Their findings were as follows: C. difficile was recoverable from air sampled at heights up to 25 cm above the toilet seat. The highest numbers of C. difficile were recovered from air sampled immediately following flushing, and then declined eight- fold after 60 min and a further three-fold after 90 min. Surface contamination with C. difficile occurred within 90 min after flushing, demonstrating that relatively large droplets are released, which then contaminate the immediate environment. The mean numbers of droplets emitted upon flushing by the lidless toilets in clinical areas were 15-47, depending on design. C. difficile aerosolisation and surrounding environmental contamination occur when a lidless toilet is flushed.

They concluded that lidless conventional toilets increase the risk of C. difficile environmental contamination, and they went onto suggest that their use should be discouraged, particularly in settings where C. difficile is common. In a 2018 study, particle and bioaerosol concentrations were measured in hospital bathrooms across three sampling conditions; no waste no flush, no waste with flush, and fecal waste with flush. Particle and bioaerosol concentrations were measured with a particle counter bioaerosol sampler both before and after a toilet flushing event at distances of 0.15, 0.5, and 1 m from the toilet for 5, 10, 15 min. The results showed that particle concentrations measured before and after the flush were found to be significantly different (0.3–10 µm). Bioaerosol concentrations when flushing fecal waste were found to be significantly greater than background concentrations (p-value = 0.005). However, the bioaerosol concentrations were not different across time (p-value = 0.977) or distance (p-value = 0.911) from the toilet, suggesting that aerosols generated may remain for

It has also been found that the use of hand dryers, especially the increasingly common jet air dryers, might have the potential for increasing the risk of aerosols.

longer than 30 min post flush. Toilets produce aerosol particles when flushed, with the majority of the particles being 0.3 µm in diameter. The particles aerosolised include microorganisms remaining from previous use or from fecal wastes. Differences in bioaerosol concentrations across conditions also suggest that toilet flushing is a source of bioaerosols that may result in transmission of pathogenic microorganisms.23


despite these findings it is still common practice in UK healthcare for toilets within clinical areas to have no lids and the aerosol created continues to create a risk of infection within the healthcare environment. It has also been found that the use of hand

dryers, especially the increasingly common jet air dryers, might have the potential for increasing the risk of aerosols. A recent study, undertaken by E Best et al, concluded that multiple examples of significant differences in surface bacterial contamination, including by faecal and antibiotic-resistant bacteria, were observed, with higher levels when jet air dryers were present versus paper towels in washrooms.24 To conclude, it is clear that bio-aerosols containing harmful pathogens can come from a number of apparatus within healthcare premises including showers, taps, washbasins, sinks, and toilets. Hand dryers are also a potential cause for concern. I believe that in order to reduce the instances of people becoming sick and sometimes dying, due to healthcare-acquired infections caused by

bio-aerosols, manufacturers should continue to innovate and design better products that reduce aerosol risk. These new designs need to ensure that aerosol production and contamination are minimised, for example the tubular washbasin that features in the design of the Angel Guard clinical unit, which helps to reduce aerosol dispersal and splashing. In addition, there should be very careful consideration of when and where to site sanitary apparatus and the risks associated with toilets within an immunocompromised patient area.

References for this article are available upon request.


Elaine Waggott

Elaine Waggott (AMRSPH) began her career working in the construction sector and co-owned a distribution company by the age of 24. Elaine first worked within the plumbing industry In 2000 where she headed up a 60 person team responsible for customer service and technical support across the UK for Ideal Standard/Armitage Shanks leading several large projects within the company as well as being involved in the process of new product development. After moving back to her home country of Scotland, she continued her career with Ideal Standard, running the business development team. Over the last three years, Elaine has been involved in the setting up of both Angel Guard and Water Kinetics. She currently holds the position of director of operations for both of these companies.

Picture of the aerosol dispersal caused by a hand dryer. 36 l WWW.CLINICALSERVICESJOURNAL.COM SEPTEMBER 2020

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