No regrets: integrating hygiene and immunisation on the frontlines of disease prevention 

7 min read
Lennie N'guni, 60, administers an anti-diarrhoea vaccine to baby Collins held by his mother Virginia Milimo 18, at Mwanza Clinic in Monze District, Zambia, January 2018.
Image: WaterAid/ PATH/ Chileshe Chanda

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:

  • Improving cost effectiveness and operational efficiency – an important factor in resource-constrained settings for both service providers and to reduce time demands for service users across vital health services.
  • Reaching underserved populations to support them to attend and complete immunisation sessions, increase trust in health services and engage in hygiene behaviour change practice.
  • Synergistic effects of increasing demand for and uptake of immunisation and other child health services, while increasing success of child caring behaviours such as exclusive breastfeeding and food hygiene.
  • Potential for improved vaccine performance, based on emerging evidence that supports the biological plausibility that improved hygiene, sanitation, clean water and soap could increase oral vaccine performance through improved gut health – a key area for further research.

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:

Local actions:

  • Ensure every immunisation clinic has basic handwashing facilities with water and soap, accessible to all staff and patients.
  • Build on a ‘do no harm' approach to actively promote hygiene and handwashing through immunisation platforms, clinics and with clinic staff through visual cues and behaviour nudges, alongside radio, music and mobile messaging platforms.
  • Accelerate development of context-specific integrated intervention packages, drawing on national guidelines and hygiene behaviour change science.
  • Initiate training of frontline health workers for integrating hygiene and immunisation.

National actions:

  • Ministries of health and related line ministries for WASH and social development should actively promote hygiene behaviours embedded with immunisation communications.
  • Include in health and immunisation budgets ringfenced funding for immediate improvements to handwashing and hygiene practices for immunisation clinics.
  • Make best use of Gavi’s flexibility to reallocate up to 10% of health system strengthening funding to prioritise hygiene integration and infection, prevention and control training.
  • Accelerate collaboration across sectors to develop national guidelines and action plans for hygiene-integrated approaches for immunisation, including readiness plans for launch of a COVID-19 vaccine.

Global actions:

  • Key allies for immunisation and WASH should champion a hygiene-integrated approach to immunisation as a ‘no regrets' action for global health.
  • Donors to Gavi should voice support for a hygiene-integrated approach to immunisation, and amplify Gavi’s flexibility to reallocate up to 10% of existing health system strengthening funding to prioritise investment in hygiene integration, hand in hand with immunisation, as a critical preventative measure in the COVID-19 response.
  • Accelerate actionable global guidance on integration of hygiene and immunisation, on the basis of existing evidence and ‘no regrets’ actions for hygiene and handwashing, to inform Gavi’s health system strengthening strategy.
A female health volunteer conducting a hygiene session in front of a group of parents and children who have come for immunisations to District Hospital Khalanga, Jajarkot, Nepal.
A hygiene-integrated immunisation approach: a female health volunteer conducts a hygiene session with parents and children who have come to the district hospital for immunisations. Jajarkot, Nepal.
Image: WaterAid/ Mani Karmacharya

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.

Julie Truelove is Senior Policy Analyst for Health and Hygiene at WaterAid UK. She tweets as @JulieTruelove. Katie Tobin is Advocacy Coordinator at WaterAid. She tweets as @travelingKT.