REPORT

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Removal efficiency of pharmaceuticals in constructed wetlands in Sweden

2019

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For bibliographic purposes this document should be cited as:

CCB Report - Removal efficiency of pharmaceuticals in constructed wetlands in

Sweden. Uppsala, Sweden, 2019

Information included in this publication or extracts thereof are free for citation on the

condition that the complete reference of the publication is given as stated above.

© Copyright 2019 by the Coalition Clean Baltic

Author: Johannes Randefelt

Layout & Production: Coalition Clean Baltic

Published in December 2019 by the Coalition Clean Baltic with contributions from the

LIFE financial instrument of the European Community, the Swedish Environmental

Protection Agency, and the Swedish Agency for Marine and Water Management.

The content of this report is the sole responsibility of CCB and can in no way be taken

to reflect the views of the funders.

Address: Östra Ågatan 53, SE-753 22, Uppsala, Sweden

+46 (0) 18 71 11 70

Email: secretariat@ccb.se

URL: www.ccb.se

Cofunded by:

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Executive summary

The release of pharmaceutical residues to the environment is a growing problem of

global concern. Many studies have reported the negative effects of pharmaceutical

residues on fish and other aquatic organisms. This master thesis has assessed five

constructed wetlands (CWs) on their removal efficiency of active pharmaceutical

substances. Influent and effluent wastewaters were analyzed for 24 common

pharmaceutical substances in constructed wetlands in Eskilstuna, Hässleholm,

Nynäshamn, Trosa and Oxelösund. The pharmaceuticals found in highest concentration

in the influent were some common anti-inflammatory substances: naproxen, ibuprofen

and diclofenac; a few antihypertensive substances: atenolol, hydrochlorothiazide,

furosemide and metoprolol and the sedative substance, oxazepam. The concentrations

varied between 0.7 μg/l and 10 μg/l. The removal efficiency was determined for 19 of

the 24 substances. For 47% of the substances there was an observed removal efficiency

of greater than 80% and for 47% of the substances a removal efficiency of 20–80% was

observed. Diclofenac, furosemide, hydrochlorothiazide and naproxen showed the

greatest removal efficiencies, 74–100%. In general, all five constructed wetlands

showed high removal efficiencies for most pharmaceutical compounds, with greater

removal efficiencies observed in Oxelösund, Nynäshamn and Trosa. The higher

removal efficiency in these wetlands is believed to be due to their characteristic

hydraulics, where wastewater basins are filled and emptied, whereas the basins in

Eskilstuna and Hässleholm have continuous flow of wastewater. A comparison of

removal efficiencies was also assessed for summer and winter conditions in Eskilstuna,

Nynäshamn, Trosa and Oxelösund wetlands. The observed removal efficiencies were

significantly greater during summer conditions.

Highlights

The removal efficiency of 24 pharmaceuticals are evaluated in constructed

wetlands.

9 out of 19 pharmaceuticals had a removal efficiency greater than 80%.

The removal efficiency of the ecotoxic substance diclofenac showed a removal

efficiency of 84-99%.

Constructed wetlands may be a cost- and resource efficient alternative for

removal of micro-pollutants.

Constructed wetlands may be an economically and environmentally suitable

compliment for small and medium-sized municipalities for treatment of

wastewater.

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Background

Over the past three decades, the issue of pharmaceutical residues in the environment has

received increased attention. Medicines and products remaining from their degradation

have been found in wastewater, surface water, groundwater and drinking water. In

Sweden, the use of medicines in daily doses per inhabitant has increased over the last

twelve years. In year 2006, 581 daily doses were used per inhabitant and in year 2018,

660 daily doses were used.

Medicines are special in many ways compared to other chemicals. They are designed to

be biologically active at very low concentrations and many of them are very persistent

(stable and difficult to break down). This design has its advantages and disadvantages.

The benefits are that the medicines are effective and provide the desired therapeutic

effect in the patient, and that the drugs have a long lifespan, usually a couple of years.

The disadvantages of the design are that they do not break down easily in nature and

that they can cause negative effects on fish and other aquatic animals and organisms.

Effects that occur in the aquatic environment are difficult to detect, as causal

relationships can be difficult to determine. There are an increasing number of studies

showing the adverse effects of medical residues in the environment, and more studies

are needed exploring how long-term exposure of low levels of medical residues can

affect the environment.

Removal efficiency of pharmaceuticals in constructed wetlands

Medical residues are reduced to some extent with traditional wastewater treatment

technology, but large quantities of medicines pass through today's wastewater treatment

plants without breaking down and end up either in sewage sludge or in receiving waters.

New technical solutions are needed to reduce medical residue emissions to the

environment. In big cities, energy and cost-intensive technical solutions are expected to

be required for wastewater treatment, but in smaller and medium-sized wastewater

treatment plants, simpler and cheaper solutions can be an alternative. One such

alternative is wastewater wetlands, so-called constructed wetlands.

Constructed wastewater wetlands have been used in Sweden for supplemental treatment

of wastewater for over two decades. Interest in constructed wetlands arose in Sweden in

the early 1990s when Oxelösund wetland was used for increased nitrogen removal. In

the late 1990s, a number of large constructed wetland facilities were built around the

country, including; Magle wetland in Hässleholm, Alhagen wetland in Nynäshamn and

Ekeby wetland in Eskilstuna. In constructed wetlands many processes occur which help

to purify the water. Biodegradation (naturally-occurring breakdown of compounds by

microorganisms such as bacteria and fungi or other biological activity) can be

considered as one of the most important processes and it benefits from warm conditions,

about 15-25° C. Plants also contribute to purification by acting as a contact surface

between microorganisms and pollutants. Sorption (a physical and chemical process by

which one substance becomes attached to another) is another mechanism that can purify

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water by binding (flocculating) substances and thus separating them from the water.

Degradation can also be carried out with the help of the sun’s natural ultraviolet light.

Five Swedish municipalities that have constructed wetlands are Eskilstuna, Hässleholm,

Nynäshamn, Trosa and Oxelösund. This study has investigated these five constructed

wetlands for treatment of medical residues in the wastewater.

Chemical analyses were performed on incoming and outgoing wastewater for 24

different medicines in each wetland. In the incoming and outgoing wastewater to the

constructed wetlands, 19 of the 24 medicines analysed were found. The medicines that

occurred in the highest concentrations in the incoming wastewater to the wetlands were

some common anti-inflammatory medicines; naproxen, ibuprofen and diclofenac, some

blood pressure lowering agents; atenolol, hydrochlorothiazide, furosemide and

metoprolol and the sedative oxazepam. These medicines were present in concentrations

between 0.7 µg/L and 10 µg/L.

By comparing volumes of medical residues entering and exiting the wetland, a removal

efficiency could be determined for each medicine. Overall, all wetlands showed a high

removal efficiency of medical residues. The wetlands in Nynäshamn, Trosa and

Oxelösund showed slightly higher removal levels than the wetlands in Eskilstuna and

Hässleholm.

A comparison was also made of how well-constructed wetlands remove medical

residues in winter and summer conditions. The results showed that wetlands remove

medical residues significantly better under the now studied summer conditions.

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LIST OF CONTENT

1 INTRODUCTION .................................................................................................... 1

1.1 PHARMACEUTICALS ................................................................................... 2

1.2 THE ROUTE OF PHARMACEUTICALS TO THE AQUATIC

ENVIRONMENT ......................................................................................................... 2

1.3 ENVIRONMENTAL IMPACTS OF PHARMACEUTICALS ....................... 3

1.4 TREATMENT TECHNOLOGIES FOR PHARMACEUTICAL RESIDUES

AND OTHER UNWANTED COMPOUNDS IN WASTEWATER ........................... 4

1.4.1 Activated carbon ....................................................................................... 5

1.4.2 Membrane filtration .................................................................................. 5

1.4.3 Ozonation ................................................................................................. 6

1.5 CONSTRUCTED WETLANDS ...................................................................... 6

1.5.1 Properties of constructed wetlands and their treatment processes ........... 7

2 A STUDY OF THE EFFECTS OF WETLAND FILTRATION ............................. 7

2.1 GEOGRAPHICAL LOCATION OF THE WETLANDS ................................ 8

2.2 DESCRIPTION OF THE PLANTS ................................................................. 8

2.2.1 Eskilstuna ................................................................................................. 8

2.2.2 Hässleholm ............................................................................................... 8

2.2.3 Nynäshamn ............................................................................................... 8

2.2.4 Trosa ......................................................................................................... 9

2.2.5 Oxelösund ................................................................................................. 9

3 MEASURED RESULTS .......................................................................................... 9

3.1 ACTIVE PHARMACEUTICAL INGREDIENTS .......................................... 9

3.1.1 Presence of active pharmaceutical ingredients ......................................... 9

3.1.2 Removal active pharmaceutical ingredients ........................................... 11

3.1.3 Removal efficiencies in summer and winter conditions ......................... 13

4 DISCUSSION ......................................................................................................... 14

4.1 DETECTION OF ACTIVE PHARMACEUTICAL INGREDIENTS ........... 14

4.2 REMOVAL OF ACTIVE PHARMACEUTICAL INGREDIENTS ............. 14

4.3 REMOVAL OF APIs IN SUMMER AND WINTER CONDITIONS .......... 15

4.4 UNCERTAINTIES ......................................................................................... 15

5 CONCLUSIONS .................................................................................................... 16

6 RECOMMENDATIONS ....................................................................................... 17

7 REFERENCES ....................................................................................................... 22

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1 INTRODUCTION

Statistical data from the Swedish eHealth Agency (eHälsomyndigheten) shows that the

historical sales volume of pharmaceuticals in Sweden steadily has increased between

the years 2002 and 2014 (Swedish eHealth Agency, 2014). The global use of

pharmaceuticals is predicted to reach 4.5 trillion doses in 2020, a 24% increase

compared to consumption levels in 2015 (Aitken & Kleinrock, 2015). The global use of

pharmaceuticals continues to increase, driven by an increased demand for medicines

that treat age related and chronical diseases and changes in clinical practice (OECD,

2015).

The increased use of medicines worldwide will lead to increased discharges of

pharmaceutical residues to the environment, unless wastewater treatment methods are

improved. Studies of the increased discharge of pharmaceutical residues to the aquatic

environment has created increased awareness of potential negative effects (Ternes et al.,

2007). Many studies have shown that pharmaceutical residues in the aquatic

environment can result in antibiotic resistant bacteria, abnormal fish behaviour and

skewed sex balance in aquatic organisms (Graae et al., 2017). To the present day, there

is still a lack of knowledge about how pharmaceutical residues found in the aquatic

environment affect human health and the risks that are associated with long term

exposure of low concentrations of pharmaceuticals (WHO, 2012). Since the long-term

effects of pharmaceuticals in the environment are difficult to predict, it is important not

to take any unnecessary risks for the environment and for human health. There is a clear

rationale for implementing advanced wastewater treatment for pharmaceuticals and

other micro-pollutants (Swedish Environmental Protection Agency, Swedish EPA,

“Naturvårdsverket”, 2017, European Commission, 2019).

Quantitively, the largest source of pharmaceutical residues in the environment in

Sweden stem from pharmaceuticals excreted via urine and excrement that end up in

wastewater treatment plants (WWTPs) (Swedish EPA, 2017). Conventional WWTPs

are not constructed to remove pharmaceutical residues and other micro-pollutants,

however existing WWTPs have shown some capacity to remove certain pharmaceutical

substances. The main removal process of pharmaceutical residues is through biological

degradation and through adsorption to sludge particles (Swedish EPA, 2017). The

consequences of ineffective removal of pharmaceuticals in WWTPs is that large

amounts of pharmaceutical residues enter natural water bodies. Even though the

concentrations that are found in the aquatic environment seem low, varying between

parts per billion and parts per trillion, these compounds can have a significant negative

effect on the aquatic ecosystem (Zhang et al., 2016).

For a sustainable and resource-effective reduction of pharmaceutical residues entering

the environment, both upstream and downstream measures are needed. Improved

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wastewater treatment technologies are part of the solution, but other measures are also

necessary, e.g. encouraging the public to reduce unnecessary consumption of medicines,

other treatments etc. The implementation of advanced water treatment technologies is

associated with increased environmental costs such as increased energy and chemical

consumption (Swedish EPA, 2017). Therefore, it is of interest to investigate other

alternatives to advanced water treatment technologies. A promising alternative and

complement to conventional WWTPs are constructed wetlands. Many studies have

shown that constructed wetlands have a high potential for the removal of organic

micropollutants and active pharmaceutical ingredients (APIs) at relatively low

maintenance costs (Hijosa-Valsero et al., 2010, Zhang et al., 2016).

1.1 PHARMACEUTICALS

Most of today's pharmaceuticals are synthetically produced to achieve high biological

activity and to be sufficiently chemically stable (persistent). This design aims to

increase the conditions for achieving the desired therapeutic effect when used

(Wahlberg et al., 2008). Pharmaceuticals are also designed to be effective at low doses

in the body and stable against e.g. gastric acid and microbial degradation. One of the

negative consequences of this persistence is that pharmaceuticals are not effectively

degraded in wastewater treatment plants (Baresel et al., 2015).

The use of pharmaceuticals is increasing due to an increasing population, the

developing countries' increased incomes, an increased life expectancy and the

introduction of new pharmaceuticals into the market (Apoteket AB, 2005). In Sweden

the consumption of pharmaceuticals has increased, from 1360 defined daily doses

(DDD) per 1000 inhabitants and day in 2006, to 1500 DDD/1000 inhabitants and day in

2014 (Baresel et al., 2015).

1.2 THE ROUTE OF PHARMACEUTICALS TO THE AQUATIC

ENVIRONMENT

In order to understand the contribution of pharmaceuticals to environmental impacts, it

is important to understand their path through society. Figure 1 shows an overview of the

flows and distribution of pharmaceuticals. The largest source of pharmaceuticals and

their residues in the environment comes from human consumption (Swedish

Environmental Protection Agency, 2017). Pharmaceuticals and their metabolites are

excreted from the human body via urine and/or faeces and end up in our wastewater

treatment plants. The pharmaceutical residues leave the system in three different ways:

1) they either chemically break down, 2) follow the outgoing treated wastewater, or 3)

get accumulated in the sewage sludge.

The decisive factors that cause the presence of pharmaceutical residues in surface water

are their respective distribution volumes, dilution of the outgoing wastewater into the

recipient waterways and the decomposing properties of each pharmaceutical. The

chemical properties of the pharmaceutical largely affect whether it will reach the

aquatic environment. There are legal requirements for pharmaceuticals to be stable for

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2–5 years in the package, which means that pharmaceuticals often have chemical

properties that make them difficult to decompose. Some pharmaceutical residues such

as penicillin and the analgesic acetaminophen are degraded almost completely in

wastewater treatment plants, while other pharmaceutical residues such as

carbamazepine pass through wastewater treatment plants unaffected (Wennmalm,

2011).

Figure 1: Overview of flows and distribution of pharmaceutical compounds for human

use to the environment (Based on Graee et al., 2017). The main flows are marked by

thicker arrows.

1.3 ENVIRONMENTAL IMPACTS OF PHARMACEUTICALS

Pharmaceuticals represent one of the few chemical groups specifically designed to

affect living cells. Thus, the active ingredients in pharmaceuticals can affect other living

organisms whose receptors, hormones and enzymes are similar to those of humans

(Gunnarsson et al., 2008). Most pharmaceuticals are chemically stable and slightly fat-

soluble. Pharmaceutical residues are decomposed in varying efficiencies in wastewater

treatment plants, and some of them are not decomposed at all and leave the wastewater

treatment plants in active form (Wennmalm, 2011). When these active pharmaceuticals

reach waterways, they can affect aquatic organisms. Environmental impacts seen in

fish, among other things, are skewed gender distribution, impaired reproductive

potential and accumulation of active pharmaceutical compounds in cellular tissue

(Wennmalm, 2011).

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Many of the tests conducted to study the ecotoxicology of pharmaceuticals are the same

ones used to study the acute toxicity of common industrial chemicals (Wahlberg et al.,

2010). The difference is that pharmaceuticals are rarely acutely toxic and therefore it is

difficult to predict effects on the environment. One of the first noticeable cases of

adverse pharmaceutical residues on the environment is from the 1990s in England,

where anglers almost only caught female fish. At first, it was believed that the reason

was due to the release of industrial chemicals with estrogenic effects, but scientific

studies conducted on male fish downstream the English wastewater treatment plants

showed that the male fish produced a protein found only in fertile females. The effect

could be linked to the wastewater content of the oestrogen ethinylestradiol, a substance

in birth control pills (Wahlberg, 2010).

The pharmaceutical compound ethinylestradiol is a synthetic oestrogen and is a very

potent hormone disruptor. Ethinyloestradiol is ten times as effective in fish as the

natural hormone oestradiol. Even low levels of ethinylestradiol detected in wastewater

treatment plants can lead to decreased production of sperm and eggs and altered mating

behaviour in fish (Porseryd, 2018).

1.4 TREATMENT TECHNOLOGIES FOR PHARMACEUTICAL RESIDUES

AND OTHER UNWANTED COMPOUNDS IN WASTEWATER

Wastewater treatment plants are not designed to decompose pharmaceutical residues or

other hazardous substances, and today's wastewater treatment plants do not remove all

of these substances (Swedish EPA, 2008). However, wastewater treatment plants have

been shown to have the ability to reduce certain pharmaceutical residues, but that the

removal efficiency greatly varies between different substances (Swedish EPA, 2008).

For example, Wahlberg et al. (2010) showed that the removal of diclofenac in WWTPs

varied between 17 and 25%. However, there are a number of treatment technologies for

the removal of pharmaceutical residues and other undesirable substances from

wastewater. The different technologies can be divided into different treatment methods:

physical, oxidative, biological and adsorptive. An overview of these is shown in Figure

2. The technologies that gave the best results for the removal of pharmaceutical residues

according to Wahlberg et al. (2010) is activated carbon treatment, membrane filtration

with reverse osmosis and ozonation technology.

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Figure 2: Schematic overview of various treatment technologies and their

implementation in wastewater treatment plants. (Based on Baresel et al., 2017)

1.4.1 Activated carbon

Activated carbon (AC) has a high capacity to adsorb organic material. One gram of AC

has an uptake area between 800 and 1200 m2 depending on the quality of the carbon.

AC wastewater treatment works best for bigger molecules and low-polarity molecules.

There are many types of ACs. Granular activated carbon (GAC) and powdered activated

carbon (PAC) have showed promising removal efficiencies for pharmaceutical residues

(Wahlberg et al., 2010). Removal efficiency with 140g/m3 of AC showed a mean

removal efficiency of 90 % for all APIs, and for 25g/m3 of AC a mean removal

efficiency of 60% was observed (Wahlberg et al., 2010).

1.4.2 Membrane filtration

Membrane filtration is a physical method for separation of particles or solutes through a

semi-permeable membrane. There are different filtration technologies, namely

microfiltration (MF), ultrafiltration (UF), nanofiltration (NF) and reverse osmosis (RO)

where the treatment name depends on the pore size of the membrane. The pore size of

the membranes decreases in the listed order. The denser the membrane the higher

pressure must be used to filter substances through the membranes, which increases the

energy consumption (Wahlberg et al, 2010). MF and UF can separate particulate

contaminants and disinfect water but has not shown efficient removal of pharmaceutical

residues or other priority substances. In contrast, Wahlberg et al. (2010) showed high

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removal efficiency of pharmaceutical residues with RO filtration in a pilot project in

Hammarby sjöstad where an observed removal efficiency of 95% was achieved.

1.4.3 Ozonation

Ozonation is an advanced oxidation process where substances are oxidized with ozone

(O3). Substances can either be oxidized by direct contact with the ozone molecule or by

indirect oxidation after the formation of hydroxyl radicals that break down specific

chemical bonds (Swedish EPA, 2017). The most common application of ozonation is

for degradation of organic micro-pollutants as the final polishing treatment after the

main water treatment process or it can be integrated into the main process. An

advantage of ozone wastewater treatment technology is that it is flexible and that doses

of ozone are easy to control. One disadvantage of this technology is the oxidation by-

products formed during the process have ecotoxicological effects, such as increased

mortality and genotoxicity in fish, worms and mussels (Margot et al, 2013). By

implementing a biological step after the ozonation treatment, such as a sand filter, one

can greatly limit the ecotoxicological effects of the by-products (Breitholtz & Larsson,

2009). A pilot project carried out at the Nykvarnsverket in Linköping showed that

ozone treatment before post-nitrification is a feasible alternative for treatment of

pharmaceutical residues. Conclusions from the study were that 42 of the studied APIs

can be removed to such an extent that they have no harmful effects in the recipient

Stångån river, when an ozone dose of 0.5-0.8 mg O3/mg DOC is applied (Sehlén et al.,

2015). In a study conducted by Wahlberg et al. (2010) the mean observed removal

efficiency with ozonation treatment for APIs was 92 %.

1.5 CONSTRUCTED WETLANDS

The term "wetland" encompasses a wide range of different aquatic environments. The

definition of wetland according to the United States Environmental Protection Agency:

“Wetlands are areas where water covers the soil, or is present either at or near the

surface of the soil all year or for varying periods of time during the year, including

during the growing season.”(EPA, 2019). In this report, wetlands, so-called constructed

wetlands, are considered a supplemental treatment for wastewater treatment plants. It is

a natural technology that uses biodegradation, sorption, plants and sunlight to clean

wastewater, among other things. Constructed wetlands are often built for the purpose of

removing nitrogen, phosphorus and particulate matter from the wastewater, and many

studies have shown that wetlands also have the potential to remove common

pharmaceutical residues (Zhang et al., 2016).

The type of wetland in focus for this report is of the type “Free Water Surface

constructed wetlands” (FWS). A typical constructed wetland with surface water flow

has open water surfaces and is similar to natural wetlands. These wetlands contain both

floating vegetation, underwater vegetation and bottom vegetation (Vymazal, 2013). The

water depth in a typical wetland with surface water flow can vary between 0.2–2,5 m

(Vymazal, 2013, Hässleholms Vatten AB, 2007). As the wastewater flows through the

wetland, it is treated by processes such as sedimentation, filtration, oxidation,

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separation, adsorption and precipitation (Kadlec & Wallace, 2009). Because these types

of wetlands are very similar to natural wetlands, they attract insects, reptiles, molluscs,

fish, birds and other wildlife.

1.5.1 Properties of constructed wetlands and their treatment processes

Wetlands are complex biological systems. Predicting the degree of removal of a

particular pharmaceutical compound in a particular wetland is difficult because the

removal depends on many different factors: the wetland's particular design, operational

and environmental conditions, properties of incoming wastewater, vegetation, and

chemical properties of the compounds. In wetlands, aerobic, anaerobic and anoxic

microenvironments coexist, and it is these environmental conditions that help reduce a

wide range of different pharmaceutical compounds. The main factor contributing to the

removal of pharmaceutical residues in constructed wetlands are biodegradation,

sorption, plant uptake and photodegradation. (Verlicchi & Zambello, 2014). The ability

of wetlands to improve the quality of outgoing wastewater depends largely on the

bacterial colonies present in the wetlands (Berglund et al, 2013).

2 A STUDY OF THE EFFECTS OF WETLAND FILTRATION

The constructed wetlands investigated in the study were Ekeby wetland, Alhagen

wetland, Trosa wetland, Brannäs wetland and Magle wetland. From each wetland, 24 h

flow proportional composite samples were collected from incoming and outgoing

wastewater, except for the outgoing wastewater in Trosa wetland. Subsequently,

chemical analysis of 24 APIs were performed. The samples taken are considered to be

representative for the concerned period. The geographical location of the plants is

shown in Figure 3. For more information about sampling methods, see the Annex.

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2.1 GEOGRAPHICAL LOCATION OF THE WETLANDS

Figure 3. Map of

the geographical

location of the

plants. (E) Ekeby

wetland in

Eskilstuna. (N)

Alhagens wetland

in Nynäshamn.

(T) Trosa wetland.

(O) Brannäs

wetland in

Oxelösund. (H)

Magle wetland in

Hässleholm. The

background map

is taken from the

The Swedish

National Land

Survey (2016).

2.2 DESCRIPTION OF THE PLANTS

For more information about the WWTPs and the wetlands, see Annex.

2.2.1 Eskilstuna

Ekeby wetland was built and commissioned in 1999. Ekeby WWTP collects sewage

from approximately 90,000 person equivalents (p.e.) with an average flow rate of

43,200 m3/day (Eskilstuna Energi & Miljö, 2016). The WWTP treatment steps include

mechanical, biological, chemical and final polishing in Ekeby wetland. The retention

time is about 6–7 days. The wetland covers an area of 28 ha with a mean depth of 1m

(Andersson & Kallner, 2002).

2.2.2 Hässleholm

The wetland in Hässleholm was built and commissioned in 1995. The WWTP in

Hässleholm collects sewage from about 24,000 p.e. and has four treatment steps

including mechanical, biological, chemical and final polishing in the Magle wetland.

The wetland has a retention time of about 7 days. The average flow rate in the wetland

is about 8,000 m3/day (Hässleholms Vatten AB, 2018).

2.2.3 Nynäshamn

The wetland in Nynäshamn was built and commissioned in 1997. The WWTP receives

sewage from approximately 17,000 p.e. (Franquiz, pers. kommun, 2019) and has

mechanical, biological, chemical treatment as well as a final polishing step in the

wetland. The wetland covers an area of about 28 ha (Andersson & Kallner, 2002). The

average flow rate in the wetland is about 4,000 m3/day. The wetland has an estimated

retention time of about 11-14 days (Näslund, 2010).

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2.2.4 Trosa

Trosa wetland was built and commissioned in 2003 to serve as a post-polishing step for

the mechanical, chemical and biological treatment at Trosa WWTP. Trosa WWTP

collects sewage from about 5,200 p.e. The wetland has a retention time of about 8 days

and covers an area of 6 ha (Näslund, 2010). The wetland consists of an overflow area

and several ponds.

2.2.5 Oxelösund

The wetland in Oxelösund was built in 1993 and was the first full-scale constructed

wetland in Sweden designed to remove excess nitrogen and phosphorus. The WWTP

has four wastewater treatment steps including mechanical, biological, chemical and a

final polishing step in the wetland. Oxelösund WWTP collects sewage from about

11,500 p.e. The wetland has an average daily flow of 3,700 m3/day, a retention time of

about 7 days (Byström et al, 2017). The wetland has an area of 23 ha (Andersson &

Kallner, 2002).

3 MEASURED RESULTS

For additional results and details, see the Annex.

3.1 ACTIVE PHARMACEUTICAL INGREDIENTS

3.1.1 Presence of active pharmaceutical ingredients

Table 1 presents the results for the measured concentrations of APIs in incoming and

outgoing wastewater in the five wetlands. In the incoming wastewater to the wetlands,

19 of the 24 pharmaceuticals analysed were found, but at very different levels. In

outgoing wastewater, 15 of the 24 pharmaceuticals analysed were found, most at

significantly lower concentrations. The pharmaceutical residues that were measured at

the highest levels in incoming wastewater varied between the wetlands. The APIs found

in the highest levels of incoming wastewater were some common painkillers/anti-

inflammatory agents (naproxen, ibuprofen and diclofenac), and some blood pressure

lowering agents (atenolol, hydrochlorothiazide, furosemide and metoprolol). These

APIs were present in concentrations between 700 ng/L and 10,000 ng/L. In the outgoing

wastewater from the wetlands, oxazepam, metoprolol, ibuprofen and carbamazepine

were measured at maximum levels from 500 ng/L to 4,300 ng/L.

10

Table 1. Measured concentrations of APIs in incoming and outgoing wastewater in the

CWs. E- Eskilstuna, H- Hässleholm, N- Nynäshamn, T- Trosa och O- Oxelösund. I=

Incoming, O= Outgoing. All concentrations in ng/L.

Active

Ingredients

EI EO

HI

HO

NI

NO

TI

TO

OI

OO

Amplodine * * 42 * * * * * 140 *

Atenolol * * 920 200 * * * * 1200 *

Bisoprolol * ** 130 89 ** * 3,8 * 530 92

Caffeine * * 16000 5400 * * * * * *

Citalopram * * 600 210 * * * * 620 **

Diclofenac 1000 150 700 98 1700 120 2500 200 1500 120

Fluoxetin * * 75 21 * * * * 70 *

Furosemid 1300 * 640 * 2600 * 1900 * 2500 *

Hydrochlorothi

azide

1200 140 1400 140 2400 160 3000 310 2600 380

Ibuprofen ** ** 6100 560 1300 ** 2800 220 430 **

Carbamazepine * * 590 500 * * * * 650 500

Ketoprofen * * 290 * * * * * 320 *

Metoprolol 12 ** 2100 1400 34 ** 31 ** 2200 510

Naproxen 590 140 2400 410 1100 * 10000 220 1700 *

Oxazepam * * 4900 4300 * * * * 3500 1900

Paracetamol * * * * * * * * * *

Propranolol ** * 130 28 ** * ** * 180 24

Ramipril * * * * * * * * * *

Ranitidine * * 21 * ** * 3 * 26 *

Risperidone * * * * * * * * * *

Sertraline * * 160 9 * * * * 81 *

Simvastatin * * * * * * * * * *

Terbutaline * * * * * * * * * *

Warfarin 3 4 9 11 6 7 12 9 9 6

*The ingredient was not detected; the concentration was under the detection limit.

**The ingredient has been detected but not quantified, the concentration is between the detection and the quantification limits.

In Figure 4 the concentrations of diclofenac, furosemide, hydrochlorothiazide and

naproxen are shown for the incoming and outgoing wastewater to and from the five

wetlands. With the exception of naproxen in Hässleholm, the levels were lower in

incoming wastewater to the wetlands of Eskilstuna and Hässleholm. The differences in

outgoing concentrations were small.

11

Figure 4. Four APIs in incoming (IN) and outgoing (OUT) wastewater of the five CWs

(E = Eskilstuna, H = Hässleholm, N = Nynäshamn, T = Trosa and O = Oxelösund).

3.1.2 Removal of active pharmaceutical ingredients

The removal efficiency was calculated for 19 APIs and is reported in Table 2. In this

study, removal efficiency is defined as the difference between the amount of incoming

and outgoing pharmaceuticals, not the difference between incoming and outgoing

concentrations.

When the concentrations were measurable, the removal efficiency was calculated for all

active ingredients in the wetlands. In cases where the levels of active ingredients in the

outgoing wastewater were too low to be detected or quantified, the level of detection or

quantification limit for the respective active ingredient is used to determine a minimum

removal efficiency.

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

EIN EOUT HIN HOUT NIN NOUT TIN TOUT OIN OOUT

Diclofenac Furosemide Hydrochlorothiazide Naproxen

[ng/l]

12

Table 2. Removal efficiencies for Eskilstuna, Hässleholm, Nynäshamn, Trosa,

Oxelösund wetland. E- Eskilstuna, H- Hässleholm, N- Nynäshamn, T- Trosa and O-

Oxelösund.

APIs E

[%]

H

[%]

N

[%]

T

[%]

O

[%]

Amplodine * **84 * * **99

Atenolol * 82 * * 100

Bisoprolol * 44 * **75 98

Citalopram * 71 * * **99

Caffeine * 72 * * *

Carbamazepine * 31 * * 89

Diclofenac 84 89 95 92 99

Fluoxetine * 77 * * 100

Furosemide **97 **95 **99 **98 100

Hydrochlorothiazide 87 92 96 90 98

Ibuprofen * 92 **98 92 **99

Ketoprofen * **94 * * **99

Metoprolol **10 45 80 **69 97

Naproxen 74 86 **99 98 100

Oxazepam * 28 * * 92

Paracetamol * * * * *

Propranolol * 82 * * 98

Ramipril * * * * *

Ranitidine * **96 * **68 **99

Risperidone * * * * *

Sertraline * 96 * * 100

Simvastatin * * * * *

Terbutaline * * * * *

Warfarin -27 1 14 28 90

*The removal efficiency has not been possible to determine as the influent or effluent concentrations were

below the quantification or detection limit

**The removal efficiency is greater than

13

Figure 5 shows the removal efficiencies [%] of six APIs in the five CWs. Figure 5

shows that the removal efficiency in Eskilstuna and Hässleholm wetlands are somewhat

lower for each API (except for the compound hydrochlorothiazide) compared to the

wetlands in Nynäshamn, Trosa and Oxelösund.

Figure 5. Removal efficiency (%) of six API in the five studied CWs.

3.1.3 Removal efficiencies in summer and winter conditions

Table 3 presents the removal efficiency for twelve APIs in the five wetlands under

summer conditions (this study) next to the previous results in winter conditions in

another study (Näslund, 2010). Overall, the removal efficiencies for all APIs are

significantly higher in summer conditions than in winter conditions. In summer

conditions, diclofenac has a removal efficiency of 84-99%, whereas in winter, a

removal efficiency of 24-36% is observed. For metoprolol, a removal efficiency of 10-

97% summertime are observed compared to -3 to 30% wintertime, and for naproxen,

removal efficiencies of 74-100% summertime and 34-75% wintertime are observed.

-40%

-20%

0%

20%

40%

60%

80%

100%

Eskilstuna Hässleholm Nynäshamn Trosa Oxelösund

14

Table 3. Compilation of removal efficiencies for Eskilstuna, Nynäshamn, Trosa and

Oxelösund wetlands summer conditions (this study) in 2019 and in winter conditions

(Näslund, 2010). (EW = Eskilstuna winter, ES = Eskilstuna summer, NW = Nynäshamn

winter, NS = Nynäshamn summer, TW = Trosa winter, TS = Trosa summer, OW =

Oxelösund winter, OS = Oxelösund summer).

ES Ew NS Nw TS Tw OS Ow

Atenolol * 27 * 53 * 53 100 53

Bisoprolol * 26 * 22 75 36 98 29

Citalopram * 45 * 84 * 97 99 63

Diclofenac 84 31 95 24 92 30 99 36

Ibuprofen * 38 98 80 92 5 99 88

Carbamazepine * 12 * 11 * -19 89 21

Ketoprofen * 56 * 3 * 19 99 32

Metoprolol 10 -3 80 30 69 27 97 18

Naproxen 74 34 99 46 90 50 100 75

Oxazepam * * * 21 * -26 92 48

Ranitidine * -39 * 92 68 56 99 88

Sertraline * 0 * * * * 100 94

*Removal efficiency not available.

4 DISCUSSION

4.1 DETECTION OF ACTIVE PHARMACEUTICAL INGREDIENTS

The APIs found in this study at the highest concentrations in incoming wastewater to

the wetlands have also been found at the highest levels in a previously conducted study

on constructed wetlands. The APIs atenolol, ibuprofen and metoprolol were also

detected in high concentrations in incoming wastewater in a study on the removal

efficiency of CWs in winter conditions (Näslund, 2010).

Many of the concentrations of APIs in the incoming water to the wetlands now studied

are so high for certain substances that they can affect and damage aquatic organisms. In

Trosa wetland, the content of diclofenac in the incoming water was 2.5 μg/l, which has

shown negative effects on fish (Memmert et al., 2013). Naproxen was found at levels up

to 10 μg/l in the wetlands studied, but these levels are not considered high enough to

affect fish and aquatic organisms (Kwak et al., 2018).

4.2 REMOVAL OF ACTIVE PHARMACEUTICAL INGREDIENTS

Overall, the CWs showed a very good ability to remove API residues. Of the 19 APIs

detected in the incoming wastewater, 9 were reduced by more than 80%. Best removal

efficiency showed furosemide, ibuprofen, ketoprofen and sertraline with a removal

efficiency of at least 92%. Bisoprolol, carbamazepine, metoprolol, oxazepam and

warfarin showed very varying removal efficiencies, between -27% and 98%. Warfarin

was the only API that had a negative removal efficiency. Probably, the negative

removal efficiency of Warfarin can be explained by the fact that the levels of incoming

and outgoing wastewater were very low, close to the detection and quantification limit

which may have given uncertain results.

15

There is some uncertainty in the determination of the respective concentrations for each

API. This can have a major impact on the calculated removal efficiency. Wahlberg et al.

(2010) showed that the uncertainty in the removal efficiency was highest when the

levels of API residues in the wastewater were low. The removal efficiency of Warfarin

is one such example. Of all the CWs studied, Oxelösund showed the highest removal

efficiency in general. All APIs analysed had a removal efficiency of 89-100% in

Oxelösund wetland. The high removal rate could be explained by the fact that the flow

out of the wetland was very low during the sampling period, which meant that the

retention time in the wetland increased significantly. Since different APIs were detected

in different wetlands, it has not been possible to calculate the removal efficiency for all

the APIs in all the wetlands. This has made it more difficult to compare the different

wetlands with each other in terms of removal efficiency for a certain API. Only for 6

APIs, the removal efficiency could be calculated in all five wetlands.

4.3 REMOVAL OF APIs IN SUMMER AND WINTER CONDITIONS

The removal efficiency in summer conditions was significantly higher for most APIs in

comparison to winter conditions. The low removal efficiencies in winter conditions can

probably be explained by low water temperatures, low biological activity, low incoming

sunshine and poor oxygen conditions. According to Hijosa-Valsero et al. (2010),

microorganisms in wetlands reach their optimal activity under warm water conditions,

about 15-25° C, which may explain why a higher removal efficiency was observed in

the CWs during this study compared to the study by Näslund (2010) conducted during

winter conditions. Even longer retention time could benefit the removal process in

summer conditions. It is therefore difficult to draw any conclusions about the

importance of different treatment mechanisms based on differences in results between

summer and winter.

4.4 UNCERTAINTIES

There are many factors that may have affected the results. Sampling, preservation of

samples and transport of the samples to the laboratory are some. In order to ensure that

the calculated removal efficiencies are correct and reasonable, the risk for dilution and

concentration of the wastewater in the CWs must be taken into account. The incoming

flow to the wetland was in most cases higher than the outgoing flow during the

sampling period. In cases where the flow data were not correct, e.g. in the case of

miscalibration of flow meters, there can be large differences in calculated removal

efficiencies for the APIs. For all wetlands, there was flow data available for incoming

and outgoing wastewater flows except Trosa wetland, where there was only flow data

for incoming wastewater. The outgoing flow in Trosa wetland was calculated using

precipitation and evaporation data and it is not considered to have affected the results

when calculating the removal efficiencies. A weakness of the current study is also that

samples were taken only at one time from both incoming and outgoing wastewater in

the respective wetlands. A more reliable approach would have been to test at several

different sampling times. In the current study, there were insufficient financial resources

to implement this. However, the 24h flow proportional composite sampling in the

current study is considered to be a robust method that gives representative results, but

the removal efficiencies should be interpreted with caution.

Issues for further study could be: if APIs decompose or accumulate in the wetlands and

how ecosystems in the wetland are affected by the accumulated residues. This issue of

16

accumulation of APIs in the biota needs attention, although there are no visible signs

that the issue is considerable and constitutes an environmental hazard, which sometimes

is the case with sewage sludge, that occasionally may contain high concentrations of

pollutants.

5 CONCLUSIONS

The current study shows that constructed wetlands have good potential to reduce a wide

range of commonly occurring pharmaceutical residues in wastewater. The high removal

efficiency observed in the wetlands can be attributed to the favourable conditions

prevailing during the summer, with high biological activity, long retention times,

sorption, plant uptake and photodegradation. Overall, a significantly higher removal

efficiency of pharmaceutical residues was observed in summer conditions than in winter

conditions for the same constructed wetlands. This study investigated the ability of five

Swedish constructed wetlands to remove pharmaceutical residues under summer

conditions. Levels of 24 different APIs were determined in incoming and outgoing

water to and from the constructed wetlands in Eskilstuna, Hässleholm, Nynäshamn,

Trosa and Oxelösund. Based on measured concentrations and with the help of flow data,

removal efficiencies have been calculated for 19 APIs. A comparison of removal

efficiencies in this study was made with a previous study done under winter conditions.

This study showed that of the 24 different APIs investigated, 19 of 24 APIs were

found in the constructed wetlands. The APIs found in the highest levels of

incoming water to the wetlands were some common anti-inflammatory

substances: naproxen, ibuprofen and diclofenac. Some antihypertensives:

atenolol, hydrochlorothiazide, furosemide and metoprolol and the sedative

oxazepam. The levels of these substances varied between 0.7 μg/l and 10 μg/l.

The current study shows that constructed wetlands have a good potential to

reduce a wide range of commonly occurring APIs in wastewater. The high

removal efficiency observed in the wetlands can be attributed to the favourable

conditions prevailing during the summer with high biological activity, long

retention times, sorption, plant uptake and photodegradation. Overall, a

significantly higher removal efficiency of API residues was observed in summer

conditions than in winter conditions. 47% of the APIs found were removed

between 20 and 80% and 47% of APIs were reduced 80% or more. All studied

wetlands showed a high removal degree of diclofenac, furosemide, hydrochloro-

thiazide and naproxen. The removal efficiency for these substances was 74–

100%.

Overall, the constructed wetlands showed a significantly higher removal

efficiency in summer conditions than in winter conditions. The differences in

removal efficiencies for each studied API under summer and winter conditions

were greatest for the APIs diclofenac, metoprolol and naproxen. For diclofenac,

a removal efficiency of 84–99% was observed in summer conditions and a

removal efficiency of 24–36% in winter conditions. For metoprolol, a removal

efficiency of 10–97% was observed in summer conditions and –3 to 30% in

winter conditions, and for naproxen a removal efficiency of 74–100% was

observed in summer conditions and 34–75% in winter conditions, respectively.

17

6 RECOMMENDATIONS

Constructed wetlands are an economically and environmentally suitable

compliment for small and medium-sized municipalities for treatment of

wastewater. Constructed wetlands have shown to reduce the flux of

pharmaceuticals and other micro-pollutants substantially to the water recipient.

When constructing wetlands, it is important to pay attention to the design, type

and retention time. The study shows that removal efficiency increases with

retention time, and that removal efficiency also increases when water flow is

filled and emptied alternately rather than flowing continuously. This is a

characteristic which can be designed into constructed wetlands.

In order to improve the performance of the wetlands, it is important to

emphasize optimal management, incorporating improved monitoring systems

covering micro plastics, pharmaceuticals and other emerging pollutants.

18

Glossary and Acronyms Angina Angina Pectoris, a coronary heart disease, owing to an

inadequate blood supply to the heart.

API An Active Pharmaceutical Ingredient is the ingredient in a

pharmaceutical that is biologically active and produces its

therapeutic effect.

Beta blockers Substance in heart medicines that cause the heart to beat more

slowly and with less force, which lowers the blood pressure.

Biological treatment Treatment of wastewater that aims to reduce organic pollutants

by the means of different bacteria and microorganisms that

transforms the organic matter into methane and carbons

dioxide.

BOD7 Biological oxygen demand, is the amount of dissolved oxygen

needed (i.e. demanded) by aerobic biological organisms to

break down organic material present in a given water sample in

7 days.

Chemical treatment Is the treatment of wastewater by adding chemicals such as

iron sulphate, and the precipitation of impurities in the

wastewater by chemical means.

CWs Constructed Wetlands, are engineered systems that use natural

functions such as vegetation, soil, and organisms to treat

wastewater.

Daily sample A sample taken as a number of samples during a period of 24

hours.

Denitrification Denitrification is the process by which nitrite and nitrate is

reduced to nitrogen gas by microbes when oxygen is not

present.

Dose Dose means a quantity of a medicine or pharmaceutical taken

or recommended to be taken at a particular time.

Flow proportional sampling The samples is taken in portions that are proportionate to the

flow over the sampling period. In such a way, the overall

sample is representing the total flow over the sampling period.

Human pharmaceuticals Human pharmaceuticals are pharmaceuticals prescribed to

humans as opposed to veterinary pharmaceuticals prescribed to

animals.

IVL The Swedish Environmental Research Institute

Mechanical Treatment Aims at separating solid matter in wastewater by mechanicals

means, such as grit removal, sand traps and primary

sedimentation without chemicals.

19

Nitrification Nitrification is the biological oxidation by bacteria of ammonia

or ammonium ions to nitrite followed by the oxidation of the

nitrite to nitrate.

NSAID Non-steroidal Anti-Inflammatory Pharmaceuticals,

pharmaceuticals that do not contain steroids nor

corticosteroids.

OECD The Organisation for Economic Co-operation and

Development

Ozone Ozone, O3, is a gas molecule consisting of three oxygen atoms.

The molecule is chemically very potent and is used to break up

chemical bonds in complex molecules, which makes it an

efficient compound to remove pharmaceuticals with.

Population Equivalent (PE) The number expressing the ratio of the sum of the pollution

load produced during 24 hours by industrial facilities and

services to the individual pollution load in household sewage

produced by one person in the same time. In Sweden 1 PE of

BOD7 is defined as 70 gram BOD7/day

Proteolytic bacteria Bacteria that are able to break down proteins into smaller

polypeptides or amino acids through proteolysis.

Recipient The body of water receiving wastewater, treated or untreated.

The recipient can be a water course, lake or sea.

Removal Efficiency The separation efficiency of a substance, comparing the

amounts in the influent and the effluent, measured as percent.

SBR The sequencing batch reactor (SBR) is a fill-and-draw

activated sludge system for wastewater treatment.

Storm water Storm water is the combination of water that originates from

precipitation events, including rain, snow and ice melt and

penetrating groundwater.

TN Total Nitrogen (TN) is the sum of all nitrogen compounds in

water.

TP The total phosphorus (TP) is a sum parameter that shows the

organic and inorganic phosphorus compounds in water.

Wastewater Wastewater is any water that has been affected by human use.

Wastewater is used water from any combination of domestic,

industrial, commercial or agricultural activities, surface runoff

or stormwater, and any sewer inflow or sewer infiltration.

Water Sampling The process of taking a portion of water for analysis or other

testing at a given moment in time.

WHO World Health Organisation.

WWTP Wastewater Treatment Plant

20

Active ingredients in pharmaceuticals (Sources: fass.se and medicines.org.uk)

Amlodipine Medication used to treat high blood pressure and coronary artery disease.

Atenolol Atenolol is a heart medicine that contains a beta blocker that cause the heart to

beat more slowly and with less force, which lowers the blood pressure.

Bisoprolol Bisoprolol is a heart medicine that contains a beta blocker that cause the heart to

beat more slowly and with less force, which lowers the blood pressure.

Carbamazepine Carbamazepine belongs to a group of medicines called antiepileptics. It can be

used to treat some forms of epilepsy and pain in the face caused by trigeminal

neuralgia (nerve pain).

Citalopram A medicine used for treatment of depressive illness in the initial phase and as

maintenance against potential relapse/recurrence. Active ingredient in for instance

Cipramil.

Diazepam Diazepam belongs to a group of medicines called benzodiazepines. Diazepam

helps in the treatment of anxiety, muscle spasms and convulsions (fits).

Diclofenac Diclofenac belongs to a group of medicines called nonsteroidal anti-inflammatory

pharmaceuticals (NSAIDs), which are used to reduce pain and inflammation.

Ethinylestradiol Ethinylestradiol (EE) is an oestrogen medication which is used widely in birth

control pills in combination with progestins.

Fluoxetine Antidepressant. The active ingredient in Fluoxetine is used to treat depression and

anxiety disorders.

Furosemide Furosemide belongs to a group of medicines called diuretics which reduce excess

water (fluid retention) in the body by increasing urine production and decreasing

the blood pressure.

Hydrochlorothiazide Hydrochlorothiazide belongs to a class of medicines known as angiotensin II

receptor antagonist, which help to control high blood pressure. Angiotensin II is a

substance in the body that causes vessels to tighten, thus causing your blood

pressure to increase. It works by blocking the effect of angiotensin II. As a result,

blood vessels relax and blood pressure is lowered.

Ibuprofen Ibuprofen belongs to a group of medicines called NSAID anti-inflammatory pain

killers. It is used to relieve pain and inflammation in conditions such as

osteoarthritis, rheumatoid arthritis, arthritis of the spine, ankylosing spondylitis,

swollen joints, frozen shoulder, bursitis, tendinitis, tenosynovitis, lower back pain,

sprains and strains.

Ketoprofen Ketoprofen belongs to a group of nonsteroidal anti-inflammatory pharmaceuticals

(NSAIDs), which are used to reduce pain and inflammation and to treat the

swelling, pain, heat, redness and stiffness in joints and muscles.

Metoprolol A selective beta-blocker used to treat chest pain (angina), heart failure, and high

blood pressure. Lowering high blood pressure helps prevent strokes, heart attacks,

and kidney problems.

Naproxen Naproxen, sold under the brand name Naprosyn among others, is a nonsteroidal

anti-inflammatory pharmaceutical (NSAID) used to treat pain, menstrual cramps,

inflammatory diseases such as rheumatoid arthritis, and fever.

Oxazepam Oxazepam is a short-to-intermediate-acting benzodiazepine. Oxazepam is used for

the treatment of anxiety and insomnia and in the control of symptoms of alcohol

withdrawal syndrome.

Paracetamol Paracetamol, also known as acetamino-phen and APAP, is a medicine used to treat

pain and fever. It is typically used for mild to moderate pain relief.

21

Propranolol A beta-receptor blocker. It is used to treat high blood pressure, a number of types

of irregular heart rate, thyrotoxicosis, capillary haemangiomas, performance

anxiety, and essential tremors. It is used to prevent migraine headaches, and to

prevent further heart problems in those with angina or previous heart attacks.

Ramipril Ramipril is a medicine used to treat high blood pressure, heart failure, and diabetic

kidney disease. Also used to prevent cardiovascular disease in those at high risk.

Ranitidin Ranitidine is a medicine which decreases stomach acid production. It is commonly

used in treatment of peptic ulcer disease, gastroesophageal reflux disease, and

Zollinger–Ellison syndrome.

Risperidon Risperidone belongs to a group of medicines called anti-psychotics. It is used to

treat schizophrenia, bipolar disorder, and irritability associated with autism.

Sertraline Sertraline is an antidepressant of the selective serotonin reuptake inhibitor (SSRI)

class. It is used to treat major depressive disorder, obsessive–compulsive disorder,

panic disorder, post-traumatic stress disorder, premenstrual dysphoric disorder,

and social anxiety disorder.

Simvastatin Simvastatin is a lipid-lowering medication. It is used along with exercise, diet, and

weight loss to decrease elevated lipid levels. It is also used to decrease the risk of

heart problems in those at high risk.

Terbutaline Terbutaline is a β2 adrenergic receptor agonist, used as a "reliever" inhaler in the

management of asthma and chronic obstructive lung disease.

Warfarin Warfarin is a medication that is used as an anticoagulant (blood thinner). It is

commonly used to treat blood clots such as deep vein thrombosis and pulmonary

embolism and to prevent stroke in people who have atrial fibrillation, valvular

heart disease or artificial heart valves.

22

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Coalition Clean Baltic is a network of environmental NGOs: Ecohome, Belarus IPO Ecopartnership, Belarus APB Birdlife, Belarus Nerush, Belarus Center for Environmental Solutions, Belarus Danish Society for Nature Conservation Estonian Green Movement Estonian Water Association (observer) Finnish Association for Nature Conservation Bund für Umwelt und Naturschutz Deutschland, BUND Environmental Protection Club of Latvia, VAK Latvian Green Movement Lithuanian Green Movement Lithuanian Fund for Nature Polish Ecological Club, PKE Green Federation - GAIA, Poland West Pomeranian Nature Society, Poland Friends of the Baltic, Russia Green Planet, Russia (observer) Swedish Society for Nature Conservation WWF Sweden SOFIA, Sweden The Western Centre of the Ukrainian Branch of the World Laboratory Lviv City Public Organization “Ecoterra”, Ukraine

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