WASH Community Programmes Key to Overcome Antimicrobial Resistance in Low and Middle-Income Countries
Sabiha Y. Essack PhD, BPharm, MPharm
Antimicrobial Research Unit, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
Antimicrobial resistance (AMR) is a critical public health challenge, comparable in scale perhaps only to the threat of rapid climate change. Currently claiming the lives of over 700,000 people each year,i AMR is likely to cause millions more deaths with an annual death toll of 10 million predicted by 2050 with 9 million of those deaths forecast to occur in Africa and Asia.ii If urgent steps are not taken to reverse this trend, low- and middle-income countries (LMICs) are set to bear the greater burden of inaction.
At present, 127 countries have developed National Action Plans (NAPs) to tackle AMR.iii These plans focus primarily on the importance of strengthening infection prevention in healthcare settings and have clear infection prevention and control (IPC) strategies but there is insufficient attention to key preventative measures such as sanitation and hygiene. With recent WHO recommendations highlighting the importance of hand hygiene to prevent the spread of the COVID-19 virus as it is primarily transmitted through respiratory droplets or contact, it is clear that hygiene behaviour is vital to combat the high burden of infectious disease.
Antibiotics have never been more vulnerable to drug-resistant bacteria and with rates of resistance to some antibiotic-bacterium combinations rising to 80-90% in some LMICs, urgent attention is now needed for sustained, infection prevention across all settings, both healthcare and in the community, to contain AMR.iv
It is well-recognised too that bacterial species such as extended-spectrum beta-lactamases (ESBL) – producing Enterobacterales initially described in relation to hospital-acquired infections, are now considered to be predominantly circulating in the community and imported into hospitals from the community, rather than vice versa.v Community-acquired ESBL infection is very high even among healthy people, with about 30% carrying ESBL E. coli. A recent study in Nepal also highlighted the significant increase of (ESBL)- and AmpC-β-lactamase-producing enteric pathogens circulating in both hospital and community environments and the need to implement control measures in both settings.vi
A 2019 meeting of international experts on behalf of the Global Hygiene Council, and resulting position paper recently published in the American Journal of Infection Control, further validates the crucial position of hygiene in combatting AMR, demonstrating how an improvement in hygienic practices in the community and home settings, can result in a mirrored reduction in antibiotic prescribing and an associated reduction in selection pressure for the development of resistance. In order to change attitudes towards hygiene in LMICs, a multi-sectoral approach that draws upon evidence from previous behavioural change programmes and interventions, is essential. Further support is also needed for all settings to ensure more rigorous hygiene practices are implemented.
South Africa are currently leading the way with a NAP that specifically addresses community infection prevention and control as one of its key strategic objectives. It recognises that access to clean and safe water, sanitation and hygiene (WASH) services are a critical part of ensuring good hygiene in the community and a reduction in the spread of infectious diseases between humans and between animals and humans. Many aspects of this programme are dealt with under Community-led WASH programmes, with the Integrated School Health Program and directed by community engagement of Community Healthcare Workers. These should be augmented to include AMR.vii
With one out of six health care facilities (16%) globally still having no hygiene serviceviii and the global burden of infectious diseases unevenly tilted towards LMICs, strengthening hygiene and sanitation measures in these countries will be one of the most vital actions against AMR.
Handwashing, a simple but often neglected practice across the world, has been estimated to reduce diarrhoea episodes by as much as 30%, highlighting the effectiveness of hygiene in slowing the spread of infection and the subsequent development of resistance.ix A study conducted among low-income communities in Cape Town, South Africa also found that hygiene education in combination with hand washing at critical times, regular bathing, disinfecting of household surface at critical times and proper waste disposal, resulted in up to five times fewer respiratory infections and households were two and a half times less likely to experience gastrointestinal illness.x
The public response to the recent COVID-19 virus has also demonstrated the impact of improved hygiene behaviours in the home and communities as well as social distancing to help potentially delay the spread of the virus in many regions.
Whilst LMICs face significant barriers that are unique to resource-constrained settings, including a lack of adequate infrastructure and an associated high burden of infectious disease that contribute to the rapid pace of resistance, it is clear that a collaborative approach underpinned by policies that prioritise preventative measures both in the community, as well as healthcare settings, are vital to reduce the global threat of AMR.
i The World Bank Pulling Together to Beat Superbugs Knowledge and Implementation Gaps in Addressing Antimicrobial Resistance October 2019. Available from:
ii Pulling Together to Beat Superbugs Knowledge and Implementation Gaps in Addressing Antimicrobial Resistance. The World Bank Report. October 2019. Available from: http://documents.worldbank.org/curated/en/430051570735014540/pdf/Pulling-Together-to-Beat-Superbugs-Knowledge-and-Implementation-Gaps-in-Addressing-Antimicrobial-Resistance.pdf
iii Pulling Together to Beat Superbugs Knowledge and Implementation Gaps in Addressing Antimicrobial Resistance. The World Bank Report. October 2019. Available from: http://documents.worldbank.org/curated/en/430051570735014540/pdf/Pulling-Together-to-Beat-Superbugs-Knowledge-and-Implementation-Gaps-in-Addressing-Antimicrobial-Resistance.pdf
iv Interagency Coordination Group on Antimicrobial Resistance. No Time To Wait: Securing the future from drug-resistant infections. April 2019. Available from https://www.who.int/antimicrobial-resistance/interagency-coordination-group/IACG_final_report_EN.pdf?ua=1. Accessed February 10, 2020
v Stadler T, Meinel D, Aguilar-Bultet L et al. Transmission of ESBL-producing Enterobacteriaceae and their mobile genetic elements – identification of sources by whole genome sequencing: study protocol for an observational study in Switzerland. BMJ Open 2018; 8: e021823. Available from: https://bmjopen.bmj.com/content/bmjopen/8/2/e021823.full.pdf
vi Mandal DK, Sah SK, Mishra SK et al. Carriage of Extended-Spectrum- β-Lactamase- and AmpC- β- Lactamase-Producing Enterobacteriaceae (ESBL-PE) in Healthy Community and Outpatient Department (OPD) Patients in Nepal. Canadian Journal of Infectious Diseases and Medical Microbiology. February 2020. Article ID 5154217. Available from: https://www.hindawi.com/journals/cjidmm/2020/5154217/
vii Departments of Health and Agriculture, Forestry and Fisheries for the Republic of South Africa: Antimicrobial Resistance National Strategy Framework; A One Health Approach 2018-2024 p.15
viii Wash in Healthcare Facilities Global Baseline Report. World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) 2019
ix Ejemot-Nwadiaro RI, Ehiri JE, Arikpo D, Meremikwu MM, Critchley JA. Hand washing promotion for preventing diarrhoea. Cochrane Database Syst Rev. 2015 Sep 3;(9):CD004265. DOI:
x Cole EC, Hawkley M, Rubino JR et al. Comprehensive family hygiene promotion in peri-urban Cape Town: Gastrointestinal and respiratory illness and skin infection reduction in children aged under 5. South African Journal of Child Health 2017; 6 (4): 109-117. Available from: http://www.sajch.org.za/index.php/SAJCH/article/view/459/359