Faecal-Oral Transmission of COVID-19

Last Updated: 17 March 2020

To date, with COVID-19 most attention has been focussed on the infection prevention and control measures around transmission by droplets and by contact. As with SARS and MERS, there is now evidence that in some cases, respiratory symptoms of COVID-19 are preceded by gastrointestinal symptoms including nausea, vomiting and diarrhoea. All three coronaviruses can infect cells in the gastrointestinal tract, and are present in the stools of patients for up to 12 days. The presence of virus in the stools poses a risk for faecal-oral transmission. If an infected person forgets to properly wash their hands after using the toilet, then anything they touch afterward might be contaminated, including the toilet door handle.  

In light of this, dental practices should pay attention to personal hygiene associated with the use of shared toilets. Effective handwashing after using the toilet is critical, using liquid soap and water for at least 20 seconds after using the toilet, and before eating or preparing food.

It is prudent to use appropriate products to disinfect the surfaces of objects and surfaces that will be touched when using the toilet, including toilet control handles, support rails, taps and door handles or door knobs. All such “high-touch-objects” surfaces (HTO) that patients touch should be cleaned regularly and at least once every day. When using a cleaning wipe or spray, wear gloves, eye protection where required, and follow the label instructions to ensure safe and effective use of the product.

We strongly recommend that a cleaning process document be written for bathroom cleaning. This document should indicate where to start on clean items in the bathroom, working towards cleaning the most contaminated items last of all. The principle in using disposable or reusable wipes, should be to use one wipe, on only one surface, and used in only one direction (Sattar 2013). Wipes should not be used continually, and where reusable wipes are the product of choice, then an appropriate contaminated product reprocessing cycle should be validated.  

With regard to patient screening, patients with enteric symptoms such as diarrhoea may potentially be in the early stages of COVID-19 infection. Monitoring patients with initial symptoms of GI distress may be appropriate to direct them to medical facilities for earlier detection, diagnosis, isolation and intervention.

Further reading on COVID-19 faecal-oral transmission:

- Yeo C, et al. Enteric involvement of coronaviruses: is faecal–oral transmission of SARS-CoV-2 possible? Lancet 2020 (February 19) https://doi.org/10.1016/S2468-1253(20)30048-0 and https://www.thelancet.com/journals/langas/article/PIIS2468-1253(20)30048-0/fulltext

- Gu J, et al. COVID-19: Gastrointestinal manifestations and potential fecal-oral transmission. Journal of Gastroenterology 2020 March https://doi.org/10.1053/j.gastro.2020.02.054 and https://www.gastrojournal.org/article/S0016-5085(20)30281-X/fulltext

- Xiao F, et al. Evidence for gastrointestinal infection of SARS-CoV-2. Gastroenterology. 2020; https://doi.org/10.1053/j.gastro.2020.02.055 and https://www.gastrojournal.org/article/S0016-5085(20)30282-1/fulltext

- Ramm et a., Pathogen transfer and high variability in pathogen removal by detergent wipes. Amer J Infection Control:2015:43:724-728

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