Harnessing COVID-19 to safeguard future health: invest in WASH and infection prevention and control to beat antimicrobial resistance

6 min read
A nurse washing her hands

Alison Macintyre

The past year has shown clearly the dangers of ignoring a pandemic, the borderless nature of global health, and that clean water and good hygiene save lives. In World Antimicrobial Awareness Week, Alison Macintyre shares how to address this growing health threat through joined-up action on antimicrobial resistance, infection prevention and control, and water, sanitation and hygiene.

We are all getting crisis fatigue, right? 2020 has been tough. But 2021 holds hope. Promising COVID-19 vaccine candidates are emerging and we are learning how to keep persistent COVID-19 outbreaks under control. But through these glimmers of hope, we can’t allow ourselves to forget that while the COVID-19 pandemic is persisting so are other emerging disease threats.

Antimicrobial resistance: a slow-moving pandemic

One crisis that has been at the forefront of WaterAid, WHO’s and UNICEF’s minds is antimicrobial resistance (AMR). AMR has been labelled a slow-moving pandemic – one we have known about for quite some time, and one, now more than ever, that needs to be tackled as we think about building back better from COVID-19.

This week (18–24 November) is World Antimicrobial Awareness Week (WAAW), which comes around each year to remind us of the risk we face of the most treatable of illnesses becoming untreatable. It reminds us to handle the medications we have now – that work – with care.

Long before COVID-19, we knew the AMR crisis was looming. We have also known what can be done to curb or even halt this slow-building pandemic. But we have not succeeded in putting these measures in place at the speed and the scale we need to. If we don’t want health crises like we have experienced in 2020 to become the new norm, we need to tackle AMR – immediately.

Sunita Kharel, senior auxiliary nurse midwife, Healthpost incharge, Bhumlutaar health post, washing her hands at a contactless handwashing station in Bhumlutaar, Kavre, Nepal, Sep 2020.

WaterAid/ Mani Karmacharya

Sunita Kharel, senior auxiliary nurse midwife at Bhumlutaar health post, using a contactless handwashing station in Kavre, one of the 77 districts in Nepal covered by the Hygiene Behaviour Change Coalition project promoting COVID-19 prevention messaging. September 2020.

Why is antimicrobial resistance so important right now?

On one hand, COVID-19 has exacerbated the emergence and spread of AMR through increased use of antimicrobials; disrupted health systems, resulting in interruptions to treatments; and increased healthcare visits, increasing the risk of healthcare-associated infections. On the other hand, to return to the glimmers of hope above, COVID-19 has drawn attention to effective disease prevention and control approaches that can be leveraged to tackle AMR. We have realised we can’t succeed in overcoming any health threat unless we get the basics right – basics such as clean water, decent sanitation and good hygiene (WASH), and proper infection prevention and control (IPC). COVID-19 has driven renewed focus on these fundamental elements of healthcare.

While the renewed attention to WASH and IPC in healthcare facilities is a welcome step, we can’t risk fatigue; we need to grasp this attention and use it as a springboard into urgent action. We were reminded of the urgency just this week as Wellcome published its new report on AMR (PDF), which highlighted, as seen in the figure drawn from their report below, water and sanitation and IPC in humans as two of the most high-impact and feasible ways of addressing AMR.

A figure from a report by Wellcome showing water and sanitation and IPC in humans as two of the most high-impact and feasible ways of addressing antimicrobial resistance.


Taken from Wellcome (2020). “The Global Response to AMR: Momentum, success, and critical gaps."

Data also remind us why we need to address this right now – recently published statistics show that more than 900 million people have to seek care at healthcare facilities that don’t have water on site. And, despite the focus on handwashing in COVID-19 responses, one in three healthcare facilities don’t have the amenities for hand hygiene where care is delivered.

We also know that up to 90% of health workers do not adhere to recommended hand hygiene practices, which will be due in part to lack of materials, but also to other factors such as norms, knowledge, limited enforcement and workload. Whatever the reasons, this has to change. It is conditions such as this that lead to up to 1 million mothers and newborns dying from preventable infections (PDF). The WASH crisis we find ourselves in shows how neglected the basics have been and how important investment is in prevention as part of AMR and all health efforts.

Hand hygiene is a critical first step, but, to really see progress, much more joined-up change across all aspects of WASH, IPC and AMR must be realised. COVID-19 has exposed the gaps in these areas and galvanised attention; now the real work begins.

How to achieve joined-up action on WASH, IPC and AMR

WaterAid, WHO and UNICEF recently published a brief outlining how urgent investing and acting on IPC and WASH is for AMR (PDF), and how joined-up action between WASH, IPC and AMR can be done. We are calling on governments to invest in WASH so that effective IPC can be enabled; if they don’t, the AMR response will be undermined. This in turn, alongside good antimicrobial stewardship, will support curbing the spread of resistant microbes. The figure below, taken from the brief, shows us this interrelatedness. It won’t happen by countries and sectors acting alone. Action must be collaborative and occur at national and global levels, alongside strong healthcare facility leadership and improvements.

A graphic taken from WaterAid, WHO and UNICEF's brief on antimicrobial resistance, illustrating how to reduce resistant microbes (investment in WASH services and enabling IPC to stop deadly infections, feeding into antimicrobial stewardship, targeted AMR services, less emergence and spread).


Taken from WaterAid, WHO and UNICEF's brief on antimicrobial resistance.

Our brief is not just rhetoric on paper; we are already putting it into practice. COMBAT AMR, a project funded by the Australian Department of Foreign Affairs and Trade’s Indo-Pacific Centre for Health Security and led by the Doherty Institute, is bringing together multiple sectors and specialists to tackle AMR in the Pacific. While the project takes a one health approach, one specific element is the implementation of joint IPC–WASH programmes in hospitals in Papua New Guinea, Fiji, Solomon Islands and Samoa. WaterAid is working collaboratively with experts to design and implement joined-up approaches to improve IPC and WASH, and address AMR needs at major national hospitals. Beyond the hospitals, these collaborative efforts will support strengthening national leadership and governance on WASH and IPC within AMR programmes.

Sadly, programmes like these are not yet the norm. We are urging all donors and countries to invest in joined-up WASH and IPC programmes in COVID-19 recovery and AMR efforts. We are calling for all IPC, WASH and AMR experts, building on COVID-19 efforts, to continue to break down silos, work together and forge new collaboration, to keep the focus and momentum on infection control and hygiene going.

At the country level, we need to invest in, and act on, what we know works:

  • Implementing strong AMR national action plans that have WASH and IPC targets and financing
  • Strengthening monitoring and data use
  • Building capacity of WASH, health, IPC and AMR sectors to tackle complex problems together
  • Drive strong coordination, joint accountability and governance
  • Share lessons of what works

Holding on to the momentum that COVID-19 has catalysed and turning it into concrete action to end the WASH and IPC crises in all healthcare settings will make safeguarding our health for the future possible and achievable.

Alison Macintyre is WaterAid's Technical Lead – Health Programmes. Follow her on Twitter at @al_macintyre.