Sanitation, Hygiene, and the Global Response to Coronavirus (COVID-19)

By Rinnah Becker and Genevieve Schutzius

April 19, 2020 • 13 min read

Last updated: May 27, 2020

Table of Contents

SARS-CoV-2 spreads through respiratory droplets.
Advances are being made to track the spread of the virus.
Handwashing and wearing cloth face coverings can reduce the spread of COVID-19.
Some communities can access water for handwashing more easily than others.
Certain groups of people stand a greater risk from the virus.
Areas of the world with inadequate medical and sanitation systems may be hit particularly hard.

As the world ushered in the year 2020, many of us (in the Western hemisphere) would have been in disbelief to hear what the COVID-19 outbreak would look like now. The pandemic has overturned reality for the entire world within a matter of weeks. Now we find ourselves living in this new reality, all together. And no one is immune to the anxiety that we feel on a global scale — we are all in it together. For those of us outside of the front lines of infection, the world has now entered a period of simply… waiting.

But as we wait — in social distance and isolation — we must not forget why and how we will fight the spread of the novel coronavirus (SARS-CoV-2) that causes the COVID-19 disease. PHLUSH exists because we believe that equitable access to sanitation and hygiene services is a human right. As sanitation advocates, we understand the importance of employing the best sanitation and hygiene practices, educating others on their importance, and ensuring equitable access to hygiene services in the case of an infectious disease outbreak.

Now is the time for each of us, as individuals, to act in the world’s best interest. There are actions that we all can make as individuals to protect the whole of the global population, including informing one another on how to reduce the spread of the coronavirus that causes COVID-19. We are also equipped to ask our government officials to prioritize taking actions to protect the most vulnerable members of our communities and our world.

SARS-CoV-2 spreads through respiratory droplets.

The virus is known to spread through the respiratory droplets of infected individuals, especially when persons are within six feet of one another. There are currently no documented cases of its spread directly through fomites (inanimate objects that are capable of spreading disease). However, CDC still recommends regular disinfection of household and public surfaces, as viable viruses have been shown in one study to survive for up to 3 days on a variety of materials, including plastic, stainless steel, copper, and cardboard (with the latter two being the least stable). Although less likely than respiratory transmission, health experts posit that touching one’s face (especially mucous membranes, such as the mouth and nose) after touching a coronavirus-contaminated surface presents another way to transmit SARS-CoV-2.

The transfer of respiratory droplets is the transmission pathway of the novel coronavirus. However, recent studies have reported the virus’ survival in fecal matter and the possibility of its transmission via the fecal-oral route. In a study of 73 hospitalized COVID patients, 39 (53.4%) tested positive for the virus’ RNA in stool samples. Of these, stool samples of 17 patients (23.3% of the total) remained positive even after respiratory samples came back negative. Researchers suspect that gastrointestinal cells of an infected individual secrete SARS-CoV-2 into the stool. However, due to the limited amount of research conducted to date on this topic, the general consensus of the scientific community and the CDC remains that the risk of coronavirus transmission via the fecal-oral route is considered to be low until more research is published.

On the other hand, a growing body of research is revealing that the aerosolization of sewage (via wastewater treatment facilities or in faulty wastewater plumbing) may present a transmission pathway if the virus is suspended in droplets respired by the potential host. During the SARS pandemic of the early 2000s, the WHO published the findings of an investigation into a “superspreading event” of the disease (342 cases and 42 deaths) on a city block in Hong Kong. Investigators discovered that the virus had been spread through aerosols leaked from the wastewater plumbing of a 50-story apartment building. More recently, the KWR Research Institute in the Netherlands discovered the presence of the virus in wastewater samples from the city of Amersfoort’s treatment plant. The presence of the virus in these samples corresponds to the timing of the cases reported in the city. These findings suggest that wastewater plumbing and the operation of treatment facilities may present a potential route of exposure to those in close contact with the aerosols generated in these processes. Fortunately, in developed countries, the disinfection step in treating wastewater is especially effective with “enveloped viruses,” or those contained in a coat of fatty lipids, such as SARS-CoV-2, minimizing the potential for the virus to enter waterways via treated wastewater effluent.

Advances are being made to track the spread of the virus.

While a vast majority of the world has been under lockdown and encouraging social distancing to slow the spread of the virus, some countries have also adopted widespread testing to strengthen the accuracy of epidemiological models. In South Korea, a rigorous testing protocol, including free walk-up or drive-in tests with 24-hour results, helped the country curb the virus early in its spread. The United States, on the other hand, has lagged in adopting adequate testing methods for a variety of reasons including unreliable test kits and slow federal response to the crisis.

A potential solution — one that could allow countries to track the virus in real time, rather than retroactively — lies in our sewage. Although the disease is spread through respiratory droplets/aerosols and does not appear to spread through the fecal-oral transmission route, feces can reveal the presence of the virus in the body. Wastewater epidemiology is an emerging field taking advantage of this “secret in the toilet.” The technology has previously been used to determine hotspots of opioid and other illicit drug use by analyzing municipal sewage for the presence of these compounds. It has even detected a polio outbreak in Israel, allowing officials to prevent it from disrupting the health system. Now, companies like Biobot Analytics, Inc. are working with municipalities to use this technology to proactively determine where the SARS-CoV-2 virus is emerging – in real time.

Handwashing and wearing cloth face coverings are ways to reduce the spread of COVID-19.

Next to social distancing/quarantining, the CDC and WHO have repeatedly touted handwashing — a simple task which often seems to bear little consequence — as the number one way to reduce the virus’ spread. Viral removal occurs both mechanically and microscopically during the action of handwashing. First, with enough friction from rubbing the hands, bacteria are physically removed from the surface of the skin. Additionally, when soap is used, the surfactants in the soap break open the lipid layer encasing the virus (thereby rendering it no longer able to infect you). Given the risk of COVID-19, it is prudent that we all reconsider our hand washing methods. One study found that only 5% of people spend more than 15 seconds lathering and rinsing. For best results, lather for at least 20 seconds and use liquid or bar soap rather than foam. Vox provides a video that explains the science of how soap works against viruses and demonstrates how to handwash effectively.

For those who are able, the CDC is now recommending the use of cloth coverings in public, made with multiple layers of fabric, which fit snugly over the mouth and nose but still allow the wearer to breathe. This recommendation is due to the uncertain origins of community-spread viruses, and the recent finding that up to 1 in 4 COVID-19 carriers may be asymptomatic but still infectious. Do note that officials are recommending that medical-grade, N95 masks (which filter up to 95% of airborne particles) are reserved for medical staff use only, because they are in short supply.

Some communities can access water for handwashing more easily than others.

For many people experiencing unsheltered homelessness, access to clean running water and disinfectants is not a given. These individuals may need to walk several city blocks or further to reach the nearest public restroom. Public restrooms frequently run out of soap, have only cold water or a broken tap, or close at night, making it harder for people without running water to wash their hands. Hand sanitizer or wipes can substitute for running water, but cost and the mass disappearance of hygiene products from stores means that this is less and less of an option.

Local governments can aid people experiencing unsheltered homelessness by making public restrooms, hand-washing stations, and portable toilets accessible. The CDC recommends that public restrooms be maintained, stocked, and left open 24 hours a day so that people experiencing homelessness have access. Additionally, it recommends setting up portable toilets or hand-washing stations in areas near encampments of 10 or more people who don’t have access to public restrooms. In Portland, where PHLUSH originated, the City had put out 14 hand-washing stations as of March 12th. It also published a map of locations with these stations. Other cities have taken further action; San Diego, for example, had put out 66 handwashing stations as of March 10th. These stations need to be maintained and stocked in order to serve their purpose.

Soap, sanitizers, and washing stations are also needed at shelters. In King County, Washington, the county with the largest number of COVID-19 cases in Washington State, the county’s homelessness response team is focusing on providing shelters with soap as an alternative to hand sanitizer and “bleach, paper towels, and spray bottles and good instructions from Environmental Health on how to use those tools” as an alternative to disinfecting wipes. The county makes bulk orders of hygiene and sanitation supplies and distributes them to shelters that fill out an online request form. Other local governments are also recommending the use of bleach solutions in the face of lack of sanitizers and wipes.

The public has gotten involved in providing handwashing services too. In response to the virus-caused closure of several public restrooms in Tuscon, Arizona, a group called Watershed Management Group is installing 20 “Tippy Taps” in areas of the city frequented by people experiencing homelessness. These user-friendly handwashing stations contain a bar of soap and a foot lever to release water from a jug. Their material cost totals around 10 to 15 dollars, and the stations are simple to construct (see instructions to build one here). These devices have been used worldwide for years with even simpler design as an easy way to provide access to handwashing services.

Water access poses a challenge not just to unhoused individuals, but also to those who have houses but cannot afford to keep paying for utilities. Many state and local governments have made the decision to restore water services and to suspend shutting off water service. Cities such as Portland, Seattle, Detroit, Houston, and Cincinnati have put a moratorium on shutting off water. This not only serves the purpose of restoring better quality of life for these people but also allows them to wash their hands, a front-line response to COVID-19. Unfortunately, some of these cities have been slow to enact the moratoriums and turn service back on. In Detroit, one of the cities with the highest rates of infection, the “COVID-19 Water Restart Plan” was announced in early March. As of March 26, only 679 households had had their service turned on, of an estimated 5,000 who needed it.

In addition to people experiencing homelessness and people unable to afford the cost of utilities, there are a number of communities in the United States that face long-term challenges with access to water, whose situation has become more dire given the need to wash hands frequently. These communities include, but are not limited to, some Native American communities, farmworker camps, and migrant and refugee camps without access to water and sanitation services. As one stark example of this, people on the Navajo Nation in the Southwest United States are often compelled to drive multiple hours to pick up barrels of water. Native American households are 19 times more likely to lack indoor plumbing than white households. Where the infrastructure for water and sanitation service is lacking, washing hands frequently may be nearly impossible and require great additional effort.


Certain groups of people stand a greater risk from the virus.

This global crisis has revealed a variety of vulnerable populations who are more prone to contracting or succumbing to the disease, either due to physical condition or exposure due to livelihood. The former include those over age 65, those living in close quarters with many people (especially nursing homes and retirement communities), and those with immunocompromised conditions. And as the pandemic has brought our society almost to a halt, the workers of essential industries such as healthcare workers, grocery workers, post office employees, cleaning workers, and utility operators are presented with higher rates of exposure daily. It is necessary that we continue social distancing and sanitation for the sake of these people in our midst.

Additionally, we are all prone to the mental strain and anxiety that the pandemic poses. Various federal, state, and local programs are now assisting citizens facing the financial strain and emotional stress that the pandemic has incurred.

In the UK, several resources have become available to people who are vulnerable to COVID-19 due to pre-existing conditions. Asthma UK, Diabetes UK, the British Heart Foundation, and the Cystic Fibrosis Trust (among others) have set up call lines and informative websites to field questions from members of these groups. The Mental Health Foundation has provided advice for those feeling anxiety and stress amidst the coronavirus pandemic. One frequent public transit-user in London stated that they are very diligent with their personal hygiene, but have noted that they “really notice how other people just aren’t.”

Some online resources have also popped up to assist with the stress that the pandemic has caused, including the CDC’s Daily Life and Coping page, which offers advice for managing the household and finding mental balance in the midst of change and uncertainty. Shine, a stress and anxiety management app, has released a website of resources to manage the anxiety surrounding COVID, which provides meditations, expert advice, and ways to take a break.

In the Portland, Oregon and surrounding Pacific Northwest communities, Mac’s List provides several useful resources for community members of all types. Of note is congressman Earl Blumenauer’s comprehensive and dynamic list of response resources for a wide range of community members, and includes options for volunteering, donating, educational resources, and loans and funds for those out of work or seeking healthcare.

Areas of the world with inadequate medical and sanitation systems may be hit particularly hard.

The novel coronavirus has clearly not discriminated, including geographically. In fact, it initially impacted developed areas, where globalization and frequent travel rapidly spread the virus. Unfortunately, developing regions, especially those areas with inadequate medical systems, are now being struck by the pandemic and are arguably more at risk of widespread disaster due to an inequitable lack of access to clean water and sanitation and hygiene services. Refugees, displaced people, and people living in crisis face a particular risk due to crowding and lack of sanitation. In the Moria reception centre on Lesvos, Greece, up to 1,300 people share a single tap for water at times, and the refugees are six to eight times more crowded than people were on the cruise ship Diamond Princess. As a point of reference, the virus spread four times more rapidly on this cruise ship than it did during the peak of the virus in Wuhan, China (see the International Rescue Committee’s graphic illustrating the connection between population density and virus spread). On April 2nd, 23 asylum seekers in Greece tested positive for COVID-19, and Greece became the first nation to quarantine one of its migrant camps to contain the virus.

Human rights groups fear a massive disaster not just in Greece, but in Bangladesh, Syria, Burkina Faso, Venezuela and other countries already experiencing various crises. As one example of many, in Somalia, a nation that has already weathered multiple crises in the last year alone, healthcare facilities are not prepared to handle an epidemic. The 800,000 people living in displacement camps in Mogadishu, Somalia lack the space to socially distance and do not have access to adequate sanitation. Moveover, the country is currently dealing with locust infestations and has recently experienced heavy flooding and drought.

There’s particular concern about the displaced people in Bangladesh and Myanmar. More than one million displaced Rohingya from Myanmar live in Bangladesh in crowded conditions, where the virus will likely spread rapidly amid inadequate sanitation. Then there are the 350,000 displaced people living in camps in Myanmar itself, which the group Human Rights Watch has described as “COVID-19 tinderboxes,” where “health conditions are already disastrous.” In these camps, up to 600 people may share a single water access point and up to 40 people can share a single toilet. Frequent, sustained handwashing and other measures such as social distancing seem nearly impossible in this environment.

According to the World Health Organization, in 2017, 785 million people did not have access to a clean, reliable drinking water source within a 30-minute round trip of the place they lived. If potable water is best for handwashing, what options do people in developing regions have for preventing the spread of the virus? Water previously used for washing dishes or laundry – even if it contains some concentration of pathogens/viruses – is effective when used with soap. In areas lacking running water, a simple two-bucket system — one bucket containing chlorine and water, the other a receptacle for used wash water — allow thousands to keep clean, but may also present a risk of rapid coronavirus transmission if many people congregate while using them. In the past, handwashing has been a critical part of the response to disease outbreaks, such as UNICEF’s collaborative action following the Ebola crisis in West Africa from 2014-2016. The response to SARS-CoV-2 may require some innovative approaches, but adequate handwashing is possible with some creativity. For example, some organizations and individuals are actively distributing sanitizer and soap (from a distance), and an innovative group named PATH is even making chlorine (for disinfectant) out of water, salt, and car batteries.

Clearly, the global community is working to solve this crisis, but there’s still work to do. Through the lens of “inaction” (via social distancing), we can still provide for one another by practicing good sanitation and hygiene, by sharing knowledge of available resources, by offering assistance to our neighbors and communities, and donating to helpful organizations. As we face the stress and anxiety caused by this global pandemic together, we must remember to stay safe, take time for ourselves, and remember we are not alone. Now, more than ever, is the time to come together to enact the highest level of sanitation and hygiene possible to slow the spread of the virus that causes COVID-19 — for ourselves, and for the global community as a whole.


About the Authors


Rinnah Becker

Rinnah began volunteering with PHLUSH in 2019 in Port Townsend, Washington, and she is excited to be involved with the group’s work. Rinnah received her B.A. in music and Spanish from St. Olaf College in Minnesota in 2017. After graduating, she served as a Fulbright Fellow in Gijón, Spain, where she taught middle school English in the bilingual programs of two public schools and volunteered at a community education foundation. She has also worked as a classroom assistant at an independent elementary school in Washington, and she currently works as a legal assistant and office administrator at a small Portland law firm. In her free time, Rinnah enjoys walking in nature, traveling, reading, and spending time with friends, family, and pets.


Genevieve Schutzius

[website, LinkedIn]

Genevieve has a background in environmental (wastewater) engineering and works as a water resources consultant. She holds a BS and MS in Environmental Engineering from University of Colorado at Boulder and Oregon State University, respectively. Her interest in global sanitation has led to coursework and volunteering in Israel, Haiti, and most recently, Vietnam, where she conducted her MS thesis research on the prevalence of antibiotic resistant bacteria in septic tank sludge and waterways in Ho Chi Minh City. She has been volunteering for PHLUSH since 2019 and is the newest member of the Board of Directors. Outside of work and PHLUSH, Genevieve is a fan of biking, singing, travel, and hanging out with friends and family (via FaceTime and Zoom, these days!).



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