Contact infection risk on Public Toilets Seats:
Surface Contamination Bio-Hazard.
A number of studies have demonstrated the contamination of toilet seats and lids, the surrounding floors, and the nearby surfaces by toilet flush aerosols. 3, 6, 9, 10, 12, 13, 16 Because both the vomit and feces of infected persons may contain extremely high pathogen concentrations, eg, 105 to 109 Shigella, 17 104 to 108 Salmonella, 17 and 108 to 109 norovirus 18 per gram of stool and at least 106 noroviruses per milliliter of vomit, 19 some fraction of the aerosol droplets produced during toilet flushing may be expected to contain microbes.
A critical determinant of the infection risk posed by a deposited pathogen will be the organism’s ability to survive on a surface. 21 Many pathogens, including Shigella, E Coli, C difficile, severe acute respiratory syndrome (SARS) coronavirus can survive on surfaces for weeks or even months. 22 These pathogens can also be present in the vomit or stools of infected persons.
Thorough cleaning and disinfection of environmental surfaces in health care facilities is a foundational component of infection control programs, 26 and disinfection is particularly important because many studies have shown that microbial surface contamination (including C difficile, vancomycin-resistant Enterococcus, and methicillin-resistant Staphylococcus aureus [MRSA]) may persist even after cleaning. 27, 28, 29
The limits of environmental cleaning in preventing the spread of viral disease are apparent with acute gastroenteritis (AGE). AGE is frequently caused by norovirus, and diarrhea and vomiting typically associated with AGE as well as the high viral loads in both stools and vomit suggest a likely toilet role in disease transmission. Environmental contamination has been shown to be a major source of AGE infection on ships, 30, 31, 32, 33, 34, 35 including during sequential voyages of a cruise ship in spite of aggressive sanitation efforts and a documented history of good Centers for Disease Control and Prevention (CDC) Vessel Sanitation Program inspection scores. 34 This may be due in part to the ability of toilets to continue generating contaminated toilet plumes during multiple flushes after original contamination as well as the apparent resistance of norovirus 36 and perhaps other viruses to cleaning and disinfection.
Gerba et al observed that MS2 bacteriophage and poliovirus were not completely cleared from a toilet even after 7 flushes and that scrubbing with or without the addition of a surfactant to the water was only minimally effective in eliminating these residual organisms. 10 The manner in which cleaning and disinfection is performed is also important in ensuring complete disinfection of surfaces, especially when surfaces are heavily contaminated. 37
(Source: Am J Infect Control. 2013 Mar; 41(3): 254–258. Published online 2012 Oct 5.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4692156/)
The COVID-19 pandemic has raised concerns about the potential risk of disease transmission in public washrooms (toilets) via direct inhalation of aerosolised viruses or contact with surfaces contaminated by respiratory droplets or faecal waste.
Faecal shedding seems to occur in COVID-19 patients with or without gastrointestinal symptoms (Gu et al., 2020), which could enable asymptomatic individuals with no respiratory symptoms to be a potential source of faecal transmission (McDermott et al., 2020). This has been indicated as a possible risk in both healthcare (Lane et al., 2020) and non-healthcare (Luo et al., 2020; Wan et al., 2021) settings. Anecdotal evidence suggests that public washrooms have been avoided by users due to the real or perceived risk of COVID-19 transmission in these environments during the pandemic (e.g. Calechman, 2020).
In general, routine use of washrooms may result in the dispersal of urine- and faecal-derived microbiota, including pathogens and opportunistic pathogens (i.e. microorganisms that do not usually infect healthy hosts but may produce infections in immunocompromised persons or in those with certain underlying diseases), and surface contamination is typically found to be higher in public toilets compared to domestic toilets (Flores et al., 2011; Gerhardts et al., 2012). Washrooms in public settings such as commercial sites, workplaces, and healthcare environments, can be unhygienic if subject to high use, and infrequent or substandard cleaning and maintenance.
Source: https://www.sciencedirect.com/science/article/pii/S0048969721050075
The world is in many ways a microbial planet and, as its inhabitants, we carry within us our own microscopic rain forests – which we exchange with the environment and each other all the time. Microbes are abundant throughout the human body, including the skin, mouth, eyes, urinary and genital organs, and gastrointestinal tracts. Most people carry up to a kilogram of microorganisms. These are largely within the gut and comprise bacteria, fungi, yeast, viruses, and sometimes parasites.
Research has shown that microbes from your gut make up 25-54% of fecal matter. Human feces can carry a wide range of transmissible pathogens: Campylobacter, Enterococcus, Escherichia coli, Salmonella, Shigella, Staphylococcus, Streptococcus, and Yersinia bacteria – as well as viruses such as norovirus, rotavirus, and hepatitis A and E, just to name a few.
So of course, there is always going to be an infection risk in encountering fecal matter…
The main risk is either indirect or direct contact with pathogenic (disease-causing) microorganisms within human waste that can cause illness. Pathogenic microorganisms of concern include bacteria, viruses, and protozoa. The diseases they cause vary in severity from mild gastroenteritis to severe and sometimes fatal diarrhea, dysentery, hepatitis, cholera, or typhoid fever. Contact with many pathogenic microorganisms can be reduced by the provision of adequate hand washing facilities and by ensuring that the toilet is designed, constructed, and maintained correctly to enable the removal of human waste.
(Source: Government of Australia. Environmental Health Directorate Public Health Division Department of Health of Western Australia 227 Stubbs Terrace Shenton Park WA 6008 PO Box 8172 Perth Business Centre WA 6849)
Even small amounts of urine left on a toilet seat for up to 45 minutes can result in cross-contamination.
(Source: “CMM and ISSA. Northbrook, IL 60062 USA)
Written by Ezekiel Richardson, MD.
Resident in Emergency Medicine, Northwestern Memorial Hospital in Chicago
Medically reviewed by Jeffrey M. Rothschild, MD, MPH.
Associate Professor of Medicine, Brigham and Women’s Hospital
Last updated January 28, 2021
Mucus is a slippery or slimy substance that is naturally produced by your bowels. It helps lubricate stool as it moves through the bowels and can protect bowel walls from more abrasive foods that you might eat (e.g. small seeds and nuts). It also helps prevent fluid loss from the walls of the colon and keeps them moist. The amount of mucus you’re producing may vary and may be accompanied by stool or blood.
A number of studies have demonstrated the contamination of toilet seats and lids, the surrounding floors, and the nearby surfaces by toilet flush aerosols.3, 6, 9, 10, 12, 13, 16 Because both the vomit and feces of infected persons may contain extremely high pathogen concentrations, eg, 105 to 109 Shigella,17 104 to 108 Salmonella,17 and 108 to 109 norovirus18 per gram of stool and at least 106 noroviruses per milliliter of vomit,19 some fraction of the aerosol droplets produced during toilet flushing may be expected to contain microbes.
A critical determinant of the infection risk posed by a deposited pathogen will be the organism’s ability to survive on a surface.21 Many pathogens, including Shigella, E Coli, C difficile, severe acute respiratory syndrome (SARS) coronavirus, and norovirus can survive on surfaces for weeks or even months.22 These pathogens can also be present in the vomit or stools of infected persons.
In 1956, Hutchinson associated the transmission of Sonne dysentery with Shigella contamination on toilet seats,23 and a number of subsequent field studies have detected contamination on toilet seats and surrounding surfaces with fecal organisms.9, 11, 24, 25
Thorough cleaning and disinfection of environmental surfaces in health care facilities is a foundational component of infection control programs,26 and disinfection is particularly important because many studies have shown that microbial surface contamination (including C difficile, vancomycin-resistant Enterococcus, and methicillin-resistant Staphylococcus aureus [MRSA]) may persist even after cleaning.27, 28, 29
The limits of environmental cleaning in preventing the spread of viral disease are apparent with acute gastroenteritis (AGE). AGE is frequently caused by norovirus, and diarrhea and vomiting typically associated with AGE as well as the high viral loads in both stools and vomit suggest a likely toilet role in disease transmission.
Environmental contamination has been shown to be a major source of AGE infection on ships,30, 31, 32, 33, 34, 35 including during sequential voyages of a cruise ship in spite of aggressive sanitation efforts and a documented history of good Centers for Disease Control and Prevention (CDC) Vessel Sanitation Program inspection scores.34
This may be due in part to the ability of toilets to continue generating contaminated toilet plumes during multiple flushes after original contamination as well as the apparent resistance of norovirus36 and perhaps other viruses to cleaning and disinfection.
Gerba et al observed that MS2 bacteriophage and poliovirus were not completely cleared from a toilet even after 7 flushes and that scrubbing with or without the addition of a surfactant to the water was only minimally effective in eliminating these residual organisms.10 The manner in which cleaning and disinfection is performed is also important in ensuring complete disinfection of surfaces, especially when surfaces are heavily contaminated.37
(Source: Am J Infect Control. 2013 Mar; 41(3): 254–258.
Published online 2012 Oct 5.
Other Rectal Discharges
Rectal discharge refers to any substance, aside from feces, that comes out of your rectum. Your rectum is the last part of your digestive system before your anus, which is the opening at the end of the system.
It usually presents as mucus or pus that you may notice in your underwear or on your stool. You may also feel the urge to have a bowel movement, but only pass mucus or a very small amount of stool.
It’s a common symptom of irritable bowel syndrome (IBS), but infections, including sexually transmitted infections (STIs) and other conditions, can also cause it.
Common accompanying symptoms of anal mucus discharge
- Other associated symptoms of mucus discharge may include the following:
- Visible mucus with or without having a bowel movement
- Blood mixed with the mucus
- Diarrhea that may be watery or bloody
- Pruritis: This is itching around the area of the anus.
- Pain or discomfort in the area of the anus
- Abdominal pain that may be severe
- Constipation
- Fever or chills
- Nausea or vomiting
Infection Causes
Many types of infections can cause inflammation of the walls of the large intestines and activate “goblet cells,” which produce mucus.
- E. Coli: There are many types of E. Coli. Some types can cause watery diarrhea while others cause bloody diarrhea or diarrhea coated in blood and mucus. Two of the most common strands that cause diarrhea with mucus are EHEC (Enterogenic Hemorrhagic E. Coli) and EIEC (Enterogenic Inflammatory E. Coli).
- Campylobacter: Campylobacter is a corkscrew-shaped bacterium that often occurs after consuming undercooked poultry or food that has fecal matter on it. This can occur if you use the restroom and then prepare food without washing your hands well enough. It can cause frequent (10 or more) loose stools per day with both blood and pus as well as severe abdominal pain.
- Entamoeba: Entamoeba is a parasite commonly contracted by ingesting feces (e.g. a food preparer’s unwashed hands). This parasite can cause a condition called amebiasis in which large amounts of diarrhea are produced that are full of the “cysts” or eggs of the organism.
Inflammatory conditions
Many diseases can cause excess mucus in the stool due to inflammation of the bowels.
- Crohn’s disease: This almost always involves the small intestine, and occasionally, it involves both the small intestine and the colon. For a small minority, only the colon is involved. Among those with colonic involvement, it is possible to have blood, pus, or mucus discharge from the anus, especially during flares.
- Ulcerative colitis: This is a separate inflammatory condition that affects the bowels. It commonly involves the lower intestines and the rectum. Colitis refers to inflammation that may cause abdominal pain, incontinence, and discharge of blood and mucus from the anus.
- Celiac disease: This may present early or later in life and classically presents with foul-smelling, floating stools, as well as diarrhea and flatulence. In extreme cases, celiac disease can cause high-volume stools with scant mucus.
- Irritable bowel syndrome (IBS): This is characterized by a cramping sensation and other variable symptoms.
Other Infections
Infections associated with foodborne illness can cause rectal discharge, often along with nausea and vomiting, cramps, and diarrhea.
Foodborne illnesses, commonly known as food poisoning, are infections that can be caused by many different types of bacteria, viruses, and parasites.
The most common infections include:
IBS
IBS is a chronic disorder of the large intestine that doesn’t have a clear cause. But experts believe that stress, large meals, and certain goods can trigger it.
Common symptoms of IBS include::
- abdominal pain and cramping
- bloating
- flatulence
- diarrhea
- constipation
- mucus in stool
Hemorrhoids
Hemorrhoids are swollen veins in your anus or lower rectum. They’re very common, affecting 3 out of 4 adults at some point, according to Mayo Clinic.
They’re usually caused by increased pressure from straining during bowel movements and chronic constipation or diarrhea. Pregnancy and obesity are risk factors.
The most common infections include:
- pain around the anus
- anal swelling or lump
- severe anal itching
- rectal discharge
- bleeding during bowel movements
STIs
Some STIs that affect your rectum or anus can cause discharge.
They’re usually transmitted through anal sex, but an infection in the genital region can also spread to the anal region.
STIs that can affect your rectum or anus include:
Rectal discharge may be your only symptom. Other symptoms can include:
- rectal pain
- anal itching
- painful bowel movements
- blisters or sores around the anus
Anal abscess or fistula
An anal abscess is an infected sac filled with pus near your anus. It’s usually caused by an acute infection in the anal glands.
In some cases, an anal abscess develops into a fistula. An anal fistula is a small channel that connects the infected anal gland to an opening on the skin. Fistulas can also be caused by other medical conditions.
Symptoms of an anal abscess include:
- rectal discharge or bleeding
Symptoms of a fistula include:
- anal pain, often severe
- pain during bowel movements
- bleeding
- foul-smelling discharge from an opening in the skin near the anus
IBD
- Inflammatory bowel disease (IBD) is the term for a group of conditions that result in chronic inflammation of your gastrointestinal (GI) tract. These main types of IBD are ulcerative colitis and Crohn’s disease.
Crohn’s disease can affect any part of your GI tract, from your mouth to your anus, but most often affects the small intestine. Ulcerative colitis affects your large intestine and rectum.
The symptoms of IBD can vary depending on the severity of the inflammation and its location.
Common symptoms include:
- abdominal pain and cramping
- diarrhea, often with pus or mucus
- blood in your stool
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