Journal of Water Process Engineering 41 (2021) 101990

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Journal of Water Process Engineering

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

Hospital wastewater as a source of environmental contamination: An

overview of management practices, environmental risks, and
treatment processes
Muhammad Tariq Khan a, Izaz Ali Shah b, **, Ihsanullah Ihsanullah c, **, Mu. Naushad d, e, f, *,
Sharafat Ali b, Syed Hassan Ali Shah b, Abdul Wahab Mohammad g
a
Department of Science and Environmental Studies, The Education University of Hong Kong, Tai po New Territories, Hong Kong
b
State Key Joint Laboratory of Environmental Simulation and Pollution Control, School of Environment, Beijing Normal University, No. 19, Xinjiekouwai Street, Beijing,
100875, China
c
Center for Environment and Water, Research Institute, King Fahd University of Petroleum and Minerals, Dhahran, 31261, Saudi Arabia
d
Advanced Materials Research Chair, Department of Chemistry, College of Science, King Saud University, Riyadh, 11451, Saudi Arabia
e
Yonsei Frontier Lab, Yonsei University, Seol, Republick of Korea
f
International Research Centre of Nanotechnology for Himalayan Sustainability (IRCNHS), Shoolini University, Solan, Himachal Pradesh, 173229, India
g
Department of Chemical and Process Engineering, Universiti Kebangsaan Malaysia, Bangi, Selangor, 43600 UKM, Malaysia

A R T I C L E I N F O A B S T R A C T

Keywords: A wide range of emerging contaminants (ECs), such as pharmaceutically active compounds, personal care
Hospital wastewater products (PCPs), endocrine-disrupting compounds (EDCs), and hormones are released into hospital wastewater
Water treatment (HWW). These contaminants can enter into natural environments, such as aquatic and terrestrial ones, thereby
Emerging contaminants
threatening human health and aquatic life. Conventional wastewater treatment plants are not designed to treat
Environment
Membranes
all types of chemical and biological contaminants, thereby allowing the release of these contaminants into water
bodies, such as rivers, streams, and groundwater. Accordingly, adequate measures and advanced technologies
should be implemented to prevent the discharge of ECs into aquatic environments. Reducing environmental
health risks of HWW is particularly important amid the persistence of the COVID-19 pandemic. Although the
necessary guidelines and legislation for wastewater treatment are available, efficient removal of ECs from HWW
requires the applications of advanced treatment technologies. This paper provides a comprehensive review of the
existing healthcare structures, ECs pathways to the environment, management practices, and effective treatment
options for removing ECs from HWW. A critical evaluation of the current research advances, knowledge gaps,
and directions for future research is also presented.

1. Introduction chemical compounds, both in their raw forms or as metabolites or

The provision of healthcare services requires the use of chemical
substances to guarantee proper diagnosis, treatment, disinfection, and
patient recovery [1]. These substances are classified into pharmaceuti­
cally active compounds (PhACs) required for healthcare procedures (e.
g., investigations, surgery, medications, and imaging) and chemicals for
controlling nosocomial infections (e.g., disinfectants) [2,3]. These
conjugates, are excreted from the bodies of patients through their urine
and feces and are often washed into sewage systems [4]. The emerging
contaminants (ECs) detected in trace concentrations (ranging from μg/L
to ng/L) can escape wastewater treatment plants (WWTPs) and thereby
lead to environmental contamination [4–6]. Healthcare facilities ac­
count for approximately 20%–25% of medicine usage among humans,
with some hospitals using tons of medicines annually [7,8].

* Corresponding author at: Advanced Materials Research Chair, Department of Chemistry, College of Science, King Saud University, Riyadh, 11451, Saudi Arabia.
** Corresponding author at: State Key Joint Laboratory of Environmental Simulation and Pollution Control, School of Environment, Beijing Normal University, No.
19, Xinjiekouwai Street, Beijing 100875, China; Center for Environment and Water, Research Institute, King Fahd University of Petroleum and Minerals, Dhahran,
31261, Saudi Arabia
E-mail addresses: Izazalishah@mail.bnu.edu.cn (I.A. Shah), ihsankhan@kfupm.edu.sa, engr.ihsan.dir@gmail.com (I. Ihsanullah), mnaushad@ksu.edu.sa
(Mu. Naushad).

https://doi.org/10.1016/j.jwpe.2021.101990
Received 23 January 2021; Received in revised form 19 February 2021; Accepted 19 February 2021
Available online 7 March 2021
2214-7144/© 2021 Elsevier Ltd. All rights reserved.
M.T. Khan et al.
Hospital effluents have been reported to contain tens to several
hundreds of micrograms per litre concentrations of antibiotics, cyto­
static, and other drugs [9,10]. In some low-flow sewer networks, hos­
pital effluents account for >80 % of all pharmaceuticals and personal
care products (PCPs) in the network load [7]. Hospital wastewaters
(HWW) are considered major contributors to ECs [11,12]. Other routes
for ECs entering into HWW include the direct disposal of unused or
expired drugs, landfill leachates, and application of sewage sludge to
ensure soil fertility [13]. Many studies have reported that hospitals
release untreated or inappropriately treated waste that contains phar­
maceuticals, such as antibiotics and resistant genes, into ambient
aquatic environments [7,14,15]. The existence of these pharmaceuticals
in various environmental matrices, including surface water, ground­
water, soil, and sediments, can threaten human health, biota, and the
environment [16,17]. Therefore, it is critical to properly treat the hos­
pital effluents to minimize their adverse impacts on the environment
[18]. Table 1 highlights the typical characteristics of HWW.
While several countries have adopted regulations for ECs, WWTPs
are neither particularly designed for treating emissions nor have any
standards and guidelines for treating micropollutants. For instance, the
European Parliament through Directive 2008/105 /EC has regulated
environmental quality standards for a very small number of emerging
micropollutants (i.e., bisphenol-A, diiron, and nonylphenol) [19].
Similarly, nonylphenol ethoxylates and nonylphenol have been recog­
nized as toxic substances by the government of Canada [20,21]. Other
HWW micropollutants, including PhACs, PCPs, and steroid hormones,
are still excluded from the list of regulated substances. Further research
is required to investigate the effect of these contaminants on public and
ecological health and to establish regulatory standards for micro­
pollutants [22]. The existence of micropollutants in the environmental
matrices pose challenges to public health and environmental sustain­
ability. Therefore it is important to improve the efficiency of wastewater
treatment facilities for the management of discharged effluents [16].
WWTPs play a vital role in reducing the levels of ECs in reclaimed
water. However, in the majority of the cases, these contaminants are not
sufficiently removed in wastewater treatment processes and persist in
the treated wastewater effluents, thereby resulting in their presence in
aquatic environments after discharge [4,7,23,24]. Several studies show
that advanced treatment technologies should be installed to reduce the
genotoxicity of HWW [25,26]. The public health risks resulting from
these contaminants can be managed in several ways, such as by
removing pathogenic microorganisms and other chemical contaminants
from wastewater and minimizing the exposure of humans to wastewater
[22]. Pharmaceuticals can be removed at the source by implementing
technical measures in hospitals or by collecting separate waste streams.
All of these options can substantially reduce the load of micropollutants.
Previous studies on the presence of ECs in various water environ­
ments have not been thoroughly reviewed to provide a comprehensive
summary of the presence/occurrence of ECs in hospital effluents.
Moreover, the removal efficiency of ECs in WWTPs treating the HWW
Table 1
Typical characteristics of HWW.
S. No Parameter Value Reference
1 Suspended solids (SS) (mg/L) 11− 900 [27,28]
2 pH 6.8− 8.6 [28,29]
3 Conductivity (mS/cm) 230− 1468 [30]
4 BOD5 (mg/L)* 80− 1530 [28,31]
5 COD (mg/L)* 150− 2664 [28,31]
6 Redox potential (mV) 820− 940 [32,33]
7 TOC (mg/L)* 30− 200 [32,33]
8 Chlorides (mg/L) 65− 359 [31,34]
9 NH+4 (mg/L) 2.53− 75 [29,30]
10 Fats and oils (mg/L) 3.5 [27]
*
BOD5: Biological oxygen demand, COD: Chemical oxygen demand, TOC:
Total organic carbon.
2
Journal of Water Process Engineering 41 (2021) 101990
has been rarely investigated. Accordingly, this review aims to address
the following inter-connected aspects reported in the literature: 1)
occurrence of ECs in HWW, 2) sources and pathways of ECs in hospital
effluents, 3) management practices, 4) ECs treatment options, and 5)
knowledge gaps and future research directions. This review will provide
relevant information that can guide decision-makers and environmental
scientists in their future policies and research endeavours.
2. Water demand and consumption in healthcare facilities
Hospitals require large amounts of water every day for various
purposes and services; however, each hospital has a different daily water
consumption rate [35]. The quantity of wastewater produced by hos­
pitals also depends on several factors, including their number of beds,
water supply, availability of general services (i.e., laundry, kitchen, and
air conditioning), types and number of wards or units, and management
policies [36]. Fig. 1 shows the percentage of water consumption of
various healthcare services in hospitals [37].
In addition, the water demand typically observed in hospitals is
estimated to range from 200 L to 1200 L bed–1 day–1 [38,39]. The
consumption of water in a hospital environment is accompanied by an
equal amount of wastewater discharge. Hospital effluents also contain
domestic discharge coming from kitchens, laundries, and toilets. The
water demand for various healthcare facilities is presented in Table 2 [7,
40].
3. Sources and transport of ECs in hospital effluents
Hospitals generate a large amount of wastewater that contain
different varieties of pollutants [4,7,41]. HWW consists of ECs and
pathogens that are excreted from human bodies through urine and feces
and often end up in sewer systems, which remain the major path for
these contaminants to enter municipal sewage systems (Fig. 2) [4,
42–44]. Consumer products, such as soaps, disinfectants, and shampoos,
are other sources of ECs [45]. The ECs released from these products are
transported to WWTPs to undergo a treatment process. However, not all
WWTPs are capable of removing all types of ECs discharged by hospitals;
therefore, they routinely help ECs to enter the natural environment [46].
The presence of these ECs in the environment can threaten both public
health and the ecosystem.
Given the unique physicochemical properties (i.e., polarity, water-
solubility, microbial resistance, and persistence) of ECs in HWW, these
bioactive chemicals may also bioaccumulate in the food chain [4].
Humans are particularly exposed to drinking water that is produced
from surface water [47]. Moreover, after treating these contaminants,
the sludge is applied to the soil as fertilizer, whereas the liquid effluent is
Fig. 1. Water consumption of hospital activities [37].
M.T. Khan et al. Journal of Water Process Engineering 41 (2021) 101990

Table 2 pharmaceuticals, chemicals, transmittable pathogens, or radioactive

Water demand for various healthcare facilities. residues [50]. The WHO guidelines provide a basis to explain the toxic
S. Name of healthcare facility Quantity (L)/patient/ nature of these wastewaters and recommend the procedure for the safe
No intervention management of HWW [51,52].
1 In-Patient Department (IPD)/hospital 40− 60 A pre-treatment of wastewater coming from medical laboratories
2 Operation theatre/delivery room 100 and dental departments is usually applied, but an amalgam separator
3 Out-Patient Department (OPD) 5 must be initially installed. The minimum requirements for releasing
4 Ambulatory Therapeutic Feeding Centre 5 HWW into municipal treatment drains include the following:
(ATFC)
5 In-patient Therapeutic Feeding Centre 30− 50
(ITFC) 1 An efficient sewage treatment system with primary, secondary, and
Supplementary Feeding Centre (SFC) 5 tertiary treatment units.
6 Cholera Treatment Centre (CTC) 60 2 The municipal sewerage system must be connected to a central
7 Severe acute respiratory syndrome (SARS) 100
treatment facility and must be able to remove at least 95 % of bac­
Isolation
8 Viral Haemorrhagic Fever (VHF) Isolation 300− 400 teria from wastewater [51].
9 Mobile clinic: infrequent visits 2 3 The sludge residue obtained after treatment should be subjected to
10 Mobile clinic: frequent visits 5 anaerobic digestion and leave minimum amounts of microscopic
(in fixed tents/existing buildings) helminth eggs per litre in the digested sludge [51].
Source: Modified from [7,40] 4 High standards must be maintained to ensure that low the treated
wastewater only has low levels of toxic compounds, cytotoxic drugs,
directly discharged into freshwater [46]. Pharmaceuticals present in antibiotics, radiation material, and pharmaceuticals [49,53].
water can also reach freshwater through run-off from land that is treated
with digested sludge for agricultural purposes [46,48]. Furthermore, The International Commission on Radiological Protection (ICRP)
ECs discharged by hospital effluents can reach the groundwater by published some guidelines for the safe release of patients treated with
leaching from the soil, which can threaten the quality of drinking water. open nuclides [54]. Given that those patients subjected to radioactive
The types of hospital services and healthcare procedures vary across treatment may have radioactive compounds in their excretory sub­
different regions of the world. Therefore, the significant pathways for stances, the ICRP recommends that the urine of these patients should be
exposure also vary geographically. For instance, the treatment models stored after therapy and suggests that the radionuclides released into
being used in developed countries are different from those being used in sewage systems may expose sewage workers and others to radiation
developing countries given the differences in their available facilities [55]. In the US, the Environmental Protection Agency (EPA) imple­
and treatment technologies. Therefore, the exposure pathway of a spe­ mented the 1972 Clean Water Act to regulate how effluents are dis­
cific region may not apply to other regions. Fig. 2 shows the major routes charged into water and to specify the effluent parameters for WWTPs
of HWW flowing to aquatic environments, to the food chain, and ulti­ [50].
mately to WWTPs for treatment and disposal. Although no laws or guidelines for managing hospital effluents have
been implemented in Europe, the European Directive n. 91 of May 21,
1991 (91/271/CEE modified from Directive 27 of February 1998 n. 98/
4. Regulations and guidelines for HWW
15/CE) requires a pre-authorization of urban wastewater before its
discharge into urban wastewater collection systems. Moreover, the Eu­
While countries and international organizations have set their own
ropean Directive n. 98 of November 19, 2008 (EU, 2008/98/EC) states
guidelines for wastewater treatment, the guidelines set by the WHO
that some hospital effluents (i.e., pharmaceuticals and personal care
remains dominant for the pre-treatment of effluents from healthcare
products or PPCPs) must not be released into sewer systems but should
facilities [49]. Depending on the service level and treatment procedures
be treated as waste and collected prior to disposal. Some European laws
of the healthcare facility, the discharged wastewater may contain

Fig. 2. Sources and pathways of ECs from HWW to aquatic environments, to the food chain, and to WWTPs for treatment and disposal.

3
M.T. Khan et al. Journal of Water Process Engineering 41 (2021) 101990

also define how hazardous waste should be managed, and the European Table 4
Directive Decision lists some hazardous waste from hospitals, including Regulations for ECs implemented in various countries [49,61].
liquid waste, medicinal products, medications, and material contami­ Country ECs regulation description
nants from substances used as solvents and soaps, that should not be
✓ Monitoring of contaminants candidate list (CCL)
dumped in filthy drains [56]. USA
✓ Monitoring of EDCs occurrence
Following these laws, hospital facilities in Europe should meet spe­ ✓ Regulations are in progress
cific industrial requirements before they can discharge wastewater into European ✓ EDCs monitoring
municipal WWTPs. A pre-treatment is usually required (such as in the Union Recommending the additives of EDCs as an additive in the
✓
products of consumers
case of Spain), but none of the existing requirements pertains to the Canada ✓ No regulations so far
characteristics of hospital waste [49]. In some instances, when the
general requirements implemented by WWTP authorities are met, the
wastewater can be considered acceptable sewage and can be dumped regarding the sources fate and transport of these ECs would help the
without any pre-treatment [49]. Even when the indicator parameters policymakers and decision-makers to design and implement the regu­
exceed the limits, the wastewater may be pre-treated, such as in the case lations more efficiently. This will ensure the limited release of ECs into
of Italy [38]. Table 3 presents the guidelines and regulations for HWW the natural environment.
treatment implemented in various countries and regulatory authorities.
The US EPA maintains a Contaminant Candidate List (CCL), the most 5. ECs in HWW
recent edition of which is the 2008 CCL3, which lists several endo­
cannabinoid compounds, estrone and organofluorine compounds, The major ECs in HWW include diagnostic agents, disinfectants,
including perfluorooctanesulfonic acid and some flame retardants [57]. PhACs and PPCPs. HWW contains various PPCPs that affect commu­
However, regulations that specify the maximum acceptable proportions nities and individuals within localities.
of these contaminants are yet to be introduced. Ecological testing of Over the past decade, more than 300 PhACs, including their me­
pharmaceuticals in marine environments is currently not required by the tabolites and some derivatives with high concentration, have been
US Food and Drug Administration (FDA) unless their concentration ex­ identified in HWW and have been traced in WWTPs [49]. Various sec­
ceeds 1 ug/L [58]. The FDA has also introduced a plan to monitor the ondary WWTPs were effective in removing the PhACs from HWW. For
harmful effects of endocrine-disrupting compounds (EDCs) on humans instance, a study reported that Sulfamethoxazole, Ciprofloxacin, and
and wildlife [59]. The document proposed some suggestions for EDCs Trimethoprim have removal rates of 21–33 %, 60–83 %, and 48–85 %,
compounds in consumer goods, inert ingredients, and aesthetics; how­ respectively. PhACs generally have an overall removal rate of 79–99 %,
ever, the US has no available laws that govern the effects of drinking with the exception of Naproxen, which has a removal rate of 57–60 %
water and wastewater on the environment [60]. [62,63]. Given these differences, further research on individual phar­
Table 4 presents the regulations for ECs that have been implemented maceutical groups needs to be conducted; however, the literature sug­
in the US, European Union, and Canada. However, there are still many gests that the removal rate of most pharmaceuticals in WWTP, except for
contaminants whose environmental impacts are yet to be explored, naproxen, exceeds 90 % [45]. Group of PPCPs such as antibiotics inhibit
thereby presenting a major obstacle for regulatory bodies that are bacterial growth which may affect the treatment process [64].
responsible for issuing wastewater legislations. Having further research PCPs, including toothpaste, soap, and dishwashing liquids, are being
used in daily life, and anti-bacterial and anti-fungal PCPs, such as tri­
closan, are being used in hospitals. Other anti-depressants work to
Table 3
inhibit the action and production of neurotransmitters. Some of the most
Guidelines and regulations related to HWW treatment.
famous antidepressants include venlafaxine and citalopram, of which
Country/ Law description Year Reference the former is a reabsorption activator of serotonin-norepinephrine that
Regulatory
is often used for treating depression [65]. WWTPs in Montreal, Canada
Authority
have reported removal rates of 10%–12% for antidepressants including
WHO Safe management of wastes 1999− 2014 [56]
Citalopram and Venlafaxine [45]. Estrogens, which are not only found in
from healthcare activities
China European Directive n. 91 of 21 1991 [56]
hospital waste but are also being released by humans and animals
May 1991 on urban wastewater through their urine and feces, had a reported removal efficiency of 40%–
treatment 90% in a study that was made among five WWTPs in Bangkok [66]. The
Germany Wastewater Ordinance (AbwV) 2004 [56] aforementioned antidepressants have low removal rates. However, the
India Environment (Protection) Act 1986 [56]
WWTP in Montreal, Canada, is only equipped with primary treatment,
Italy DPR n. 227/2011 on 2011 [56]
simplification on and WWTP with secondary or tertiary treatment are expected to have
environmental law higher removal efficiency [45,67]. In order to eliminate such class of
Spain Decree 57/2005, of June 30, 2005 [56] PPCPs from wastewater, primary and secondary treatment processes
which revises the Annexes of
required advanced treatment technologies. More advance research is
Law 10/1993, of October 26,
on Industrial Liquid Discharges
needed to study the fate of PPCPs following more advanced treatments.
to the Comprehensive
Sanitation System 6. Health and environmental risks associated with HWW
Law on environmental
2014 [56]
protection
Vietnam
National Technical Regulation
HWW is 5–15 times more toxic than domestic wastewater [14]. The
2010 [56] release of healthcare effluents carrying ECs into the aquatic environ­
on Health Care Wastewater
Effluent Guidelines and ment poses a high risk to water quality, aquatic ecosystems, and human
US EPA 1976− 2016 [56]
Standards (CFR 40) health [7,68]. Infectious outbreaks in low-income countries are among
International
Release of patients after the most serious consequences of releasing these ECs into aquatic en­
Atomic Energy 2009 [56]
Agency (IAEA)
radionuclide therapy vironments, while the pollution from pharmaceuticals and other
Release of patients after chemicals remains the major health risk for people in developing and
ICRP therapy with unsealed 2004− 2013 [56] high-income countries [22]. The chemicals being discharged by hospi­
radionuclides tals contaminate the water systems of cities and may cause skin diseases
or enteric illness. Similarly, the microorganisms from HWW have been

4
M.T. Khan et al.
known to cause diarrhoea and cholera outbreaks [33]. The majority of
these contaminants are capable of inhibiting biological activities at
treatment plants [14,69]. The ECs in HWW effluents escape from
WWTPs, and their widespread occurrence in water bodies, such as lakes,
rivers, and groundwater, can be detrimental to the health of humans and
wildlife. ECs and their residues enter and accumulate in the food chain
via discharged effluents and through the reuse of treated sewage sludge
for agriculture application [70].
Antibiotics, such as fluoroquinolones, macrolides, sulfonamides,
β-lactam, lincosamides, trimethoprim, and metronidazole, are generally
found in HWW [39,71]. The residual quantities of these antibiotics in
HWW can increase the resistance of bacteria to a wide range of biocides
[72]. Antimicrobial excretion, in combination with high microbial
biomass and an abundance of nutrients, makes wastewater a potential
location for horizontal gene transfer and become a reservoir of
antimicrobial-resistant bacteria [73]. Specifically, the occurrence of
resistant organisms can be expected in hospital facilities where medi­
cines are being used on a large scale. Through this path, resistance genes
are introduced in natural bacterial ecosystems where non-pathogenic
bacteria can serve as reservoirs of resistance genes [74,75]. Antibiotic
resistance genes may also spread in drinking and recreational water and
facilitate the spread and evolution of clinical resistance genes and their
vectors. Opportunistic pathogens may become resistant upon acquiring
a resistant gene [76].
Multidrug-resistant bacteria in the environment can infect humans
and animals via contaminated food and drinking water or directly from
the environment [77]. While antibiotic-resistant bacteria are not
considered primary pathogens, they can threaten public health by
transmitting their resistance to other microorganisms, particularly
human pathogens [78,79]. Although several studies have identified the
presence of pharmaceuticals, such as antibiotics, in hospital effluents,
their environmental effects and persistence in conventional wastewater
treatment processes remain largely unknown [80].
Certain substances discharged by HWW, such as antitumor agents,
antibiotics, and organohalogen compounds, pass through WWTPs
without any degradation. After these substances reach the aquatic sys­
tem, they negatively affect the receiving waters and their living species
[69]. Some of these PPCPs bioaccumulate in aquatic organisms and lead
Fig. 3. ECs occurrence, pathways, health risks, and release from HWW.
5
Journal of Water Process Engineering 41 (2021) 101990
to unexpected disturbances. For instance, chronic/long term exposure to
estrogenic contaminants in water can lead to liver enlargement in fish
[81].
Some substances found in wastewaters are genotoxic and are sus­
pected to be a possible cause of cancers observed over the past decades
[25]. Water genotoxicity studies are of interest because epidemiologic
investigations have established a link between genotoxic drinking water
intake and a rise in cancers [82]. The occurrence of ECs in HWW, their
pathways, and their associated health risks are shown in Fig. 3.
Pharmaceuticals, such as psychotropic substances at trace concen­
trations (i.e., ng/L to μg/L), have toxic effects on aquatic organisms. The
effects of WWTP effluents on the oogenesis and/or embryogenesis of
amphipod crustacean Gammarus fossarum, Japanese fish medaka Ory­
zias latipes, mollusk Radix peregra, and planarian Schmidtea polychroa
have also been reported [9]. A decrease in the number of oocytes and
produced embryos has been observed in G. fossarum and S. polychroa
[9]. Similarly, effluents can affect the hatching rate of R. peregra and the
macroinvertebrate communities living in the receiving rivers [83,84].
Therefore, further research is required to understand the potential im­
pacts of residues of different pharmaceuticals on ecosystem service de­
livery and to characterize the relationship between ecosystem services
and human well-being [85]. There may be hundreds of disease-causing
organisms present in sewage and wastewater that are yet to be identi­
fied; therefore, HWW poses a greater threat to human health [86].
Future research should focus on the occurrence (and driving factors) of a
wide range of PPCPs in various environmental matrices and their im­
pacts on human health due to long term exposure.
7. Technologies for HWW treatment
Various treatment techniques are currently employed for the
removal of various pollutants including ECs and pharmaceuticals from
water [33,87–93]. This section reviews the most studied among these
technologies. Fig. 4 shows various treatment processes in a typical
WWTP.
M.T. Khan et al. Journal of Water Process Engineering 41 (2021) 101990

Fig. 4. Various treatment processes in a typical WWTP.

7.1. Conventional wastewater treatment
Table 5 summarizes the ECs concentration in HWW and their
removal efficiencies in various conventional treatment technologies.
Conventional technologies for wastewater treatment can be categorized
into preliminary, primary, secondary, and tertiary technologies, as dis­
cussed below.
7.1.1. ECs removal during preliminary and primary treatments
Removal of ECs during the primary treatment process is limited due
to the hydrophilic nature of the hospital wastewater contaminants [3,
94]. The efficiency of coagulation, flocculation, and flotation in
removing ECs from hospital effluents have been examined in previous
studies [95,96]. For instance, a study in Brazil used a septic tank and an
anaerobic filter filled with raw effluent from a hospital and found that
only diclofenac and some fragrances have an average removal of more
than 60 %, whereas ciprofloxacin has the removal of only 17 % [96].
Another study reported a <28 % removal efficiency for estriol (E3) in
sedimentation tanks [97]. Triclosan (TCS) removal by primary treat­
ment varies significantly due to the high water consumption rate and
short hydraulic retention time in a sedimentation tank [98]. Adsorption
is recognized as one of the main mechanisms of PPCPs removal in

Table 5
ECs concentration in HWW and removal efficiencies by conventional treatment technologies.
Treatment unit EC Influent Effluent Removal efficiency Reference
(ng/L) (ng/L)

Primary treatment Trimethoprim 95 ± 23 91 ± 28 4 [130]

Primary Venlafaxine 195 175 10 [65]
Treatment
Primary treatment Diclofenac – – 28 [97]
Primary treatment Tetracycline (TC) – – 50 [131]
Primary treatment Trimethoprim (TMP) – – 12 [126]
Primary treatment Estriol – – 45 [97]
Primary treatment Methylparaben – – 71.6 [132]
Primary treatment Oxytetracycline (OTC) – – 8 [131]
Secondary treatment Amoxicillin 261 ± 3 66 ± 2 74 [130]
Activated Sludge Ciprofloxacin 150 60 60 [133]
Activated Sludge Trimethoprim 330 170 48 [133]
Activated Sludge Erythromycin 3900 1100 71 [133]
Activated Sludge Ibuprofen 83,500 6500 92 [62]
Activated Sludge Sulfamethoxazole 300 200 33 [133]
Activated Sludge Sulfamethoxazole 390 310 20 [134]
Activated Sludge Trimethoprim 590 180 69 [134]
Activated Sludge Estrone 30 13 56 [135]
Activated Sludge Estradiol 8 – – [135]
Activated Sludge Triclosan 1900 114 94 [135]
Activated sludge system Carbamazepine 15,780 7570 52 [136]
with tertiary treatment
Activated sludge system Diclofenac 1660 430 74 [136]
with tertiary treatment
Activated sludge system Napoxen 1880 190 84 [136]
with tertiary treatment

6
M.T. Khan et al.
primary treatment processes [95]. Studies have identified that ozona­
tion, Fenton, and photo-Fenton processes as suitable solutions for the
preliminary treatment of HWW from a technical perspective [99,100].
An improved biodegradability can be achieved via photo-Fenton pro­
cesses [99], which may also work as a disinfectant step, given its ability
to remove total coliforms and thermos-tolerant coliforms [100].
A septic tank is used in three hospital WWTP located in Brazil, Nepal,
and Ethiopia. In this septic tank, by decelerating the wastewater flow,
part of the solids settles to the bottom of the tank while the floatable
solids (e.g., fats, oil, and grease) rise to the top. Up to 50 % of the solids
retained in the tank are decomposed, whereas the rest accumulate as
sludge at the bottom and need to be removed periodically by pumping
the tank [49].
Another example of primary treatment is chemical flocculation,
which is applied in a dedicated full-scale hospital WWTP in Korea with
the aim of removing suspended solids and colloids from wastewater that
does not settle spontaneously [101]. Lien et al. (2016) applied filtration
and other physicochemical processes as preliminary treatment before
conventional activated sludge (CAS) treatment in two hospitals in
Vietnam [102].
An economic analysis should be performed to assess investment,
operational, and maintenance costs. Moreover, the adequateness of
adopting these advanced technologies as pre-treatment also needs to be
confirmed from a toxicological perspective. The capabilities of primary
treatment processes (i.e., sedimentation) in removing PPCPs are very
limited, given the hydrophilic nature of most PPCPs [3,94]. Primary
treatment is also insufficient to remove PPCPs. However, up to 40 % of
fragrances (e.g., Toxalide fragrance (AHTN) and Galaxolide fragrance
(HHCB)) can be efficiently removed in primary treatment due to the
high partition coefficients between the liquid and solid phases. A study
found a strong correlation between the concentrations of AHTN and
HHCB in sewage treatment plant (STP) effluent (r2 = 0.71) [103]. The
similar removal mechanisms of AHTN and HHCB, namely, sorption and
volatilization, in STPs resulted from their similar physicochemical
properties [70].
7.1.2. ECs removal in secondary treatment
The technologies applied in secondary wastewater treatment should
be carefully chosen based on their present level of application at full-
scale WWTPs and their performance for the removal of the selected
ECs [104]. Previous studies suggest that CAS procedure and ultrafil­
tration (UF) membrane bioreactors can effectively remove ECs from
HWW [39,105]. Moving bed biofilm reactors have also been introduced
as potential alternatives to the CAS process and membrane filtration
bioreactors and have been proven to efficiently remove ECs [104]. The
CAS technology requires a settling step at the end, yet it has been widely
applied in large-scale sewage treatment plants. Conversely, membrane
filtration, which requires one processing component in the membrane
filtration bioreactor, helps to achieve a clear, good quality effluent after
treatment [49]. The CAS method and membrane filtration bioreactors
can also effectively remove some major compounds from HWW, such as
methylparaben, caffeine, ethylparaben, triclosan, ibuprofen, and gal­
axolide [106]. Several experiments have proven that membrane filtra­
tion bioreactors are approximately 30%–55% more efficient than the
CAS method [39]. In addition, membrane filtration bioreactors can
remove mefenamic acid, diclofenac, indomethacin, and gemfibrozil
more effectively than the CAS method [39]. However, some materials,
such as carbamazepine, have not been removed by either of these ap­
proaches [39]. Given their high cost and frequent maintenance re­
quirements, membrane filtration bioreactors are not widely used for
treating hospital effluents [31]. Many countries also prefer using the
CAS method due to its cost-effectiveness and high efficiency under
different conditions [49].
In general, the ECs degradation rate observed in hospital WWTPs is
higher than that observed in urban WWTPs. However, the concentration
of ECs in HWW remains higher after undergoing biological treatment in
7
Journal of Water Process Engineering 41 (2021) 101990
hospital WWTPs than in urban WWTPs, given the higher influent con­
centration in the former [49]. Pharmaceuticals from all investigated
therapeutic classes (i.e., beta-blockers, nonsteroidal anti-inflammatory
drugs, antibiotics, analgesics, and anticonvulsants) have been effi­
ciently removed except for carbamazepine. High removal efficiency for
antibiotics, non-steroidal anti-inflammatory drugs (NSAIDs), and
beta-blockers are observed during the HWW treatment [107]. Based on
these removal rates, a separate treatment can benefit the removal of ECs
from HWW [107]. Analgesic paracetamol has the highest concentration
among all pharmaceuticals in wastewaters but also shows the highest
removal efficiency (99.9 %). Conversely, the anticonvulsant carbamaz­
epine has the lowest concentration but is hardly removed during treat­
ment (3.5 % removal rate). A study reported that carbamazepine
concentrations in hospital treated effluents (HTE) are slightly higher
than those in the effluent HWW [107]. Fig. 5 illustrates a typical CAS
process.
7.1.3. ECs removal in tertiary treatment
Those pollutants that are not removed during the aforementioned
processes are removed in tertiary treatment. Filtering through activated
carbon in powdered or granular form has been applied to remove ECs
and other compounds through sorption [108,109]. Several studies have
assessed the adsorption of other emerging trace and organics comprising
a range of PPCPs and EDCs on activated carbon in both laboratory sys­
tems and full-scale WWTPs [110,111]. However, only a few have
examined granular activated carbon adsorption as an option for tertiary
wastewater treatment. Granular-activated carbon facilities in conven­
tional WWTPs achieve removal of 74 % and 80 % for Erythromycin and
carbamazepine, respectively [112]. Tertiary treatment can be applied
exclusively or in combination with UV or chlorine disinfection or pol­
ishing [49]. A study presented a global overview of tertiary treatment
for removing pollutants in hospital effluents [39]. Different strategies,
such as poly-aluminum chloride UV and advanced oxidation processes
(AOPs), have also been assessed for their pollutant removal efficiency.
Adding granular activated carbon at approximately one gram per litre
into the aeration tank of an activated sludge reactor can help remove
PhACs groups, such as carbamazepine, diclofenac, and diazepam [113].
The NH4Cl-induced activated carbon (NAC) has also been studied for the
removal of PhACs from water [114].
However, only a few studies have examined the application of PAC
and membrane bioreactors for removing micropollutants. Despite the
proven efficiency of these technologies, a bigger picture of the process is
yet to be drawn even though their removal performance has already
been reported in the literature [115,116]. Activated carbon has also
been proven to effectively remove PPCP residues from the treated ef­
fluents. Results of these studies show that activated carbon beds can be a
suitable alternative to ozone treatment with 90%–98% PPCPs removal
efficiency. These carbon beds can remove 43%–64% of PCPs from
sewage effluents in large-scale sewage treatment plants and have
demonstrated their efficiency in removing estrogens. However, their
removal rates vary across different types of PCPs; for instance, anti­
spasmodics have removal rates of 84%–99%, whereas carbamazepine
and propranolol have removal rates of only 17%–23% [117]. Several
reactors have also been examined for their application of biotransfor­
mation and adsorption in removing PPCPs.
When opting for a suitable treatment for PPCPs, some factors, such as
the associated hydraulics, operating cost, and capacity clogging prob­
lem, must be taken into consideration [118]. The tertiary treatment has
been used solely or in combination with other polishing treatment,
including chlorine disinfection [36,39]. Disinfection is crucial in
ensuring the safe discharge of wastewater to drainage systems and water
bodies [38]. This process is always performed right before the products
are discharged to the environment. The different removal efficiency of
PPCPs and ECs are obtained through different treatment technologies
employed for the treatment of HWW [49]. Powdered activated carbon,
UV, and AOPs have removal rates of greater than 90 % for PhACs,
M.T. Khan et al.
Fig. 5. CAS process.
whereas chlorination and coagulation for PhACs removal only achieve
removal rates of 20 %–70 % and 20 %–40 %, respectively [119].
Parabens are widely used in food and PPCPs and can be removed by
conventional sewage treatment plants with a more than 90 % removal
rate [120]. However, few parabens and their byproducts in conventional
sewage treatment plants are removed by using advanced treatment
techniques, such as UF and ozonation [121]. Results of another study
show that only 1%–10% of the target PPCPs can be removed by UF. In
this case, low removal efficiency may be linked to the small size of the
target HWW contaminants than to the membrane pores [122]. During
the backwashing, several parabens released from the membrane or
during pH fluctuations of the influent [123]. However, ozonation ach­
ieves a removal rate of more than 98 % for parabens, except for
de-chlorinated compounds. These findings agree with a previous study
that reported a parabens removal rate of 99%–100% by ozonation
within a short hydraulic retention time [124]. Several studies have also
highlighted the effectiveness of UV radiation in removing PPCPs and
found that the combination of biological processes and UV can notice­
ably improve the collective treatment of PPCPs in sewage treatment
plants [122,125,126]. A study found that incorporating filtration and
ozonation into the CAS process can effectively remove most of the target
PPCPs with a removal rate of about 80 % [127]. Compared with the use
of a single biological process, those systems that combine bioreactors
and AOPs (e.g., UV/O3/H2O2) noticeably enhance the removal effi­
ciencies of cyclophosphamide and ifosfamide from 59 % and 35 % to
>99 %, respectively [128]. While the chemicals added during chlori­
nation and ozonation have some toxicity, they show a high pollutant
removal efficiency [128]. However, these chemical techniques do not
effectively remove biologically active antibiotics and light-resistant UV
filters [129].
7.2. Membrane filtration
Membrane filtration techniques, such as reverse osmosis (RO) and
nanofiltration (NF) are effective processes for removing emerging pol­
lutants from wastewater [70]. NF removes pharmaceutical com­
pounds/pollutants from wastewater in three steps, namely, adsorption,
sieving, and electrostatic repulsion [137]. The physical properties of
8
Journal of Water Process Engineering 41 (2021) 101990
pollutants, including their charge, molecular size, diffusivity, solubility,
hydrophobicity, and polarity, determine their removal efficiency. Other
factors that affect pollutant removal include membrane properties,
water feed quality, and membrane operating conditions [138]. The ca­
pabilities of two types of submerged NF flat sheet modules in removing
pharmaceuticals from STPs have been investigated in previous research
[139]. Both of these membranes have retained approximately 60 % of
diclofenac and naproxen and only removed a small proportion of car­
bamazepine [140]. Therefore, unlike carbamazepine, diclofenac, and
naproxen may be obstructed by the negatively charged membrane sur­
face [140]. However, in all sewage treatment plants, this treatment step
may not be successful based on its removal efficiencies for the afore­
mentioned compounds. For more polar compounds, NF usually achieves
a higher pollutant removal efficiency compared with UF membrane
[141].
The application of RO and NF membrane for removing PPCPs have
also been analyzed in previous research [141]. NF achieves average
retention efficiencies of 82 % and 97 % for neutral pollutants and ionic
contaminants, respectively, whereas RO can achieve removal rates of
85%–99%. A study compared the potential application of different
structural patterns for removing PPCPs from selected water sources and
found that combining ozone treatment with NF greatly affects the
pollutant removal potential [142]. For example, NF followed by ozon­
ation can remove >90 % of pollutants from both natural water and
secondary effluents with ozone doses of 2.25 mg/L and 3.75 mg/L,
respectively [70]. By contrast, ozonation with an initial dose of 2.25
mg/L, followed by NF in natural waters can achieve a high removal
efficiency of >70 % in the permeate stream [143].
While NF and RO can effectively degrade PPCPs, some substances do
not pass from the membranes [70]. UF and RO can remove >80 % EDCs
and pharmaceuticals [63,144]. In addition, RO achieves a removal ef­
ficiency of >90 % for naturally occurring and synthetic steroids, orga­
nohalides, and other compounds [145]. However, RO achieves low
removal rates for diclofenac (55.2 %–60 %) and ketoprofen (64.3 %). A
study reported that RO achieved removal rates of 90 % or better for
naturally occurring and synthetic steroids, organohalides and other
compounds. RO can remove all the investigated compounds below their
corresponding detection limits, including those that have not been
M.T. Khan et al. Journal of Water Process Engineering 41 (2021) 101990

significantly removed at sludge retention time (SRTs) of 30 days (e.g.,
galaxolide) via CAS or media filtration [39]. Many studies have inves­
tigated the rejection of ECs by FO membranes, whose rejection mecha­
nisms are similar to those of NF and RO. The rejection of ECs is mainly
governed by size exclusion (steric interaction) and electrostatic in­
teractions. The affinity of specific organic molecules to the forward
osmosis (FO) membrane (e.g., through hydrophobic interaction) may
also influence the rejection, particularly when the solute is comparable
in size or smaller than the pore of the FO membrane [146]. Table 6
presents the membrane-based separations of ECs and their removal
efficiencies.
8. Current HWW management practices in various countries
Each country adopts a different approach to HWW treatment, as
shown in Table 7. HWW is continuously being discharged into waste­
water drains unchecked and eventually flow into municipal WWTPs
where they are mixed with effluents before final treatment [156]. This
practice is common in Iran, Japan, Egypt, Australia, South Africa, India,
Bangladesh, Congo, Algeria, Vietnam, Ethiopia, Pakistan, Nepal, and
Taiwan [49]. The worldwide distribution of ECs removal from HWW is
shown in Fig. 6.
Hospital effluents are imminent sources of toxic compounds in
aquatic environments due to their discharge into drains and freshwater
bodies without pre-treatment [158]. Table 7 shows the treatment
methods adopted by various countries. For instance, the majority of the
hospitals in Pakistan discharge their wastewater without pre-treatment
[159,160], whereas some hospitals in Taiwan discharge effluents
directly into freshwater bodies without treatment [49,160,161].
9. Management of HWW: a conceptual framework
To ensure efficient HWW management, government authorities,
pharmaceutical industries, and scientific institutions that use scientific
data and methodical approaches should work in a collaborative man­
agement cycle. The unknown and new sources of contaminants must be
considered by wastewater management, including research institutions,
as sources of compounds whose physical and psychological health ef­
fects are yet to be characterized [180]. Financial institutions may also be
incentivized to support wastewater treatment facilities and infrastruc­
ture in an integrated, multifaceted public health risk reduction plan
typically presented in the WHO guidelines [181,182]. The most chal­
lenging part of this approach is the limited awareness of the public and
private sectors and the poor enforcement of laws and regulations.

Table 6
Membrane-based separation of ECs.
Membrane Membrane material Type of ECs Concentration Filtration Feed type Removal Reference
type conditions efficiency (%)

UF MWNT–TiO2 Ibuprofen 10 mg/L – Synthetic wastewater 45 [147]

UF MWNT–TiO2 Carbamazepine 10 mg/L – Synthetic wastewater 80 [147]
UF MWNT–TiO2 Acetaminophen 10 mg/L – Synthetic wastewater 24 [147]
UF PES/N-doped carbon Caffeine 11.76 ± 1.5 (ng/L) Cross-flow Drinking water and 87.24 [148]
nanotubes (CNTs) wastewater
UF PES/N-doped CNTs Galaxolide 3476.86 ± 14.3 Cross-flow Drinking water and 99.92 [148]
(ng/L) wastewater
UF PES/N-doped CNTs Carbamazepine 58.09 ± 0.22 ng/L Cross-flow Drinking water and 88.97 [148]
wastewater
UF PES/N-doped CNTs Tonalide 153.91 ± 2.9 (ng/ Cross-flow Drinking water and 98.85 [148]
L) wastewater
NF-270 PA Diclofenac 1 mg/dm3 Cross-flow DI water 85 [149]
NF-270 PA Ibuprofen 1 mg/dm3 Cross-flow DI water 71 [149]
NF- TFC PA Carbamazepine 20 ug/L Cross-flow Synthetic wastewater 89 [150]
NF- TFC PA Metoprolol 20 ug/L Cross-flow Synthetic wastewater 88 [150]
NF- TFC PA Ranitidine 20 ug/L Cross-flow Synthetic wastewater 88 [150]
NF- TFC PA Chloramphenicol 20 ug/L Cross-flow Synthetic wastewater 81 [150]
NF Polyether sulfone (PES) Amoxicillin 20 mg/L Cross-flow Distilled water 94 [151]
NF PES Ceftriaxone 20 mg/L Cross-flow Distilled water 99 [151]
RO PA, thin-film composite Nitrobenzene 1000 ppm Dead-end Synthetic wastewater 54− 59 [152]
(TFC)
RO PA, TFC Phenol 1000 ppm Dead-end Synthetic wastewater 43− 61 [152]
RO PA, TFC Aniline 1000 ppm Dead-end Synthetic wastewater 52− 66 [152]
RO (BW30) PA Atrazine 2 uM Cross-flow Milli-Q 93.7 [153]
RO (BW30) PA Phenol 2 uM Cross-flow Milli-Q 47.3 [153]
RO (BW30) PA Sulfamethoxazole 2 uM Cross-flow Milli-Q 75.2 [153]
RO (BW30) PA 4- chlorophenol 2 uM Cross-flow Milli-Q 60.9 [153]
RO (BW30) PA Carbamazepine 2 uM Cross-flow Milli-Q 84.3 [153]
RO-XLE PA, TFC Perfluorohexanoic 100 mg/L Cross-flow Synthetic wastewater 97.99 [154]
acid
RO-BW30 PA, TFC Perfluorohexanoic 100 mg/L Cross-flow Synthetic wastewater 96–99 [154]
acid
FO Cellulose triacetate (CTA) Trimethoprim 200 μg/L Cross-flow Model synthetic (>95) [155]
wastewater
FO CTA Roxithromycin 200 μg/L Cross-flow Model synthetic (>95) [155]
wastewater
FO CTA Norfloxacin 200 μg/L Cross-flow Model synthetic (>95) [155]
wastewater
FO CTA 4-chlorophenol, 2 uM Cross-flow Milli-Q 38.6 [153]
FO CTA Phenol, 4- 2 uM Cross-flow Milli-Q 21.9 [153]
FO CTA Atrazine, 2 uM Cross-flow Milli-Q 48.7 [153]
FO CTA Sulfamethoxazole 2 uM Cross-flow Milli-Q 89.7 [153]
FO CTA Carbamazepine, 2 uM Cross-flow Milli-Q 82.6 [153]
FO PA, TFC Nitrobenzene 1000 ppm Dead-end Synthetic wastewater 75− 77 [152]
FO PA, TFC Phenol 1000 ppm Dead-end Synthetic wastewater 72− 76 [152]
FO PA, TFC Aniline 1000 ppm Dead-end Synthetic wastewater 88− 92 [152]

9
M.T. Khan et al. Journal of Water Process Engineering 41 (2021) 101990

Table 7 evaluating/rating risks, (4) identifying and evaluating the possible in­
Treatment approaches for HWW in different countries. terventions; (5) implementing a mitigation program, and (6) monitoring
Country Treatment/disposal Reference and evaluating the program performance. All ECs in aquatic environ­
ments comprise two or more compounds that act in a similar fashion,
China Specific treatment [49]
Australia Co-treatment [162,163] have familiar synergic or addictive effects, and show higher toxicity
India Direct disposal into the environment/co- [164,165, compared with single compounds [49].
treatment/specific treatment 166] Managing HWW may be difficult given the unknown disastrous ef­
Pakistan Direct disposal to the environment [160,167] fects of ECs and because preventive measures can only be taken when
Bangladesh Direct disposal into the environment [168]
Indonesia Specific treatment/direct disposal into the [169]
the toxicity and concentrations of these compounds are known. Certain
environment compounds in HWW, namely, ofloaxacin, 17α-ethinyllestradiol, eryth­
Iran Specific treatment/co-treatment [170,171] romycin, and sulfamethoxazole, need to be managed more efficiently
Iraq Specific treatment [172] compared with others [185]. The above framework can be modified to
Japan Co-treatment [173]
cover a wider spectrum of compounds and treatment scenarios.
Republic of Specific treatment [101]
Korea
South Africa Co-treatment [174] 10. HWW in the context of COVID-19
Vietnam Direct disposal into the environment [175]
Thailand Co-treatment [99] Healthcare facilities are significant sources of environmental con­
Taiwan Direct disposal into the environment [161]
Nepal Direct disposal into the environment [176]
taminants, especially during the COVID-19 pandemic. Laboratory and
Ethiopia Direct disposal into the environment [177] research activities and medicine excretion by patients are major sources
Egypt Co-treatment [178] of these contaminants [186]. Various measures have been taken recently
Congo Direct disposal into the environment [164] to investigate and treat infectious diseases [187]. Recent reports show
Algeria Direct disposal into the environment [179]
that coronavirus 2 (SARS-CoV-2) was initially detected in the stool
samples of infected patients [188–190]. In this case, in addition to direct
Evaluating the available technologies plays an essential role in the cre­ contact and respiratory routes of infection, the stool of patients can be
ation and execution of policy packages [22]. Fig. 7 presents a six-step another possible route of transmission for this virus [191]. The possi­
general conceptual framework for assessing and mitigating the human bility of fecal–oral transmission has been recently highlighted by re­
and ecological health risks associated with ECs in HWW. The six searchers, where the virus can reach the human body by entering
sequential steps are (1) identifying the hazard, (2) analyzing risks, (3) through the mouth, mucus, and contaminated water [189]. Therefore,

Fig. 6. Worldwide treatment of ECs in HWW (The map was prepared in ArcMap/GIS 10.5 software by using data from Table 7 and Ref. [119,157] Reproduced with
permission from Ref. [119]. Copyright (2015), Elsevier B.V.

10
M.T. Khan et al. Journal of Water Process Engineering 41 (2021) 101990

Fig. 7. A conceptual framework for health and environmental risk assessment. Reproduced with permission from Ref. [183,184]. Copyright (2018 & 2019), Elsevier
B.V.

Fig. 8. Routes of SARS-CoV-2 transmission in water environments. Reproduced with permission from Ref. [193,194]. Copyright (2020), Elsevier B.V.

11
M.T. Khan et al.
the possibility of transmitting SARS-CoV-2 through fecally contami­
nated food should be considered. Poor sanitation facilities, such as
public toilets and handwashing facilities, can facilitate a fecal or
mucosal transmission of the virus when people touch their mouths,
noses, and eyes without washing their hands [191]. A study reported
that infected people, whether symptomatic or asymptomatic, can spread
SARS-CoV-2 through their excreta [192]. In addition, people sharing the
same toilet facility can infect their family members through
feces–aerosol transmission [191]. Fig. 8 highlights the major routes of
SARS-CoV-2 transmission in water environments and their ultimate
disposal in WWTP.
With the widespread of COVID-19 in countries all over the world,
including Australia [195,196], India [197], Italy, Japan [198], US
[199], Ecuador [200], the Netherlands [201], and China [191], the
monitoring of sewage would allow very early detection of the entrance
of the virus into a community [202]. Several studies from different
countries have detected the genetic material of SARS-CoV-2 in the stools
of asymptomatic and symptomatic patients [188,203–205]. However,
the capability of recovered patients to spread the virus is yet to be
verified. In addition, these studies have produced inconsistent results
that require a more in-depth investigation. For instance, while some
studies have detected the live virus in stools [188,203,205], others have
only detected the genetic material of SARS-CoV-2. Fecal–oral and
fecal–mucosal transmission should be considered in epidemic manage­
ment and prevention because the viruses in sewage and sanitation fa­
cilities can last for long periods [204]. Previous studies show that
SARS-CoV-2 can survive at pH levels of <8. For instance, a study re­
ported that SARS-CoV-2 is highly sensitive and can be inactivated in
chlorinated water [206]. By contrast, it was reported that SARS-CoV-2
RNA was unexpectedly present in the septic tank after disinfection
with 800 g/m3 sodium hypochlorite [189,207]. The virus might be
protected by organic contents during disinfection, has been released to
the tank after the free chlorine levels have declined, and spread through
drainage pipelines. Therefore, the existing protocol developed by WHO
for HWW disinfection may not be able to completely eliminate
SARS-CoV-2 from water. Waste handling and hygiene practices, espe­
cially in healthcare and self-quarantine centres, therefore require revi­
sion [208].
Monitoring sewage can help determine the severity of the COVID-19
outbreak and guide health authorities in implementing the relevant
measures and tracking the source of the virus. The sewage epidemiology
or waste-based epidemiology (WBE) method can be used to provide an
early warning system for the COVID-19 pandemic and to track potential
outbreaks related to pathogenic viruses, such as hepatitis A, poliovirus,
and norovirus. In wastewater environments, SARS-CoV-2 transferred
through feces can survive from hours to days [209]. Polymerase chain
reaction (PCR) can be used to detect the virus load in a patient and in
wastewater. Moreover, highly efficient and economic tools and methods
for rapidly detecting SARS-CoV-2 in wastewater have been developed,
including enzyme-linked immunosorbent assay (ELISA), biosensors, and
the paper-based indicator method [210]. For the above reasons, WBE-
and RNA-based SARS-CoV-2 detection have emerged as important
research areas that can help authorities plan their public health in­
terventions and safeguard their communities from other infectious
diseases.
11. Knowledge gaps and future research directions
Given that hospital facilities treat patients suffering from different
ailments, HWWs have 5%–15% more pollution load compared with
wastewater discharged from other sources [26]. Future research should
then continue monitoring the ECs from hospital sewage and explore
other advanced technologies for HWW treatment. Future studies should
also examine the effects of hospital effluents on human and environ­
mental health. The available data on human exposure to ECs released
from HWW is largely inconsistent, and previous studies on the health
12
Journal of Water Process Engineering 41 (2021) 101990
and environmental impacts of HWW have left many gaps. Therefore,
future studies should explore the ECs contained in HWW across various
regions and the occurrence (and the corresponding drivers) of phar­
maceuticals to which humans are exposed. The available data are also
applicable to only a few geographic regions, most of which are well
regulated and have good infrastructure for water and wastewater
treatment. Those regions that are lacking in such infrastructure tend to
accumulate concentrations of ECs. Therefore, HWW monitoring cam­
paigns should be promoted to measure the concentrations of pharma­
ceuticals in the drinking water and food items being consumed in these
regions and assess their effects on human health. Many studies have
highlighted wastewater surveillance as a sensitive tool for monitoring
the circulation of viruses in the population and may even complement
the available measures for detecting the presence and prevalence of
infectious diseases in cases when the capacity for clinical testing is
limited. However, only a few studies have explored the survival of
SARS-CoV-2 in wastewater and their potential transmission through the
environment. Given the persistence of the COVID-19 pandemic, the
transmission of these viruses via hospital sewage and HWW require an
urgent investigation. The potential of bioremediation and other novel
techniques for the treatment of HWW should also be explored
[211–216].
12. Conclusion
Healthcare facilities discharge ECs and microbes into aquatic sys­
tems without prior treatment (in most cases), thereby threatening the
health and sustainability of the environment. Given the high toxicity and
pollutant load of HWW, relevant treatment methods and infrastructure
should be designed based on the type of the discharging healthcare fa­
cility and the catchment area. ECs are frequently detected downstream
of WWTPs, given that these plants are not designed to eliminate all types
of contaminants. HWWs mainly undergo pre-treatment, biological
treatment, advanced treatment, and post-treatment phases in these
plants. However, advanced treatment steps, such as ozonation, activated
carbon, or AOPs, are sometimes required to effectively eliminate these
contaminants. Governments and scientific institutions also need to
formulate a cooperative action plan to protect humans and the envi­
ronment from these contaminants. Inputs from pharmaceutical in­
dustries may also be taken into consideration, and financial institutions
can be incentivized to support wastewater treatment facilities and
infrastructure. These initiatives require coordination and mobilization
among different stakeholders and enforcement of the relevant laws and
regulations. Amid the COVID-19 pandemic, the wastewater discharged
from hospitals and quarantine centres have introduced additional
environmental challenges. Proper management and surveillance of this
wastewater can contribute to the overall management of the pandemic
and to advanced planning for another possible wave of infections.
CRediT authorship contribution statement
Muhammad Tariq Khan: Conceptualization, Writing - original
draft, Writing - review & editing. Izaz Ali Shah: Conceptualization,
Writing - original draft, Writing - review & editing. Ihsanullah Ihsa­
nullah: Writing - review & editing, Supervision. Mu. Naushad: Writing
- review & editing, Supervision. Sharafat Ali: Writing - original draft.
Syed Hassan Ali Shah: Writing - original draft. Abdul Wahab
Mohammad: Writing - review & editing, Supervision.
Declaration of Competing Interest
The authors declare no conflict of interest.
M.T. Khan et al. Journal of Water Process Engineering 41 (2021) 101990

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