Urban Water Security Research Alliance Reduction of Pharmaceutical - PowerPoint PPT Presentation

Urban Water Security Research Alliance Reduction of Pharmaceutical Loads in Municipal Wastewater: Would Onsite Treatment of Hospital Wastewater be Effective? Kristell Le Corre Hospital Wastewater Science Forum, 19-20 June 2012

FROM SEWERS TO TREATMENT PLANTS Wastewater as a resource Energy (sewage/sludge) Domestic wastewater Recycling Water (AWTP) SEWER WWTP Nutrients Stormwater (P, N) Discharge to the environment Industrial effluents Hospital effluents SUBJECT TO TRADE WASTE APROVALS ???

TRADE WASTE What about hospitals? CURRENT LEGISLATION Wastewater including toilets, showers and hand basins is considered as domestic wastewater . All other waste discharged (labs etc.) from hospitals to the sewer is considered as trade waste. BUT… Parameters (mg/L) Unit Domestic wastewater Hospital wastewater pH 7-7.5 7.7-8.1 BOD 100-400 200 (average) COD 250-1,000 500 (average) mg/L SS 100-350 160 (average) TN 20-85 5-80 TP 4-15 0.2-13 unit/100mL Total coliforms 10 5 -10 8 10 6 -10 9 100 Analgesics 11.9 11 Antibiotics 1.2 24 Cytostatics 3.0 5.9 ß-Blockers 3.2 µg/L 1,008 ICM 7.00 32 Gadolimum 0.7 13 Platinum 0.15 1371 AOX 150 Verlicchi et al., (2010) Journal of Hydrology, 389, 416-428

ARE HOSPITALS A MAJOR POINT SOURCE? Hospitals are seen as significant contributors of toxic or hazardous compounds such as heavy metals, cleaning chemicals, pharmaceuticals, pathogenic organisms. Should additional source control through onsite treatment be applied? Would onsite treatment of hospital wastewater be an effective way to reduce pharmaceutical loads in municipal wastewater, hence in the feed of AWTP?

ARE HOSPITALS A MAJOR POINT SOURCE? Contradictory results to date “…If, for whatever motivation, hospital wastewater shall be treated separately onsite, it must be noted, that for many Human substances no major overall reduction can be achieved since medicine many pharmaceuticals are taken on a regular basis at home..” Ort et al., 2010. Water Res. Excretion Municipal Hospital + Wastewater Wastewater Wastewater WWTP “…Informed scientists agree that urgent measures must be taken in order to set guidelines for the treatment of HWWs…. Surface Experimental studies are also necessary because there is still a Water remarkable paucity of data concerning the possible impacts of HWW on the environment.” Drinking Verlicchi et al, 2011. Wat. Sci. Tech. water

THE HOSPITAL WASTEWATER PROJECT Experimental approach vs. Predictive approach

EXPERIMENTAL APPROACH

CASE STUDY: CABOOLTURE HOSPITAL Caboolture Hospital flow contribution to STP is 1%

CABOOLTURE HOSPITAL Summary of results 59 substances n=17 max <5% 5%< max <15% n=11 n=2 max >15% n=5 Only detected at hospital n=24 Not detected above LOQ at both sites

LIMITATIONS OF THE EXPERIMENTAL APPROACH Access to Analytical sewers methods High flow and concentration variations Diversity and number of active ingredients 150 4900 detected Active Ingredients Site specificity Active (hospital - Ingredients catchment) (TGA, 2011 ) worldwide (Runnalls et al., 2010)

PREDICTIVE APPROACH

METHODOLOGY A novel approach using pharmaceutical consumption audit data in hospitals and by the general population Evaluation of the contribution (%) of a hospital to the loads of pharmaceuticals in municipal wastewater Mass Mass Excretion X Consumption Consumption ratio Hospital Hospital X 100 = Contribution Mass Mass Mass Mass (%) + Excretion Excretion + X X Consumption Consumption Consumption Consumption ratio ratio Hospital Population Hospital Population

AUDIT DATA Mass Consumption Hospital Mass Consumption Population Queensland Public Hospitals National Consumption Audit Data (Medicare Australia – Pharmaceutical benefit scheme - (Medication Services Queensland) PBS) Medicines dispensed annually to Annual amount of medicines in-patients in public hospitals by subsidised by the general population strength, brand, form and quantity in Australia 107 Hospitals 923 Entries 70319 Entries >733 Distinct gener ic s > 2000 Distinct generics

HOSPITALS AND COMPOUNDS INVESTIGATED Identification and quantification of compounds exclusively used in hospitals Determination of the contribution of the 6 hospitals investigated to the load (97-100% contribution) that may require further attention. of 589 screened compounds in municipal wastewater.

RESULTS Overall pharmaceutical consumption Hospital QEII CAB IPS PC PA RBWH Catchment Oxley CAB IPS Luggage Point Total mass used in hospitals 481 340 556 2,640 1,948 2,324 (g/day) Total mass consumed by the 35,624 5,725 9,542 72,775 72,775 72,775 general population (g/day) Total mass in the corresponding STP influent 36,105 6,065 10,098 79,688 (g/day) Overall contribution 1% 6% 6% 9%

RESULTS Contributions of the 6 hospitals investigated Contribution <15% 15 % < Contribution <50% Y axis = Percentage of compounds per contribution classes % For 63 to 84 % of the The percentage of 50 < Contribution <97% Contribution >97% compounds, the compounds exclusively used contribution of an at hospitals ranges from 10% individual hospital is likely at QEII to 20% at RBWH to be less than 15%

RESULTS Hospital specific pharmaceuticals A high contribution may not be synonymous Percentage of compounds returning a hospital contribution between 97 and 100% of a high consumption / or level in wastewater and excretion in hospitals ABACAVIR - ANTIVIRAL (HIV treatment) Contribution 100% 0.06 g y -1 bed -1 to 0.3 g y -1 bed -1 Consumption 0.3 µg L -1 to 1.0 µg L -1 Predicted Concentration Heff Predicted 0.003 µg L -1 to 0.004 µg L -1 Concentration STPinf Prescription mode Qualified medical practitioners through hospital-based pharmacies (HSDP, 2011) Comment Most likely excreted at home 153 Hospital-specific Overestimated contribution compounds

EFFECT EVALUATION Percentage of compounds returning a hospital contribution between 97 and 100% Prediction of concentrations (µg L -1 ) in hospital effluents and influents of the corresponding STPs Determination of an effect threshold (µg L -1 ) for each of the hospital-specific compounds Comparison of predicted concentrations with effect thresholds as margin of exposure (MOE) Effect threshold MOE MOE >100 = Predicted concentration (H eff or STP inf ) Unlikely to cause concern for human health 153 Hospital-specific compounds Method derived from the Australian guidelines for water recycling: augmentation of water supply (NRMC2008)

RESULTS List of hospital-specific compounds with an MOE <100 in influent of STPs Hospitals QEII CAB IPS PC PA RBWH Number of hospital-specific compounds 54 56 74 92 112 123 Number of compounds with a MOE in Hospital Effluent ≤ 100 15 26 33 32 28 41 Number of compounds with a MOE in STP influent ≤ 100 0 3 3 8 9 9 Generic name Therapeutic class MOE Bupivacaine Anaesthetic 71 47 69 69 69 33663 Piperacillin Antibiotic 79 8 8 8 7599 2058 Tazobactam Antibiotic 32 3 3 3 3030 820 Oxybuprocaine Anaesthetic 71 71 71 594 248 126 Pancuronium Neuromusc. Blocking agent 48 48 48 1122 NU 912 Ropivacaine Anaesthetic 68 68 68 532 365 892 Tropicamide Mydriatic 53 53 53 2121 1415 519 Cefazolin Antibiotic 32 NC NC NC NC NC Infliximab Immunosuppressant 81 81 NU NU NU NU Vincristine Sulphate Antineoplastic 0.4 0.4 NU NU NU NU Levobupivacaine Anaesthetic 100 67325 447 NU NU 2978 Suxamethonium Anaesthetic 98 15213 256 371 357 357 Results available Le Corre et al., (2012), Environment International 45, 99–111

PREDICTIVE VS. EXPERIMENTAL APPROACH Caboolture hospital Case Study Predictions Compounds 59 over 4 days 589 investigated Selection of Analytically measurable Consumed at the hospital compounds Overall results For 47% of the compounds CAB For 78% of the compounds Hospital contributed less than CAB Hospital contributes less 15% than 15% Specific results 5 compounds exclusively 56 hospital specific- detected at the hospital site compounds 2 compounds, roxithromycin and 3 compounds (bupivacaine / trimethoprim, with a contribution > piperacillin / tazobactam) with 15% MOE<100. Comparison of Contributions for 75% of the compounds investigated contribution results experimentally in good agreement with predictions Roxithromycin Mean 26% - Max 56 % 19% Trimethoprim Mean 10% - Max 18 % 13% Main conclusion Caboolture Hospital is not a major point source

EXPERIMENTAL APPROACH PART 2

CASE STUDY 2 Ipswich Hospital Ipswich Hospital flow contribution to STP is 1.2 % STP Population in sewer catchment area approx. 75,000 m k 2 1 ~ 3.9 beds / 1000 inhabitants

IPSWICH HOSPITAL Sampling location Manhole Control box Data logger Flow measurement Inside view of Outside view of the system the system

PRELIMINARY RESULTS Example of a daily flow pattern in the sewer 5:10 pm to 10:00 pm 10:00 pm to 5:30 am 5:30 am to 5:10 pm Flow [L/s] Time [h-min-s] Start of wastewater Collection of 8L (1 record every 10 second) collection bottle