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. 2023 May 15;109(1):191-200.
doi: 10.4269/ajtmh.22-0554. Print 2023 Jul 5.

Improving Access to WHO Formulations of Alcohol-Based Hand Rub in Healthcare Facilities: A District-Wide Approach

Fred Tusabe  1 , Judith Nanyondo  1 , Matthew J Lozier  2 , Maureen Kesande  1 , Olive Tumuhairwe  3 , Martin Watsisi  4 , Fred Twinomugisha  5 , Alexandra Medley  2 , Julius Mutoro  6 , Mohammed Lamorde  1 , David Berendes  2
Affiliations

Improving Access to WHO Formulations of Alcohol-Based Hand Rub in Healthcare Facilities: A District-Wide Approach

Fred Tusabe et al. Am J Trop Med Hyg. .

Abstract

Alcohol-based hand rub (ABHR) is an effective hand hygiene measure to mitigate and prevent infectious disease transmission in healthcare facilities (HCFs); however, availability and affordability in low- and middle-income countries are limited. We sought to establish centralized local production of ABHR using a district-wide approach to increase provider access at all public HCFs in Kabarole and Kasese Districts in Western Uganda. Partner organizations worked with district governments to adapt and implement the WHO protocol for local ABHR production at the district scale. These groups identified and upgraded sites for ABHR production and storage to ensure recommended security, ventilation, and air conditioning. District governments selected technicians for training on ABHR production. Raw materials were sourced within Uganda. Alcohol-based hand rub underwent internal quality control by the production officer and external quality control (EQC) by a trained district health inspector before distribution to HCFs. We assessed ABHR production and demand from March 2019 to December 2020. All ABHR batches (N = 316) met protocol standards (alcohol concentration: 75.0-85.0%) with a mean of 79.9% (range: 78.5-80.5%). Internal quality control measurements (mean alcohol concentration: 80.0%, range: 79.5-81.0%) matched EQC measurements (mean: 79.8%, range: 78.0-80.0%). Production units supplied ABHR to 127 HCFs in Kasese District (100%) and 31 HCFs in Kabarole District (56%); 94% of HCFs were small (dispensary or next higher level). This district-wide production met quality standards and supplied ABHR to many HCFs where facility-level production would be unfeasible. Low- and middle-income countries may consider district models to expand ABHR production and supply to smaller HCFs.

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Figures

Figure 1.
Figure 1.
Map of Uganda showing districts with alcohol-based hand rub production units. IDI = Infectious Diseases Institute at Makerere University.
Figure 2.
Figure 2.
Alcohol-based hand rub (ABHR) quality check, packaging, and management at healthcare facilities (HCFs). (A) ABHR quality check. (B) Packaging and quarantining for 72 hours before use. (C) ABHR management at HCFs.
Figure 3.
Figure 3.
Total locally produced alcohol-based hand rub (ABHR) (L) distributed to healthcare facilities (HCFs) in Kabarole between February 2019 and December 2020. The number of HCFs receiving locally produced ABHR varied over time due to the ongoing efficacy trial and different phases of the project. From February to June 2019, 5 HC IIs, 9 HC IIIs, and 1 HC IV received ABHR that was locally produced (approximately half of the facilities due to the phase 1 design). Prior to the efficacy trial in late 2018, WHO distributed 10 L of commercially produced ABHR to all HCFs in response to Ebola outbreak concerns. From July to September 2019, 7 HC IIs, 7 HC IIIs, and 1 HC IV received locally produced ABHR (the other half of facilities due to the phase 1 design). In June 2019, the project team and local government worked to redistribute the remaining commercial ABHR to the 5 HC IIs, 9 HC IIIs, and 1 HC IV that previously received, locally produced ABHR; this redistribution ensured that ABHR—locally produced for those designated to receive it, or commercially made and previously distributed—was available for all HCFs in Kabarole District for the second half of 2019. From October 2019 to December 2020 (end of phase 1, all of phase 1a), 12 HC IIs, 16 HC IIIs, and 2 HC IVs received locally produced ABHR. One hospital received locally produced ABHR from January to December 2020.
Figure 4.
Figure 4.
Total alcohol-based hand rub (ABHR) (L) distributed to healthcare facilities in Kasese District between January and December 2020 (phase 2).
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