July 31st 2013: Lifting the lid on toilet hygiene

Over the years, there has been constant debate about whether and to what extent western toilets might be a route of transmission of infection. In Western Europe, for a long time, the general “expert” consensus was that, for a “normal healthy household”, the infection risk from the toilet was negligible. However, although it seems likely that the risks are less than those associated with hands and high frequency contact surfaces, there is now a feeling that there may be some risk, particularly where someone in the home is vomiting into the toilet or has fluid diarrhoea. The concerns relate both to direct transmission via inhalation of aerosols generated during flushing, as well as surface and hand transfer resulting from aerosol deposition on surfaces around the toilet. This article gives a comprehensive review of the data on this subject that has accumulated from various sources over the past 60−70 years, and highlights some of the changes that have occurred to influence opinion. Some of the change in attitudes has come from increasing concerns about viruses, particularly norovirus, the emergence of C. difficile, and the ongoing shift towards shorter hospital stays and increased care of vulnerable groups in the community. The review  includes a compilation of the epidemiological studies of disease outbreaks such as norovirus and SARS and the possible relationship to spread via toilet aerosols. The review can be found at: American Journal of Infection Control 2013;41:254-8.