Introduction
WHO aims to highlights a number of key messages and documents on hand hygiene in the prevention of Ebola Virus Disease, including stories from the field. Many of the existing WHO hand hygiene improvement tools are also relevant in Ebola response and recovery including a guide to local production of alcohol-based handrub instructions as part of the WHO recommendation for a multimodal infection prevention improvement strategy.
Stories from the field
Thanks to Dr Joyce Hightower for submitting this story from Guinea.
Here in Guinea in the midst of all of the garbage in the streets, gutters and beaches one finds hand washing stations with chlorinated water, at the entrances to health facilities, markets, restaurants, business offices and hotels. But more and more alcohol-based hand rubs are appearing as alternatives in similar places. When you think of the effort and money that has gone into "changing the behavior of the masses" in a short time, its been quite an undertaking! If it were only materials that had been made available, the numbers of people willing to convert to the religious cleaning of hands would most likely not be as successful. The fact is the "rule" is that if you are non compliant with hand hygiene you do not enter, wherever it is that you want to enter. The fact that there is a significant sense of being ostracized for not complying publicly, with a health driven activity, is a striking innovation. The benefits go beyond changing behavior to break the chain of transmission for Ebola, the annual cholera cases have in fact been reduced to practically zero. Schools did not reopen until hand sanitizing stations were in all school facilities. And making hand washing stations accessible throughout the city helped to overcome the problem of there not being running water available in most places. The question is whether there will be the same passion for clean hands once Ebola reaches zero and the fear of this dreaded disease is gone.
A Swiss led project to support local production of alcohol-based handrub in Ebola affected countries
Thanks to Dr Olivier Hagon, Hôpitaux Universitaires de Genève.
The lack of availability of alcohol-based handrub is unfortunately
common in West Africa. At the start of Ebola outbreak in 2014, a project
was proposed and initiated to support local production of alcohol-based
handrub in affected countries.
The challenges included registering the proposed product at the Ministry
of Health and Social Welfare (MoHSW), providing the alcohol-based
handrub kits and the consumables required, training Liberian hospital
pharmacists, selecting pilot hospitals with the support of the MoHSW,
and finally locally producing alcohol-based handrub based on the World
Health Organisation formula. Evaluation of the project to ensure
sustainability was also planned from the outset.
As part of the project:
- MoHSW recorded ABHR as part of the pharmaceutical products list.
- The Swiss Agency for Development and Cooperation (SDC) provided 10
kits for the production of ABHR, in addition to local supplies of
ethanol 95% being procured.
- University Hospitals of Geneva provided technical support for
training.
- The MoHSW selected 3 pilot hospitals: Redemption Hospital, Monrovia,
James N. Davis Jr. Memorial Hospital (JDJ), Monrovia, Phebe Hospital
N’Bonga.
- In November 2014, 21 pharmacists and 1 laboratory technician were
trained during 2 days. After the training, the production of the ABHR,
produced according to the WHO standards, began.
Different aspects of safe ABHR production were addressed and were vital
to success: logistics, actual production with pharmacy ownership,
distribution, effective use of the ABHR in practice, inter-actions with
hospital management and the MoHSW.
The three hospitals have produced hundreds of bottles of ABHR based on a
basic formula of how many times health workers would clean their hand
in a working day. The ABHR pharmacists continued to spend 80% of their
time on their regular work during a production week. In all three
hospitals, 90% of the staff approached knew about the ABHR and used it
willingly.
Despite the Ebola crisis, this project has shown that it is possible to
produce locally AHBR in such situations and contributes to saving lives.
The plan to spread local production to other Ebola affected countries
is also being explored.
Hand hygiene and infection
prevention and control in Mali 2014-2015 – lessons from the past help to
stop an Ebola Virus Disease (EVD) Outbreak
Thanks to Dr JP Ngandu-Mbanga for submitting this story from Mali.
By launching national campaigns and actions at the point of care, Mali has been a pioneer country on improvement of hand hygiene in health care over the past years. The response to the recent EVD outbreak built on these previous actions and highlighted the critical need for refreshed messaging.
Back in 2007, the Honourable Minister for Sport and Youth (acting for the Minister of Health) formally committed
Mali’s support to implementing actions to reduce health care-associated
infection, in line with the WHO "Clean Care is Safer Care" programme.
This ran alongside the introduction of a multimodal hand hygiene improvement strategy,
which was implemented at the Hôpital du Point G, in Bamako, from
December 2006 through June 2008. This was the first hospital on the
African continent to take up this multimodal challenge, which consisted
of introducing a locally produced alcohol-based handrub; monitoring hand
hygiene compliance; providing performance feedback; educating staff;
posting reminders in the workplace; and promoting an institutional
safety climate. Local handrub production and quality control proved to
be feasible, affordable, and satisfactory and health-care workers’
compliance with hand hygiene and knowledge thereof increased
significantly
Building on these past achievements and an understanding of the
importance of infection prevention and control and hand hygiene, several
activities were rapidly put in place in response to the EVD outbreak;
successful results were achieved in a short time thanks to political
commitment, community participation and good collaboration among
partners under WHO technical coordination. Facilities improved,
health-care worker and community knowledge and compliance also improved.
A fall in the rate of diarrhoeal diseases was also reported. These
were the main activities:
- Training of trainers” by WHO staff to professionals from different
hospitals. This included emphasis on the amount of alcohol-based handrub
to be used, and was followed up by further training during site visits;
- Training of cadres and non-professionals from all seven district hospitals of Bamako and Kati;
- Cross-border meetings with community members and professionals from
Kouremale, Mali with their counterparts in Kouremale, Guinea, to
strengthen joint efforts with hand hygiene practices;
- Development of a video message on the importance of hand hygiene for
both health-care workers and community members to prevent EVD
transmission, in close collaboration with the communication
sub-committee and a local journalist. The video message was played on
national TV immediately after the evening news;
- Hand hygiene resources made available and distributed in all
health-care facilities, border crossings, schools, churches and mosques,
government and other public institutions e. g. banks and private sector
firms throughout the country. Some individuals could purchase ABHR e.g.
hotels, while others were donated through different partners;
- Two local events strongly supported by the availability of hand
hygiene resources and supervised by trained teams to ensure the
achievement of standards by all in attendance. These were the Maouloud
Festival and the International Trade Fair of Bamako called “Febak”.
During these large events, not one case of contamination was reported,
either during or after;
- The three districts of Kayes (Kita, Kanieba and Kayes) visited with
hand hygiene messages reinforced. In Kayes, the surveillance team
replaced recommendations for handwashing with alcohol-based handrub for
every driver that entered the ground of a facility. Training on the
quantity of handrub to be used on clean hands (not soiled) and
sensitization with community members on the importance of handwashing
was also key;
- A feedback meeting held with all authorities from the public, private
and confessional district health-care facilities to influence
decision-making, and to ensure a continued sustainability and monitoring
process.
The teams working during the EVD outbreak were proud to see behaviour
change from health-care workers and the general public, thanks to
implementation of the multimodal hand hygiene improvement approach. They
worked closely with Ministry of Health and WHO leads until came
declaration of the end of the outbreak.