emission of pharmaceuticals from care units into …...1 emission of pharmaceuticals from care units...
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1
Emission of pharmaceuticals
from care units into wastewater:
from identification of sources to
monitoringBarry Pieters1, Lideke Vergouwen, Jeroen Horstman, Anja Derksen and Nicolas Coutton
1Grontmij | AquaSense, Amsterdam, The Netherlands, [email protected]
2
Pharmaceuticals and environment: lots of attention!
3
Introduction
Why research on pharmaceuticals necessary?
Not a priority compound in WFD! Still no environmental threshold
values…
Large diversity pharmaceuticals:active compounds formulations metabolites
Human 850 12.000 ?
Veterinary 200 2.500 ?
Designed for pharmacological effect at very low concentrations
Diffuse perceptions on environmental risks
Occurrence in surface water, groundwater and drinking water
4
Many types of human pharmaceuticals: Anti-depressives
ß-blockers
Anti-epileptics
Analgetics
Antibiotics
X-ray contrast compounds
Hormones
Cholesterol reducing compounds
…
Information necessary about:intake in The Netherlands, occurrence in aquatic environment, ecotoxicity,
measures for reduction emission, identification discharge routes, bioavailability
Introduction
5
Wat is main emissionroute human pharmaceuticals?
Effluents from wastewater treatment plants (WTP’s)
Why a problem?
Possible negative effects on aquatic community (e.g. endocrine disruption)
Contamination of drinking water for human consumption
What should be done?
Identification emission hot-spots!
Introduction
6
Ministry of Housing, Spacial Planning and the Environment (VROM):
2006: “research needs to be performed on how to implement cost-effective measures for emission reduction for hospitals and care institutions”
Introduction
7
Verg(h)ulde pillen project (2005-2009): HOSPITALS
Description research: Literature study
and chemical monitoring of emissions
from hospitals (and households)
Aim: Characterize emissions from
hospitals in order to make
recommendations on cost-effective
measures for discharge reductions
Funding: STOWA (Foundation for
Applied Water Research)
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0
200
400
600
800
1000
1200
1400
1600
WWTP W1: total load W1: without X-ray WWTP W2: total load W2: without X-ray WWTP W3: total load W3: without X-ray
19% from Hospital H1 22% from Hospital H1 34% from Hospital H2 9% from Hospital H2 44% from Hospital H3 7% from Hospital H3
Load
of
ph
arm
aceu
tica
ls a
t W
WTP
(kg/
year
)
Emission from Hospital (analysis 2007/2008) Emission from Households (analysis 2007/2008)
WWTP W1 WWTP W2 WWTP W3
Loads of pharmaceuticals at WWTP
9
Main conclusions
Bulk emission from hospitals are 50-70 compounds
X-ray contrast compounds (>50%) and antibiotics most
relevant pharmaceuticals discharged by hospitals
Comparison with estimated discharge househoulds
Locationspecific!
Prescriptions: 17-55% from hospital
Chemical measurements: 19-44% from hospital
What is the emission of pharmaceuticals from the
remaining care institutions?
10
ZORG project (2009): CARE INSTITUTIONS
Aim:
Collect data on nature and extent of pharmaceutical
emissions from care institutions
Gather information for discussions on cost-effective
measures for emission reduction
Set-up
A. Literature study
B. Chemical and effect measurements wastewater
Funding: STOWA (Foundation for Applied Water
Research) and participation of 7 different waterboards
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A Literature study
Description types of care institutions
Numbers of locations, beds and patients
Use and intake pharmaceuticals
Ecotoxicological effects
Selection criteria for monitoring sites
wastewater
Development pharmaceutical trends
12
Identified care institutions:
Home for the elderly
Nursery homes
Physical disabled
Mental disabled
Sensory disabled
Severely mental disabled (GGZ)
Care institutions for addictions
13
Hospitals and nursing/elderly homes
in The Netherlands
14
Mental and physical disabled in The Netherlands
15
Number of locations and (average) beds
per type of care institution
0
500
1000
1500
2000
2500
3000
3500
Aa
nta
l lo
cati
es
0
20000
40000
60000
80000
100000
120000
Aa
nta
l b
ed
den
0
200
400
600
800
1000
1200
Gem
idd
eld
aan
tal b
ed
den
per
inste
llin
g Academisch ziekenhuis
Algemeen ziekenhuis
Verpleegtehuis
Verzorgingstehuis
Verstandelijke gehandicapten
Lichamelijke gehandicapten
GGZ
0
500
1000
1500
2000
2500
3000
3500
Aa
nta
l lo
cati
es
0
20000
40000
60000
80000
100000
120000
Aa
nta
l b
ed
den
0
200
400
600
800
1000
1200
Gem
idd
eld
aan
tal b
ed
den
per
inste
llin
g Academisch ziekenhuis
Algemeen ziekenhuis
Verpleegtehuis
Verzorgingstehuis
Verstandelijke gehandicapten
Lichamelijke gehandicapten
GGZ
Academic hospital
Common hospital
Home for the elderly
Nursery home
Mental disabled
Physical disabled
Severely mental disabled (GGZ)
Nu
mb
er
of lo
ca
tions
Nu
mb
er
of b
ed
s
Nu
mb
er
of b
ed
s p
er
loca
tion
16
How do people live?
17
Intake pharmaceuticals by age
18
Demographic trends >65 jaar
0
200000
400000
600000
800000
1000000
1200000
1400000
1600000
1800000
2005 2010 2015 2020 2025
85+
80-84
75-79
70-74
65-69
0
500000
1000000
1500000
2000000
2500000
2005 2010 2015 2020 2025
85+
80-84
75-79
70-74
65-69
1.6 million males in 2025
1.9 million females in 2025
Increased use
pharmaceuticals expected!
19
Results inventory intake pharmaceuticals
from care institutions
Estimation of:
Load per institution
Load per person per
institution
Load with incorporation
excretion factors
Load with incorporation
environmental risk-index:
Defined Daily Dosis
Prescriptions
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Name of institution Location Type of institution # Residents Format data Time span
1 Zorggroep Reinalda Haarlem Home for the elderly / nursery home 155 Prescription 7 days
2 De Schoel Sleen Home for the elderly 27 Intake 1 day
3 De Lisse Asten Home for the elderly 62 Prescription 12 months
4 Ambachtshuys Meppel Mental disabled 5 Intake 1 day
5 Zorgboerderij Anderen Anderen Mental disabled 10 Intake 1 day
6 Robert Coppes Stichting Vught Sensory disabled 7 Intake 1 day
7 Bartimeus Zeist Sensory / mental / physical disabled 338 Prescription 6 months
8 Esdégé-reigersdaal Heerhugowaard Mental / physical disabled 360 Prescription 1 month
10 Ziekenhuis Gelderse Vallei Wolfheze Severely mental disabled (GGZ) 524 Sales 12 months
Prescription 14 daysHet Dorp9 Arnhem Physical disabled 675
Approached care institutions: 10
21
Establisment database excretion factors
for 367 compounds
22
Total load in gram per year
with and without excretion (*)
0
20000
40000
60000
80000
100000
120000
140000
Eld
erl
y /
nu
rsery
ho
me
** * * * *
**
*
*
V - Varia
S - Sensorische organen
R - Ademhalingssysteem
P - Antiparasitische middelen,
insecticiden en repellents
N - Zenuwstelsel
M - Spier- en skeletsysteem
L - Antineoplasie en
immunomodulerende stoffen
J - Anti-infectie middelen voor
systemisch gebruik
H - Systemische hormonale
preparaten, met uitzondering van
insuline en geslachtshormonen
G - Genito-urinaire systeem en
geslachtshormonen
D - Dermatologica
C - Cardiovasculair systeem
B - Bloed en bloedvormende organen
A - Spijsverteringsstelsel en
metabolisme
Main groups (ATC-code)
Eld
erl
y
ho
me
Eld
erl
y
ho
me
Men
tal d
isab
led
Men
tal d
isab
led
Sen
so
ry d
isab
led
Sen
s / p
hys /
men
tal
dis
ab
led
Ph
ysic
al
/ m
en
tal
dis
ab
led
Ph
ysic
al
/ m
en
tal
dis
ab
led
Severe
ly
men
tal d
isab
led
GG
Z
23
Total load in gram per person per year with
and without excretion (*)
0
100
200
300
400
500
600
700
800
* * * * *
*
* * **
V - Varia
S - Sensorische organen
R - Ademhalingssysteem
P - Antiparasitische middelen,
insecticiden en repellents
N - Zenuwstelsel
M - Spier- en skeletsysteem
L - Antineoplasie en
immunomodulerende stoffen
J - Anti-infectie middelen voor
systemisch gebruik
H - Systemische hormonale
preparaten, met uitzondering van
insuline en geslachtshormonen
G - Genito-urinaire systeem en
geslachtshormonen
D - Dermatologica
C - Cardiovasculair systeem
B - Bloed en bloedvormende organen
A - Spijsverteringsstelsel en
metabolisme
Main groups (ATC-code)E
lde
rly /
nu
rsery
ho
me
Eld
erl
y
ho
me
Eld
erl
y
ho
me
Men
tal d
isab
led
Men
tal d
isab
led
Sen
so
ry d
isab
led
Sen
s / p
hys /
men
tal
dis
ab
led
Ph
ysic
al
/ m
en
tal
dis
ab
led
Ph
ysic
al
/ m
en
tal
dis
ab
led
Severe
ly
men
tal d
isab
led
GG
Z
24
Total load per year with and without
excretion (*) as percentage (%)
0
20
40
60
80
100 * * * * * * * * * * V - Varia
S - Sensorische organen
R - Ademhalingssysteem
P - Antiparasitische middelen,
insecticiden en repellents
N - Zenuwstelsel
M - Spier- en skeletsysteem
L - Antineoplasie en
immunomodulerende stoffen
J - Anti-infectie middelen voor
systemisch gebruik
H - Systemische hormonale
preparaten, met uitzondering van
insuline en geslachtshormonen
G - Genito-urinaire systeem en
geslachtshormonen
D - Dermatologica
C - Cardiovasculair systeem
B - Bloed en bloedvormende organen
A - Spijsverteringsstelsel en
metabolisme
Main groups (ATC-code)
Eld
erl
y /
nu
rsery
ho
me
Eld
erl
y
ho
me
Eld
erl
y
ho
me
Men
tal d
isab
led
Men
tal d
isab
led
Sen
so
ry d
isab
led
Sen
s / p
hys /
men
tal
dis
ab
led
Ph
ys
ica
l /
me
nta
l d
isa
ble
d
Ph
ysic
al
/ m
en
tal
dis
ab
led
Severe
ly
men
tal d
isab
led
GG
Z
Pe
rce
nta
ge (
%)
25
Environmental risk-index: load / DDDwith and without excretion (*)
0
20
40
60
80
100
Perc
en
tag
e (
%)
* * * * * * * * * *V - Varia
S - Sensorische organen
R - Ademhalingssysteem
P - Antiparasitische middelen,
insecticiden en repellents
N - Zenuwstelsel
M - Spier- en skeletsysteem
L - Antineoplasie en
immunomodulerende stoffen
J - Anti-infectie middelen voorsystemisch gebruik
H - Systemische hormonale
preparaten, met uitzondering van
insuline en geslachtshormonen
G - Genito-urinaire systeem en
geslachtshormonen
D - Dermatologica
C - Cardiovasculair systeem
B - Bloed en bloedvormende organen
A - Spijsverteringsstelsel en
metabolisme
Main groups (ATC-code)
Eld
erl
y/ n
urs
ery
ho
me
Eld
erl
yh
om
e
Eld
erl
yh
om
e
Men
tal d
isab
led
Men
tal d
isab
led
Sen
so
ryd
isab
led
Sen
s/ p
hys
/ m
en
tal d
isab
led
Ph
ysic
al/ m
en
tal d
isab
led
Ph
ysic
al/ m
en
tal d
isab
led
Sev
ere
lym
en
tal d
isab
led
GG
Z
0
20
40
60
80
100
Perc
en
tag
e (
%)
* * * * * * * * * *V - Varia
S - Sensorische organen
R - Ademhalingssysteem
P - Antiparasitische middelen,
insecticiden en repellents
N - Zenuwstelsel
M - Spier- en skeletsysteem
L - Antineoplasie en
immunomodulerende stoffen
J - Anti-infectie middelen voorsystemisch gebruik
H - Systemische hormonale
preparaten, met uitzondering van
insuline en geslachtshormonen
G - Genito-urinaire systeem en
geslachtshormonen
D - Dermatologica
C - Cardiovasculair systeem
B - Bloed en bloedvormende organen
A - Spijsverteringsstelsel en
metabolisme
Main groups (ATC-code)
Eld
erl
y/ n
urs
ery
ho
me
Eld
erl
yh
om
e
Eld
erl
yh
om
e
Men
tal d
isab
led
Men
tal d
isab
led
Sen
so
ryd
isab
led
Sen
s/ p
hys
/ m
en
tal d
isab
led
Ph
ysic
al/ m
en
tal d
isab
led
Ph
ysic
al/ m
en
tal d
isab
led
Sev
ere
lym
en
tal d
isab
led
GG
Z
26
0 1 2 3 4 5 6 7 8 9 10
A02BC05 - esomeprazol
A03AA04 - mebeverine
A03FA03 - domperidon
A10BA02 - metformine
C07AA07 - sotalo l
C07AB03 - atenolo l
J01CA04 - amoxicilline
J01CF05 - flucloxacilline
J01EE01 - cotrimoxazol
J01M A02 - ciprofloxacine
M 01AE01 - ibuprofen
M 03BX01 - baclofen
M 03CA01 - dantro leen
N03AA02 - fenobarbital
N03AB02 - fenyto ine
N03AD01 - ethosuximide
N03AF01 - carbamazepine
N03AG01 - valpro inezuur
N03AX09 - lamotrigine
N03AX10 - taloxa
N03AX14 - levetiracetam
N05AD05 - pipamperon
N05AN01 - lithiumcarbonaat
N06AB04 - citalopram
S01EC01 - acetazolamide
without excretion
with excretionSensory / physical / mental disabled
A02BC05 - esomeprazolA03AA04 - mebeverine
A03FA03 - domperidon
A10BA02 - metformine
C07AA07 - sotalol
C07AB03 - atenolol
J01CA04 - amoxicillineJ01CF05 - flucloxacilline
J01EE01 - cotrimoxazol
J01MA02 - ciprofloxacineM01AE01 - ibuprofen
M03BX01 - baclofen
M03CA01 - dantroleenN03AA02 - fenobarbital
N03AB02 - fenytoineN03AD01 - ethosuximide
N03AF01 - carbamazepine
N03AG01 - valproinezuur
N03AX09 - lamotrigine
N03AX10 - taloxa
N03AX14 - levetiracetamN05AD05 - pipamperon
N05AN01 - lithiumcarbonaat
N06AB04 - citalopramS01EC01 - acetazolamide
X X
X
X X
X X
1 2 3 4 5 6 7 8 9 10
65
32
Ac
tive
co
mp
ou
nd
OMG TZW
Total load in gram per person per year
Top 90% of prescribed individual active compounds
29
Sample locations: participation 7 different waterboards
Care institution Households
Surface water
WWTP
De Dommel
Aa en Maas
Zeeuwse Eilanden
Vallei & Eem
Hunze en Aas
Rivierenland
Roer en Overmaasxx
x
x
30
Questions
?