October 14, 2021
Sign mounted on tree outside local ABHR production facility in Amuru, Uganda that says, “Together we will kick COVID-19 out of Uganda.” Photo credit: IDI
As COVID-19 spread around the world in early 2020, countries – rich and poor – quickly faced a global shortage of hand sanitizer, one of the protective products that contribute to stopping the spread of the disease. However, some healthcare facilities (HCFs) in Uganda did not have to scramble to find hand sanitizer. With support from CDC, a local partner—the Infectious Diseases Institute (IDI)—was already helping these facilities produce their own low-cost alcohol-based hand rub (ABHR) and providing communications materials to promote good hand hygiene practices.
During the COVID-19 pandemic, keeping hands clean is essential to help prevent the virus that causes COVID-19 from spreading. This is particularly important for healthcare workers (HCWs), to stop the transfer of germs from one patient to another.
Unless hands are visibly soiled, CDC and the World Health Organization (WHO) recommend using an alcohol-based hand rub instead of soap and water in most medical situations because healthcare workers are more likely to use it than soap and water. Hand rubs are generally less irritating to hands and are effective in the absence of a sink, according to WHO. However, in Uganda, ABHR is expensive and not readily available in poor and hard to reach communities.
Fortunately, a solution was already in place, initiated by a novel study that began in the Kabarole district of southwestern Uganda in 2018. That’s when CDC, IDI, and the International Water and Sanitation Centre (IRC WASH) collaborated to study the benefits of producing ABHR locally, and how it could improve hand hygiene among health workers. Researchers found that hand hygiene was low due to limited access to water and soap, which is why making their own hand sanitizer proved so valuable.
Over the next year, 30 health clinics received hand sanitizer produced at an ABHR production unit at the highest-level community health facility, next to a district hospital.
“We sent two technical staff to the facility to support production, distribution, and coordination of the locally produced hand rub. The technical officer, from our partner organization IDI, was responsible for internal quality control and trained district staff handled external quality control,” says Maureen Kesande, the senior Infection Prevention and Control (IPC)/WASH project officer at IDI. “When the alcohol-based hand rub was delivered to each health care facility, we held hand hygiene sensitization meetings with facility management, supported them to set up or re-activate IPC committees, and trained designated staff to monitor use of the hand sanitizer and update stock cards,” says Kesande.
Locally produced alcohol-based hand rub filled in bottles that range from small to medium and large bottles are on display in production facility in Tororo, Uganda. Photo credit: IDI
Just as the ABHR study was reaching its halfway mark, Uganda registered a case of Ebola that crossed into the Kasese district, which borders the Democratic Republic of Congo.
With more support from the CDC’s Global Health Security program and the Division of Foodborne, Waterborne, and Environmental Diseases, IDI expanded the alcohol-based hand rub production model to the Kasese district to support the Ebola prevention and preparedness efforts in December 2019. Here, the team also trained two ABHR producers and set up a production unit at the district health offices which supplied the hand sanitizer to 150 public and government facilities as well as a few high-risk communities.
As a result, when Uganda faced containing the spread of COVID-19, these infection prevention measures were already in place in both the Kabarole and Kasese districts.
“The ABHR project not only increased availability, access, and acceptability of alcohol-based hand rub, it also improved hand hygiene compliance among health care providers—paving the way for the larger, $1.1m CDC/IDI WASH project today,” Kesande says.
She adds that these efforts were such a relief for the districts participating in the study when COVID-19 broke out because there was already a good supply of hand sanitizer available and staff was already trained to continue producing more hand rub.
Another benefit from all these efforts is that many health care workers were already practicing hand hygiene because of infection prevention control mentorship activities.
“Information, education, and communication materials on hand hygiene, which are one of the critical components of COVID-19 prevention and control, were also already in place and they were quickly adapted,” says Kesande.
With COVID-19 now in Uganda, the team extended their project to two border districts—Tororo in the eastern part of the country (bordering Kenya) and Amuru in north western Uganda (bordering South Sudan). These districts were considered high risk areas for seeing more COVID-19 because the neighboring countries had already registered cases. Indeed, a majority of the first confirmed cases in Uganda were truck drivers identified at border crossings.
CDC and its partner IDI are the primary partners for Uganda’s Ministry of Health (MOH) during the COVID-19 response. Fred Tusabe, who is IDI’s ABHR Project Technical Production Officer, says the alcohol-based hand sanitizer project saves MOH and implementing districts a lot of IPC-related costs.
“A liter of commercial sanitizer is about $7. When we produce it locally, we almost cut that price in half—down to about $4,” Tusabe explains.
“We use the WHO standard protocols for local production of ABHR, and efficacy is guaranteed because the quality is monitored and tested before being placed on the shelf.” Not surprisingly, demand for hand sanitizer increased a lot during the COVID-19 pandemic as did the costs for buying ABHR and production supplies, like ethanol.
“The price for a liter of commercial hand sanitizers rose to $54 from $7 before COVID,” Tusabe says. “Our ABHR project could not have been timelier.”
Olive Tumuhairwe, the Kabarole District IPC Focal Person, says the ABHR project has increased their health care workers’ confidence in their ability to respond to disease outbreaks.
“Our health care workers did not panic. COVID-19 found us in a good place,” she says. “The baseline infection prevention control assessment revealed that most of the health care workers had only seen hand sanitizers with bazungu (white) interns who would have them in their pockets before the pandemic.”
When COVID-19 struck, Uganda’s National Medical Stores, which by law are charged with getting, storing and distributing essential medical supplies, started distributing hand rub.
“All we got was 24 liters, which could only serve two big health care facilities for a month,” Tumuhairwe explains. “As such, use of the hand sanitizers was limited to senior health care workers. However, with the ability to now produce their own hand rub, everyone is covered.”
“We have enough stock now,” she adds, noting that they are able to produce 40 liters of hand sanitizer in just 10-20 minutes.
IDI also trained staff in two regional referral hospitals: Jinja and Mubende—and has a model ABHR production unit in Kampala. The project now plans to expand operations into the high risk, hard to reach border districts in the Karamoja region in northeastern Uganda.
“I’m happy that our efforts are helping to strengthen preparedness and response for outbreaks, as it has been with COVID-19,” says Tusabe.
Dr. Amy Boore, who leads CDC’s disease outbreak and emergency response efforts in Uganda commits to continuing support of this model and roll-out of ABHR programs as a key ‘IPC outbreak preparedness package.
“Our CDC technical teams have continued advocating with health leaders to strengthen the model—production and distribution of ABHR—and hope to strengthen it more through the MOH IPC pillar.”
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