Bacterial Contamination on Community and Household Latrine Surfaces in Kathmandu, Nepal

Shannon McGinnis1, Dianna Marini2, Prakash Amatya2, Heather Murphy1

1WHAM Lab- Temple University, Epidemiology and Biostatistics, Philadelphia, Pennsylvania, USA 2AEROSAN Toilets, Halifax, Canada Background

SDG goals for improving WASH include: • Ending open defecation • Achieving universal access to basic services • Progress towards safely managed services

However, basic sanitation services by definition do not include shared facilities Background

Shared or community sanitation facilities are excluded from the “basic” sanitation definition due to concerns around accessibility, safety, gender equity, and cleanliness

• While, some studies have identified health risks associated with using a shared sanitation facility • There is still lack of evidence that there is a significant difference in cleanliness and subsequent health benefits between private and shared and sanitation Study site: Kathmandu, Nepal

• Nepal is urbanizing rapidly (population of Kathmandu to double within the next 50 years)

• Kathmandu is facing a shortage of sanitation facilities because: • population growth an urbanization • lack of financial resources • 2015 earthquake Background

Latrine Technology

• Community sex segregated latrines ( with urinals for men) • Pay per use, run by private operators • Anaerobic digestion • Cleaning practices • Slab- water only • Other surfaces- soap and water Purpose

• To quantify and compare bacterial contamination on latrine surfaces on two types of community latrines and household latrines in Kathmandu, Nepal

• To identify surfaces that may be more likely to contribute to disease transmission. Sites

• Two community toilet sites in Kathmandu • Swabbed during “dirty” and “clean” conditions Sites

Five household sites in Kathmandu: • 3 Western-style toilets (1 multi-family, 2 single family) • 2 pit latrines (1 legal slum, 1 illegal slum) • Swabbed once at midday (asked not to clean) Sites

• Two university control sites located at Temple University in Philadelphia, PA • Swabbed once at end of day • Temple Library site selected due to heavy traffic Surfaces Swabbed

Household Latrines Community Latrines Surface Surface Type Avg Area N Surface Type Avg Area N N ID Swabbed Swabbed (Dirty) (Clean) TS Toilet seat for cistern 76cm2 5 Latrine slab 55cm2 16 11 flush toilets or latrine slab for pit latrines AC Spray handle/bucket 23cm2 5 Tap used for anal 140cm2 16 11 for anal cleansing cleansing DH Door Handle 82cm2 5 Door Handle 30cm2 16 11 W Wall (Pit latrines only) 100cm2 2 Wall 100cm2 16 11 SH Sink handle at 424cm2 3 Sink handle at 218cm2 6 3 handwashing station handwashing station F Flush (cistern flush 10cm2 3 Flush (United States 28cm2 6 1 toilets only) control site only) Fl Floor (United States 100cm2 5 control site only) M Money (collected from 45cm2 2 latrine operator at community site 1)* Methods

• Swabs were collected and stored in Amies/PBS/Sodium thiosulfate solution • Swabs were vortexed in solution • Analyzed for total coliforms and E. coli using membrane filtration • Samples were processed in the ENPHO lab in Kathmandu, Nepal Results

• 96 swab samples were taken from community toilet sites in Kathmandu (March 2018) • 23 samples were collected from household sites • 24 samples were taken from toilets at Temple University (April 2018) • Almost all samples collected at Temple site recovered no bacterial contamination Bacterial Concentrations by Surface Type for Community Latrines under “Dirty” Conditions

Total Coliforms by Surface Type E. coli by Surface Type

TS= Toilet Seat; AC= Anal cleansing bucket; DH= Door handle; W= Wall; S= Sink handle Bacterial Concentrations by Surface Type for Community Latrines under “Clean” Conditions Total Coliforms by Surface Type E. coli by Surface Type

TS= Toilet Seat; AC= Anal cleansing bucket; DH= Door handle; W= Wall; S= Sink handle Bacterial Concentrations by Surface Type for Household Latrines

Total Coliforms by Surface Type E. coli by Surface Type

TS= Toilet Seat; AC= Anal cleansing bucket; DH= Door handle; W= Wall; S= Sink handle Results

Comparing Bacterial Contamination of Community Latrine Surfaces during Clean and Dirty conditions (red if significant)

Surface N Total Coliforms E. coli Type Median Median p-value Median Median p-value (cfu/cm2) (cfu/cm2) (cfu/cm2) (cfu/cm2) Before After Before After Cleaning Cleaning Cleaning Cleaning

TS 10 214.77 0 <0.01 56.25 0.003 <0.01 AC 10 1.90 0.02 0.01 0.30 0.01 0.01 DH 10 0.99 0.10 0.06 0.47 0.04 0.06 W 10 0.24 0 0.01 0.1 0 0.02 SH 3 1.46 0.24 0.25 0.09 0.01 0.25 TS= Toilet Seat; AC= Anal cleansing bucket; DH= Door handle; W= Wall; S= Sink handle

*Wilcoxin Signed Rank Tests Results

Comparing Bacterial Contamination of Community Latrines during Dirty conditions to Household (HH) Latrines Total Coliforms E. coli Surface Household Community Household Community p- Household Community p- Type N N Median Median value Median Median value (cfu/cm2) (cfu/cm2) (cfu/cm2) (cfu/cm2) Before Before Cleaning Cleaning TS 5 10 0.55 214.77 <0.01 0.19 56.25 <0.01 AC 5 10 1.39 1.90 0.67 0.38 0.30 0.67 DH 5 10 0 0.99 0.16 0 0.47 0.10 W 2 10 0.24 0.24 0.59 0.08 0.10 0.66 F 3 0 0.08 NA NA 0.08 NA NA SH 3 3 0.03 1.46 0.10 0.01 0.09 0.10

TS= Toilet Seat; AC= Anal cleansing bucket; DH= Door handle; W= Wall; S= Sink handle *Wilcoxin Signed Rank Tests Results

Comparing Bacterial Contamination of Community Latrines during Clean conditions to Household (HH) Latrines Total Coliforms E. coli Surface Household Community Household Community p- Household Community p- Type N N Median Median value Median Median value (cfu/cm2) (cfu/cm2) (cfu/cm2) (cfu/cm2) After After Cleaning Cleaning TS 5 10 0.58 0 0.22 0.19 0.004 0.28 AC 5 10 1.39 0.02 0.50 0.38 0.01 0.50 DH 5 10 0 0.10 0.45 0 0.04 0.45 W 2 10 0.24 0 0.19 0.08 0 0.19 F 3 0 0.29 NA NA 0.08 NA NA SH 3 3 0.03 0.02 1 0.01 0.01 1

TS= Toilet Seat; AC= Anal cleansing bucket; DH= Door handle; W= Wall; S= Sink handle

*Wilcoxin Signed Rank Tests Conclusions

• We found almost no difference in bacterial contamination between household and community latrines in Kathmandu, Nepal

• A significant difference was found when comparing toilet seats/latrine slabs between dirty community and household latrines

• This relationship was not found when comparing clean community and household surfaces Conclusions

Most contaminated surfaces in: Community latrines: • Toilet seat/latrine slab, • Tap/handle/bucket used for anal cleansing • Door handles Household latrines: • Toilet seat/latrine slab, • Tap/handle/bucket used for anal cleansing • Door handles • Flush handle Conclusions

• Results support previous research that suggests that shared/community sanitation facilities may not be less clean than household facilities • This research highlights which surfaces are important for cleaning interventions • More frequent cleaning during the day could also increase cleanliness of community latrines Limitations

• Several important factors that may impact the relevance of these results to other settings include: • The role of specific cleaning practices (identifying best practices for cleaning) • Latrine maintenance • Construction of latrines (including materials surfaces were made of) • Type of latrine/ treatment system • Cleaning and hygiene behaviors • Etc. Limitations

• This research had a small sample size • Focused on fecal indicator organisms and not on pathogens • Future research is needed Future Research/ Next Steps

• Establish cleaning guidelines for latrine operators • Investigate pathogen occurrence/ survival on surfaces • Investigate pathogen inactivation in the anaerobic digester Acknowledgements Contact Information

Heather Murphy, Ph.D. Assistant Professor Department of Epidemiology and Biostatistics Water Health and Applied Microbiology Lab ( WHAM Lab)

[email protected]