1. Hand hygiene practices
Hand hygiene is extremely important. Cleaning hands with soap and water or an alcohol-based hand rub should be performed according to the instructions known as “My 5 moments for hand hygiene”.15 If hands are not visibly dirty, the preferred method is to perform hand hygiene with an alcohol-based hand rub for 20−30 seconds using the appropriate technique.16 When hands are visibly dirty, they should be washed with soap and water for 40−60 seconds using the appropriate technique.17 Hand hygiene should be performed at all five moments, including before putting on PPE and after removing it, when changing gloves, after any contact with a patient with suspected or confirmed COVID-19 infection or their waste, after contact with any respiratory secretions, before eating, and after using the toilet.18 If an alcohol-based hand rub and soap are not available, then using chlorinated water (0.05%) for handwashing is an option, but it is not ideal because frequent use may lead to dermatitis, which could increase the risk of infection and asthma and because prepared dilutions might be inaccurate.19 However, if other options are not available or feasible, using chlorinated water for handwashing is an option.
Functional hand hygiene facilities should be present for all health care workers at all points of care and in areas where PPE is put on or taken off. In addition, functional hand hygiene facilities should be available for all patients, family members, and visitors, and should be available within 5 m of toilets, as well as in waiting and dining rooms and other public areas.
2. Sanitation and plumbing
People with suspected or confirmed COVID-19 disease should be provided with their own flush toilet or latrine that has a door that closes to separate it from the patient’s room. Flush toilets should operate properly and have functioning drain traps. When possible, the toilet should be flushed with the lid down to prevent droplet splatter and aerosol clouds. If it is not possible to provide separate toilets, the toilet should be cleaned and disinfected at least twice daily by a trained cleaner wearing PPE (gown, gloves, boots, mask, and a face shield or goggles). Further, and consistent with existing guidance, staff and health care workers should have toilet facilities that are separate from those used by all patients.
WHO recommends the use of standard, well-maintained plumbing, such as sealed bathroom drains, and backflow valves on sprayers and faucets to prevent aerosolized faecal matter from entering the plumbing or ventilation system,20 together with standard wastewater treatment.21 Faulty plumbing and a poorly designed air ventilation system were implicated as contributing factors to the spread of the aerosolized SARS coronavirus in a high-rise apartment building in Hong Kong in 2003.22 Similar concerns have been raised about the spread of the COVID-19 virus from faulty toilets in high-rise apartment buildings.23 If health care facilities are connected to sewers, a risk assessment should be conducted to confirm that wastewater is contained within the system (that is, the system does not leak) before its arrival at a functioning treatment or disposal site, or both. Risks pertaining to the adequacy of the collection system or to treatment and disposal methods should be assessed following a safety planning approach,24 with critical control points prioritized for mitigation.
For smaller health care facilities in low-resource settings, if space and local conditions allow, pit latrines may be the preferred option. Standard precautions should be taken to prevent contamination of the environment by excreta. These precautions include ensuring that at least 1.5 m exists between the bottom of the pit and the groundwater table (more space should be allowed in coarse sands, gravels, and fissured formations) and that the latrines are located at least 30 m horizontally from any groundwater source (including both shallow wells and boreholes).21 If there is a high groundwater table or a lack of space to dig pits, excreta should be retained in impermeable storage containers and left for as long as feasible to allow for a reduction in virus levels before moving it off-site for additional treatment or safe disposal, or both. A two-tank system with parallel tanks would help facilitate inactivation by maximizing retention times, as one tank could be used until full, then allowed to sit while the next tank is being filled. Particular care should be taken to avoid splashing and the release of droplets while cleaning or emptying tanks.