Toilet hygiene-review and research needs.

The goal of good toilet hygiene is minimizing the potential for pathogen transmission. Control of odours is also socially important and believed to be a societal measure of cleanliness. Understanding the need for good cleaning and disinfecting is even more important today considering the potential spread of emerging pathogens such as SARS-CoV-2 virus. While the flush toilet was a major advancement in achieving these objectives, exposure to pathogens can occur from failure to clean and disinfect areas within a restroom, as well as poor hand hygiene. The build-up of biofilm within a toilet bowl/urinal including sink can result in the persistence of pathogens and odours. During flushing, pathogens can be ejected from the toilet bowl/urinal/sink and be transmitted by inhalation and contaminated fomites. Use of automatic toilet bowl cleaners can reduce the number of microorganisms ejected during a flush. Salmonella bacteria can colonize the underside of the rim of toilets and persist up to 50 days. Pathogenic enteric bacteria appear in greater numbers in the biofilm found in toilets than in the water. Source tracking of bacteria in homes has demonstrated that during cleaning enteric bacteria are transferred from the toilet to the bathroom sinks and that these same bacteria colonize cleaning tools used in the restroom. Quantitative microbial risk assessment has shown that significant risks exist from both aerosols and fomites in restrooms. Cleaning with soaps and detergents without the use of disinfectants in public restrooms may spread bacteria and viruses throughout the restroom. Odours in restrooms are largely controlled by ventilation and flushing volume in toilet/urinals. However, this results in increased energy and water usage. Contamination of both the air and surfaces in restrooms is well documented. Better quantification of the risks of infection are needed as this will help determine what interventions will minimize these risks.

Humans peeing: Justice-involved women's access to toilets in public spaces.

Justice-involved women face myriad challenges as they negotiate the terms of community supervision and manage the long-term implications and stigma of living with a criminal record. Major tasks that women juggle include securing safe, affordable housing, finding and retaining employment, accessing physical and mental health care (including substance use treatment), and handling relationships with family, friends, children, and intimate partners. In addition to these responsibilities, women must meet their basic physiological needs to eat, sleep, and use the toilet. Women's ability to safely meet their personal care needs may impact their capacity to manage their criminal-legal challenges. This study uses qualitative methods to understand justice-involved women's lived experiences related to urination. Specifically, the study reports on a thematic analysis of 8 focus groups conducted with justice-involved women (n = 58) and the results of a toilet audit conducted in the downtown areas of the small city in the United States where the focus group participants were living. Findings suggest that women had limited access to restrooms and reported urinating outside. Lack of restroom access impacted their engagement with social services support and employment and their ability to travel through public spaces. Women perceived their public toilet options as unsafe, increasing their sense of vulnerability and reinforcing the idea that they did not have full access to citizenship in the community because of their criminal-legal involvement. The exclusion and denial of women's humanity that is perpetuated by a lack of public toilet access impacts women's psychosocial outcomes. City governments, social service agencies, and employers are encouraged to consider how lack of toilet access may impact their public safety and criminal-legal objectives and expand opportunities for people to access safe restroom facilities.

[Educating to properly close the toilet knob taps or to replace them]. / Educare a chiudere in modo corretto i rubinetti a manopola del bagno o a sostituirli.

Systematic reviews have shown a prevalence close to 20% of gastrointestinal symptoms in COVID-19 positive patients, with nearly 40% of patients shedding viral RNA in their faeces, even if it may not be infectious, possibly because of inactivation by colonic fluid.According to current evidence, this virus is primarily transmitted by respiratory droplets and contact routes, including contaminated surfaces. The virus is quite stable on stainless steel, being detected up to 48-72 hours after application. Therefore, some individuals can be infected touching common contaminated surfaces, such as bathroom taps. Taps can be underestimated critical points in the transmission chain of the infection. Indeed, just by turning the knob, people leave germs on it, especially after coughing over their hands, sneezing, and/or blowing their nose. After handwashing with soap, user take back their germs when turning the knob. Paradoxically, the following user collects the germs back on his/her fingers by implementing a preventive measure, maybe before putting food into the mouth or wearing contact lenses.The Italian National Institute of Health recommends to clean and disinfect high-touched surfaces, but it is unrealistic and inefficient to do so after each tap use. As an alternative, new toilets should install long elbow-levers - or at least short levers - provided that people are educated to close them with the forearm or the side of the hand. This is already a standard measure in hospitals, but it is particularly important also in high-risk communities, such as retirement homes and prisons. It would be important also in schools, in workplaces, and even in families, contributing to the prevention both of orofaecal and respiratory infections.In the meantime, people should be educated to close existing knobs with disposable paper towel wipes or with toilet paper sheets.

Gender-Neutral Toilets: A Qualitative Exploration of Inclusive School Environments for Sexuality and Gender Diverse Youth in Western Australia.

School toilets have been identified by sexuality and gender diverse (SGD) students as the least safe spaces in educational institutions. They are sites of verbal, physical and sexual victimisation. Providing gender-neutral toilets in primary and secondary schools may reduce the bullying and victimisation of SGD students, particularly those who are transgender or gender-diverse. This study explored factors influencing the inclusion of gender-neutral toilets in primary and secondary schools in Western Australia. Thirty-four interviews were conducted from May to December 2020 with policy makers or practitioners (n = 22) and school staff (n = 12) in Perth, Western Australia. Interviews were conducted online and face-to-face using semi-structured interview guides. A thematic analysis of the cross-sectional qualitative data was undertaken. School staff, policy makers, and practitioners identified school toilets as sites of bullying and victimisation of SGD youth and expressed support for gender-neutral toilets as an anti-bullying strategy. Perceived barriers to introducing gender-neutral toilets in schools included financial and spatial costs, building code compliance constraints, resistance from parents and students, privacy and confidentiality concerns, and cultural appropriateness. Including gender-neutral toilets in schools may reduce school-based bullying and victimisation, and improve the mental and physical health of SGD youth.

Improving Toilet Usability and Cleanliness in Public Schools in the Philippines Using a Packaged Operation and Maintenance Intervention.

This study evaluated the impact of packaged interventions for operation and maintenance (O&M) on the usability and cleanliness of toilets in public schools in the Philippines. In this cluster-randomized controlled trial, the divisions of Roxas City and Passi City were randomly assigned to the intervention or control group. Schools in Roxas City (n = 14) implemented the packaged O&M interventions; schools in Passi City (n = 16) formed the control group. Outcome variables were toilet usability-defined as accessible, functional and private-and toilet cleanliness, measured using the Sanitation Assessment Tool (SAT) and the Cleaner Toilets, Brighter Future (CTBF) instruments at baseline and at four months follow-up through direct observation of school toilets. SAT results showed that intervention schools had a 32.0% (4.6%; 59.3%) higher percentage of usable toilets than control schools at follow-up after full adjustment (p = 0.024). CTBF results found a similar result, although this was not statistically significant (p = 0.119). The percentage of toilets that were fully clean was 27.1% (3.7%; 50.6%) higher in intervention schools than in control schools after adjustment (p = 0.025). SAT results also showed an improvement in cleanliness of toilets in intervention schools compared to those in controls, but this did not remain significant after adjustment. The findings indicate that the additional implementation of O&M interventions can further stimulate progress towards reaching Water, Sanitation and Hygiene service levels aligned with the Sustainable Development Goals.

Changes in residents' hygiene awareness and behaviors in public toilets before and during the COVID-19 pandemic in Hangzhou, China: a two-round cross-sectional study.

BACKGROUND: Hygiene behaviors in public toilets are important to prevent the transmission of infectious diseases, especially during the pandemic. All through the novel coronavirus (COVID-19) pandemic, governments in many countries published guidance on personal hygiene for the general population to prevent disease transmission. This study aimed to investigate improvements in residents' hygiene awareness and behaviors in public toilets before and during the pandemic. METHODS: We recruited 316 residents between November and December 2018 before the pandemic, and 314 residents between December 2020 and January 2021 during the pandemic in the same study sites in Hangzhou, a well-developed city in China. Residents' hygiene behaviors in public toilets, hygiene awareness, risk perception, and sociodemographic factors were collected. Bivariate analysis and multivariable logistic regressions were used to test the differences between the two rounds. We conducted an observational study to record the provision of hygiene amenities at toilets during the pandemic. RESULTS: After controlling for sociodemographic factors (gender, marital status, age, education level, and monthly household income), compared with respondents recruited before the pandemic, respondents recruited during the pandemic were more likely to perceive the risks of infection when using public toilets (aOR = 1.77, 95%CI [1.20, 2.60]), and were more likely to be aware of the risks of touching contaminated toilet facilities (aOR = 1.72, 95%CI [1.17, 2.54]) and the risks of not using soap to wash one's hands after using the toilet (aOR = 1.93, 95%CI [1.38, 2.72]). They were more likely to always clean their toilet seat with alcohol (aOR = 1.88, 95%CI [1.01, 3.51]), wash hands with soap (aOR = 1.52, 95%CI [1.09, 2.10]) and dry their hands with a dryer (aOR = 1.78, 95%CI [1.16, 2.71]), but they were less likely to always wash their hands after using the toilets (aOR = 0.57, 95%CI [0.32, 1.00]). Among 70 public toilets observed, 9 provided alcohol for toilet seat disinfection, 52 provided soap, 33 provided paper towels, and 41 had working hand dryers. CONCLUSIONS: Despite the overall improvement, residents' hygiene behaviors in public toilets and the supply of hygiene amenities were still suboptimal during the pandemic. Further hygiene education and an adequate supply of hygiene amenities in public toilets are needed to promote residents' hygiene behaviors.

Effects of face masks and ventilation on the risk of SARS-CoV-2 respiratory transmission in public toilets: a quantitative microbial risk assessment.

Public toilets may increase the risk of COVID-19 infection via airborne transmission; however, related research is limited. We aimed to estimate SARS-CoV-2 infection risk through respiratory transmission using a quantitative microbial risk assessment framework by retrieving SARS-CoV-2 concentrations from the swab tests of 251 Thai patients. Three virus-generating scenarios were investigated: an infector breathing, breathing with a cough, and breathing with a sneeze. The infection risk (95th percentile) was as high as 10-1 with breathing and increased to 1 with a cough or a sneeze. No significant gender differences for toilet users (receptors) were noted. The highest risk scenario, namely breathing with a sneeze, was further evaluated for risk mitigation measures. Mitigation to a lower risk under 10-3 succeeded only when the infector and the receptor both wore N95 respirators or surgical masks. Ventilation of up to 20 air changes per hour (ACH) did not decrease the risk. However, an extended waiting time of 10 min between an infector and a receptor resulted in approximately 1.0-log10 further risk reduction when both wore masks with the WHO-recommended 12 ACH. The volume of expelled droplets, virus concentrations, and receptor dwell time were identified as the main contributors to transmission risk.

SARS-CoV-2 RNA in Swabbed Samples from Latrines and Flushing Toilets: A Case-Control Study in a Rural Latin American Setting.

Information about factors potentially favoring the spread of SARS-CoV-2 in rural settings is limited. Following a case-control study design in a rural Ecuadorian village that was severely struck by the pandemic, SARS-CoV-2 RNA were detected by real-time PCR in swabs obtained from inner and upper walls in 24/48 randomly selected latrines from case-houses and in 12/48 flushing toilets from paired control-houses (P = 0.014; McNemar's test). This association persisted in a conditional logistic regression model adjusted for relevant covariates (OR: 4.82; 95% CI: 1.38-16.8; P = 0.014). In addition, SARS-CoV-2-seropositive subjects were more often identified among those living in houses with a latrine (P = 0.002). Latrines have almost five times the odds of containing SARS-CoV-2 RNA than their paired flushing toilets. Latrines are reservoirs of SARS-CoV-2 RNA, and it cannot be ruled out that latrines could contribute to viral transmission in rural settings. Frequent disinfection of latrines should be recommended to reduce the likelihood of fecal contamination.

Mobile phones of paediatric hospital staff are never cleaned and commonly used in toilets with implications for healthcare nosocomial diseases.

An ever-increasing number of medical staff use mobile phones as a work aid, yet this may pose nosocomial diseases. To assess and report via a survey the handling practices and the use of phones by paediatric wards healthcare workers. 165 paediatric healthcare workers and staff filled in a questionnaire consisting of 14 questions (including categorical, ordinal and numerical data). Analysis of categorical data used non-parametric techniques such as the Chi-squared test. Although 98% of respondents (165 in total) report that their phones may be contaminated, 56% have never cleaned their devices. Of the respondents that clean their devices, 10% (17/165) had done so with alcohol swabs or disinfectant within that day or week; and an additional 12% respondents (20/165) within that month. Of concern, 52% (86/165) of the respondents use their phones in the bathroom, emphasising the unhygienic environments in which mobile phones/smartphones are constantly used. Disinfecting phones is a practice that only a minority of healthcare workers undertake appropriately. Mobile phones, present in billions globally, are therefore Trojan Horses if contaminated with microbes and potentially contributing to the spread and propagation of micro-organisms as per the rapid spread of SARS-CoV-2 virus in the world.

Toilet Paper, Minced Meat and Diabetes Medicines: Australian Panic Buying Induced by COVID-19.

The COVID-19 pandemic has impacted the management of non-communicable diseases in health systems around the world. This study aimed to understand the impact of COVID-19 on diabetes medicines dispensed in Australia. Publicly available data from Australia's government subsidised medicines program (Pharmaceutical Benefits Scheme), detailing prescriptions by month dispensed to patients, drug item code and patient category, was obtained from January 2016 to November 2020. This study focused on medicines used in diabetes care (Anatomical Therapeutical Chemical code level 2 = A10). Number of prescriptions dispensed were plotted by month at a total level, by insulins and non-insulins, and by patient category (general, concessional). Total number of prescriptions dispensed between January and November of each year were compared. A peak in prescriptions dispensed in March 2020 was identified, an increase of 35% on March 2019, compared to average growth of 7.2% in previous years. Prescriptions dispensed subsequently fell in April and May 2020 to levels below the corresponding months in 2019. These trends were observed across insulins, non-insulins, general and concessional patient categories. The peak and subsequent dip in demand have resulted in a small unexpected overall increase for the period January to November 2020, compared to declining growth for the same months in prior years. The observed change in consumer behaviour prompted by COVID-19 and the resulting public health measures is important to understand in order to improve management of medicines supply during potential future waves of COVID-19 and other pandemics.

What is the risk of acquiring SARS-CoV-2 from the use of public toilets?

Public toilets and bathrooms may act as a contact hub point where community transmission of SARS-CoV-2 occurs between users. The mechanism of spread would arise through three mechanisms: inhalation of faecal and/or urinary aerosol from an individual shedding SARS-CoV-2; airborne transmission of respiratory aerosols between users face-to-face or during short periods after use; or from fomite transmission via frequent touch sites such as door handles, sink taps, lota or toilet roll dispenser. In this respect toilets could present a risk comparable with other high throughput enclosed spaces such as public transport and food retail outlets. They are often compact, inadequately ventilated, heavily used and subject to maintenance and cleaning issues. Factors such as these would compound the risks generated by toilet users incubating or symptomatic with SARS-CoV-2. Furthermore, toilets are important public infrastructure since they are vital for the maintenance of accessible, sustainable and comfortable urban spaces. Given the lack of studies on transmission through use of public toilets, comprehensive risk assessment relies upon the compilation of evidence gathered from parallel studies, including work performed in hospitals and prior work on related viruses. This narrative review examines the evidence suggestive of transmission risk through use of public toilets and concludes that such a risk cannot be lightly disregarded. A range of mitigating actions are suggested for both users of public toilets and those that are responsible for their design, maintenance and management.

Why did all the toilet paper disappear? Distinguishing between panic buying and hoarding during COVID-19.

The COVID-19 pandemic led to panic buying in many countries across the globe, preventing vulnerable groups from accessing important necessities. Some reports inaccurately referred to the panic buying as hoarding. Although hoarding is a separate issue characterised by extreme saving behaviour, the two problems may be influenced by similar factors. Participants from Australia and the United States (final N = 359) completed online self-report measures of panic buying, hoarding, shopping patterns, perceived scarcity, COVID-19 illness anxiety, selfishness, and intolerance of uncertainty. Our findings showed that panic buying was related to hoarding symptoms (r's = .23 - .36), and yet, both were uniquely associated with different psychological factors. Whilst panic buying was most strongly related to greater perceived scarcity (r's = .38 - .60), hoarding was most related to a general intolerance of uncertainty (r's = .24 - .57). Based on our findings, future strategies to prevent panic buying should focus on reducing perceived scarcity cues in the community, as this seems to be the primary driver of panic buying. Another preventative strategy to reduce excessive acquiring and saving may be to implement educational programs to increase people's ability to tolerate distress and uncertainty.

Aerosol and bioaerosol particle size and dynamics from defective sanitary plumbing systems.

Aerosols are readily transported on airstreams through building sanitary plumbing and sewer systems, and those containing microbial pathogens (known as bioaerosols) are recognized as contributors to infection spread within buildings. When a defect occurs in the sanitary plumbing system that affects the system integrity, a cross-transmission route is created that can enable the emission of bioaerosols from the system into the building. These emission occurrences are characterized as short-burst events (typically <1 min in duration) which make them difficult to detect and predict. The characterization of these emission events is the focus of this research. Two methods were used to characterize bioaerosol emission events in a full-scale test rig: (a) an Aerodynamic Particle Sizer (APS) for particle size distribution and concentrations; and (b) a slit-to-agar sampler to enumerate the ingress of a viable tracer microorganism (Pseudomonas putida). The APS data confirmed that most particles (>99.5%) were <5 µm and were therefore considered aerosols. Particles generated within the sanitary plumbing system as a result of a toilet flush leads to emissions into the building during system defect conditions with an equivalence of someone talking loudly for over 6 and a half minutes. There were no particles detected of a size >11 µm anywhere in the system. Particle count was influenced by toilet flush volume, but it was not possible to determine if there was any direct influence from airflow rate since both particle and biological data showed no correlation with upward airflow rates and velocities. Typical emissions resulting from a 6 L toilet flush were in the range of 280-400 particles per second at a concentration of typically 9-12 number per cm3 and a total particle count in the region of 3000 to 4000 particles, whereas the peak emissions from a 1.2 L toilet flush were 60-80 particles per second at a concentration of 2.4-3 number per cm3 and a total particle count in the region of 886 to 1045 particles. The reduction in particles is in direct proportion to the reduction in toilet flush volume. The slit-to-agar sampler was able to provide viable time course CFU data and confirmed the origin of the particles to be the tracer microorganism flushed into the system. The time course data also have characteristics consistent with the unsteady nature of a toilet flush.

Anxiety and Panic Buying Behaviour during COVID-19 Pandemic-A Qualitative Analysis of Toilet Paper Hoarding Contents on Twitter.

Background: The coronavirus disease 2019 (COVID-19) pandemic had increased population-level anxiety and had elicited panic buying behaviour across the world. The over-hoarding of toilet paper has received a lot of negative public attention. In this work, we used Twitter data to qualitatively analyse tweets related to panic buying of toilet paper during the crisis. Methods: A total of 255,171 tweets were collected. Of these 4081 met our inclusion criteria and 100 tweets were randomly selected to develop a coding scheme in the initial phase. Random samples of tweets in folds of 100 were then qualitatively analysed in the focused coding phase until saturation was met at 500 tweets analysed. Results: Five key themes emerged: (1) humour or sarcasm, (2) marketing or profiteering, (3) opinion and emotions, (4) personal experience, and (5) support or information. About half of the tweets carried negative sentiments, expressing anger or frustration towards the deficiency of toilet paper and the frantic situation of toilet paper hoarding, which were among the most influential tweets. Discussion: Panic buying of toilet paper was seen during the 2020 pandemic period with a mass amount of related content spread across social media. The spontaneous contagion of fear and panic through social media could fuel psychological reactions in midst of crises. The high level of negative social media posts regarding the toilet paper crisis acts as an emotional trigger of public anxiety and panic. Conclusions: Social media data can provide rapid infodemiology of public mental health. In a pandemic or crisis situation, real-time data could be monitored and content-analysed for authorities to promptly address public concerns.

The distribution of SARS-CoV-2 contamination on the environmental surfaces during incubation period of COVID-19 patients.

Roles of environmental factors in transmission of COVID-19 have been highlighted. In this study, we sampled the high-touch environmental surfaces in the quarantine room, aiming to detect the distribution of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on the environmental surfaces during the incubation period of coronavirus disease 2019 (COVID-19) patients. Fifteen sites were sampled from the quarantine room, distributing in the functional areas such as bedroom, bathroom and living room. All environmental surface samples were collected with sterile polyester-tipped applicator pre-moistened in viral transport medium and tested for SARS-CoV-2. Overall, 34.1% of samples were detected positively for SARS-CoV-2. The positive rates of Patient A, B and C, were 46.2%, 0% and 61.5%, respectively. SARS-CoV-2 was detected positively in bedroom and bathroom, with the positive rate of 50.0% and 46.7%, respectively. In contrast, living room had no positive sample detected. Environmental contamination of SARS-CoV-2 distributes widely during the incubation period of COVID-19, and the positive rates of SARS-CoV-2 on environmental surfaces are relatively high in bathroom and bedroom.

Sanitation Practices during Early Phases of COVID-19 Lockdown in Peri-Urban Communities in Tamil Nadu, India.

In countries without adequate access to improved sanitation, government-imposed restrictions during the COVID-19 pandemic can impact toilet usage. In India, where millions have recently transitioned to using a toilet, pandemic-related barriers to use might increase open defecation practices. We assessed changes in reported defecation practices in peri-urban communities in Tamil Nadu. Field assistants conducted phone surveys in 26 communities in two districts from May 20, 2020 to May 25, 2020. They asked respondents about their access to a toilet, whether they or a family member left their house to defecate in the past week, and whether specific practices had changed since the lockdown. Among 2,044 respondents, 60% had access to a private toilet, 11% to a public or community toilet, whereas 29% lacked access to any toilet facility. In our study, 92% of the respondents did not change their defecation behaviors in the 2 months following the pandemic-related lockdown. About a third (27%) reported that they or a family member left their house daily to defecate amid lockdown measures. A majority of those with private toilets (91%) or with public toilets (69%) continued using them. Respondents with private toilet access were more likely to report an increased frequency of handwashing with soap (prevalence ratio [PR]: 1.78, 95% CI: 1.04-3.05) since the lockdown. The lack of private toilets contributes to the need to leave the house amid a lockdown. Maintaining shared toilets require disinfection protocols and behavioral precautions to limit the risk of fomite transmission. Robust urban COVID-19 control strategies should include enhanced sanitation facility management and safe usage messaging.

Toilets dominate environmental detection of severe acute respiratory syndrome coronavirus 2 in a hospital.

Respiratory and fecal aerosols play confirmed and suspected roles, respectively, in transmitting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). An extensive environmental sampling campaign of both toilet and non-toilet environments was performed in a dedicated hospital building for patients with coronavirus disease 2019 (COVID-19), and the associated environmental factors were analyzed. In total, 107 surface samples, 46 air samples, two exhaled condensate samples, and two expired air samples were collected within and beyond four three-bed isolation rooms. The data of the COVID-19 patients were collected. The building environmental design and the cleaning routines were reviewed. Field measurements of airflow and CO2 concentrations were conducted. The 107 surface samples comprised 37 from toilets, 34 from other surfaces in isolation rooms, and 36 from other surfaces outside the isolation rooms in the hospital. Four of these samples were positive, namely two ward door handles, one bathroom toilet seat cover, and one bathroom door handle. Three were weakly positive, namely one bathroom toilet seat, one bathroom washbasin tap lever, and one bathroom ceiling exhaust louver. Of the 46 air samples, one collected from a corridor was weakly positive. The two exhaled condensate samples and the two expired air samples were negative. The fecal-derived aerosols in patients' toilets contained most of the detected SARS-CoV-2 in the hospital, highlighting the importance of surface and hand hygiene for intervention.