-W&H reports

  1. Ebola and WaSH webinar notes (Global PPP for Handwashing)

Overview

  • ​Hoping to apply lessons learned from Ebola to future outbreaks
  • Without proper WaSH practices, Ebola could still pose a threat
  • There is no proven vaccine for Ebola, so establishing good practices (including inWaSH) is extremely important

​Presentation1: Alice Urban,Global Communities

  • ​GC had been implementing a USAID-funded Community-Led Total Sanitation (CLTS) project in West Africa ("Improved Water, Sanitation, and Hygiene" or "IWASH"), which put them in a unique situation to observe WaSH aspects of the Ebola response
  • "Natural Leaders" identified through CLTS process facilitated important health messaging and distribution of initialhygiene supplies during the Ebola outbreak because they were trusted by communities
  • NLs understood local contexts and were able to deliver messaging effectively
  • High suspicion of health workers during the Ebola response--NLs were seen asmore trustworthy sources of information because they already had established relationships with communities
  • NLs had already demonstrated efficacy by helping their communities achieve ODF status
  • Of the ODF communities sampled by GC, 100% were Ebola-free, compared to 73% of communities where GC had general programs (not CLTS), and24% in communities where GC was not involved (*note: presenter acknowledged that this was not a systematicstudy/RCT, but it is still quite telling)
  • Ramifications beyond the crisis: post-Ebola momentum for CLTS
  • When communities saw that the ODF communities had been Ebola-free, their demand for CLTS programs increased
  • Main point: CLTS can be more than just a tool for sanitation promotion; it can be harnessed to promote other community health and development objectives (including disease outbreaks like Ebola)
  • ​In particular, NLs and CLTScommunitiescan improve dissemination of health messaging

Presentation 2: Francois Bellet,UNICEF - "Ebola: fighting the unknown"

  • ​First priority: WaSH in health care facilities--infection prevention and control (IPC)
  • WaSH in Ebola treatment centers
  • WaSH in health facilities (general, not Ebola treatment)
  • WaSH in communities
  • WaSH in affected households
  • WaSH in quarantined communities
  • WaSH in communities in general
  • WaSH in schools (only once schools reopened in Feb 2015)
  • Development of a "safe school protocol"
  • Important note: the key components of Ebola response were a "no-touch" policy and early referral of patients--WaSH was only acontributing factor​
  • Important not to overemphasize handwashing, which could create a false sense of invincibility that compromises other key strategies
  • But empowerment (through CLTS or otherwise)does seem to be a protective factor against Ebola
  • Lessons learned
  • Timely guideline production is important--Ebola framework for WaSH in schools can nowbe applied to the next outbreak
  • Importance of building on experience of local actors (ex:throughCLTS)
  • Importance of sustaining the handwashing norms created during the outbreak

Presentation 3: Nora Chea, CDC

  • "​Infection prevention and control" usually means prevention of transmission in healthcare facilities
  • ​Standard precautions are foundation for preventing infections in healthcare settings
  • WaSH is relevant to nearly all of the components of IPC in HCFs(except for personal protective equipment - hazmat suits, etc.)
  • Hand hygiene
  • Environmental cleaning
  • Prevention of sharps injuries
  • Waste management
  • Disinfection and sterilization of medical equipment
  • Low-resource settings make WaSH particularly challenging
  • Take-home messages
  • WaSH is the basic need for effectiveIPC in healthcare settings
  • For the sake of sustainability, IPC plans must include a WaSH section
  • There must be a collaboration between WaSH and IPC at all levels--international, national, and facility levels
  1. SIGAR report

“We found that five [out of 32] facilities did not have running water, three appeared not to have electricity, and eight may not have adequate or consistent power required for proper lighting and to refrigerate some pharmaceuticals and vaccines. The PCH program provided funding to implementing partners for basic utilities, including electricity, to provide an adequate storage environment for core stocks of pharmaceuticals. The absence or inconsistency of electricity to refrigerate these basic stocks raises questions about whether the USAID funding is indeed reaching these facilities. Finally, our site inspections found that at least 16 facilities disposed of medical waste in open-air kilns, some of which were publicly accessible. This method of unsecured disposal does not adhere to best practices and raises the risk that patients seeking treatment—or children we observed playing outside at several facilities—could be accidently exposed to contaminated waste. Photos 3 and 4 show easily accessible, open-air kilns used to dispose of waste at two facilities.”

  1. “Hand hygiene in health care facilities”

“Poor hand hygiene among health-care workers in low-income and middle-income countries (LMICs) is due in part to inadequate access to, and use of, WASH services in health-care facilities.”

“Current indicators for monitoring WASH in health-care facilities likely underestimate the scale of the problem in many countries, given that they do not comprehensively measure quality, quantity and functionality of these services.”

  1. Making health a right for all

“Those attending healthcare facilities are often particularly susceptible to disease and infection. A systematic review of Healthcare-Associated Infections (HAIs), infections contracted in the healthcare setting that were not present at the time of admission, was carried out in Africa in 2011. It found HAI infection rates as high as 45.6% in some countries. HAI rates are closely linked to WASH and hygiene in healthcare facilities is fundamental to infection prevention and control. This is of critical importance in high-volume facilities where infections can spread most rapidly. It should also be considered in terms of health issues for which the main strategy is to increase healthcare services utilisation. For example, encouraging women to give birth in healthcare facilities is one of the key strategies for reducing maternal mortality. Globally, 8% of maternal mortality is caused by sepsis. The absence of sufficient infection prevention and control measures in healthcare facilities should therefore be of particular concern to those attempting to redress the slow progress to reduce maternal mortality globally.”

“WASH is essential for ensuring that people living with HIV/AIDS live healthy and productive lives. People living with HIV/AIDS are six times more likely than people without HIV to acquire a diarrhoeal disease. In addition, babies born to mothers living with HIV are three times more likely to have diarrhoea. People living with HIV/AIDS need two and a half times the amount of water needed by people without HIV, as well as improved hygiene and sanitation to help prevent opportunistic infections. An adequate supply of water is essential for home-based care of people living with HIV/AIDS. Furthermore, Anti-Retroviral drugs (ARVs) are essential to enable people living with HIV/AIDS to lead healthy and productive lives. Their consumption requires approximately 1.5 litres of safe water every day. The physical burden of fetching water is also a strain for people living with HIV/AIDS when they experience reduced energy levels, side effects from HIV medication and/or symptoms of opportunistic infections.”

“In healthcare facilities where water is not readily available, additional non-medical costs may be incurred by patients. For example, patients may be forced to bring their own drinking water and/or pay for water for washing or laundry. In some cases, women giving birth must buy their own ‘clean birth kit’ which includes a plastic sheet and gloves to compensate for the lack of adequate hygiene provision in maternity units. These costs must be considered as part of overall efforts to reduce the cost of accessing healthcare services.”

  1. WASH in health-care facilities – why and how

“The impact of lack of WASH in HCFs is devastating, contributing to millions of infection-related deaths each year. When these infections do not result in death, they can cause prolonged hospital stays, long-term disability, increased antibiotic resistance and economic burden on health-care systems. Additionally, both lack of access to adequate WASH and high risk of infection in HCFs themselves can adversely affect patients’ willingness to seek care at HCFs, which increases the risk of health complications and death. Similarly, these conditions negatively impact health-care staff attendance, morale, retention and safety.”

  1. Healthy Start: the first month of life (WaterAid)

“As part of the Millennium Development Goals, there was a concerted effort to increase the number of births attended by a skilled health worker, and in particular births in healthcare facilities. Yet even in the very facilities that are set up to serve their communities with healthcare and welcome new life into the world, there is often no constant clean water supply, functioning toilets or handwashing facilities. As clearly set out in the World Health Organization’s (WHO) ‘Essential environmental health standards in healthcare’, these are the basic front line defences in the battle against infection and a lack of those services calls into question whether such establishments can adequately serve as healthcare facilities. A 2015 WHO survey of healthcare facilities in 54 developing countries revealed that 38% lack a clean water supply, 19% do not provide improved sanitation, and 35% do not have soap for handwashing. In the Sub-Saharan African countries surveyed, that percentage rises to 42%. Those figures also do not reflect whether the water supply is constant. The WHO estimates that of those healthcare facilities that have some form of clean water supply, around half do not have a reliable supply.”

“A recent study to assess the water and sanitation conditions during birth in Tanzania showed that, on average 44% of healthcare facilities where women give birth had adequate water and sanitation facilities, but only a quarter of delivery rooms within those health centres had water and toilet provision. The researchers estimated that even if every woman in Tanzania chose to give birth in a health centre, less than two thirds of those births (59%) would be in centres that could provide the mother and baby with a safe environment.”

“With no readily available source of clean water to clean the wards or hands, healthcare facilities can become harbours for dangerous bacteria with health workers unknowingly transmitting disease from one patient to the next. A review in 2011 of healthcare acquired infections showed that in some developing countries up to one in every two patients (45.6%) left hospital with an infection they had not had on arrival. In one study at a large African teaching hospital, handwashing was only attempted 12% of the time and done effectively in only 4% of opportunities, despite nine in ten of the wards having a sink with soap available. A study in maternity units in Southern Nigeria showed that only two out of five facilities had soap or antiseptic in or near operating theatres or delivery rooms.”

“Sepsis is an invasive infection normally caused by bacteria. The bacteria that cause neonatal sepsis are acquired shortly before, during, and after delivery. They can be obtained directly from mother's blood, skin, or birth canal before or during delivery, or from the environment during and after delivery. Clean water, safe sanitation and hygienic practices of healthcare staff and mothers in birth facilities can reduce the risk of infection in both cases. Clean delivery practices and handwashing during delivery, and handwashing by healthcare providers after delivery are necessary for reducing the risk of sepsis. Infections can also be easily transmitted if dirty implements are used to cut the umbilical cord, and by contaminated surfaces such as beds and other objects. A failure to make sure that a woman has a clean place to give birth, that a midwife, birth attendant or doctor has clean hands when helping her deliver and that the blade which separates the child from his mother by cutting the umbilical cord is clean puts a baby at risk of contracting sepsis.”

“Beyond the risk of infection that such conditions can cause, lack of clean water, toilets and good hygiene may have other consequences for healthcare users. For example, women in labour may be asked to bring in their own jerry cans of water for drinking and washing during the birth. Such water may be fetched from unsafe sources such as rivers or ponds. This not only puts mothers and their babies at grave risk of contracting a potentially fatal infection, but the lack of hygienic conditions can put women off attending healthcare facilities, thereby undermining efforts to increase the proportion of births assisted by skilled attendants. Provision of water and sanitation services in healthcare facilities can also empower healthcare workers to provide safer care for mothers and newborns, thereby supporting efforts to increase staff retention and motivation.”