To the Editor:
The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) presents an unprecedented challenge to global health.
1
The looming threat of socioeconomic collapse, livelihood, and human security needs to be intervened.2
Action taken to disrupt the pathways of viral transmission can have positive outcomes on the coronavirus disease 2019 disease burden.The primary transmission route of the virion through respiratory aerosols is well documented.
3
There is an emerging recognition of potential transmission of SARS-CoV-2 through aerosolization of virus-laden stools.4
Air sampling for SARS-CoV-2 in hospital toilets used by patients has yielded positive results.5
,6
Recent studies reported the presence of SARS-CoV-2 viral RNA in fecal samples that were detected even after 22.3±29.8 (mean ± SD) days from diagnosis.7
,8
Another review suggested that SARS-CoV-2 can be excreted in urine in addition to stool.9
The phylogenetically related severe acute respiratory syndrome coronavirus 1 transmission through fecal bioaerosols was well highlighted in the Amoy Garden residential complex incident in Hong Kong in 2003.
10
This outbreak led to more than 300 confirmed cases and 50 fatalities.10
,11
Clusters of fecal transmissions of SARS-CoV-2 are being reported in hospitals and high-rise apartments in China. Epidemiological investigations using tracer studies point toward passage of virus-laden fecal bioaerosols through exhaust fans and faulty sewage systems.12
With the exponential rise in world infection rates, such a transmission modality poses a potential risk for countries with high population densities. The lesser spatial separation of living spaces in concentrated areas presents a major risk for fecal aerosol infiltration. As evidence of transmission through lesser known pathways accumulates, innovative approaches may be needed.
In the November issue of Mayo Clinic Proceedings, McDermott et al
13
suggested shutting the toilet lid while flushing, closing lavatory doors, staff education, adequate ventilation, better plumbing, and UV irradiation of circulating air for hospital infection control.14
These recommendations are salutary and can add to the efficacy of hospital infection control. We suggest an additional universally affordable option that could disinfect aerosols at its source, in the clinical as well as community settings.Adding a household disinfectant (5% sodium hypochlorite [NaOCl]) in the water cistern of the flush tank could be useful. This step can be achieved by treating with sustained-release NaOCl tablets in addition to liquid bleach. Such treated water (reaching 1% NaOCl concentration) could lower the quantum of viable viral particles in the fecal aerosol generated during flushing. Sodium hypochlorite releasing free chlorine is suggested for inactivation of SARS-CoV-2 in residential and hospital wastewater treatment plants.
15
Further studies are needed to test the resultant reduction in viral density and thereby contagion dissemination. However, it appears plausible at this stage that the addition of NaOCl disinfectant in the toilet flush could contain fecal virus-laden bioaerosols.References
- Guide to understanding the 2019 novel coronavirus.Mayo Clin Proc. 2020; 95: 646-652
- Potential impact of the COVID-19 pandemic on HIV, tuberculosis, and malaria in low-income and middle-income countries: a modelling study [published correction appears in Lancet Glob Health. 2021;9(1):e23].Lancet Glob Health. 2020; 8: e1132-e1141
- Transmission routes analysis of SARS-CoV-2: a systematic review and case report.Front Cell Dev Biol. 2020; 8: 618
- Fecal-oral transmission of SARS-CoV-2: review of laboratory-confirmed virus in gastrointestinal system [published online ahead of print October 14, 2020].(Int J Colorectal Dis)https://doi.org/10.1007/s00384-020-03785-7
- Aerodynamic analysis of SARS-CoV-2 in two Wuhan hospitals.Nature. 2020; 582: 557-560
- Air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from a symptomatic patient.JAMA. 2020; 323: 1610-1612
- Value of viral nucleic acid in sputum and feces and specific IgM/IgG in serum for the diagnosis of coronavirus disease 2019.Front Cell Infect Microbiol. 2020; 10: 445
- Detection of SARS-CoV-2 RNA in fecal specimens of patients with confirmed COVID-19: A meta-analysis.J Infect. 2020; 81: e31-e38
- Diagnostic and methodological evaluation of studies on the urinary shedding of SARS-CoV-2, compared to stool and serum: a systematic review and meta-analysis.Cell Mol Biol (Noisy-le-grand). 2020; 66: 148-156
- Emergencies preparedness, response: update 95 – SARS; chronology of a serial killer. World Health Organization website.(Accessed September 3, 2020.)
- Environmental transmission of SARS at Amoy Gardens.J Environ Health. 2006; 68: 26-30
- Probable evidence of fecal aerosol transmission of SARS-CoV-2 in a high-rise building.Ann Intern Med. 2020; 173: 974-980
- COVID-19 and gastrointestinal symptoms: recognition, containment, and learning from the past.Mayo Clin Proc. 2020; 95: 2320-2324
- Gut involvement by COVID-19 [editorial].Mayo Clin Proc. 2020; 95: 2309-2311
- Disinfection technology of hospital wastes and wastewater: suggestions for disinfection strategy during coronavirus disease 2019 (COVID-19) pandemic in China.Environ Pollut. 2020; 262: 114665
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Published online: December 29, 2020
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Potential Competing Interests: The authors report no competing interests.
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