ABOVE THE RIM: "THE TOILET VOLCANO"

J. Darrel Hicks, Dan Mueller

World Toilet Day is observed each year on Nov. 19 to bring attention to the lack of toilets for billions of people globally. It encourages everyone to learn and spread the word about how proper toilets and sanitation can save lives.

Rather than discussing the lack of toilets, we are bringing awareness that The "Toilet Volcano" is very common in any washroom. This is when aerosols are produced during the toilet flushing.

Fecal bacteria (yes, poop particles) and viruses are ejected from the toilet during flushing. These have the potential to travel over eight feet from the toilet. The droplets settle out in the washroom contaminating the restroom with fecal microorganisms. Due to the amount of area that the Plume effect covers, it impacts a lot of the washroom.?

Bacteria, viruses, and spores are transported in droplets. Knowing where the droplets go is the crux of the problem and is the reason we need to study how diseases spread.

A team of scientists put physics of fluids to the test to investigate droplets generated from flushing a toilet and a urinal in a public restroom under normal ventilation conditions.?

To measure the droplets, they used a particle counter placed at various heights of the toilet and urinal to capture the size and number of droplets generated upon flushing.

Results of the study, published in the journal Physics of Fluids, demonstrate how public restrooms could serve as hotbeds for airborne disease transmission, especially if they do not have adequate ventilation or if toilets do not have a lid or cover. Most public restrooms in the United States often are not equipped with toilet seat lids and urinals are not covered.?

The droplets were detected at heights of up to 5 feet for 20 seconds or longer after initiating the flush. Researchers detected a smaller number of droplets in the air when the toilet was flushed with a closed lid, although not by much, suggesting that aerosolized droplets escaped through small gaps between the cover and the seat.?

Water can harbor germs that threaten the safety of patients and spread antibiotic resistant pathogens or healthcare-associated infections (HAIs). Water management programs in healthcare facilities are an important way to help protect vulnerable patient populations as well as staff and visitors.?

Clostridioides difficile (C. diff) is a gram-positive, spore-forming anaerobe associated with infections ranging from diarrhea to severe disease with complications such as pseudomembranous colitis, toxic megacolon and death. C. diff infection (CDI) is recognized as the leading cause of gastroenteritis-associated deaths and the most common cause of healthcare-associated infections (HAI) in the United States. Healthcare-associated CDI contributes to increased length of hospital stays, 40 percent higher expenditures for each diagnosed case and higher readmission rates and mortality. Excess expenditures related to CDI in acute care hospitals are estimated to be $4.8 billion.

CDI is also increasingly diagnosed in patients in nursing homes and long-term acute care facilities, adding to a change in CDI epidemiology, including a rise in economic burden, morbidity and mortality.?

When it comes to contaminated hospital surfaces, CDI is winning the battle against disinfectants. C. diff is one of the most difficult HAI agents to eradicate because of the limited number of antibiotics or disinfectants effective against this bacterium. When the environment becomes hostile, bacteria like C. diff form spores that resist heat and chemical disinfectants, allowing them to survive when most common bacteria would die.

Later, when the environment becomes more favorable for bacteria, the C. diff returns to its original state and where it begins to infect and multiply again.?

Research shows that toilet plume aerosol generated by flushing chemotherapeutically tainted human waste contaminates bathroom environments. It also results in chemotherapy being detected in caregivers’ urine samples. The potential risks associated with toilet plume produced by flush toilets has been described in scientific literature since the 1970s and surfaced again recently.?

Products marketed as "toilet bowl cleaner/disinfectant" are often “ready to use.” Adding them to a half gallon of water in the bowl dilutes them further. How effective is that practice at eliminating spore forming C-diff??

We need a quantitative risk assessment and related research to investigate these transmission risks in healthcare facilities. There is a lack of national and international toilet plume studies and along with the best ways to mitigate the risk of "Toilet Plume" to staff and building occupants. These studies should lead to the creation of a national standard of engineering controls that prevent unnecessary exposure to aerosolized fecal particles that are breathed into the respiratory tract of humans.