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Impact of usership on bacterial contamination of public latrine surfaces in Kathmandu, Nepal [1]

['Alexis L. Mraz', 'Water', 'Health', 'Applied Microbiology Lab', 'Wham Lab', 'Department Of Epidemiology', 'Biostatistics', 'College Of Public Health', 'Temple University', 'Philadelphia']

Date: 2023-03

According to the United Nations (UN) Sustainable Development Goals (SDGs), community or public toilets shared by more than one household are not considered “safely managed” under SDG 6.2. However, many populations around the globe, particularly in urban settings, lack access to private sanitation facilities. For this reason, there is a need to evaluate the cleanliness of community or public toilets in these settings and examine best practices for maintaining them. This study had three aims: 1) build on previous data collected in March 2018 at public latrines to determine whether cleaning protocols were sustained, 2) examine relationships between latrine cleanliness and usership, and 3) identify latrine surfaces with higher concentrations of bacterial contamination. In March 2018 and December 2019, swab samples were collected from public latrine surfaces in Kathmandu, Nepal. Sampling occurred in “clean” conditions–after cleaning and before the latrine was opened for use–and “dirty” conditions–during operating hours. Samples were analyzed for concentrations of total coliforms (TC) and Escherichia coli (EC). The number of latrine users prior to the “dirty” sample collection was recorded (in December 2019 only). Results found that both TC and EC concentrations were significantly lower during “clean” rather than “dirty” conditions and both TC and EC concentrations increased with the number of users over time. TC and EC concentrations differed by surface type during dirty and clean conditions (p<0.05). Findings suggest cleaning protocols established at this public toilet site were adequately maintained two years later.

Funding: This research was funded through the Grand Challenges Canada (#1910-30928 to DM). through funding that was awarded to Aerosan Toilets. This research was undertaken, in part, thanks to funding from the Canada Research Chairs Program, specifically Dr. Heather Murphy’s Tier II Canada Research Chair in One Health (#460792 to HM). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Authors Alexis Mraz (AM), Shannon McGinnis (SM), Heather Murphy (HM), Prakash Amatya (PA), Dianna Marini (DM) received partial salary support from Grand Challenges Canada.

Introduction

The United Nations (UN) adopted 17 Sustainable Development Goals (SDG) in 2015 as part of the 2030 Agenda for Sustainable Development, a call to improve the lives and prospects of people globally. SDG 6 focuses on clean water and sanitation, with target 6.2 focusing specifically on achieving “access to adequate and equitable sanitation and hygiene for all and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations [1].” SDG 6.2 seeks to improve access to “safely managed” sanitation defined as “use of improved facilities that are not shared with other households and where excreta are safely disposed of in situ or removed and treated offsite.” The term “improved” in this context refers to the hygienic separation of human excreta from human contact [2]. A variety of facilities can meet this requirement, including those with sewer connections, septic systems connections, pour-flush latrines, ventilated improved pit latrines, pit latrines with a slab or composting toilets [3]. However, community facilities, facilities shared between households or public toilets are not considered “safely managed” even if the excreta is safely disposed of and treated, and therefore do not count towards meeting the goals outlined in SDG 6.2 [2]. Shared facilities are considered “limited” and fall below “basic” and “safely managed” sanitation on the sanitation ladder. However, the World Health Organization (WHO) does highlight and acknowledge that shared facilities are an incremental and often necessary step towards safely managed sanitation [4].

The Joint Monitoring Programme for Water Supply and Sanitation (JMP), by the WHO and the United Nations International Children’s Emergency Fund (UNICEF) is tasked with monitoring progress towards SDG 6. According to JMP’s 2021 report, 78% of the global population had access to “improved” sanitation in 2020, where 54% of the global population had access to “safely managed” sanitation (defined as a private improved facility, in which fecal matter is safely disposed of on site or transported and treated off-site) and 24% had access to “basic” sanitation (a private improved facility, not shared with other households, which separates fecal matter from human contact) [2, 5]. The percent of the global population using open defecation dropped to 6% in 2020 from 10% in 2015 [5]. Those having access only to “unimproved sanitation”–(pit latrines without slab or platform, hanging latrines or bucket toilets) accounted for 8% of the global population in 2020, dropping from 10% 2015 [5]. While 7% had access to “limited” sanitation which are improved facilities shared between two or more households [2, 5]. Access to improved sanitation is more limited in least developed countries, particularly in sub-Saharan Africa, Oceania, and Central and Southern Asia [3]. Lack of access to clean water and improved sanitation contributes to about 3.3% of global deaths and 4.6% of the global burden of disease [3]. In children under 5 the burden of disease is even higher with 13% of deaths and 12% of disability adjusted life years (DALYs) attributable to water, sanitation and health (WASH) issues [3]. Use of improved sanitation has been demonstrated to promote overall community health. In a study of 41 countries, predominantly in South America and Africa, reduced stunting and childhood death was observed when 80% or more individuals in a village or community were utilizing improved sanitation [6].

There are several barriers to the use of community latrines or public toilets such as: safety issues, cleanliness and challenges associated with operation. Concern for physical safety, particularly at night and for women, is one barrier in using public toilets [7, 8]. Unhygienic conditions resulting in a health concerns and/or a feeling of disgust is another barrier [9, 10]. Operational considerations include distance and time to a latrine, user fees, maintenance, and access to running water and soap [9–11]. These concerns are reported less frequently in those that use communal latrines in comparison to those who rely on open-defecation [10]. In many urban centers, private household latrines are not only cost-prohibitive but space prohibitive, highlighting the need for shared sanitation options to end open defecation [12, 13]. Furthermore, it could be argued that some forms of shared sanitation may be more “safely managed” if the waste is emptied and disposed of appropriately or treated on-site compared to households who may empty their latrines illegally into the environment [14]. For instance, the public toilets in the current study treated the waste with an anaerobic digester prior to discharging the small liquid fraction of waste into the receiving environment. The log removal of pathogens in an anerobic digester is expected to be higher than typical household sanitation systems such as a pit latrine, cesspit/ soakpit or septic system [4, 15–18].

As population growth increases in cities around the world, shared toilets are a necessary intervention for providing access to sanitation when there is inadequate space and resources for households to have their own individual toilet facilities. One argument against community latrines or public toilets is that they are not adequately cleaned and maintained. Consequently, for shared sanitation to be considered “safely managed”, it is important to also understand the cleanliness of shared latrines to see if they can provide an effective and clean alternative to privately owned toilets.

To date there is limited research on the microbiological cleanliness of shared sanitation in low-income countries although there is some work in high income countries demonstrating contamination in public flush toilets [19]. What appears to be lacking is evidence supporting frequency of cleaning and cleaning methods required to reduce microbial contamination specifically in toilet facilities.

In response to the 2015 earthquake, Aerosan Toilets, a Canadian Non-Governmental Organization (NGO) with operations in Nepal, began assessing community and public toilets in Kathmandu, Nepal, to determine how to meet the urban sanitation need, particularly for women. Aerosan built biogas latrines utilizing an anaerobic digester which provides power to local businesses. All latrines are sex-segregated, operated by trained staff, are cleaned regularly, and have hand washing facilities with soap. Latrines were built and initially operated by Aerosan before transitioning ownership and operations to local private operators. Aerosan worked with the Sanitation Workers’ Cooperative (Co-op) to provide training to and elevate the social status of those who work in sanitation-related jobs (including operating Aerosan toilets). The Co-op supported sanitation workers’ upwards mobility and improved working conditions and financial well-being. McGinnis et al. (2019) sampled Aerosan’s pilot latrines in 2018 which were overseen by Aerosan at the time of the study. Later in 2018, the operations of the pilot latrines fully transitioned to private operators. We returned nearly two years later to collect additional data to achieve the following aims:

Determine if cleaning protocols and standards established and evaluated in March 2018 were sustained by private operators ~2 years later. Understand the relationship between usership and bacterial contamination of the latrine surfaces to advise cleaning frequency. Identify surfaces in the latrine facilities that had the highest levels of microbiological contamination

This work fills an important gap in knowledge on whether cleaning practices can be maintained over time by public toilet operators as well as how frequently latrines should be cleaned based on usership.

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[1] Url: https://journals.plos.org/water/article?id=10.1371/journal.pwat.0000091

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