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The Role of The Public Toilet Pathogen Transmitter
The Role of The Public Toilet Pathogen Transmitter
The Role of The Public Toilet Pathogen Transmitter
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Clara Greed
University of the West of England, Bristol
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What is This?
This paper discusses the role of public toilets, as transmitters of disease, but also
of their importance in contributing to the health and well-being of society.
Research has shown that public toilets are vital components in creating
sustainable, accessible, inclusive cities. But there is no mandatory legislation
requiring local authorities to provide them. Over 40% have been closed in the UK
in the last 10 years. The promotion of the 24 hour city, characterized by a male
youth drinking culture, along with toilet closure, has resulted in increased street
urination, creating the conditions for the spread of previously-eradicated, water-
borne diseases in city streets. Less visible, but as virulent, has been the effect of
toilet closure for women. Women, in response to lack of toilet provision, are likely
to ‘hold on’ resulting in urine (and pathogen) retention, and bladder distension
increasing the propensity for continence problems. The elderly and people with
disabilities may simply not go out for fear of there being no toilet when they need
one. Those toilets that are available may be unusable. Lack of regulation or
compulsory standards result in poor toilet design, inadequate maintenance and
management, and unhygienic conditions, resulting in the spread of MRSA and
other drug-resistant diseases. Recommendations are summarized for the provi-
sion of a spatial hierarchy of toilet provision that would both meet user needs and
reduce the chances of the public toilets acting as epicentres of germ transmis-
sion. Unless compulsory legislation, increased funding, and improved manage-
ment, maintenance and cleaning regimes are instigated, public toilet provision
will continue to be a source of disease.
1 The importance of public toilets are better defined as ‘away from home’
toilets.4 Section 1 sets out ‘the problem’ of
1.1 Introduction and contents what is wrong with the present nature of
This paper discusses the role of the public public toilet provision in the UK. Section 2
toilet in contributing to pathogen transmis- summarizes the limitations of legislation and
sion and physical debility, but, also, poten- toilet policy. Section 3 provides key recom-
tially, advancing the health of the nation.1 3 mendations, arising from the author’s re-
Public toilets may be defined as comprising search, on ideal provision: and thus better
both traditional ‘on-street’, local authority hygiene and health for all.
public toilets and ‘off-street’ toilets to which
the public has right of access, which, together, 1.2 The importance of public toilets for all: the
missing link
Research has demonstrated that public
Address for correspondence: Dr Clara Greed, Professor of toilet provision constitutes the vital, missing
Inclusive Urban Planning, Faculty of the Built Environment,
University of the West of England, Bristol BS16 1QY, UK. link that would enable the creation of sus-
E-mail: Clara.Greed@uwe.ac.uk or ClaraGreed@aci.com tainable, accessible, inclusive cities.5 If the
# The Chartered Institution of Building Services Engineers 2006 10.1191/0143624406bt151oa
128 The role of the public toilet
government wants people to leave their cars at sion is being cut back. The proliferation of
home and travel by public transport, cycle or bars, clubs and pubs (public houses) in city
walk, then the provision of public toilets is centres has resulted in increased alcohol con-
essential, especially at transport termini. Pub- sumption, typified by a binge drinking, male,
lic transport passengers, pedestrians, and youth culture:12 and street urination. The lack
cyclists* unlike car drivers* cannot speed to
/ / of public toilets, along with crumbling sew-
the nearest motorway service station to use the erage systems and neglect of drainage issues, is
toilet when they find the local public toilets resulting in the spread of Cryptosporidium
have been closed. It should not be assumed parvum. C. parvum (a parasitic protozoa) is
that only a minority will need on-street public the fourth most commonly identified cause
toilets, because alternative off-street toilet of gastro-enteritis and thus diarrhoea.13 His-
options are readily available. Members of toric water-borne diseases, such as cholera,
the public are not automatically entitled or typhoid and dysentery, that were prevalent in
able to use the toilets in public houses, bars, the nineteenth century, have returned to the
and fast food restaurants. Access may be city streets.14,15
restricted to customers only and children
may be barred from licensed premises. Min- 1.4 Public toilets: unsanitary facilities
ority and religious groups may be wary of One of the main means of transmission of
using toilets in premises where alcohol or non- many classic diseases and many urinary,
halal food is served.6 vaginal and anal infections is from human
Women are particularly in need of public faeces; therefore it is extremely important
toilets as they are the ones who are out and to provide adequate, hygienic public toilets.
about in the day time, travelling on Hospital toilets, rather than public toilets,
public transport more than men, and often have received greater media interest in recent
accompanied by children or by elderly and years. MRSA in hospitals has been attributed
disabled relatives.7 Surveys have shown that 1 to lack of basic hygiene, and, in particular, to
in 4 of European women between 35 and 70 the role of dirty hospital toilets as transmitters
years of age suffer some degree of urinary of disease.16 Campaigns to encourage people
stress incontinence which restricts their will- to wash their hands after using the toilet have
ingness to travel, but only a third have sought been introduced, along with improved toilet
medical help.8 Yet, there is less public provi- cleaning regimes. The contracting out of
sion for women than men in many cities. cleaning and maintenance services along
Accessible toilets must be provided under the with the privatization of many health, welfare
Disability Discrimination Act 1995 (DDA) and local authority functions has led to
but this does not, necessarily, mean that reduced in-house control over cleaning stan-
everyone’s toilet needs are now being met.9,10 dards. But, CA-MRSA (Community-Ac-
Ordinary toilets may prove inaccessible for quired MRSA) bacterial strains found in
women with pushchairs, those with luggage, public toilets may prove far more serious.17
the pregnant and the elderly, because of In public toilets, complete strangers mix
narrow entrances, small cubicles, turnstiles and use the same sanitary facilities, with all
and step access.11 the related risks of bodily fluid exchange,
contamination and organism transmission.
1.3 Street urination: an unsanitary solution Desylpere18 has demonstrated that the chances
Government policies to promote the eve- of pathogen transmission are very high even in
ning economy, the 24 hour city, tourism and toilets that may appear to look clean, as every
public transport use, have all increased the door handle (especially the last one out to the
need for toilets, whilst, paradoxically, provi- street), tap, lever, flush, lock, bar of soap, toilet
C Greed 129
roll holder, and turnstile, is a potential germ Women need to sit down to use the toilet (at
carrier. Ostensibly, hygienic equipment, such as least in the West) but have difficulty doing so
electric hand-driers (often imagined to be safer because of narrow cubicle design, whilst the
than towels) may blow germs back into the positioning of the sanitary disposal bin or
atmosphere. Their use can contribute to the jumbo-sized, toilet roll holder may restrict
spread of Legionnaire’s disease, which is trans- sitting space. Women are also concerned about
mitted through contaminated air.19 Flushing ‘catching germs from the toilet seat’.27 Both
the toilet can also result in mini-droplets of men and women view toilets as sites of crime,
contaminated air passing into the respiratory dirt, disease, sex and disorder.28 Studies have
system.18 long shown that around 80% of women
Fears about catching ‘new diseases’ such as ‘hover’ over the seat to urinate when in public
SARS (Severe Acute Respiratory Syndrome) toilets, whereas they prefer to sit when using
figure strongly in the public mind.20,21 Fear of their toilet at home. Hovering contributes to
catching exotic diseases, such as Ebola, are residual urine retention, as the bladder cannot
expressed by passengers using airport toilets. empty properly and thus to the development
The prevalence of E. coli (Escherichia coli of continence problems.29,30 Research has
0157), in Britain and internationally, has led found that crouching (squatting) reduces urine
to a renewed concern with food hygiene and flow by 21% and increases by 150% the
also with toilet hygiene. E. coli can be chances of residual urine remaining in the
transmitted through food, by sewage, infected bladder.31
water, faeces, and from person to person by
touch.22
2 Regulatory and legal context
1.5 The debilitating effect of poor toilet 2.1 Lack of mandatory requirements
provision and design Public toilet provision is governed by the 1936
Research has shown that referrals for uri- Public Heath Act which gives local authorities
nary tract infections, problems of distended permissive, rather than mandatory, powers to
bladders, and a range of other uro-gyneco- provide public toilets. Section 87, sub Section
logical problems have increased proportio- 3 gives local authorities the right to build and
nately to toilet closure.23 The chances of run on street ‘public conveniences’ and to
streptococcal toxic shock syndrome from charge such fees as they think fit ‘other than
sanitary protection is increased if there are for urinals’. If local authorities do choose to
no toilets available to change tampons.19,24 provide toilets then these are subject to British
Changing facilities are also needed by men Standard 6465 requirements, along with
and women suffering urinary and anal/faecal Part G of the Building Regulations entitled
incontinence.25 Absolutely hygienic condi- ‘Hygiene’.32 The standards have also been
tions are needed for changing colostomy much criticized as being minimal, discrimina-
bags (for faecal waste) along with good light- tory towards women, not retrospective, weakly
ing, shelves to put equipment on, and hot enforced. Disabled toilet provision is subject
water supply.26 Public toilets may also offer to Part ‘M’ of the Building Regulations,33
baby changing facilities, another activity re- along with British Standard BS8300 on dis-
quiring cleanliness both for the baby and abled access,34 which provide a more enligh-
mother, requiring adequate washing facilities tened set of standards. BS6465 Part 1 has
and disposal bins to ensure that subsequent recently been revised to include higher stan-
users are not confronted with unsanitary dards of provision, and is awaiting final
conditions. publication.35
130 The role of the public toilet
mice, fleas, and ticks: vectors that spread lack of facilities, and estimate future demand
disease.42 trends. Undertaking this exercise in a rational
manner would reveal the extent of the problem
and the pent-up demand for public toilets.
3 Toilet provision recommendations
3.2 Levels of provision
3.1 A spatial toilet strategy At minimum, it is recommended that ‘a
It is vital to adopt a high-level strategic policy local authority should provide no fewer than
approach to toilet issues, to replace the present one cubicle per 500 women and female
fragmented and ineffective situation. The children and one cubicle or one urinal per
development of a hierarchy of toilet provision 1100 men, and no fewer than one unisex
would enable facilities to be targeted to area cubicle for use for people with disabilities
need.43 Both spatial (geographical location) per 10 000 population and no fewer than
and temporal (patterns and peaks of usage) one unisex nappy changing facility per
considerations need to be taken into account 10 000 people dwelling in the area.’45 The
in developing a hierarchy of provision to cover relevant ‘population’ in question should in-
the whole city, see Figure 1. clude commuters, tourists and visitors as well
The central area is the main focus of the as residents.
city’s business and retail activities, and the
part of the city that tourists are likely to 3.3 Temporal factors
visit.44 Historically the main transport routes A distinction needs to be made between
radiate out from the city centre, downtown locations where there is an ‘interval’ when
railway and bus stations being the main gate- large numbers of people need to use the toilet
ways to the rest of the city. It is recommended within a short space of time, for example in
that toilets should be provided in all city theatres and sports stadia, as against locations
centres and transport termini, including at where usage is more gradual throughout the
least one 24 hour facility. In such downtown day, such as in a library or museum35 Differ-
locations, a comprehensive range of toilet ences between days also need to be taken into
facilities might be provided in toilet ‘super account; Saturdays, school half-terms and the
blocks’. At the district and local neighbour- shopping days before Christmas are likely to
hood level less facilities are needed, but be generate long queues for women’s toilets.
provision should be linked to needs generated
by local shopping centres, car parks and 3.4 Detailed siting considerations
transport termini. A combination of local In deciding where to put the toilet thorough
pubs, hot food ‘takeaways’, clubs, pubs, taxi site appraisal should be carried out using all
ranks and bus stops, results in a potential the skills of urban design. Many well-designed
‘toilet hotspot’, see Figure 2. In smaller toilets have been placed in a bad location only
settlements, rural areas and outlying suburbs, to be trashed by vandals, especially if hidden
some toilet blocks should be provided to from view behind bushes. Toilets should be
ensure coverage. proudly placed in central public thoroughfares
A thorough survey should be undertaken of and squares, in open well-lit areas as valuable
all locations, and likely user needs identified. townscape elements.46
Plan-making has three stages, namely, SAP / Clear footpath links should be ensured
Survey - Analysis - Plan. Applying this
/ / from toilets to coach pick-up points, bus
approach to the development of toilet policy, stops, pedestrian crossings, and car parking.
the toilet planner needs to ‘survey’ the existing Increased foot flow past the toilets is likely
situation of the area, identify problems, note to reduce loitering and increases natural
132 The role of the public toilet
Out of Town
development
location
Suburban housing
‘Anywheresville’
location
City Centre,
main transport
termini location
Commuter village
location
Toilets
Motorway arterial road
and ring road location
Figure 1 City-wide hierarchy of toilet provision (Source: Inclusive urban design: public toilets2)
Figure 2 District-level principles of toilet provision (Source: Inclusive urban design: public toilets2)
should be free from clutter. Recycling skips circulation. In hotter climates, toilets need to
should not be placed alongside toilets, adding be well ventilated and shaded from direct
to the insalubrious, unhygienic image of the sunlight.
public toilet. Toilet block location should take
into account local micro-climatic conditions 3.6 Internal design
to increase user safety. Frosty hollows and It is not the purpose of this paper to detail
windswept sites should be avoided, in favour internal design considerations (see Greed2)
of sites open to the sunlight and good air but as a general principle, any toilet block
134 The role of the public toilet
Table 1 Toilet location priorities
carefully as these ‘small’ factors determine a
A toilet strategy, an overall plan setting out the hierarchy, toilet’s accessibility.26,47 It is recommended
location and distribution of public toilets should be that a 250 mm clearance is maintained right
provided for every local authority as part of mainstream around the toilet seat, so doors do not
urban policy.
impinge on the rim of the toilet bowl, and,
Public toilets should be provided in:
. All main public transport termini and stations and ideally, sanitary disposal facilities are ducted
major car parks into the back wall of the cubicle.
. Central areas, and in all district centres, and local
shopping centres
. All parks, allotments, urban farms and leisure areas 3.7 Cleaning and hygiene
. At main junctions and by post offices in all suburban areas Once built toilets cannot be left alone to
. Out of town developments in office, industrial and look after themselves. The initial capital costs
retail parks
. In all villages over 5000 in population and at reason- of toilet construction and equipment may only
able distances along main roads account for 20% of the total toilet cost over 5
. User consultation and public participation should years; running costs are considerable. Good
shape toilet policy making
. In summary toilet ‘hotspots’ should be identified and design must be complemented by efficient
concentrated upon. maintenance and regular cleaning regimes.
As Mary Schramm, a leading expert in clean-
ing science has stated, ‘architects never think
provision should be adequate for both women about the problems trying to clean the build-
and men, as illustrated by Figure 4. The size of ings they design’.41 Cleaning considerations
cubicles, location of sanitary bin and toilet should figure prominently in the development
roll, distance between the edge of the door and of the local authority’s total toilet strategy.
toilet pan, all need to be thought through Liaison and communication needs to take
X GENTS
X
MULTI-USER
LADIES
No steps! Access
should be at grade
or use ramp
Figure 3 Local toilet siting principles (Source: Inclusive urban design: public toilets2)
C Greed 135
place between toilet-providers, manufacturers, are inefficient. To reduce the risk of Legion-
and designers; and cleaning experts, health naire’s disease, traditional roller towels are to
and caring experts in order to meet user needs be preferred to electric dryer systems: pro-
in a salubrious manner. vided the roller is kept in good repair and the
To reduce germ transmission toilet users towels are frequently replaced.
must wash their hands. Soap might best be It is recommended that touch-free flushes,
dispensed in automatic dispensers that do not taps, and door opening devices be provided to
require the user to touch the mechanism. If reduce cross-contamination. Such high-tech
bars of soap are provided they should be put gadgets are vulnerable to vandalism. Having
in receptacles that facilitate drainage, so the invested in such equipment it is more cost-
user is not confronted with a soggy, germ- effective to provide on-site toilet attendants as
infested mess. Paper towels create waste and their presence reduces anti-social behaviour.
136 The role of the public toilet
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