Water, sanitation and hygiene interventions to reduce healthcare-associated infections among mothers and neonates in low- and middle-income countries

Klein, Eili and Megiddo, Itamar and Tseng, Katie and Galato, Oliver and Laxminarayan, Ramanan (2019) Water, sanitation and hygiene interventions to reduce healthcare-associated infections among mothers and neonates in low- and middle-income countries. In: The annual spring conference for The Society for Healthcare Epidemiology of America (SHEA), 2019-04-24 - 2019-04-26.

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Abstract

Background: Despite global improvements in water, sanitation and hygiene (WASH), many healthcare facilities in low- and middle-income countries still lack access to basic WASH services, which threatens patient safety by reducing the capacity to effectively conduct infection prevention and control (IPC) leading to the spread of healthcare-associated infections (HAIs). This is particularly important for pregnant women and neonates, who are especially vulnerable to infection. Though the percentage of institutional births has been increasing in LMICs, gaps remain in understanding the impact and cost-effectiveness of WASH interventions on HAI morbidity and mortality among mothers and neonates in LMICs. Methods: We developed a representative model of the Indian healthcare system, and estimated the impact, cost, and cost-effectiveness of improving WASH in healthcare facilities in India. We analyzed five scenarios: (1) increased access to water in facilities below standard; (2) improved sanitation in facilities below standard; (3) increased IPC due to increased water; (4) increased IPC through non-water-based efforts; and (5) limited increase in hand-hygiene IPC only. Effectiveness was measured as the change in HAI cases and deaths, as a result of interventions. HAIs in the analysis were restricted to bacterial infections not directly caused by unclean water. Cost-effectiveness was measured as the cost per death averted over a 5-year-period. Results: There are an estimated 6,000 deaths in pregnant mothers and nearly 50,000 neonatal deaths in India due to HAIs annually. Investments in improving water access and sanitation (scenarios 1 & 2) had only a limited impact on HAI mortality (Figure 1). However, increases in water-based IPC significantly reduced HAI deaths across all facilities and settings, though the impact was greater in rural areas where water is currently less available and IPC compliance is typically lower. Non-water based IPC was also effective in reducing the impact of HAIs, however was generally less cost-effective (Figure 2). Conclusions: We found that improvements in water quality and accessibility can aid in reducing mortality caused by HAIs, governments and healthcare facilities. However, the effectiveness and cost-effectiveness of these improvements to reduce HAIs are limited unless paired with improvements in IPC. While non-water based IPC activities were effective, improving access to clean water would have additional impacts through reductions in direct infections making them likely to be far more cost-effective. As LMICs continue to grow economically, prioritizing these types of infrastructure projects can have large benefits both directly through reductions in diarrheal disease and indirectly through reductions in HAIs.

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