Open defecation and squat toilets, an overlooked risk of fecal transmission of COVID-19 and other pathogens in developing communities.

Shiyi Sun,Jie Han

doi:10.1007/s10311-020-01143-1

Abstract

The novel coronavirus disease COVID-19 has infected over 46 million people in 219 countries and territories. Following evidence of viral loadings and infectivity of feces of infected individuals, public health authorities have suggested to take precautions on the transmission of COVID-19 via fecal-associated routes. Recent discussions on fecal transmission of COVID-19 have mainly focused on municipal sewage. Yet, a widely neglected aspect in containing the virus is that a major part of the population in developing regions do not have access to private, clean sanitary facilities. Therefore, we hypothesize that open defecation and the prevalent use of squat toilets are additional risk factors in those communities. Here, we review fecal transmission of COVID-19, the practices of open defecation, and the resultant routes of transmission of fecal pathogens. Also, we highlight the open design of common squat toilets and the potential exposure to fecal droplets and residues. We observed that at least 20 countries reporting more than 10,000 confirmed infections have 5–26% of their population practicing open defecation. We illustrate the potential routes of transmission of COVID-19 and other fecal pathogens via human feces in communities practicing open defecation. Here, poor hand hygiene, contaminated shoes and objects, mechanical vectors, and outdoor human activities can all contribute to fecal transmission. Other risk factors include squat pans with lidless designs and open flushing mechanisms, in-cubicle open waste bins, and the lack of water-sealing U-traps in squat toilets.

Highlights

The global outbreak of the coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is rapidly sweeping across the world, which has caused over 46.5 million confirmed cases including more than 1.2 million deaths as of November 3, 2020 (WHO 2020a)
Existing evidence and scholarly discussions indicate that open defecation is a relatively common practice in many developing countries, which can be hardly eliminated in a short term due to the complex driving factors such as the lack of sanitary facilities, personal preferences, and religious beliefs
Due to the common lidless design, open flushing mechanism, and absence of integrated U-traps, flushing of squat toilets can generate large amounts of bioaerosols and splashes, potentially exposing users to fecal pathogens and contaminating the ambient air and surrounding surfaces, which all contribute to the transmission of COVID-19 and other fecal pathogens, especially in high turnover squat toilets or those shared between different households

Summary

Introduction

The global outbreak of the coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is rapidly sweeping across the world, which has caused over 46.5 million confirmed cases including more than 1.2 million deaths as of November 3, 2020 (WHO 2020a). A 2019 joint report issued by the United Nation Children’s Fund (UNICEF) and the WHO showed that, around the globe, there were 673 million people still defecating in the open, and 1.3 billion people had to make use of limited (i.e., sharing improved sanitation facilities with other households) or unimproved sanitation facilities (UNICEF and WHO 2019) Most of those communities were located in developing countries across Asia and Africa. The lidless design and open flushing mechanism could expose users to fecal droplets and residues, posing additional risks of virus transmission in public toilets and those shared between different households in the current pandemic. We highlight these longstanding issues by focusing on open defecation and squat toilets, both as probable but neglected sources of fecal-associated transmission of the novel coronavirus in these communities. A further suspected link between open defecation and COVID-19 is that people who lived with diarrhea, malnourishment, stunting, and other diseases that can be spread by open defecation may be more vulnerable to COVID-19 infection or symptom aggravation due to their existing conditions (Guerrant et al 2013; Rytter et al 2014; Stewart et al 2013)

Conclusion

Findings

Compliance with ethical standards