State of the World’s Hand Hygiene
HAND HYGIENEA global call to action to make hand hygiene a priority in policy and practice State of the Worlds 2 S TAT E O F T H E WO R L D ' S H A N D H YG I E N E A G L O B A L C A L L T O AC T I O N T O M A K E H A N D H YG I E N E A PR I O R I T Y I N P O L I CY A N D PR AC T I C E Published by UNICEF and WHOProgramme Division/WASH3 United Nations PlazaNew York, NY 10017 USAwww.unicef.org/wash United Nations Childrens Fund (UNICEF) and World Health Organization (WHO), 2021 Suggested citation: United Nations Childrens Fund and World Health Organization, State of the Worlds Hand Hygiene: A global call to action to make hand hygiene a priority in policy and practice, UNICEF, New York, 2021. UNICEF ISBN: 978-92-806-5290-1 Permission is required to reproduce any part of this publication. For more information on usage rights, please contact nyhqdoc.permit@unicef.org The designations employed in this publication and the presentation of the material do not imply on the part of the World Health Organization (WHO) and United Nations Childrens Fund (UNICEF) the expression of any opinion whatsoever concerning the legal status of any country or territory, or of its authorities or the delimitations of its frontiers. Dotted and dashed lines on maps may represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by WHO and UNICEF in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO and UNICEF to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO and UNICEF be liable for damages arising from its use. The statements in this publication are the views of the author(s) and do not necessarily reflect the policies or the views of UNICEF or WHO. Edited by Jeff Sinden. Publication design by Blossom. http://www.unicef.org/wash http://nyhqdoc.permit@unicef.org S TAT E O F T H E WO R L D ' S H A N D H YG I E N E A G L O B A L C A L L T O AC T I O N T O M A K E H A N D H YG I E N E A PR I O R I T Y I N P O L I CY A N D PR AC T I C E 3 Acknowledgements This report is the result of collaboration between a large number of contributors, reviewers and editors. The development of the report was led by Ann Thomas (Senior Advisor, WASH, UNICEF), under the overall direction and guidance of Kelly Ann Naylor (Director for WASH, UNICEF) and Bruce Gordon (Coordinator of Water, Sanitation, Hygiene and Health, World Health Organization). Clarissa Brocklehurst acted as Managing Editor. This document could not have been produced without the valuable contributions of Nathaniel Paynter, Tom Slaymaker, Christian Snoad, Job Ominyi, Mitsunori Odagiri and Guy Hutton at UNICEF, and Joanna Esteves Mills, Rick Johnson, Betsy Engebretson, Maggie Montgomery, Benedetta Allegranzi, Claire Kilpatrick and Kerstin Schotte at WHO. WHO and UNICEF are grateful to the many others who assisted with contributions, including Om Prasad, Helen Hamilton and Julie Truelove, WaterAid; Julia Rosenbaum, FHI360; Claire Chase, World Bank; Cheryl Hicks, WASH4Work; Jason Cardosi, LIXIL; Jeff Albert, Aquaya; Andrea Beatriz Lee-Llacer and Beverly Ho, Government of the Philippines; Ben Mandell and Jessica Jacobson, Water.org; Belinda Makhafola, Environmental Health Services, Government of South Africa; Ian Ross and Daniel Korbel, London School of Hygiene and Tropical Medicine, and Peter van Maanen, consultant. The authors would like to pay tribute to Val Curtis, Director of the Environmental Health Group at the London School of Hygiene and Tropical Medicine, who tragically died in 2020. Val was a champion of hand hygiene, and her work did more than anyone elses to raise the profile of hygiene and behaviour change in global health and political agendas. 4 S TAT E O F T H E WO R L D ' S H A N D H YG I E N E A G L O B A L C A L L T O AC T I O N T O M A K E H A N D H YG I E N E A PR I O R I T Y I N P O L I CY A N D PR AC T I C E Contents 1 2 3 Acknowledgements Foreword Acronymsand abbreviations Executive summary Endnotes WHY IS THIS REPORT NECESSARY? 1.1 Defining the challenge 1.2 A timeline of hand hygiene history 1.3 Things you need to know before reading this report WHY INVEST IN HAND HYGIENE? 2.1 Hand hygiene protects health 2.2 Hand hygiene has positive economic impacts 2.3 Hand hygiene is good for society as a whole WHAT IS THE CURRENT STATUS OF PROGRESS IN GLOBAL HAND HYGIENE? 3.1Monitoring hand hygiene 3.2Hand hygiene in households 3.3 Hand hygiene in schools 3.4 Hand hygiene in health care facilities 3.5 Hand hygiene in other settings 13 14 16 18 21 22 23 25 27 28 29 35 38 413 8 9 10 83 S TAT E O F T H E WO R L D ' S H A N D H YG I E N E A G L O B A L C A L L T O AC T I O N T O M A K E H A N D H YG I E N E A PR I O R I T Y I N P O L I CY A N D PR AC T I C E 5 4 5 6WHAT IS THE STATUS OF POLICY AND FINANCE FOR HAND HYGIENE? 4.1 Status of national hygiene policies and plans 4.2National targets for hygiene 4.3The cost of achieving universal hand hygiene 4.4Current investment levels and sources of funding GOVERNMENTS CAN ACCELERATE HAND HYGIENE PROGRESS WITH PROVEN, EFFECTIVE APPROACHES 6.1 Good governance begins with leadership, effective coordination and regulation 6.2 Smart public finance unlocks effective household and private investment 6.3 Capacity at all levels drives progress and sustains services 6.4Reliable data support better decision-making and stronger accountability 6.5Innovation leads to better approaches and meets emerging challenges 6.6Looking ahead: A pathway to 2030 IMAGINING A BETTER FUTURE: A DRAMATIC ACCELERATION IN PROGRESS REQUIRES WORK ON MANY FRONTS 5.1 The COVID-19 pandemic is an inflection point 5.2 Countries are rising to the challenge 45 46 48 49 53 65 66 69 71 75 78 81 57 58 60 6 S TAT E O F T H E WO R L D ' S H A N D H YG I E N E A G L O B A L C A L L T O AC T I O N T O M A K E H A N D H YG I E N E A PR I O R I T Y I N P O L I CY A N D PR AC T I C E Tables, figures and boxes TABLES TABLE 1: SDG service ladder for hygieneTABLE 2: Number and percentage of countries with national hygiene plans that have been costed and supported by sufficient financial resourcesTABLE 3: National hygiene coverage targets and alignment with SDG 6 FIGURES FIGURE 1: A timeline of progress in hand hygieneFIGURE 2: Progress in coverage of hygiene services between 2015 and 2020FIGURE 3: Population with no handwashing facilities at home, 2020 (%)FIGURE 4: Population with basic hygiene facilities in Haiti, disaggregated by SDG region, country, urban/rural, sub-national region and wealth quintiles, (%)FIGURE 5: Progress towards universal basic hygiene among countries with more than 99% coverage in 2020, by national income category, 2015-2020FIGURE 6: Top countries in expanding hand hygiene coverage, 2015-2020FIGURE 7: Basic hygiene vs improved and accessible water on premises, (%)FIGURE 8: Progress in basic hygiene services (2015-2020), and acceleration needed to reach universal coverage by 2030FIGURE 9: Hygiene in schools (% of schools and number of children)FIGURE 10: Trends in global coverage of hygiene in schools, 2015-2019, (% of schools)FIGURE 11: Regional coverage of hygiene in schools, 2015-2019 (%)FIGURE 12: Handwashing before eating and after using the toilet in schools in Latin America and the Caribbean, (%)FIGURE 13: Use of soap for handwashing by girls and boys, (%)FIGURE 14: Hand hygiene services in health care facilities, by country, 2019, (%)FIGURE 15: Proportion of health care facilities with hand hygiene at points of care, 2019, (%)FIGURE 16: Progress in basic hand hygiene services in fragile and conflict-affected countries, (%)FIGURE 17: Inequalities in basic hygiene services: Globally, in fragile contexts and NigerFIGURE 18: Households in refugee camps with access to soap, (%) 19 4748 173030 32 323334 35353636 373741 40 424243 S TAT E O F T H E WO R L D ' S H A N D H YG I E N E A G L O B A L C A L L T O AC T I O N T O M A K E H A N D H YG I E N E A PR I O R I T Y I N P O L I CY A N D PR AC T I C E 7 505455 14181924395253556263 636767686870 72 73 74767779 80 80 FIGURE 19: Estimated annual cost of providing hand hygiene in all households in 46 least-developed countries, (US$)FIGURE 20: Sufficiency of financial resources allocated to hygiene to meet national targetsFIGURE 21: Government spending on hygiene compared to drinking water and sanitation, 14 countries, (%) BOXESBOX 1: Defining hygiene and hand hygieneBOX 2: Defining handwashing facilitiesBOX 3: Soap and water, or alcohol-based hand rub?BOX 4: Handwashing is a highly cost-effective intervention in domestic settingsBOX 5: Points of careBOX 6: Ensuring the availability of affordable soap and alcohol-based hand rubsBOX 7: Government investment in behaviour change: The example of tobacco useBOX 8: Tracking hygiene expenditure through WASH accounts in MaliBOX 9: Accelerating progress on hand hygiene through local government in the PhilippinesBOX 10: Hygiene promotion at scale in ZambiaBOX 11: Focusing on hand hygiene in public places in IndonesiaBOX 12: South Africa: Developing and using a national hand hygiene policyBOX 13: Taking an all-of-government approach to hygiene in NigeriaBOX 14: Hand hygiene as part of Clean Green PakistanBOX 15: Integrating hygiene and immunization programming in NepalBOX 16: Mobilizing COVID-19 funding for hand hygiene in the Lao Peoples Democratic RepublicBOX 17: The African Sanitation Policy Guidelines provide support to governments to include hand hygiene in sanitation policyBOX 18: In Timor-Leste, a twinning partnership with Macao focused on improvements in health care facilitiesBOX 19: The International Labour Organization provides guidance to workplaces to ensure hand hygieneBOX 20: Monitoring hand hygiene behaviour in public places in Indonesia using mobile phonesBOX 21: Use of SMS surveys to gather information on handwashing and soap access in AfricaBOX 22: Leveraging an existing partnership to innovate for handwashing: The SATO TapBOX 23: A social enterprise responds to the need for innovative portable handwashing facilities: The HappyTapBOX 24: Inclusive design makes handwashing accessible for people living with disabilities in the United Republic of Tanzania and Zambia 8 S TAT E O F T H E WO R L D ' S H A N D H YG I E N E When COVID-19 emerged nearly two years ago, the world was without vaccines or medicines for this novel virus. One of the most critical tools in our arsenal for preven-ting infection was also one of our oldest: hand hygiene. But it was one that nearly a third of the world could not use. The benefits of hand hygiene in preventing the transmission of infectious diseases have been known since 1850. For example, proper hand hygiene has been proven to reduce deaths from respiratory and diarrheal diseases in children under five by 21 per cent and 30 per cent respectively. Yet in 2021, an estimated 2.3 billion people globally cannot wash their hands with soap and water at home and one-third of the worlds health facilities lack hand hygiene re-sources at the point of care. Meanwhile, nearly half of schools worldwide do not have basic hygiene services, affecting 817 million children. Over the past five years, half a billion people have gained access to basic hand hygie-ne facilities a rate of 300,000 per day. This is progress, but it is far too slow. At the current rate, almost two billion people will still lack access to basic hand hygiene faci-lities in 2030, negatively impacting other development priorities, including education, health, nutrition, and economic growth. COVID-19 created a unique moment for hand hygiene, with unprecedented attention, resources, and political will. However, we know from previous emergencies that such attention can be fleeting. In 2020, UNICEF, WHO and other partners launched the Hand Hygiene for All initiative, with the aim of channeling momentum around hand hygiene into long-term sustainable change. The State of the Worlds Hand Hygiene is the flagship report of the Hand Hygiene for All initiative, and is a companion piece to last years State of the Worlds Sanitation report. The reports message is clear: we must quadruple the current rate of progress to achieve the Sustainable Development Goal target on hand hygiene. We call on all governments to make the cost-effective investments in hand hygiene that will save many lives. Now is the time for governments, donors, and multilateral agencies to step up and support this most fundamental of public health interventions. Hand hygiene is essen-tial to primary health care, universal health coverage, and disease control. With the right leadership on hand hygiene, we can make the world a healthier place for all. Foreword MS. HENRIETTA H. FOREExecutive Director UNICEF DR. TEDROS ADHANOM GHEBREYESUSDirector-General World Health Organization https://www.unicef.org/reports/state-worlds-sanitation-2020 9 S TAT E O F T H E WO R L D ' S H A N D H YG I E N E A G L O B A L C A L L T O AC T I O N T O M A K E H A N D H YG I E N E A PR I O R I T Y I N P O L I CY A N D PR AC T I C E Acronymsandabbreviations ABHR alcohol-based hand rubAMCOW African Ministers Council on WaterCDC Centres for Disease Control and PreventionCSO civil society organizationsDALY disability-adjusted life yearDHS Demographic and Health SurveyEMIS education management information systemESA external support agencyGLAAS Global Analysis and Assessment of Sanitation and Drinking-WaterHBCC Hand Hygiene Behaviour Change CoalitionHH4A Hand Hygiene for AllHHMA Hand Hygiene Market AcceleratorILO International Labour OrganizationIPC infection prevention and controlJMP WHO-UNICEF Joint Monitoring Programme for Water Supply, Sanitation and HygieneOECD Organization for Economic Co-operation and DevelopmentMICS Multiple Indicator Cluster SurveyMOOC massive open online courseNGO non-governmental organizationSDG Sustainable Development GoalUNICEF United Nations Childrens FundUNHCR United Nations High Commission for RefugeesUSAID United States Agency for International DevelopmentWASH water, sanitation and hygieneWBCSD World Business Council for Sustainable DevelopmentWHO World Health Organization S TAT E O F T H E WO R L D ' S H A N D H YG I E N E A G L O B A L C A L L T O AC T I O N T O M A K E H A N D H YG I E N E A PR I O R I T Y I N P O L I CY A N D PR AC T I C E 10 Executive Summary Sustainable Development Goal (SDG) 6 calls for the global community to achieve ac-cess to hygiene for all by 2030. Hand hygiene is one of the most important elements of hygiene. However, both access to the facilities to practise hand hygiene and support for the behaviours required are missing in many settings. It is estimated that three out of ten people, 2.3 billion globally, lack a facility with water and soap available to wash their hands at home, including 670 million who have no handwashing facility at all. Facilities are also missing in many health care facilities, schools and public places. For instance, 7 per cent of health care facilities in sub-Sa-haran Africa, and 2 per cent globally, have no hand hygiene services at all, and 462 million children attend schools with no hygiene facilities. The simple act of cleaning hands can save lives and reduce illness by helping prevent the spread of infectious diseases. These diseases can be caused by pathogens (germs) transmitted through the air or via surfaces, food or human faeces. Because people fre-quently touch their face, food and surfaces, hands play a significant role in spreading disease. It is estimated that half a million people die each year from diarrhoea or acute respiratory infections that could have been prevented with good hand hygiene. As well as preventing a multitude of diseases, hand hygiene can help avoid significant financial costs resulting from sickness and death. During the COVID-19 pandemic, hand hygiene received unprecedented attention and became a central pillar in national COVID prevention strategies. This has created a unique opportunity to position hand hygiene as an important long-term public policy issue. The evidence shows that hand hygiene is a highly cost-effective investment, pro-viding outsized health benefits for relatively little cost; truly a no-regrets investment. Despite efforts to promote hand hygiene, often supported by the international commu-nity and coinciding with epidemics or emergencies, the rates of access to hand hygiene facilities remain stubbornly low. If current rates of progress continue, by the end of the SDG era in 2030, 1.9 billion people will still lack facilities to wash their hands at home. Governments should commit to hand hygiene not as a temporary public health inter-vention in times of crisis, but as a vital everyday behaviour that contributes to health 11 S TAT E O F T H E WO R L D ' S H A N D H YG I E N E A G L O B A L C A L L T O AC T I O N T O M A K E H A N D H YG I E N E A PR I O R I T Y I N P O L I CY A N D PR AC T I C E and economic resilience. The global community finds itself at a unique moment in time one of both urgency and opportunity. The time to accelerate progress on hand hygiene is now before the next health crisis is upon us. Both citizens and governments have a role to play. Governments should show lead-ership and make hand hygiene a public policy issue, backed with relevant regulation and enforcement. Water must be made easily accessible to allow hand hygiene every-where, and hand hygiene facilities should be available and used in every health care facility and school. Governments should make strategic investments in promotion and capacity building. Analysis shows that government expenditure in hand hygiene pro-motion will heavily leverage investments by households. Individuals should adopt and maintain hand hygiene behaviours, and expect others to do the same. Households can invest in handwashing facilities, which can be as simple as a jug and a bowl, and purchase soap. The private sector has a role to play, working with governments, to make hand hygiene facilities, water and soap widely available and affordable by all. As this report shows, investment in five key accelerators governance, financing, capacity development, data and information, and innovation identified under the UN-Water SDG 6 Global Acceleration Framework can be a pathway towards achiev-ing hand hygiene for all. Good governance begins with leadership, effective coordination and regu-lation: It is critical that governments establish clear policy relating to both service availability that facilitates handwashing, including readily availa-ble water, and the behaviours required to ensure hand hygiene is common practice in all relevant settings. Hand hygiene should be championed by a head of state, minister or another senior political figure ready to assume the challenge of driving progress. Local leadership is equally important; states, districts and villages should also be committed. All levels of government need to be clear that hand hygiene is a crucial public policy issue, and progress requires targets, strategies, roadmaps and budgets. Smart public finance unlocks effective household and private investment: Governments should seek ways to ensure public spending has the maxi-mum impact possible and stimulates investments from households and the private sector. The cost of hand hygiene can be shared between government and cit-izens. Strategic government spending on promotion, reinforcement and education both catalyses and optimizes household investment. Governments should invest in hand hy-giene in schools and health care facilities, set clear rules for these facilities, and regulate businesses so that hand hygiene is ensured. Governments have an important role to play in investing in water supply systems, so that they provide easily available water in quantities that facilitate handwashing. Capacity at all levels drives progress and sustains services: Governments should assess current capacity with respect to their hand hygiene poli-cy and strategies, identify gaps and develop capacity-building strategies based on the rigorous application of best practice. There are serious gaps in capacity for the promotion and sustained uptake of hand hygiene, and for many stake-holders this represents uncharted territory. Research into what works in various set-tings has resulted in critical hand hygiene innovations over the decades. This research is ongoing, and it remains a challenge for governments and others to keep up with the evolving evidence base to ensure effective implementation of innovation. In many S TAT E O F T H E WO R L D ' S H A N D H YG I E N E A G L O B A L C A L L T O AC T I O N T O M A K E H A N D H YG I E N E A PR I O R I T Y I N P O L I CY A N D PR AC T I C E 12 cases, countries need to invest in entirely new skillsets, in terms of how to create an enabling policy environment, promote hand hygiene, incentivize the private sector to engage, and regulate and enforce policy. Capacity needs to be built at all levels, across all settings: both nationally and locally, within governments, the private sector and society as a whole. Reliable data support better decision-making and stronger accountability: Governments should address the need for consistent data on hand hy-giene in order to inform decision-making and make investments strategic. While there have been dramatic improvements in the availability of data on hand hy-giene in recent years, particularly for households, gaps still remain. There are aspects of hand hygiene in health care facilities that are not comprehensively monitored, and little data exists on the availability and affordability of soap. The lack of data makes tracking progress against national and international targets problematic, and, in turn, makes decisions about policy, programming and investment difficult for governments. Data can be collected through incorporating a standardized handwashing module in household surveys and also through innovative approaches using mobile phones. Examples include crowdsourced data on hand hygiene in public places in Indonesia, and data collected by SMS surveys in Africa on the effects of the COVID-19 pandemic on the availability of soap. Innovation leads to better approaches and meets emerging challenges: Governments and supporting agencies should encourage innovation, par-ticularly on the part of the private sector, in order to roll out hand hygiene for all, in all settings. New ideas are needed to overcome challenges, such as lack of water supply, uneven soap availability and the impediment of affordability. 13 S TAT E O F T H E WO R L D ' S H A N D H YG I E N E 1Why is this report necessary?1.1 Defining the challenge1.2 A timeline of hand hygiene history1.3 Things you need to know before reading this report UNICEF/UNI367259/Fazel S TAT E O F T H E WO R L D ' S H A N D H YG I E N E 14 1 Defining the challenge1.1The second target under SDG 6 calls for the global community to: By 2030, achie-ve access to adequate and equitable sani-tation and hygiene for all and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations. Hand hygiene is one of the most important elements of hygie-ne. However, both access to the facilities to practise hand hygiene and support for the behaviours required are missing in many settings. UNICEF/UN0414850/NaftalinBOX 1 Defining hygiene and hand hygieneHygiene is a broad term and encompasses many activities. It can include hand hygiene (both hand-washing and the use of hand sanitizers such as alco-hol-based hand rubs (ABHRs)), menstrual hygiene management, oral hygiene, environmental cleaning in health care facilities and food hygiene. One of the challenges is that there is no clear, agreed-upon, in-ternationally recognized definition of hygiene. The World Health Organization (WHO) has pre-pared guidelines on hand hygiene in health care settings, and issues resources that are regularly updated, but there is no internationally recognized definition, or normative guidance on hand hygiene for households, schools and other settings.1 15 S TAT E O F T H E WO R L D ' S H A N D H YG I E N E It is estimated that three out of ten people, 2.3 billion globally, lack a facility with water and soap avail-able to wash their hands at home, including 670 million who have no handwashing facility at all. Facilities are also missing in many health care fa-cilities, schools and public places, even though there is evidence that the pres-ence of hand hygiene facilities is a strong determinant of regular hand hygiene in households and health care facilities. Hand hygiene is one of the most important measures to prevent the spread of infectious diseases, in-cluding diarrhoeal diseases and respiratory diseases, such as COV-ID-19. The COVID-19 pandemic has brought unprecedented attention to the role of hand hygiene in controlling disease and has created a unique opportunity to position it as an important public poli-cy issue. For instance, WHO states that control of COVID-19 requires a compre-hensive package of preventive measures, which includes frequent hand hygiene.2 However, there is a grave and very real risk that the emergency responses adopt-ed during the pandemic will not evolve into long-term commitments to hand hy-giene. Experience has shown that height-ened interest in hand hygiene associated with disease outbreaks is often followed by a rapid decline.3 There is, therefore, a significant risk that this crucial moment of opportunity will be lost. This report outlines the extent of the challenge in making sure hand hygiene is available to everyone across multiple settings, including schools, health care facilities, workplaces and public spaces. It offers concrete examples of success in a number of countries, and outlines the key actions governments and their develop-ment partners should take to make hand hygiene for all a reality. The evidence shows that hand hy-giene is a highly cost-effective in-vestment, providing outsized health benefits for relatively little cost. Both citizens and governments have a role to play. Governments should show lead-ership and make hand hygiene a public policy issue. Individuals should adopt and maintain hand hygiene behav-iours, and demand that others do the same. Strategic investments should be made by governments in promotion and capaci-ty-building to leverage investments made by households and businesses. Govern-ments should ensure that water is easily accessible to make hand hygiene possible everywhere, and that hand hygiene facili-ties are available and used in every health care facility and school. U NIC EF/U N04 1013 4/St ephe n/In finity Imag es S TAT E O F T H E WO R L D ' S H A N D H YG I E N E A G L O B A L C A L L T O AC T I O N T O M A K E H A N D H YG I E N E A PR I O R I T Y I N P O L I CY A N D PR AC T I C E 16 A timeline of hand hygiene history 1.2 The history of hand hygiene begins in the mid-nineteenth century. In 1847, the hand-hygiene pioneer Ignaz Semmelweis championed handwashing with a chlo-rinated lime solution as a way to reduce the terrifyingly high rates of mortality in maternity clinics, publishing a book in 1861 that made the link between puerper-al fever (also known as childbed fever) and the lack of hand hygiene by attend-ing doctors.4 Florence Nightingale im-plemented hygiene measures, including handwashing by staff, in the hospitals of the Crimean War and showed statistical-ly that these measures reduced mortality among soldiers. Over time, the evidence expanded, and hand hygiene was shown to help prevent a range of respiratory and diarrhoeal dis-eases and be crucial in fighting bacterial infections in health care facilities. In the early years of the new millennium, the profile of hand hygiene as a vital public health intervention rose, with increasing engagement of social and behavioural scientists. Additionally, the private sector began playing an important role, bringing marketing expertise and advice on how to improve markets for hand hygiene products. This led to the emergence of multi-stakeholder partnerships and the development of a range of resources. The Public-Private Partnership for Hand-washing was launched in 2001 by mem- bers that included the World Bank, the Centres for Disease Control and Preven-tion (CDC), UNICEF, Johns Hopkins Uni-versity, the London School of Hygiene and Tropical Medicine, the United States Agency for International Development (USAID), Unilever, Proctor and Gamble and Colgate-Palmolive. The following year, an important set of guidelines was pub-lished by partnership member CDC. A few years later, the partnership launched Glob-al Handwashing Day, which is now ob-served annually on 15 October by over one hundred countries, with schoolchildren as particularly enthusiastic participants. The partnership has continued to expand and broaden, and has almost 40 members and affiliates. In parallel, WHO issued the WHO Guide-lines on Hand Hygiene in Health Care, along with an improvement strategy, as-sessment tools and improvement toolkit, and has continued to update and add to these resources.5 Experience has shown that progress on hand hygiene is periodically accelerat-ed by high-profile disease outbreaks, including H1N1 influenza, Ebola viral dis-ease and, most recently, COVID-19. In re-sponse to COVID-19, governments have promoted hand hygiene, not only as a first line of defence in controlling the pan-demic, but also to increase resilience to future disease outbreaks. 17 S TAT E O F T H E WO R L D ' S H A N D H YG I E N E FIGURE 11847 2000 2003 2008 2014 2015 2017 2021 2020 Ignaz Semmelweis demonstrates the connection between hand hygiene and the prevention of postpartum infectionsFlorence Nightingale champions hand hygiene in army hospitals during the Crimean War Seminal paper published, demonstrating a significant reduction of health-care-associated infections associated with improved hand hygiene6 Public-Private Partnership for Handwashing launched CDC issues guidelines on hand hygiene in health care West Africa Ebola outbreak Minimum requirements for infection prevention and control (IPC) programmes launched by WHO, with hand hygiene prominent Launch of first State of the Worlds Hand Hygiene report End date of the SDGs COVID-19 pandemicWHO issues recommendations on hand hygiene in the context of COVID-197 The Hand Hygiene for All initiative launched by UNICEF, WHO and partners in response to COVID-19 pandemic SDGs adopted by United Nations Member States. SDG Target 6.2 includes hygiene, with an indicator related to handwashing with soap Public-Private Partnership for Handwashing becomes the Global Handwashing Partnership SDG service ladder for hygiene established by the WHO-UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene (JMP). Hygiene coverage, measured by handwashing at home, reported in 2017 JMP Data Update, with data for 71 countries8 Seminal paper published, suggesting a more than 40% reduction in diarrhoea risk in the community through handwashing with soap9 WHO launches the First Global Patient Safety Challenge, with a focus on hand hygiene to reduce health-care-associated infections and antimicrobial resistance Public-Private Partnership for Handwashing holds the first Global Handwashing Day on 15 October H1N1 pandemic Issuance of WHO Guidelines on Hand Hygiene in Health Care and launch of the global hand hygiene campaign Save Lives: Clean Your Hands First World Hand Hygiene Day on 5 May, targeted at health care workers 1854 - 1856 2001 2002 2005 2019 2009 2030 A timeline of progress in hand hygiene S TAT E O F T H E WO R L D ' S H A N D H YG I E N E A G L O B A L C A L L T O AC T I O N T O M A K E H A N D H YG I E N E A PR I O R I T Y I N P O L I CY A N D PR AC T I C E 18 Things you need to know before reading this report 1.3 While definitions of hygiene can be broad, this report focuses on hand hygiene spe-cifically, and even more specifically, on handwashing with soap. Good hand hy-giene entails the effective removal of germs from hands. Although liquid and gel hand sanitizers, such as ABHRs, play an important role in health care facilities, and are increas-ingly used to supplement handwashing in schools, offices and public places, this report focuses on handwashing with soap as a widely practised behaviour in industrialized and developing countries alike, and the one that is most common in households. Gathering information on handwashing is difficult. Simply asking people if they wash their hands is a notoriously unrelia-ble method. Observing handwashing can also introduce bias when the observed are aware their behaviour is being mon-itored, and is costly to carry out at scale. In health care facilities, WHO guidelines call for hand hygiene to be monitored through direct observation. There is also growing interest in electronic monitoring, focused on the point of care, as reliable systems are developed. In light of the difficulty in measuring hand hygiene through observation, progress to-wards the global SDG target on hygiene is measured with a simple indicator related to the existence of facilities for handwash-ing with soap at the household level (In-dicator 6.2.1b: the proportion of the pop-ulation with handwashing facilities with soap and water at home). The presence of hand hygiene facilities is also used as a proxy measure in measuring coverage in schools and health care facilities. BOX 2Defining handwashing facilities Handwashing facilities may be fixed or mobile, and include a sink with tap water, buckets with taps, tip-py-taps, and jugs or basins designated for handwa- shing. Soap includes bar soap, liquid soap, powder detergent, and soapy water, but does not include ash, soil, sand or other handwashing agents. The hand hygiene service ladder Hand hygiene is monitored globally by the JMP using globally agreed-upon definitions and methods. Households or schools that have a handwashing facility with soap and water available on prem-ises meet the criteria for basic hygiene service. These facilities may take sever-al forms, as may the soap (see Box 2). Households or schools that have a facility but lack water or soap are classified as Sour ce: J MP 19 S TAT E O F T H E WO R L D ' S H A N D H YG I E N E having limited service, and are distin-guished from households or schools that have no facility at all. In some cultures, ash, soil, sand or other materials are used as handwashing agents, but these are less effective than soap and are therefore counted as a limited service. In health care facilities, ABHRs are also included in the definition of hygiene service, and are considered the gold standard, when available and if hands are not visibly dirty (see Box 3).10 The SDG service ladder for hygiene in households, schools and health care fa-cilities is shown in Table 1. Soap and water, or alcohol-based hand rub? When practised correctly, it can be quicker, ea-sier and more effective to clean hands with ABHR rather than washing hands with soap and water. Encouraging the use of ABHR by health care wor-kers can greatly improve hand hygiene complian-ce, as well as providing an alternative when there are water shortages. However, ABHR is less ef-fective when hands are visibly dirty or soiled with blood or other bodily fluids. In such cases (and after using the toilet), handwashing with soap and water is recommended. Some pathogens (such as Clostridium difficile) may not be effectively removed or inactivated by ABHR. If exposure to such pathogens is strongly suspected or proven, handwashing with soap and water is the preferred means of hand hygiene.11 BOX 3 SDG service ladder for hygieneTABLE 1SERVICE LEVEL DEFINITION Basic For households: Availability of a handwashing facility on premises with soap and water.For schools: Handwashing facilities with water and soap available at the school at the time of the survey.For health care facilities: A functional hand hygiene facility with water and soap and/or ABHR at points of care, and within five metres of the toilets. Limited For households: Availability of a handwashing facility on premises lacking soap and/or water.For schools: Handwashing facilities with water but no soap available at the school at the time of the survey.For health care facilities: Functional hand hygiene facilities are available either at points of care or toilets, but not both. No Facility For households: No handwashing facility on premises.For schools: No handwashing facilities or no water available at the school.For health care facilities: No functional hand hygiene facilities are available either at points of care or toilets. Source: WHO-UNICEF Joint Monitoring Programme S TAT E O F T H E WO R L D ' S H A N D H YG I E N E A G L O B A L C A L L T O AC T I O N T O M A K E H A N D H YG I E N E A PR I O R I T Y I N P O L I CY A N D PR AC T I C E 20 Drivers of hand hygiene behaviour Behaviour is influenced by a range of so-cial, environmental and psychological de-terminants. In domestic settings, some of the most influential determinants include knowledge, perception of risk, psycholog-ical trade-offs, characteristic traits such as gender or education, and availability of in-frastructure. For instance, there is evidence that the presence of handwashing facili-ties acts as a cue or reminder and works to overcome some of the factors that may prevent handwashing.12 These determinants are factors that can be altered to help prompt a change in be-haviour, such as handwashing with soap, and for a behaviour change intervention to be effective, it must address the factors that influence a behavioural outcome. Ev-idence shows that simply sharing knowl-edge of good hygiene practice rarely re-sults in sustained behaviour change (i.e., knowledge is necessary but not suffi-cient). Interventions to promote hand hygiene should be designed based on an understanding of what peo-ple care about, and should engage relevant social norms to trigger and reinforce handwashing practice. While fear acts as a temporary stimulus for handwashing, for instance, during out-breaks of Ebola or COVID-19, this is often a temporary trigger, and when the threat recedes, so do the behaviours. For sustained hand hygiene im-provements, it is important to con- sider motives and emotions that will change peoples long-term mindset. These include affiliation (es-tablishing a sense of solidarity in the home and society), nurture (the desire to care for, look after and protect chil-dren),13 and disgust (the desire to avoid anything contaminating).14,15,16 Hygiene behaviour change programmes have been shown to be successful if they use multimodal approaches, address a range of determinants, use emotions (such as disgust, nurture, social status and affili-ation), and change behavioural settings through the placement of infrastructure with visual cues (sometimes referred to as nudges) to change the environment where behaviour occurs.17,18 While alter-ing the physical environment can nudge handwashing improvement, the science of habit formation has also been applied to handwashing. This aims to shift hand-washing behaviour from a goal-oriented, conscious practice to an unconscious behaviour that is reflexively practised.19 For health care settings, WHO has de-veloped a multimodal approach based on the premise that multiple elements, all essential and complementary, must be in place and used in combination to achieve optimal hand hygiene.20 The five elements are: system change; training and education; monitoring and feed-back; reminders and communications; and the presence of a safety culture. The multimodal approach has been applied in a wide range of countries since 2006, and has been demonstrated to be an effective way to improve hand hygiene practices and patient outcomes.21,22 U NIC EF/U NI3 5781 2/Bu ta 21 S TAT E O F T H E WO R L D ' S H A N D H YG I E N E 2Why invest in hand hygiene? UNICEF/UN0224066/Sokhin2.1 Hand hygiene protects health2.2 Hand hygiene has positive economic impacts2.3 Hand hygiene is good for society as a whole S TAT E O F T H E WO R L D ' S H A N D H YG I E N E 222 Hand hygiene protects health 2.1 The simple act of cleaning hands can save lives and reduce illness by helping prevent the spread of in-fectious diseases. These diseases can be caused by bacterial, viral or protozoan pathogens (germs) transmitted through the air or via surfaces, food or human faeces. Because people frequently touch their face, food and surfaces, hands play a significant role in spreading disease. It is estimated that half a million people die each year from diarrhoea or acute respiratory infections that could have been prevented with good hand hygiene. The health condi-tions that can be reduced through hand hygiene include: Acute respiratory infections, which are a leading cause of morbidity and mortality in the world.23 These include COVID-19 and pneumonia, the single largest in-fectious cause of death among children under 5 years of age in low- and mid-dle-income countries.24 Estimates from 2016 show that, 370,000 deaths caused by acute respiratory infections each year could have been prevented through ba-sic hand hygiene.25 Diarrhoeal disease, which is a major pub-lic health concern and a leading cause of disease and death among children under 5 years of age in low- and middle-in-come countries. This includes cholera, an acute diarrhoeal disease that can kill within hours if left untreated. Based on estimates from 2016, it is estimated that 165,000 deaths caused by diarrhoea each year could be prevented through basic hand hygiene.26 Stunting, which can be caused by repeat-ed bouts of diarrhoea and affects nearly one quarter of children under 5 years of age globally.27 Poor physical growth in early life affects cognitive development and increases the risk of illness and death in childhood.28 Sepsis, which is a preventable, life-threat-ening condition characterized by severe organ dysfunction, and is often relat-ed to inadequate quality of care. Sepsis accounts for a significant proportion of neonatal and maternal deaths global-ly, as well as health-care-associated in-fections.29 Hand hygiene during labour, delivery and post-natal care is critical to reducing infection. Health-care-associated infections, or no-socomial infections, are a leading cause of avoidable harm, jeopardize patient safety and represent a massive disease burden. The most common are surgical infections, hospital-acquired pneumonia, cathe-ter-associated urinary tract infections, and bloodstream infections. Many are caused by antibiotic-resistant organisms. It is esti-mated that hand hygiene can reduce up to 50 per cent of these infections.30 Hand hygiene also enables several addi-tional indirect health benefits, including: Unlocking other hygiene practices: The basin, water supply and soap required for handwashing unlock additional beneficial hygiene practices (e.g., facial cleanliness to reduce trachoma transmission). Reducing the burden on the health sys-tem: By reducing the strain of infectious 23 S TAT E O F T H E WO R L D ' S H A N D H YG I E N E diseases on the health system, hand hy-giene can free up resources to address other health priorities. Increasing health-care-seeking behaviour: In health care facilities, inadequate water, sanitation and hygiene (WASH) conditions, including a lack of handwashing facilities, have a negative impact on staff morale, pa-tient health-care-seeking behaviour (espe-cially among pregnant women) and their overall health care experience.31 Improving overall quality of care in health care settings: As an action relevant to all those working in health care settings, hand hygiene can be an entry point that catalyses other quality improvements. Reducing antimicrobial resistance: By re-ducing the need to treat infectious diseases with antibiotics, hand hygiene can substan-tially reduce antimicrobial resistance, ex-tending the useful life of last-line-of-defence antimicrobials. By reducing the spread of antibiotic-resistant infections, it also reduc-es deaths and health costs due to untreat-able infections, which often lead to sepsis. Hand hygiene has positive economic impacts 2.2 Significant financial costs result from sickness and death related to poor hand hygiene. These costs fall on both the patient and the health sys-tem. They include direct costs, such as the costs of medical treatment borne by households or governments for pre-ventable diseases, and non-medical costs, including out-of-pocket payments and travel costs for households seeking health care. Indirect costs include income loss, school absence and lost productivity associated with sickness. An influential review of the cost-effective-ness of interventions for improving child health concluded that domestic hand hygiene promotion is highly cost-ef- U NIC EF/U N04 1483 7/N afta lin S TAT E O F T H E WO R L D ' S H A N D H YG I E N E A G L O B A L C A L L T O AC T I O N T O M A K E H A N D H YG I E N E A PR I O R I T Y I N P O L I CY A N D PR AC T I C E 24 U NIC EF/U N03 8425 0/C aas fective, on par with oral rehydration therapy and most childhood vacci-nations (see Box 4).32 A 2012 study by the Organization for Economic Co-oper-ation and Development (OECD) suggests that, in the organizations member states, investments in hand hygiene in health care facilities generate savings in health expenditure that are, on average, 15 times the implementation costs.33 Hand hygiene in the workplace has posi-tive economic benefits as it protects both workers and, in retail and hospitality set-tings, customers. Hand hygiene is thus considered essential to ensuring busi-ness continuity and is increasingly seen as an important investment for the private sector.34 It is also essential in countries wishing to build their tourism industry. BOX 4Handwashing is a highly cost-effective intervention in domestic settings A 2002 study considered a hygiene promotion intervention implemented in urban Burkina Fa-so.35 The success of the intervention was eval-uated through a study of handwashing uptake and behaviour by mothers of young children, and the findings from this evaluation were combined with secondary data on health risk reduction in the intervention area. The study examined the direct medical savings for the government and households, due to diarrhoeal disease, plus in-direct savings related to caretaker time and lost productivity associated with child death. The authors concluded that the cost to society (the provider of the intervention plus the households who participated) of the intervention was equal to US$51 per case of diarrhoea averted (2002 prices), falling to US$7.90 if indirect benefits were included. At the time, the annual cost of the pro- gramme was 0.001 per cent of the annual health budget of Burkina Faso. Such results are hard to interpret alone. However, the Disease Control Priorities (DCP) project pro-vides combined assessments of the cost-effective-ness of health interventions, measured in terms of the extent to which they can avert disability-adjust-ed life years (DALYs). DALYs are the sum of years of potential life lost due to premature mortality and the years of productive life lost due to disability. In 2016, drawing on the study in Burkina Faso, the DCP project estimated that the cost for every DALY averted through handwashing was US$88-225. On this basis, the DCP project rated handwashing as a very cost-effective intervention for child health, placing it on a similar level to oral rehydration ther-apy and most childhood vaccinations. 36 25 S TAT E O F T H E WO R L D ' S H A N D H YG I E N E Hand hygiene is good for society as a wholeIn addition to the health benefits, good hand hygiene has positive societal im-pacts that cannot easily be quantified. For instance, access to improved WASH ser-vices has been shown to reduce stress, particularly among women and people living with disabilities, by increasing feel-ings of dignity, privacy and safety, and de-creasing feelings related to disgust, fear of violence, injury and shame. The ability to maintain personal hygiene has an im-portant role to play in this, as it is linked to feelings of dignity and pride.37 Research in Malawi demonstrated that the adverse effects of poor hand hygiene dis-proportionately affect people living with disabilities.38 Globally, it has been shown that the most vulnerable populations and those in resource-poor settings suffer the most from the negative impacts of poor WASH.39 Improvements in hand hygiene, therefore, contribute to reducing inequality. The infectious diseases that hand hy-giene can help control keep kids out of school and adults out of work, affect-ing the short- and long-term economic well-being of households. Because poor-er households are more exposed to key factors that cause illness, a pattern of de-cline in health and socioeconomic status can be created. Reduced school attain-ment and household productivity affect national economic development, which, in turn, affects a countrys ability to pro-vide essential services. Underfunded health services are further pressured by the need to treat preventable infectious diseases, with far-reaching implications. This cycle of decline is exacerbated by emerging global trends, such as the in-creased risk of global disease outbreaks and antimicrobial resistance. Just as inadequate hand hygiene can cre-ate this downward cycle, good hand hy- U NIC EF/U N02 2538 6/Br own 2.3 S TAT E O F T H E WO R L D ' S H A N D H YG I E N E A G L O B A L C A L L T O AC T I O N T O M A K E H A N D H YG I E N E A PR I O R I T Y I N P O L I CY A N D PR AC T I C E 26 U NIC EF/U N02 9313 1/H olt giene can lead to an upward spiral of mu-tually reinforcing improved health, social and economic outcomes. Keeping hands free of germs in the household, at school, and when visiting health services keeps infectious diseases at bay, enabling indi-viduals to survive, thrive and make an ac-tive
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