The Importance of Hand Hygiene During a Pandemic
Good hand hygiene is a highly cost-effective public health measure and a cornerstone of safe and effective healthcare. It is crucial for protecting against a range of diseases, stopping the transmission of COVID-19, and preventing other outbreak-related illnesses. Hand hygiene is also critical for combating antimicrobial resistance (AMR).
During the COVID-19 pandemic, hygiene practices like handwashing and environmental cleaning have been identified as important ways to prevent the spread of disease. However, before the pandemic, access to essential water, sanitation, and hygiene (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, the Centers for Disease Control and Prevention (CDC) partnered with various organizations and governments to support WASH activities in healthcare facilities, community settings, and households across multiple countries. These efforts aimed to improve access to hand hygiene resources, increase the use of hand hygiene services, and enhance environmental cleaning practices.
Improving Hand Hygiene Access in Healthcare Settings
The CDC and its partners assessed WASH conditions and implemented WASH projects in 114 healthcare facilities across six countries. While most facilities had an improved water source onsite, hand hygiene resources were often missing at points of care. Additionally, healthcare providers frequently did not follow recommended hand hygiene practices when in contact with patients, being more likely to perform hand hygiene after contact rather than before.
In response, the CDC and partners provided handwashing stations or alcohol-based hand rub (ABHR) for points of care, entrances, exits, and toilets. Healthcare facilities serving refugee populations and internally displaced people also received environmental cleaning and hygiene kits, as well as hygiene education for staff and patients.
In some locations, partners trained local technicians to produce and distribute ABHR using the World Health Organization’s (WHO) guide to local production, adapted to the district scale. This approach aimed to ensure sustainable access to ABHR, as it can complement handwashing stations in community settings where clear supply systems may not be in place.
Addressing Gaps in Community Settings
The CDC and partners also focused on improving access to hand hygiene resources and promoting good hygiene practices in 59 community institutions, such as markets, schools, and points of entry, across Uganda and the Democratic Republic of the Congo (DRC).
While some community institutions had an improved water source onsite, other locations like markets and points of entry often did not. Even when water was available, handwashing stations were not always present at critical locations like entrances, exits, and toilets. Staff at these locations reported that previously supplied handwashing stations were no longer working due to poor planning and management.
To address these gaps, the CDC and partners focused on improving access to handwashing stations, locally produced ABHR, and hygiene education materials at key locations. They also created standard procedures for the management and maintenance of these resources to ensure they remained functional.
Challenges in Household Settings
The CDC and partners’ assessment of household settings in Burkina Faso revealed that most households had an improved water source, but many did not have handwashing stations. Nearly half of the surveyed households reported that they did not use soap when washing hands.
Initially, the partners provided handwashing stations to public locations, hoping they would be shared by nearby households and anyone passing by as a cost-effective strategy to improve community coverage. However, many of these stations quickly broke down due to a lack of clear responsibility for management and maintenance.
The partners then shifted their approach, providing hand hygiene kits (including handwashing stations, water storage containers, and soap) directly to households or compounds, as well as constructing public handwashing stations attached to responsible community organizations, such as schools and community centers. They also emphasized educational messages to reinforce good hand hygiene practices.
Addressing Gaps in WASH Regulations
The study conducted by the CDC and its partners demonstrated 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 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, disinfection, and other changes. The CDC contributed to efforts by the WHO and the United Nations Children’s Fund (UNICEF) to develop the first guidance for WASH in public spaces, which is crucial for ensuring access to hand hygiene resources and promoting sustained hygiene practices.
Ensuring Sustainable Access to Alcohol-Based Hand Rub
Alcohol-based hand rubs (ABHR) have been proven to be an effective complement to handwashing stations in healthcare facilities. In community settings, ABHR are recommended when handwashing with soap and water is not practically available.
In the right circumstances and settings, local production of ABHR may be a low-cost and effective complement to handwashing stations in community settings. 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, in Uganda, locally produced ABHR follows healthcare-facility supply chains due to Ebola preparedness efforts. But markets and schools are often excluded from these distribution efforts. To ensure sustainable access to ABHR, it is crucial 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.
The Importance of Behavior Change and Management
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, the 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.
Management of hand hygiene stations, such as keeping them working and well-stocked and ensuring continuous access to ABHR, 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.
Conclusion
The COVID-19 pandemic has highlighted the crucial role of hand hygiene in preventing the spread of infectious diseases. The CDC’s partnerships and initiatives have demonstrated the need to improve access to WASH services, promote sustainable ABHR production and distribution, and foster behavior change to ensure consistent hand hygiene practices in healthcare facilities, community settings, and households.
Going forward, it is essential to address the gaps in international WASH guidance for public spaces, strengthen the management and infrastructure for hand hygiene resources, and continue to educate and engage communities on the importance of hand hygiene. By taking a comprehensive, interprofessional approach, we can work towards the goal of universal hand hygiene and improve global health outcomes.
For more information on CDC’s efforts to improve access to WASH and other global WASH initiatives, visit the Joint Action for Water website.
