IFIC survey on global practices related to disposal of faeces and urine

Berlin, 1. April 2014 MEIKO-Workshop

Walter Popp

Around 40 % of world population does not have access to appropriate sanitary facilities.

Death of around 1,5 mio children under the age of 5.

15 % of world population still practice open (WHO).

Defecation and are typical inquiries in any medical assessment – important symptoms.

Most of multiresistant gramnegative bacteria are living in our guts.

But: Little is known about handling of feces and urine in world wide.

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1 Method

Survey from July 2012 – April 2013.

Electronic tool (SurveyMonkey).

Manual completion by paper forms distributed by collaborating partner MEIKO – conferences and similar events.

8 languages: Spanish, French, German, English, Japanese, Thai, Chinese, Mongolian.

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Results

1,440 answers. 109 answers of them given on paper questionnaires: mostly Thailand, China, India, Mongolia.

Answers from 93 countries.

Few answers from South America (only Uruguay) and African countries (but South Africa).

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2 Country Total answers Germany 178 Canada 161 Countries with more than United States 141 10 answers France 76 Australia 66 Thailand 55 Mongolia 41 India 40 United Kingdom 34 China 32 South Africa 23 Egypt 22 Netherlands 19 Hong Kong 17 Pakistan 17 Uruguay 17 Indonesia 16 Denmark 16 Saudi Arabia 11 Tunisia 11 Belguim 10 Norway 10 Total 1013

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Country GDP in US$ per Total capita 2012 answers Countries with more than Norway 99557,73 10 Australia 67035,57 66 10 answers and their GDP Denmark 56210,23 16 Canada 52218,99 161 United States 49965,27 141 Netherlands 46054,41 19 Belguim 43412,53 10 Germany 41514,17 178 France 39771,84 76 United Kingdom 38514,46 34 Hong Kong 36795,82 17 Saudi Arabia 20777,67 11 Uruguay 14449,50 17 South Africa 7507,67 23 China 6091,01 32 Thailand 5473,75 55 Tunisia 4236,79 11 Mongolia 3672,97 41 Indonesia 3556,79 16 Egypt 3187,31 22 India 1489,24 40 Pakistan 1290,36 17

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3 Number of beds Median 350. Range 4 (India) – 8.000 (South Africa).

Location 77 % urban hospitals, 23 % rural hospitals. Most of all rural from Mongolia (59 %) and Belgium (44 %).

Typical situation of defecation of . Open outside 1 % . Some sort of bog outside 1 % . Bog inside or outside 1 % . with water flushing system inside and/or outside 20 % . Toilet with water flushing system inside only 79 % Rural hospitals may be under-represented

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Sinks for hand washing available near by Yes 99 % No 1 % (n=17)

Other types of hand hygiene facilities (alcohol based gels or similar) For staff only 21 % For patients only 5 % For both 75 %

Regular cleaning of defecation area . With disinfectant 57 % . With cleaning agent 41 % . No regular cleaning 2 % (n=31)

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4 availability For each room 65 % For whole ward 35 %

Toilets for patients and staff Different 96 %

Sex specific toilets . For patients 61 % . For staff 57 %

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Who is caring if defecation is done in bed . himself 6 % . Relatives or friends or caregivers 24 % . Nurses 76 % . Other staff 41 %

If bedpans are used Multiple use 76 % Nearly 100 % Norway, Denmark, Netherlands, Germany, France, Hong Kong, Uruguay, Thailand, Tunisia, Mongolia,Indonesia Made from plastics 49 % Made from steel 51 % Single use 24 % Nearly 100 % Australia, UK; above 50 % Canada, US, China Macerator in 38 % (especially Australia, UK)

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5 Bedpan washer . Available in 50 %

If bedpan washer available Working with . heat only 32 % . chemical disinfectant and heat 41 % . chemical disinfectant only 30 %

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If bedpans are cleaned manually, it is done . in dirty utility room 61 % . in patient´s 44 % . other rooms 10 %

. Many comments from Belgium, Canada, US that the advice from IPC is to clean and disinfect bedpans after each use, but nurses do it only with water in the bathroom because of workload, sometimes followed by wiping or spraying with disinfectant.

. Different comments from Canada and US that single use bags/liners are used inside the bedpan which are given to waste. (reason for cleaning in bathroom?)

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6 Without bedpan, defecation in bed is done . without any additional means 9 % . in nappiles 86 % . on special textile 15 % . on paper 4 %

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Additional comments In general n=280 Re religious and cultural background n=337

Few sent photos

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7 Different comments that water supply is needed near to toilet because of need to clean themselves and wash hands after defecation and urination, also because of religious reasons (muslims).

Below: typical hand shower used when people clean by hand in countries with no (Oman, 2013).

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Typical ground toilet and water supply in a small hospital (left) and toilet in a big hospital (right) (Damaskus, Syria, 2010)

Comments from Germany about intercultural conflicts when Arab patients are defecating by sitting on toilet seats. Cleaning staff may refuse to clean and fecal contamination of shower hoses has been found.

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8 Typical “LOTA” used for cleaning after defecation in case no shower is available (Pakistan, 2013)

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For India, it was commented that “ward boys” are caring for cleanliness on wards, but their education is very bad and cleaning and disposing feces is seen as a dirty job.

For Pakistan, it was commented that usually non-muslim staff is responsible for cleaning toilets. This is the reason why cleaning is breaking down during Christmas time.

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9 Toilet in a district hospital (secondary level) (left), with a family doctor (primary level), Ulaanbaatar, Mongolia, 2010

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10 Conclusions

First description of situation worldwide.

Most answers from urban hospitals - situation might be worse in countryside.

Big influences of religion and culture.

Big difference re bedpan use in similarly developed countries. (eg single use bedpans and maceration in UK and steel bedpans and washer disinfector in Germany)

It would make sense to develop recommendations – also with respect to multiresistant bacteria.

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11 Thanks to

Michael Borg and Simeone Zarafa (SurveyMonkey)

Judith Richards (IFIC and native English)

Khand Zorigt (statistics)

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