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Opinion
Gastrointestinal manifestations of coronavirus disease 2019 (COVID-19) are immediately reminiscent of previous coronavirus outbreaks and should raise concern about faecal shedding as a mode of transmission in hospital settings. Severe acute respiratory syndrome coronavirus 1 (SARS-CoV-1), the coronavirus that caused SARS, was primarily transmitted by droplets and personal contact. However, analysis of a community cluster of SARS in Hong Kong that originated from an index patient with diarrhoea suggested that faecal shedding and air movement of contaminated bio-aerosols was a major contributor to the 187-person outbreak [ ]. Similarly, airborne SARS probably contributed to another large hospital outbreak [ ]. Bio-aerosols containing live pathogens can be produced by toilet flushing [ ], and 95% of droplets produced by flushing are small enough to present an airborne infection concern (≤2 μm) [ ]. Thus, transmission of virus shed in faeces through bio-aerosols may be an under-recognized infection control issue for health care facilities with high numbers of patients shedding virus in stool.
