key: cord-0959435-4nz3v2uw
authors: Achak, Mounia; Alaoui, Soufiane Bakri; Chhiti, Younes; M’hamdi Alaoui, Fatima Ezzahrae; Barka, Noureddine; Boumya, Wafaa
title: SARS-CoV-2 in hospital wastewater during outbreak of COVID-19: A review on detection, survival and disinfection technologies
date: 2020-10-24
journal: Sci Total Environ
DOI: 10.1016/j.scitotenv.2020.143192
sha: fa6bf28b035be38da8b4c550bfdd6ecb4672982c
doc_id: 959435
cord_uid: 4nz3v2uw

Currently, the apparition of new SARS-CoV, known as SARS-CoV-2, affected more than 34 million people and causing high death rates worldwide. Recently, several studies reported SARS-CoV-2 ribonucleic acid (RNA) in hospital wastewater. SARS-CoV-2 can be transmitted between humans via respiratory droplets, close contact and fomites. Fecal-oral transmission is considered also as a potential route of transmission since several scientists confirmed the presence of SARS-CoV-2 RNA in feces of infected patients, therefore its transmission via feces in aquatic environment, particularly hospital wastewater. Hospitals are one of the important classes of polluting sectors around the world. It was identified that hospital wastewater contains hazardous elements and a wide variety of microbial pathogens and viruses. Therefore, this may potentially pose a significant risk of public health and environment infection. This study reported an introduction about the Physical-chemical and microbiological characterization of hospital wastewater, which can be a route to identify potential technology to reduce the impact of hospital contaminants before evacuation. The presence of SARS-CoV-2 in aqueous environment was reviewed. The knowledge of the detection and survival of SARS-CoV-2 in wastewater and hospital wastewater were described to understand the different routes of SARS-CoV-2 transmission, which is also useful to avoid the outbreak of CoV-19. In addition, disinfection technologies used commonly for deactivation of SARS-CoV-2 were highlighted. It was revealed that, chlorine-containing disinfectants are the most commonly used disinfectants in this field of research. Meanwhile, other efficient technologies must be developed and improved to avoid another wave of the pandemic of COVID-19 infections.

SARS-CoV-2 from hospital wastewater , Zhang et al. 2020e, Xing et al. 2020 .

In this review, an introduction about the Physical-chemical and microbiological characterization of hospital wastewater was reported. The information on presence of SARS-CoV-2 in aqueous environment was addressed. The knowledge of the detection and survival of SARS-CoV-2 in wastewater and hospital wastewater were described to understand the different routes of SARS-CoV-2 transmission, which is also useful to avoid the outbreak of CoV-19. Furthermore, the inactivation of coronavirus in hospital wastewater using disinfectants and disinfection technologies are discussed. The efficiency, advantages and limitations of these disinfectants were highlighted.

The wastewater amount produced by hospitals reached 200 to 1200 L/bed of hospitalized people/day (Verlicchi et al. 2010a ). The increase of wastewater charge depends on various parameters as medical specialty, bed capacity, climate, geographical factors, cultural and nature of services offered by the healthcare institution (e.g., kitchen, bathroom and laundry).

The pollutant substances in hospital wastewater are divided into two main categories as macro-pollutants and micro-pollutants. As shown in Table 1 , micro-pollutants included absorbable organic halogens (AOX), analgesics, cytostatics, hormones, detergents, antiseptics, contrast substances, phenols, antibiotics such as paracetamol, ciprofloxacin and sulfamethoxazole, and heavy metals such as cadmium, chrome, iron, copper, lead, nickel, and zinc. While macro-pollutants substances are physic-chemical parameters as pH, chemical demand of oxygen (COD), biological demand of oxygen (BOD), total demand of oxygen (TOC), suspended solids (SS), ammonium ions and J o u r n a l P r e -p r o o f Journal Pre-proof chloride, microbiological taminants as coliforms, bacteria (enterococcus, lococcus, shigella, salmonella) and viruses. Diwan et al. 2009; Lien et al. 2016 Pieczyńska et al. 2017 Guedes-Alonso et al. 2014 Roudbari and Rezakazemi, 2018 Verlicchi et al. 2010a; Basturka et al. 2020 Basturka et al. 2020 El-Ogri et al. 2016 Kummerer et al. 1999; Lenz et al. 2007 Kummerer et al. 1998 Kummerer and Helmers 2000 Basturka et al. 2020 Macro-pollutants parameters (COD, BOD, TOC, SS, ammonium ions and chloride) Microbiological taminants Viruses disinfection, laboratory activities, anesthetics and sterilization products, nutrient solutions used in microbiology laboratories Atmosphere, soil, medical devices and water employed in the hospital practice human fecal matter from infected persons Kumari et al. 2020 Nuñez and Moretton, 2007; Kaur et al. 2020 Xu et al. 2005 Symonds et al. 2009; Prado et al. 2011; Radin, 2014; Gerba et al. 2017; Holshue et al. 2020; Wu et al. 2020b Based on the above, hospital wastewater is considered as a source of pathogenic microorganisms, toxic chemicals and radioactive elements. It constitutes a source of transmission of infections and epidemic diseases (Sanaa et al. 2019) , which may present a potential danger to humans and their environment. Table 2 presented the analysis of the physical-chemical and microbiological characteristics of different hospitals in various countries. Management of this effluent varies from country to country.

Generally, it was discharged in municipal sewage network without pre-treatment. Data indicated in Table 2 can be a route to identify potential technology to reduce the impact of hospital contaminants before evacuation. Moreover, according to several studies, the physical-chemical and microbiological characterization of hospital wastewater and urban wastewater showed that the charge pollutant in hospital effluent is in general higher than in urban wastewater (Tsakona et al. 2007; Mesdaghinia et al. 2009; Verlicchi et al. 2010b; Verlicchi et al. 2012 ).

Referring to comprehensive review of the literature, Table 3 can compiled the main characterization of hospital wastewater and urban wastewater (Verlicchi et al. 2012) . As showed, COD, BOD and SS in hospital wastewater are 2-3 times higher than urban wastewater. This observation indicates that the collection of hospital wastewater together with urban wastewater increases more pollutant concentration and a dedicated pre-treatment of hospital wastewater before discharge was recommended (Verlicchi et al. 2010a ). Parameter Hospital wastewater urban wastewater pH 6.9-9.18 7.5-8.5 Conductivity (mS cm -1 ) 750-1,000 420-1,340 SS (mg L -1 ) 120-400 120-350 COD (mg L -1 ) 450-2,300 500-600 BOD 5 mg L -1 150-603 100-400 TKN (mg L -1 ) 30-100 20-70 NH 4 (mg L -1 ) 10-55 12-45 P tot (mg L -1 ) 3-8 4-10 Chlorides (mg L -1 ) 80-400 30-100 Fats and oils (mg L -1 ) 13-60 50-150 Total detergents (mg L -1 ) 3-7.2 4-8 Total coliforms (MPN/100 mL) 10 6 -10 9 10 7 -10 8 Faecal coliforms (MPN/100 mL) 10 3 -10 7 10 6 -10 7 J o u r n a l P r e -p r o o f Journal Pre-proof E. coli (MPN/100 mL) 10 3 -10 6 10 6 -10 7 Streptococci (MPN/100 mL) 10 3 -10 5 10 3 -10 5

In addition to pathogenic microorganisms, radioactive elements and toxic chemicals, (Lago et al. 2003; Lefkowitz et al. 2018) . These viruses are some of the principal human pathogens viruses transmissible via water media, notably hospital wastewater. As known, enteric viruses cause waterborne diseases such as diarrhea (Pietruchinski et al. 2006 ) and are associated with other disease outbreaks (Thongprachum et al. 2018 

Based on recent and previous published studies, many pathways of SARS-CoV-2 transmission were discussed. As shown in Figure 3 , SARS-CoV-2 can be transmitted between humans via respiratory droplets, when any individual is in close contact with an infected person, a high risk of contamination is possible mainly when this person coughs, sneezes, talks, or exhales (Morawska and Cao, 2020) . Some droplets (0.5-20.0 μm) lingering in the air are more likely to be retained in the respiratory tract and produce the infection (McCluskey et al. 1996) . Indeed, some other droplets are too heavy to remain in the air, and fall on floors; consequently, all surfaces become contaminated with SARS-CoV-2, touching by a susceptible person would be infected.

The viability of SARS-CoV-2 in droplets form is more stable than aerosols on plastic and stainless steel, copper, cardboard, and glass with durations detected up to 72, 4, 24, and 84 h, respectively. For this reason, maintaining social distance and cleaning hands regularly are the main measure recommended by the World Health Organization (WHO, 2020a). Based on a study carried out by Morawska (2006) , it was estimated that some droplets ejected from an infected individual, convert to aerosol particles (small aerodynamic diameters), and then become airborne. For that, the presence of droplets in the air for longer period is limited; evaporation process transforms droplets to bioaerosol residues, which could linger in the air for extended periods.

J o u r n a l P r e -p r o o f (Wang and Du, 2020) . Read (2020) reported that there was cases of COVID-19 reported positive in cruise ship, when many of the infections occurred after the imposition of isolation that confined passengers for the majority of time to their cabins, and limited direct contact, and with hand hygiene carefully obeyed, giving evidence of the airborne transmission.

Based on the above studies, experiences, and understanding the basic science of viral infection spread, it is strongly plausible that SARS-CoV-2 virus spread through the air. If this is the case, according to Morawska and Cao (2020) , it will take at least several months for this to be confirmed by science, especially it is difficult to directly detect the viruses traveling in the air. This is valuable time lost that could be used to properly control the epidemic and prevent more infections and loss of life.

Contact transmission route is caused by close contact, this type of transmission located when viral particles, emitted from infected person, are in contact with object, then another individual touches that object, then touches one of his senses (noise, mouth, eyes). The virus immediately enters to respiratory tract (Chin et al. 2020 ).

Contact transmission also caused when people is in face-to-face contact with a confirmed or probable case for more than 15 minutes in total over the course of a week, or people shares an enclosed space with a confirmed or probable case for more than two hours. During the spread of COVID-19, many reports confirmed that the primary route of transmission of SARS-CoV-2 is face-to-face contact transmission, can occur by direct and indirect contact via respiratory droplets such as talking, breathing, sneezing, coughing and close contact with infected people or with surfaces and fomites in the immediate environment or with objects used by the infected person (Morawska, 2006) . Agency (EPA), is classified as PM 10 (diameter <10 μm) and PM 2.5 (diameter <10 μm).

In this trend, the long-term exposure to air pollution may represent a favorable context for the spread of the virus, while the combination of SARS-CoV-2 and particulate matter may produce a loaded airborne (Fattorini and Regoli 2020; Conticini et al. 2020 ).

Based on various researchers, Table 4 summarized the correlation between environment factors and SARS-CoV-2 survival. J o u r n a l P r e -p r o o f

Based on previous studies (Xu et al. 2005; Radin, 2014; Graaf et al. 2017 

As mentioned in Table 2 Table 5 summarized concentration methods and main RT-qPCR and nested RT-PCR assays available for SARS-CoV-2.

As reported in J o u r n a l P r e -p r o o f N_Sarbeco assay produced positive signals for two wastewater samples (12 copies/100mL) with 22% positive rate, while the same samples were negative when tested using NIID_2019-nCOV_N. N_Sarbeco assay is more sensitive than the NIID_2019-nCOV_N assay.

Number of COVID-19 cases should have a linear relationship with viral RNA copies in wastewater. 98.5% SARS-CoV-2 genome sequence from the wastewater Presence of SARS-CoV-2 at high titers (>2 10 5 copies/L) in the period from March 18 -25. Viral titers observed were significantly higher than expected based on clinically confirmed cases as of March 25.

Increase of genome units in raw wastewater accurately followed the increase of human COVID-19 cases. SARS-CoV-2 concentration exceeds 3.16 10 6 and less 10 5 with 100% and 75% of positive rate for untreated and tread wastewater respectively. The results indicated that COVID-19 viral RNA was detected in two samples and a correlation of confirmed cases was also established in the locations from where samples were lifted (Lakshmi, 20020) . Study carried out by Wurtzer et al. (2020) in Paris (France) demonstrated the detection of viral genome before the exponential phase of the epidemic. A similar study conducted in Murcia (Spain) by Randazzo et al. (2020) indicated that SARS-CoV-2 could be detected weeks before the first confirmed case. La Rosa et al. (2020) revealed that 6 out of 12 influent sewage samples, collected between February and April 2020 from wastewater treatment plants in Milan and Rome (Italy) were positive. A published study by Wu et al. (2020b) announced the presence of SARS-CoV-2 at high titers in the period from March 18 -25 using RT-qPCR in tested wastewater collected at a major urban treatment facility in Massachusetts (United States).

On the other hand, Gormley et al. (2020) and Carducci et al. (2020) reported that aerosols generated from wastewater system are considered as a potential transmission route of COVID-19. According to Casanova et al. (2009) According to previous studies, the exposure to UV light can also decrease the activity of coronavirus, especially SARS-CoV, in aquatic environment (Darnell et al. 2004 ). It was demonstrated that UV-B (315-280 nm) and UV-C (190-290 nm) cause a significant and rapid decrease in infectious SARS-CoV (Pratelli, 2008) . The effectiveness of UV light in the inactivation of SARS-CoV-2 is not yet explored to date.

However, if this behavior occurs, it is evident to take into account the variation of season and geography in UV light availability (Grigalavicius et al. 2016 ).

On the other hand, the presence of suspended organic matter in wastewater can also affect coronavirus survive. As reported by Murray and Jackson (1992) , suspended solids can provide shielding from light and affect settling behavior. Although, it may also influence the viral diffusion coefficient and potentially result in clusters of viruses.

Evaluation of the presence of SARS-CoV-2 viral RNA in septic tanks of Wuchang Cabin Hospital by Zhang et al. 2020d indicated a high level of (0.5-18.7) × 10 3 copies/L after disinfection with sodium hypochlorite. This result set evidence to release of virus embedded in patient's stool, protected by organic matters, in septic tanks.

The detection of coronavirus and then its survival in wastewater can be influenced by pathway used for quantification of RNA viruses. Literature reviews showed that several qRT-PCR assays have been designed for the detection of SARS-CoV-2, which are efficient for wastewater surveillance (Vogels et al. 2020; Corman et al. 2020; Chan et al. 2020) . However, despite the fact that qPCR method is rapid, sensitive and accurate, it remains limited due to the presence of high load of organic contaminants in wastewater, especially in hospital wastewater, which often interfere with downstream virus detection.

Nonetheless, many other emerging technologies were tested for SARS-CoV-2 detection in wastewater samples, including digital PCR, isothermal amplification and biosensors (Farkas et al. 2020 ). However, these methods are more expensive and less sensitive (Ishii et al. 2014 ).

Knowledge of the presence of the coronavirus (and more specifically of SARS-CoV-2) in wastewater, along with its survival generates a great debate since the outbreak of COVID-19. and Sun et al. (2020) reported that the infectivity of SARS-CoV-2 in wastewater has not been assessed, even though culturable viral particles have been detected in the feces of infected individuals. Venugopal et al.

(2020) indicated that the survival of the viruses decreased drastically when the parameters such temperature, UV-light and organic matter were unfavorable. In addition, the presence of solvents and detergents in wastewater can compromise the viral envelope (Gundy et al. 2009 ). However, according to World Health Organization (WHO, 2020c) , there is no evidence on the persistence of SARS-CoV-2 virus in wastewater. Along these same lines, Naddeo and Liu (2020) showed that the persistence of SARS-CoV-2 in the environment could be short, although little is known concerning survival of this virus in wastewater.

Although the presence, survival of SARS-CoV-2 and its transfer from wastewater systems, especially infectious disease units such hospitals, accommodate many sources of uncertainty, it is recommended to be treated and disinfected in order to limit its outbreak in the population, and its effect on public health.

In many countries such as Australia, Iran, Egypt, India, Japan, South Africa, and J o u r n a l P r e -p r o o f coagulation-flocculation and Fenton-oxidation studies (Kühn et al. 2003; Yu et al. 2013; Chen et al. 2014; Fan et al. 2017; Christensen and Myrmel, 2018) . Recently, other promising technologies were developed such as constructed wetland (Khan et al. 2020) and supercritical water oxidation (Top et al. 2020) .

Methodical researches regarding the disinfection of SARS-CoV in wastewater and hospital wastewaters, particularly distinct disinfection propositions throughout the coronavirus pandemic, were targeted by various studies (Kühn et al. 2003; Yu et al. 2013; Chen et al. 2014; Fan et al. 2017; Christensen and Myrmel, 2018) . The complete deactivation of SARS-CoV can be achieved by combination of three steps of water processing.

The first stage, known as primary treatment, concerning the remove of material that will either float or readily settle out by gravity by sedimentation or flotation processes.

The second stage, known as secondary treatment, concerning remove of the soluble organic matter that escapes primary treatment and the suspended solids, which protect virus from disinfection, by free chlorine. Removal is usually accomplished by biological processes (trickling filter, activated sludge process, and oxidation pond) in which microbes consume the organic impurities as food, converting them into carbon dioxide, water, and energy for their own growth and reproduction. This stage is generally considered a practical and available hospital wastewater treatment technology that is particularly well suited to destroying pathogens, as relatively long retention times, (Table 6 ). In case of COVID-19, few numbers of studies were developed the disinfection of wastewater and hospital wastewater spiked with SARS-CoV-2. This scarcity of information can be caused by the lack of environmental research on COVID-19, insufficient of laboratory equipment and/or the risk to workers handling wastewater.

The review reported by Wang et al. (2020d) represented the disinfection technologies commonly used for hospital wastewater such as ultraviolet light (UV), ozone, Chlorinecontaining disinfectants, and provided just suggestions for hospital wastewater disinfection during COVID-19 pandemic in China. To determine the sustainable technology to inactive SARS-Cov-2, Wang et al. (2020d) indicated that the disinfection technologies adopted during SARS epidemic could be used as good reference to inactivation of SARS-Cov-2 in hospital wastewater, due to the similarities between SARS-CoV-1 and SARS-CoV-2. The disinfection with free chlorine for effective centralized disinfection was also suggested by World Health Organization (WHO, 2020d) under optimal conditions (pH<8.0, contact time least 30 minutes and concentration dosage ≥ 0.5 mg/L).

According to previous study (Wang et al. 2020d; How et al. 2017) , chlorine-based disinfectants are widely used for their broad sterilization spectrum, high inactivation J o u r n a l P r e -p r o o f efficiency and easy decomposition with little residue, as well as represents the best economic solution. However, excess use of chlorine-based disinfectants can generate more than 600 kinds of disinfection by-products, which are harmful to ecosystems and human health (Table 6) (Richardson, 2011; Wang et al. 2014; Luo et al. 2020b ). On the other hand, chlorine reacts with ammonia contains in wastewater and forms a new product (chloramine), which behaves differently to free chlorine during disinfection (Wang et al. 2005b) . As part of an emergency treatment of hospital wastewater containing SARS-CoV-2, China has launched a guideline requiring free chlorine ≥ 6.5 mg/L at 1.5 hour of contact time and without condition of pH. and sedimentation tank (not detected-2208 copies/L). In the third hospital treatment unit (Wuchang Fangcang Hospital), there was two disinfection units (preliminary disinfection tank followed by septic tank). SARS-CoV-2 RNA was detected in wastewater from the septic tanks disinfected by 800 mg/L of sodium hypochlorite, ranging from 557 to 18,744 copies/L, and it declined to non-detected after the dosage of sodium hypochlorite increased to 6,700 mg/L. Absence of SARS-CoV-2 viral RNA in the effluent of septic tanks after disinfection with 800 g/m3of sodium hypochlorite. Presence of SARS-CoV-2 viral RNA in the influent of septic tanks with the increase of sodium hypochlorite (6700 g/m3), suggested that SARS-CoV-2 might be embedded in patient's stools, protected by organic matters from disinfection, and slowly release when free chlorine declines.

255 copies/L of SARS-CoV-2 viral RNA were detected only in adjusting tank of Jinyintan Hospital. SARS-CoV-2 viral RNA was found in first adjusting tank (633 copies/L), MBBR (not Wang et al. 2005 Ciejka et al. 2017 Zhang et al. 2020d J o u r n a l P r e -p r o o f detected-505 copies/L), and sedimentation tank (not detected-2208 copies/L). SARS-CoV-2 RNA was detected in wastewater from the septic tanks disinfected by 800 mg/L of sodium hypochlorite, ranging from 557 to 18,744 copies/L, and it declined to non-detected after the dosage of sodium hypochlorite increased to 6,700 mg/L.

J o u r n a l P r e -p r o o f

This review highlighted the detection, survival and route transmission of SARS-CoV-2 in hospital wastewater during outbreak of CoV-19. The disinfection technologies of this virus were also discussed, with special emphasis on efficiency of disinfection technologies used commonly for deactivation of SARS-CoV-2 from hospital wastewater.

Physical-chemical and biological characterization of hospital wastewater presents a wide range of hazardous pollutants, such as pharmaceutical residues, chemical substances, radioisotopes, and microbial pathogens and viruses as SARS-CoV-2. The discharge of this effluent into the municipal collector or directly onto surface water without any treatment represents a chemical, biological, and physical risk for public and environmental health, and allows a rapid outbreak of CoV-19.

There are many pathways of SARS-CoV-2 transmission; it can be transmitted between humans via respiratory droplets, aerosol, close contact and fomites. Fecal-oral transmission is considered also as a potential route of transmission since several scientists confirmed the presence of SARS-CoV-2 RNA in feces of infected patients.

The survival of SARS-CoV-2 could be influenced by different parameters such as temperature, pH, retention time, organic matter, light exposure and aerobic organisms, as well as by pathways used for quantification of RNA viruses.

Many techniques were developed to removal of organic pollutants and microbial pathogens and viruses from hospital wastewater. According to few studies investigating the deactivation of SARS-Co V-2 showed that chlorine-based disinfectants are widely used for their broad sterilization spectrum, high inactivation efficiency and easy decomposition with little residue, as well as represents the best economic solution. The J o u r n a l P r e -p r o o f complete deactivation of SARS-CoV-2 can be achieved by combination of other technologies (biological and/or physical-chemical processes).

In the meantime, we should to develop more secure, efficient, economical disinfection technologies in order to limit the transmission of COVID-19 and to avoid other waves of the pandemic of COVID-19 infections.

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Time Course Quantitative Detection of SARS-CoV-2 in Parisian Wastewaters Correlates

Confirmed Cases. medRxiv

No association of COVID-19 transmission with temperature or UV radiation in Chinese cities

Three cases of novel coro

Enteric involvement of coronaviruses: is faecaloral transmission of SARS-CoV-2 possible ?

Survival of respiratory viruses on fresh produce

Design and running for a hospital wastewater treatment project

Fecal specimen diagnosis 2019 novel coronavirus-infected pneumonia

2020 b. Isolation of 2019-nCoV from a stool specimen of a laboratory-confirmed case of the coronavirus disease 2019 (COVID-19)

Virus shedding patterns in nasopharyngeal and fecal specimens of COVID-19 patients

Potential spreading risks and disinfection challenges of medical wastewater by the presence of Severe Acute Respiratory Syndrome Coronavirus

Association between ambient temperature and COVID-19 infection in 122 cities from China

Association between short-term exposure to air pollution and COVID-19 infection: evidence from China

Mounia ACHAK, Younes CHHITI, Fatima Ezzahrae M'hamdi Alaoui and Noureddine Barka analyzed, interpreted the research data and contributed to writing the manuscript. Soufiane Bakri Alaoui and Wafaa Boumya analyzed literature data and prepared manuscript.

The authors declare that they have no competing interests

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