Aghalari et al.

Globalization and Health (2020) 16:13

https://doi.org/10.1186/s12992-020-0546-y

REVIEW Open Access

Effectiveness of wastewater treatment

systems in removing microbial agents: a
systematic review
Zahra Aghalari1*, Hans-Uwe Dahms2,3,4, Mika Sillanpää5, Juan Eduardo Sosa-Hernandez6 and
Roberto Parra-Saldívar6

Abstract
Background: Due to unrestricted entry of wastewater into the environment and the transportation of microbial
contaminants to humans and organisms, environmental protection requires the use of appropriate purification
systems with high removal efficiency for microbial agents are needed. The purpose of this study was to determine
the efficacy of current wastewater treatment systems in removing microbes and their contaminants.
Methods: A systematic review was conducted for all articles published in 5 Iranian environmental health journals in
11 years. The data were collected according to the inclusion and exclusion criteria and by searching the relevant
keywords in the articles published during the years (2008–2018), with emphasis on the efficacy of wastewater
treatment systems in removing microbial agents. Qualitative data were collected using a preferred reporting items
for systematic reviews and meta-analyzes (PRISMA) standard checklist. After confirming the quality of the articles,
information such as the name of the first author and the year of publication of the research, the type of study, the
number of samples, the type of purification, the type of microbial agents and the rate of removal of microbial
agents were entered into the checklist. Also the removal rates of the microbial agents mentioned in the studies
were compared with united states environmental protection agency (US-EPA) standards.
Results: In this study, 1468 articles retrieved from 118 issues of 5 environmental health journals were reviewed.
After reviewing the quality of the articles in accordance with the research objectives, 14 articles were included in
the study that were published between 2010 and 2018. In most studies, two main indicators Total coliforms and
Fecal coliforms in wastewater were investigated. Removing fungi and viral contamination from wastewater was not
found in any of the 14 studies. Different systems (activated sludge, stabilization ponds, wetlands, and low and
medium pressure UV disinfection systems were used to remove microbial agents in these studies. Most articles
used active sludge systems to remove Total coliforms and Fecal coliforms, which in some cases were not within the
US-EPA standard. The removal of Cysts and Parasitic eggs was only reporte from stabilization pond systems (SPS)
where removal efficiency was found in accordance with US-EPA standards.
(Continued on next page)

* Correspondence: [email protected]
1
Faculty of Public Health, Gonabad University of Medical Sciences, Gonabad,
Iran
Full list of author information is available at the end of the article

© The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Aghalari et al. Globalization and Health (2020) 16:13 Page 2 of 11

(Continued from previous page)

Conclusions: Different types of activated sludge systems have higher efficacy to remove microbial agents and are
more effective than other mentioned systems in removing the main indicators of sewage contamination including
Total coliforms and Fecal coliforms. However, inappropriate operation, maintenance and inadequate handling of
activated sludge can also reduce its efficiency and reduce the removal of microbial agents, which was reported in
some studies. Therefore, it is recommended to conduct research on how to improve the operation, maintenance,
and proper management of activated sludge systems to transfer knowledge to users of sludge systems and prevent
further health issues related to microbial agents.
Keywords: Systematic analysis, Wastewater, Treatment, Microbial agents, Environmental health, Articles, Journals

Introduction fever, and tuberculosis, viruses can cause hepatitis, and

Due to hazardous impacts of municipal, industrial and protozoa can cause dysentery [16, 17]. Many microbial
hospital wastewater on water, soil, air and agricultural agents attached to suspended solids in wastewater if
products, wastewater treatment and the proper disposal inadequately treated and wastewater discharge into the
of the sludge produced are indispensable from an envir- environment, such as river water, green space, and crops,
onmental safety point of view [1, 2]. Economically, put humans and aquatic organisms at risk [18, 19]. There-
effective wastewater treatment has important effects on fore, utilization of appropriate wastewater treatment sys-
saving water, and preventing unnecessary water losses tems tailored to a variety of microbial agents is essential to
[3]. In arid and semiarid countries such as Iran, the achieve as complete as possible elimination of biological
water demand has increased and annual rainfall is low agents. For example, in the study of Sharafi et al., (2015)
also in regions of North Africa, Southern Europe, and in with the aim of determining the removal efficiency of par-
large countries such as Australia and the United States. asites from wastewater using a wetland system, the re-
Consequently, reuse of sewage is the most sustainable moval rates of protozoan cysts and Parasite eggs were 99.7
and long-term solution to the problem of water scarcity and 100%, respectively [20]. Okoh, et.al. (2010) reported
[4, 5]. In the next 30 years, the world’s population will that activated sludge processes, oxidation pools, activated
increase by more than double. Due to population carbon filtration, lime and chlorination coagulation elimi-
growth, the amount of water available in 1960 was re- nated removed 50–90% of wastewater viruses [21]. Waste-
duced to 3300 cubic meters and in 1995 it was reduced water from wastewater treatment plants, is used in Iran
to 1250 cubic meters. This trend is projected to decrease without restrictions and controls like in many other coun-
to 650 cubic meters worldwide by 2025 [6]. Due to this tries. Therefore, it is necessary to employ proper sewage
water shortage crisis, water from wastewater treatment treatment systems, before water can be publicly used such
need to be reused increasingly in the near future [6]. as for irrigation. This study is focusing on the efficacy of
Wastewater reuse requires treatment and application of different wastewater treatment systems in removing mi-
appropriate wastewater treatment systems [7]. In recent crobial agents.
years, increased research has been done on wastewater
treatment using simple, low-cost, easy-to-use methods
in developing countries [8, 9]. Systems and processes Methods
such as activated sludge, aerated lagoons, stabilization Study protocol
ponds, natural and synthetic wetlands, trickling filters, This systematic review study was carried out to deter-
rotating biological contactors (RBCs) have been used for mine the efficacy of wastewater treatment systems in the
wastewater treatment and removal of physical, chemical removal of microbial agents (bacteria, parasites, viruses,
and biological contaminants [10, 11]. Among different and fungi) by searching all articles published in 5 Iranian
contaminants of wastewater, microbial agents becoming Journals of Environmental Health. The data were col-
increasingly important and their removal efficiency lected by referring to the specialized site of each jour-
should be reported in different wastewater treatment nal, from the beginning of 2008 to the latest issue of
systems [12, 13]. Biological contaminants in wastewater 2018. Reviewed journals included; Iranian Journal of
are different types of bacteria (Fecal coliforms and Health and Environment (IJHE), Journal of Environmental
Escherichia coli, Salmonella, Shigella, Vibrio cholerae), Health Engineering (JEHE), Journal of Research in Environ-
diverse Parasite cysts and eggs, viruses and fungi. All of mental Health (JREH), and two English-language journals,
them can be hazardous to environmental and human Environmental Health Engineering and Management
health depending on the type and amount [14, 15]. For Journal (EHEMJ), Journal of Environmental Health Science
example, bacteria in wastewater cause cholera, typhoid and Engineering (JEHSE).
Aghalari et al. Globalization and Health (2020) 16:13 Page 3 of 11

Search strategy Table 1 Check list of quality assessment tool for observational
Inquired information was collected by searching for key- cohort and cross-sectional studies (Ref. [22])
words on the sites of Iranian specialty health journal. Criteria
Key words included; ‘waste water’ OR ‘waste-water’ OR 1. Was the research question or objective in this paper clearly stated?
‘wastewater treatment’ OR ‘effluent’ OR ‘sewage’ OR 2. Was the study population clearly specified and defined?
‘sewage treatment’ OR ‘sewage disposal’ OR ‘wastewater
3. Was the participation rate of eligible persons at least 50%?
disposal’ AND ‘treat’ OR ‘remove’ AND ‘microb’ AND
4. Were all the subjects selected or recruited from the same or similar
‘pathogen’ AND ‘bacteria’ AND ‘virus’ AND ‘parasite’
populations (including the same time period)? Were inclusion and
AND ‘FCs’ OR ‘Fecal coliforms’ AND ‘Iran’. exclusion criteria for being in the study prespecified and applied
A manual search was performed by checking all uniformly to all participants?
published articles. This way, the abstracts of all published 5. Was a sample size justification, power description, or variance and
articles were reviewed over the period of 11 years between effect estimates provided?
2008 and 2018. 6. For the analyses in this paper, were the exposure(s) of interest
measured prior to the outcome(s) being measured?
Inclusion criteria 7. Was the timeframe sufficient so that one could reasonably expect to
see an association between exposure and outcome if it existed?
Inclusion criteria for this study included the year of
publication, type of wastewater samples (municipal 8. For exposures that can vary in amount or level, did the study examine
different levels of the exposure as related to the outcome (e.g.,
wastewater, domestic wastewater, hospital wastewater), categories of exposure, or exposure measured as continuous
number of samples (more than 5 wastewater samples), variable)?
treatment procedures (different types), state the required 9. Were the exposure measures (independent variables) clearly defined,
and mention the type of purification (type of treatment, valid, reliable, and implemented consistently across all study
type of microbial agents, amount or percentage of participants?
microbial agents removed). 10. Was the exposure(s) assessed more than once over time?
11. Were the outcome measures (dependent variables) clearly defined,
Exclusion criteria valid, reliable, and implemented consistently across all study
participants?
Exclusion criteria for this study were: lack of access to
the full article, inappropriate subject matter, inadequacy 12. Were the outcome assessors blinded to the exposure status of
participants?
of the method of treatment and purification, lack of
13. Was loss to follow-up after baseline 20% or less?
expression of the type of microbial agents removed,
review studies, and letters to the editor. 14. Were key potential confounding variables measured and adjusted
statistically for their impact on the relationship between exposure(s)
and outcome(s)?
Quality assessment articles
This study is based on standard checklist PRISMA (Pre-
ferred Reporting Items for Systematic Reviews and paper [23–25]. The checklist included the name of the
Meta-analyzes). The US-based National Institute of Health first author, the year of publication of the research, the
Quality Assessment Tool for Observational Cohort and type of study, the number of samples, the type of purifi-
Cross-Sectional Studies [22] for qualitative studies was cation, the type of microbial agents and the rate of mi-
used. This checklist is made based on the following criteria: crobial removal. Additionally, the removal rates of the
Yes, No, cannot determine, Not applicable, and Not microbial agents mentioned in the studies were com-
reported. It has eliminated the scoring problems. The pared with US-EPA standards [26, 27] (Table 2).
checklist included 14 questions that were used for research
purposes, samples, inclusion and exclusion criteria, find- Findings
ings, results and publication period of each of the 14 articles Search results
(Table 1). In this study, 1468 articles related to 118 issues of 5 envir-
onmental health journals were reviewed. In the first phase
Extract information from articles of the search process, 216 articles on wastewater treatment
In order to extract information, all articles were evalu- were identified. Then, 196 inappropriate and irrelevant arti-
ated independently by two reviewers based on inclusion cles were excluded for the purpose of the study. Finally,
and exclusion criteria. Both reviewers eventually summa- after reviewing the information and quality of the articles,
rized the information and in cases where the informa- 14 articles were eligible for systematic review (Fig. 1).
tion was inconsistent a third reviewer’s comments was
used. The information extracted from the articles was Descriptive results of articles
included in the researcher’s checklist for qualitative ap- Of the 14 articles reviewed, the largest number of arti-
proval and used in other prior author studies of this cles (9 articles; 64.2%) were published between 2014 and
Aghalari et al. Globalization and Health (2020) 16:13 Page 4 of 11

Table 2 Removal of microbial agents in treated wastewater not specified. In the articles, participation rate of eligible
according to US-EPA standards (Ref. [26, 27]) persons, inclusion and exclusion criteria, exposure (s)
Parameter Standard were evaluated more than once, and blinding of partici-
Total coliforms 1000 aMPN/100 mL pant exposure status was not relevant and not applicable
Salmonella Not detected/50 g of final product (Q10, Q4, Q3 and Q12) (Table 3).
Escherichia coli < 100 aMPN per gram (dry weight)
Fecal coliforms < 1000 aMPN per gram (dry weight)
Article features
Enteric viruses < 1 PFU per 4 g total dry solids Articles on the efficacy of a variety of purification sys-
Helminth eggs (Ascaris sp. < 1 per 4 g total dry solids tems for the removal of microbial agents were published
and Taenia sp.) between 2010 and 2018. All studies don in the labora-
a
MPN Most Probable Number tory. The largest sample size was related to Derayat
et al., 2011 [30] in Kermanshah with 120 wastewater
2018. Most of the experiments were carried out on samples. Wastewater studies were carried out in differ-
wastewater samples in Tehran (28.58%). In total, studies ent cities of North, East, West and Central Iran. Most
were conducted in 10 cities of Iran (Fig. 2). studies have investigated bacterial factors in wastewater
Concerning the type of microbial agents, it was found and the efficacy of removing fungi and viral contamin-
that a total of 14 articles have eliminated types of bac- ation in wastewater was not found in any study (Table 4).
teria and parasites from municipal, hospital and indus- In most articles, the type of sewage treatment system
trial wastewater (Fig. 3). In 11 articles, two main was activated sludge. For example were the removal
microbial indices (Total coliforms and Fecal coliforms) rates of microbial agents in wastewater investigated in
were used as bioindicators to evaluate the efficacy of the the study by Derayat et al., 2011 [30], Baghapour et al.,
wastewater treatment systems (Fig. 3). 2013 [31] and Nahavandi et al., 2015 [37] on Conven-
tional Activated Sludge, Ghoreishi et al., 2016 [38] on
extended aeration activated sludge (Table 4).
Quality assessment of articles Evaluation of the removal of microbial agents in ac-
The qualitative results of the articles showed that most cordance with US-EPA standards showed that in some
of the studies were of good quality but in many articles articles the removal of Total coliforms and Fecal coli-
the method of determination of sample size (Q5) was forms was not within acceptable ranges. For example, in

Fig. 1 Flowchart describing the study design

Aghalari et al. Globalization and Health (2020) 16:13 Page 5 of 11

Fig. 2 Cities selected for wastewater sampling in 14 articles

the study of Ghoreishi et al., 2016 [38], although several method [42]. The reason for the poor performance of
different systems were used to remove Total coliforms, activated sludge to remove Total coliforms can be attrib-
eimination efficiency never reached US-EPA standards. uted to factors such as management problems and oper-
Moreover, the activated sludge process did not have the ation of the activated sludge system, which results in the
efficiency to remove Parasitic eggs as reported in the production of bulk waste and sludge. This problem is
study by Nahavandi et al., 2015 [37] (Table 4). one of the most important disadvantages of activated
sludge systems and should be addressed once a month
Discussion by experienced staff and monitoring experts to correct
Examination of microbial removal rates in the study of it. Overall, different activated sludge systems are the best
Ghoreishi et al., 2016 [38] that none of the Total Coli- choice for this type of wastewater due to the amount of
forms removal was US-EPA standard although both ex- municipal wastewater pollutants because of high purifi-
tended aeration activated sludge and conventional cation efficiency to reduce biochemical oxygen demand
activated sludge systems were used to remove Total coli- (BOD5) [43, 44].
forms. The US-EPA standard for Total coliforms removal Removal of Cysts and Parasitic eggs in the study of
is 1000 MPN/100 mL, and wastewater showing this Derayat et al., (2011), which used stabilization pond sys-
amount of Total coliforms is capable of being discharged tems, was reported as being in accordance with US-EPA
into the receiving waters [26, 27]. A study by Paiva et al., standards [30]. A study by Amahmid et al. (2002) aimed
2015 on domestic wastewater in tropical Brazil also at the treatment of municipal wastewater with a stabi-
showed that removal of Total coliforms through the use lized pond system in Morocco showing that Cyst and
of activated sludge was not a desirable remediation Parasitic egg removal efficiency was 100% and that the

Fig. 3 Types of microbial agents removed in wastewater based on the articles

Aghalari et al. Globalization and Health (2020) 16:13 Page 6 of 11

Table 3 Quality of studies using the quality assessment of the NIH for cohort and cross-sectional studies
Author/Year/ Ref Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Q14
Hashemi et al., 2010 [28] ✓ ✓ NA NA ✓ ✓ ✓ ✓ ✓ NA ✓ NA ✓ ✓
Banejad et al., 2010 [29] ✓ ✓ NA NA ✓ ✓ ✓ ✓ ✓ NA ✓ NA ✓ ✓
Derayat et al., 2011 [30] ✓ ✓ NA NA ✓ ✓ ✓ ✓ ✓ NA ✓ NA ✓ ✓
Baghapour et al., 2013 [31] ✓ ✓ NA NA × ✓ ✓ ✓ ✓ NA ✓ NA ✓ ✓
Safari et al., 2013 [32] ✓ ✓ NA NA × ✓ ✓ ✓ ✓ NA ✓ NA ✓ ✓
Navidjouy et al., 2014 [33] ✓ ✓ NA NA × ✓ ✓ ✓ ✓ NA ✓ NA ✓ ✓
Karimi et al., 2014 [34] ✓ ✓ NA NA × ✓ ✓ ✓ ✓ NA ✓ NA ✓ ✓
Aslani et al., 2014 [35] ✓ ✓ NA NA × ✓ ✓ ✓ ✓ NA ✓ NA ✓ ✓
Jamshidi et al., 2014 [36] ✓ ✓ NA NA × ✓ ✓ ✓ ✓ NA ✓ NA ✓ ✓
Nahavandi et al., 2015 [37] ✓ ✓ NA NA × ✓ ✓ ✓ ✓ NA ✓ NA ✓ ✓
Ghoreishi et al., 2016 [38] ✓ ✓ NA NA × ✓ ✓ ✓ ✓ NA ✓ NA ✓ ✓
Mollaie Tavani et al., 2017 [39] ✓ ✓ NA NA × ✓ ✓ ✓ ✓ NA ✓ NA ✓ ✓
Sasani et al., 2017 [40] ✓ ✓ NA NA NA ✓ ✓ ✓ ✓ NA ✓ NA ✓ ✓
Choopan et al., 2018 [41] ✓ ✓ NA NA ✓ ✓ ✓ ✓ ✓ NA ✓ NA ✓ ✓
*
Cases that were followed in the articles were marked✓ and those that were not followed were marked×. Items that were not executable were also identified by
the word “NA” not applicable

pond system showed a proper performance [45]. A large reactions, bacterial uptake and toxicity [51] and the
number of stabilized pond systems were been con- interference in each of these (microbial communities)
structed and used in countries such as the United States, will affect the rate of removal of Total coliforms and
New Zealand, India, Pakistan, Jordan and Thailand [3]. other microbial agents. Removal of pathogens such as
In Iran, a number of these systems were constructed for Escherichia coli and Cryptosporidium was also per-
the treatment of wastewater in Arak, Gilan West and formed in wetlands but is often not in compliance with
Isfahan [46]. Stabilization ponds have a high acceptabil- environmental standards [52]. In addition, although
ity due to their simplicity of operation, and lack of wetlands are economical and widely used in wastewater
mechanical and electrical equipment compared to other treatment systems because of easy to operate, maintain,
sewage treatment systems, their high efficiency in re- and operate at a low price [53–55], but they don’t seem to
moving pathogenic organisms [47]. A major drawback be a good option for removing all of the microbial agents.
for stabilization ponds is the need for extensive land, the In a study by Hashemi, et.al. (2010) on UV disinfection
low quality of effluents due to the presence of algae, and system included low pressure (LP) and UV disinfection
odor production that limits the use of this type of treat- system including medium pressure (MP) to remove Total
ment system near habitated areas. To improve the qual- coliforms, Fecal coliforms and Fecal streptococci. All investi-
ity of resulting effluents, chemical compounds need to gated microbial agents were completely eliminated [28].
be consolidated, such as by coagulation and the applica- However, it was reported that the direct disinfection of sec-
tion of microstrainers, stabilization ponds and rock ondary effluents with LP and MP systems and even their
filters [47, 48]. integration due to high concentrations of suspended solids
As for wetlands by Karimi et al. (2014) on Fecal coli- was not possible. Therefore, disinfection of wastewater with
forms, Escherichia coli and Fecal streptococci show that UV irradiation requires higher effluent quality through im-
wetlands did not perform well to remove microbial proved system utilization or application of an advanced
agents (removal rate for Fecal coliforms 1.13 × 1014 treatment plant prior to disinfection [28]. In 1988, about
MPN/100 mL and Escherichia coli 5.03 × 1012 MPN/ 300 and in 2004 about 4300 sewage treatment plants in the
100 mL) [34]. In a study by Decamp et al. (2000), the United States, (that are more than 20% of filtration plants)
mean removal of Escherichia coli through the wetland used a UV system for wastewater disinfection. The number
was 41 to 72% at the in situ scale and 96.6 to 98.9% at of wastewater treatment plants having UV systems has in-
the experimental scale [49]. In the study of Evanson creased in the US, Europe and East Asia. This trend is ex-
et al. (2006), Fecal coliforms removal rate was 82.7 to pected to expand further in the coming decades. Although
95.99% [50]. Removal of Total coliforms and Fecal the use of UV radiation for wastewater disinfection has
coliforms in the wetlands is done by various biological many potential advantages, it also has disadvantages in
factors such as nematodes, protozoa, bacterial activity, terms of cost, lamp deposition, and the possible reactivation
bacteriophage production, chemical factors, oxidation of targeted pathogenic microorganisms after treatment
Table 4 Information from articles on the efficacy of different wastewater treatment systems to remove microbial agents
Author/Year/Ref Sample Size Type of samples/City Types of wastewater treatment systems Microbial agent Microbial agent Compliance with
removal rate US-EPA Standard
(Ref. [26, 27])
Hashemi et al., 2010 [28] 17 Municipal wastewater/Esfahan UV disinfection system including Total coliforms 1000 MPN/100 mL Yes
low pressure (LP)
Fecal coliforms 400 MPN/100 mL Yes
Fecal streptococci 400 MPN/100 mL Yes
UV disinfection system including Total coliforms 1000 MPN/100 mL Yes
medium pressure (MP)
Fecal coliforms 400 MPN/100 mL Yes
Fecal streptococci 400 MPN/100 mL Yes
Aghalari et al. Globalization and Health

LP + MP Total coliforms 1000 MPN/100 mL Yes

Fecal coliforms 400 MPN/100 mL Yes
Fecal streptococci 400 MPN/100 mL Yes
Banejad et al., 2010 [29] 12 Domestic wastewater/Hamedan Flocculation and coagulation with Total coliforms 97% Yes
moringa peregrina seeds
(2020) 16:13

Escherichia coli 97% Yes

Derayat et al., 2011 [30] 120 Municipal wastewater/Kermanshah Conventional activated sludge Cysts 97.5% Yes
and Gilangharb
Parasite eggs 98.3% Yes
Stabilization pond systems Cysts 100% Yes
Parasite eggs 100% Yes
Baghapour et al., 2013 [31] 64 Municipal wastewater/Shiraz Activated sludge Total coliforms 1291.11 ± 1165.88 No
MPN/100 mL
Fecal coliforms 675.22 ± 1008.21 No
MPN/100 mL
Helminth egg 73.61 ± 96.125 N/L No
Safari et al., 2013 [32] 7 Municipal wastewater/Shahrak Two-stage fluidized bed reactor (FBR) Fecal coliforms 35–75% No
Gharb Tehran (without chlorine
addition)
Fecal coliforms 67–97% No
(with the chlorine
addition)
Navidjouy et al., 2014 [33] 8 Municipal treatment plants and Activated sludge Helminth egg 94.8–95.7% Yes
slaughterhouse treatment plants/
Protozoa (oo)cyst 79.3–85.8% No
Tehran
Karimi et al., 2014 [34] 100 Municipal wastewater/Yazd Wetlands Fecal coliforms 1.13 × 1014 MPN/100 No
Escherichia coli 5.03 × 1012 MPN/100 mL No
Aslani et al., 2014 [35] 9 Municipal wastewater/North of Activated sludge effluent Fecal coliforms 5.5 ± 05 MPN/100 mL No
Tehran
Jamshidi et al., 2014 [36] 70 Lit Domestic wastewater/Tehran Anaerobic baffled reactor (ABR) Total coliforms 99% Yes
followed by Bio-rack wetland
Page 7 of 11
Table 4 Information from articles on the efficacy of different wastewater treatment systems to remove microbial agents (Continued)
Author/Year/Ref Sample Size Type of samples/City Types of wastewater treatment systems Microbial agent Microbial agent Compliance with
removal rate US-EPA Standard
(Ref. [26, 27])
planted with Phragmites sp. and Typha sp.
Nahavandi et al., 2015 [37] 8 Municipal treatment plants and Activated sludge Helminth egg 94.8–95.7% Yes
slaughterhouse treatment plants/
Protozoa (oo)cyst 79.3–85.8% No
Tehran
Ghoreishi et al., 2016 [38] 9 Municipal wastewater/Azerbaijan Extended aeration activated sludge/Tabriz Total coliforms 2.17 × 105 MPN/100 mL No
Province
Extended aeration activated sludge/ Total coliforms 1.34 × 106 MPN/100 mL No
Marand
Aghalari et al. Globalization and Health

Extended aeration activated sludge/Jolfa Total coliforms 1.82 × 106 MPN/100 mL No

5
Activated sludge/Ajabshir Total coliforms 4.53 × 10 MPN/100 mL No
Extended aeration activated sludge/Ahar Total coliforms 2.25 × 103 MPN/100 mL No
3
Extended aeration activated sludge/ Total coliforms 3.93 × 10 MPN/100 mL No
Mianeh
(2020) 16:13

Conventional activated sludge/Maragheh Total coliforms 3.02 × 104 MPN/100 mL No

6
SBR/Bostanabad Total coliforms 1.09 × 10 MPN/100 mL No
Extended aeration activated sludge/Sarab Total coliforms 2.02 × 103 MPN/100 mL No
Mollaie Tavani et al., 2017 [39] 16 Hospital wastewater/Behshahr Conventional activated sludge Total coliforms 46 MPN/100 mL Yes
Fecal coliforms 4.75 MPN/100 mL Yes
12
Sasani et al., 2017 [40] 36 Municipal wastewater/Ahvaz Conventional activated sludge Total coliforms 7.8 × 10 MPN/100 mL No
Choopan et al., 2018 [41] 45 Municipal wastewater/Torbat- Activated sludge Fecal coliforms 200 MPN/100 mL Yes
heydarieh
*In compliance with the US-EPA standard, the results of studies within the US-EPA standard range were marked with Yes and the results of studies that exceeded the US-EPA standard were marked with No.
Page 8 of 11
Aghalari et al. Globalization and Health (2020) 16:13 Page 9 of 11

[56]. Wastewater treatment professionals should therefore Permission to collect data

be aware of new replacement processes and perform pilot We have a permission to collect the data from the source.

scale assessments prior to changing treatment processes.

Authors’ contributions
One of the strengths of this study is addressing the ef- ZA conceived the study, made final decisions on the inclusion of journal
ficacy of wastewater treatment systems by comparing articles and extracted data from them, and wrote and revised the
the removal efficiency of various microbial agents that manuscript. HUD, MS, JESH and RPS wrote and revised the manuscript. All
authors read and approved the final manuscript.
have received little attention as yet. In most studies, only
one type of system for removing different physical, Funding
chemical and microbial contaminants in a single type of This research was funded by the Deputy of Research and Technology of
wastewater was investigated and it was not possible to Gonabad University of Medical Sciences. The funders did not have any role
in the design of the study and collection, analysis, and interpretation of data
compare the removal efficiency of microbial agents. One and in writing the manuscript.
of the limitations of this study was the lack of reviewing A grant from MOST to Tan Han Shih (Hans-Uwe Dahms) is gratefully
published articles on wastewater treatment systems in acknowledged (MOST 107–2621-M-037-001 and MOST 108–2621-M-037-001
to T.H. Shih). A NSYSU/KMU collaboration is acknowledged (108-PO25).
other than the 5 Iranian journals. This limitation, how-
ever, might be negligible because the research on waste- Availability of data and materials
water treatment was done by environmental health Not applicable.
professionals. Therefore, most studies in this area are
published in specialized environmental health journals. Ethics approval and consent to participate
This study was approved and registered by the Code of Ethics
(IR.GMU.REC.1396.110).
Conclusion
Different types of activated sludge systems have better effi- Consent for publication
cacy to remove microbial agents and are more effective Not applicable.
than other systems in removing the main indicators of
Competing interests
sewage contamination including Total coliforms and Fecal The authors declare that they have no competing interests.
coliforms. However, inappropriate operation, maintenance
and inadequate handling of activated sludge can also reduce Author details
1
Faculty of Public Health, Gonabad University of Medical Sciences, Gonabad,
the efficiency of microbial agent removal, which has been Iran. 2Department of Biomedical Science and Environmental Biology,
reported in some studies. Therefore, it is recommended to Kaohsiung Medical University, Kaohsiung 80708, Taiwan, Republic of China.
3
conduct research on how to increase the operation, main- Research Center for Environmental Medicine, Kaohsiung Medical University,
Kaohsiung 80708, Taiwan, Republic of China. 4Department of Marine
tenance and proper management of activated sludge Biotechnology and Resources, National Sun Yat-sen University, Kaohsiung
systems and provide the results to utility personnel respon- 80424, Taiwan, Republic of China. 5Department of Civil and Environmental
sible to work with this system in order to correct the sys- Engineering, Florida International University, Miami, FL, USA. 6Tecnologico de
Monterrey, School of Engineering and Sciences, Campus Monterrey, Ave.
tem quality output in a timely manner. In future research, Eugenio Garza Sada 2501, CP 64849 Monterrey, Nuevo Leon, Mexico.
it is recommended that employed treatment methods inte-
grate two or more purification systems, which then could Received: 22 October 2019 Accepted: 28 January 2020
more effectively remove microbial agents. Additionally, the
reports of removal efficiency should include each of the in- References
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