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

Brauer, Michael; Zhao, Jeff T; Bennitt, Fiona B; Stanaway, Jeffrey D

BackgroundLow-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 handwashing access is limited. ObjectivesTo estimate global access to handwashing with soap and water to inform use of handwashing in the prevention of COVID-19 transmission. MethodsWe 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. ResultsDespite overall improvements from 1990 (34.7% [95% uncertainty interval 32.5-36.7] without access) to 2019 globally, in 2019, 2.01 (1.89-2.13) billion people--26.0% (24.4-27.6) of the global population lacked access to handwashing. More than 50% of the population in sub-Saharan Africa were without access to handwashing in 2019, while in eight countries, more than 50 million persons lacked access. DiscussionFor 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.