Vaccines are vital but they must go hand-in-hand with good hygiene to fight disease

7 min read
Swala Kumari Singh (right) shows a fan displaying five key hygiene behaviours to Chandra Malla (black shawl) during a hygiene session in Jajarkot, Nepal.
Image: WaterAid/Mani Karmacharya

Vaccines are a critical public health tool, but they must be delivered alongside other essential measures to control diseases sustainably and comprehensively. As WaterAid's work with the Government of Nepal shows, combining hygiene behaviour change with routine immunisation is key to tackling the diseases of inequality – and COVID-19.

As we celebrate World Immunisation Week, access to vaccines – particularly COVID-19 vaccines – is at the forefront of global health discussions and an urgent priority for governments around the world. The recent development of a portfolio of effective vaccines against COVID-19, alongside the availability of other routine vaccines for many preventable diseases and illnesses, reminds us of the critical importance of immunisation as a vital public health tool.

Vaccines are one critical tool for disease prevention, but they do not deliver themselves – especially on a global scale. Vaccines require a functioning health system with supply chains, trained healthcare workers, and facilities and spaces to deliver them safely. Critically, no vaccine is 100% effective, and we know from COVID-19 that variants continue to pose new threats.

Vaccines must be delivered alongside other essential public health measures, including water, sanitation and hygiene (WASH), to deliver a comprehensive and sustainable approach to disease control. A strong health system, particularly primary healthcare, is therefore fundamental to delivering essential health services and quality of care. In confronting the pandemic, the World Health Organization’s advice for getting vaccinated against COVID-19 states that the vaccine is only “one part of managing COVID-19, in addition to the main preventative measures” including distancing, frequent handwashing, wearing a mask and opening windows for ventilation.

An opportunity to bring together hygiene and immunisation

The COVID-19 pandemic has highlighted the importance of good hygiene practices, including handwashing with soap, to prevent the spread of infectious diseases. Many other infectious diseases, too, make handwashing with soap one of the best buys in health. Yet two in five households globally do not have adequate handwashing facilities. Even more shockingly, one in three healthcare facilities do not have adequate handwashing amenities where care is provided. This is a critical lack of the basic facilities needed to deliver safe, quality healthcare and prevent the spread of disease in healthcare settings.

Sunita Kharel, a senior auxiliary nurse midwife at Bhumlutaar Health Post, uses a contactless handwashing station in Kavre, Nepal. September 2020.
Sunita Kharel, a senior auxiliary nurse midwife at Bhumlutaar Health Post, uses a contactless handwashing station in Kavre, Nepal. September 2020.
Image: WaterAid/Mani Karmacharya

Almost one year ago, we examined the delivery of immunisation integrated with hygiene as a ‘no regrets’ intervention on the frontlines of the pandemic (PDF). Scaling up hygiene behaviour change and handwashing facilities, alongside water and sanitation services, has never been more urgent – these interventions continue to lag behind as a long-term disease prevention measure. Equally, the COVID-19 pandemic will not be brought under control without equitable access to vaccines.

This is why we fully support the WHO Vaccine Equity Declaration, which urgently calls for the equitable rollout of COVID-19 vaccines, including vaccinations for all healthcare workers, people at greatest risk of contracting COVID-19 and marginalised populations with limited access to health services and resources to practice broader public health measures. This is an important opportunity to bring together the vital services of hygiene and vaccination, using the reach of an established delivery mechanism such as immunisation as an additional entry point to reach everyone, everywhere with WASH.

Joint interventions are proven to enhance cost- and time-effectiveness, reach underserved populations and amplify synergistic impacts. Routine immunisation services also reach more children than any other health intervention. These services can be enhanced to reach children and their caregivers with hygiene interventions too. This not only delivers a comprehensive approach to disease control, but can also strengthen uptake and trust of the immunisation programme.

A way forward: from theory to practice

Although the case for integrating hygiene and immunisation systems is strong, there are relatively few examples globally where this has been done, and at scale. An exception is the Government of Nepal’s innovative work, which has led the way in integrating hygiene interventions and routine immunisation – first introduced with the rotavirus vaccine and now being adapted to the roll out of the COVID-19 vaccine.

The experience of WaterAid and the Government of Nepal over the past nine years has shown that this integrated approach to hygiene behaviour change within the routine immunisation system is feasible – the Nepali government supported the initiation of a nationwide scale up in early 2020. Integrating with existing government platforms and mechanisms has been highly effective in achieving hygiene results – results that became urgently needed to confront the COVID-19 pandemic. The established model, poised for national scale up at just the right time, has enabled the Government of Nepal and its partners to quickly adapt the approach for the COVID-19 vaccine rollout.

Adapting Nepal’s established routine immunisation model to COVID-19 vaccination

  • A joint creative team made up of public health experts and representatives from Nepal’s National Health Education Information and Communications Centre, Family Welfare Division, from the National Health Training Center, and from WaterAid, designed simple tools for COVID-19 preventative behaviours that could be adapted into existing hygiene behaviour packages during routine immunisation sessions. The tools included 10,000 flipcharts, used by health workers at Expanded Programme on Immunisation (EPI) clinics during hygiene promotion sessions, and 650,000 stickers which were given to mothers and guardians participating in routine immunisation hygiene sessions.
  • As nationwide lockdowns began, it was critical that a ‘do no harm’ principle was adhered to by WaterAid, our partners and all stakeholders. As such, Nepal’s Department of Health Services, Family Welfare Division, enabled the safe delivery of hygiene behaviour change training materials across all 77 districts and 753 local municipalities.
  • Based on the existing integrated platform for routine immunisation and hygiene, COVID-19 preventative hygiene behaviours were included in the vaccination campaign implementation guidelines endorsed by the Ministry of Health and Population, including on vaccination cards.
Materials were developed to remind people about hygiene and other COVID-19 preventative measures at the time of their vaccinations.
Materials were developed to remind people about hygiene and other COVID-19 preventative measures at the time of their vaccinations.
Image: WaterAid

Training for new integrated ways of working

  • WaterAid provided technical support for the training of provincial health officers who, in turn, have trained health workers and vaccinators on COVID-19 preventative measures. As of March 2021, 23,517 local and district health workers have been trained in COVID-19 preventative behaviours, and in ways to integrate hygiene training alongside routine immunisations. They have also delivered monthly hygiene sessions alongside routine immunisation clinics.
  • More than 16,000 immunisation clinics across Nepal have the tools and resources for hygiene behaviour change, inclusive of COVID-19 preventative behaviours, embedded into their hygiene sessions which target 650,000 new mothers and guardians each year.
  • Some 311 contactless handwashing facilities have been constructed at EPI clinics and healthcare facilities in six districts, to promote handwashing behaviours among patients, health workers and staff – in addition to 83,615 soap bars, 40,000 hand sanitizers and 60,000 masks being provided.

The pandemic has highlighted the vulnerabilities of some communities to new and emerging diseases and the resurgence of common childhood diseases when routine immunisation systems are disrupted. Hygiene measures remain the backbone of disease control and preparedness – whether for the COVID-19 pandemic, for diseases of inequality such as cholera that continue to affect marginalised communities, or indeed for the pandemics of the future. Integrating hygiene and immunisation services at this critical time offers a unique opportunity to reimagine delivery mechanisms to maximise the reach and scale of each intervention, strengthen health systems, and improve health outcomes with WASH reaching everyone, everywhere sustainably.


  • Hygiene is a best-buy investment for governments: Preventive behaviours, such as regular handwashing with soap, remain a pillar of public health and building resilience to future disease outbreaks.
  • Comprehensive approaches are needed to prevent diseases and confront outbreaks: New and emerging variants of disease, the efficacy of different vaccines and the inequity in access to vaccines all highlight the importance of continued investment across robust preventive measures, including hygiene.
  • A catalytic moment for WASH: The COVID-19 pandemic has highlighted the critical impact of WASH inequalities, providing a once-in-a-generation opportunity to build momentum on hygiene for health and WASH for all.
  • WASH is critical for ensuring safe settings to deliver vaccinations: It is essential to practice key hygiene behaviours, including handwashing with soap and wearing a mask, when delivery COVID-19 vaccines and for maintaining safe routine immunisation services. Improving WASH in all healthcare settings is critical to the safe delivery of vaccines too.
  • Hygiene is fundamental for health and disease control: Investments in hygiene and WASH in healthcare facilities are critical to deliver a comprehensive approach to health and disease control, protecting frontline health workers and other staff, while strengthening health systems to deliver quality health care on a path to universal health coverage.

Upama Adhikari Tamang is Senior Health and Hygiene Coordinator; Khakindra Bhandari is Team Lead for the Hygiene Promotion through Routine Immunisation Programme; Dhirendra Bhujel is the Senior Project Coordinator, Hygiene Response for the Hygiene and Behaviour Change Coalition, and Julie Truelove is WaterAid's Senior Policy Analyst for Hygiene.

Top image: Swala Kumari Singh (right) shows a fan displaying five key hygiene behaviours to Chandra Malla (black shawl) during a hygiene session in Jajarkot, Nepal.