American Journal of Environmental Sciences 1 (4): 259-263, 2005

ISSN 1553-345X
© 2005 Science Publications

Hospital Wastewater Treatment Using an Integrated Anaerobic

Aerobic Fixed Film Bioreactor
1
A. Rezaee, 1M. Ansari, 1A. Khavanin , 1A. Sabzali and 2M.M. Aryan
1
Department of Environmental Health, Faculty of Medical Sciences
Tarbiat Modares University, Tehran, Iran
2
Sevom Shaban Hospital, Qiyam Square, Tehran, Iran

Abstract: The design and operation of wastewater treatment systems for hospital is a challenge for
wastewater engineers. In this study, a pilot-scale system integrated anaerobic-aerobic fixed film reactor
for hospital wastewater treatment was constructed and its performance was evaluated. The aim of the
study was the elimination of organic compounds and a significant reduction of bacteria. The system
had been operated for 90 days. The results show that the system efficiently removed 95.1% of the
chemical oxygen demand (COD) from a hospital wastewater with the influent COD of 700 mg L¯ 1 , P P

leaving 34 mg L¯ 1 COD in the effluent. The significant removal of pathogenic bacterial has been do
P P

after operating of the system. The advantages of the treatment system studied for small wastewater
flows include: (I) simple operation and maintenance; (II) efficient removal of COD and bacteria; and
(III) low-energy consumption.

Key words: Hospital, wastewater, treatment, fixed film

INTRODUCTION antibiotics in the discharged sewage; (IV) excreta from

patients being treated with cytotoxic drugs may be
Hospitals generate on average 750 L of wastewater collected separately and adequately treated [2,3] . In
P P

by bed and a day [1] . These effluents are loaded with

P P normal circumstances, the usual secondary
pathogenic microorganisms, pharmaceutical partially bacteriological treatment of sewage, properly applied,
metabolised, radioactive elements and other toxic complemented by anaerobic digestion of sludge, can be
chemical substances. The dosage of pollutants of considered as sufficient. During outbreaks of enteric
hospital origin shows that certain substances, such as disease, however, or during critical periods (usually in
anti-tumor agents, antibiotics and organohalogen summer time because of warm weather and in autumn
compounds, leave mostly wastewater treatment because of reduced river water flow), effluent
plants [2,3] . By leaving the wastewater treatment plants,
P P disinfection by chlorine dioxide(ClO 2 ) or by any other
B B

these chemical compounds can provoke the pollution of efficient process is recommended. If the final effluent is
the natural environment by entailing a biological discharged into coastal waters close to shellfish
imbalance. In case the environmental conditions habitats, disinfection of the effluent will be required
allowing the degradation of these substances are not throughout the year. To stop the phenomenon of excess
gathered, they can exercise negative effects on the load in the process of the wastewater treatment plant, it
receiving waters and the living species. In countries that seems important to consider upstream treatments to
do not experience epidemics of enteric disease and that hospital wastewater before their discharge in the
are not endemic for intestinal helminthiasis, it is municipal sewage system [4] . Conventional suspended-
P P

acceptable to discharge the sewage of health-care growth activated sludge processes, which have been
establishments to municipal sewers without used successfully and widely to treat municipal
pretreatment, provided that the following requirements wastewater during the last hundred years, are not
are need: (I) the municipal sewers are connected to always suitable for treating some wastewater flows [5] . P P

efficiently operated sewage treatment plants that ensure Factors that should be taken into account when
at least 95% removal of bacteria; (II) the sludge designing hospital wastewater treatment plants include
resulting from sewage treatment is subjected to land requirement, construction cost, operation cost,
anaerobic digestion, leaving no more than one maintenance and landscape. The plants should be
helminthes egg per litre in the digested sludge; (III) the operated without the continuous supervision of highly-
waste management system of the health-care qualified operators and should only need to be checked
establishment maintains high standards, ensuring the a few times a year. The maintenance on the mechanical
absence of significant quantities of toxic chemicals, parts should be easy. Biological treatment systems are
pharmaceuticals, radionuclides, cytotoxic drugs and used, sludge disposal should be infrequent-once or
Corresponding Author: A. Rezaee, Department of Environmental Health, Faculty of Medical Sciences Faculty, Tarbiat
Modares University, Tehran, Iran
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 Am. J. Environ. Sci., 1 (4): 259-263, 2005

twice per annum. Finally, the designer should make The unit includes; aneronic, fixed film and suspended
sure that the plant or facilities are in keeping with the growth units. The anaerobic reactor tank was covered
surroundings. Therefore, the facilities for small using strong fiberglass 15 mm thick shuttering.
wastewater treatment ought to be not only Aeration pipes were placed under the fixed film
environmentally sound but also human friendly. There bioreactor to provide the oxygen for microorganisms
are great variety of systems that combine suspended and to create a mixed wastewater. The size of each
growth processes and attached growth processes [6] . P P
biofilm media block was 0.3 m × 0.3 m providing a
Among the latter several random media filters have total media surface area in the tank. A single-phase
been tested. Some experiences have been developed kilowatt hour meter was fitted to the electricity supply
combining anaerobic and aerobic zones in separate to measure the power consumption by the motor. The
zones in the so-called baffled reactors and employing hospital wastewater was transfer into bioreactor and
an air-lift system for recirculation. There is treated to evaluate the system’s performance. A pump
considerably less experience with integrated systems was connected to the reactor tank through a motorized
allowing the co-existence of anaerobic and aerobic valve with a 3 mm diameter pipe and act as the feed pipe
B B

populations inside the same reactor without physical to the reactor. A water level sensor was used to control
separation. In the system, attached-growth the influent pump and to keep the water level in the
microorganisms in a biofilm on the surface of plastic bioreactor constant. An electric timer was fitted to this
biomedia modules, which were vertically moved valve. When the timer was switched on, the reactor tank
repeatedly into and out of the bulk fluid, were was fed with synthetic wastewater. The outlet was at a
employed to remove pollutants from wastewater, in height of 0.8 m in the tank and was controlled by an
terms of chemical oxygen demand. The fixed film electric timer. When the wastewater had settled after
system has been proven to remove nutrients efficiently treatment the treated clarified water was allowed to
from wastewater [7,8] . This study aims at presenting both
P P
flow to a pump sump.
the primary results on the biological characterisation of
the hospital wastewater before their discharge in the Table 1: Operating for integrated anaerobic-aerobic fixed film
municipal sewage system and their effects on the urban bioreactor
Phase Operation Duration
wastewater systems and the environment. The fixed-
Anaerobic Insert of wastewater in anaerobic tank 6h
film reactors with arranged media allow a simple Aerobic Aeration with diffuser 6h
division in anaerobic, aerobic and transition (anoxic) Settling Settling of sludge 2h
zones [9] . On the other hand and considering the high
P P

suspended solid concentration of wastewaters like the Operation of the unit: Two cycles per day was chosen
ones in the slaughterhouse, this packing material and the phases used in the bioreactor. The pump
minimizes the clogging risk, frequent in random- pumped the hospital wastewater into the reactor tank to
support filters [10] . The purpose of this paper was to
P P

give an inflow of 40 L per cycle. The system was

B B

summarize the long-term performance experience of operated for 3 months. In order to simplify sludge
integrated anaerobic-aerobic fixed film bioreactor disposal, the reactor was de-sludged once on the 30th
system for hospital wastewater treatment. The removal day.
efficiency of pollutants and significant removal of
pathogenic bacterial were analyzed. Analytical methods: COD, BOD, turbidity, pH and
temperature were measured in accordance with the
MATERIAL AND METHODS standard methods [11] . Filtered samples were obtained by
P P

filtering the wastewater through a Whatman filter paper

Collection of samples: Sterile 500 mL glass bottles (pore size 1.2 mm). Dissolved oxygen (DO) was
were used to collect effluent sample from each stage of measured in situ with an electrochemical a digital DO
treatment like anaerobic, aeration and other tanks. meter.
Samples were collected twice a day (10a.m. and 2p.m.)
Bacterial counts in liquid wastewater: All the
during the study period. Duplicate samples were samples were vigorously shaken before preparation of
collected and stored in a refrigerator. After collection dilutions. Serial tenfold dilutions of the different
all the samples were processed. treatment stage samples were prepared in diluent. All
the dilutions were made in Phosphate buffered saline
The pilot-scale system: The pilot-scale system was (NaCl-8 gm L¯ 1 , K2HPO4-1.21 gm L¯ 1 , KH2PO4-0.34
P P P P

designed and installed in Tarbiat Modaress University gm L¯ 1 with pH 7.3) containing 0.05% Tween 20.
P P

with a treatment capacity of 40 L/day of Shevom

B B
wastewater was crushed in sterile mortar and suspended
Shaban hospital wastewater. The bioreactor was in 100 mL diluent. Ten fold dilutions (100 mL)
separated into three equal parts by a plate. The of samples were plated on nutrient agar plates in
operational phase of the unit is given in duplicate. Also, most probable number ( MPN) tests
Table 1 and was controlled by electric timers. were do for bacterial counts.

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Selective bacterial counts: Tenfold dilutions (100 mL) breakpoint. This may be done with chlorine dioxide
of samples were plated on Mackonkey agar plates in (which is the most efficient), sodium hypochlorite, or
duplicate for coliform and fecal enterococcal counts. chlorine gas. Another option is ultraviolet light
Mackonkey agar was selected since it allows disinfection. Disinfection of the effluents is particularly
differential growth of both coliforms and enterococci. important if they are discharged into coastal waters
close to shellfish habitats, especially if local people are
RESULTS AND DISCUSSION in the habit of eating raw shellfish. The sludge from the
sewage treatment plant requires anaerobic digestion to
In hospital a variety of substances besides ensure thermal elimination of most pathogens.
pharmaceuticals are in use for medical purposes as Alternatively, it may be dried in natural drying beds and
diagnostics and disinfectants. Besides the active then incinerated together with solid infectious health-
substances, formulation adjuvants and in some care waste. On-site treatment of hospital sewage will
instances, pigments and dyes are also drug components. produce a sludge that contains high concentrations of
Disinfectants, in particular are often highly complex helminths and other pathogens. According to the
products or mixtures of active substances. After relevant WHO guidelines, the treated wastewater
application, many drugs are excreted non-metabolised should contain no more than one helminthes egg per
by the patients and enter into wastewater. After their litre and no more than 1000 faecal coliforms per 100mL
use and disinfectants also reach the wastewater. The if it is to be used for unrestricted irrigation. The sludge
different substances, which are not biodegradable, may should be applied to fields in trenches and then covered
finally enter surface water by wastewater treatment with soil. Integrated anaerobic-aerobic fixed-film
plants effluents and enter groundwater after the reactor with arranged media, fed with hospital
application of sewage sludge as fertilisers. The wastewater, achieved organic matter removal
composition of the wastewater from Sevom Shaban efficiencies of 95.1%. These results were consistent
hospital is presented in Table 1. Hospitals consume an with the conclusions obtained by other working with
important volume of water a day. In Sevom shaban integrated anaerobic/aerobic bioreactor, who pointed
out that the main function of the non-aerated zone was
hospital, the average needs in water was estimated at
the conversion of slowly biodegradable matter into
1000 L/bed/day [12] . Indeed the consumption of
short chain fatty acids, easily oxidized in the anoxic and
P P

domestic water, is on average 100 L/person/day, while

aerobic processes. Anyway, it is possible that the
the value generally admitted for hospitals varies from
anaerobic COD removal was underestimated because a
400 to 1200 L/day/bed. In France, the average needs in
part of methane was probably stripped in the aerobic
water of a university hospital center is estimated at 750
zone. Organic matter concentration in the effluent was
L/bed/day [1] . This important consumption in water of
P P

approximately constant, around 450 mg L¯ 1 COD and

hospitals gives significant volumes of wastewater
P P

270 mg L¯ 1 BOD5, independent from feed

loaded with microorganisms, heavy metals, toxic
P P

concentration and organic loading rate. Consequently, it

chemicals and radioactive elements [4] . As a result the
P P

can be considering that organic matter removal takes

hospitals generate hybrid wastewater, at the same place simultaneously by aerobic oxidation, anoxic and
moment domestic, industrial and effluents of care and anaerobic processes. It was found out that most of the
medical research. Efficient treatment of hospital sewage COD was removed through aerobic oxidation (85%),
should include the following operations: (I) Primary while the anaerobic removal stood only for 15%. These
treatment, (II) Secondary biological purification; Most results were consistent with the conclusions obtained by
helminths will settle in the sludge resulting from other working with integrated anaerobic-aerobic
secondary purification, together with 90-95% of bioreactor, who pointed out that the main function of
bacteria and a significant percentage of viruses; the the non-aerated zone was the conversion of slowly
secondary effluent will thus be almost free of biodegradable matter into short chain fatty acids, easily
helminths, but will still include infective concentrations oxidized in the anoxic and aerobic processes. Anyway,
of bacteria and viruses, (III) Tertiary treatment; The it is possible that the anaerobic COD removal was
secondary effluent will probably contain at least 20 mg underestimated because a part of methane was probably
L¯ 1 suspended organic matter, which is too high for
P P

stripped in the aerobic zone. The main reason for the

efficient chlorine disinfection. It should therefore be low extension of the anaerobic process was the high
subjected to a tertiary treatment, such as lagooning; if mixing pattern existing in the integrated reactor, which
no space is available for creating a lagoon, rapid sand justified that the in situ measure of dissolved oxygen
filtration may be substituted to produce a tertiary concentration in the samples taken from the bottom of
effluent with a much reduced content of suspended the anaerobic zone were dissolved oxygen, which
organic matter (<10 mg L¯ 1 ), (IV) Chlorine
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seriously limited the anaerobic process. In fact, the
disinfection; To achieve pathogen concentrations biomass accumulated at the bottom of the aerated zone
comparable to those found in natural waters, the tertiary did not present any nitrifying activity, according to the
effluent will be subjected to chlorine disinfection to the respirometry tests.
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Table1: Feed and effluent wastewater characteristics

COD BOD5 NH4+-N Turbidity T (C) pH Coliforms E. coli
(mg L¯ 1 ) P (mg L¯ 1 )
P P P (NTU) (number/100 mL) (number/100 mL)
Influent 450 270 18 95 24 6-8 4 × 103 >1600
Effluent 80 30 2.5 <5 24 7.2 400 <30

Competition for dissolved oxygen inside the biofilm other viruses such adenovirus, were identified in the
will depend strongly on the biofilm thickness and the hospital effluents. Enterovirus appears in important
distribution of heterotrophic and autotrophic quantity in wastewater. Their presence, as marker of
populations. Biofilm showed an autotrophic- viral pollution, in the hospital effluents is to correlate to
heterotrophic activity accumulation. The hospital that of other viruses. Besides, the HIV, causal agent of
effluents have generally a very weak microbiological the AIDS, was isolated from biological liquids and
load resulting from the regular use of disinfectants. excretions of infected persons. These liquid effluents,
These bactericides can have a negative influence on the directly rejected in the network drainage of research
biological processes of the wastewater treatment plant. laboratories and hospitals, can contribute under certain
Even by considering that these effluents are diluted physico-chemical conditions to the presence of the
after their discharge towards the municipal wastewater virus in the urban sewer networks and in the wastewater
treatment plant, it remains evident that it is not treatment plant). Hospital wastewater reveals the
necessary to neglect the possibility that certain presence of molecules chlorinated in high
substances present in the wastewater treatment plant concentrations and in a punctual way the presence of
effluents can generate by cumulative effect a biological heavy metals such as mercury and silver. Wastewater
imbalance in aquatic ecosystem. To protect the natural composition refers to the actual amounts of physical,
environment against the phenomenon of excess load in chemical and biological constituents present in
the processes of the wastewater treatment plant, it wastewater. Depending on the concentration of these
seems important to consider upstream treatments of constituents, municipal wastewaters are classified in
hospital wastewater before their discharge in the strong, medium or weak [9] . On the basis of this
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municipal sewage system [13] . Indeed, the contact of

P P information, Chitnis have compared the average
hospital pollutants with the elements of the aquatic concentrations obtained for the hospital effluents with
ecosystems puts in evidence a danger which is bound to the medium values of the municipal wastewater [3] . This
P P

the existence of hazardous substances, i.e., which have comparison allows appreciating the strong content in
the potentiality to exercise negative effects on the pollutants of the hospitable effluents.
environment and the living species [14] . In case the P P

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