Relevant Research Publications

Hospital-Associated Infections

Kathleen A.N. Aithinne MS, Casey W. Cooper MS, Robert A. Lynch PhD , David L. Johnson PhD

Toilet plume aerosol generation rate and environmental contamination

following bowl water inoculation with Clostridium difficile spores

American Journal of Infection Control 47 (2019) 515−520

  1. Magill SS, O’Leary E, Janelle SJ, et al. Changes in prevalence of

health care–associated infections in U.S. hospitals. N Engl J Med.


  1. US Centers for Disease Control and Prevention. HAI and Antibiotic Use

Prevalence Survey. Available at



  1. Monegro AF, Regunath H. Hospital Acquired Infections. In: StatPearls

[Internet]. Treasure Island (FL): StatPearls Publishing; 2020. Available at:


  1. Dancer SJ. Controlling hospital-acquired infection: Focus on the role

of the environment and new technologies for decontamination. Clin

Microbiol Rev. 2014;27(4):665-690.


Infection via Toilet Plume Aerosol

  1. Knowlton SD, Boles CL, Perencevich EN, Diekema DJ, Nonnenmann MW.

Bioaerosol concentrations generated from toilet flushing in a hospitalbased

patient care setting. Antimicrob Resist Infect Control. 2018;7:16.


  1. Johnson D, Lynch R, Marshall C, Mead K, Hirst D. Aerosol generation by

modern flush toilets. Aerosol Sci Technol. 2013;47(9):1047-1057.


  1. Johnson DL, Mead KR, Lynch RA, Hirst DV. Lifting the lid on toilet plume

aerosol: A literature review with suggestions for future research. Am J

Infect Control. 2013;41(3):254-258.


  1. Verani M, Bigazzi R, Carducci A. Viral contamination of aerosol and

surfaces through toilet use in health care and other settings. Am J Infect

Control. 2014;42(7):758-762.


  1. Best EL, Sandoe JA, Wilcox MH. Potential for aerosolization of

Clostridium difficile after flushing toilets: The role of toilet lids in reducing

environmental contamination risk. J Hosp Infect. 2012;80(1):1-5.


  1. Couturier J, Ginevra C, Nesa D, et al. Transmission of Legionnaires’

Disease through toilet flushing. Emerg Infectious Dis. 2020;26(7):1526-



  1. Wilson GM, Jackson VB, Boyken LD, et al. Bioaerosols generated

from toilet flushing in rooms of patients with Clostridioides

difficile infection. Infect Control Hosp Epidemiol. 2020;41(5):517-521.


  1. Johnson DL, Lynch RA, Villanella SM, et al. Persistence of bowl water

contamination during sequential flushes of contaminated toilets. J

Environ Health. 2017;80(3):34-49.


  1. Barker J, Jones MV. The potential spread of infection caused by aerosol

contamination of surfaces after flushing a domestic toilet. J Appl

Microbiol. 2005;99(2):339-347.


Spread of SARS-CoV-2 via fecal and aerosol transmission

  1. Lo IL, Lio CF, Cheong HH, et al. Evaluation of SARS-CoV-2 RNA shedding

in clinical specimens and clinical characteristics of 10 patients with

COVID-19 in Macau. Int J Biol Sci. 2020;16(10):1698-1707.


  1. Lescure FX, Bouadma L, Nguyen D, et al. Clinical and virological data of

the first cases of COVID-19 in Europe: A case series. Lancet – Infect Dis.

2020;S1473-3099(20)30200-0. doi:10.1016/S1473-3099(20)30200-0.


  1. Zhang T, Cui X, Zhao X, et al. Detectable SARS-CoV-2 Viral RNA in feces

of three children during recovery period of COVID-19 pneumonia. J Med

Virol. 2020;10.1002/jmv.25795. doi:10.1002/jmv.25795.


  1. Tian Y, Rong L, Nian W, He Y. Review article: Gastrointestinal features in

COVID-19 and the possibility of faecal transmission. Aliment Pharmacol

Ther. 2020;51(9):843-851.


  1. Ling Y, Xu SB, Lin YX, et al. Persistence and clearance of viral RNA in

2019 novel coronavirus disease rehabilitation patients. Chin Med J.2020;133(9):1039-1043.

  1. Xiao F, Tang M, Zheng X, Liu Y, Li X, Shan H. Evidence for gastrointestinal

infection of SARS-CoV-2. Gastroenterol. 2020;158(6):1831-1833.e3.


  1. Parasa S, Desai M, Thoguluva Chandrasekar V, et al. Prevalence of

gastrointestinal symptoms and fecal viral shedding in patients with

Coronavirus Disease 2019: A systematic review and meta-analysis. JAMA

Netw Open. 2020;3(6):e2011335.


  1. Sheikh K. Flushing the toilet may fling coronavirus aerosols all over.

New York Times. June 16, 2020. Available at: https://www.nytimes.




  1. Prather KA, Wang CC, Schooley RT. Reducing transmission of SARSCoV-
    Science. 2020;368(6498):1422-1424.


  1. Chan KH, Sridhar S, Zhang RR, et al. Factors affecting stability and

infectivity of SARS-CoV-2 [published online ahead of print, 2020 Jul 8]. J

Hosp Infect. 2020;S0195-6701(20)30339-X.


  1. Liu Y, Ning Z, Chen Y, et al. Aerodynamic analysis of SARS-CoV-2 in two

Wuhan hospitals. Nature. 2020;582(7813):557-560.


  1. Morawska L, Milton DK. It is time to address airborne transmission of

COVID-19 [published online ahead of print, 2020 Jul 6]. Clin Infect Dis.

2020;ciaa939. doi:10.1093/cid/ciaa939


  1. Thompson D. Standard methods rid hospital rooms of coronavirus.

HealthDay News, March 9, 2020. Available at https://www.webmd.




  1. McDermott CV, Alicic RZ, Harden N, Cox EJ, Scanlan JM. Put a lid on it:

are faecal bio-aerosols a route of transmission for SARS-CoV-2? J Hosp

Infect. 2020;105(3):397-398.


  1. Lewis D. Mounting evidence suggests that coronavirus is airborne – but

health advice has not caught up. Nature. 2020;583:510-513.


  1. Wang JX, Li YY, Liu XD, Cao X. Virus transmission from urinals. Phys

Fluids (1994). 2020;32(8):081703


  1. Kang M, Wei J, Yuan J, et al. Probable Evidence of Fecal Aerosol

Transmission of SARS-CoV-2 in a High-Rise Building [published online

ahead of print, 2020 Sep 1]. Ann Intern Med. 2020;10.7326/M20-0928.


Hazardous Drug Exposure

  1. Walton A, Bush MA, Douglas C, Allen DH, Polovich M, Spasojevic I.

Surface Contamination With Antineoplastic Drugs on Two Inpatient

Oncology Units. Oncol Nurs Forum. 2020;47(3):263-272.


  1. Bohlandt A, Sverdel Y, Schierl R. Antineoplastic drug residues

inside homes of chemotherapy patients. Int J Hyg Environ Health.



  1. Hedmer M, Tinnerberg H, Axmon A, Jonsson BA. Environmental and

biological monitoring of antineoplastic drugs in four workplaces in a

Swedish hospital. Int Arch Occup Environ Health. 2008;81(7):899-911.


  1. Walton AL. Doing the Dirty Work: Who Handles Antineoplastic Drug

Contaminated Excreta and do They Do It Safely?. Asia Pac J Oncol Nurs.



  1. Yuki M, Ishida T, Sekine S. Secondary Exposure of Family Members to

Cyclophosphamide After Chemotherapy of Outpatients With Cancer: A

Pilot Study. Oncol Nurs Forum. 2015;42(6):665-671.



  1. Easty AC, Coakley N, Cheng R, et al. Safe handling of cytotoxics: guideline

recommendations. Curr Oncol. 2015;22(1):e27-e37.


  1. Power LA, Coyne JW. ASHP Guidelines on Handling Hazardous Drugs.

Am J Health-Syst Pharm. 2018;75(24):1996-2031.


  1. Oncology Nursing Society. Toolkit for Safe Handling of Hazardous Drugs

for Nurses in Oncology. 2018. Available at:


  1. U.S Pharmacopeia. USP General Chapter <800> Hazardous Drugs–

Handling in Healthcare Settings. 2016. Available at: https://www.


Effect of Toilet Plume Aerosol on Healthcare Workers

  1. Efstathiou G, Papastavrou E, Raftopoulos V, Merkouris A. Factors

influencing nurses’ compliance with Standard Precautions in order to

avoid occupational exposure to microorganisms: A focus group study.

BMC Nurs. 2011;10:1.


  1. International Safety Center. EPINet Report for Blood and Body Fluid

Exposures. 2018. Available at:




  1. Monette M. Flush and run. CMAJ. 2012;184(11):E581-E582.


  1. Statement of Support to WHO from Built Environment Experts. 2020.

Available at:


Over the years, dozens of papers and clinical guidelines have been published characterizing occupational and environmental risks of aeration and contamination of bloodborne and infectious disease and hazardous chemicals like chemotherapy drugs.

More than 25% of post-flush cultures test positive for infectious microorganisms that can cause healthcare associated infections to patients, personnel, or visitors, including Enterococcus faecalis, E. faecium, and C. difficile.



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