- Email: [email protected]
MICROBIOLOGY OF HOSPITAL TOILETS
700 4. Department of Health and Social Security. Using Computers to Improve Health Services. 1971. 5. Framework for Government Research and Development. Cmnd. 4814. H.M. Stationery Office, 1972.
A** The types of information on health services required by medical administration would come under the following APPENDIX
headings: (1) (2) (3) (4) (5) (6)
Finance, expenditure, Forward planning.
resource
Physical
allocation.
Public
consultative/advisory machinery. Quality control of health-services administration and intelligence systems.
(16) Communication. * APPENDIX B*
The types of information
Population.
engineering
systems would be:
clinical
resources:
information for
planning.
Manpower. Voluntary services and workers. Advisory committees. Hospitals, clinics, health centres, and other health-care units.
(7) (8) (9) (10) (11)
(12) (13) (14) (15)
Population demands and health-service transactions. Morbidity/disability/mortality. Quality control. Control and prevention of disease.
(1) Storage/retrieval systems (e.g., records). (2) Scheduling systems (e.g., organisation of follow-up clinics). (3) Return systems (e.g., laboratory request and report systems). (4) Simulation systems (e.g., network analysis). (5) Data transformation systems (e.g., graphic outputs). (6) Conversational/reactive systems (e.g., programmed teaching). (7) Utility systems (e.g., sub-routine libraries). full versions of these appendices may be obtained from E. G. K.
Environmental control.
Public Health
using the toilet
a survey of toilets in use in hospital carried out, and experiments were done. The toilets were in good working order, and were cleaned
was
MICROBIOLOGY OF HOSPITAL TOILETS
daily.
S. W. B. NEWSOM MATERIALS AND METHODS
Sims Woodhead Memorial
Laboratory, Papworth Hospital, Cambridge CB3 8RE
possibility of hospital infection arising in the toilet has been studied. Cultures were made of the air, water, and surfaces of hospital toilets, and of the bacteria in the air or splashes produced after whole or homogenised fæces Sum ary
or
The
large numbers of bacterial cells had been flushed. ability of various fæcal bacteria to survive
The
desiccation
was
also tested.
Contamination of the
hospital toilets by fæcal bacteria was surprisingly low. An explanation for this is deduced from the low number of bacteria in fæces in relation to that found to be required to produce an aerosol, or a heavily contaminated splash. The hospital toilet seems an unlikely source of infection, unless it is grossly soiled Salmonella are potentially dangerous by fæces. because organisms, they resist drying and small-dose infection is thought to occur, but no evidence is available to incriminate the toilet in such infection. Thus simple cleaning and the maintenance of a good flushing system are the main principles of toilet care. INTRODUCTION
HOSPITAL toilets might seem an obvious potential of infection. Bacteria-laden aerosols have been demonstrated after flushing a laboratory toilet.1 However, in one outbreak of Salmonella typhimurium infections, circumstantial evidence incriminating the toilet was not confirmed by bacteriological investigation.2 The spread of Shigella sonnei infection in a nursery school has been traced to the toilet,3 and can be controlled by cleaning the seat and making the children dip their hands in disinfectant. Hospital patients may be susceptible to infection, not only from bowel pathogens but also from the other enterobacteria and Pseudomonas spp. present in normal fxces. To evaluate the risk for hospital patients from source
The survey was done in a cardiothoracic hospital, with in geriatric and mental hospitals. Random samples of toilet air, water, and surfaces were cultured. The air was sampled by exposing settle plates for 1 hour, or sometimes overnight. Three 0-02 ml. drops of water were cultured, and agar impressions were taken from surfaces. The cultures were sown on MacConkey agar (tested to ensure that it did not inhibit Escherichia coli) and incubated for 48 hours at 37 °C. Colonies of fxcal bacteria were counted. Natural and artificial inocula were flushed in two toilets and the splashes or aerosols produced were cultured. Natural inocula were faeces or 100 ml. of fxces homogenised in water. The artificial inocula were 1010-1011 bacterial cells, in 100 ml. distilled water. The bacteria were grown on nutrient agar and included: E. coli, S. typhimurium, S. sonnei, Proteus mirabilis, Serratia marcescens, Klebsiella aerogenes.. Enterobacter cloaca, Pseudomonas ceruginosa, and an Achromobacter sp. obtained from laboratory cultures. The aerosols were sampled with a slit sampler (Casella) set to measure 2 c.ft. of air in 2 minutes. The splashes were cultured by inverting a 10 in. square assay dish full of agar over the bowl and leaving it for 2 minutes after the toilet had been flushed. MacConkey’s medium was used, but some controls with nutrient agar were included in case any aerosol-damaged bacteria failed to grow on the inhibitory medium. The wash-out of bacteria from the toilet bowl was checked by counts, before and after a flush. The counts were done on 7% horse-blood agar by the dropping technique. The ability of faecal bacteria to survive desiccation was measured by putting 0-1 ml. drops of normal or enriched faeces into compartments of a polystyrene ’Repli-dish’ (Dyos Plastics) and allowing them to dry on the laboratory bench. The enriched fxces contained 109 cells per ml. of S. sonnei, S. typhimurium, or E. coli. Control drops of these organisms dried in water were also tested. The crusts were moistened and spread on MacConkey agar. The viable bacteria were counted after 48 hours’ incubation. A few extra tests
made of E. coli surviving in faeces on a toilet seat, and on a metal surface. Finally the escherichia or shigella present in normal, infected, and liquid stools were counted. counts were
701 RESULTS
TABLE II-AVERAGE NUMBER OF BACTERIA PER 2 C.ft. OF AIR AFTER THE INOCULUM HAD BEEN FLUSHED
Air Environmental contamination was much less than expected. Fxcal bacteria grew on 17 out of 64 settle plates exposed in two ward toilets. 3 of the plates had been exposed overnight and 1 was covered by a large splash containing two hundred colonies of escherichia; the other plates had only one or two, and at the most ten colonies on them. No escherichia grew on 64 plates exposed in the refectory male toilet, although enterococci grew on 3. This toilet was in constant use; the results of the water tests (table i) and the amount of cigarette ash on the plates were an indirect indication of its popularity. Water Table i records the numbers of escherichia found in water samples from sixteen hospital toilets (eight for patients of each sex) on each of 11 days. 109 of TABLE I-TOILET WATER COUNTS-NUMBERS OF ESCHERICHIA PER 0-02 ml. DROP
Numbers of tests are shown in italic type. * Escherichia counted.
faeces grew one, one, and three colonies of escherichia (toilet B, 4 ft. cistern); 1011 escherichia were needed Similar aerosols to produce a consistent aerosol. 1011 cells the were obtained when of shigella, salmonor klebsiella were flushed. Larger air found with the proteus and enterobacter, but by far the most bacteria were present in the aerosols generated from 1011 cells of pseudomonas or achromobacter. The numbers of bacteria-laden drops splashed up by flushing the different inocula are recorded in table III. Sixty-two tests were done. The flush of the toilets produced 70-80 visible droplets. An average of 18 bacteria-laden drops was found after flushing homogenate in toilet A, 50 in B (12 ft. cistern), and 13 in B (4 ft. cistern). The flush of 1011 escherichia
ella, serratia, counts were
counts of 65, 75, and 39, respectively. Table iv shows that the number of bacteria in the toilet was reduced 100 times by a flush. The cistern held 2 litres and the bowl 10 litres, so the reduction is not due to dilution. Table v shows the results of desiccation. The count of natural escherichia fell rapidly for 8 hours,
produced
the 176 samples were free from escherichia; only 9 contained more than 50 escherichia per 0-02 ml. A second series of nineteen tests and twelve from the geriatric hospital gave similar results. Three out of the eleven toilets in the mental hospital had large numbers of escherichia in them; they had been used, but not flushed.
TABLE III-AVERAGE NUMBER OF BACTERIA-LADEN DROPS PRODUCED BY FLUSHING VARIOUS INOCULA DOWN TWO TOILETS
Surfaces The same toilets were examined for surface contamination. Five sets of impressions were taken in the cardiothoracic unit and one in each of the others. The seat, lid, flush, and grab and door handles were sampled. Escherichia grew on 19 out of 293 impressions, although never were more than four colonies seen. 12 positive isolations came from seats, 4 from flush handles, and 3 from the underside of lids. Many other
bacteria, including staphylococci were found, especially on the flush and grab handles-no doubt a
reflection of those
on
the user’s hands.
Inoculation Experiments 116 air samples were taken while the different inocula were flushed down two toilets (table 11). 3 of the 22 plates exposed for the flush of homogenised
TABLE IV-THE EFFECTS OF FLUSHING ON NUMBER OF BACTERIA IN TOILET WATER
702 TABLE V-NUMBER OF BACTERIA SURVIVING DESICCATION IN THE INDICATED SPECIMEN
++++== confluent growth semiconfluent growth + + + 100-500 colonies ++
+ I±
=
=50-100 colonies = 10-50 colonies
=
thereafter some cells survived for 8 days. The counts of the added escherichia and the shigella fell for 3 days, none survived more than 5. The salmonella survived undiminished for 7 days, and only died out by day 12. Drops of fxces allowed to dry on a toilet seat or a metal surface were almost free from escherichia in 2 hours; in fact, by the time a crust was formed the escherichia were dead. Enterococci, on the other hand, were very resistant to desiccation and outlived the salmonella. The counts of bacteria in fasces were: escherichia in solid stools 108 per g. (eight tests), in liquid stools 107 per g. (two tests), and S. sonnei 106-108 per g.
(three tests). DISCUSSION
The toilets were clean and well maintained, but it was still surprising to detect so few faecal bacteria-a finding also reported by Maurer and her colleagues.44 The number of free aerobic bacteria (anaerobes comprise 99-99% of faecal bacteria but do not cause hospital infection) in normal or homogenised faeces is low compared with the 1011 required to produce an aerosol. Bound and Atkinsonproduced minimal aerosols by flushing a culture of escherichia, Darlow and Bale1 generated a larger one from 1011 cells of serratia, and I produced appreciable aerosols from pseudomonas and achromobacter. These are not normal bowel pathogens and were not found in the toilets. None the less, the generation of aerosols from these species, which can live at low temperatures in water, is interesting. Perhaps the enterobacteria are killed by " cold shock " s or by aerosolisation. Thomsonfound up to 109 salmonella; but only 107 klebsiella, 104 pseudomonas,8,9 and 106-108 shigella3 have been found per g. feeces-low numbers compared with those needed to produce an aerosol. The bacteria in the toilet water were rapidly washed away by the flush; Darlow and Balefound a thousandfold dilution per flush. The flushing of urine could explain the comparatively low counts in the female
toilets. can be contaminated by splashes, as the 3 grew settle-plate result predicted. Hutchinson shigella from splashes and Burgess 10 saw living trichomonads on a glass plate after a flush of infected urine. The splashing varies with cistern height and bowl design. A double-trap syphonic toilet in my own home produced more splashes than the washdown type, presumably because the water level was nearer the seat. The splashes often contained only two or three colony-forming particles, and the results
Surfaces
one
of the seat cultures and the drying tests suggest that these soon die. Hutchinson3 showed that shigella in bulk faeces survived well, but small numbers died in 2-3 days; Pettit and Lowbury 11 found that 2 hours’ drying killed 97-8% of escherichia cells suspended in deionised water. Salmonella survived well and could be a hazard, and there might be a risk from other organisms for a limited time after the use of a toilet. The number of bacteria found in the toilet must be compared with that required for colonisation or infection. At least 106 pseudomonas or 104 escherichia must be ingested to survive in the bowel. 12,13 Infectious doses of lOb-10salmonella have been found, and of 103 S. typhi in people receiving antibiotics. 14,15 Dupont et al.13 caused infection with 102 S. flexneri, and circumstances suggest that low-dosage infection with salmonella may occur, but this has not been confirmed experimentally nor traced to the toilet. Infection from the hospital toilet is, therefore, unlikely unless the seat or handles are heavily coated with faeces. This could happen in mental hospitals or children’s wards, and outbreaks of bowel infections have occurred in such places, but it is unlikely elsewhere. Typhoid patients could possibly disseminate dangerous numbers of bacteria but do not use a communal toilet.
Toilet care should be mainly mechanical. The ball valve should be set to the correct height, and the flush made to work properly. The surfaces and handles must be kept clean. Foot-operated flushes are preferable, and some type of automatic flush might be valuable in children’s wards and mental hospitals. The best fitment is a British Standard wash-down bowl with a low cistern; but the latter must be capable of a good clearing action. The care of the bowl should be restricted to cleaning. The standard scouring powder is adequate for this if used in conjunction with the brush and flushed away. It should not be just poured into the toilet and left, for it may clog up. The more conventional descaling agents may be required in hard-water areas. There is no reason to pour large quantities of disinfectants into the bowl; this is uneconomic and aimed at a non-existent danger. Maurer’s group 4 showed that the best method of keeping the toilet brush was to shake it and store it dry. Finally, as always, the care of the hands is of paramount importance in preventing hospital infection, and the provision and use of a wash-basin close to the toilet is essential. This work
was
done
at
the request of the Division of Enand Social Security,
gineering of the Department of Health
703
through its study group porting it.
no.
9, and I
am
grateful to them for
sup-
1. Darlow, H. M., Bale, W. R. Lancet, 1959, i, 1196. 2. Datta, N., Pridie, R. B. J. Hyg., Camb. 1960, 58, 229. 3. Hutchinson, R. I. Mon. Bull. Min. Hlth Lab. Serv. 1956, 15, 110. 4. Maurer, I., Efstratiou, A., Watson, H. M. Br. Hosp. J. 1972, 72, suppl. 19. 5. Bound, W. H., Atkinson, R. I. Lancet, 1966, i, 1369. 6. Meynell, G. G. J. gen. Microbiol. 1958, 19, 380. 7. Thomson, S. J. Hyg., Camb. 1954, 52, 67. 8. Gould, J. C., Keay, A. J. Br. med. J. 1970, iv, 56. 9. Gould, J. C. Personal communication, 1970. 10. Burgess, J. A. Br. J. vener. Dis. 1963, 39, 248. 11. Pettit, F., Lowbury, E. J. J. Hyg., Camb. 1968, 66, 393. 12. Buck, A. C., Cooke, E. M. J. med. Microbiol. 1969, 2, 521. 13. Dupont, H. L., Formal, S. B., Hornick, R. B., Snyder, M. J., Libonati, J. P., Sheahan, D. G., Labrec, E. H., Kalas, J. P. New Engl. J. Med. 1971, 285, 1. 14. McCulloch, N. B., Eisele, C. W. J. infect. Dis. 1951, 88, 278. 15. Hornick, R. B., Greisman, S. E., Woodward, T. E., Dupont, H. L., Dawkins, A. T., Snyder, M. J. New Engl. J. Med. 1970, 283, 686.
England Now
Great ideas, from the Greeks onwards, come in one’s bath. Contemplating my battered body, I wondered what my colleagues would make of it, if it were presented as an 8 A.M. offering on their altar, and what the evidence in court would be. By Sherlock Holmes out of Bernard Spilsbury, we have become accustomed to ex cathedra pronouncements of omniscience and infallibility, arousing a nice mixture of respect and awe in the audience. " The body was obviously that of a manic-depressive cobbler with a nagging wife, whose hobby was racing pigeons, and who had an illegitimate grand-daughter in the Seychelles." Applause in court; would that my own performance in the witness-box approached that level. But perhaps some friend and colleague, lumbered with me, might achieve brilliance ? " The body was that of a middle-aged man; pertinent external findings included numerous and randomly situated cutaneous injuries, minor lacerations and bruises of varying ages and stages of healing. There had been recent marked weight-loss in this previously obese individual, and on the soles of both feet were a group of recent skin lesions resembling burns." The court is properly awed. " Doctor, what do those findings suggest ?" " Well, it appears likely that he was under restraint, and struggled to escape, injuring himself; that he has been starved; and that some form of persuasion involving burning has been applied to his feet." A dreadful set of findings; consternation. Reality is as bizarre but less systematic. The skin lesions represent the accumulated minor summer traumas of garden, tenniscourt, and a habit of overturning small sailing-boats with subsequent attempts to right them. Starvation-well, weight-watching is the polite term for it, if one does not happen to be fascinated by a diet of unlimited baked okra. But burns to the soles of the feet ? If you’ve ever tried barbecuing on a hot day with a strong wind when you’ve lost your sandals, and had a sudden gust scatter hot coals over the patio, you’ll understand. *
*
lurid colours than modern camping fashion dictates. Visually I wallowed in unashamed vanity. Function is what bothers me now. Courtesy requires that I should extend salutations to headmistresses, stray bishops, and parents: and more importantly to potential customers with acceptable offspring. Instinct whispers that I should raise my hat. But my M.D. hat is a square velvet contraption with all the characteristics of a soggy ravioli casing. I never know whether all four corners will flop in quadriplegia, or only the lateral ones like goats’ ears: depends on the wind and humidity, I suppose. But my hat cannot be raised with one hand, nor replaced without the aid of two and a travelling mirror. So what should one do ? I have tried bowing low, but the trailing silk-lined hood gets caught on my buttocks, and its frontal anchor-loop forcibly avulsed from the top waistcoat button. Thus, on attempting return to an erect posture, the lilac band springs up garrottingly across the larynx until my face turns a similar hue. Resulting anoxia triggers off a reflex spinal twitch, and bang goes another lumbar disc. A curtsey is safer, and sometimes passes without comment in a girls’ school. Genuflexion or the kissing of hands depends on what sort of bishop turns up. The only other alternative seems a classical roman salute, but
more
REFERENCES
In
library :the family assembled the components around me, until the looking-glass reflected a walking bell tent in even
*
Can anyone recommend a male model school for dignified deportment while wearing academic robes ? When fate landed me with the chairmanship of the governors of a very nice independent girls’ school I was expected to appear on annual-speech-day platforms in the full glory of academic regalia. So I bought a package deal of scarlet and lilac finery. It was rather like opening an i.Q. testing kit, without any sheet of instructions. With the aid of pictures in Edwardian copies of Punch from the public
I reckon that
a
toga
must
have been custom-built for the
job. From the voluminous folds of an M.D. gown it becomes a toss-up whether the saluting arm pops out like a jack-in-the-box, or writhes impotently under the silk, miming a punch-and-judy show. Beyond that, all I can do is exclaim Hi there and wink. *
*
*
In our rural part of the world, the welfare of our farmer patients is of concern to us all. We are accustomed to them getting out of their large cars to come and complain bitterly
about the misadventures that have befallen their crops. However, this year’s fine weather for the harvest has abolished the usual run of complaints and I have heard only two-and these are new ones. One from a farmer’s wife" If only we could have some rain to give us a break from the harvest "-and the other from a farmer-" The blasted yield is so heavy that I have nowhere to store any more of the staff *
*
*
From the M*d*c*l D*f*nc* Union’s annual report: " An elderly woman became ill, though not seriously. For trivial reasons her son did not wish her to be treated by her N.H.S. doctor, Dr. X. He wrongly thought that Dr. X’s partner, Dr. Y, was a woman and put a note requesting Dr. Y to visit through the letter box at the surgery." *
*
*
Browsing through a pile of old 78s I was entranced to upon a fairly well preserved disc recorded by the Savoy Havana Band (HMV no. B.5027). Pre-automaticlinkage days, and in the Charleston style, it would seem to be some 40 years old.* The lyric is brief: come
Masculine women, feminine men, which is the rooster, which is the hen ? It’s hard to tell them apart, today. Let’s say. Every city, learning to shi, rub-a-dub-dub (inaudible). It’s hard to tell them apart, today. Hey-hey! Girls were girls and boys were boys when I was a tot. Now we don’t know who is who or even what’s what. Knickers and trousers, baggy and wide. Nobody knows who’s walking inside. Both masculine women and feminine men.
Should make the charts
as
a re-issue.
Masculine Women, Feminine Men was a foxtrot composed by E. Leslie and James V. Monaca; copyright, 1925, Lawrence Wright Music Ltd. The H.M.V. disc was issued in April, 1926.-ED. L.
A** The types of information on health services required by medical administration would come under the following APPENDIX
headings: (1) (2) (3) (4) (5) (6)
Finance, expenditure, Forward planning.
resource
Physical
allocation.
Public
consultative/advisory machinery. Quality control of health-services administration and intelligence systems.
(16) Communication. * APPENDIX B*
The types of information
Population.
engineering
systems would be:
clinical
resources:
information for
planning.
Manpower. Voluntary services and workers. Advisory committees. Hospitals, clinics, health centres, and other health-care units.
(7) (8) (9) (10) (11)
(12) (13) (14) (15)
Population demands and health-service transactions. Morbidity/disability/mortality. Quality control. Control and prevention of disease.
(1) Storage/retrieval systems (e.g., records). (2) Scheduling systems (e.g., organisation of follow-up clinics). (3) Return systems (e.g., laboratory request and report systems). (4) Simulation systems (e.g., network analysis). (5) Data transformation systems (e.g., graphic outputs). (6) Conversational/reactive systems (e.g., programmed teaching). (7) Utility systems (e.g., sub-routine libraries). full versions of these appendices may be obtained from E. G. K.
Environmental control.
Public Health
using the toilet
a survey of toilets in use in hospital carried out, and experiments were done. The toilets were in good working order, and were cleaned
was
MICROBIOLOGY OF HOSPITAL TOILETS
daily.
S. W. B. NEWSOM MATERIALS AND METHODS
Sims Woodhead Memorial
Laboratory, Papworth Hospital, Cambridge CB3 8RE
possibility of hospital infection arising in the toilet has been studied. Cultures were made of the air, water, and surfaces of hospital toilets, and of the bacteria in the air or splashes produced after whole or homogenised fæces Sum ary
or
The
large numbers of bacterial cells had been flushed. ability of various fæcal bacteria to survive
The
desiccation
was
also tested.
Contamination of the
hospital toilets by fæcal bacteria was surprisingly low. An explanation for this is deduced from the low number of bacteria in fæces in relation to that found to be required to produce an aerosol, or a heavily contaminated splash. The hospital toilet seems an unlikely source of infection, unless it is grossly soiled Salmonella are potentially dangerous by fæces. because organisms, they resist drying and small-dose infection is thought to occur, but no evidence is available to incriminate the toilet in such infection. Thus simple cleaning and the maintenance of a good flushing system are the main principles of toilet care. INTRODUCTION
HOSPITAL toilets might seem an obvious potential of infection. Bacteria-laden aerosols have been demonstrated after flushing a laboratory toilet.1 However, in one outbreak of Salmonella typhimurium infections, circumstantial evidence incriminating the toilet was not confirmed by bacteriological investigation.2 The spread of Shigella sonnei infection in a nursery school has been traced to the toilet,3 and can be controlled by cleaning the seat and making the children dip their hands in disinfectant. Hospital patients may be susceptible to infection, not only from bowel pathogens but also from the other enterobacteria and Pseudomonas spp. present in normal fxces. To evaluate the risk for hospital patients from source
The survey was done in a cardiothoracic hospital, with in geriatric and mental hospitals. Random samples of toilet air, water, and surfaces were cultured. The air was sampled by exposing settle plates for 1 hour, or sometimes overnight. Three 0-02 ml. drops of water were cultured, and agar impressions were taken from surfaces. The cultures were sown on MacConkey agar (tested to ensure that it did not inhibit Escherichia coli) and incubated for 48 hours at 37 °C. Colonies of fxcal bacteria were counted. Natural and artificial inocula were flushed in two toilets and the splashes or aerosols produced were cultured. Natural inocula were faeces or 100 ml. of fxces homogenised in water. The artificial inocula were 1010-1011 bacterial cells, in 100 ml. distilled water. The bacteria were grown on nutrient agar and included: E. coli, S. typhimurium, S. sonnei, Proteus mirabilis, Serratia marcescens, Klebsiella aerogenes.. Enterobacter cloaca, Pseudomonas ceruginosa, and an Achromobacter sp. obtained from laboratory cultures. The aerosols were sampled with a slit sampler (Casella) set to measure 2 c.ft. of air in 2 minutes. The splashes were cultured by inverting a 10 in. square assay dish full of agar over the bowl and leaving it for 2 minutes after the toilet had been flushed. MacConkey’s medium was used, but some controls with nutrient agar were included in case any aerosol-damaged bacteria failed to grow on the inhibitory medium. The wash-out of bacteria from the toilet bowl was checked by counts, before and after a flush. The counts were done on 7% horse-blood agar by the dropping technique. The ability of faecal bacteria to survive desiccation was measured by putting 0-1 ml. drops of normal or enriched faeces into compartments of a polystyrene ’Repli-dish’ (Dyos Plastics) and allowing them to dry on the laboratory bench. The enriched fxces contained 109 cells per ml. of S. sonnei, S. typhimurium, or E. coli. Control drops of these organisms dried in water were also tested. The crusts were moistened and spread on MacConkey agar. The viable bacteria were counted after 48 hours’ incubation. A few extra tests
made of E. coli surviving in faeces on a toilet seat, and on a metal surface. Finally the escherichia or shigella present in normal, infected, and liquid stools were counted. counts were
701 RESULTS
TABLE II-AVERAGE NUMBER OF BACTERIA PER 2 C.ft. OF AIR AFTER THE INOCULUM HAD BEEN FLUSHED
Air Environmental contamination was much less than expected. Fxcal bacteria grew on 17 out of 64 settle plates exposed in two ward toilets. 3 of the plates had been exposed overnight and 1 was covered by a large splash containing two hundred colonies of escherichia; the other plates had only one or two, and at the most ten colonies on them. No escherichia grew on 64 plates exposed in the refectory male toilet, although enterococci grew on 3. This toilet was in constant use; the results of the water tests (table i) and the amount of cigarette ash on the plates were an indirect indication of its popularity. Water Table i records the numbers of escherichia found in water samples from sixteen hospital toilets (eight for patients of each sex) on each of 11 days. 109 of TABLE I-TOILET WATER COUNTS-NUMBERS OF ESCHERICHIA PER 0-02 ml. DROP
Numbers of tests are shown in italic type. * Escherichia counted.
faeces grew one, one, and three colonies of escherichia (toilet B, 4 ft. cistern); 1011 escherichia were needed Similar aerosols to produce a consistent aerosol. 1011 cells the were obtained when of shigella, salmonor klebsiella were flushed. Larger air found with the proteus and enterobacter, but by far the most bacteria were present in the aerosols generated from 1011 cells of pseudomonas or achromobacter. The numbers of bacteria-laden drops splashed up by flushing the different inocula are recorded in table III. Sixty-two tests were done. The flush of the toilets produced 70-80 visible droplets. An average of 18 bacteria-laden drops was found after flushing homogenate in toilet A, 50 in B (12 ft. cistern), and 13 in B (4 ft. cistern). The flush of 1011 escherichia
ella, serratia, counts were
counts of 65, 75, and 39, respectively. Table iv shows that the number of bacteria in the toilet was reduced 100 times by a flush. The cistern held 2 litres and the bowl 10 litres, so the reduction is not due to dilution. Table v shows the results of desiccation. The count of natural escherichia fell rapidly for 8 hours,
produced
the 176 samples were free from escherichia; only 9 contained more than 50 escherichia per 0-02 ml. A second series of nineteen tests and twelve from the geriatric hospital gave similar results. Three out of the eleven toilets in the mental hospital had large numbers of escherichia in them; they had been used, but not flushed.
TABLE III-AVERAGE NUMBER OF BACTERIA-LADEN DROPS PRODUCED BY FLUSHING VARIOUS INOCULA DOWN TWO TOILETS
Surfaces The same toilets were examined for surface contamination. Five sets of impressions were taken in the cardiothoracic unit and one in each of the others. The seat, lid, flush, and grab and door handles were sampled. Escherichia grew on 19 out of 293 impressions, although never were more than four colonies seen. 12 positive isolations came from seats, 4 from flush handles, and 3 from the underside of lids. Many other
bacteria, including staphylococci were found, especially on the flush and grab handles-no doubt a
reflection of those
on
the user’s hands.
Inoculation Experiments 116 air samples were taken while the different inocula were flushed down two toilets (table 11). 3 of the 22 plates exposed for the flush of homogenised
TABLE IV-THE EFFECTS OF FLUSHING ON NUMBER OF BACTERIA IN TOILET WATER
702 TABLE V-NUMBER OF BACTERIA SURVIVING DESICCATION IN THE INDICATED SPECIMEN
++++== confluent growth semiconfluent growth + + + 100-500 colonies ++
+ I±
=
=50-100 colonies = 10-50 colonies
=
thereafter some cells survived for 8 days. The counts of the added escherichia and the shigella fell for 3 days, none survived more than 5. The salmonella survived undiminished for 7 days, and only died out by day 12. Drops of fxces allowed to dry on a toilet seat or a metal surface were almost free from escherichia in 2 hours; in fact, by the time a crust was formed the escherichia were dead. Enterococci, on the other hand, were very resistant to desiccation and outlived the salmonella. The counts of bacteria in fasces were: escherichia in solid stools 108 per g. (eight tests), in liquid stools 107 per g. (two tests), and S. sonnei 106-108 per g.
(three tests). DISCUSSION
The toilets were clean and well maintained, but it was still surprising to detect so few faecal bacteria-a finding also reported by Maurer and her colleagues.44 The number of free aerobic bacteria (anaerobes comprise 99-99% of faecal bacteria but do not cause hospital infection) in normal or homogenised faeces is low compared with the 1011 required to produce an aerosol. Bound and Atkinsonproduced minimal aerosols by flushing a culture of escherichia, Darlow and Bale1 generated a larger one from 1011 cells of serratia, and I produced appreciable aerosols from pseudomonas and achromobacter. These are not normal bowel pathogens and were not found in the toilets. None the less, the generation of aerosols from these species, which can live at low temperatures in water, is interesting. Perhaps the enterobacteria are killed by " cold shock " s or by aerosolisation. Thomsonfound up to 109 salmonella; but only 107 klebsiella, 104 pseudomonas,8,9 and 106-108 shigella3 have been found per g. feeces-low numbers compared with those needed to produce an aerosol. The bacteria in the toilet water were rapidly washed away by the flush; Darlow and Balefound a thousandfold dilution per flush. The flushing of urine could explain the comparatively low counts in the female
toilets. can be contaminated by splashes, as the 3 grew settle-plate result predicted. Hutchinson shigella from splashes and Burgess 10 saw living trichomonads on a glass plate after a flush of infected urine. The splashing varies with cistern height and bowl design. A double-trap syphonic toilet in my own home produced more splashes than the washdown type, presumably because the water level was nearer the seat. The splashes often contained only two or three colony-forming particles, and the results
Surfaces
one
of the seat cultures and the drying tests suggest that these soon die. Hutchinson3 showed that shigella in bulk faeces survived well, but small numbers died in 2-3 days; Pettit and Lowbury 11 found that 2 hours’ drying killed 97-8% of escherichia cells suspended in deionised water. Salmonella survived well and could be a hazard, and there might be a risk from other organisms for a limited time after the use of a toilet. The number of bacteria found in the toilet must be compared with that required for colonisation or infection. At least 106 pseudomonas or 104 escherichia must be ingested to survive in the bowel. 12,13 Infectious doses of lOb-10salmonella have been found, and of 103 S. typhi in people receiving antibiotics. 14,15 Dupont et al.13 caused infection with 102 S. flexneri, and circumstances suggest that low-dosage infection with salmonella may occur, but this has not been confirmed experimentally nor traced to the toilet. Infection from the hospital toilet is, therefore, unlikely unless the seat or handles are heavily coated with faeces. This could happen in mental hospitals or children’s wards, and outbreaks of bowel infections have occurred in such places, but it is unlikely elsewhere. Typhoid patients could possibly disseminate dangerous numbers of bacteria but do not use a communal toilet.
Toilet care should be mainly mechanical. The ball valve should be set to the correct height, and the flush made to work properly. The surfaces and handles must be kept clean. Foot-operated flushes are preferable, and some type of automatic flush might be valuable in children’s wards and mental hospitals. The best fitment is a British Standard wash-down bowl with a low cistern; but the latter must be capable of a good clearing action. The care of the bowl should be restricted to cleaning. The standard scouring powder is adequate for this if used in conjunction with the brush and flushed away. It should not be just poured into the toilet and left, for it may clog up. The more conventional descaling agents may be required in hard-water areas. There is no reason to pour large quantities of disinfectants into the bowl; this is uneconomic and aimed at a non-existent danger. Maurer’s group 4 showed that the best method of keeping the toilet brush was to shake it and store it dry. Finally, as always, the care of the hands is of paramount importance in preventing hospital infection, and the provision and use of a wash-basin close to the toilet is essential. This work
was
done
at
the request of the Division of Enand Social Security,
gineering of the Department of Health
703
through its study group porting it.
no.
9, and I
am
grateful to them for
sup-
1. Darlow, H. M., Bale, W. R. Lancet, 1959, i, 1196. 2. Datta, N., Pridie, R. B. J. Hyg., Camb. 1960, 58, 229. 3. Hutchinson, R. I. Mon. Bull. Min. Hlth Lab. Serv. 1956, 15, 110. 4. Maurer, I., Efstratiou, A., Watson, H. M. Br. Hosp. J. 1972, 72, suppl. 19. 5. Bound, W. H., Atkinson, R. I. Lancet, 1966, i, 1369. 6. Meynell, G. G. J. gen. Microbiol. 1958, 19, 380. 7. Thomson, S. J. Hyg., Camb. 1954, 52, 67. 8. Gould, J. C., Keay, A. J. Br. med. J. 1970, iv, 56. 9. Gould, J. C. Personal communication, 1970. 10. Burgess, J. A. Br. J. vener. Dis. 1963, 39, 248. 11. Pettit, F., Lowbury, E. J. J. Hyg., Camb. 1968, 66, 393. 12. Buck, A. C., Cooke, E. M. J. med. Microbiol. 1969, 2, 521. 13. Dupont, H. L., Formal, S. B., Hornick, R. B., Snyder, M. J., Libonati, J. P., Sheahan, D. G., Labrec, E. H., Kalas, J. P. New Engl. J. Med. 1971, 285, 1. 14. McCulloch, N. B., Eisele, C. W. J. infect. Dis. 1951, 88, 278. 15. Hornick, R. B., Greisman, S. E., Woodward, T. E., Dupont, H. L., Dawkins, A. T., Snyder, M. J. New Engl. J. Med. 1970, 283, 686.
England Now
Great ideas, from the Greeks onwards, come in one’s bath. Contemplating my battered body, I wondered what my colleagues would make of it, if it were presented as an 8 A.M. offering on their altar, and what the evidence in court would be. By Sherlock Holmes out of Bernard Spilsbury, we have become accustomed to ex cathedra pronouncements of omniscience and infallibility, arousing a nice mixture of respect and awe in the audience. " The body was obviously that of a manic-depressive cobbler with a nagging wife, whose hobby was racing pigeons, and who had an illegitimate grand-daughter in the Seychelles." Applause in court; would that my own performance in the witness-box approached that level. But perhaps some friend and colleague, lumbered with me, might achieve brilliance ? " The body was that of a middle-aged man; pertinent external findings included numerous and randomly situated cutaneous injuries, minor lacerations and bruises of varying ages and stages of healing. There had been recent marked weight-loss in this previously obese individual, and on the soles of both feet were a group of recent skin lesions resembling burns." The court is properly awed. " Doctor, what do those findings suggest ?" " Well, it appears likely that he was under restraint, and struggled to escape, injuring himself; that he has been starved; and that some form of persuasion involving burning has been applied to his feet." A dreadful set of findings; consternation. Reality is as bizarre but less systematic. The skin lesions represent the accumulated minor summer traumas of garden, tenniscourt, and a habit of overturning small sailing-boats with subsequent attempts to right them. Starvation-well, weight-watching is the polite term for it, if one does not happen to be fascinated by a diet of unlimited baked okra. But burns to the soles of the feet ? If you’ve ever tried barbecuing on a hot day with a strong wind when you’ve lost your sandals, and had a sudden gust scatter hot coals over the patio, you’ll understand. *
*
lurid colours than modern camping fashion dictates. Visually I wallowed in unashamed vanity. Function is what bothers me now. Courtesy requires that I should extend salutations to headmistresses, stray bishops, and parents: and more importantly to potential customers with acceptable offspring. Instinct whispers that I should raise my hat. But my M.D. hat is a square velvet contraption with all the characteristics of a soggy ravioli casing. I never know whether all four corners will flop in quadriplegia, or only the lateral ones like goats’ ears: depends on the wind and humidity, I suppose. But my hat cannot be raised with one hand, nor replaced without the aid of two and a travelling mirror. So what should one do ? I have tried bowing low, but the trailing silk-lined hood gets caught on my buttocks, and its frontal anchor-loop forcibly avulsed from the top waistcoat button. Thus, on attempting return to an erect posture, the lilac band springs up garrottingly across the larynx until my face turns a similar hue. Resulting anoxia triggers off a reflex spinal twitch, and bang goes another lumbar disc. A curtsey is safer, and sometimes passes without comment in a girls’ school. Genuflexion or the kissing of hands depends on what sort of bishop turns up. The only other alternative seems a classical roman salute, but
more
REFERENCES
In
library :the family assembled the components around me, until the looking-glass reflected a walking bell tent in even
*
Can anyone recommend a male model school for dignified deportment while wearing academic robes ? When fate landed me with the chairmanship of the governors of a very nice independent girls’ school I was expected to appear on annual-speech-day platforms in the full glory of academic regalia. So I bought a package deal of scarlet and lilac finery. It was rather like opening an i.Q. testing kit, without any sheet of instructions. With the aid of pictures in Edwardian copies of Punch from the public
I reckon that
a
toga
must
have been custom-built for the
job. From the voluminous folds of an M.D. gown it becomes a toss-up whether the saluting arm pops out like a jack-in-the-box, or writhes impotently under the silk, miming a punch-and-judy show. Beyond that, all I can do is exclaim Hi there and wink. *
*
*
In our rural part of the world, the welfare of our farmer patients is of concern to us all. We are accustomed to them getting out of their large cars to come and complain bitterly
about the misadventures that have befallen their crops. However, this year’s fine weather for the harvest has abolished the usual run of complaints and I have heard only two-and these are new ones. One from a farmer’s wife" If only we could have some rain to give us a break from the harvest "-and the other from a farmer-" The blasted yield is so heavy that I have nowhere to store any more of the staff *
*
*
From the M*d*c*l D*f*nc* Union’s annual report: " An elderly woman became ill, though not seriously. For trivial reasons her son did not wish her to be treated by her N.H.S. doctor, Dr. X. He wrongly thought that Dr. X’s partner, Dr. Y, was a woman and put a note requesting Dr. Y to visit through the letter box at the surgery." *
*
*
Browsing through a pile of old 78s I was entranced to upon a fairly well preserved disc recorded by the Savoy Havana Band (HMV no. B.5027). Pre-automaticlinkage days, and in the Charleston style, it would seem to be some 40 years old.* The lyric is brief: come
Masculine women, feminine men, which is the rooster, which is the hen ? It’s hard to tell them apart, today. Let’s say. Every city, learning to shi, rub-a-dub-dub (inaudible). It’s hard to tell them apart, today. Hey-hey! Girls were girls and boys were boys when I was a tot. Now we don’t know who is who or even what’s what. Knickers and trousers, baggy and wide. Nobody knows who’s walking inside. Both masculine women and feminine men.
Should make the charts
as
a re-issue.
Masculine Women, Feminine Men was a foxtrot composed by E. Leslie and James V. Monaca; copyright, 1925, Lawrence Wright Music Ltd. The H.M.V. disc was issued in April, 1926.-ED. L.