Global access to handwashing: implications for COVID-19 control in low-income countries

Abstract

Abstract Background Low-income countries have reduced health care system capacity and are therefore at risk of substantially higher COVID-19 case fatality rates than those currently seen in high-income countries. Handwashing is a key component of guidance to reduce transmission of the SARS-CoV-2 virus, responsible for the COVID-19 pandemic. Prior systematic reviews have indicated the effectiveness of handwashing to reduce transmission of respiratory viruses. In low-income countries, reduction of transmission is of paramount importance but social distancing is challenged by high population densities and access to handwashing facilities with soap and water is limited. Objectives To estimate global access to handwashing with soap and water to inform use of handwashing in the prevention of COVID-19 transmission. Methods We utilized observational surveys and spatiotemporal Gaussian process regression modeling in the context of the Global Burden of Diseases, Injuries, and Risk Factors Study, to estimate access to a handwashing station with available soap and water for 1062 locations from 1990 to 2019. Results Despite overall improvements from 1990 (33.6% [95% uncertainty interval 31.5–35.6] without access) to 2019, globally in 2019, 2.02 (1.91–2.14) billion people—26.1% (24.7–27.7) of the global population lacked access to handwashing with available soap and water. More than 50% of the population in sub-Saharan Africa and Oceania were without access to handwashing in 2019, while in eight countries, more 50 million or more persons lacked access. Discussion For populations without handwashing access, immediate improvements in access or alternative strategies are urgently needed, while disparities in handwashing access should be incorporated into COVID-19 forecasting models when applied to low-income countries. Funding Bill & Melinda Gates Foundation. MB was supported in part by the Pathways to Equitable Healthy Cities grant from the Wellcome Trust.