CDC and Partners Support Efforts to Improve Universal Hand Hygiene

Mural on school building illustrating handwashing steps and encouraging students to practice hand hygiene. Nairobi, Kenya.

Photo Credit: Graeme Prentice-Mott

Global WASH in the time of COVID-19

Increasing access to water, sanitation, and hygiene (WASH) infrastructure and hygiene practices is key to reducing the spread of diseases. During the COVID-19 pandemic, hygiene practices like handwashing and environmental cleaning were identified as important ways to prevent the spread of disease. However, before the pandemic, access to essential WASH services was limited in some low- and middle-income countries for a considerable portion of the population.

To reduce the spread of COVID-19, CDC’s Waterborne Disease Prevention Branch and Emergency Response and Recovery Branch partnered with US research institutions, CDC country offices, and organizations and governments to support WASH activities in the following countries: Belize, Dominican Republic, El Salvador, Guatemala, Haiti, Honduras, Kenya, Uganda, Burkina Faso, and the Democratic Republic of the Congo (DRC). CDC and partners assessed WASH conditions and implemented WASH projects in select healthcare facilities, community settings, and households that were considered higher risk for COVID-19 transmission.

Activities to reduce the spread of COVID-19

CDC and partners focused on improving access to hand hygiene resources, use of hand hygiene services, and environmental cleaning of shared toilets in 114 healthcare facilities across six countries, 59 community institutions (such as markets, schools, and points of entry) in Uganda and DRC, and 405 households in Burkina Faso. These activities included:

Assessing baseline WASH conditions and hand hygiene practices.
Starting new WASH programs to improve hygiene and reduce COVID-19 transmission.
Monitoring and evaluating the impact of the WASH programs.

CDC and partners adapted common WASH tools to the COVID-19 context to assess needs and monitor new programs. To develop new prevention guidance, CDC and partners used global guidance for reducing the spread of COVID-19 and adapted guidance from settings like schools and healthcare facilities for settings without any existing WASH standards, such as markets and points of entry.

Findings

Hand Hygiene Champions pose in front of ABHR dispenser in San Pedro de Macoris, Dominican Republic.

Healthcare settings

Although most of the healthcare facilities in this study had an improved water source onsite, hand hygiene resources were often missing at points of care. Frequently, healthcare providers did not follow recommended hand hygiene practices when in contact with patients. They were more likely to perform hand hygiene after contact with a patient than before, which suggests that efforts to encourage hand hygiene should emphasize the importance of protecting the patient as well as the healthcare worker.

In response to these findings, CDC and partners provided handwashing stations or alcohol-based hand rub for points of care, entrances, exits, and toilets. Healthcare facilities serving refugee populations and internally displaced people received environmental cleaning and hygiene kits and hygiene education for health facility staff and patients. In some locations, partners trained local technicians to produce and distribute alcohol-based hand rub using the World Health Organization’s (WHO) Guide to Local Production adapted to district scale.

Hand hygiene educational materials with locally produced alcohol-based hand rub at a hospital in Moca, Dominican Republic.

Community settings

While some community institutions such as schools usually had an improved water source onsite, other places like markets and points of entry often did not. Even when a water source was available, handwashing stations were not always present at critical locations such as entrances, exits, and toilets. Staff at these locations reported that previously supplied handwashing stations were no longer working due to poor planning and management. Even where hygiene resources were available, community members often did not follow recommended hand hygiene practices.

To address these gaps in availability of resources and hygiene practices, CDC and partners focused on improving access to handwashing stations, locally produced alcohol-based hand rub, and hygiene education materials at entrances, exits, latrines, and classrooms. CDC and partners also created standard procedures for management and maintenance to keep these resources working.

Household settings

Most households in the assessment had an improved water source, but many did not have handwashing stations. Nearly half of households surveyed reported that they did not use soap when washing hands.

CDC and partners initially provided handwashing stations to public locations in hopes that they would be shared by nearby households and anyone passing by as a cost-effective strategy to improve community coverage. However, many quickly broke down due to lack of clear responsibility for management and maintenance. Partners then shifted to providing hand hygiene kits (for example, handwashing stations, 20-L water storage containers, and bars of soap), constructing public handwashing stations attached to responsible community organizations (for example, schools and community centers) and educational messages to households or compounds.

Gaps identified and lessons

Handwashing station at public market entrance. Nyando, Kenya

Photo Credit: Christina Craig

Gap in WASH regulations

The study demonstrates there is a gap in the international WASH guidance for public spaces. Although the United Nations General Council has underlined the human right to receive WASH services in public places and many individual countries may have guidelines, there is no systematic, international guidance for WASH standards in public areas. In some countries and settings, standard procedures for public facilities need to expand with guidance on cleaning and disinfecting and other changes. CDC is contributing to efforts by WHO and the United Nations Children’s Fund (UNICEF) to develop the first guidance for public spaces.

Management and infrastructure

Management of hand hygiene stations—for example, keeping handwashing stations working and well-stocked and ensuring continuous access to alcohol-based hand rub—is a critical prevention measure. It is important to consider the various structural levels needed to improve and maintain hand hygiene resources that promote hygiene behavior. If problems with proper hand hygiene technology and access are not resolved, awareness of hand hygiene among the community can become insufficient. New evaluations of these areas can help ensure that WASH resources to prevent COVID-19 are accessible and practical for all. There is also need for greater water supply for handwashing and improved management of public sanitation facilities.

Following hand hygiene recommendations is key

Access to hand hygiene resources is necessary to prevent disease, but it is not enough if recommended hygiene practices are not followed at key times. Across countries and settings, CDC and partners identified inadequate hand hygiene access, low hygiene practice (such as using hand sanitizer or washing hands after using the toilet), and a need to make it easier for people and communities to follow recommendations for reducing the spread of COVID-19.

Public health partners in Kenya train sanitation workers who empty pit latrines on hygiene practice and personal protective equipment use.

Photo Credit: Graeme Prentice-Mott

Alcohol-based hand rubs are effective, supply chain important to consider

In healthcare facilities, alcohol-based hand rubs have been proven to be an effective complement to handwashing stations. In community settings, alcohol-based hand rubs are recommended when handwashing with soap and water are not practically available. In the right circumstances and settings, local production of alcohol-based hand rub may be a low-cost and effective complement to handwashing stations in community settings as well. However, it is important to examine how supply chains can deliver locally produced hand rub consistently to community settings that, unlike healthcare facilities, do not have clear supply systems in place. For example, because of Ebola preparedness efforts, locally produced hand rub in Uganda follows healthcare-facility supply chains. Markets and schools are often excluded from distribution efforts. To ensure sustainable access to alcohol-based hand rubs, it is important to determine whether existing local production for healthcare facilities can also supply communities or if community-based production and distribution strategies would be more effective.

Continued collaboration

CDC has ongoing collaborations with partners to improve access to WASH services and infrastructure around the world. Find more Global WASH stories at CDC at Work.

For more information on CDC’s efforts to improve access to WASH and other global WASH information, visit CDC’s Global Water, Sanitation, and Hygiene site.

To read more about this WASH intervention, visit PLOS Water.