A mixed-methods study on toilet hygiene practices among Chinese in Hong Kong

Retrospective genome-oriented analysis reveals low transmission rate of multidrug-resistant Pseudomonas aeruginosa from contaminated toilets at a bone marrow transplant unit

BACKGROUND

Prevention of toilet-to-patient transmission of multidrug-resistant Pseudomonas aeruginosa (MDR PA) poses management-related challenges at many bone marrow transplant units (BMTUs).

AIM

To conduct a longitudinal retrospective analysis of the toilet-to-patient transmission rate for MDR PA under existing infection control (IC) measures at a BMTU with persistent MDR PA toilet colonization.

METHODS

The local IC bundle comprised: (1) patient education regarding IC; (2) routine patient screening; (3) toilet flushing volume of 9 L; (4) bromination of toilet water tanks, and (5) toilet decontamination using hydrogen peroxide. Toilet water was sampled periodically between 2016 and 2021 (minimum every three months: 26 intervals). Upon MDR PA detection, disinfection and re-sampling were repeated until ≤3 cfu/100 mL was reached. Whole-genome sequencing (WGS) was performed retrospectively on all available MDR PA isolates (90 out of 117 positive environmental samples, 10 out of 14 patients, including nine nosocomial).

FINDINGS

WGS of patient isolates identified six sequence types (STs), with ST235/CT1352/FIM-1 and ST309/CT3049/no-carbapenemase being predominant (three isolates each). Environmental sampling consistently identified MDR PA ST235 (65.5% ST235/CT1352/FIM-1), showing low genetic diversity (difference of ≤29 alleles by core-genome multi-locus sequence typing (cgMLST)). This indicates that direct toilet-to-patient transmission was infrequent although MDR PA was widespread (detection on 79 occasions, detection in every toilet). Only three MDR PA patient isolates can be attributed to the ST235/CT1352/FIM-1 toilet MRD PA population over six years.

CONCLUSION

Stringent targeted toilet disinfection can reduce the potential risk for MDR PA acquisition by patients.

Assessment of water, sanitation, and hygiene among women living in precarious households in a Turkish urban area

BACKGROUND

This study aimed to identify the determinants of water, sanitation, and hygiene (WASH) behaviors and conditions among women in poor neighborhoods in Izmir, Turkey, and to develop a scale for assessing WASH behaviors and conditions that is specifically designed for use in precarious urban areas.

METHODS

The study used a cross-sectional design, as well as a methodological feature for developing the scale. The sample size was calculated as 243 households out of 2667 households in the Basmane neighborhood, with a 95% confidence interval and a 6% margin of error, and a woman who was responsible for cleaning was invited to participate from each household. The scales for WASH behaviors and conditions, which served as dependent variables, were developed in a four-stage process, yielding two distinct scales. The WASH-Behaviors Scale had 14 items about hand, body, and home hygiene, whereas the WASH-Conditions in Households Scale included 16 items about variables like area per capita, physical structure, and cleaning tool availability. Age, ethnicity, number of children, education, work status, and income were among the independent variables. Data was collected through household visits. The scales' validity was evaluated using exploratory factor analysis. Linear logistic regression analysis was employed to assess the determinants of WASH behaviors.

RESULTS

The women, with an average age of 40.65 ± 14.35 years, faced economic challenges, as a substantial portion earned an income below the minimum wage. More than half of them were uninsured, and 72.6% were identified as migrants or refugees. Factor analysis confirmed the compatibility of both scales (KMO = 0.78-0.80, p < 0.05), elucidating 52-54% of the total variance. Factors such as ethnicity, number of children, husband's education level, income perception, and WASH conditions explained 48% of WASH behaviors.

CONCLUSIONS

WASH-Behaviors and WASH-Conditions in Households scales met the validity criterion, and their scores were related to basic sociodemographic and economic characteristics like education, income, household size, and ethnicity. The scale development process emphasized the importance of considering both behaviors and household conditions, albeit using different techniques. The findings indicated that WASH conditions are more problematic than behaviors, and that behavioral interventions will not work unless the conditions are corrected.

Perceived Use Cases, Barriers, and Requirements for a Smart Health-Tracking Toilet Seat: Qualitative Focus Group Study

BACKGROUND

Smart bathroom technology offers unrivaled opportunities for the automated measurement of a range of biomarkers and other data. Unfortunately, efforts in this area are mostly driven by a technology push rather than market pull approach, which decreases the chances of successful adoption. As yet, little is known about the use cases, barriers, and desires that potential users of smart bathrooms perceive.

OBJECTIVE

This study aimed to investigate how participants from the general population experience using a smart sensor-equipped toilet seat installed in their home. The study contributes to answering the following questions: What use cases do citizens see for this innovation? and What are the limitations and barriers to its everyday use that they see, including concerns regarding privacy, the lack of fit with everyday practices, and unmet expectations for user experience?

METHODS

Overall, 31 participants from 30 households participated in a study consisting of 3 (partially overlapping) stages: sensitizing, in which participants filled out questionnaires to trigger their thoughts about smart bathroom use and personal health; provotyping, in which participants received a gentle provocation in the form of a smart toilet seat, which they used for 2 weeks; and discussion, in which participants took part in a web-based focus group session to discuss their experiences.

RESULTS

Participants mostly found the everyday use of the toilet, including installation and dismantling when necessary, to be relatively easy and free of complications. Where complications occurred, participants mentioned issues related to the design of the prototype, technology, or mismatches with normal practices in using toilets and hygiene. A broad range of use cases were mentioned, ranging from signaling potentially detrimental health conditions or exacerbations of existing conditions to documenting physical data to measuring biomarkers to inform a diagnosis and behavioral change. Participants differed greatly in whether they let others use, or even know about, the seat. Ownership and control over their own data were essential for most participants.

CONCLUSIONS

This study showed that participants felt that a smart toilet seat could be acceptable and effective, as long as it fits everyday practices concerning toilet use and hygiene. The range of potential uses for a smart toilet seat is broad, as long as privacy and control over disclosure and data are warranted.

Exploring expectations of Chinese patients for total knee arthroplasty: once the medicine is taken, the symptoms vanish

BACKGROUND

Preoperative expectations of total knee arthroplasty (TKA) outcomes are important determinants of patient satisfaction. However, expectations of patients in different countries are affected by cultural background. The general goal of this study was to describe Chinese TKA patients' expectations.

METHODS

Patients scheduled for TKA were recruited in a quantitative study(n = 198). The Hospital for Special Surgery Total Knee Replacement Expectations Survey Questionnaire was used for survey TKA patients' expectations. Descriptive phenomenological design was used for the qualitative research. Semi-structured interviews were conducted with 15 TKA patients. Colaizzi's method was used for interview data analysis.

RESULTS

The mean expectation score of Chinese TKA patients was 89.17 points. The 4 highest score items were walk short distance, remove the need for walker, relieve pain and make knee or leg straight. The 2 lowest score items were employed for monetary reimbursement and sexual activity. Five main themes and 12 sub-themes emerged from the interview data, including multiple factors raised expectations, expectations of physical comfort, expect various activities back to normal, hope for a long joint lifespan, and expect a better mood.

CONCLUSIONS

Chinese TKA patients reported a relatively high level of expectations, and differences across cultures result in different expectation points than other national populations, requiring adjustment of items when using assessment tools across cultures. Strategies for expectation management should be further developed.

LEVEL OF EVIDENCE

Level IV.

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.

Suitability of aircraft wastewater for pathogen detection and public health surveillance

International air travel is now widely recognised as one of the primary mechanisms responsible for the transnational movement and global spread of SARS-CoV-2. Monitoring the viral load and novel lineages within human-derived wastewater collected from aircraft and at air transport hubs has been proposed as an effective way to monitor the importation frequency of viral pathogens. The success of this approach, however, is highly dependent on the bathroom and defecation habits of air passengers during their journey. In this study of UK adults (n = 2103), we quantified the likelihood of defecation prior to departure, on the aircraft and upon arrival on both short- and long-haul flights. The results were then used to assess the likelihood of capturing the signal from infected individuals at UK travel hubs. To obtain a representative cross-section of the population, the survey was stratified by geographical region, gender, age, parenting status, and social class. We found that an individual's likelihood to defecate on short-haul flights (< 6 h in duration) was low (< 13 % of the total), but was higher on long-haul flights (< 36 %; > 6 h in duration). This behaviour pattern was higher among males and younger age groups. The maximum likelihood of defecation was prior to departure (< 39 %). Based on known SARS-CoV-2 faecal shedding rates (30-60 %) and an equal probability of infected individuals being on short- (71 % of inbound flights) and long-haul flights (29 %), we estimate that aircraft wastewater is likely to capture ca. 8-14 % of SARS-CoV-2 cases entering the UK. Monte Carlo simulations predicted that SARS-CoV-2 would be present in wastewater on 14 % of short-haul flights and 62 % of long-haul flights under current pandemic conditions. We conclude that aircraft wastewater alone is insufficient to effectively monitor all the transboundary entries of faecal-borne pathogens but can form part of a wider strategy for public heath surveillance at national borders.

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.

Big Data-Driven Measurement of the Service Capacity of Public Toilet Facilities in China

Public health facility planning is one of the important contents of national land planning, which needs to balance geospatial equity and service capacity. However, assessment models and data acquisition methods based on a geosystemic analysis perspective have been lacking for a long time. By focusing on urban public toilets and taking the highly urbanized city of Shenyang, China as the study area, this study developed a new data strategy for urban public facilities with points of interests (POI) big data as the main data source, and subsequently corrected the POI data and analyzed the errors through a field survey, and conducted an empirical assessment oriented toward spatial equity and service capacity to discover the development dynamics of urban facilities over the past ten years and the impacting factors. We found that the integrated population and spatial elements could more accurately evaluate the service capacity of public toilets. Meanwhile, POI data have value in the research of public health facilities, but there are some errors in data quality and data access. The study empirically explores the geographic analysis methods of field research data (small data) and POI data (big data) with empirical contributions.

Aerosol transmission of SARS-CoV-2 due to the chimney effect in two high-rise housing drainage stacks

Stack aerosols are generated within vertical building drainage stacks during the discharge of wastewater containing feces and exhaled mucus from toilets and washbasins. Fifteen stack aerosol-related outbreaks of coronavirus disease 2019 (COVID-19) in high-rise buildings have been observed in Hong Kong and Guangzhou. Currently, we investigated two such outbreaks of COVID-19 in Hong Kong, identified the probable role of chimney effect-induced airflow in a building drainage system in the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We injected tracer gas (SF6) into the drainage stacks via the water closet of the index case and monitored tracer gas concentrations in the bathrooms and along the facades of infected and non-infected flats and in roof vents. The air temperature, humidity, and pressure in vertical stacks were also monitored. The measured tracer gas distribution agreed with the observed distribution of the infected cases. Phylogenetic analysis of the SARS-CoV-2 genome sequences demonstrated clonal spread from a point source in cases along the same vertical column. The stack air pressure and temperature distributions suggested that stack aerosols can spread to indoors through pipe leaks which provide direct evidence for the long-range aerosol transmission of SARS-CoV-2 through drainage pipes via the chimney effect.

Confidence to manage menstruation among university students in Australia: Evidence from a cross-sectional survey

Objectives:

There has been increased attention to university students’ experiences of menstrual disorders, and access to menstrual products, in high-income countries. Less attention has been directed to other aspects of their menstrual experience, including confidence for menstrual management. This study aimed to understand the factors affecting university students’ confidence to manage menstruation at university.

Methods:

An online survey was completed by 410 participants (age range: 16–46 years, mean = 20.1 years) who menstruate and study at an Australian university. Participants reported demographic characteristics, confidence to manage menstruation at university, and personal, physical and environmental factors. A Mann–Whitney U-test analysed differences in confidence between groups of students. Pearson’s correlation coefficient and bivariate linear regressions determined associations between factors and confidence. Statistically significant associations were inputted into a multiple linear regression model. P-values less than 0.05 were considered significant.

Results:

A minority of students (16.2%) felt completely confident to manage their menstruation at university. Menstrual knowledge, positive perceptions of menstruation and comfort to discuss menstruation with others positively predicted confidence. Physical menstrual symptoms, negative perceptions of menstruation, perceived stigma and using a menstrual cup or period underwear predicted lower confidence. In multiple regression, private and clean and sanitary university bathroom facilities, changing menstrual products at university, perceived stigma and negative perceptions of menstruation remained significant predictors.

Conclusion:

Most students did not have complete confidence to manage their menstruation at university. Several personal, physical and environmental factors were related to students’ confidence to manage menstruation. Assessment of these factors in future research with university students is recommended to enable a comprehensive understanding of their menstrual needs, and inform interventions aimed at improving their menstrual management confidence at university.

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.

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.

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.