The social and economic benefits of improved hand hygiene

Professor Dr Thomas Szucs, Director of the European Center of Pharmaceutical Medicine, and member of the Global Hygiene Council’s expert panel, discusses the widespread repercussions of infectious diseases and how they can be prevented through hygiene.

Health disasters as a result of infectious diseases, such as the recent SARS-CoV-2 (COVID-19) pandemic, the outbreak of Ebola in West Africa, and Zika virus in Brazil, currently pose one of the greatest threats to human existence. Additionally, with many of these disease-causing pathogens having no current therapeutic treatment or being resistant to the majority of modern medicines,^1,2 there is an urgent need for solutions to tackle these crises. In the last three years, COVID-19 has caused 6.5 million deaths³ and in 2019 alone, 4.95 million deaths were associated with antimicrobial-resistant bacteria.⁴ Threats to human health are not the only disastrous implication of the increasing prevalence of transmissible diseases caused by microorganisms. There are also socioeconomic consequences.

A single emerging infectious disease is predicted to cost the global economy $30-50bn⁵ and has financial implications for all sectors including health, tourism and travel, agriculture, and government tax revenue.⁶ The most recent pandemic starkly highlights the extent of economic damage infectious diseases can cause. The Organisation for Economic Cooperation and Development estimates that as a result of COVID-19, in 2020, global economic growth declined by 3.4%. By mid-2021, although global GDP showed signs of recovery, income losses as a result of the pandemic were estimated to be $4.5 trillion.⁷ This is only the second negative year since World War II.⁸ Even seasonal transmissible illnesses, such as the common cold, are estimated to cost between $25 and $40bn annually.⁹ Economic losses materialise in different ways. There are the direct costs of treating the disease in a medical setting, costs of loss of life but also indirect costs. These indirect costs include absenteeism and lost time at work resulting in a loss of productivity and business opportunities.

Better prophylactic measures, alongside management of symptoms and vaccinations, are needed to prevent the economic costs of disease before they arise. Improved home and community hygiene with a focus on handwashing is a key measure that could be implemented globally with extensive health and pharmacoeconomic benefits as a result of disease prevention. A recent convening of the Global Hygiene Council (GHC) of experts concluded that governments and health authorities should better evaluate the socioeconomic benefits of investing in hygiene initiatives as a critical and cost-effective solution to protecting against the spread of infectious diseases.¹⁰

How improving hygiene affects the costs of medical care

Improved hygiene in the home and community has been shown to decrease the transmission of antimicrobial-resistant pathogens and reduce the reliance on antibiotics.¹¹ Treating these multidrug-resistant infections in hospitals costs an estimated $4.6bn a year due to the requirement of substantial healthcare resources.¹² Allowing AMR bacteria or other infectious disease pathogens to spread to pandemic levels could be even more costly. During the most recent pandemic, based on private health insurance in the US, the mean cost of hospitalisation due to COVID-19 was $21,752, increasing to $49,441 if the patient required a ventilator and further care.¹³ In the UK, the COVID pandemic has increased the cost of keeping frontline NHS services running by £4-5bn a year;¹⁴ as of September 2021, UK spending on medical and healthcare measures for COVID-19 exceeded £55.2bn and includes PPE procurement, vaccine and antibody supply and enhancing discharges from hospitals when capacity was in crisis.¹⁵

In the case of serious infectious diseases, patients require an extended hospital stay and long-term care, elevating costs. The average stay in hospital for a patient with tuberculosis (TB) is 20 – 60 days, but this can increase to 180 days for cases of multidrug-resistant TB.¹⁶ As a result of this extended hospitalisation period, in Europe, the mean treatment costs of TB are €7,848 for susceptible strains, but €168,310 for those that are drug resistant.¹⁷ Medical costs incurred from infectious diseases are also extensive in low- and middle-income countries (LMIC) as demonstrated by the 2014 Ebola outbreak in West Africa. This epidemic was 11 times larger than all previous outbreaks combined. As well as costing $2.2bn in GDP across Guinea, Liberia and Sierra Leone, it caused an 8% decrease in the healthcare workforce of Liberia and a 23% reduction in the ability to deliver health services in Sierra Leone.¹⁸ Ultimately, the damage to healthcare infrastructure by one disease causes an increase in deaths and costs due to other transmissible diseases compounding the problem.¹⁸

Cost of loss of life

From 1918-2020, the CDC states there have been five pandemics.¹⁹ Although highly sensitive, based on the number of lives lost and the average global value of statistical life (AGVSL), the cost of lives lost in these 102 years is estimated to be $3tr.²⁰ During the COVID-19 pandemic there was also a strong correlation between lives lost and loss of GDP.²⁰

Costs due to absenteeism and loss of productivity

As well as direct costs to the health sector, infectious diseases result in absenteeism of those that are sick, and in many cases their carers as well, causing a drop in productivity and lost business opportunities. A study of healthcare workers in an Italian hospital found that 11,100 working days a year are lost as a result of flu, equating to an economic loss of €1.7m.²¹ Even when days are not missed (presenteeism), epidemics can cause individuals to be less effective at work also contributing to disrupted productivity. Flu is associated with significant workplace productivity loss with an average full-time employee losing around 3.5 days a week (following symptom onset) due to an influenza infection.²² Indirect costs of viral respiratory tract infections, including absenteeism, can even exceed those of direct medical costs having been estimated annually at $22.5 billion and $17 billion respectively.²³

Other economic losses

Epidemics and pandemics of airborne transmissible diseases can cause multisector disruption, and economic damage and impede trade and tourism.²⁴ In some cases, this can be a result of poor public understanding of a disease and its transmission. In 2009, the H1N1 outbreak, negative media coverage and the use of the misnomer ‘swine flu’ caused a global decline in the value of pork markets as consumers inaccurately feared consuming pork would result in infection.²⁵ In a week of the term becoming widespread, the Chicago Board of Trade announced a reduction in sales of hogs amounting to the equivalent of $6.9m, with 64% of surveyed people admitting to having stopped consuming pork during the outbreak.²⁵ Mere public perceptions of the risks of H1N1 is estimated to have cost Mexico $27m in lost pork trade^{26, 24} therefore the importance of insuring public understanding and accurate campaigns such as those proposed by the GHC extend beyond health implications. Epidemics can also impact tourism, both through direct travel bans and public reluctance to travel to affected countries. Tourism is still impacted in many African countries years after the 2014 Ebola outbreak, where the loss of capital even affects neighbouring countries where the disease was not prevalent.²⁷

Introducing global improvements in all aspects of hygiene has the potential to reduce the spread of infectious diseases and as such, minimise the associated economic costs. In particular, a focus on improved handwashing could be a simple and economically viable intervention. A recent study on the personal protective effect of handwashing during the COVID-19 pandemic showed that ‘moderate-frequency’ handwashing significantly reduced the risk of acquiring COVID.²⁸ It has been shown that when a hand hygiene programme is implemented in schools, student absenteeism is reduced, especially during flu season.²⁹ In low and middle-income countries, where the burden of resistant infections is the greatest,⁴ improved hand hygiene could greatly reduce healthcare-associated infections.³⁰ Current compliance with WHO guidelines on handwashing and use of alcohol-based hand sanitisers appear to be as low as 8.5%³¹ and in 2019, an estimated quarter of health facilities in the 46 UN-designated least-developed countries did not have access to basic water facilities.³² Urgent changes and investment in hand hygiene are needed as ensuring everyone has access to soap and water could reduce epidemic infections by 20%.³³

The potential health benefits of investing in hand hygiene are clear but these measures are also cost-effective and could save money in the long run when compared to inaction or other mitigation strategies. Crucially, these measures are actionable in LMICs where lost productivity from poor hygiene and quality of care is estimated to cost $1.4tr annually.³² Conversely, achieving basic water, sanitation and hygiene (WASH) services to permit effective handwashing by 2030 would cost between $6.5 – $9.6bn.³² If current rates of progress continue, WASH services will only be available to 78% of the world in 2030 leaving 1.9 billion people without handwashing facilities.³⁴ If governing bodies invested $1 per person, per year in hand hygiene, it would protect against disease and prevent future pandemics and death.³⁴

The benefits of investing in handwashing measures alongside promotional campaigns are not limited to LMICs. The evidence above shows that infectious diseases do not discriminate by location or economy and high-income countries could also see economic benefits from improved hand hygiene. Hand hygiene non-compliance is associated with significant costs to hospitals, especially in relation to nosocomial infections. Methicillin-resistant Staphylococcus aureus (MRSA) infections can cost $1,777,283 annually. In a 200-bed US hospital, a 1% increase in hand-hygiene compliance could result in an annual saving of $39,650.³⁵  Similar findings have been observed in the UK where increases in handwashing behaviours could save the NHS between £322m and £1bn per year.³⁶

Investing in hand hygiene is cost-effective and offers significant economic benefits. Implementation of handwashing programmes or campaigns is a comparatively simple measure and offers a great return on investment. A 2017 study found that instigating a national handwashing programme in India could yield a return of $5.64 bn – a 94-fold return on investment and a value that equates to 0.3% of India’s GDP.³⁷ In China a similar programme could give a 35-fold return on investment offering excellent value for money whilst reducing infections and saving lives.³⁷ It is predicted that for every dollar invested in hand hygiene, a country can expect to save $15.³⁴ Compared to other interventions, handwashing is particularly cost-effective. An investment of $3.35 in the promotion of handwashing is estimated to return the equivalent health benefits as an $11 investment in toilet infrastructure, a $200 investment in household water supplies, or an investment of thousands of dollars in vaccinations.³⁸ By comparison, fully establishing a routine vaccination programme in one LMIC could result in an incremental annual cost of between $19m and $123m.³⁹ Even simpler community mandates are less cost-effective than handwashing, with social distancing measures adopted in 2020 against COVID-19 estimated to have cost the US a 25% decrease in GDP compared to 2019.²⁰

Following the evidence presented here, the GHC is calling on governments, health authorities and corporations to evaluate the economic benefits of investing in hygiene initiatives to achieve universal hand hygiene. Measures proposed by the GHC include ensuring global access to handwashing facilities, including soap and water, and investing in hygiene education and promotional campaigns. These should ensure public understanding of transmissible diseases and highlight how individuals and communities can prevent the spread of infectious diseases through improved hand hygiene. The momentum established in response to COVID-19 around highlighting the importance of hand hygiene cannot be allowed to dwindle and further work is required to ensure compliance with implemented measures is upheld to reduce the impact of future pandemics. Although the next infectious disease outbreak cannot be predicted, proactive steps can be taken to invest in protection for both human health and the economy. Action is needed locally and at the global and international levels, and investments in handwashing measures could help reduce the burden of infectious diseases improving both epidemic and economic outcomes.

References

1. Karakonstantis, S., Kritsotakis, E.I. and Gikas, A. 2020. Pandrug-resistant Gram-negative bacteria: a systematic review of current epidemiology, prognosis and treatment options. Journal of Antimicrobial Chemotherapy 75(2), pp. 271–282. Available at https://academic.oup.com/jac/article/75/2/271/5581812 [Accessed: 16 November 2022].
2. CDC 2022. Zika Virus: Treatment. Available at: https://www.cdc.gov/zika/symptoms/treatment.html [Accessed: 16 November 2022].
3. WHO 2022. WHO Coronavirus (Covid-19) Dashboard. Available at: https://covid19.who.int/ [Accessed: 16 November 2022].
4. Murray, C.J. et al. 2022. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. The Lancet 399(10325), pp. 629–655. Available at: http://www.thelancet.com/article/S0140673621027240/fulltext [Accessed: 14 November 2022].
5. Global Virome Project 2018. Global Costs of Emerging Infectious Diseases: an Economic Case for the Global Virome Project. Available at: http://livescience.ecohealthalliance.org/predict/reports/2018-04-16-edi-economic-case-for-the-GVP.pdf [Accessed: 16 November 2022].
6. Smith, K.M., Machalaba, C.C., Seifman, R., Feferholtz, Y. and Karesh, W.B. 2019. Infectious disease and economics: The case for considering multi-sectoral impacts. One Health 7, p. 100080. DOI: 10.1016/J.ONEHLT.2018.100080.
7. Jackson, JK., Weiss, MA., Schwarzenberg, AB., Nelson, RM., Sutter, KM and Sutherland MD. 2021. Global Economic Effects of Covid-19. Congressional Research Service; R46270(81). Available at https://sgp.fas.org/crs/row/R46270.pdf [Accessed: 06 January 2023].
8. McDonnell, A. and Klemperer, K. 2022. WASHing Away Resistance: Why the UK Should Invest in Water, Sanitation, and Hygiene to Tackle Anti-Microbial Resistance.
9. Bramley, T.J., Lerner, D. and Sarnes, M. 2002. Productivity losses related to the common cold. Journal of occupational and environmental medicine 44(9), pp. 822–829. Available at: https://pubmed.ncbi.nlm.nih.gov/12227674/ [Accessed: 24 November 2022].
10. GHC 2022. Making Hygiene Matter in Home and Community Settings to Reduce the Development of Antimicrobial Resistance (AMR) and Future Pandemics
11. Maillard, J.Y. et al. 2020. Reducing antibiotic prescribing and addressing the global problem of antibiotic resistance by targeted hygiene in the home and everyday life settings: A position paper. American Journal of Infection Control 48(9), pp. 1090–1099. doi: 10.1016/J.AJIC.2020.04.011.
12. Nelson, R.E. et al. 2021. National Estimates of Healthcare Costs Associated With Multidrug-Resistant Bacterial Infections Among Hospitalized Patients in the United States. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 72(Suppl 1), pp. S17–S26. Available at: https://pubmed.ncbi.nlm.nih.gov/33512523/ [Accessed: 24 November 2022].
13. Tsai, Y., Vogt, T.M. and Zhou, F. 2021. Patient Characteristics and Costs Associated With COVID-19-Related Medical Care Among Medicare Fee-for-Service Beneficiaries. Annals of internal medicine 174(8), pp. 1101–1109. Available at: https://pubmed.ncbi.nlm.nih.gov/34058109/ [Accessed: 15 November 2022].

14  NHSProviders 2021. A reckoning: the continuing cost of COVID-19. Available at: https://www.nhsconfed.org/system/files/2021-09/A-reckoning-continuing-cost-of-COVID-19.pdf [Accessed: 16 November 2022].

15. BMJ 2022. The public finance cost of covid-19. London. Available at: https://www.bmj.com/content/376/bmj.o490 [Accessed: 16 November 2022].
16. Migliori, G.B. et al. 2021. Tuberculosis, COVID-19 and hospital admission: Consensus on pros and cons based on a review of the evidence. Pulmonology 27(3), pp. 248–256. doi: 10.1016/J.PULMOE.2020.12.016.
17. Diel, R., Vandeputte, J., de Vries, G., Stillo, J., Wanlin, M. and Nienhaus, A. 2014. Costs of tuberculosis disease in the European Union: a systematic analysis and cost calculation. European Respiratory Journal 43(2), pp. 554–565. Available at: https://erj.ersjournals.com/content/43/2/554 [Accessed: 24 November 2022].
18. CDC 2016. Cost of the Ebola Epidemic. Available at: https://www.cdc.gov/vhf/ebola/pdf/cost-ebola-multipage-infographic.pdf [Accessed: 15 November 2022].
19. CDC 2018. Past Pandemics. Available at: https://www.cdc.gov/flu/pandemic-resources/basics/past-pandemics.html [Accessed: 15 November 2022].
20. Kaplan, S., Lefler, J. and Zilberman, D. 2022. The political economy of COVID-19. Applied Economic Perspectives and Policy 44(1), pp. 477–488. Available at: https://onlinelibrary.wiley.com/doi/full/10.1002/aepp.13164 [Accessed: 15 November 2022].
21. Gianino, M.M. et al. 2019. Cost of Sickness Absenteeism during Seasonal Influenza Outbreaks of Medium Intensity among Health Care Workers. International Journal of Environmental Research and Public Health 2019, Vol. 16, Page 747 16(5), p. 747. Available at: https://www.mdpi.com/1660-4601/16/5/747/html [Accessed: 16 November 2022].
22. van Wormer, J.J., King, J.P., Gajewski, A., McLean, H.Q. and Belongia, E.A. 2017. Influenza and Workplace Productivity Loss in Working Adults. Journal of occupational and environmental medicine 59(12), pp. 1135–1139. Available at: https://pubmed.ncbi.nlm.nih.gov/28759481/ [Accessed: 16 November 2022].
23. Fendrick, A.M., Monto, A.S., Nightengale, B. and Sarnes, M. 2003. The economic burden of non-influenza-related viral respiratory tract infection in the United States. Archives of internal medicine 163(4), pp. 487–494. Available at: https://pubmed.ncbi.nlm.nih.gov/12588210/ [Accessed: 16 November 2022].
24. Smith, K.M., Machalaba, C.C., Seifman, R., Feferholtz, Y. and Karesh, W.B. 2019. Infectious disease and economics: The case for considering multi-sectoral impacts. One Health 7, p. 100080. doi: 10.1016/J.ONEHLT.2018.100080.
25. Attavanich, W., McCarl, B.A. and Bessler, D. 2011. The Effect of H1N1 (Swine Flu) Media Coverage on Agricultural Commodity Markets. Applied Economic Perspectives and Policy 33(2), pp. 241–259. Available at: https://onlinelibrary.wiley.com/doi/full/10.1093/aepp/ppr008 [Accessed: 24 November 2022].
26. Rassy, D. and Smith, R.D. 2013. The economic impact of H1N1 on Mexico’s tourist and pork sectors. Health Economics 22(7), pp. 824–834. Available at: https://onlinelibrary.wiley.com/doi/full/10.1002/hec.2862 [Accessed: 24 November 2022].
27. Novelli, M., Gussing Burgess, L., Jones, A. and Ritchie, B.W. 2018. ‘No Ebola…still doomed’ – The Ebola-induced tourism crisis. Annals of Tourism Research 70, pp. 76–87. doi: 10.1016/J.ANNALS.2018.03.006.
28. Beale, S. et al. 2020. Hand Hygiene Practices and the Risk of Human Coronavirus Infections in a UK Community Cohort [version 2; peer review: 2 approved] report. Available at: https://wellcomeopenresearch.org/articles/5-98 [Accessed: 16 November 2022].
29. Azor-Martínez, E. et al. 2014. The impact of common infections on school absenteeism during an academic year. American Journal of Infection Control 42(6), pp. 632–637. doi: 10.1016/J.AJIC.2014.02.017.
30. Loftus, M.J. et al. 2019. Hand hygiene in low- and middle-income countries. International Journal of Infectious Diseases 86, pp. 25–30. doi: 10.1016/J.IJID.2019.06.002.
31. Tschudin-Sutter, S., Sepulcri, D., Dangel, M., Schuhmacher, H. and Widmer, A.F. 2015. Compliance with the World Health Organization Hand Hygiene Technique: A Prospective Observational Study. Infection Control & Hospital Epidemiology 36(4), pp. 482–483. Available at: https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/abs/compliance-with-the-world-health-organization-hand-hygiene-technique-a-prospective-observational-study/12BB771020D36350DA8A2719A47FD197 [Accessed: 15 November 2022].
32. Chaitkin, M. et al. 2022. Estimating the cost of achieving basic water, sanitation, hygiene, and waste management services in public health-care facilities in the 46 UN designated least-developed countries: a modelling study. The Lancet Global Health 10(6), pp. e840–e849. Available at: http://www.thelancet.com/article/S2214109X22000997/fulltext [Accessed: 14 November 2022].
33. WaterAid 2021. Economic report: unlock trillions of dollars with clean water, decent toilets and hygiene . Available at: https://www.wateraid.org/us/media/economic-report-unlock-trillions-of-dollars-with-clean-water-decent-toilets-and-hygiene#:~:text=Ensuring%20everyone%20has%20a%20toilet,%24420%20billion%20in%20productive%20value. [Accessed: 16 November 2022].
34. WHO 2021. Investing $1 per person per year in hand hygiene could save hundreds of thousands of lives. Available at: https://www.who.int/news/item/15-10-2021-investing-1dollar-per-person-per-year-in-hand-hygiene-could-save-hundreds-of-thousands-of-lives [Accessed: 15 November 2022].
35. Cummings, K.L., Anderson, D.J. and Kaye, K.S. 2010. Hand hygiene noncompliance and the cost of hospital-acquired methicillin-resistant Staphylococcus aureus infection. Infection control and hospital epidemiology 31(4), pp. 357–364. Available at: https://pubmed.ncbi.nlm.nih.gov/20184440/ [Accessed: 15 November 2022].
36. Cawthorn, K.-R., Dean, J. and Cooke, R.P. 2020. The financial impact of improved hand hygiene on healthcare-associated infections in the UK. Canadian Journal of Infection Control 35(3), pp. 117–122. Available at: https://www.ipac-canada.org/photos/custom/CJIC/CJIC_Fall2020_Cawthorne.pdf [Accessed: 15 November 2022].
37. Townsend, J., Greenland, K. and Curtis, V. 2017. Costs of diarrhoea and acute respiratory infection attributable to not handwashing: the cases of India and China. Tropical medicine & international health : TM & IH 22(1), pp. 74–81. Available at: https://pubmed.ncbi.nlm.nih.gov/28043097/ [Accessed: 15 November 2022].
38. Global Handwashing Partnership 2017. Why Handwashing: Economic Impact. Available at: https://globalhandwashing.org/about-handwashing/why-handwashing/economic-impact/ [Accessed: 16 November 2022].
39. Banks, C., Portnoy, A., Moi, F., Boonstoppel, L., Brenzel, L. and Resch, SC. 2021. Cost of vaccine delivery strategies in low- and middle-income countries during the COVID-19 pandemic. Vaccine 39, pp. 5046-5054. Available at: https://pubmed.ncbi.nlm.nih.gov/34325935/ [Accessed: 6 January 2023].

Professor Dr Thomas Szucs, MD, MBA, MPH, LLM, JSD
Director of the European Center of Pharmaceutical Medicine/Institute of Pharmaceutical Medicine
University of Basel, Switzerland
https://ecpm.unibas.ch/institute/who-we-are/team/thomas-szucs

This article is from issue 24 of Health Europa Quarterly. Click here to get your free subscription today.

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