Abstract:
Good sanitation and hygiene have been recommended as an effective response in managing and controlling transmission of Coronavirus disease (COVID-19). Adherence to given recommendations reduces the transmission rate and lowers overall infections and number of cases in a disease. Hand washing has been identified to be one of the key measures that will help in combating COVID-19. Hand washing as a control measure should be practiced using clean water and soap to protect from contracting other infections. Hand sanitizing with alcohol-based hand sanitizers have also been shown to have activity against Coronavirus.
Fecal matter have been found to harbor coronavirus particles which presents a probable risk of oral-fecal transmission thus need to adopt good sanitation measures. Proper sewage disposal, use of latrines and toilets is a principal measure in this case just as was advanced in the fight against cholera disease[1].
To ensure compliance with these techniques, access to clean water, soap and sanitizers where necessary coupled with good fecal waste handling & disposal will be critical in the fight against COVID-19.
In this paper, we review literature sources on infection prevention and control in line with the recommended practices and emerging evidence with regard to COVID-19 to advocate for IPC in the wake of this disease to flatten the curve of transmission.
Key words: Hand hygiene, Water Sanitation and Hygiene (WASH), Infection Prevention and Control.
Background
Coronavirus disease (COVID-19) is spread through respiratory droplets from an infected person to an uninfected person when he/she coughs or sneezes either through inhalation or when the virus particles land on surfaces and are picked up by individuals who then introduce them into their bodies. Good sanitation and hygienic practices are expected to prevent the spread of the infection by either preventing release of these respiratory droplets into the air and also prevent introduction into the body from surfaces.
The disease may also be transmissible through fecal matter even though there still isn’t any evidence to this effect. The risk is based on findings of viral particles in feces of individuals suffering from COVID-19[2]. Additionally, 2-10% of COVID-19 patients have been found to present with diarrhea which is attributed to gastrointestinal tract (GIT) effects of the virus i.e. interaction with angiotensin converting enzyme type 2 receptors (ACE2) in the GIT[3]. The World Health Organization (WHO) have recommended reliable access/provision of safe water, sanitation and hygiene as essential towards preventing infectious disease outbreaks including COVID-19.[4]
Hand washing
Hand washing is very important to minimize the spread of the respiratory droplets harboring coronavirus particles thus minimizing spread of the virus. Hands should be washed with clean water and soap for about 40-60 seconds[5]. Hands should be washed in accordance with the recommended guidelines paying attention to the folds of the hands and even the nails and be frequently within a day. The WHO also recommends that hand washing be done prior to donning on personal protective equipment (PPE) e.g. masks, after pitting on, when changing gloves, after contact with any person suspected of or having COVID-19, after contact with respiratory secretions, human waste, before eating, after eating and after using the toilet.[6]
Hand washing using clean water and soap is the most ideal method of maintaining hand hygiene. Clean water should thus be made accessible to every person worldwide and within reach of the elderly, the disabled and children. Studies have shown that strategically positioning water facilities where they can be seen improves on their use[7]. Hand washing facilities should be placed in health facilities for easy access and use by frontline healthcare workers as they are more exposed at this point in time. A systemic review of research in workplaces in 2018 found that simple provision of hand hygiene products accompanies with education on appropriate use led to better compliance to hand hygiene measures[8]. Written signs, towel and automatic soap dispensers were also found to improve hand washing practices.
Ensuring access to these facilities to individuals at their convenience should be a priority at this time when we are putting to place interventions to curtail the spread of COVID-19. If people cannot access these facilities, they will not be able to practice hand hygiene which puts everyone at risk. This is regardless of how clear our communication and advice with regard to hand hygiene is.
Use of hand sanitizers
Use of hand sanitizers as an alternative to hand washing have been advocated for. In this context, the guidelines are specific on use of alcohol-based sanitizers which have activity against coronaviruses. They are recommended when it is not feasible to wash hands. It’s recommended that hand rubbing with sanitizers be done for 20 -30 seconds and should involve all parts of the hand just like hand washing. In the event that an alcohol based hand sanitizer is not available, chlorinated water of about 0.05% can be used however this should be a last resort because of its potential harm to in individuals[9].
Hand sanitizers have become affordable and easily accessible during this period and people tend to prefer them. They are easy to carry and use at any instant. They can be carried by children, adults and even the elderly. Just like hand washing, placing sanitizers at places where they can easily be seen in hospitals or work places and even at the streets increases their use[8].
Access and Affordability of Clean Water and Sanitizers in Kenya
The right to clean water is recognized as being essential for full enjoyment of human rights and for prevention of spread of the COVID-19 disease. Kenya has a population of 47.5 million people and about 60 percent of its urban population live in informal settlements. This population are accustomed to intermittent supply of clean running water. In these settlements, water is sold which in most accounts is expensive making this a hurdle in the response to COVID-19. For example the price of piped water in Nairobi is about 53 shillings per cubic meter compared to 10-50 Kenyan shillings for a 20 liter jerry can in informal settlements[10].
The country is currently experiencing heavy rainfalls accompanied with flooding which have led to loss of lives, swept homes away and presents a further risk of contracting water borne diseases. To those affected protecting themselves from COVID-19 is a secondary concern after meeting their basic needs which is now close to impossible. With flooding surface run-off carries waste and probable pathogens towards water bodies and with poor water treatment facilities the risk is compounded to those who depend on springs and surface water for their domestic use. Additionally, the government have persistently called on the affected families to relocate with little consideration that they may not have the means to or even a place to relocate to at this time.
Sanitizers on the other hand have to be accessible, affordable and of the right quality as a standard requirement to be allowed for trade. These are measures that should be enforced by Kenya Bureau of Statistics (KEBS) and the Pharmacy and Poisons Board (PPB). A 100ml bottle of hand sanitizer currently retails at Kshs. 250 while 500ml bottle goes for Kshs. 1000. A recent study by IPSOS Public Affairs indicates that nearly half of Kenyan households earn less than Kshs. 1000 per month while 2 percent have no income[11]. This translates to clear unaffordability of these sanitizers which makes it irresponsible to major on advising individuals to use facilities they cannot afford. Compounded on the economic downturn in the wake of this disease such a directive is totally inconsiderate.
Quality standards of the sanitizers currently in the market is a concern especially as the sale of sanitizers presents an easy opportunity to cash in on in the wake of layoffs coupled with longstanding poverty and unemployment. This exposes the public to sub-standard products which gives them a false sense of protection and may even lead to skin complications such as allergic dermatitis depending on the constitution of the product. There is need to tighten regulations and ensure all those involved in production of such products are meeting the standards as specified. Standardizing prices for hand sanitizers will protect willing and able users from exploitation from unscrupulous business people.
Fecal waste management
Feces have been found to contain coronavirus particles which presents a probable route of transmission. This is a risk to communities with poor fecal habits as well as caregivers handling human feces. It’s therefore important to ensure proper sanitation and fecal waste management measures are put in place as a precautionary measure at this time considering there hasn’t been any confirmed transmission from feces.
Proper fecal waste management and defecation habits have been proven to be effective in controlling spread of other infections like cholera and typhoid. It’s imperative that we apply these very principles in safeguarding ourselves from potential spread through fecal waste.
Conclusion
Infection prevention and control are the primary mechanisms for averting an epidemic of this magnitude. It’s therefore important to get it right in terms of policies and guidelines as well as the operational support put in place to enable them achieve the desired outcomes. Directives and guidelines must thus be contextualized and be considerate of the target population to which it is intended. Directives backed with science should be matched with improved access to facilities and resources that ensure compliance.
[1] Five Basic Cholera Prevention Steps: https://www.cdc.gov/cholera/preventionsteps.html [2] Holshue ML, DeBolt C, Lindquist S, Lofy KH, Wiesman J, Bruce H, et al. First case of 2019 novel coronavirus in the united states, N Engl J Med 2020. https://www.nejm.org/doi/full/10.1056/NEJMoa2001191 [3] Huang C, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China, Lancet. 2020 https://www.sciencedirect.com/science/article/pii/S0140673620301835 [4] WHO Interim guidance on COVID-19 water, sanitation, hygiene and waste management, 2020. https://apps.who.int/iris/bitstream/handle/10665/331846/WHO-2019-nCoV-IPC_WASH-2020.3-eng.pdf [5] WHO guidelines on hand hygiene in healthcare, Geneva: World Health Organization: 2009: https://www.who.int/gpsc/5may/tppls/9789241597906/en/ [6] Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: https://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected [7] Cure, L., & Van Enk, R. (2015) Effect of hand sanitizer location on hand hygiene compliance :American journal of infection control , 43(9), 917-921: https://doiorg/10106/jajjc201505013 [8] Gould, D, J., et al. Interventions to improve hand hygiene compliance in patient care. Cochrane database of systematic reviews. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005186.pub4/abstract [9] WHO guidelines on hand hygiene in healthcare, Geneva: World Health Organization: 2009 https://www.who.int/gpsc/5may/tppls/9789241597906/en/ [10] United Nations Human Rights Organization Journal on Water in Kenya, February 2020. https://www.ohchr.org/EN/NewsEvents/Pages/COVID19_RighttoWaterKenya.aspx [11] IPSOS Kenya report, 2020. https://www.standardmedia.co.ke/article/2001276202/what-majority-of-kenyan-households-earn-in-a-month
Authors: Ms. Veronica Njambi and Dr. Odhiambo David