On the one hand, the procedure needs to guar-
antee satisfactory cleanliness and disinfection levels, avoiding
possible nosocomial infections. On the other side, high water and
energy consumptions and an overdosing of chemical inputs will
rise the generation of wastewaters with toxic potential and severely
increase the negative environmental impacts associated with
hospital laundries (Altenbaher et al., 2011; Fijan et al., 2008)
Therefore, it is necessary to adopt actions aiming at a correct
management of hospital laundry effluents. In this sense, the se-
lection for an adequate treatment system is of crucial importance in
this process.
Pasqualini Blass et al. (2016) proposed a new framework to
measure the environmental performance of Brazilian hospitals.
This approach considered the design, implementation and analysis
of environmental management procedures aiming for controlling
pollutant emissions within the scope limits of the health care in-
stitutions. The guidelines of this organization considered, among
other points, the environmental performance of hospitals as
grouped indicators, i.e. in the same way as the possibilities offered
by Grouping or Weighting through LCA.
The review written by Pesqueira et al. (2020) considered char-
acterization evaluations of several treatment processes for appli-
cation in urban effluents (iron catalyzed advanced oxidation
process, ozonation, activated carbon, electro-Fenton, photocatalysis
with UVA and UVC radiation, fotoperoxidation, membrane bio-
reactors, micro and nanofiltration and reverse osmosis). The study
has a very close connection with the topic addressed here,
demonstrating potential for focusing on hospital effluents, i.e., one
of the material flows that, together with the waste, will have the
greatest demand for management in health care units, both for
disinfection and for detoxification (Pauwels and Verstraete, 2006).
Fig. 1 summarizes management actions that could be useful in
the decision-making process for hospital effluents. Based on it, it
becomes evident how important planning, development and con-
trol measures are to select methods, processes and procedures for a
proper management of hospitals sewage liabilities, aiming for
reduction, segregation and treatment before its disposal into the
urban network.
Processes that include the hydrodynamic cavitation studied by
Yuequn et al. (2016) revise applications with approaches to the
reaction mechanisms that generate free radicals from micro-
bubbles. Degradation experiments evaluating the effect of the
initial concentration of the pesticide imidacloprid were carried out
using the Venturi cavitation reactor slit. The obtained results
revealed an increase of the pseudo-first-order rate constant from
0.79  10
3 min
1 to 1.27  10
3 min
1 with the initial concen-
tration decreasing from 60 ppm to 20 ppm. Yuequn et al. (2016) also
mentioned the possibility of the combined use of cavitation with
other treatment technologies such as electrooxidation, H2O2, Fen-
ton and UV. According to authors, this technology might be to be
applied as a particularly preliminary and/or tertiary step in the
treatment of hospital wastewaters aiming at the degradation of
priority organic pollutants.
Another technology, also depicted in Fig. 1, with advanced
oxidative process characteristics is Plasma (Cui et al., 2018). In
3
general, there are three different discharge modes for liquid
treatment solutions: discharges above the surface of the liquids,
direct discharges into liquids and discharges into bubbles/vapor
into liquids. During these discharges, sufficient radicals and species
will be produced. Plasma can be combined with Fenton or UVB
radiation. When considering the Fenton process, the authors
endorse the use of nano structured magnetite.
Similar to Plasma, the application of Microwaves (MW) also
presents good potential for the removal of organic compounds,
including the frequently detected in hospital wastewaters. How-
ever, studies involving this technology are also still in the bench
scale scenario. Remya and Lin (2011), describe experiments that
address the chemical reactions in the MW alone or integrated with
activated carbon, providing points of degradation by concentration
of energy, as well as with adjuvants that configure advanced
oxidative processes: Fenton, Foto-Fenton; UV/TiO2; UV/Bi2WO6 and
O3.
Over the last years, few studies have, in a more effective way,
investigated the treatment of hospital effluents with potential for a
comprehensive treatment in the preliminary, primary, secondary or
tertiary stages. Among them, the researches carried out by
Shrestha, Habert and Laber (2011) as well as Beyne and Redaie
(2011), this also including a system similar to UASB/Biofilter
coupled with wetland built with subsurface horizontal flow, can be
cited.
In the specific context of hospital laundries, photoperoxidation
was applied by Zotesso (2015), in a bench scale experiment, for the
treatment of effluents generated at this hospital sector. The
research consisted of 3 stages: (1) a physical-chemical pre-treat-
ment (coagulation/flocculation); (2) an anthracitic filtration and (3)
a UV/H2O2 process. The photoperoxidation assays were carried out
using photo-reactor equipped with a low-pressure mercury-vapor
UVC lamp. The influence of the H2O2 dose was investigated through
different COD/[H2O2] ratios. The obtained results showed satisfac-
tory color and turbidity removals during the pre-treatment of the
effluent. In the UV/H2O2 process, the ratio 1: 1.5 (COD: [H2O2]) led
to 87% COD removal in relation to the COD value of the pre-treated
effluent.
In summary, the aspect of a reduced number of researches with
specificity for the treatment of hospital effluents, evidences the
need to address the application of treatment alternatives that
might effectively reduce the environmental burdens associated
with hospital laundry effluents, directing the focus of bibliometric
studies to this theme.
3. Bibliometric analysis and treatment methods
3.1. Bibliometric analysis
Aiming to have an overview about the publication scenario
regarding the treatment of hospital wastewaters, a literature
research was conducted using the Web of Science (Thomson Reu-
ters) database on 5th December 2019. This platform was selected
because of the quality-controlled database of peer-reviewed
research material related to the study subject. The term used for
the first literature research was: “Treatment of Hospital Wastewa-
ters”. The obtained results showed a total of 810 publications over a
period of almost 30 years (Fig. 2A). The first studies addressing this
topic date from de The Earlies 90’. From 2005 ongoing it is possible
to observe a clear increasing trend until 2019. On the other hand,
despite the generation of high wastewater volumes with known
toxic characteristics, few researches have been directed to the
second searched term: “Hospital Laundry Wastewaters”. Based on
Fig. 2B, it is possible to observe that to form 1998 to 2019 only 20
publications were found by the Web of Science platform. Lastly, the
4 C.A. Lutterbeck et al. / Journal of Cleaner Production 273 (2020) 122851
Fig. 1. Treatment methods that could integrate WWTPs with application potential to hospital laundry wastewaters.
third searched term was a combination of the terms “life cycle
assessment” and “advanced oxidation process” (Fig. 2C). The ob-
tained records showed a total of 46 publications along 16 years
(2004e2019).
After obtaining the information from the Web of Science data-
base, bibliometric mapping using VOSviewer software (version
1.6.12) was carried out (Colares et al., 2020). The bibliometric
analysis allowed for the identification of the main aspects related to
the treatment of hospital wastewaters. The network view shows
the extracted items labeled in a circle so that each circle size is
defined by the item occurrence. The bigger the circle, the bigger the
occurrence. The color defines to what cluster an item is inserted
and the lines represent the links between the items. Moreover, the
distance between two items indicates the strength of the rela-
tionship, i.e., the closer the items are the more related they are and
vice versa (Eck and Waltman, 2019). As one can observe in Fig. 3,
two main groups can be identified on the bibliometric maps: in red,
a group of terms more related to the monitoring of hospital
wastewaters, including presence/concentration of different phar-
maceuticals as well as the of biological contaminants and in green a
group of terms more associated with the treatment of hospital ef-
fluents by different systems, including biological treatments and
AOP’s.
Fig. 4 shows a density visualization map. In this type of map,
items are represented by their label, similar as in the network
visualization. Each point has a color that indicates the density of
items at that point, with the colors ranging from blue to green to
yellow. The software arranges the colors so that the larger the
number of items in the neighborhood of a point and the higher the
weights of the neighboring items, the closer the color of the point is
to yellow. However, the smaller the number of terms in a neigh-
borhood of a point on the map and the lower the weights of the
neighboring items, the closer the color of the area is to blue (Eck
and Waltman, 2019). In the present research, 3 hot spots (in red)
can be distinguished in Fig. 4. The first one (A) highlights the term”
wastewater treatment plant”, indicating a clear association of
studies related to treatment of hospital effluents. The second one
(B) establishes a relation between the concentration of pollutants
detected in hospital wastewaters and the possible ecotoxic effects
associated with them. Finally, hot spot “C” makes reference to the
presence of micropollutants in hospital wastewaters.
As already mentioned, the second search used the term “hos-
pital laundry wastewaters”. Since it was more specific, a reduced
number of articles related to the topic was found. As can be visu-
alized in Fig. 5, the network view presents a smaller size in com-
parison to the depicted in Fig. 3. Two different clusters can be
 C.A. Lutterbeck et al. / Journal of Cleaner Production 273 (2020) 122851 5

Fig. 2. Publications related to the searched terms from the Web of Science database. (A): “hospital wastewater treatment”, (B): “hospital laundry wastewater”, (C): “life cycle
assessment and advanced oxidation process”.

Fig. 3. Cluster graphic obtained through bibliometric mapping using VOSviewer and the Web of Science database involving the term “hospital wastewater treatment”.
6 C.A. Lutterbeck et al. / Journal of Cleaner Production 273 (2020) 122851

Fig. 4. Bibliometric map of the term “hospital wastewater treatment” based on density visualization from VOSViewer.

Fig. 5. Cluster graphic obtained through bibliometric mapping using VOSviewer and the Web of Science database involving the term “hospital laundry wastewater”.
 C.A. Lutterbeck et al. / Journal of Cleaner Production 273 (2020) 122851 7

Fig. 6. Bibliometric map of the term “hospital laundry wastewater” based on density visualization from VOSViewer.

observed: one in red that encompasses terms related to general 3.2. Treatment methods
characterization parameters (“turbidity”, “analysis”) and toxicity
(“EC50”) of the effluents as well as treatment alternatives (“photo- This section presents a summary of characterization studies and
catalytic ozonation”, “disinfection”) and in green terms associated of different treatment alternatives for hospital laundry wastewa-
with the washing process (“textile”, “laundering procedure”, ters, as well as a brief sub-section presenting novel treatment al-
“temperature”). The density visualization map enables to distin- ternatives. Table 1 encompasses the main investigated parameters
guish 5 different hotspots (Fig. 6). One of them is mainly related to as well as the results obtained by worldwide research groups.
the reduction or removal of the toxicity (A) while the other is
associated with the treatment of the generated effluents (B). Hot
3.2.1. Physicochemical methods
spots “C”, “D” and “E” are clearly linked to the washing process 
Sostar-Turk et al. (2005) studied the treatment of effluents
since they reference terms such “laundering procedure”, “washing
produced at a laundry that washes hospital clothes using a tunnel
process”, “hospital”, “water” and “wastewater”.
washer and adopting different process: precipitation/coagulation,
Lastly, the third search of the bibliometric analysis used a
flocculation with adsorption on granular activated carbon (GAC)
combination of two terms: “life cycle assessment” and “advanced
ultrafiltration (UF) and reverse osmosis (RO). According to the au-
oxidation process”. Based on Fig. 7 it is possible to distinguish three
thors, chemical analyzes showed that parameter values of un-
main groups. One group, marked in red, includes some of the main
treated wastewaters like pH, total phosphorous (total P), COD and
advanced oxidation processes (“photo Fenton”, “photocatalysis”)
BOD5 exceeded Slovenian regulatory guidelines. Usually the BOD5/
that were submitted to LCA as well as the impact categories. The
COD ratio is used to evaluate the biodegradability (amenability to
most highlighted words of the green group were “technology”,
biological treatment) of the wastewaters. According to
“water”, “assessment” and “analysis”, indicating that this cluster
Kajitvichyanukul and Suntronvipart (2006) when the BOD5/COD is
can be related to studies more connected to environmental policy
in the range over or equal to 0.5, the wastewaters is easily
and legislation. The blue group provides the main study topics
degradable. However, with a BOD5/COD <0.5, there is a possibility
involving wastewater treatments and operational conditions such
for chemical substances which have low biodegradability to slacken
as “methodology”, “consumption of electricity” and “hydrogen
or delay the biological process. So, the analysis revealed that the
peroxide”. Fig. 8 presents the density visualization map indicating
raw effluents presented good biodegradability with a COD/BOD5
six hot spots related to the researched terms. It is possible to
ratio of 0.7.
observe that the terms “process” and “treatment” are the most 
Concerning the treatments, Sostar-Turk et al. (2005) observed
evidenced and that they are directly linked to the term impact.
that coagulation did not satisfactory reduced COD and BOD5 values
After the bibliometric mapping and analysis, a literature review
(36% and 51% respectively). Nevertheless, the obtained results
was carried out in order to better comprehend the connections
showed that GAC filtration could remove 93% and 95% of COD and
between the extracted items presented in the VOSviewer map.
BOD5, respectively. Both treatments reduced the pH and satisfac-
Furthermore, information concerning different treatments of hos-
tory removed total P values, so that they are in compliance with
pital laundry wastewaters were processed and presented in the
Slovenian emission standards. Although UF attained more than 95%
following sections.
of total P removal, the process failed to satisfactory reduce the COD
and BOD5 parameters. Conversely, RO achieved the best results
8 C.A. Lutterbeck et al. / Journal of Cleaner Production 273 (2020) 122851

Fig. 7. Cluster graphic obtained through bibliometric mapping using VOSviewer and the Web of Science database using the combination of the terms “life cycle assessment” and
“advanced oxidation process”.

Fig. 8. Bibliometric map of the combined terms life cycle assessment” and “advanced oxidation process based on density visualization from VOSViewer.
Table 1
Comparative table with different treatment alternatives for hospital laundry wastewaters.

Treatment Method Organic Load Removal Nitrogen P Removal Turbidity Color pH Temperature Toxicity Reduction References
Removal Removal Removal

Physicochemical Methods
Precipitation/coagulation COD and BOD5 removals 5.5% Total 90% total Raw 9.6 and treated 7.9 Raw 62  C 
Sostar-Turk
of 36% and 51% Nitrogen and P and treated et al. (2005)
respectively 2% for NeNH3 22  C
flocculation with adsorption 93% and 95% of COD and 5.5% Total 90% total e Raw 9.6 and treated 6.8 Raw 62  C 
Sostar-Turk
on granular activated BOD5 Nitrogen and P and treated et al. (2005)
carbon (GAC) 6% for NeNH3 22  C
ultrafiltration (UF) COD and BOD5 removals 99.9% Total 95% total e e Raw 9.7 and treated 8.3 Raw 62  C 
Sostar-Turk
of 55% and 56% Nitrogen and P and treated et al. (2005)
respectively 99.9% for N 53.8  C
eNH3
reverse osmosis (RO) COD and BOD5 99.9% Total 98.5% of e Raw 9.7 and treated 7.6 Raw 62  C 
Sostar-Turk
reductions of 98.9% and Nitrogen and total P and treated et al. (2005)
99.2% 99.9% for N 27.8  C

C.A. Lutterbeck et al. / Journal of Cleaner Production 273 (2020) 122851

eNH3
ultrafiltration (UF) COD removal of 90e94% e Raw around 11 and treated Ashfaq et al.
around 8 (2017)
ultrafiltration-nanofiltration COD removal of 97% Raw around 10 and treated Ashfaq et al.
(UFeNF) around 8 (2017)
coagulation/flocculation with COD reductions (˂ 30%) 100% removal 100% removal EC20 of 41.86% Zotesso et al.
Tanfloc SG, PAC and (2017)
aluminum sulphate
Coagulation/Floculation with COD removals varying 100% removal 100% removal 7 Zotesso et al.
Tanfloc SG followed by between 29% and 50% (2017)
filtration with anthracite
bed
UF polyethersulfone (PES) COD removal of 90e94% e e Raw 10.9 and treated 10.7 Ashfaq and
membrane Hazim (2018)
Advanced Oxidation Processes
Fenton COD reduction of 68%, 0% Total 0% Total P 65.3% Raw 8.6 Kist et al.
while for BOD5 this Nitrogen (2006)
decrease was of 26%
O3/UV COD reduction of 29.8% e 30.5% e Raw 10.9 and treated 10.6 Kist et al.
and 41.6% for BOD5 (2008)
UV/TiO2 COD reduction of 20.3% 43.3% Raw 10.9 and treated 10.4 Kist et al.
and 68.5% for BOD5 (2008)
O3/TiO2 COD reduction of 27.9% 32.2% e Raw 10.9 and treated 10.4 Kist et al.
and 39.7% for BOD5 (2008)
UV/TiO2/O3 COD reduction of 30.2% 48.8% Raw 10.9 and treated 10.2 Kist et al.
and 75.1% for BOD5 (2008)
O3 COD and BOD5 removals TKN by 86.8% total P by 88.7% Raw 8.04, treated 2.75 Acute toxicity against D. magna 96.6% Kern et al.
of 43.7% and 32.2% 24.3% (2013)
UV COD and BOD5 removals TKN by 42.7% total P by 67.1% Raw 8.04, treated 3.21 Acute toxicity against D. magna 96.3% Kern et al.
of 30.4% and 31.8% 51.6% (2013)
UV/O3 COD and BOD5 removals TKN by 44.4% total P by 87.7% Raw 8.04, treated 2.76 Acute toxicity against D. magna 92.1% Kern et al.
of 37.2% and 26.9% 44.3% (2013)
2þ
UV/O3/Fe COD and BOD5 removals TKN by 86.8% total P by 57.1% Raw 8.04, treated 2.64 Acute toxicity against D. magna 96.2% Kern et al.
of 59.1% and 50.3% 74.7% (2013)
Electrooxidation (EO) „Rinse step” COD and „Rinse step” „Rinse step” „Rinse step” untreated 6.72 and „Rinse step” acute toxicity against Lutterberck
BOD5 removals of 9.3% turbidity color increase treated 7.18 “Wash step”, D. magna 79% “Wash step” reduction of et al. (2014)
and 9.1%, respectively increase of of 315% untreated 10 and treated 10.4 acute toxicity towards D. magna of 91% %
362%
“Wash step” COD
removal of 41%
(continued on next page)

9
Table 1 (continued )

10
Treatment Method Organic Load Removal Nitrogen P Removal Turbidity Color pH Temperature Toxicity Reduction References
Removal Removal Removal

“Wash step”, “Wash step”,

increase of the increase of
turbidity 150% the color 151%
EO/O3 „Rinse step” COD and „Rinse step” „Rinse step” „Rinse step” untreated 7.89 and „Rinse step” acute toxicity against Lutterberck
BOD5 removals of 0% turbidity color increase treated 8.75 “Wash step”, D. magna 75% “Wash step” reduction of et al. (2014)
and 32%, respectively increase of 14% of 18.3% untreated 10.1and treated 10.4 acute toxicity towards D. magna of 90% %
“Wash step” COD “Wash step”, “Wash step”,
removal of 31.3% increase of the increase of
turbidity 84.3% the color
68.6%
EO þ O3 „Rinse step” COD and „Rinse step” „Rinse step” „Rinse step” untreated 6.72 and „Rinse step” acute toxicity against Lutterberck
BOD5 removals of 1.8% turbidity color increase treated 7.18 “Wash step”, D. magna 35% “Wash step” reduction of et al. (2014)
and 31%, respectively increase of of untreated 9.98 and treated 3.23 acute toxicity towards D. magna of 67%
“Wash step” COD “Wash step”, “Wash step”,
removal of 24% increase of the increase of

C.A. Lutterbeck et al. / Journal of Cleaner Production 273 (2020) 122851

turbidity 542% the color 553%
Electrocoagulation (EC) 89.1% removal of COD 81% 77.8% removal Initial 7 Zazouli et al.
removal of color (2016)
of
phosphate
Coagulation/Floculation/UV/ 100% removal for BOD5 Increase of Total P by 97.2% 95% Raw 9.9, treated 6.8 100% removal of toxic effects agaist Zotesso et al.
H2O2 and COD 1600% 11.1% Artemia salina, (2017)
UV/TiO2 COD removals between 37% 74.3% Raw 10.4, treated 2.5 Zotesso et al.
30 and 40% (2017)
UV/ZnO COD removals between 57.7% 73% Raw 10.4, treated 2.5 Zotesso et al.
30 and 40% (2017)
O3 COD and BOD5 removals53.4% for N Total P Slight increase from EC50 6.7%e11.8% Schwaickhardt
of 50.8% and 3% eNH3 and 8.2% 4.2% against D. magna et al. (2017)
for TKN
UVV/UVC/O3 COD and BOD5 removals 0% for NeNH3 Total P 0% 100% removal of toxic effects against Schwaickhardt
of 30.5% and 26.5% and 8.2% for D. magna et al. (2017)
TKN
UV/H2O2 COD removal of 45.1% Removal of Removal of Raw 9.3, treated 9 Souza et al.
53.4%, 48.5% (2019)
 C.A. Lutterbeck et al. / Journal of Cleaner Production 273 (2020) 122851
considering all the investigated treatments, with total P, COD and
BOD5 reductions of 98.5%, 98.9% and 99.2%, respectively.
Ashfaq et al. (2017) assessed the performances of two different
systems for the treatment of a laundry wastewater from a Doha
hospital: a single low-molecular weight cut-off (MWCO) ultrafil-
tration (UF) stage and a two-stage ultrafiltration-nanofiltration
(UFeNF) system. The efficiency of the treatments was evaluated
based on the removal of the organic load and compliance with the
Qatari national emission standard requirements.
Results of the characterization parameters showed that the raw
wastewaters from the contaminated area presented high organic
load (COD values > 1100 mg L
1) while for the uncontaminated
area these values were almost 4 times lower (284 mg L
1). More-
over, the untreated wastewaters of both contaminated and un-
contaminated areas presented alkaline nature due to the presence
of detergents. On the other hand, authors observed that both
treatment systems (single and dual) were efficient considering
COD, with removals ranging from 90 to 97% for the effluents
generated at the contaminated and uncontaminated areas. This
results fully attended the Qatari national emission guidelines.
Ashfaq et al. (2017) also highlighted that the quality provided from
both processes was found to be compliant with both the Italian and
Chinese guidelines relating to wastewater reuse for laundering.
Zotesso (2017) investigated the treatment of hospital laundry
wastewaters by coagulation/flocculation and anthracite bed filtra-
tion processes. The authors tested three different coagulants,
namely, Tanfloc SG, PAC and aluminum sulphate, using different
concentrations and varying the pH. Coagulation/flocculation assays
were performed on a Jar-Test with a fast mixing speed (FMS) of
120 rpm and a low mixing speed (LMS) of 15 rpm, over times of 3
and 15 min, respectively. In a second step, experiments were per-
formed on a Jar-Test and subsequently filtered on a 20 cm high
anthracite bed, containing approximately 495 g of anthracite.
Mean results of the characterization of the raw effluents showed
DQO and DBO5 values of 405 and 190 mg L
1, respectively, indi-
cating that the investigated wastewaters may have some refractory
characteristics (relation BOD5/COD of 2). Regarding the treatments,
despite good color and turbidity removals under optimized pH and
concentrations, none of the coagulants achieved satisfactory COD
reductions (˂ 30%). For the treatments using filtration with
anthracite bed, authors found COD removals varying between 29%
and 50%.
Ashfaq and Hazim (2018) used single UF polyethersulfone (PES)
membrane to treat laundry wastewater from one of the main
hospitals in Qatar, varying operational parameters of pressure, flow
rate and temperature. The obtained results showed that raw
wastewaters were not in accordance with Qatari and International
Emission guidelines considering the organic load (COD varied from
360 to 580 mg L
1) pH and TSS. Concerning the treatment assays,
authors verified that the treated effluents fully attended Chinese,
American, Italian and Qatari emission guidelines, taking into ac-
count the investigated parameters. Furthermore, Ashfaq and Hazim
(2018), also observed that increases in the pressures and in the
temperature lead to decreases of the COD reductions, while a
higher flow rate presented a positive correlation with a higher COD
removal.
3.2.2. Advanced oxidation processes
Kist et al. (2006) investigated the Fenton reaction using a
600 mL glass reactor at 22  C and under magnetic stirring. Exper-
iments were carried at pH 3.5 during 30 min and using 100 mg L
1
H2O2 and 20 mg L
1 Fe2þ (relation 5:1). General characterization
parameters showed that the raw wastewaters did not present a
good biodegradability with BOD5/COD relation of 0.4. According to
the authors, this recalcitrant behavior may be related to the
11
addition of several chemical products to the laundering process:
acid liquid detergent (nonionic surfactant nonyl phenol ethoxylate
and acidulant inorganic acid), liquid alkaline detergent (alkaline-
sodium hydroxide agent, sequestering agent, nonionic nonyl
phenol ethoxylate surfactant, optical brightening agent and enzy-
matic agent), oxidant (hydrogen peroxide and peracetic acid) and
glycerin. pH of the untreated wastewaters was slightly alkaline
(around 8.5).
Results of the Fenton experiments showed a COD reduction of
68%, while for BOD5 this decrease was of 26%. Such results confirm
that the reactions were able to degrade the refractory compounds
present in the raw wastewaters and in this way improve the
biodegradability of the effluents (relation of 0.9) which passed to a
condition of easy biodegradable (Kajitvichyanukul and
Suntronvipart, 2006). The Fenton reaction also showed a good
disinfection potential, with the raw wastewaters passing from
1.6  104 to under the determination by the biological method.
Nevertheless, authors observed that the Fenton experiments failed
to remove the Total Nitrogen from the effluents.
Kist et al. (2008) focused their research on the disinfection of
hospital laundry effluents by means of heterogeneous photo-
catalysis with UV, O3 and TiO2 and their possible combinations. The
authors used a ramp-type reactor for TiO2 (P25 Degussa) fixation
and for photochemical diffusion of the ozonized air. The reactor was
provided with O3 diffusers, a 30 W low-pressure mercury vapor
discharge lamp (germicidal lamp) and an acrylic 6 L recirculation
tank with a submerged water recirculation pump (with capacity for
180 L he 1). Experiments were carried out during 60 min and pH
was kept at an alkaline range (8e9) in order to favors the hydroxyl
radical formation, either by photoirradiation or by radical decom-
position of the dissolved O3. Maximum ozone formation rate was
5.80 mg O3 h
1 in the reactor’s internal air system, with a minimum
UV radiation incidence time of 1 h.
The characterization of the raw effluents showed a relation
BOD5/COD of 0.64, indicating that the wastewaters were easily
biodegradable, which is in contradiction to the results obtained by
Kist et al. (2006). Furthermore, the authors verified the presence of
liquid acid detergent (nonylphenol ethoxylate and inorganic acid),
liquid alkaline detergent (sodium hydroxide, sequestering agent,
nonylphenol ethoxylate, optical brightener, enzymatic agent),
oxidant (hydrogen peroxide and peracetic acid), and glycerin in the
raw wastewaters.
In relation to the disinfection experiments, low reduction rates
for UV, O3 and TiO2 processes individually were observed. Ac-
cording to Kist et al. (2008), the limitations concerning the use of
UV radiation are related to the high turbidity of the wastewaters
under study. Ozonation, when used alone, demonstrated a low
disinfection rate. TiO2 was used in isolation for predicting the ef-
fects of adsorption, without heightened expectations for disinfec-
tion efficacy. Results of the heterogeneous photocatalytic
experiments showed that the best performance considering
reduction of the organic load and disinfection was achieved by the
UV/TiO2/O3 system. COD and BOD5 removals were around 30% and
75% respectively, whereas, a 100% disinfection rate and a microbi-
ological inactivation of 0.5070 min
1 for Escherichia coli and of
0.5505 min
1 for thermotolerant coliforms was reached.
Kern et al. (2013) assessed the efficiency of different AOP’s based
on photocatalytic ozonation (O3, UV, UV/O3 and UV/O3/Fe2þ) for the
treatment of hospital laundry wastewaters. The experiments were
carried out using a rectangular column-type acrylic reactor con-
taining a 15-W germicidal lamp with a wavelength of 254 nm
placed at the center of the reactor. O3 was generated by the corona
effect using a RADAST 2C OzoOxi ozonizer, with maximum gener-
ating capacity of 2000 mg h
1. Gas was transferred to the reactor by
an air compressor, and diffused into the reactor by four air stones,
12 C.A. Lutterbeck et al. / Journal of Cleaner Production 273 (2020) 122851
placed on each corner and coupled to the base. Reaction time was
180 min and the assessment of the efficiency occurred based on
removals of the load parameters and reductions of toxicity and
genotoxicity.
The analysis of the investigated wastewaters revealed high
organic and eutrophying load with several parameters such as COD,
BOD5 and TKN much above the maximal emission limits estab-
lished by Brazilian and International resolutions. Nevertheless, the
characterization results showed the raw effluents as “easily
biodegradable”, with a BOD5/COD relation of 0.57. Degradation
experiments revealed that the UV/O3/Fe2þ 150 mg L
1 was the most
efficient method attaining reductions of 59.1%, 50.3% and 86.8%, for
COD, BOD5 and TKN, respectively. It is also noteworthy that, despite
the high microbiological load of the raw wastewaters (thermoto-
lerant coliforms 2.8  107 and E. coli 2.1  107), all the treatments
were efficient and fully disinfected the effluents.
Concerning ecotoxicity assays Kern et al. (2013) verified that the
raw effluents presented, based on a classification proposed by Lobo
et al. (2006), extreme acute toxicity against the microcrustacean
Daphnia magna. The authors attributed this condition to the pres-
ence of high levels of nitrogen compounds as well as to the pres-
ence of specific chemical substances, such as glutaraldehyde,
disinfectants and surfactant mixtures. Detoxification assays
showed significant acute toxicity reductions (p ˂ 0.05) for the UV, O3
and UV/O3/Fe2þ 150 mg L
1 experiments.
The cytogenetic assessment revealed strong levels of genotox-
icity of the raw wastewaters for meristematic cells of A. cepa,
especially cytotoxicity (alterations of the mitotic index) and
mutagenicity (increases of the frequency of micronucleated cells)
indicators. According to the authors, these results might be
attributed to the presence of specific chemical substances, such as
glutaraldehyde, disinfectants and surfactant mixtures. The evalua-
tion of the performance of the different AOP’s showed that, in
general, the best results were achieved by the UV/O3/Fe2þ
150 mg L
1. After the treatments by this integrated method, Kern
et al. (2013) verified a complete absence of cytotoxic, genotoxic
and mutagenic effects.
The research conducted by Lutterbeck et al. (2014) investigated
the treatment of hospital laundry effluents by electrooxidation (EO)
and electrooxidation combined with ozonation (EO þ O3 and EF/
O3). Samples were collected at a hospital with 180 beds and located
in a municipality of Vale do Rio Pardo, RS, Brazil. Once the washing
process involves different steps, authors performed preliminary
analysis in order to identify the most critical fractions of the ef-
fluents. So, after this initial characterization, Lutterbeck et al. (2014)
decided to perform the treatment assays with the wastewaters
generated after the steps called „Rinse” and „Wash” since this were
the most critical fractions. Analysis of the characterization param-
eters of the „Rinse” showed COD and BOD5 values of 838.9 mg L
1
and 440.7 mg L
1, respectively, indicating a biodegradability
behavior of these effluents (BOD5/COD relation of 0.53), high
turbidity (213.94 NTU) and strong eutrophying potential with
values of Total Kjedahl Nitrogen of 67.6 mg L
1 and Total P of
1.95 mg L
1. The other critical fraction called „Wash” presented
very high refractory characteristics with a BOD5/COD relation of
0.03 (COD of 555.6 mg L
1 and BOD5 of 16 mg L
1). The effluents
generated at this step also showed alkaline pH (9.5), high turbidity
(73.6 NTU) and Total Kjedahl Nitrogen and Total P of values
3.13 mg L
1 and 0.19 mg L
1. Finally, raw effluents of the rinse step
presented high toxicity (28.2%) against D. magna while for the
„wash“ effluents this toxicity was extreme (14.2%) (Lobo et al.,
2006).
Regarding the assays under optimized conditions, the best re-
sults for the treatment of the wastewaters generated at the rinse
step were obtained by the EO process after 60 min and with the
addition of 1000 mg L
1 of NaCl (to improve the conductivity). The
treatment reduced the acute toxicity by 79%, so that the effluents
passed to a condition of moderately toxic (61.6%). Nevertheless, the
treatment was not able to achieve high COD and BOD5 removals
(9.3% and 9.1%, respectively) and presented high turbidity and color
increases after the experiments (362% and 315%). Lutterbeck et al.
(2014) attributed these increases mainly to the formation of ferric
ions formed during the process. In the same way, EO performed
during 60 min presented the best results, with a reduction of acute
toxicity towards D. magna of 91% (effluents improved from a con-
dition of “extremely toxic” to “slightly toxic”) and a COD removal of
41%. Again, increases of the turbidity (150%) and color (151%) values
were observed after the experiments Authors pointed out that, due
to the presence of blood, feces and other secretions, turbidity and
color indices measured in the tests carried out with the effluent
from the “rinse” fraction, were much higher than those found in the
“wash” fraction.
Zazouli et al. (2016) used electrocoagulation with iron elec-
trodes for the pretreatment of the wastewaters generated at a
hospital laundry located in the Gorgan city, northern Iran. The re-
sults of the characterization analysis showed that the untreated
effluents had the presence of high organic content, with COD and
BOD5 values much above the national Iran Guidelines for waste-
waters disposal in water bodies. Also, the authors observed a re-
fractory behavior of the effluents since the BOD5/COD relation was
low (0.21). In the same way, color values were in disagreement,
being almost 9 times higher than the maximum values established
by the Iran EPA. Regarding the treatments, authors performed
electrocoagulation experiments with varying pH, reaction time and
applied voltage. The results showed that under optimized condi-
tions (pH 7 and 40V) electrocoagulation removed 89.1%, 77.8%, and
81% of COD, color and phosphate.
Zotesso (2017) investigated the performance of three photo-
catalytic methods (UV/H2O2, UV/TiO2 e UV/ZnO). The UV/H2O2
experiments were carried out during 120 min using a reactor
consisting of a cylindrical tube provided with a UV-C 10 W low
pressure mercury vapor lamp protected by a quartz cylinder. The
effluent (500 mL) was kept under magnetic stirring and different
pH ranges and H2O2 concentrations were tested. The reactor used
in the UV/TiO2 and UV/ZnO was of the “mud type”, composed of a
beaker of 2 L immersed in a thermostatic bath with continuous
circulation of water. In order to maintain the catalyst in suspension,
magnetic stirring was also used. 4 UV-C 15 W lamps were hori-
zontally positioned above the effluents. UV/TiO2 and UV/ZnO assays
were carried out during 180 min, with the pH adjusted to an acid
range (2.5) and varying the concentrations of both catalysts. The
performance of all the AOP’s was based on COD removals.
The characterization parameters showed COD, and BOD5 means
around 400 mg L
1 and 200 mg L
1 respectively, indicating
therefore a good biodegradable of the raw wastewaters (relation
COD/BOD5 around 2). Before the UV/H2O2 experiments, the raw
effluents were submitted to a pre-treatment with Tanfloc SG
coagulant (pH ¼ 6 and 120 mg L
1). The obtained results indicated
almost 100% COD removal after 120 min under optimized condition
(pH 9 and reason H2O2/COD ¼ 2). On the one hand the Author
observed that almost all the hydrogen was consumed during the
reactions (93e97%) and so attributed the high COD removals to the
OH* radicals formed by the photolytic degradation of H2O2. On the
other hand, the results of the photocatalytic assays using semi-
conductors (TiO2, TiO2eP25 and ZnO) did not vary, with COD re-
ductions staying between 30 and 40% even altering the catalyst
concentrations (50e200 mg L
1). So, Zotesso (2017) decided to
choose the UV/H2O2 process to continue the other stages of the
research.
The results of the acute ecotoxicity assays towards the
 C.A. Lutterbeck et al. / Journal of Cleaner Production 273 (2020) 122851
microcrustacean Artemia salina showed an EC50 of 26.2% of the
untreated effluents. Nevertheless, samples collected after the pre-
treatment and after UV/H2O2 process presented absence of toxic
effects. The acute bioassays using Vibrio fischeri indicated non-toxic
effects of the raw and treated effluent. However, samples collected
after the coagulation pre-treatment presented an EC20 of 41.86%.
The authors stated that this result might be associated with an
increase of the NeNH4 levels in the effluents. Lastly non-toxic ef-
fects were observed for all the samples in the germination and root
elongation assays with Lactuca sativa.
Schwaickhardt et al. (2017) carried out studies aiming for the
treatment of hospital laundry wastewaters by the combined use of
VUV and UVC photoreactors. The authors investigated different
configurations using two different lamps. The performance was
assessed based on the reduction of the load parameters and of the
acute toxicity against D. magna. The experiments were carried out
through the recirculation of the wastewater samples between two
photoreactors for 180 min. An acrylic horizontal reactor (500 mL)
and containing a 14 W vacuumeUV lamp was used for the O3
generation and degradation of the samples. The ozone dose
generated in the system was equivalent to 160 mg O3 h
1. The
vertical reactor had a useful volume of 1250 mL and was designed
in a cylindrical format with a glass wall. An 11W UVC lamp sur-
rounded by a quartz tube was used as the irradiation source. Ex-
periments using 7 different configurations were performed.
The analytical characterization revealed raw wastewaters with a
very high organic load, with COD and BOD5 values of 6364 mg L
1
and 2040 mg L
1, respectively. According to the authors, these
values are almost 20 times higher than the maximal emission limits
established by Brazilian guidelines. Besides, it is also noteworthy
that the relation BOD5/COD of 0.32 indicates that the untreated
effluents present some refractory characteristic and so a biological
treatment would not be adequate for its treatment. The results of
the gas chromatography analysis showed the occurrence of some
important classes of compounds in the laundry wastewater, such as
surfactants, organic acids, and products containing aromatic rings.
Among the compounds identified in the raw wastewaters, the
presence of lidocaine and dipyrone, two drugs widely used in
hospitals, and of the antioxidant of butyl hydroxytoluent (BHT) was
mentioned. The ecotoxicity assays showed that the untreated ef-
fluents were extremely toxic against D. magna (6.37%).
Schwaickhardt et al. (2017) attributed this extreme toxicity to the
complex matrix of the raw wastewaters, containing the compounds
found in the gas chromatography analysis.
Concerning the degradation experiments, the configuration
using only O3 achieved the highest COD removals (50.8%). Ac-
cording to the authors, this result can be attributed to the recir-
culation of the wastewaters that was used in the other
configurations and which in turn, decreases the height of the water
column in the horizontal reactor and consequently decreases the
contact time between the O3 and the wastewaters (residence time).
Moreover, the authors also observed that the O3 process presented
the highest BOD5/COD ratio (0.63), greatly improving the biode-
gradability of the untreated effluents (0.32). The VUV and UVC also
achieved good BOD5/COD ratios.
Regarding the ecotoxicity experiments, the samples submitted
to the VUV/UVC/O3 treatment presented an EC50 of 100%, indicating
absence of toxicity. Thus, Schwaickhardt et al. (2017) concluded
that despite the partial elimination of some compounds by the
VUV/UVC/O3 system, the non-toxic effects of the treated samples
suggest that the formed by-products are less (or non-toxic) than
the parent compounds. In fact, the results of the chromatographic
analysis showed a partial elimination of some compounds found in
the untreated effluents, such as dodecanoic acid, oleic acid, and
dipyrone by the VUV/UVC/O3 system. Nevertheless, the appearance
13
of new peaks in the chromatograms after the experiments suggests
that transformation products were formed by this partial degra-
dation. The O3 process presented an extreme toxicity (very close to
the untreated effluent), indicating that an increase of the biode-
gradability ratio of the effluent is not necessarily related to a
decrease of the toxicity. The UVC and UVC/O3 treatments also
demonstrated good performances, with the samples improving
from a condition of extremely toxic to moderately toxic towards D.
magna.
Souza et al. (2019) evaluated the treatment of hospital laundry
effluents by UV/H2O2 in the city of Maringa, Brazil. The authors
performed assays varying the pH and H2O2 concentrations in order
to optimize the process. The results of the characterization showed
that the COD and BOD5 values of the raw wastewaters were above
the limits established by the Brazilian Legislation for disposal in
water bodies and might have some recalcitrance (relation BOD5/
COD of 0.41). Furthermore, analysis of the untreated effluents did
not reveal high turbidity values while color varied from sampling to
sampling. Assays showed that the best results were achieved with
pH 9 and ratio [COD]: [H2O2] of 1:2.5 (COD removal of 60.3%).
Nevertheless, even under optimized conditions the treatment was
not efficient in reducing color and turbidity.
3.2.3. Novel treatment technologies
As already mentioned, one of the major problems regarding
hospital laundries is the release of wastewaters directly into the
sewer network with no preliminary treatment. This is especially
problematic since these effluents may contain a wide range of
micropollutants, and it is well known that conventional wastewater
treatment plants are unable to remove/eliminate most of such
compounds. So, there is an urgent need to seek for alternatives that
could treat effectively these effluents, avoiding the bio-
accumulation of micropollutants and the consequent negative ef-
fects on human and environmental health.
In this sense, the present sub-section will present a brief sum-
mary of some cutting-edge technologies, that might be, in the
future, used in the treatment of hospital laundry wastewaters,
replacing other treatments methods or applied in an integrated
system.
Alsbaiee et al. (2016) assessed the efficiency of porous b-cyclo-
dextrin polymers (P-CDPs) to remove organic micropollutants
(including dyes, pesticides and pharmaceuticals) from water. The
findings obtained by the authors revealed that P-CDPs presented
important advantages over other polymers and activated carbon:
have a faster sequestration of a variety of organic micropollutants
with adsorption rate constants 15 to 200 times greater than those
of other tested materials and can be regenerated several times
using a mild washing procedure with no loss in performance. Ac-
cording to Alsbaiee et al. (2016), both aspects will have direct im-
pacts on treatment costs, demonstrating that P-CDPs will be more
economically competitive in comparison to other adsorbents.
Mushtaq et al. (2019) investigated the capability of magneto-
electric cobalt ferriteebismuth ferrite (CFOeBFO) coreeshell
nanoparticles (CoFe2O4eBiFeO3) under magnetic fields to degrade
different organic compounds. The results of the experiments
showed a non-selective degradation of organic pollutants with 97%
removal efficiency for a synthetic dye (rhodamine B) and over 85%
removal efficiency for a cocktail of five routinely used pharma-
ceuticals, via advanced oxidation processes, without involvement
of any sacrificial molecules or cocatalysts. Authors also verified that
hydroxyl and superoxide radicals were the main reactive species in
the magnetoelectrically induced catalytic degradation of organic
compounds.
Peydayesh et al. (2020) evaluated the performance of aerogels as
a sustainable treatment alternative for the removal of organic
14 C.A. Lutterbeck et al. / Journal of Cleaner Production 273 (2020) 122851
contaminants from water. Authors used amyloid fibrils prepared
from b-lactoglobulin (the major constituent of milk whey protein)
as building blocks for the fabrication of the aerogels. The results of
the study revealed removal efficiencies of 92%, 78%, and 98% for the
phenolic compound Bentazone, the dye Bisphenol A, and non-
steroidal anti-inflammatory drug Ibuprofen, respectively. Further-
more, Peydayesh et al. (2020) also verified a high reusability of the
amyloid fibrils aerosols with no significant changes in its removal
performance.
The studies reported in this sub-section revealed important
advances in the development of new technologies for the treatment
wastewaters containing micropollutants. The results presented
here showed that the tested materials achieved good removals
rates for different compounds (dyes, pharmaceuticals, pesticides
and phenolic compounds) besides being economic and environ-
mentally sustainable. So, they may constitute an interesting alter-
native for the treatment of toxic effluents such as they generated at
hospital laundries. However, one should be aware that the studies
described above have been focused on the primary elimination/
removal of the parent compounds, i.e. disregarding the formation
of by-products which can be even more toxic or recalcitrant than
the parent compounds. Therefore, future removal/elimination
studies should also encompass assays to evaluate the possible toxic
effects of the compounds/wastewaters.
4. Life cycle assessment and prognosis scenarios
Besides the lack of efficient systems for the treatment of hospital
(laundry) wastewaters, the few existing do not consider the major
environmental impacts associated with them (Schwaickhardt et al.,
2017). So, in order to establish a comparison about the performance
of the treatments, the present section will present the results of the
application of Life Cycle Assessment of five researches described
above, aiming to identify the most efficient treatment as well as the
most impacting aspects related to the operation of the treatment
system.
Life Cycle Assessment (LCA) is a standardized methodology by
ISO 14040 (ISO-International Organization for Standardization,
2006) and 14044 (ISO-International Organization for
Fig. 9. Network analysis comparing the contribution of the different treatments during their operations (considering materials and energy consumed) with a cut-off point of 1.95 Pt.
Standardization, 2006) that evaluates the potential environmental
impacts of a product or a process throughout its lifecycle, from
cradle to grave (Baumann and Tillman et al., 2004). It may have
great relevance in the decision making-process to select the tech-
nology that should be applied in each case (Gallego-Schmid and
Tarpani, 2019).
In the present study, LCA was applied to the operation phase of
the treatments so that the inventoried data considered only the
consumption of electricity and input of chemical products
(Table S1), i.e., disregarding the constructions phase. In order to
evaluate and compare the different treatment scenarios, the
treatment of 1m3 was chosen as the functional unit (FU). Accord-
ingly, data regarding the operation of the treatments were collected
from them provided by the investigated studies. Then, a life cycle
inventory (LCI) was constructed, using Ecoinvent datasets relative
to the lifecycle of the energy and raw materials consumed by the
processes.
The inventory of the wastewater’s pollutant loads was associ-
ated with the characterization analyzes of the following parame-
ters: COD, BOD5, total P and TKN. Equivalence quantity for the
materials and energy balance considered 1 m3 of liquid wastewa-
ters generated as the flow reference for the load parameters: COD
in kg m
3; BOD5 in kg m
3; TKN in kg m
3 and total P in kg m
3.
Characterization and normalization procedures were applied in the
Midpoint scale.
The collected data were inserted in the SimaPro 8.04 software
and then the Impact 2002þ method (Jolliet et al., 2003) was
applied. The methodological approach of the assessment method
“Impact 2002þ” proposes a feasible implementation of a midpoint
in a combined approach to damage. It connects all types of in-
ventory results of the life cycle (elementary flows and other in-
terventions), through several average levels for different damage
categories (Varanda et al., 2011). The environmental impacts were
evaluated according to 15 different indicators: non-renewable en-
ergy (NRE), carcinogenic (CA), non-carcinogenic (NCA), respiratory
inorganic (RI), ionizing radiation (IR), ozone depletion (OD), res-
piratory organics (RO), aquatic ecotoxicity (AE), terrestrial ecotox-
icity (TE), terrestrial acidity (TA), land occupation (LO), aquatic
acidification (AA), aquatic eutrophication (AEU), global warming
 C.A. Lutterbeck et al. / Journal of Cleaner Production 273 (2020) 122851 15

Fig. 10. LCA - Characterization (A) and Normalization (B) values of the system’s operation (material and energy consumed) using SimaPro 8.04 and IMPACT Method 2002 þ/
Excluding Infrastructure. Abbreviations: CA e Carcinogens; NCA e Non-Carcinogens; RI e Respiratory Inorganics; IR e Ionizing Radiation; OLD e Ozone Layer Depletion; RO e
Respiratory Organics; AE e Aquatic Ecotoxicity; TE e Terrestrial Ecotoxicity TA e Terrestrial Acidification; LO eLand Occupation; AA e Aquatic Acidification; AEUe Aquatic
Eutrophication; GW e Global Warming; NRE e Non-Renewable Energy; MEe Mineral Extraction.

(GW) and mineral extraction (ME) (Mun ~ oz et al., 2006).
In order to improve the understanding and applications of the
LCA, the following standards were considered: ISO 14040 (Envi-
ronmental Management - Life Cycle Assessment - Principles and
Framework) and ISO 14044 (Environmental Management - Life
Cycle Assessment - Requirements and Guidance).
Fig. 9 presents the results of percentile contribution values ob-
tained by the network flowchart considering the raw and treated
effluents by different processes. On the one hand, the higher im-
pacts caused by the UVV/UVC/O3 and UVC/O3/Fe2þ treatments are
noteworthy. On the other hand, the impacts caused by the other
three systems present minor environmental burdens (UV/TiO2/O3,
Fenton and EO). These high differences might be attributed mainly
to two key points. The studies conducted by Schwaickhardt et al.
(2017) and Kern et al. (2013) were carried out with effluents con-
taining high organic loads (Table 1) and required high consumption
of chemical products and of electricity (Table S1). Longer treat-
ments times (180min), along with the use of an UV germicidal lamp
(15W), an ozone generator and the consumption of catalyst (Fe2þ)
and pH adjusters (H2SO4 and NaOH) increased the negative envi-
ronmental impacts in the study performed by Kern et al. (2013).
Considering the adopted functional unit (1m3 of treated waste-
water), the UVC/O3/Fe2þ method consumed 0.15 kg of catalyst
(FeSO4), 1.47 Kg of H2SO4 (98%) and 0.2 of NaOH. The used quan-
tities correspond to an impact of 0.119 kg of COeq 2 for the H2SO4
(98%), while for the consumption of 0.2 kg of NaOH and of 0.15 kg
FeSO4, these values correspond to 0.237 and 0.0398 kgCOeq 2 ,
respectively. These inputs also present significant weights in terms
of non-renewable energies, having in this case energy values of
7.34 MJ, 3.43 MJ and 0.597 MJ for H2SO4 98%, NaOH and FeSO4,
respectively. In the same way, Schwaickhardt et al. (2017) also used
longer treatment times (180 min). Moreover, the use of two lamps
(UVV and UVC) and of a recirculation pump increased even more
the environmental burdens because of the high consumption of
electricity (60 Kw to treat 1m3).
The environmental impact assessment of the operation’s phase
consisted of the classification of the processes into different envi-
ronmental impact categories (Impact, 2002þ method) followed by
characterization. The inventoried results were later normalized in
order to perceive the magnitude of the impact caused by the
environmental problems from a global point of view (Varanda et al.,
2011). The characterization operation’s phase depicted in Fig. 10A
again evidences the high environmental pressures associated with
the UVV/UVC/O3 system, being the most impacting treatment in 14
of the 15 analyzed categories. This result might be attributed to the
high consumption of electric energy. Although approximately 67%
of the Brazilian energy matrix comes from hydroelectric plants
(EPE, 2019), the use of other non-environmentally friendly energy
sources, such as thermoelectric plants, considerably raises the
negative environmental impacts associated with electricity con-
sumption. In contrast, the low environmental impacts caused by
the EO process also draw attention. For comparison purposes, EO
energy requirements for the treatment of 1m3 were 40 times lower
than they used in the UVV/UVC/O3.
Studies involving the treatment of effluents by advanced
oxidation processes have also reported the high environmental
burdens occasioned by the electricity consumption. Ko € hler et al.
(2012) investigated the elimination of pharmaceutical residues in
biologically pre-treated hospital wastewater using UV radiation.
The results of the LCA of different scenarios showed that the
16 C.A. Lutterbeck et al. / Journal of Cleaner Production 273 (2020) 122851
electricity consumption was responsible for the main generated
impacts accounting for around two thirds of the total. It must be
highlighted that the electric consumption values used by Ko € hler
et al. (2012) were much lower, ranging from 4 to 10 Kwh/m3,
than the calculated by Schwaickhardt et al. (2017) (60 Kwh/m3). Li
et al. (2019) compared the environmental impacts caused by three
different AOP’s, ozonation, granular activated carbon adsorption
and reverse osmosis in the treatment of wastewaters containing
pharmaceuticals and personal care products (PPCPs). The authors
findings showed that all the investigated treatments were partic-
ularly sensitive to electricity consumption in each impact category.
Because of the higher electricity requirements reverse osmosis
presented the higher environmental burdens, impacting mainly the
categories of acidification, global warming, ozone depletion and
smog air in scenarios. The characterization of the performance of
the treatments revealed that the treated and untreated effluents
did only impact the aquatic eutrophication category (Fig. S1). The
high organic load present in the wastewaters of the study carried
out by Schwaickhardt et al. (2017) confer to them major environ-
mental pressures.
A closer look onto the normalization graph (Fig. 10B) shows that
the most impacted categories by the different treatments were
non-carcinogens (NCA), ionizing radiation (IR), global warming
(GW) and non-renewable energy (NRE). The research carried out by
Rodriguez-Garcia et al. (2011) assessed the performance of 24
WWTPs by LCA. The results of the investigation identified elec-
tricity consumption, chemicals, and primary solids as the main
contributors to the categories of climate change, metal depletion,
and human toxicity, whereas the water quality presented only
minor impacts under the whole wastewater treatment process. In
another work concerning the treatment of hospital wastewaters
Fig. 11. (A) Impacts of the four main impact categories associated with the operation of the treatments (considering materials and energy consumed). (B) Prognosis scenario of the
EO treatment replacing the Brazilian traditional energy matrix by solar energy comparing the four main impact categories.
Raghuvanshi et al. (2017) used the software Umberto NXT and
considered a functional unit of 1500 m3 day
1 of treated effluent,
over 365 days of the year, for a period of 50 years. In this case, for
the full-scale station, the researchers applied the LCA model with
Technosphere (direct inventory for the defined scope mass and
energy balance), Ecosphere (with choice of damage categories) and
Valuesphere (with the three groups involving Ecosystem Quality,
Human Health and Resources). The scope of the studies involved
the water collection for treatment and use operations, as well as the
generated effluents, detailing the treatment with the activated
sludge stage, the total operation of the WWTP for the preliminary
and tertiary stages, and the reuse of the effluent. In the Endpoint
stage, GW was the main impact for Ecosystem Quality. Human
Health has involved the damage of GW to human health and the
emission of particulate matter. Finally, for Resources, non-
renewable resource damage was strongly associated with acti-
vated sludge and redistribution with the reuse of treated waste-
water. Nine categories of the main stages were identified in the
midpoint, with capture and filtration presenting the lowest impacts
on the values of kg CO2 eq, kg 1.4 DCBeq, kg PM10eq, kg CFC-11 eq,
kg Peq and kg Feeq.
Fig. 11A compares 4 impact groups associated with the opera-
tion of the different treatments. Based on the single punctuation
score, it becomes evident how impacting was the UVV/UVC/O3
treatment, mainly in the groups of human health and climate
change. On the other hand, EO environmental burdens were almost
negligible when compared to the other treatments.
So, in summary, EO presented the best results, mainly due to
lower electric energy consumption. Even though, aiming to further
reduce the environmental impacts of the system, a prognosis sce-
nario replacing the traditional energy matrix by solar energy was
 C.A. Lutterbeck et al. / Journal of Cleaner Production 273 (2020) 122851 17

created for the EO treatment. The choice for the use of solar energy
in the LCA prognosis scenario occurred due to the huge potential of
Brazil for this energy matrix. The solar energy sector has been
growing more than 200% per year in Brazil, i.e. the number of new
systems installed and connected to a network it exponentially
growing over the last years. According to the report published by
the Brazilian Micro and Small Business Support Service (SEBRAE,
2018) there is a trend for a significant change in the Brazilian en-
ergy matrix, with the photovoltaic energy moving from the less
representative source in 2012 to the most representative in 2040
with an installed capacity between 110 and 126 GW (GW). As one
can visualize in Fig. 11B, the replacement of the energy source,
reduce by more than a half the negative impacts of the treatment,
mainly in the human health group. Characterization (12A) and
Normalization (12B) graphics also highlight the environmental
benefits achieved from the use of solar energy instead of the Bra-
zilian traditional energy matrix (Fig. 12).
Similar results have also been reported by other authors. Opher
and Friedler (2016) evaluated the environmental impacts caused by
four alternatives for a hypothetical city’s water-wastewater service
system. The investigation revealed that changes in the electricity
mix, with an increased use of renewable energy sources in detri-
ment to fossil fuels, would lead to considerable reductions of the
environmental burdens of the most impact categories. In the same
manner De Feo and Ferrara (2017) observed that the replacement of
traditional energy mix present in some European countries (fossil,
nuclear, hydro) by electricity with photovoltaic systems would
noticeably lower the negative impacts of activated sludge used in
the treatment of urban wastewaters. According to Li et al. (2019) the
choice for a suitable treatment, with a reduction of the dependency
of fossil fuels and an increased use of more environmentally
friendly energy sources can significantly lower the GHG emissions
and consequently the global warming as well as protect human
health and the environment.
The results presented in this section demonstrated that LCA is
an essential tool in decision-making process for choosing the most
adequate alternative for the treatment of hospital laundry waste-
waters. Because of particular characteristics, such as the presence of
microcontaminants that may confer higher toxicity levels, different
aspects need to be considered when treating these effluents.
Although LCA results showed that the effluents did only impacted
the AEU category, one should be aware that these investigations
only considered load parameters (COD, BOD5, TKN and total P), i.e.,
disregarding toxicity analysis. So, traditional treatments methods,
despite reduce load parameters, might fail to reduce possible toxic
effects, and a final treatment stage would be necessary. On the
other hand, the use of treatments with high electric energy re-
quirements might significantly raise the environmental burdens of
the system. According to Li et al. (2019), in some cases the relative
benefits from the toxicity reductions are less than the burdens
brought by introducing advanced wastewater treatment processes
because of the indirect toxicity generated during the additional
electricity production, as well as contributions from the disposal of
materials. Hence, the use of AOP’s in the treatment of hospital
laundry effluents should be considered, however, as a part of an
integrated system and using more green energy sources instead of
fossil fuels.

Fig. 12. Comparison of the Characterization (A) and Normalization (B) values of the system’s operation (material and energy consumed)) in a prognosis scenario of the EO treatment
replacing the Brazilian traditional energy matrix by solar energy using SimaPro 8.04 and IMPACT Method 2002 þ/Excluding Infrastructure. Abbreviations: CA e Carcinogens; NCA e
Non-Carcinogens; RI e Respiratory Inorganics; IR e Ionizing Radiation; OLD e Ozone Layer Depletion; RO e Respiratory Organics; AE e Aquatic Ecotoxicity; TE e Terrestrial
Ecotoxicity TA e Terrestrial Acidification; LO eLand Occupation; AA e Aquatic Acidification; AEUe Aquatic Eutrophication; GW e Global Warming; NRE e Non-Renewable Energy;
MEe Mineral Extraction.
18 C.A. Lutterbeck et al. / Journal of Cleaner Production 273 (2020) 122851
5. Conclusions
Considering the risks that hospital laundry wastewaters may
represent to human and environmental health, the present
research aimed to review studies regarding the characterization
and the treatment of these effluents. The obtained results showed
that, despite the risks associated with hospital laundry wastewa-
ters, currently both characterization and treatment studies are
scarce. Moreover, the few studies dealing with this topic, pretty
much, do not address toxicity investigations.
As already expected, LCA proved to be an important tool in the
decision-making process for the choosing the best treatment
alternative. The analysis of the five studies submitted to LCA
revealed, on the one hand, that the performance of the treatments
regarding reduction of load parameters did only play a minor role
in the environmental pressures of the systems. On the other hand,
the operational parameters of the treatments were responsible for
high negative impacts. Because of the use of non-renewable energy
sources, the consumption of electricity was the main responsible
for the impacts in most of the analyzed categories. Therefore,
treatment systems with high energy requirements should be
avoided, even when achieving good pollutant removal rates due to
relevant “environmental costs”. In this sense, the application of
AOP’s in the treatment of hospital laundry wastewaters should be
done carefully, i.e., as pre- or post-treatment in an integrated sys-
tem and prioritizing alternatives with low electricity consumption,
such as electrooxidation. Furthermore, the replacement of fossil
fuels by more environmental-friendly energy sources will also
significantly contribute to lower the negative impacts.
Lastly, the present research demonstrated that the treatment of
hospital laundry wastewaters remains as a challenge task mainly
because the majority of the studies approached here was carried
out at lab scale, and the switch for real scale needs carefully eval-
uation concerning costs, energy requirements and environmental
impacts.
Declaration of competing interest
The authors declare that they have no known competing
financial interests or personal relationships that could have
appeared to influence the work reported in this paper.
Acknowledgements
Carlos Alexandre Lutterbeck thanks the Brazilian “Conselho
Nacional de Desenvolvimento Científico e Tecnolo  gico” (CNPq) for
^ 10.1016/j.jhazmat.2006.05.064.
their financial support (Grant N. 157933/2018-0). Enio Leandro
Machado acknowledges the financial support provided by CNPq-
Project 307257/2015-0, CNPq-Project 307599/2018-3 and Fundaça ~o
de Amparo a  Pesquisa no Rio Grande do Sul (Fapergs Project. PqG Nr
17/2551-0001069-8. Gustavo Stolzenberg Colares thanks CAPES
“Comissa ~o de Aperfeiçoamento de Pessoal de Nível Superior e
Funding Support Code e 001”.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.jclepro.2020.122851.
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