June 5, 2020
By: Julie Truelove and Katie Tobin, WaterAid
As global health donors gather virtually for Gavi’s Global Vaccine Summit on 4 June, hosted by UK Prime Minister Boris Johnson, Julie Truelove and Katie Tobin make the case for why they should be talking about investing now in improving access to hygiene services, and how this should go hand in hand with investing in vaccines.
Hygiene is a first line of defence against COVID-19
While the world waits for a vaccine, we collectively rely on critical measures of prevention to control the transmission of COVID-19 – and to avoid future health crises caused by the disruption of key global health interventions during the pandemic.
One of the most effective methods of disease prevention, hand hygiene is at the core of public health advice from the World Health Organization (WHO). Evidence suggests handwashing with soap can reduce cases of pneumonia by 50% and acute respiratory infection by 16–23%, while reducing risk of endemic diarrhoea by 48%.
Neglecting investment in hygiene undermines health system strengthening
Governments and donors have long neglected to invest adequately in the basics of clean water, soap and decent toilets. Even now, hygiene investment to bolster weak health systems is largely absent from COVID-19 national responses and donor support. (Gavi is a notable exception to this trend, having enabled recipients of its funding to reallocate up to 10% of health system strengthening budgets – including to hygiene and infection, prevention and control – to address the COVID-19 crisis.) We recently called on governments and donors to take seven critical actions to accelerate hygiene investment, including by initiating mass public health information campaigns at nationwide levels, and to urgently increase financial support for hygiene services for communities and frontline health workers.
The pandemic has disrupted public health programmes
Compounding the challenges of minimising the impact of COVID-19 on global health, immunisation services have been delayed or disrupted since the pandemic began, in part to avoid spreading disease at crowded clinics and putting frontline health workers, carers and patients at risk. According to UNICEF, Gavi and WHO, this has put 80 million children under one year of age at risk of vaccine-preventable diseases including measles, diphtheria and polio.
While many countries grapple with restarting immunisation services, the Global Task Force for Cholera Control has emphasised the need for adequate water, sanitation and hygiene (WASH) services as one of six critical steps required to resume preventative oral cholera vaccinations in hotspots.
The case for joint delivery of hygiene and vaccines
To mitigate the long-term impacts of COVID-19 on global public health, joint delivery of hygiene and immunisation services is essential. Because immunisation programmes reach more people than any other health intervention does, they are a crucial entry point to integrate WASH – with particular emphasis on hygiene behaviour change. Hygiene-integrated approaches must become the new normal for vaccine delivery.
Our recent research with SHARE and numerous partners presented the case for integrating WASH and context-specific hygiene behaviour change interventions into immunisation sessions. The research showed potential positive outcomes from this hygiene-integrated model to include:
Global guidance from WHO emphasises that linking prevention and control efforts for diarrhoeal diseases could lead to greater health outcomes compared to results from single interventions, including preventative measures like improved living conditions and WASH. Context-specific planning, budget allocation, implementation and evaluation can establish robust, integrated platforms for hygiene and immunisation.
In Nepal, we worked with the London School of Hygiene and Tropical Medicine (LSHTM) to undertake a scoping study to assess the feasibility of incorporating hygiene behaviour change into the country’s already successful immunisation programme. The intervention improved key hygiene behaviours (related to exclusive breastfeeding, handwashing with soap, food hygiene, faeces management and water and milk treatment) from 2% at baseline assessment to 53% after one year. The project also increased immunisation coverage and led to a 10% decrease in diarrhoea prevalence in those who took part in the pilot.
Based on this successful intervention, the integration of hygiene promotion with routine immunisation will be scaled up to national level with the introduction of a rotavirus vaccine, scheduled for June 2020. Despite the COVID-19 pandemic, massive training programmes for these interactive sessions have already taken place across health offices in Nepal. Watch our short film about the project, below.
‘No regrets’ actions for disease prevention
Investing in hygiene-integrated approaches now is a no regrets action to confront COVID-19, help maintain the essential provision of vaccines, and build resilience against subsequent health crises related to preventable diseases. Building towards longer-term strategies, urgent action must start now, at all levels:
Prioritising investment in hygiene now will ready plans and mechanisms for joint delivery of hygiene and immunisation
Prioritising joint delivery of hygiene and immunisation programming, including critical funding for integrating hygiene with immunisation, is essential to establish a new normal – and particularly vital in this period of vulnerability before a COVID-19 vaccine is universally available. The pandemic has exacerbated inequalities along lines of income, gender, age, location, disability and health status, and these factors of discrimination – which already play out in terms of who has access to clean water and soap and to sanitation – will likely also be manifest in who has access to a vaccine and when.
Supporting the call by UNAIDS, Oxfam and more than 150 world leaders for a People’s Vaccine, we emphasise the need to act now to prevent the continued spread of the pandemic. Prioritising hygiene now will ready national plans and delivery mechanisms across ministries for health, immunisation and WASH; help strengthen critical routine and mass immunisation services with hygiene interventions for the long term; and prepare hygiene-integrated approaches to improve the effectiveness of the eventual roll-out of a COVID-19 vaccine. We hope to hear Gavi and its donors supporting this call when they make their commitment on 4 June.
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