title: Lifting the lid on toilet plume aerosol: a literature review with suggestions for future research.
abstract: BACKGROUND
  The potential risks associated with "toilet plume" aerosols produced by flush toilets is a subject of continuing study. This review examines the evidence regarding toilet plume bioaerosol generation and infectious disease transmission.
  
  
  METHODS
  The peer-reviewed scientific literature was searched to identify articles related to aerosol production during toilet flushing, as well as epidemiologic studies examining the potential role of toilets in infectious disease outbreaks.
  
  
  RESULTS
  The studies demonstrate that potentially infectious aerosols may be produced in substantial quantities during flushing. Aerosolization can continue through multiple flushes to expose subsequent toilet users. Some of the aerosols desiccate to become droplet nuclei and remain adrift in the air currents. However, no studies have yet clearly demonstrated or refuted toilet plume-related disease transmission, and the significance of the risk remains largely uncharacterized.
  
  
  CONCLUSIONS
  Research suggests that toilet plume could play a contributory role in the transmission of infectious diseases. Additional research in multiple areas is warranted to assess the risks posed by toilet plume, especially within health care facilities.
authors.affiliation: Department of Occupational and Environmental Health, University of Oklahoma College of Public Health, Oklahoma City, OK 73126-0901, USA. David-Johnson@ouhsc.edu
authors.forename: David L
authors.initials: DL
authors.lastname: Johnson
authors.forename: Kenneth R
authors.initials: KR
authors.lastname: Mead
authors.forename: Robert A
authors.initials: RA
authors.lastname: Lynch
authors.forename: Deborah V L
authors.initials: DV
authors.lastname: Hirst
mesh_terms: D000336:Aerosols; D000391:Air Microbiology; D018562:Disease Transmission, Infectious; D006801:Humans; D018570:Risk Assessment; D014038:Toilet Facilities
chemical_list: D000336:Aerosols