Danish Management of Hospital Wastewater Ulf Nielsen 07.04.2014 Agenda Danish Management of Hospital Wastewater • Are hospitals important point sources? • How are the hospitals regulated by Danish authorities and what is the expected requirements? • What’s the status of the Danish full scale treatment test? © DHI Hospital wastewater Hospital wastewater consists of a complex mixture of: • Pharmaceuticals (antibiotics, cytostatics, antiviral drugs, parasitic agents, contrast media etc.) • Microorganisms/pathogens (antibiotic resistant bacteria, viruses etc.) • Laboratory chemicals (dyes etc.) • Cleaning agents (especially disinfectants) Hospital WWTP Sewer workers Recipient water body Combined sewer overflows Flooding • Risks to aquatic environments and human health remain unclear. Only approx. 450 of 1100 pharmaceuticals used in DK have been environmentally assessed Greater Copenhagen Area • Total population in catchment areas: 2 mill (1.6 mill. to WWTP Lynetten) Are hospitals important point sources? WWTP Lynetten Population Hospitals Outpatient clinics WWTP Damhusåen WWTP SCA Mapping of pharmaceutical discharges API consumption at hospitals and in the primary sector Calculation based on sales data. Excluding metabolism (100% excretion). API discharge from hospital API discharge from primary sector Hospital water consumption Concentration in hospital wastewater = PECHospital Total amount discharged to WWTP Total water volume discharged to WWTP Wastewater concentration = PECinlet WWTP removal taken into account where data is available, otherwise no removal is assumed. Illustration modified from Daughton and Ternes, 2000 Treated wastewater concentration = PECoutlet Environmental risk Dilution in receiving water body = 2-50 Environmental concentration = PEC PEC/PNEC DHI database • Danish Health Agency (DHA) register number of sold packages, number of pills/fluids in each packages and amount of actice substance in each pill/fluid • DHI get’s the raw data from DHA on hospital and section level for DK • In the database we connect the consumption of each package and calculate the consumption of active substances for: − Each hospital and sections inside the hospital − The population consumption in the 5 Danish regions Hospitals- a point source? Cytostatics Inpatient 16 % (32 kg) Outpatient 83 % (164 kg) Hospitals 1 % ( 1,2 kg) General public Data (2012) from Copenhagen catchment area (WWTP Lynetten) Hospitals- a point source? Endocrine Therapy Inpatient 42 % (12 kg) 54 % (15 kg) Outpatient Hospitals 4 % ( 1 kg) General public Data (2012) from Copenhagen catchment area (WWTP Lynetten) Hospitals- a point source? Antibiotics Inpatient Outpatient 26 % (1490 kg) 2 % (134 kg) Hospitals 72 % (4186 kg) General public Data (2012) from Copenhagen catchment area (WWTP Lynetten) Hospitals- a point source? Pain killers (analgesics) Inpatient Outpatient 4 % (1669 kg) 0,2 % (69 kg) Hospitals 96 % (38787 kg) General public Data (2012) from Copenhagen catchment area (WWTP Lynetten) DK regulation of Hospital Wastewater • Hospital wastewater is regulated as industrial wastewater • Hospitals are viewed as industrial point sources • All industrial discharges to sewer - if different from household wastewater - need a permit • Direct discharge to surface water is possible if the wastewater is sufficient treated to comply with Water Quality Criteria Minister of Environment and the municipalities • Letter from the Minister of Environment to the municipalities in May 2011: ”the municipalities have to issue wastewater permits for all hospitals” and ”a dialogue on BAT is needed” • In December 2013 the municipalities have finalised a guideline for municipal regulation of hospitals with: − Guidance on prioritization and proportionality − Pharmaceutical assessments − Limit values • All hospitals have to prepare a wastewater technical description, which is the basis for the wastewater permit © DHI Regulatory prioritization of health care institutions in DK Prioritized point sources: • Source of > 2% of the total load of specific hazardous pharmaceuticals supplied to the local WWTP • Uses cytostatics or contrast media • > 1000 in- or outpatients per year • > 500 surgeries per year Psychiatric institutions • > 100 beds Smaller institutions are seen as diffuse sources and are not regulated (now) © DHI Municipal ranking of hospitals/health institutions Environmental assessment ”method-pieces” to put together the overall environmetal assessment/ranking ”puzzle”: • ABC hazardous assessment of pharmaceuticals • Limit values (LM) for discharge to sewer • Contribution of antibiotics to the local WWTP Minor source Medium source Major source A - Highly hazardous pharmaceuticals [kg/yr] B- Hazardous pharmaceuticals [kg/yr] Sum of exceedance of LM* in wastewater (Meas. konc./LM) Antibiotics contribution (excl. penicillins) to WWTP [%] < 50 < 300 <5 <5 50 - 100 300 - 500 5 - 20 5 - 20 > 100 > 500 > 20 > 20 ABC environmental assessment of inherent properties A: Higly hazardous substances. Unwanted in the sewer system B: Hazardous substances Should be reduced to below environmental quality standards C: Not problematic substances, when discharged to sewer Limit values for discharge to sewer • 33 pharmaceuticals used at hospitals plus supplementary 7 from psychiatric institutions – Total: 40 pharmaceuticals • Derived from PNEC (predicted no effect concentration) - most sensitive water living organisms • Only selected substances with robust effect data (assessment factor ≤100 and no QSAR) is used • Removal rate in WWTP is taken into account Antibiotics contribution to municipal WWTP • Total contribution without penicillins and out-patients Copenhagen University Hospital Consumption: 496 kg/y Contribution: 28% WWTP Lynetten Total catchment: 1.795 kg/y Ranking of hospitals in the Capital Region of Denmark Hospital/ Psychiatric Center Bornholm Amager Psych. Ballerup Psych. St. Hans No. of beds 100 120 140 180 Sum of Highly Hazardous exceedance of hazardous Catchment/ pharmaceuticals LM* in wasterecipient pharmaceuticals water (Meas. [kg/yr] [kg/yr] konc./LM) Small/ marine Large/ marine Large/ marine Large/ marine Antibiotics contribution Classification (excl. as point penicillins) source [%] 15 134 58 Medium source 25 205 2 Minor source 9 33 < 0,1 Minor source 68 50 < 0,1 Minor source Medium source Medium source Gentofte 280 Large/marine 52 337 2 Glostrup 310 Large/ marine 50 286 13 670 Small/ fresh 130 989 79 Major source 111 818 27 Major source 147 754 9 Major source 436 1381 28 Major source 181 700 18 Major source New Northern Zealand Hvidovre New Bispebjerg Copenhagen New Herlev 800 860 1100 1100 Large/ marine Large/ marine Large/ marine Large/ marine 25 104 Best Available Techniques (BAT) and proportionality Principle: The larger point source - the larger compliance investments/costs are fair! Size as point source Plans for construction/renovation Size of health institution Need for investments in BAT Requirements and actions (BAT) in Capital Region of Denmark Full-scale treatment at Herlev Hospital • • • • Full solution - water, sludge, air Project from 2012-2015 (start: May 2014) Total budget including building: 5.8 mill. € Total estimated running costs (incl. sludge handling): 1.3 €/m3 MBR technology: Grundfos Biobooster Polishing technologies: Ultraaqua Air treatment: Neutralox Testing and documentation: DHI Other partners: Herlev Hospital, Business Innovation Fund, Capital Region of Denmark, the municipalities of Herlev and Copenhagen, Lynettefællesskabet I/S © DHI Objectives of full-scale plant • Direct discharge to the local stream • Reuse of the treated water (tecnical water, cooling water) • Payback periode: 6-7 years • Continuous operation during 1 year to document treatment efficiency, robustness and operational costs • Optimization of the combination of MBR and polishing technologies • Environmental and health risk assessments, with the aim of direct discharge to the local stream • Development of methods for continuous monitoring and control of operations and effluent water quality © DHI Operation of full-scale plant • Two lines for testing; one with GAC+ ozone, the other with ozone + GAC • Flow: approx. 150.000 m3/yr (hospital with 900 beds) Screening © DHI MBR Polishing Overview of planned full-scale test plant © DHI Information brochure Full scale test plant Just e-mail: [email protected] © DHI Agenda Danish Management of Hospital Wastewater • Are hospitals important point sources? Yes, for groups of pharmaceuticals, such as antibiotics and cytostatics • How are the hospitals regulated by Danish authorities and what is the expected requirements? By the municipalities as industrial point sources. Depending on “size” substitutions, selected treatment or full treatment • What’s the status of the Danish full scale treatment test? Started up now (May 2014). Documented performance: February 2014 © DHI Next steps: Water efficient hospitals in the Capital Region of Denmark Major goals: • Water savings • Reduced risk of internal waterborne infections • Use of secondary quality water • No negative impact on the aquatic environment
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