New analysis shows that disinfection is the most effective way to prevent viral contamination of restroom surfaces

Researchers find that closing the toilet lid before flushing does not reduce the spread of viral particles

Peer-Reviewed Publication

ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL

Arlington, Va. — January 25, 2024 — A new study published today in the American Journal of Infection Control (AJIC) demonstrates that viral particles spread to many restroom surfaces during toilet flushing, regardless of whether the toilet lid is up or down. In this analysis, the only meaningful way of reducing viral particles was through disinfection of the toilet, toilet water, and nearby surfaces.

 

Scientists have long known that the process of toilet flushing can aerosolize pathogens expelled into the toilet bowl by an unhealthy individual. The aerosol plume created from the force of flushing can travel five feet or more, spreading pathogens to floors, walls, sinks, and other nearby surfaces in a bathroom.1 Prior studies have found that closing the toilet lid can help reduce the spread of bacterial pathogens, but until now, there has not been a report of whether the same is true for viral pathogens, which tend to be much smaller than their bacterial counterparts.

In this new study, scientists from the University of Arizona and research firm Reckitt Benckiser analyzed the spread of viral particles induced by toilet flushing, with toilet lids open and closed to determine any difference in outcome. Using a virus that is not pathogenic to humans as a proxy for more dangerous viruses, they seeded toilets with varying doses of the virus, flushed, and then collected samples from the toilet bowl water as well as surfaces on the toilet, floor, and walls. In a separate analysis of the effectiveness of cleaning the toilet with a disinfectant, samples were also collected from the toilet bowl brush and its caddy. The study included both household and public toilets; the impact of toilet lid closure could only be studied with the household toilet since public toilets typically do not have lids.

With the household toilet, researchers found that there was no statistical difference in the amount of virus collected from surfaces on the toilet or the nearby floor whether the toilet was flushed with the lid up or down. Viral contamination of the surrounding walls was minimal in both cases, while the toilet seat was the most contaminated surface. Similar patterns of contamination were observed with the public toilet.

The study also reviewed the effects of cleaning the toilet, both with and without disinfectant. Cleaning with only the brush left behind substantial contamination, but cleaning the toilet bowl with a disinfectant and brush significantly reduced the amount of virus found in the toilet. Results show that adding disinfectant to the toilet bowl before flushing or using disinfectant dispensers in the toilet tank were both effective ways to reduce contamination from flushing.

“In healthcare settings, any potential means of pathogen transmission must be addressed to keep all of our patients — including the most vulnerable, such as immunocompromised individuals — as healthy as possible,” said Charles P. Gerba, PhD, professor of virology at the University of Arizona and senior author of this study. “With results showing that closing toilet lids has no meaningful impact on preventing the spread of viral particles, our study highlights the importance of regular disinfection of toilets to reduce contamination and prevent the spread of viruses.”

Additional findings from the study include:

• Cleaning with a disinfectant and brush reduced viral contamination on the toilet by more than 99.99% and on the brush by 97.64%.
• Closing the toilet lid may alter the direction of the aerosol plume. In this study, floor surfaces in front of and to the left of the toilet were more contaminated after flushing with a closed lid than with an open lid, and floor surfaces to the right of the toilet were less contaminated.
• These findings extend to households. When one member of a household is sick, particularly with an infection that causes gastroenteritis, the regular incorporation of a disinfectant during cleaning or prior to flushing may help reduce the spread of infection to others in the household.

“This study helps establish a clearer understanding of how pathogens spread and the measures we can take to break those chains of transmission,” said Tania Bubb, PhD, RN, CIC, FAPIC, 2024 APIC president. “It also underscores the importance of regular disinfection of surfaces in healthcare settings for reducing the spread of viral infections.”

References

1. Crimaldi JP, True AC, Linden KG, Hernandez MT, Larsen LT, Pauls AK. Commercial toilets emit energetic and rapidly spreading aerosol plumes. Sci Rep. 2022;12:20493. https://doi.org/10.1038/s41598-022-24686-5.

About APIC

Founded in 1972, the Association for Professionals in Infection Control and Epidemiology (APIC) is the leading association for infection preventionists and epidemiologists. With more than 15,000 members, APIC advances the science and practice of infection prevention and control. APIC carries out its mission through research, advocacy, and patient safety; education, credentialing, and certification; and fostering development of the infection prevention and control workforce of the future. Together with our members and partners, we are working toward a safer world through the prevention of infection. Join us and learn more at apic.org.

About AJIC

As the official peer-reviewed journal of APIC, The American Journal of Infection Control (AJIC) is the foremost resource on infection control, epidemiology, infectious diseases, quality management, occupational health, and disease prevention. Published by Elsevier, AJIC also publishes infection control guidelines from APIC and the CDC. AJIC is included in Index Medicus and CINAHL. Visit AJIC at ajicjournal.org.

NOTES FOR EDITORS

“Impacts of lid closure during toilet flushing and of toilet bowl cleaning on viral contamination of surfaces in United States restrooms,” by Madison P. Goforth, Stephanie A. Boone, Justin Clark, Priscilla B. Valenzuela, Julie McKinney, M. Khalid Ijaz, and Charles P. Gerba, was published online in AJIC on January 25, 2024. Available at: https://doi.org/10.1016/j.ajic.2023.11.020

AUTHORS

Charles P. Gerba, PhD (Corresponding author: gerba@arizona.edu), University of Arizona

Madison P. Goforth, PhD, University of Arizona

Stephanie A. Boone, PhD, University of Arizona

Justin Clark, MS, University of Arizona

Priscilla B. Valenzuela, MS, University of Arizona

Julie McKinney, PhD, Reckitt Benckiser LLC

M. Khalid Ijaz, DVM, MSc (Honors), PhD, FRSPH, Reckitt Benckiser LLC

 

# # #

---

JOURNAL

American Journal of Infection Control

DOI

10.1016/j.ajic.2023.11.020 

METHOD OF RESEARCH

Experimental study

SUBJECT OF RESEARCH

Not applicable

ARTICLE TITLE

Impacts of lid closure during toilet flushing and of toilet bowl cleaning on viral contamination of surfaces in United States restrooms

ARTICLE PUBLICATION DATE

25-Jan-2024

COI STATEMENT

Drs. Julie McKinney and M. Khalid Ijaz are engaged in R&D at Reckitt Benckiser LLC. The other authors declare no competing interests. Funding/support: This study was funded by a grant to the University of Arizona from Reckitt Benckiser.

'Smart toilet' monitors for signs of disease

by Stanford University Medical Center

Credit: CC0 Public Domain

There's a new disease-detecting technology in the lab of Sanjiv "Sam" Gambhir, MD Ph.D., and its No. 1 source of data is number one. And number two.

It's a smart toilet. But not the kind that lifts its own lid in preparation for use; this toilet is fitted with technology that can detect a range of disease markers in stool and urine, including those of some cancers, such as colorectal or urologic cancers. The device could be particularly appealing to individuals who are genetically predisposed to certain conditions, such as irritable bowel syndrome, prostate cancer or kidney failure, and want to keep on top of their health.

"Our concept dates back well over 15 years," said Gambhir, professor and chair of radiology. "When I'd bring it up, people would sort of laugh because it seemed like an interesting idea, but also a bit odd." With a pilot study of 21 participants now completed, Gambhir and his team have made their vision of a precision health-focused smart toilet a reality.

Gambhir's toilet is an ordinary toilet outfitted with gadgets inside the bowl. These tools, a suite of different technologies, use motion sensing to deploy a mixture of tests that assess the health of any deposits. Urine samples undergo physical and molecular analysis; stool assessment is based on physical characteristics.

The toilet automatically sends data extracted from any sample to a secure, cloud-based system for safekeeping. In the future, Gambhir said, the system could be integrated into any health care provider's record-keeping system for quick and easy access.

A paper describing the research will be published April 6 in Nature Biomedical Engineering. Gambhir is the senior author. Seung-min Park, Ph.D., senior research scientist; David Won, MD, Ph.D., former visiting scholar in the Molecular Imaging Program at Stanford; and postdoctoral scholar Brian Lee, Ph.D., share lead authorship.

Pulling double duty

The toilet falls into a category of technology known as continuous health monitoring, which encompasses wearables like smart watches. "The thing about a smart toilet, though, is that unlike wearables, you can't take it off," Gambhir said. "Everyone uses the bathroom—there's really no avoiding it—and that enhances its value as a disease-detecting device."

Although the idea may take some getting used to, Gambhir, who holds the Virginia and D.K. Ludwig Professorship for Clinical Investigation in Cancer Research, envisions the smart toilet as part of the average home bathroom. In facilitating that broad adaption, Gambhir designed the "smart" aspect as an add-on—a piece of technology that's readily integrated into any old porcelain bowl. "It's sort of like buying a bidet add-on that can be mounted right into your existing toilet," he said. "And like a bidet, it has little extensions that carry out different purposes."

These extensions sport an array of health-monitoring technologies that look for signs of disease. Both urine and stool samples are captured on video and are then processed by a set of algorithms that can distinguish normal "urodynamics" (flow rate, stream time and total volume, among other parameters) and stool consistencies from those that are unhealthy.

Alongside physical stream analysis, the toilet also deploys uranalysis strips, or "dipstick tests," to measure certain molecular features. White blood cell count, consistent blood contamination, certain levels of proteins and more can point to a spectrum of diseases, from infection to bladder cancer to kidney failure. In its current stage of development, Gambhir said, the toilet can measure 10 different biomarkers.

It's still early days, though, with a total of 21 participants having tested the toilet over the course of several months. To get a better feel for "user acceptance" more broadly, the team surveyed 300 prospective smart-toilet users. About 37% said they were "somewhat comfortable" with the idea, and 15% said they were "very comfortable" with the idea of baring it all in the name of precision health.

ID please

One of the most important aspects of the smart toilet may well be one of the most surprising—and perhaps unnerving: It has a built-in identification system. "The whole point is to provide precise, individualized health feedback, so we needed to make sure the toilet could discern between users," Gambhir said. "To do so, we made a flush lever that reads fingerprints." The team realized, however, that fingerprints aren't quite foolproof. What if one person uses the toilet, but someone else flushes it? Or what if the toilet is of the auto-flush variety?

They added a small scanner that images a rather camera-shy part of the body. You might call it the polar opposite of facial recognition. In other words, to fully reap the benefits of the smart toilet, users must make their peace with a camera that scans their anus.

"We know it seems weird, but as it turns out, your anal print is unique," Gambhir said. The scans—both finger and nonfinger—are used purely as a recognition system to match users to their specific data. No one, not you or your doctor, will see the scans.

By no means is this toilet a replacement for a doctor, or even a diagnosis, Gambhir said. In fact, in many cases, the toilet won't ever report data to the individual user. In an ideal scenario, should something questionable arise—like blood in the urine—an app fitted with privacy protection would send an alert to the user's health care team, allowing professionals to determine the next steps for a proper diagnosis. The data would be stored in a secure, cloud-based system. Data protection, both in terms of identification and sample analyses, is a crucial piece of this research, Gambhir said. "We have taken rigorous steps to ensure that all the information is de-identified when it's sent to the cloud and that the information—when sent to health care providers—is protected under HIPAA," he said, referring to the Health Insurance Portability and Accountability Act, which restricts the disclosure of health care records.

Smart toilet 2.0

As Gambhir and his team continue to develop the smart toilet, they're focusing on a few things: increasing the number of participants, integrating molecular features into stool analysis and refining the technologies that are already working. They're even individualizing the tests deployed by the toilet. For example, someone with diabetes may need his or her urine monitored for glucose, whereas someone else who is predisposed to bladder or kidney cancer might want the toilet to monitor for blood.

Gambhir's other goal is to further develop molecular analysis for stool samples. "That's a bit trickier, but we're working toward it," Gambhir said. "The smart toilet is the perfect way to harness a source of data that's typically ignored—and the user doesn't have to do anything differently."

German toilet paper calculator takes aim at virus panic-buying

---

More information: A mountable toilet system for personalized health monitoring via the analysis of excreta, Nature Biomedical Engineering (2020). DOI: 10.1038/s41551-020-0534-9 , https://nature.com/articles/s41551-020-0534-9

Journal information: Nature Biomedical Engineering 

Flushing the toilet could create a 3-foot vortex of airborne coronavirus poop particles, a new study shows

Holly Secon

Multiple studies have found traces of the coronavirus in infected patients' poop. New Africa/Shutterstock


Multiple studies have found traces of the coronavirus in infected patients' poop.
A new study found that when toilets are flushed, they create a cloud of tiny aerosol droplets — which could contain the virus — up to 3 feet above the toilet bowl.

The cloud can remain there for about one minute and might land on other surfaces around the bathroom.

It's unclear if you could be infected from this level of exposure because scientists still don't know how much of the virus you need to be exposed to in order to get sick.

But you should close the toilet lid before you flush to prevent this cloud from escaping into the bathroom.

It's well-known by now that the coronavirus can spread from person to person via respiratory droplets.

But droplets aren't the only bodily fluid that the virus can travel in: Multiple studies have found traces of it in infected patients' poop.

A new study from the American Institute of Physics evaluated how far these potentially viral poop particles could spread when you flush a toilet. It found that a toilet's flush could spew tiny droplets from the toilet — and the material inside — up to 3 feet from the toilet, which could land on other surfaces around the bathroom.

It also found that the turbulence from a flush generated such small particles that they could float in the air around the toilet for up to a minute, where they could be inhaled by another bathroom user. Shared bathrooms can be risky for this reason.

"One can foresee that the velocity will be even higher when a toilet is used frequently, such as in the case of a family toilet during a busy time or a public toilet serving a densely populated area," Ji-Xiang Wang, a coauthor of the study who researches fluid dynamics at Yangzhou University, said in a press release.

It's unclear if the amount of virus that would be in these particles is enough to infect another person, but you should still lower the lid before you flush.

The study helps highlight the risks that could be posed by shared bathrooms as the US and other countries reopen. In general, four main factors raise your risk of catching the virus: enclosed spaces, crowds, close contact with others, and difficulty social distancing.

A small enclosed space like a bathroom presents a high risk, particularly if many people are sharing it.

Toilet flushes create a 'vortex' of droplets above the bowl

The researchers used a fluid-dynamics model to track the movement of the droplets in a toilet bowl after a flush.

When a toilet flushes, water from the tank above the bowl is pushed down into the water in the bowl — creating turbulence and changes in airflow.

The researchers studied two common types of siphon toilets. One has a single toilet inlet valve for flushing water. The other has two inlet valves, which create a rotating flow.

These valves determine the amount of pressure that the water used for flushing applies to the raw waste in the bowl. That means different amounts of the wastewater in the bowl will be spewed out.

The simulation results for flushing a one-valve toilet for 1.4 seconds. American Institute of Physics

For both types of toilets, as the water pours into the toilet bowl from one side, it splashes the opposite side, creating a vortex near the far wall.

The vortex continues upward in the air above the bowl because of inertia.

"Therefore, an airflow vortex also appears in the air zone above the toilet seat," the researchers wrote. The droplets in this vortex are carried to a height of up to 3 feet. The droplets are so small that they can float there for up to one minute.

A two-valve toilet creates an even faster vortex, forcing about 60% of these small particles into the air even more quickly, the simulation shows.

If there is infected fecal matter in the toilet, the clouds will contain them.

Still, it's unclear if these viral poop clouds can get you sick

It's unknown whether these small particles can get you sick because scientists are still not sure how much of the coronavirus you need to be exposed to in order to get infected.

The particles that are spewed from a toilet are tiny — they're known as aerosols, which are smaller than the droplets that the virus prefers to travel in.

Scientists agree that the virus is primarily transmitted through respiratory droplets — particles larger than 5 micrometers — when an infected person coughs, sneezes, or speaks.

Brooklyn's Domino Park on May 17 in New York. AP Photo/Kathy Willens

A clear solution to this dangerous problem is to close the lid before flushing. But in many countries, including the US, toilets in public restrooms don't typically have lids.

The researchers said a new toilet design could help prevent infectious-disease transmission. A toilet with a lid that closes automatically before flushing, for example, could avoid the issue.

Wiped out of toilet paper? Here’s why

This undated photo provided by Georgia-Pacific shows the production line at the Georgia-Pacific plant in Atlanta. NCSolutions, a data and consulting firm, said online and in-store U.S. toilet paper sales rose 51% between Feb. 24, 2020 and March 10, as buyers started getting uneasy about the growing number of coronavirus cases. (Georgia-Pacific via AP)


What does toilet paper have to do with the global coronavirus pandemic?

Nothing.

Yet millions of people have been panicking about their household supply. Store shelves have been emptied. Amazon is often out of stock. And social media is bursting with jokes and pleas for a roll or two.

The good news: Things are calming down, at least in the U.S., after a buying spree in mid-March. But it’s not yet clear when — if ever — buying habits will get back to normal.




Here’s all you ever wanted to know about toilet paper during a pandemic:

WHY IS TOILET PAPER IN SHORT SUPPLY?

One reason is because people are hoarding. Some were stockpiling last month in advance of city and state lockdown orders. It’s a common reaction in times of a crisis, when consumers feel a need for control and security, says David Garfield, global leader of the consumer products practice at AlixPartners, a consulting firm.


NCSolutions, a data and consulting firm, said online and in-store U.S. toilet paper sales rose 51% between Feb. 24 and March 10, as buyers started getting uneasy about the growing number of virus cases. But sales rocketed a whopping 845% on March 11 and 12 as states announced lockdowns.

WHAT ARE SOME OTHER REASONS FOR THE SHORTAGES?

Toilet paper flows from paper mills to retail stores through a tight, efficient supply chain. Toilet paper is bulky and not very profitable, so retailers don’t keep a lot of inventory on hand; they just get frequent shipments and restock their shelves.





“You never noticed because it’s so well-managed,” said Jim Luke, an economics professor at Lansing Community College in Michigan, who used to be a strategist for a toilet paper distribution company.

The amount of toilet paper the average American uses hasn’t changed; it’s still around 141 rolls per year (compared to 134 rolls in Germany and just 49 rolls in China, AlixParters says). But even small changes in buying habits can throw everything into disarray.

With a regional disruption like a hurricane, stores can redirect some inventory to the affected area. But a global pandemic doesn’t leave a lot of wiggle room.

CAN’T COMPANIES JUST MAKE MORE TOILET PAPER?

The big three U.S. toilet paper companies — Georgia-Pacific LLC, Proctor & Gamble Co. and Kimberly-Clark Corp. — were already running their toilet paper plants 24 hours a day before the new coronavirus hit. That’s the only way they can make a profit on such a low-margin product.


The companies are trying to increase output by making fewer varieties of toilet paper. They’re also trying to get the product to stores more quickly. Atlanta-based Georgia-Pacific is working with packaging suppliers to get more materials and maximizing the number of deliveries it can ship from its facilities.
Full Coverage: Life during a pandemic

CAN SUPPLIES BE REDIRECTED TO HOUSEHOLDS INSTEAD OF BUSINESSES THAT ARE NOW CLOSED?

No. Commercial toilet paper uses a different kind of pulp and is produced on different machines. Many institutional rolls are intentionally larger, so cleaning staff don’t have to refill them as often and people don’t steal them, Luke said. Plusher toilet paper for home use also has different packaging requirements, Garfield said.

Prior to the coronavirus crisis, about half of U.S. toilet paper sales were commercial, while the other half were for homes, Garfield said. That’s changing; AlixPartners estimates U.S. household demand is up 40% as offices and schools close.

But Georgia-Pacific said commercial demand hasn’t yet fallen. It has seen a surge of orders from hospitals and other essential businesses that are still operating.

ARE SUPPLIES IN GROCERIES AND OTHER RETAILERS IMPROVING?

Demand has softened a bit since mid-March, so that should make it easier to find toilet paper. NCSolutions said sales are down 62% right now compared to the “extreme buying period” of March 11-24. But they’re still 6% higher than they were before the new coronavirus hit the U.S.

Kroger, the nation’s biggest grocery chain, said most of its stores are now getting truckloads of paper products every day or every other day. Kroger and other retailers have also established limits on the amount of toilet paper people can buy at one time.

WHEN WILL THINGS GET BACK TO NORMAL?

Nobody knows. For one thing, the new coronavirus could permanently increase the demand for household toilet paper.

“Will the workforce go back to work like they did before? If people work from home, this could be much more prolonged,” says NCSolutions CEO Linda Dupree.

Raising prices on toilet paper — as was done in 1973 during the oil embargo — might curb hoarding, Garfield said. But it would make it harder for some consumers to afford.

ARE THERE WAYS TO CUT DOWN ON TOILET PAPER USE?

U.S. searches for “bidet” reached an all-time high in March, according to Google Trends. Tushy, which makes a $100 bidet attachment for toilets, said its sales spiked in mid-March, hitting $1 million in a single day. Sales are still running 10 times ahead of projections, Tushy said.

Why toilet paper has become the latest coronavirus panic buy


By Scottie Andrew, CNN

Masks were the first to go. Then, hand sanitizers.

© Peter Parks/AFP/Getty Images Shelves are empty of toilet rolls in a supermarket in Sydney on March 4, 2020. - Australia's biggest supermarket announced a limit on hand sanitisers and toilet paper purchases after the global spread of coronavirus sparked a spate of panic buying Down Under.

Now, novel coronavirus panic buyers are snatching up ... toilet paper?

Retailers in the US and Canada have started limiting the number of toilet paper packs customers can buy in one trip. Some supermarkets in the UK are sold out. Grocery stores in Australia have hired security guards to patrol customers.

© WILLIAM WEST/AFP/Getty Images Supermarkets in Australia are largely selling out of toilet paper due to novel coronavirus fears. An Australian newspaper even printed out eight extra pages in a recent edition to serve as emergency toilet paper.

An Australian newspaper went so far as printing eight extra pages in a recent edition -- emergency toilet paper, the newspaper said, should Aussies run out.


Why? Toilet paper does not offer special protection against the virus. It's not considered a staple of impending emergencies, like milk and bread are.

So why are people buying up rolls more quickly than they can be restocked?


Reason 1

People resort to extremes when they hear conflicting messages

Steven Taylor is a clinical psychologist and author of "The Psychology of Pandemics," which takes a historic look at how people behave and respond to pandemics. And compared to past pandemics, the global response to the novel coronavirus has been one of widespread panic.

"On the one hand, [the response is] understandable, but on the other hand it's excessive," Taylor, a professor and clinical psychologist at the University of British Columbia, told CNN. "We can prepare without panicking."

The novel coronavirus scares people because it's new, and there's a lot about it that's still unknown. When people hear conflicting messages about the risk it poses and how seriously they should prepare for it, they tend to resort to the extreme, Taylor said.

"When people are told something dangerous is coming, but all you need to do is wash your hands, the action doesn't seem proportionate to the threat," he said. "Special danger needs special precautions."


Reason 2
Some are reacting to the lack of a clear direction from officials

Several countries have already imposed mass quarantines. People buying up toilet paper and other household supplies may be preparing for the same thing in their city, said Baruch Fischhoff, a psychologist and professor in the Department of Engineering and Public Policy and the Institute for Politics and Strategy at Carnegie Mellon University.

"Unless people have seen ... official promises that everyone will be taken care of, they are left to guess at the probability of needing the extra toilet paper, sooner rather than later," he told CNN. "The fact that there are no official promises might increase those probabilities."


Reason 3

Panic buying begets panic buying

Images of empty shelves and shopping carts piled high with supplies have inundated news reports and social feeds. People see images of panic buyers, assume there's a reason to panic and buy up supplies, too, Taylor said.

"People, being social creatures, we look to each other for cues for what is safe and what is dangerous," he said. "And when you see someone in the store, panic buying, that can cause a fear contagion effect."

All those photos of empty shelves may lead people to believe that they must rush out and grab toilet paper while they still can. And what started as perceived scarcity becomes actual scarcity, Taylor said.

Social media is a huge player in novel coronavirus fear-mongering, Taylor said. Misinformation spreads with ease, and open platforms amplify voices of panic.

Reason 4

It's natural to want to overprepare

There may be some practicality in stocking up, says Frank Farley, a professor at Temple University and former president of the American Psychological Association.

With the CDC and other international health agencies now advising that certain populations should stay home and avoid contact with other people or crowds, it's natural to want to prepare, he said.

"[The novel coronavirus] is engendering a sort of survivalist psychology, where we must live as much as possible at home and thus must 'stock up' on essentials, and that certainly includes toilet paper," he told CNN. "After all, if we run out of [toilet paper], what do we replace it with?"

You'll be spending money on toilet paper at one point or another -- the only extra costs are the hassle of doing it sooner rather than later, contending with long lines and having difficulty finding it, Fischhoff said.

Since they'll eventually use the toilet paper, the analysis is different than if they'd bought something they likely wouldn't use, like a perishable item, he said.

The US Department of Homeland Security advises Americans to keep at least two weeks' worth of food, toiletries and medical supplies on hand anyway, but Taylor said most people don't. So when health officials publicly advise to stock up, they may take it to the extreme.


Reason 5

It allows some to feel a sense of control

The people who are stocking up on supplies are thinking about themselves and their family and what they need to do to prepare, Taylor said -- not healthcare workers, sick people or even regular folks who might run out of toilet paper sometime soon.

"It's all due to this wave of anticipatory anxiety," Taylor said. "People become anxious ahead of the actual infection. They haven't thought about the bigger picture, like what are the consequences of stockpiling toilet paper."

But people only act that way out of fear. Fischhoff said that preparing, even by purchasing toilet paper, returns a sense of control to what seems like a helpless situation.

"Depending on how people estimate the chances of needing the toilet paper, the hassle might be worth it," he said. "If it gave them the feeling that they had done everything that they could, it might free them to think about other things than coronavirus.

WE ALL WONDERED
Why toilet paper has become the latest coronavirus panic buy

By Scottie Andrew, CNN 3/9/2020

Masks were the first to go. Then, hand sanitizers.© Peter Parks/AFP/Getty Images Shelves are empty of toilet rolls in a supermarket in Sydney on March 4, 2020. - Australia's biggest supermarket announced a limit on hand sanitisers and toilet paper purchases after the global spread of coronavirus sparked a spate of panic buying Down Under.

Now, novel coronavirus panic buyers are snatching up ... toilet paper?

Retailers in the US and Canada have started limiting the number of toilet paper packs customers can buy in one trip. Some supermarkets in the UK are sold out. Grocery stores in Australia have hired security guards to patrol customers.

© WILLIAM WEST/AFP/Getty Images Supermarkets in Australia are largely selling out of toilet paper due to novel coronavirus fears. An Australian newspaper even printed out eight extra pages in a recent edition to serve as emergency toilet paper.

An Australian newspaper went so far as printing eight extra pages in a recent edition -- emergency toilet paper, the newspaper said, should Aussies run out.


Why? Toilet paper does not offer special protection against the virus. It's not considered a staple of impending emergencies, like milk and bread are.

So why are people buying up rolls more quickly than they can be restocked?


Reason 1



People resort to extremes when they hear conflicting messages

Steven Taylor is a clinical psychologist and author of "The Psychology of Pandemics," which takes a historic look at how people behave and respond to pandemics. And compared to past pandemics, the global response to the novel coronavirus has been one of widespread panic.

"On the one hand, [the response is] understandable, but on the other hand it's excessive," Taylor, a professor and clinical psychologist at the University of British Columbia, told CNN. "We can prepare without panicking."

The novel coronavirus scares people because it's new, and there's a lot about it that's still unknown. When people hear conflicting messages about the risk it poses and how seriously they should prepare for it, they tend to resort to the extreme, Taylor said.

"When people are told something dangerous is coming, but all you need to do is wash your hands, the action doesn't seem proportionate to the threat," he said. "Special danger needs special precautions."


Reason 2



Some are reacting to the lack of a clear direction from officials

Several countries have already imposed mass quarantines. People buying up toilet paper and other household supplies may be preparing for the same thing in their city, said Baruch Fischhoff, a psychologist and professor in the Department of Engineering and Public Policy and the Institute for Politics and Strategy at Carnegie Mellon University.

"Unless people have seen ... official promises that everyone will be taken care of, they are left to guess at the probability of needing the extra toilet paper, sooner rather than later," he told CNN. "The fact that there are no official promises might increase those probabilities."




Reason 3



Panic buying begets panic buying

Images of empty shelves and shopping carts piled high with supplies have inundated news reports and social feeds. People see images of panic buyers, assume there's a reason to panic and buy up supplies, too, Taylor said.

"People, being social creatures, we look to each other for cues for what is safe and what is dangerous," he said. "And when you see someone in the store, panic buying, that can cause a fear contagion effect."

All those photos of empty shelves may lead people to believe that they must rush out and grab toilet paper while they still can. And what started as perceived scarcity becomes actual scarcity, Taylor said.

Social media is a huge player in novel coronavirus fear-mongering, Taylor said. Misinformation spreads with ease, and open platforms amplify voices of panic.


Reason 4



It's natural to want to overprepare

There may be some practicality in stocking up, says Frank Farley, a professor at Temple University and former president of the American Psychological Association.

With the CDC and other international health agencies now advising that certain populations should stay home and avoid contact with other people or crowds, it's natural to want to prepare, he said.

"[The novel coronavirus] is engendering a sort of survivalist psychology, where we must live as much as possible at home and thus must 'stock up' on essentials, and that certainly includes toilet paper," he told CNN. "After all, if we run out of [toilet paper], what do we replace it with?"

You'll be spending money on toilet paper at one point or another -- the only extra costs are the hassle of doing it sooner rather than later, contending with long lines and having difficulty finding it, Fischhoff said.

Since they'll eventually use the toilet paper, the analysis is different than if they'd bought something they likely wouldn't use, like a perishable item, he said.

The US Department of Homeland Security advises Americans to keep at least two weeks' worth of food, toiletries and medical supplies on hand anyway, but Taylor said most people don't. So when health officials publicly advise to stock up, they may take it to the extreme.


Reason 5



It allows some to feel a sense of control

The people who are stocking up on supplies are thinking about themselves and their family and what they need to do to prepare, Taylor said -- not healthcare workers, sick people or even regular folks who might run out of toilet paper sometime soon.

"It's all due to this wave of anticipatory anxiety," Taylor said. "People become anxious ahead of the actual infection. They haven't thought about the bigger picture, like what are the consequences of stockpiling toilet paper."

But people only act that way out of fear. Fischhoff said that preparing, even by purchasing toilet paper, returns a sense of control to what seems like a helpless situation.

"Depending on how people estimate the chances of needing the toilet paper, the hassle might be worth it," he said. "If it gave them the feeling that they had done everything that they could, it might free them to think about other things than coronavirus."

 

On World Toilet Day, over 1.5bn people still have no access to basic sanitation

Established by World Toilet Organisation in 2001, the day was made an official United Nations Observance in 2013.

News Desk Published November 19, 2025  

“In a world reshaped by rising climate pressures, urban growth, and inequality, safe sanitation remains a cornerstone of public health and human dignity,” says United Nations Secretary-General Antonio Guterres in a statement on World Toilet Day on November 19.

Established by the World Toilet Organisation in 2001, the day was made an official United Nations Observance in 2013.

Every year, UN-Water — the UN’s coordination mechanism on water and sanitation — sets the theme for this day. In 2025, the theme is ‘Sanitation in a changing world’, which, according to the UN reminds us “that no matter what the future holds, we’ll always need the toilet”.

A toilet stands outside the Llamocca family home at Villa Lourdes in Villa Maria del Triunfo on the outskirts of Lima, Peru, on October 7, 2015. — Reuters

“The humble toilet is an icon of progress — preventing disease, protecting the environment, and preserving dignity and opportunity. Without safe sanitation, sustainable development falters. Contaminated water can spread diarrhoeal illnesses, which kill over 1,000 children a day,” says Guterres.

It is important to note, however, that over 1.5 billion people still do not have basic sanitation services, such as private toilets or latrines, according to World Health Organisation. Of these, 419 million still defecate in the open, for example, in street gutters, behind bushes or into open bodies of water.

“Untreated human waste pollutes ecosystems and fuels greenhouse gas emissions,” the UN chief points out. “And for millions of women and girls, the lack of a secure toilet means missed work and school.”

A public toilet stands surrounded by snow near the 2011 Applied Physics Laboratory Ice Station north of Prudhoe Bay, Alaska, on March 18, 2011. — Reuters

Poor sanitation reduces human well-being, social and economic development due to impacts such as anxiety, risk of sexual assault, and lost opportunities for education and work, according to the WHO.

It is linked to transmission of diarrhoeal diseases such as cholera and dysentery, as well as typhoid, intestinal worm infections and polio; furthermore, it exacerbates stunting and contributes to the spread of antimicrobial resistance.

Even where there are toilets around the world, some hardly warrant the name. In a Syrian refugee settlement camp in Lebanon’s Bekaa Valley, for example, toilets surrounded by graffiti-covered corrugated sheet sit right up against flimsy tents. In the Marcory district of Abidjan, Ivory Coast, a “private” stall is simply built of spare bits of lumber and metal.

Toilets donated by Unicef and World Vision stand near tents at a Syrian refugee settlement camp in Qab Elias in the Bekaa Valley, near Baalbek, Lebanon, on October 17, 2015. — Reuters

---

Header Image: An open toilet is seen in a field in Gorba in the eastern Indian state of Chhattisgarh. — Reuters

Smart toilet designs in Cambodia held promise, but a key piece was missing

University of Colorado at Boulder

FacebookXLinkedInWeChatBlueskyMessageWhatsAppEmail

 

image: 

A man digs a pit for an alternating dual-pit latrine (ADP) in rural Cambodia. (University of Colorado Boulder)

view more 

Credit: University of Colorado Boulder

A smart toilet design introduced in rural Cambodia was supposed to change lives—keeping families safe and protecting the environment.

However, while households reported that they liked the new system, a crucial piece was missing: using it correctly.

James Harper, an assistant teaching professor in the Paul M. Rady Department of Mechanical Engineering at CU Boulder, recently led a behavioral study analyzing toilet use in Cambodia. The work, conducted through Harper’s own research consultancy Realize Research in partnership with international development organization iDE, assessed rural households using a backyard sanitation system designed for families to treat human waste themselves.

“Here in the States, we don’t need to think about clean water coming from our tap or having a toilet that flushes, but there are plenty of places around the world that do,” said Harper. “Cambodia is a country of about 17 million people where sanitation systems are lacking. There have been a lot of innovations to help bring new infrastructure and practices to rural areas of the country, and this study examined one of those innovations from a behavioral perspective.”

An easy, effective sanitation solution

iDE partnered with local business owners to promote, sell, and install alternating dual-pit latrines (ADP) across six Cambodian provinces. These pour-flush toilet systems are most commonly used in off-grid locations and are an adaptation of single-pit latrines like those commonly found in U.S. national parks.

Since 2009, iDE has facilitated the implementation of over 410,000 basic, pour-flush latrines, representing nearly one in five toilets in all of rural Cambodia.

The ADP is essentially a new second pit and is sold as an upgrade to an existing single-pit latrine that is currently full of waste. When one pit fills—usually after two to five years of regular use by a household of five—users can switch to using the empty second pit. 

When the initial installation is performed, the service provider mixes hydrated lime, a common soil conditioner used globally in agriculture, into the first pit to speed up the process of treating the waste and kill pathogens that endanger humans.The toilet is then connected to the new second pit. 

After the second pit fills, users are encouraged to call their original service provider or they can empty the first pit safely using shovels and buckets, and then reconnect their toilet back to the first pit. The lime mixture and storage time remove most pathogens after two years, making the treated waste easy and safer to compost, allowing the cycle to repeat indefinitely.

It’s not the most glamorous engineering project, but Harper says ADPs are extremely effective at killing off dangerous pathogens, especially in areas with limited infrastructure. The waste they produce can be used, somewhat surprisingly, for agricultural purposes, as well. 

Human waste is replete with nutrients that plants love, so as long as pathogens are removed, human waste can be a great fertilizer.

“Lime is a cheap agricultural amendment that’s commonly used around the world to change the pH of soil to improve crop production,” Harper said. “We use it to raise the pH in a full pit to kill pathogens that endanger humans. Then, that human waste can be used as a fertilizer to make crops grow better.”

The interesting, important results

From a theoretical standpoint, ADP latrine implementation in Cambodia was sound. It was safe, cost-effective and came with a number of potential benefits for the area. 

However, the team recognized early that long-term use of the system depended on the engagement and behavior of the households themselves.

After multiple training sessions and allowing families to manage their ADPs themselves, iDE and Harper surveyed 765 households to see how well people were using the toilets and following the recommended guidelines, particularly those about waiting 2 years before emptying and switching their pit connections. Despite a general understanding of the required steps and expectations, they found that follow-through among households was inconsistent.

According to the survey, only 40% of people could recall certain details of recommended ADP maintenance, including how long before emptying a pit can be done safely. In fact, not one household in the entire study waited the recommended two-year period before emptying, potentially exposing themselves and others in their community to health risks via pathogen exposure.

Harper says there were clear motivations for the results. Some families opted to empty pits early before hosting guests during cultural events. Others simply reconnected their old pits to their toilets without emptying the dried, compacted waste. But overall, households just did not want to manage their own waste—for obvious reasons.

“Ultimately, what the study highlighted was the difference between theory and practice,” said Harper. “We learned that households can’t—and actually shouldn’t—be relied upon to completely manage their own waste, and that’s a reasonable finding. We don’t manage our own waste in the States; we just flush and forget. So, why would we expect something different from people in Cambodia? 

While the ADP could be a great product, its use in the real world is different than we assumed during design, and that’s why the design must be improved going forward—to meet the need while working within the real-world constraints of our users.”

iDE will use the results of this study to pivot and experiment with other solutions. They are currently testing and scaling up a service-based approach where waste can be disposed of safely on the household premises by a trained service provider. All a household needs to do is call when they need help emptying their pits.

But Harper and his iDE colleague Tyler Kozole also hope the study can be a moment of learning that all engineers across any discipline can benefit from, too.

“We recognize that this research indicates what could be viewed as a type of failure in our work,” said Kozole, director of iDE Cambodia’s Wash, Sanitation and Hygiene (WASH) program. “We’re broadcasting this research to advocate for embracing and learning from failures. If the whole sector embraced this mindset, we’d solve problems faster, use our resources more efficiently and ultimately make the kind of impact we’re trying to see in the world.”

A man puts the finishing touches on an ADP in rural Cambodia. (University of Colorado Boulder)

Credit

University of Colorado Boulder

---

Journal

PLOS One

DOI

10.1371/journal.pone.0332118 

Article Title

Household perceptions, practices, and experiences with real-world alternating dual-pit latrines treated with storage and lime in rural Cambodia