Toilet plume aerosol generation rate and environmental contamination following bowl water inoculation with Clostridium difficile spores

Identification of carbapenemase-producing Enterobacteriaceae reservoirs in wet hospital environments as a potential factor in patient acquisition: A cross-sectional study in a French university hospital in 2023

OBJECTIVES

Wet hospital environments have been documented as potential reservoirs for Carbapenemase-producing Enterobacteriaceae (CPE), possibly contributing to outbreaks among inpatients. Our objectives were to assess the prevalence of CPE reservoirs in a hospital's wet environments and to investigate the contamination of adjacent dry surfaces.

METHODS

From March to August 2023, we conducted a cross-sectional study in two hospital wards experiencing ongoing large outbreaks. Sampling of the environment was undertaken in two distinct phases. During phase 1, 38 shower drains and 38 toilet bowls, defined as the wet environment, were sampled using swabs. Phase 2 consisted in sampling adjacent dry surfaces, using wipes in rooms that had tested positive during phase 1. Samples were plated on a selective medium (chromID®CARBASMART, bioMérieux). Species were identified using the matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF) technique. Carbapenemases were detected by OKNVI RESIST-5® (CORIS BioConcept).

RESULTS

From the 38 patient rooms, 76 samples were taken during phase 1. All in all, 33 (86.8%) rooms presented at least one CPE reservoir in the wet environment; there were 32 (84.2%) contaminated shower drains and six (15.8%) contaminated toilet bowls. Among 57 identified CPEs, the most frequent strain was Enterobacter cloacae VIM (13, 22.8%). During phase 2, 11 (8.3%) out of 132 samples tested positive for CPE. Enterobacter cloacae complex VIM accounted for six (54.5%) of the CPE strains.

CONCLUSION

These findings suggest that the wet hospital environments were broadly contaminated with CPE, mostly Enterobacter cloacae VIM. The spread of CPE from wet environments to dry surfaces seemed limited.

Reducing the particles generated by flushing institutional toilets. Part II: Assessing a portable and reusable toilet cover in U.S. hospitals

Flushing uncovered toilets in hospitals has been shown to produce toilet plume aerosols (TPA) in a wide size ranging from nanometers to micrometers. Studies have shown that TPA can carry infectious pathogens and hazardous drugs used in cancer treatment. To mitigate the risk of exposure, some researchers have recommended covering the toilet during flushing, and guidelines from the Oncology Nursing Society have specifically recommended covering the toilet when flushing excreta from patients receiving chemotherapy. Because existing literature primarily focused on controlled laboratory settings or small case studies, there has been a need for a real-world, multi-center study in clinical settings to measure TPA by flushing both covered and un-covered toilets. To address this gap, the authors initiated a multicenter study to measure TPA in clinical settings and to assess the effectiveness of a commercially available, portable, and reusable toilet cover. The study enrolled 15 hospital centers (145 toilets) in nine U.S. states which included seven National Cancer Institute (NCI)-designated comprehensive cancer centers. The particle number concentrations were measured using a TSI optical particle counter (TSI 9306) with six size bins (0.3 to 25.0 µm) positioned 22 inches above the floor. The results showed that the ambient particle number concentrations in the HEPA-filtered floor bathrooms (376 ± 857#/L) are significantly lower than the non-HEPA-filtered ones (7,432 ± 9,207#/L). The mean particle number concentrations generated by flushing are 3,951 ± 8,606#/L with a median of 1,916#/L, ranging from 136#/L to 71,959#/L. Results with cover demonstrated a reduction in the total number of particles of 101 ± 11% regardless of the HEPA filter usage (p = 0.0002 in the Mann-Whitney U test). Mixed-effects modeling revealed that the overall level of particle reduction is substantial regardless of state (nine total), floor levels, flush volumes, and inpatient versus outpatient. This study provides evidence supporting the use of the tested portable toilet cover as an intervention to reduce healthcare workers', patients', and visitors' exposure to toilet plume aerosols in clinical settings.

Exploring toilet plume bioaerosol exposure dynamics in public toilets using a Design of Experiments approach

Bioaerosols generated during toilet flushing can contribute to the spread of airborne pathogens and cross-contamination in indoor environments. This presents an increased risk of fomite-mediated or aerosol disease transmission. This study systematically investigated the factors contributing to increased bioaerosol exposure following toilet flushing and developed an empirical model for predicting the exposure-relevant bioaerosol concentration. Air in a toilet cubicle was sampled by impaction after seeding with Clostridium difficile spores. Design of Experiments (DoE) main effects screening and full factorial design approaches were then employed to investigate the significant factors that heighten the risk of exposure to bioaerosols post-flush. Our findings reveal that the inoculated bacterial concentration (C), time elapsed after flushing (t), lateral distance (d), and mechanical ventilation (v) are significant predictors of bioaerosol concentration, with p-values < 0.05. The interaction term, C × d showed a marked increase in bioaerosol concentration up to 232 CFU/m3 at the closest proximity and highest pathogen load. The interplay of C and t (C × t) demonstrated a time-dependent attenuation of bioaerosol viability, with concentrations peaking at 241 CFU/m3 immediately post-flush and notably diminishing over time. The lateral distance and time post-flush (d × t) interaction also revealed a gradual decrease in bioaerosol concentration, highlighting the effectiveness of spatial and temporal dilution in mitigating bioaerosol exposure risks. Furthermore, there is an immediate rise in relative humidity levels post-flush, impacting the air quality in the toilet environment. This study not only advances our understanding of exposure pathways in determining bioaerosol exposure, but also offers pivotal insights for designing targeted interventions to reduce bioaerosol exposure. Recommendations include designing public toilets with antimicrobial surfaces, optimizing ventilation, and initiating timely disinfection protocols to prioritise surfaces closest to the toilet bowl during peak exposure periods, thereby promoting healthier indoor environments and safeguarding public health in high-traffic toilet settings.

The Occupational and Environmental Hazards of Uncovered Toilets

ABSTRACT

Substantial evidence demonstrates that plumes from uncovered toilets potentially expose nurses and other health care workers to aerosols containing infectious agents and hazardous drugs, including antineoplastic drugs. Most hospitals in the United States utilize flushometer-type toilets, which operate under high pressure and do not have a permanently attached closure or lid, which is known to reduce the aerosols generated by flushing. This article aims to raise awareness among nurses of the potential exposure risks associated with toilet plume aerosols, so they can educate other health care workers and take part in initiatives to address these risks.

Update on potential interventions to reduce the risk for transmission of health care-associated pathogens from floors and sinks

Health care facility floors and sink drains and other wastewater drainage sites are universally contaminated with potential pathogens and there are plausible mechanisms by which organisms can be disseminated from these sites. However, floors and sink drains are not addressed as potential sources of pathogen transmission in most health care facilities. One factor that has hindered progress in addressing floors and sinks has been the lack of practical and effective measures to reduce the risk for dissemination of organisms from these sites. This article provides an update on some of the potential interventions being used to reduce the risk for transmission of health care-associated pathogens from floors and sinks. Practical approaches to address these sites of contamination are emphasized.

Toilet plume bioaerosols in health care and hospitality settings: A systematic review

BACKGROUND

The spread of some respiratory and gastro-intestinal infections has been linked to the exposure to infectious bioaerosols released after toilet flushing. This represents a health hazard and infection risk for immunocompromised patients, health workers and the public, particularly within the health care and hospitality settings. This systematic review provides current knowledge and identifies gaps in the evidence regarding toilet plume bioaerosols and the potential contributory role in spreading infections in health care and hospitality settings.

METHODS

The PRISMA guidelines were used. Searches were run in PubMed, Scopus, and Google Scholar from 1950 to 30th June 2021. Searches of global and regional reports and updates from relevant international and governmental organizations were also conducted.

RESULTS AND CONCLUSION

The search yielded 712 results, and 37 studies were finally selected for this review. There is a lack of national and international bioaerosol sampling and exposure standards for health care and hospitality settings. Toilet plume bioaerosols are complex in nature, thus, measured bioaerosol concentrations in these settings depend on many variables and may differ for every pathogen responsible for a particular infectious disease. The contact and airborne transmission risks posed by toilet plume bioaerosols also remain unquantified. They are an important pathway that can increase the exposure to enteric and airborne pathogens. Hence, quantitative risk assessment and related research are needed to investigate these transmission risks.

Spread of flushing-generated fecal aerosols in a squat toilet cubicle: Implication for infection risk

Toilet flushing generates and spread fecal aerosols, potentially leading to infection transmission risk. Squat toilets are widely used in public restrooms in some Asian countries including China and India, and remain to be studied. Aerosol dispersion while flushing squat toilet in cubicle was visualized, while the aerosol concentrations were measured on different surfaces by monitoring fluorescence intensity through seeding simulated fluorescence feces. Flushing-generated fecal aerosols could spread to the breathing zone, deposit on floor, and partitions in squat toilet cubicles, and spread even beyond to the restroom lobby. A total of 0.24 % and 0.17 % of seeded fecal waste deposits on the floor and partition (lower than 0.20 m) for each flush. Aerosol concentration decays rapidly, with 86.8 ± 2.2 % reduction in the second minute after a previous flush compared to that in the first minute. Public toilet users are recommended to wait for 2 min after the early flush before entering the cubicle.

Commercial toilets emit energetic and rapidly spreading aerosol plumes

Aerosols can transmit infectious diseases including SARS-CoV-2, influenza and norovirus. Flushed toilets emit aerosols that spread pathogens contained in feces, but little is known about the spatiotemporal evolution of these plumes or the velocity fields that transport them. Using laser light to illuminate ejected aerosols we quantify the kinematics of plumes emanating from a commercial flushometer-type toilet, and use the motion of aerosol particles to compute velocity fields of the associated flow. The toilet flush produces a strong chaotic jet with velocities exceeding 2 m/s; this jet transports aerosols to heights reaching 1.5 m within 8 seconds of initiating a flush. Quantifying toilet plumes and associated flow velocities provides a foundation for future design strategies to mitigate plume formation or to disinfect pathogens within it.

Particle exposure risk to a lavatory user after flushing a squat toilet

Squat toilets are widely used in developing countries due to local customs and low costs. The flushing of a squat toilet can entrain strong airflow and produce aerosols. This investigation constructed a lavatory mock-up with a squat toilet. The flushing-induced airflow was both visualized and quantitatively measured by particle image velocimetry. The maximum height of the impacted airflow was identified by an ultrasonic anemometer. For inference of the particle emission rate, the toilet bowl was covered by an enclosed box for particle concentration measurement. The risks from skin contact of the deposited particles on the flushing button and the door handle and the possible inhalation of the released aerosols were evaluated. The results revealed that flushing a squat toilet can drive toilet plume to rise up to 0.9 m above the toilet bowl. A single flushing process can produce 0.29 million particles with diameters greater than 0.3 μm, among which 90% of the particles are submicron-sized. The flushing may cause particles to deposit on the flushing button and lavatory door handle as well as inhalation exposure even remaining in the lavatory for half a minute after flushing, especially for those lavatory users whose respiratory zones are below 1.0 m.

Reducing the particles generated by flushing institutional toilets

Airborne particles play a significant role in the transmission of SARS-CoV-2, the virus that causes COVID-19. A previous study reported that institutional flush-O-meter (FOM) toilets can generate 3-12 times as many droplets as other toilets by splashing (large droplets) and bubble bursting (fine droplets). In this study, an aerosol suppression lid was evaluated to measure the reduction of particles by size using three metrics; number, surface area, and mass concentrations. To quantify toilet flush aerosol over time, detailed particle size distributions (from 0.016-19.81 µm across 152 size bins) were measured from a FOM toilet in a controlled-environment test chamber, without ventilation, with and without use of the suppression lid. Prior to each flushing trial, the toilet bowl water was seeded with 480 mL fluorescein at 10 mg/mL. A high-speed camera was used to record the large droplet movements after flushing. An ultraviolet-visible spectrophotometer was used to analyze the wipe samples to evaluate the contamination on the lid. The particle number, surface area, and mass concentrations without a lid were elevated compared to a lid in the first 90 sec. Overall, the lid reduced 48% of total number concentration, 76% of total surface area concentration, and 66% of total mass concentration, respectively. Depending on the particle size, the number concentration reduction percentage ranged from 48-100% for particles larger than 0.1 µm. Large droplets created by splashing were captured by the high-speed camera. Similar studies can be used for future particle aerodynamic studies. The fluorescein droplets deposited on the lid back sections, which were closer to the FOM accounted for 82% of the total fluorescein. Based on two-way ANOVA analysis, there were significant differences among both the experimental flushes (p = 0.0185) and the sections on the lid (p = 0.0146). Future work should explore the aerosolization produced by flushing and the performance of the lid in real restroom environments, where feces and urine exist in the bowl water and the indoor ventilation system is in operation.

Certain Rooms in Intensive Care Units May Harbor Risk for Clostridioides difficile Infection

Abstract Background: Clostridioides difficile infection (CDI) is a common and sometimes life-threatening illness. Patient-, care-, and room hygiene-specific factors are known to impact CDI genesis, but care provider training and room topography have not been explored. We sought to determine if care in specific intensive care unit (ICU) rooms asymmetrically harbored CDI cases. Patients and Methods: Surgical intensive care unit (SICU) patients developing CDI (July 2009 to June 2018) were identified and separated by service (green/gold). Each service cared for their respective 12 rooms, otherwise differing only in resident team composition (July 2009 to August 2017: green, anesthesia; gold, surgery; August 2017 to June 2018: mixed for both). Fixed/mobile room features and provider traffic in three room zones (far/middle/near in relation to the toilet) were compared between high-/low-incidence rooms using observation via telecritical care video cameras. Results: Seventy-four new CDI cases occurred in 7,834 consecutive SICU admissions. In period one, green CDI cases were almost double gold cases (39 vs. 21; p = 0.02) but were similar in period two in which trainee service allocation intermixed. High-incidence rooms had closer toilet-to-intravenous pole proximity than low-incidence rooms (7.7 + 1.8 feet vs. 3.9 + 1.5 feet; p = 0.02). High-incidence rooms consistently housed mobile objects (patient bed, table-on-wheels) farther away from the toilet. Although physician time spent in each zone was similar, nurses spending more than 15 minutes in-room more frequently stayed in the far/middle zones in high-incidence rooms. Conclusions: Distinct SICU room features relative to toilet location and bedside clinician behaviors interact to alter patient CDI acquisition risk. This suggests that CDI risk occurs as a structural aspect of ICU care, offering the potential to reduce patient risk through deliberate room redesign.

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.

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.

On the Critical Role of Human Feces and Public Toilets in the Transmission of COVID-19: Evidence from China

The surprising spread speed of the COVID-19 pandemic creates an urgent need for investigating the transmission chain or transmission pattern of COVID-19 beyond the traditional respiratory channels. This study therefore examines whether human feces and public toilets play a critical role in the transmission of COVID-19. First, it develops a theoretical model that simulates the transmission chain of COVID-19 through public restrooms. Second, it uses stabilized epidemic data from China to empirically examine this theory, conducting an empirical estimation using a two-stage least squares (2SLS) model with appropriate instrumental variables (IVs). This study confirms that the wastewater directly promotes the transmission of COVID-19 within a city. However, the role of garbage in this transmission chain is more indirect in the sense that garbage has a complex relationship with public toilets, and it promotes the transmission of COVID-19 within a city through interaction with public toilets and, hence, human feces. These findings have very strong policy implications in the sense that if we can somehow use the ratio of public toilets as a policy instrument, then we can find a way to minimize the total number of infections in a region. As shown in this study, pushing the ratio of public toilets (against open defecation) to the local population in a city to its optimal level would help to reduce the total infection in a region.

Utilization of Antibacterial Nanoparticles in Photocurable Additive Manufacturing of Advanced Composites for Improved Public Health

This paper presents the additive manufacturing and characterization of nanoparticle-reinforced photocurable resin-based nanocomposites with a potential antimicrobial function for improved public health applications. Two types of photocurable resins are reinforced by titanium dioxide (TiO₂) or zinc oxide (ZnO) nanoparticles with average diameters in the 10-30 nm range to provide antimicrobial properties. The developed nanocomposites can be additively manufactured using the digital light processing method with an outstanding surface quality and precise geometrical accuracy. Experimental characterizations are conducted to investigate key mechanical properties of the 3D printed nanocomposites, including Young's Modulus, tensile strength, and abrasion resistance. Specimens produced were observed to demonstrate the following characteristics during testing. Tensile strength increased by 42.2% at a maximum value of 29.53 MPa. The modulus of elasticity increased by 14.3%, and abrasion resistance increased by 15.8%. The proper dispersion of the nanoparticles within the cured resin is validated by scanning electron images. The wettability and water absorption testing results indicate that the developed nanocomposites have an outstanding water resistance capability. The pairing of digital light processing with these novel nanocomposites allows for the creation of complex composite geometries that are not capable through other manufacturing processes. Therefore, they have the potential for long-term usage to improve general public health with antimicrobial functionality. The pairing of an unmodified photocurable resin with a 1% ZnO concentration demonstrated the most promise for commercial applications.

Opportunities for Nanomedicine in Clostridioides difficile Infection

Clostridioides difficile, a spore-forming bacterium, is a nosocomial infectious pathogen which can be found in animals as well. Although various antibiotics and disinfectants were developed, C. difficile infection (CDI) remains a serious health problem. C. difficile spores have complex structures and dormant characteristics that contribute to their resistance to harsh environments, successful transmission and recurrence. C. difficile spores can germinate quickly after being exposed to bile acid and co-germinant in a suitable environment. The vegetative cells produce endospores, and the mature spores are released from the hosts for dissemination of the pathogen. Therefore, concurrent elimination of C. difficile vegetative cells and inhibition of spore germination is essential for effective control of CDI. This review focused on the molecular pathogenesis of CDI and new trends in targeting both spores and vegetative cells of this pathogen, as well as the potential contribution of nanotechnologies for the effective management of CDI.

Aerosol generation in public restrooms

Aerosolized droplets play a central role in the transmission of various infectious diseases, including Legionnaire's disease, gastroenteritis-causing norovirus, and most recently COVID-19. Respiratory droplets are known to be the most prominent source of transmission for COVID-19; however, alternative routes may exist given the discovery of small numbers of viable viruses in urine and stool samples. Flushing biomatter can lead to the aerosolization of micro-organisms; thus, there is a likelihood that bioaerosols generated in public restrooms may pose a concern for the transmission of COVID-19, especially since these areas are relatively confined, experience heavy foot traffic, and may suffer from inadequate ventilation. To quantify the extent of aerosolization, we measure the size and number of droplets generated by flushing toilets and urinals in a public restroom. The results indicate that the particular designs tested in the study generate a large number of droplets in the size range 0.3   μ m - 3   μ m , which can reach heights of at least 1.52 m. Covering the toilet reduced aerosol levels but did not eliminate them completely, suggesting that aerosolized droplets escaped through small gaps between the cover and the seat. In addition to consistent increases in aerosol levels immediately after flushing, there was a notable rise in ambient aerosol levels due to the accumulation of droplets from multiple flushes conducted during the tests. This highlights the need for incorporating adequate ventilation in the design and operation of public spaces, which can help prevent aerosol accumulation in high occupancy areas and mitigate the risk of airborne disease transmission.

Bioaerosol emissions from activated sludge basins: Characterization, release, and attenuation

This article presents a critical review of the peer-reviewed literature related to bioaerosol generation from activated sludge basins. Characterization techniques include a variety of culture- and nonculture-based techniques, each with unique features. Bioaerosols contain a variety of clinical pathogens including Staphylococcus saprophyticus, Clostridium perfringens, and Salmonella enteritidis; exposure to these microorganisms increases human health risks. Release mechanisms involve splashing and bubble burst dynamics. Larger bubbles emit more aerosol particles than smaller ones. Attenuation strategies include covering sources with lids, adjusting the method and intensity of aeration, and using free-floating carrier media. Future studies should combine culture and non-culture based methods, and expand chemical databases and spectral libraries in order to realize the full power of real-time online monitoring.

The bioaerosols emitted from toilet and wastewater treatment plant: a literature review

The aerosols harboring microorganisms and viruses released from the wastewater system into the air have greatly threatened the health and safety of human beings. The wastewater systems, including toilet and wastewater treatment plant (WWTP), are the major locations of epidemic infections due to the extensive sources of aerosols, as well as multifarious germs and microorganisms. Viruses and microorganisms may transport from both toilet and hospital into municipal pipes and subsequently into WWTP, which accounts for the main source of bioaerosols dispersed in the air of the wastewater system. This review aims to elaborate the generation, transmission, and diffusion processes of bioaerosols at toilet and WWTP. Moreover, the main factors affecting bioaerosol transmission and the corresponding prevention strategies for the airborne and inhaled bioaerosols are also discussed. Collectively, this review highlights the importance of managing bioaerosol occurrence in the wastewater system, which has aroused increasing concern from the public.

Comparison and evaluation of a high volume air sampling system for the collection of Clostridioides difficile endospore aerosol in health care environments

BACKGROUND

Environmental contamination of patient rooms and adjacent areas with C. difficile spores is a recognized transmission risk. Previous studies have shown that spores are aerosolized during patient care. These spores can remain airborne for extended periods and may contaminate distant surfaces. High-volume air sampling equipment allows for the collection of a large volume of air and was evaluated in the collection of C. difficile aerosol.

METHOD

Air samplers evaluated in this research included the DFU-1000, XMX/2L-MIL, Biocapture-650, and a MB2. Aerosols of C. difficile were generated in a 5-m³ chamber and each air sampler sampled in the aerosol test chamber simultaneously with referee air samplers.

RESULTS

The DFU-1000 achieved the highest efficiency of the 4 air samplers (P = .0145) with a mean efficiency of 38.60%. The relative efficiencies of the Biocapture-650, XMX/2L-MIL, and MB2 were 28.16%, 10.51%, and 3.05%, respectively.

DISCUSSION/CONCLUSIONS

This study demonstrated high variation based on the sampling method employed. Based on the results of these studies, high-volume air samplers may be effectively applied to sample for airborne C. difficile in health care environments. The high sampling flow rate of the DFU-1000 would allow for the complete sampling of a patient room-sized volume in less than 1 hour.

Bathroom contamination by antibiotic-resistant Enterobacterales (ESBLPE and CPE): an experimental study

BACKGROUND

Extended-spectrum β-lactamase-producing Enterobacterales (ESBLPE) and carbapenemase-producing Enterobacterales (CPE) cause serious infections. Their presence in urine may lead to environmental contamination potentially responsible for cross-transmission.

AIM

To evaluate the level of spraying and contamination after emptying urine in the toilet and rinsing in the sink, a common practice in the healthcare setting.

METHODS

For each test, the procedure was similar: seat raised, emptying urinal bottle into the toilet at the height of the bowl, rinsing in the sink and flushing. To study splash-drops, water and fluorescein were mixed in the urinal bottle. In each area, the splash-drops frequency and level were assessed with UV. To study contamination, three ESBLPE and one CPE were diluted in saline, 10⁶/mL. Contamination was assessed by sampling before, immediately after and 3 h after the test. The swabs were cultured and the colonies counted and identified.

FINDINGS

The areas at the highest risk of spraying were the toilet bowl contour (N = 36/36), the underside of the toilet seat (N = 34) and the inside of the sink (N = 34). Except for gloves (N = 14), there was low clothing contamination. The most frequently contaminated areas were inside the sink (40/48), where the highest levels of contamination were found (14/48).

CONCLUSION

Emptying the urinal bottles in the toilet followed by sink rinsing is associated with a significant risk of projection and contamination, depending on the area (highest risk at the sink), but the bacteria did not survive beyond 3 h. This practice, which carries a risk of cross-transmission, should be reviewed.

Viable bacterial communities on hospital window components in patient rooms

Previous studies demonstrate an exchange of bacteria between hospital room surfaces and patients, and a reduction in survival of microorganisms in dust inside buildings from sunlight exposure. While the transmission of microorganisms between humans and their local environment is a continuous exchange which generally does not raise cause for alarm, in a hospital setting with immunocompromised patients, these building-source microbial reservoirs may pose a risk. Window glass is often neglected during hospital disinfection protocols, and the microbial communities found there have not previously been examined. This pilot study examined whether living bacterial communities, and specifically the pathogens Methicillin-resistant Staphylococcus aureus (MRSA) and Clostridioides difficile (C. difficile), were present on window components of exterior-facing windows inside patient rooms, and whether relative light exposure (direct or indirect) was associated with changes in bacterial communities on those hospital surfaces. Environmental samples were collected from 30 patient rooms in a single ward at Oregon Health & Science University (OHSU) in Portland, Oregon, USA. Sampling locations within each room included the window glass surface, both sides of the window curtain, two surfaces of the window frame, and the air return grille. Viable bacterial abundances were quantified using qPCR, and community composition was assessed using Illumina MiSeq sequencing of the 16S rRNA gene V3/V4 region. Viable bacteria occupied all sampled locations, but was not associated with a specific hospital surface or relative sunlight exposure. Bacterial communities were similar between window glass and the rest of the room, but had significantly lower Shannon Diversity, theorized to be related to low nutrient density and resistance to bacterial attachment of glass compared to other surface materials. Rooms with windows that were facing west demonstrated a higher abundance of viable bacteria than those facing other directions, potentially because at the time of sampling (morning) west-facing rooms had not yet been exposed to sunlight that day. Viable C. difficile was not detected and viable MRSA was detected at very low abundance. Bacterial abundance was negatively correlated with distance from the central staff area containing the break room and nursing station. In the present study, it can be assumed that there is more human traffic in the center of the ward, and is likely responsible for the observed gradient of total abundance in rooms along the ward, as healthcare staff both deposit more bacteria during activities and affect microbial transit indoors. Overall, hospital window components possess similar microbial communities to other previously identified room locations known to act as reservoirs for microbial agents of hospital-associated infections.

Can a toilet promote virus transmission? From a fluid dynamics perspective

Currently, a novel coronavirus named "SARS-CoV-2" is spreading rapidly across the world, causing a public health crisis, economic losses, and panic. Fecal-oral transmission is a common transmission route for many viruses, including SARS-CoV-2. Blocking the path of fecal-oral transmission, which occurs commonly in toilet usage, is of fundamental importance in suppressing the spread of viruses. However, to date, efforts at improving sanitary safety in toilet use have been insufficient. It is clear from daily experience that flushing a toilet generates strong turbulence within the bowl. Will this flushing-induced turbulent flow expel aerosol particles containing viruses out of the bowl? This paper adopts computational fluid dynamics to explore and visualize the characteristics of fluid flow during toilet flushing and the influence of flushing on the spread of virus aerosol particles. The volume-of-fluid (VOF) model is used to simulate two common flushing processes (single-inlet flushing and annular flushing), and the VOF-discrete phase model (DPM) method is used to model the trajectories of aerosol particles during flushing. The simulation results are alarming in that massive upward transport of virus particles is observed, with 40%-60% of particles reaching above the toilet seat, leading to large-scale virus spread. Suggestions concerning safer toilet use and recommendations for a better toilet design are also provided.