Expert panellist and antimicrobial resistance (AMR) advisor to the Global Hygiene Council, Sabiha Essack explores the role of hand hygiene in reducing the risk of AMR.
Regular hand washing or use of sanitiser has become commonplace for many as societies increasingly recognise the importance of good hygiene practices in curbing the spread of infection. It is estimated that routine hand washing could reduce the risk of communicable diseases by up to 59% and equally, could prevent up to a million deaths per year. Policymakers have recognised just how vital access to clean water and sanitation is and aim to make clean water accessible to all by 2030 as part of the Sustainable Development Goals (SDGs). At present, three in 10 people around the world still do not have access to basic hygiene services making global public health threats like antimicrobial resistance all the more worrying.
Raising awareness of good hand hygiene practices is a key aim of the Global Hygiene Council (GHC), HEQ spoke to expert panellist and AMR advisor to the GHC, Sabiha Essack about the integral role of hand hygiene in the fight against antimicrobial resistance.
What role do good hand hygiene practices play in the prevention of infection, particularly during a global pandemic?
Hygiene, and specifically hand hygiene practices, plays a central role in infection prevention. According to the World Bank, the promotion of hygiene and sanitation is the most cost-effective health measure to reduce disease. During the pandemic, we saw the success of governmental and public health hygiene promotion and education to drive the uptake of hand hygiene. Hand hygiene habits were globally adopted as a critical way of reducing the spread of COVID-19.
The increased emphasis on promoting effective handwashing behaviours since the beginning of the COVID-19 pandemic needs to continue, as hand hygiene reduces the spread of many common infections, including respiratory and diarrhoeal infections. Handwashing with soap and water has been estimated to save a million lives from diarrhoeal-related death alone, highlighting the impact a simple hand hygiene intervention can have.
It is now widely accepted that good hand hygiene practices can reduce the rates of infectious illnesses in the community and prevent the escalation of new public health threats. COVID-19 is an ideal leveraging point to highlight the importance of water, sanitation, and hygiene (WASH) to mitigate antimicrobial resistance (AMR).
AMR is not the next pandemic. It is not a silent pandemic. It is here now, and it affects us in many ways. It affects human health as we know it, it affects food security and our environment, and that is why good hygiene is so important.
At a recent meeting convened by the Global Hygiene Council (GHC), experts discussed the importance of sustaining long-term habitual hand hygiene practices to reduce the risk of future pandemics. It was agreed that washing hands at key moments of risk is more important than the frequency of handwashing and that handwashing should occur at times and places where there is a risk of spreading infectious agents. Some examples are before and after using the toilet and before and after handling raw meat or fish during food preparation.
What external factors might affect differences between demographics in approaches to hand hygiene?
External factors, such as access to appropriate hygiene facilities, resources, and education, have an impact on approaches to hand hygiene.
As of 2020, 2.3 billion people lacked basic hygiene services (a handwashing facility with soap and water) and 1.6 billion people had access to handwashing facilities that lacked water or soap.
WASH facilities are disproportionately poor in low-to-middle income countries (LMICs). When looking at the community level, the highest number of people without access to hygiene are in sub-Saharan Africa and South Asia, which are the very regions with a disproportionately high burden of AMR. Over 80% of rural Africans – 530 million people – do not use a handwashing facility or use limited services without soap and water. Over 50% of rural South Asians – 640 million people – also have no or limited handwashing services.
From an LMIC perspective, there is a need to improve health literacy and contextualise the problem and interventions by highlighting the impact of hand hygiene on a family’s health at a particular time or place. Having access to the required resources does not always translate to the uptake of hand hygiene. In addition to access to facilities, we need to ensure we promote the capability, opportunity and motivation through knowledge and resources to engender sustainable behaviour change in hand hygiene. Research from the GHC in seven countries showed that, on average, 27% of primary school children did not learn how to wash their hands at school. In India, this was as high as 42%, whereas in China it was 20%. Instilling the knowledge in children of how and when to wash hands can help lead to a lifetime of effective hand hygiene habits and reduce the spread of harmful microbes and infections.
Should public messaging around AMR and infection control emphasise more clearly the importance of hand hygiene?
The World Health Organization (WHO) has declared AMR as one of the top 10 global public health threats facing humanity, requiring urgent multisectoral action. It is without a doubt that hygiene, including hand hygiene, has a critical role to play in mitigating AMR.
Hand hygiene will help to reduce the incidence of ALL common, transmissible infections, whether viral or bacterial. The lower the incidence of infection, the lesser the need for or prescription of antimicrobials and the lower the selection pressure for the development or increase in AMR.
At the recent GHC meeting, experts emphasised the impetus that COVID-19 has provided in learning about infection prevention and control (IPC) and the type of hand hygiene messaging that resonates with the public. It is important that messaging around the role of hand hygiene, AMR and infection control adopts innovative ways of saying the same things differently. The message should always be fresh and exciting, keeping it at the forefront of everybody’s minds to drive action and prevent message fatigue.
It is paramount that public messaging showcases how adopting and sustaining hygiene behaviour as a habit can benefit health and social lives on a personal level. The focus should be on what is in it for the individual rather than broad messaging about reducing pressure on health systems.
Of every 100 hospitalised patients at any given time, seven in
developed countries and 10 in developing countries will acquire
at least one healthcare-associated infection
© iStock/shapecharge
What actions can healthcare professionals take to minimise the risk of spreading infections?
One outcome of COVID-19 was, undeniably, improved IPC. There was a dramatic improvement in hand hygiene compliance and the availability of alcohol hand rub, personal protective equipment (PPE) and IPC training.
Of every 100 hospitalised patients at any given time, seven in developed countries and 10 in developing countries will acquire at least one healthcare-associated infection. The continued use of face masks, enhanced hygiene practises and physical distancing could reduce the incidence of all infections in healthcare settings, but this may not be sustainable at the levels adopted during COVID-19. However, consistent efforts around infection prevention and ensuring that healthcare professionals are equipped with the knowledge and resources to carry out effective infection prevention should be the norm. A lower incidence of infection means a reduction in antimicrobial prescription and a subsequent reduction in the selection pressure for AMR.
Healthcare professionals can also help reduce infections outside the healthcare setting by advocating good hand hygiene in the home and community, and encouraging patients to adopt and sustain good habits.
What can be done at a policy level to reduce the spread of AMR?
Behavioural change is central to reducing the spread of infectious diseases and mitigating AMR. Behavioural change must occur at all levels from the bottom up (general public) and top-down, driven by government and other policymakers and stakeholders.
Policymakers should focus on initiatives aimed at improving health literacy. These initiatives must also focus on hygiene habits – defining a clear pathway to sustaining behaviours. Appropriate behaviours need to be made easy and include facilities and infrastructure to facilitate handwashing behaviours rather than relying on knowledge transfer alone.
National Action Plans (NAPs) on AMR recognise the importance of strengthening infection prevention in healthcare settings with clear IPC strategies, but they give insufficient attention to such preventative measures in everyday life in the community. Only three of the WHO European region’s NAPs specifically address infection prevention at community level.
The GHC is calling for all policymakers to acknowledge the critical importance of taking an infection prevention approach through improved WASH programmes to reduce infection rates, the need for antimicrobials and the subsequent selection pressure for the development or escalation of AMR. If we are to curtail the escalating burden of AMR, policymakers must revise NAPs on AMR by adopting strong recommendations on the use of WASH measures in a community setting and ensuring that public messaging reiterates how adopting and sustaining good hygiene behaviours can benefit health and social lives on a personal level.
Professor Sabiha Essack
B. Pharm., M. Pharm., PhD
South African Research Chair in Antibiotic Resistance & One Health
Professor of Pharmaceutical Sciences and director of the Antimicrobial Research Unit, College of Health Sciences, University of KwaZulu-Natal
www.hygienecouncil.org
https://twitter.com/hygiene_council
This article is from issue 21 of Health Europa Quarterly. Click here to get your free subscription today.
