Open Defecation and Squat Toilets Pose Elevated Risks of Fecal Transmission of COVID-19 in Developing Communities

Abstract

While current guidelines focus on social distancing, face covering, cleaning and disinfecting, fecal transmission of COVID-19 remains a less recognized and under-investigated route in community environments. This contrasts to the fact that unequivocal evidence, reported by a number of studies, showed the prolonged shedding of SARS-CoV-2 by symptomatic and non-symptomatic individuals in feces at substantial viral loads. Under ambient conditions, SARS-CoV-2 remains viable in human feces for hours to several days, showing infectivity to both human and animals. A widely neglected obstacle in current efforts on preventing the spread of the virus is that a significant population in developing countries do not have access to clean, private sanitary facilities. There are at least 20 countries which reported large numbers of COVID-19 infections have a significant portion of their population practicing open defecation (5%-26%). An even wider risk factor lies in the design of the toilets in these communities. Unlike the closestools often found in western homes, open-flushing squat toilets are extremely common in countries in southeast Asia, central America, and Africa. The lidless design and open flushing mechanism may easily expose users to fecal matter and pathogens, including SARS-CoV-2 in the current pandemic. While public education and emergency orders may help reduce the rates of open defecation during COVID-19, these open squat toilets constitute an essential part of the existing sanitary infrastructure in these communities, which cannot be upgraded or replaced in the near term. Recent discussions on fecal transmission of COVID-19 have predominantly focused on sewage-associated routes. In light of this gap, we raise these longstanding issues to the attention of regulators, international aid organizations, and people in these communities. In the events of community-wide outbreaks, as currently seen in India and other developing countries, fecal transmission may become a significant contributor of virus spread in these communities. In this article, we illustrate the most probable mechanisms with photographs of squat toilet sites to highlight these risks in developing communities. Given the persisting increase of COVID-19 infections in India and many other developing countries, these warrant urgent attention by regulators and present a priority research topic for the scientific community.