Global access to handwashing: implications for COVID-19 control in low-income countries

  1. Michael Brauer
  2. Jeff T Zhao
  3. Fiona B Bennitt
  4. Jeffrey D Stanaway

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Abstract

Background

Low-income countries have reduced health care system capacity and are therefore at risk of substantially higher COVID-19 case fatality rates than those currently seen in high-income countries. Handwashing is a key component of guidance to reduce transmission of the SARS-CoV-2 virus, responsible for the COVID-19 pandemic. Prior systematic reviews have indicated the effectiveness of handwashing to reduce transmission of respiratory viruses. In low-income countries, reduction of transmission is of paramount importance but social distancing is challenged by high population densities and access to handwashing facilities with soap and water is limited.

Objectives

To estimate global access to handwashing with soap and water to inform use of handwashing in the prevention of COVID-19 transmission.

Methods

We utilized observational surveys and spatiotemporal Gaussian process regression modeling in the context of the Global Burden of Diseases, Injuries, and Risk Factors Study, to estimate access to a handwashing station with available soap and water for 1062 locations from 1990 to 2019.

Results

Despite overall improvements from 1990 (33.6% [95% uncertainty interval 31.5–35.6] without access) to 2019, globally in 2019, 2.02 (1.91–2.14) billion people—26.1% (24.7–27.7) of the global population lacked access to handwashing with available soap and water. More than 50% of the population in sub-Saharan Africa and Oceania were without access to handwashing in 2019, while in eight countries, more 50 million or more persons lacked access.

Discussion

For populations without handwashing access, immediate improvements in access or alternative strategies are urgently needed, while disparities in handwashing access should be incorporated into COVID-19 forecasting models when applied to low-income countries.

Funding

Bill & Melinda Gates Foundation. MB was supported in part by the Pathways to Equitable Healthy Cities grant from the Wellcome Trust.

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  1. ScreenIT

    SciScore for 10.1101/2020.04.07.20057117: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board Statementnot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    No key resources detected.

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    As in most global-scale analyses, these estimates include several limitations. Most importantly, while we developed comprehensive global estimates, a number of potential sources from 2000 to 2005 reported a soap indicator which included “other handwashing agents” such as ash, sand, or soil and therefore did not meet JMP’s definition for basic hygiene (The WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene (JMP)). This considerable limitation is reflected in the uncertainty in national-level estimates. These national level estimates are based on recently available survey data; however, the year of the most recent survey varies by location, also contributing to uncertainty. While our spatiotemporal model estimates incorporate trends to estimate access in 2019, the most recent source input data may have been from earlier years (Excel File S1, Excel File S2). Similarly, estimates for years prior to 2008 were derived from the ST-GPR model and not from survey inputs. This is reflected in uncertainty intervals (Figures S22-S29). Further, our estimates likely do not reflect recent disruptive events such as conflict, large-scale migration, or natural disasters. These events are likely to increase the number of people living without access to handwashing and also to increase the number of people living in densely populated settings where social distancing is also challenged. As the input data sources are based on snapshot observations, they also do not refle...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

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  2. Version published to 10.1101/2020.04.07.20057117v2 on medRxiv
  3. Version published to 10.1289/ehp7200
  4. Version published to 10.1101/2020.04.07.20057117v1 on medRxiv