Shared toilet facilities and COVID-19: Guidelines for reopening and management

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  • Carol McCreary
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Shared toilet facilities and COVID-19: Guidelines for reopening and management

I am pleased to submit "Public Restrooms and COVID-19: Guidelines for Reopening" www.phlush.org/2020/06/30/public-restroo...lines-for-reopening/   While they are addressed to local officials and facility managers in the United States (where we currently face a dangerous surge in infections), guidelines apply to any shared toilet.

Based on currently up-to-date scientific understanding of the transmission of SARS-CoV-2, including pre-symptomatic and asymptomatic contagion, we propose these six guidelines.  Each emerged from a large number of studies hyperlinked in each section.  A bibliography is at the end of the document.

1. Reopen public restrooms as they are crucial to the revival of economic and community life.

2. Understand the longevity of SARS-CoV-2 in enclosed space. Ask users to wear masks in shared toilet facilities and to exit as soon as they have finished their business.

3. Fit toilet seats with lids if they don’t have them because flushing can propel aerosols with infectious virus into the restroom.

4. Remove forced-air hand dryers that spread viruses and bacteria and provide paper towels for hand drying.

5. Place hand-hygiene stations at the entrance restrooms and ask users to clean hands before entering to avoid surface contamination.

6. Establish new restroom maintenance protocols, ensure constant ventilation, choose appropriate cleaning technologies, train cleaners, and provide signage to educate users.

PHLUSH homepage www.phlush.org/ has a red button with "COVID Pandemic Response" www.phlush.org/responding-to-coronavirus/ for ongoing PHLUSH research and resources for understanding and combatting COVID-19. Our focus is on the evolving science of SARS-CoV-2 transmission and hygiene measures we can take to interrupt it.  

We welcome your comments.

Carol
Carol McCreary
Public Hygiene Lets Us Stay Human (PHLUSH)
1240 W. Sims Way #59, Port Townsend, Washington 98368 USA

Toilet availability is a human right and well-designed sanitation systems restore health to our cities, our waters and our soils.
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  • Chaiwe
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Re: Shared toilet facilities and COVID-19: Guidelines for reopening and management

Thank you for sharing Carol. I had a look through and think these guidelines do need to circulate widely. 

This point actually enlightened me, I simply had no idea:

4. Remove forced-air hand dryers that spread viruses and bacteria and provide paper towels for hand drying.

Details on the website you shared as follows:

''Studies showing the dangers of hand dryers are not new. In 2014, researchers at the University of Leeds applied harmless bactobacilli to test subjects’ hands to mimic the incomplete washing of someone who may use soap but for less than 20 minutes. Three drying methods were tested: jet air or blade dryers, traditional warm air dryers, and paper towels. After the use of each, air samples were collected at one and two meters away. The expensive new jet air dryers proved the most contaminating.  They produced airborne bacterial counts  4.5 times higher than the regular warm air dryers and 27 times higher than hand drying with paper towels.''

Chaiwe
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Chaiwe Mushauko-Sanderse BSc. NRM, MPH
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  • Elisabeth
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Re: Shared toilet facilities and COVID-19: Guidelines for reopening and management

I agree with Chaiwe and also feel that Carol's guideline document is very important. Thank you Carol for sharing it. (should it also go into the SuSanA library? We might need it in pdf format for that)

Whenever I come across an important publication on sanitation topics I automatically think to myself: "Could this be used to enrich a Wikipedia article on something?". In this case, I used it to enrich the Wikipedia article about public toilets:  https://en.wikipedia.org/wiki/Public_toilet

I added this new section:

Health risks from spreading disease
Public toilets may cause people to be infected with some diseases, particularly if hygiene is lacking. In 2020 during the  COVID-19 pandemic , it become clear that COVID-19 spreads not only through respiratory droplets but through aerosol particles which remain suspended for much longer. [15]  There are multiple touch points in public toilets – stall door locks, flush handles, and faucets. [15]  The NGO PHLUSH has published guidelines on the safe reopening of public toilets. [15]  This includes for example: "Place hand-hygiene stations at the entrance restrooms and ask users to clean hands before entering to avoid surface contamination."

Is this good or should I expand?

The information about the forced-air hand dryers I am not so sure about. Is the scientific evidence conclusive? You only mentioned one study from 2014. I hunted around a bit more and found this review article from 2012 which seems pretty convincing:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538484/
The Hygienic Efficacy of Different Hand-Drying Methods: A Review of the Evidence

From the abstract:

This review found little agreement regarding the relative effectiveness of electric air dryers. However, most studies suggest that paper towels can dry hands efficiently, remove bacteria effectively, and cause less contamination of the washroom environment. From a hygiene viewpoint, paper towels are superior to electric air dryers. Paper towels should be recommended in locations where hygiene is paramount, such as hospitals and clinics.

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  • Carol McCreary
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Re: Shared toilet facilities and COVID-19: Guidelines for reopening and management

Thank you, Chaiwe and Elisabeth for your encouragement. 

I'm happy to report that PHLUSH colleague Genevieve Schutzius will be presenting the guidelines at SuSanA's 30th meeting. I believe the presentation is on August 20th late in the session in the CEST time zone.  (That's when the day finally dawns for those of us on the West Coast.)  Genevieve is a sanitation engineer who has researched the prevalence of anti-microbial resistant bacteria in septic systems and waterways in Vietnam.  She knows her pathogens!

We are updating the guidelines in light of new research on SARS-CoV-2 aerosol contagion risks and possible new directives on social distancing. ( Here in the US, we've been observing 6 feet - a bit less than 2 meters -  distance between individuals. This week the governor of Washington State announced a new requirement for indoor gyms and fitness studios where people do strenuous exercise. It's 17 feet or over five meters so that each person has 300 square feet or nearly 28 square meters! )

Yes, it would be a good idea to make an illustrated .pdf for the SuSanA library.  However, scientists' understanding of the length of time aerosols with the active virus can remain suspended in the enclosed indoor space typical of a restroom is likely to evolve.  Everything else we know about COVID-19 and the novel virus that causes it will probably change as well.   Wikipedia, however, might be a good place to follow or initiate such a discussion. 

Please note that our resource list on managing shared toilets is updated regularly.  The list has a mix of news articles and reports of research, both peer-reviewed and not; dates of new postings generally appear at the top of each section with the date of posting in red.  We invite others to use this resource list.  docs.google.com/document/d/1vBrxDDcnPuyS...DvBBTHtiAA22-Ls/edit   Additional resources appear on our COVID Pandemic Response Page: www.phlush.org/responding-to-coronavirus/

Best wishes,
Carol
Carol McCreary
Public Hygiene Lets Us Stay Human (PHLUSH)
1240 W. Sims Way #59, Port Townsend, Washington 98368 USA

Toilet availability is a human right and well-designed sanitation systems restore health to our cities, our waters and our soils.
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  • ToddBlack
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Re: Shared toilet facilities and COVID-19: Guidelines for reopening and management

Carol McCreary wrote: I am pleased to submit "Public Restrooms and COVID-19: Guidelines for Reopening" https://www.phlush.org/2020/06/30/public-restrooms-and-covid-19-guidelines-for-reopening/   While they are addressed to local officials and facility managers in the United States (where we currently face a dangerous surge in infections), guidelines apply to any shared toilet.

Based on currently up-to-date scientific understanding of the transmission of SARS-CoV-2, including pre-symptomatic and asymptomatic contagion, we propose these six guidelines.  Each emerged from a large number of studies hyperlinked in each section.  A bibliography is at the end of the document.
1. Reopen public restrooms as they are crucial to the revival of economic and community life.
2. Understand the longevity of SARS-CoV-2 in enclosed space. Ask users to wear masks in shared toilet facilities and to exit as soon as they have finished their business.
3. Fit toilet seats  with lids if they don’t have them because flushing can propel aerosols with infectious virus into the restroom.
4. Remove forced-air hand dryers that spread viruses and bacteria and provide paper towels for hand drying.
5. Place hand-hygiene stations at the entrance restrooms and ask users to clean hands before entering to avoid surface contamination.
6. Establish new restroom maintenance protocols, ensure constant ventilation, choose appropriate cleaning technologies, train cleaners, and provide signage to educate users.
PHLUSH homepage https://www.phlush.org/ has a red button with "COVID Pandemic Response" https://www.phlush.org/responding-to-coronavirus/ for ongoing PHLUSH research and resources for understanding and combatting COVID-19. Our focus is on the evolving science of SARS-CoV-2 transmission and hygiene measures we can take to interrupt it.  

We welcome your comments.

Carol


Totally agree with points 2,3,5!

but! The first one not really about "Guidelines for reopening and management" - it is a fact, no economy can survive without diners, restaurants, etc.!
Point 4. It is actually safe if customers don't touch the bottom part of a dryer.
Point 6. Isn't that something that should be always? Not just during a pandemic?

thanks
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  • Carol McCreary
  • Carol McCreary's Avatar
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  • I'm Program Manager at PHLUSH (Public Hygiene Lets Us Stay Human) www.phlush.org
  • Posts: 177
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Re: Shared toilet facilities and COVID-19: Guidelines for reopening and management

Thanks, Todd for the feedback. 

PHLUSH is revising the Guidelines for reopening and managing restrooms in light of new evidence on 1) infectious aerosol size; 2) asymptomatic SARS-CoV-2 spread; and the imperative of masking to avoid inhaling the infectious exhalations of previous users. 

Note that live virus can remain suspended in an enclosed space for some time.  This is the research we are following closely.   Our resource list on managing shared toilets is here.  docs.google.com/document/d/1vBrxDDcnPuyS...DvBBTHtiAA22-Ls/edit   Below are several resources from the mainstream media which include links to peer-reviewed research as well as to news from the various research laboratories.  Highly recommended!

Mandavilli, Apoorva. (2020, August 6). Even Asymptomatic People Carry the Coronavirus in High Amounts.  New York Times. Korean study in JAMA  offers more definitive proof that people without symptoms carry just as much virus in their nose, throat and lungs as those with symptoms, and for almost as long." experts now say 30 to 40 percent of cases are likely to be asymptomatic spreaders."Asymptomatic people became virus-free a little sooner: around Day 17, compared with Day 19 or 20 for those with symptoms."  www.nytimes.com/2020/08/06/health/corona...f5466e58d381c37f6706  

Tufekci, Zeynep. (2020, July 30) We Need to Talk About Ventilation. The Atlantic. "..despite mounting evidence of its importance, we are stuck practicing hygiene theater—constantly deep cleaning everything—while not noticing the air we breathe." Covers early WHO misconceptions about droplet travel and distancing guidelines based on them. It takes time to figure out. "..historically, it took centuries to understand how pathogens such as the plague, smallpox, and yellow fever were transmitted and how they worked. ..there are still debates about how common annual influenza spreads. www.theatlantic.com/health/archive/2020/...transmission/614737/

Marr, Lindsey C. (2020, July 30) Yes, the Coronavirus Is in the Air. New York Times.  Recent findings call for care in opening windows and improving airflow indoors and are evidence of the need for quality masks that fit well. "...basic physics says that a 5-micron droplet takes about a half-hour to drop to the floor from the mouth of an adult of average height — and during that time, the droplet can travel many meters on an air current." www.nytimes.com/2020/07/30/opinion/coronavirus-aerosols.html


  
Carol McCreary
Public Hygiene Lets Us Stay Human (PHLUSH)
1240 W. Sims Way #59, Port Townsend, Washington 98368 USA

Toilet availability is a human right and well-designed sanitation systems restore health to our cities, our waters and our soils.
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