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.

Determinants of malaria infections among children in refugee settlements in Uganda during 2018-2019.

BACKGROUND: While 5% of 247 million global malaria cases are reported in Uganda, it is also a top refugee hosting country in Africa, with over 1.36 million refugees. Despite malaria being an emerging challenge for humanitarian response in refugee settlements, little is known about its risk factors. This study aimed to investigate the risk factors for malaria infections among children under 5 years of age in refugee settlements in Uganda. METHODS: We utilized data from Uganda's Malaria Indicator Survey which was conducted between December 2018 and February 2019 at the peak of malaria season. In this national survey, household level information was obtained using standardized questionnaires and a total of 7787 children under 5 years of age were tested for malaria using mainly the rapid diagnostic test. We focused on 675 malaria tested children under five in refugee settlements located in Yumbe, Arua, Adjumani, Moyo, Lamwo, Kiryadongo, Kyegegwa, Kamwenge and Isingiro districts. The extracted variables included prevalence of malaria, demographic, social-economic and environmental information. Multivariable logistic regression was used to identify and define the malaria associated risk factors. RESULTS: Overall, malaria prevalence in all refugee settlements across the nine hosting districts was 36.6%. Malaria infections were higher in refugee settlements located in Isingiro (98.7%), Kyegegwa (58.6%) and Arua (57.4%) districts. Several risk factors were significantly associated with acquisition of malaria including fetching water from open water sources [adjusted odds ratio (aOR) = 1.22, 95% CI: 0.08-0.59, P = 0.002], boreholes (aOR = 2.11, 95% CI: 0.91-4.89, P = 0.018) and water tanks (aOR = 4.47, 95% CI: 1.67-11.9, P = 0.002). Other factors included pit-latrines (aOR = 1.48, 95% CI: 1.03-2.13, P = 0.033), open defecation (aOR = 3.29, 95% CI: 1.54-7.05, P = 0.002), lack of insecticide treated bed nets (aOR = 1.15, 95% CI: 0.43-3.13, P = 0.003) and knowledge on the causes of malaria (aOR = 1.09, 95% CI: 0.79-1.51, P = 0.005). CONCLUSIONS: The persistence of the malaria infections were mainly due to open water sources, poor hygiene, and lack of preventive measures that enhanced mosquito survival and infection. Malaria elimination in refugee settlements requires an integrated control approach that combines environmental management with other complementary measures like insecticide treated bed nets, indoor residual spraying and awareness.

The pit latrine paradox in low-income settings: A sanitation technology of choice or a pollution hotspot?

Pit latrines are widely promoted to improve sanitation in low-income settings, but their pollution and health risks receive cursory attention. The present narrative review presents the pit latrine paradox; (1) the pit latrine is considered a sanitation technology of choice to safeguard human health, and (2) conversely, pit latrines are pollution and health risk hotspots. Evidence shows that the pit latrine is a 'catch-all' receptacle for household disposal of hazardous waste, including; (1) medical wastes (COVID-19 PPE, pharmaceuticals, placenta, used condoms), (2) pesticides and pesticide containers, (3) menstrual hygiene wastes (e.g., sanitary pads), and (4) electronic wastes (batteries). Pit latrines serve as hotspot reservoirs that receive, harbour, and then transmit the following into the environment; (1) conventional contaminants (nitrates, phosphates, pesticides), (2) emerging contaminants (pharmaceuticals and personal care products, antibiotic resistance), and (3) indicator organisms, and human bacterial and viral pathogens, and disease vectors (rodents, houseflies, bats). As greenhouse gas emission hotspots, pit latrines contribute 3.3 to 9.4 Tg/year of methane, but this could be an under-estimation. Contaminants in pit latrines may migrate into surface water, and groundwater systems serving as drinking water sources and pose human health risks. In turn, this culminates into the pit latrine-groundwater-human continuum or connectivity, mediated via water and contaminant migration. Human health risks of pit latrines, a critique of current evidence, and current and emerging mitigation measures are presented, including isolation distance, hydraulic liners/ barriers, ecological sanitation, and the concept of a circular bioeconomy. Finally, future research directions on the epidemiology and fate of contaminants in pit latrines are presented. The pit latrine paradox is not meant to downplay pit latrines' role or promote open defaecation. Rather, it seeks to stimulate discussion and research to refine the technology to enhance its functionality while mitigating pollution and health 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.

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.

Ventilation reconstruction in bathrooms for restraining hazardous plume: Mitigate COVID-19 and beyond.

Converging evidence reports that the probability of vertical transmission patterns via shared drainage systems, may be responsible for the huge contactless community outbreak in high-rise buildings. Publications indicate that a faulty bathroom exhaust fan system is ineffective in removing lifted hazardous virus-laden aerosols from the toilet bowl space. Common strategies (boosting ventilation capability and applying disinfection tablets) seem unsustainable and remain to date untested. Using combined simulation and experimental approaches, we compared three ventilation schemes in a family bathroom including the traditional ceiling fan, floor fan, and side-wall fan. We found that the traditional ceiling fan was barely functional whereby aerosol particles were not being adequately removed. Conversely, a side-wall fan could function efficiently and an enhanced ventilation capability can have increased performance whereby nearly 80.9% of the lifted aerosol particles were removed. There exists a common, and easily-overlooked mistake in the layout of the bathroom, exposing occupants to a contactless vertical pathogen aerosol transmission route. Corrections and dissemination are thus imperative for the reconstruction of these types of family bathrooms. Our findings provide evidence for the bathroom and smart ventilation system upgrade, promoting indoor public health and human hygiene.

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.

Transmission of COVID-19 and other infectious diseases in public washrooms: A systematic review.

BACKGROUND: The risk of infectious disease transmission in public washrooms causes concern particularly in the context of the COVID-19 pandemic. This systematic review aims to assess the risk of transmission of viral or bacterial infections through inhalation, surface contact, and faecal-oral routes in public washrooms in healthcare and non-healthcare environments. METHODS: We systematically reviewed environmental sampling, laboratory, and epidemiological studies on viral and bacterial infection transmission in washrooms using PubMed and Scopus. The review focused on indoor, publicly accessible washrooms. RESULTS: Thirty-eight studies from 13 countries were identified, including 14 studies carried out in healthcare settings, 10 in laboratories or experimental chambers, and 14 studies in restaurants, workplaces, commercial and academic environments. Thirty-three studies involved surface sampling, 15 air sampling, 8 water sampling, and 5 studies were risk assessments or outbreak investigations. Infectious disease transmission was studied in relation with: (a) toilets with flushing mechanisms; (b) hand drying systems; and (c) water taps, sinks and drains. A wide range of enteric, skin and soil bacteria and enteric and respiratory viruses were identified in public washrooms, potentially posing a risk of infection transmission. Studies on COVID-19 transmission only examined washroom contamination in healthcare settings. CONCLUSION: Open-lid toilet flushing, ineffective handwashing or hand drying, substandard or infrequent surface cleaning, blocked drains, and uncovered rubbish bins can result in widespread bacterial and/or viral contamination in washrooms. However, only a few cases of infectious diseases mostly related to faecal-oral transmission originating from washrooms in restaurants were reported. Although there is a risk of microbial aerosolisation from toilet flushing and the use of hand drying systems, we found no evidence of airborne transmission of enteric or respiratory pathogens, including COVID-19, in public washrooms. Appropriate hand hygiene, surface cleaning and disinfection, and washroom maintenance and ventilation are likely to minimise the risk of infectious disease transmission.

Detection of SARS-CoV-2 RNA on contact surfaces within shared sanitation facilities.

Contamination of contact surfaces with SARS-CoV-2 has been reported as a potential route for the transmission of COVID-19. This could be a major issue in developing countries where access to basic sanitation is poor, leading to the sharing of toilet facilities. In this study, we report SARS-CoV-2 contamination of key contact surfaces in shared toilets and the probabilistic risks of COVID-19 infections based on detection and quantification of the nucleic acid on the surfaces. We observed that 54-69% of the contact surfaces were contaminated, with SARS-CoV-2 loads ranging from 28.1 to 132.7 gene copies per cm2. Toilet seats had the highest contamination, which could be attributed to shedding of the virus in feces and urine. We observed a significant reduction in viral loads on the contaminated surfaces after cleaning, showing the potential of effective cleaning on the reduction of contamination. The pattern of contamination indicates that the most contaminated surfaces are those that are either commonly touched by users of the shared toilets or easily contaminated with feces and urine. These surfaces were the toilet seats, cistern handles and tap handles. The likelihood (probability) of infection with COVID-19 on these surfaces was highest on the toilet seat (1.76 × 10-4(1.58 × 10-6)) for one time use of the toilet. These findings highlight the potential risks for COVID-19 infections in the event that intact infectious viral particles are deposited on these contact surfaces. Therefore, this study shows that shared toilet facilities in densely populated areas could lead to an increase in risks of COVID-19 infections. This calls for the implementation of risk reduction measures, such as regular washing of hands with soap, strict adherence to wearing face masks, and effective and regular cleaning of shared facilities.

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.

An Evaluation of the Hand Hygiene Behaviour and Compliance of the General Public When Using Public Restrooms in Northern Ireland (NI) during the Initial Weeks of the Novel Coronavirus (COVID-19) Pandemic.

BACKGROUND: The ongoing novel coronavirus (COVID-19) global pandemic has resulted in significant levels of morbidity and mortality worldwide, particularly among the elderly and immuno-suppressed groups. Although adequate hand hygiene (HH) behaviour and compliance is widely accepted as being the most effective self-protective measure in preventing the spread of diseases like COVID-19, previous research suggests that normal hand hygiene compliance is poor, but generally improves during a disease pandemic. This research aimed to evaluate the hand hygiene behaviour and compliance of the general public in the initial weeks of the COVID-19 pandemic in Northern Ireland (NI). METHODS: This cross-sectional study involved the use of infrared-imaging cameras to observe the hand hygiene behaviour and compliance of the general public when using one set of male and female public restrooms. RESULTS: The findings of this study indicated that the level of hand hygiene compliance of the general public was poor in the initial weeks, with 82.93% overall not washing their hands adequately. CONCLUSIONS: Inadequate HH behaviour and compliance may have added significantly to the rapid rate of spread of COVID-19 in the initial weeks of the pandemic in NI. Current public health campaigns do not appear, based on this study, to have the desired impact and may need to be reviewed or re-enforced in order to achieve the levels of hand hygiene compliance required to slow the spread of COVID-19 and other communicable diseases in the future.

Conceptual Behaviour Underpinning the Occurrence of Nonfaecal Matter in Faecal Sludge in Some Urban Communities, Ghana.

Faecal sludge (FS) management is pertinent to the achievement of sustainable development goal 6.2 around the world; yet it is constrained by urbanisation challenges, waste management complexities, and defective attitudes. These deny communities of the plausible supply of resources from FS. This paper assesses the perception underpinning the occurrence of nonfaecal matter in FS in Ghana. Primary data were obtained from 400 respondents in four communities in Brong Ahafo and Greater Accra Regions of Ghana, using a structured questionnaire. Data were analysed by using STATA software version 15. Chi-square test and multiple logistic regression were conducted on all independent variables and statistical significance was accepted at p < 0.05. The study identified the following as the most perceived frequently disposed nonfaecal matter into FS: sanitary pads and diapers (38.5%), fabrics/rags (23.2%), toilet rolls (20.8%), razor/shaving sticks (10.3%), and others (7.2%). Gender, state of toilet facility (roof or unroofed), presence of container for collecting other types of waste in the toilet room, and state of container in toilet room either covered or uncovered were the factors found to be significantly associated with the disposal of solid waste (SW) into FS at 95% confidence level. The fear of exposing used sanitary materials for rituals, the use of fabric as an alternative to toilet rolls, and the desire to conceal aborted pregnancies from the public were some of the reasons alluded to the disposal acts. Education and awareness campaigns on proper SW disposal practices, appropriate use of toilet facilities, and the resource potentials of FS were found to be the best way forward to discourage indiscriminate disposal of SW into FS.

Hazardous Drug Contamination: Presence of Bathroom Contamination in an Ambulatory Cancer Center.

BACKGROUND: Many hazardous drugs (HDs) are excreted in urine and feces, and evidence has shown that bathrooms of patients receiving chemotherapy at home are contaminated with HDs. However, little information exists on bathroom contamination in ambulatory clinics where HDs are administered. OBJECTIVES: This project aimed to determine the presence of HD residue in the patient and staff bathrooms of an ambulatory cancer center. METHODS: A quality improvement project was initiated to examine potential contamination by the HDs 5-fluorouracil and oxaliplatin in a patient bathroom and a secured badge-access staff bathroom in the infusion department of an ambulatory comprehensive cancer center. Twice-daily wipe testing was conducted on the floor in front of the toilet and the flush handle for five consecutive days. FINDINGS: Sixty-five percent of the samples from the floor of the patient bathroom were positive for at least one of the HDs. In the staff bathroom, 35% of the floor samples were positive for at least one HD. None of the flush handle samples were above the level of detection.

Knowledge, attitudes, and practices around hand drying in public bathrooms during the COVID-19 pandemic in the United States.

Hand drying is the critical, final step of handwashing. A cross-sectional survey of U.S. adults assessed self-reported hand drying practices in public bathrooms and found increased preference for using electric hand dryers, wiping hands on clothing, and shaking hands and decreased preference for using paper towels during the COVID-19 pandemic relative to before. Respondents expressed concerns about contacting SARS-CoV-2 when touching surfaces in public bathrooms which may be influencing self-reported drying method preference.

A place-based analysis of COVID-19 risk factors in Bangladesh urban slums: a secondary analysis of World Bank microdata.

BACKGROUND: There is a lack of research investigating the confluence of risk factors in urban slums that may make them accelerators for respiratory, droplet infections like COVID-19. Our working hypothesis was that, even within slums, an inverse relationship existed between living density and access to shared or private WASH facilities. METHODS: In an exploratory, secondary analysis of World Bank, cross-sectional microdata from slums in Bangladesh we investigated the relationship between intra-household population density (crowding) and access to private or shared water sources and toilet facilities. RESULTS: The analysis showed that most households were single-room dwellings (80.4%). Median crowding ranged from 0.55 m2 per person up to 67.7 m2 per person. The majority of the dwellings (83.3%), shared both toilet facilities and the source of water, and there was a significant positive relationship between crowding and the use of shared facilities. CONCLUSION: The findings highlight the practical constraints on implementing, in slums, the conventional COVID19 management approaches of social distancing, regular hand washing, and not sharing spaces. It has implications for the management of future respiratory epidemics.

Improving Public Toilet Environment and Hygiene Practices in an Asian City: Voices From Hong Kong Residents.

Toilet hygiene is an important preventive measure for infectious diseases, including severe acute respiratory syndrome (SARS) and COVID-19. This study explored public's opinions on improving toilet environment and hygiene practices in Hong Kong. A mixed-method approach was applied. We conducted 4 focus groups plus 3 individual interviews among the Hong Kong Chinese, followed by a questionnaire survey with 300 respondents recruited from various districts. Difference in response distributions between groups with different demographics was tested by Pearson χ2 test. Instead of advocating for advanced toilet facilities, respondents were mostly concerned about basic hygiene issues. Malfunctioning facilities resulting from poor toilet management, such as clogged toilets, stained facilities, and problematic flushing systems, were most cited as barriers to toilet hygiene practices. Three quarters of the survey respondents expressed concerns over worn and poorly maintained toilets, shortage of janitors, and cleansing supplies. However, respondents who were older (P < .001), less educated (P < .001), and had lower income (P = .001) were significantly more likely to find hygiene conditions in public toilets satisfactory. The findings reflected the substandard of the current provisions as a developed city in Asia. Enhanced efforts by the government to maintain basic toilet supplies and facilities is the key to improving public compliance to toilet hygiene practices.

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.