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Water, sanitation, hygiene and waste management for preventing COVID-19 WPRO Region WHO Virtual Training 15 April 2020 Maggie Montgomery (montgomerym@who.int) 3
Latest figures Total global cases: 1.8 million Total global deaths: 117,000 4
WASH important to Global COVID-19 response UN-Wide plan WHO Response Pillar 1: Country-level coordination, planning, and monitoring Pillar 2: Risk communication and community engagement Pillar 3: Surveillance, rapid response teams, and case investigation Pillar 4: Points of entry 12 Pillar 5: National laboratories Pillar 6: Infection prevention and control Pillar 7: Case management Pillar 8: Operational support and logistics
Takeaways Hand hygiene: Frequent and effective hand 1. hygiene - one of the most important prevention measures. Hand hygiene at the right time. Environmental hygiene: Effective inactivation on 2. surfaces can be achieved within 1 minute using common disinfectants Water and sanitation: Existing WHO guidance on 3. the safe management of drinking-water and sanitation services applies to the COVID-19 outbreak. 4. WASH investments: Should be fundamental to all country preparedness and response plans. Co-benefits: Many will be realized through good 5. WASH, including preventing millions of deaths each year caused by other infectious diseases. 6
COVID-19 virus • Enveloped virus, surrounded by weak lipid membrane • Relatively fragile in the environment and will become inactivated much faster than non-enveloped human enteric viruses (e.g. norovirus, rotavirus, hepatitis A virus) Current evidence suggests infectious COVID-19 virus may be • excreted in faeces, regardless of diarrhoea or signs of intestinal infection. Only one study has cultured COVID-19 virus from a single stool specimen • Approximately 2−27% of those with confirmed COVID -19 have diarrhoea and several studies have detected viral RNA fragments in faecal matter of COVID-19 cases Risk of transmission of COVID-19 virus from the faeces of an • infected person appears to be low 7
Survival of human coronaviruses Temp ( O C) Media Time Removal Reference Wang et al, J Virol Methods, 2005 Dechlorinated tap 20 2 days None water surviving Gundy et al Food Environ Virol, 2009 Dechlorinated tap 23 8-12 days 99.9% water Wang et al, J Virol Methods, 2005 Hospital 20 2 days None wastewater surviving Casanova, et al, Water Research, 2009 Settled sewage 25 14 days 99.9% Gundy et al Food Environ Virol, 2009 Wastewater 23 2-4 days 99.9 % Lai, et al., Clinical Infectious Disease, Baby faeces 20 3 hours* None 2005 surviving Lai, et al., Clinical Infectious Disease, Adult faeces 20 1 day None 2005 surviving Lai, et al., Clinical Infectious Disease, Cotton gown 20 5 min- 24 None 2005 hours** surviving Various surfaces Average 20 2 hours-9 days None Kampf, et al., Journal of Hospital Infection, 2020; Dorelman, et al., NEJM, (review of 22 studies surviving 2020 + one study on SARS-CoV-2) *Quicker die off attributed to lower pH in baby feces (pH 6-7). 8 **Quicker die off when there is a lower initial concentration of the virus.
Safely managed water supply Water safety planning Guidelines E.g. boiling, high Water performing ultra or nano filters, solar, treatment UV, or appropriately performance dosed chlorine KEY CONSIDERATIONS • Use water safety plan approach (protection Health from source to consumer) care • Residual chlorine of ≥0.5 mg/l after at least 30 facilities minute of contact time and at pH < 8.0 • Point of use treatment where safe, piped supplies are not available
Safely managed sanitation • Safe management at every point of the sanitation chain; system should be able to meet an increase in demand Important to check safety plumbing (e.g. sealed bathroom • drains, backflow valves on bathroom sprayers and faucets) Staff and patients should have separate toilets; where • possible COVID-19 patients should have their own toilets • Regular cleaning and disinfection of bathrooms and anyone with risk of exposure to excreta should wear PPE Practical, simple wastewater treatment technologies exist • (e.g. septic tank + leach field; waste stabilization pond, burying and covering sludge) WHO (2018) Guidelines on Sanitation and Health https://www.who.int/water_sanitation_health/publications/guidelines-on-sanitation-and-health/en/
Improving hand hygiene in health care facilities Use multi-modal approach (systems change, training, evaluation and feedback, • reminders, and “safety” culture) Critical actions: • • Procurement of adequate quantities of hand hygiene supplies for staff, patients and visitors • Refreshers of hand hygiene training • Refreshers of reminders/communications about its importance to prevent the spread of the COVID-19 virus. 11
Safe health care waste management • Follow regular safe management of waste practices (e.g. segregation, treatment, safe disposal) • Use PPE while handling waste (boots, apron, long- sleeved gown, thick gloves, mask and goggles or face shield) • Waste generated during home care: put in bin and bagged but not labeled “infectious” Non-infectious and Yellow Sharps box recycling containers container (lined) (lined) 12
Cleaning • Follow existing recommendations (e.g. trained staff, SOPs on cleaning technique and materials, cleaning frequency based on risks) • Existing disinfectants are effective (e.g. 70% ethyl alcohol and 0.1% sodium hypochlorite for surfaces and 0.5% sodium hypochlorite for blood/spills) • Studies from Singapore and China indicate recommended cleaning techniques effective for killing COVID-19 virus • Soiled linens should be machine washed (60-90 C) with detergent OR soaked in warm water and detergent followed by 0.5% chlorine 13
WHO Hand Hygiene Campaign and global recommendations • High level advocacy on hand hygiene (HH) • Currently huge gaps in access: • 2 in 5 health care facilities globally lack hand Public handwashing station in hygiene at point of care Indonesia • 3 billion individuals, globally, without basic hand hygiene facilities at home • Only half of schools globally have hand washing facilities with soap and water • WHO recommends obligatory HH in front of all public buildings, transit hubs, etc. under leadership of public health authorities 12 • Maintenance and use should be supported by ABHR at grocery store in Geneva building manager/transport provider, civil society/NGO or private sector
Hand hygiene facility options • Ideal materials (in order of effectiveness) Water and soap or ABHR Ash or mud Water alone • Water does not need to be drinking-water quality • Water quantity: 0.5-2 l/person • Local breweries, pharmacies, etc. encouraged to make ABHR (examples from Switzlerand, US) Soapy water HH station • Design considerations: in Cox’s Bazaar Tap can be turned off with arm or foot Size and quantity appropriate for type & number of users Grey water should be captured and emptied Easy to repair and parts can be sourcedlocally 12 • Hygiene promoters should be considered «essential service providers» given free movement and neccessary protection
What you can do? • Advocate for inclusion of WASH in country COVID-19 plans (WASH in HCF, WASH in schools, hand hygiene in public settings, WASH service providers as «essential» • Make rapid WASH improvements in health care facilities, especially where COVID-19 patients are/will be treated • Strengthen support to water and sanitation workers and hygiene promoters (protective gear, training, hand hygiene at work and home) • Install hand hygiene facilities and make use obligatory • Ensure water and sanitation providers have back-up supplies and contingency plans for disinfection chemicals, fecal 12 indicator and chlorine testing equipment
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