Accelerated alcohol-based hand rub production supports Uganda hospitals during Ebola outbreak

On January 11 2023, the Ugandan Ministry of Health declared the end of the Ebola outbreak caused by Sudan ebolavirus (SUDV), which began on September 20, 2022. A total of 143 confirmed cases and 55 deaths were reported across nine districts – Mubende, Kyegegwa, Kassanda, Kagadi, Bunyangabu, Kampala, Wakiso, Masaka, Jinja.

Keeping hands clean prevents the spread of infectious diseases, like Ebola, especially in healthcare settings. The availability of alcohol-based hand rub, which is effective in killing Ebola, encourages and reminds healthcare workers to follow recommended hand hygiene practices, which lowers the risk of infection among patients and staff.

When the outbreak was first declared, affected healthcare facilities did not have to rush to find alcohol-based hand rub. Three production centers quickly provided alcohol-based hand rub to more than 200 health facilities in the affected districts as a result of existing programs funded by CDC’s Global Health Security program and Division of Foodborne, Waterborne, and Environmental Diseases (DFWED) and supported by CDC and the Infectious Diseases Institute (IDI) of Uganda.

Background on CDC-IDI relationship and ongoing efforts

Since 2018, DFWED’s Global Water, Sanitation, and Hygiene (WASH) program and the CDC Uganda country office have collaborated with IDI to improve access and use of alcohol-based hand rub for healthcare workers by supporting local production of alcohol-based hand rub. Efforts to increase availability of alcohol-based hand rub and encourage healthcare workers and the community to clean their hands more often included:

• Supplying raw materials to make alcohol-based hand rub
• Identifying and renovating a district production and storage facility
• Training and mentoring alcohol-based hand rub producers
• Supporting distribution and plans for restocking supplies
• Monitoring use of alcohol-based hand rub at healthcare facilities and key community settings

From 2018 through 2022, agreements with 9 districts in Uganda (Kabarole, Kasese, Amuru, Tororo, Moroto, Kotido, Adjumani, Koboko, and Kampala) were made to increase districts’ involvement and ownership of alcohol-based hand rub production. A few facilities, like Kasangati Health Centre IV in the Kampala district, double as training centers and production facilities for alcohol-based hand rub. So far, the program has provided alcohol-based hand rub and expanded access to hand hygiene resources to more than 200 healthcare facilities and over 60 community settings in Uganda.

Preparedness Efforts Fuel Swift Response to New Cases

The first cases of SUDV were detected at the Mubende Regional Referral Hospital in Central Uganda. It was here that a small group of five healthcare workers provided supportive care for patients in an isolation unit. Since no vaccine was available for Sudan ebolavirus, basic treatment (such as providing fluids and electrolytes and using medication to support blood pressure) was implemented early to improve patients’ chances of survival. However, providing direct care to patients also put healthcare workers at high risk, and by the end of the outbreak, healthcare workers made up 13% of the confirmed cases.

To prevent Ebola from spreading to healthcare workers and the community, increased access to hand hygiene materials is crucial among other personal protective efforts. After four years of joint preparedness efforts with CDC, IDI rapidly mobilized resources to the affected districts at the onset of the outbreak and produced more than 16,400 liters of alcohol-based hand rub in 7 days. This rapid production resulted in enough alcohol-based hand rub to provide the necessary supply at every healthcare facility in the affected districts for up to three months. This included the Mubende Regional Referral Hospital which currently hosts two Ebola treatment units, giving healthcare workers easy access to hand hygiene resources. In addition to providing alcohol-based hand rub, IDI’s infection prevention program also provides tips on how to use alcohol-based hand rub effectively.

Looking Ahead

Preparedness efforts paid off, but there is still work to do. The current demand for alcohol-based hand rub is estimated at about 19,000 liters per month for the districts affected by the outbreak, the equivalent of a quarter of a residential swimming pool. Although the prices of raw materials are likely to increase, producing alcohol-based hand rub has saved about $15 per gallon ($4 per liter) over the commercial purchase price.

With CDC support, IDI is currently thinking of ways to scale up local production of alcohol-based hand rub at the national level to ensure ongoing access in Ugandan healthcare facilities and community settings (such as markets and schools). Along with sustaining and scaling up production and distribution of alcohol-based hand rub, IDI has created —and is currently piloting—an online training on the production of alcohol-based hand rub at the local level. CDC and IDI are finding ways to encourage quick mobilization of resources (such as alcohol-based hand rub, trained producers, and raw materials) when there is a public health emergency.