"Handwashing - Are we ready?" by Adriel Chen and Steve Cunningham

Reflecting on encouraging handwashing as a public health measure.

Dr Adriel Chen and Steve Cunningham 

Handwash
Handwashing by Melissa Jeanty from Unsplash.

As the United Kingdom emerges from a prolonged lockdown to protect citizens from Covid-19, a key focus is on maintaining a low R rate by limiting exposure to cross infection in public spaces. As with other public health messages in this pandemic there is an onus on individual responsibility to limit risk of infection and the principle method to achieve this is communicated as the need for regular and fastidious hand hygiene. The World Health Organisation (WHO), UK Government and other public health bodies have the same recommendation; to wash hands regularly and to use appropriate (minimum 70% alcohol) hand sanitiser at other times(1,2).

These simple messages have resonated with the public, but as lockdown begins to ease, the practicalities of instituting these measures across society at the available frequency to be effective require improved guidance and practical solutions. Although the WHO recommends that member states “provide universal access to public hand hygiene stations”(3), the UK currently has no clear recommendations on the frequency, availability, and the responsibility of providing hand hygiene stations in public spaces(4). An onus has been placed on business owners and service providers to provide hand hygiene facilities for public use, but without a corresponding partnership by government to enable hand hygiene in non-business spaces. 

The first component of hand hygiene, to wash hands, is virtually impossible for most of the UK population outside the family home. Where public washrooms are available they most often are not touch free to enter and exit (negating the hand washing episode). Countries with experience of significant infectious disease epidemics look to resolve this by making available hand washing stations in public spaces, with widely available wash basins, innovative touch free taps and good adoption by local communities(5–8). This experience, mostly from countries in Africa, could provide templates for the UK to enable temporary hand washing areas in public spaces in city centres, shopping malls and public parks. Public handwashing stations could also provide visual reminders that this is not normal, but a ‘new normal’(5).

The second component of hand hygiene, to use hand sanitiser, is suggested to be used where hand washing is not available. In practice (as above) that is outside the family home for many. Hand sanitiser at an appropriate alcohol strength is expensive (with evidence of rampant price inflation in many markets) and so is unaffordable by many in society, particularly those now demonstrated to be most at risk of Covid-19,

In the UK the onus has been on business and councils to develop strategy, mostly orientated around the availability of hand sanitiser, however, other governments in developed nations have provided more directive policy with regard to making available hand washing where possible. Danish schools focus on handwashing every two hours, with handwashing stations installed outside school buildings(9–11). This is paired with enforced breaks for handwashing, with no emphasis on mask-wearing among students and teachers.  Singapore also supports public handwashing stations as an addition to policy on hand sanitiser use(12–14). Businesses and schools have been instructed to provide hand sanitiser at entrances and in every room, and to regularly clean surfaces with high contact frequency. Students are required to wash their hands before leaving classrooms, and cleaning supplies have been provided in each classroom for students to wipe down surfaces such as desks before they leave. This emphasis on hand hygiene and sanitation extends to physical exercise classes, with students being asked to wipe down equipment before returning them(15). New Zealand supports handwashing in workplaces and schools with clear guidance and instruction(16). Schools and workplaces, including offices, are required to provide facilities for everyone on site to regularly wash their hands. Where this is not feasible, for example entrances to buildings, hand sanitiser has been recommended(17).

So as lockdown eases, we should encourage and enable a more equitable safe socialisation for all in society. This is of particular relevance to those who to date have had an unequal experience, and includes amongst others, people living in sheltered housing and families living in flats with children.

To control the spread of coronavirus, the pillars of good hygiene will have to be enforced and reiterated. Wash hands frequently and with soap, for at least 20 seconds. Avoid touching your face and wear a mask if you have been advised to do so. Good habits should be encouraged and barriers to hand hygiene should be reduced. To enable all in society to be able to deliver their individual responsibility to this aim, public hand washing facilities should be made commonly available at speed and scale. This would be ineffective without good hand washing technique- more information needs to be produced and provided to guide the public.

Learning from success- New Zealand has been championed as a model for successful intervention. A 4-level threat system was developed, with Level 3 (2nd highest) allowing for the reopening of schools and small businesses(18). Clear guidelines for schools have been established mandating the availability of hand washing stations or hand sanitiser in every occupied room. Businesses have also received clear guidance to provide hand sanitiser to customers and staff(19). Australia has also championed a similar approach, recommending the availability of hand hygiene facilities across various industries including restaurants, film, and white-collar office workers.

Rapid review of handwashing efforts across selected countries

Denmark

Hand washing every 2 hours in schools. Facilities available – hand washing stations installed outside every school. Hand washing enforced with regular breaks for students and staff to wash hands

New Zealand

The country has a 4-tier threat level system. Level 3 (2nd highest) allows for reopening of schools and small businesses.

All classrooms or every occupied room and nurseries must have hand sanitiser available. All students encouraged to wash hands frequently.

All businesses must provide hand washing facilities to customers and staff. If this is not possible (for example, at building entrances) they are to supply hand sanitiser instead.

Australia

Extensive guidelines for various industries including ensuring all camera operators are equipped with personal hand sanitiser. Disinfectant wipes around printers, doors, cupboard handles for all workplaces

Singapore

Singapore has clear guidance on good cleaning and sanitation practices. Cleaning agents (e.g. liquid soap, toilet paper) must be available at all toilets and hand-wash stations. Disinfecting agents (e.g. hand sanitisers) must be installed at all human traffic stoppage points within the workplace, such as entrances, reception areas, security booths and lift lobbies. Disinfecting agents (e.g. disinfectant sprays, paper towels and wipes) must be provided at meeting rooms and other common spaces such as pantries or canteens. Students required to wear masks. Businesses are required to wipe down high-contact surfaces, such as door handles, tables, elevator buttons. SG clean campaign launched with the aim to find and fix hygiene gaps e.g. inadequate or missing soap/lotion, ensure handwashing in hawker centres, public areas, schools, and manage the overall availability of hand washing facilities and sanitiser.

South Korea

Clear guidance from government on reopening. Workplaces required to provide and distribute hand hygiene products/facilities.

West Africa

Hand washing still possible through public health interventions and ingenuity. In West Africa, public health officials organised a network of public hand-washing stations in 2014. This was redeployed for the coronavirus pandemic.

Ethiopia

Government provided free masks, soap, and hand sanitiser to public. Paired with campaigns to encourage hand washing and public education on good hand-washing technique.

Rwanda

Hand washing facilities are  widely available. Public health authorities have deployed portable wash sinks at banks, shops, restaurants, and bars. No-touch wash sinks use minimal water and is user operated with a foot switch.

Lesotho

Simple hand washing stations designed and rolled out to public; this was NGO-led.

Zimbabwe

Introduction of hands-free taps (Tippy Tap). These can be made with minimal equipment. The design is easily reproduced and widely shared. This system is highly efficient and uses about 40ml per wash.

 

Recommendations for the UK

Good policy should be followed up with comprehensive implementation. Clear and specific guidance should be considered (as of time of writing clear guidance is now being issued by the UK Government). Following this local authorities and businesses should increase the availability of hand sanitiser and hand washing stations in public spaces. Public education regarding hand hygiene and encouraging hand washing should be implemented.

 

References

  1. WHO. Coronavirus [Internet]. 2020 [cited 2020 Jun 7]. Available from: https://www.who.int/health-topics/coronavirus#tab=tab_1

  2. BBC. PM on coronavirus: “Wash your hands” - BBC News [Internet]. 2020 [cited 2020 Jun 7]. Available from: https://www.bbc.co.uk/news/av/uk-politics-51682581/boris-johnson-advises-people-to-wash-hands-to-avoid-coronavirus

  3. World Health Organisation. Recommendations to Member States to improve hand hygiene practices to help prevent the transmission of the COVID-19 virus [Internet]. 2020 [cited 2020 Jun 7]. Available from: https://www.who.int/publications/i/item/recommendations-to-member-states-to-improve-hand-hygiene-practices-to-help-prevent-the-transmission-of-the-covid-19-virus

  4. Guidance for food businesses on coronavirus (COVID-19) - GOV.UK [Internet]. Department for Environment Food and Rural Affairs,. [cited 2020 Jun 27]. Available from: https://www.gov.uk/government/publications/covid-19-guidance-for-food-businesses/guidance-for-food-businesses-on-coronavirus-covid-19

  5. Gharib M. How Do You Wash Your Hands To Fend Off Coronavirus If Water Is Scarce? [Internet]. NPR. 2020 [cited 2020 Jun 19]. Available from: https://www.npr.org/sections/goatsandsoda/2020/03/30/819151076/how-do-you-wash-your-hands-to-fend-off-coronavirus-if-water-is-scarce

  6. Berting N. Innovative Handwashing Stations Pop Up Across Africa [Internet]. What Design Can Do. 2020 [cited 2020 Jun 19]. Available from: https://www.whatdesigncando.com/stories/hand-washing-stations-africa/

  7. Pilling D. Africa’s Covid-19 response is a glimpse of how things could be different [Internet]. Financial Times. 2020 [cited 2020 Jun 19]. Available from: https://www.ft.com/content/124dd4f4-8a0b-11ea-9dcb-fe6871f4145a

  8. Uwiringiyimana C. Rwanda keeping coronavirus at bay with campaign of public handwashing [Internet]. Reuters. 2020 [cited 2020 Jun 19]. Available from: https://uk.reuters.com/article/uk-health-coronavirus-rwanda/rwanda-keeping-coronavirus-at-bay-with-campaign-of-public-handwashing-idUKKBN20Y2SL

  9. Mulvahill E. Denmark Is Reopening Schools. Here’s What it Looks Like. [Internet]. weareteachers.com. 2020 [cited 2020 Jun 19]. Available from: https://www.weareteachers.com/denmark-reopening-schools/

  10. Dandanell N, Pancevski B. Where Schools Reopen, Distancing and Disinfectant Are the New Coronavirus Routine [Internet]. Wall Street Journal. [cited 2020 Jun 19]. Available from: https://www.wsj.com/articles/where-schools-reopen-distancing-and-disinfectant-are-the-new-coronavirus-routine-11586971911

  11. Knudson A. Schools begin to reopen around the world: Here’s a peek inside [Internet]. silive.com. 2020 [cited 2020 Jun 19]. Available from: https://www.silive.com/coronavirus/2020/05/schools-begin-to-reopen-around-the-world-heres-a-peek-inside.html

  12. NEA Singapore. Good Cleaning & Sanitation Practices [Internet]. Singapore; 2020 [cited 2020 Jun 19]. Available from: https://www.sfa.gov.sg/docs/default-source/our-services/good-cleaning-and-sanitation-practices_english-compressed.pdf

  13. Requirements for Safe Management Measures at the Workplace [Internet]. Singapore; 2020 [cited 2020 Jun 19]. Available from: https://www.mom.gov.sg/covid-19/requirements-for-safe-management-measures

  14. NEA Singapore. “SG Clean” Campaign Launched To Rally Public And Businesses To Work Together To Keep Singapore Clean [Internet]. 2020 [cited 2020 Jun 19]. Available from: https://www.nea.gov.sg/media/news/news/index/sg-clean-campaign-launched-to-rally-public-and-businesses-to-work-together-to-keep-singapore-clean

  15. Back to School Measures to safeguard students [Internet]. [cited 2020 Jun 30]. Available from: https://www.schoolbag.sg/story/back-to-school-measures-to-safeguard-students

  16. Ministry of Education NZ. COVID-19 guidance for early learning services at Alert Level 3 [Internet]. 2020 [cited 2020 Jun 8]. Available from: https://covid19.govt.nz/alert-system/alert-level-3/#education

  17. Guidelines for businesses and services at Alert Level 1 | Ministry of Health NZ [Internet]. [cited 2020 Jul 1]. Available from: https://www.health.govt.nz/our-work/diseases-and-conditions/covid-19-novel-coronavirus/covid-19-information-specific-audiences/guidelines-businesses-and-services-alert-level-1

  18. New Zealand COVID-19 Alert Levels [Internet]. Wellington; 2020 [cited 2020 Jun 8]. Available from: https://www.mpp.govt.nz/assets/Uploads/COVID-Alert-levels-v2.pdf

  19. COVID-19 and food safety in Alert Level 3 [Internet]. 2020 [cited 2020 Jun 8]. Available from: https://web.archive.org/web/20200426152926/https://www.mpi.govt.nz/protection-and-response/coronavirus/coronavirus-and-food-safety/covid-19-and-food-safety-in-alert-level-3/

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