*Assistant Professor, Centre for Hospital Management, School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai, Maharashtra
†Student (Post Graduate Diploma in Water, Sanitation and Hygiene [PDG-WASH]), Tata Institute of Social Sciences, Tuljapur, Osmanabad, Maharashtra
Address for correspondence
Prof Dhananjay Mankar
Assistant Professor, Centre for Hospital Management, School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai, Maharashtra
Out of quite a few zoonotic disease outbreaks in the last two decades, coronavirus disease 2019 (COVID-19) has left no stone unturned. COVID-19 pandemic demanded a reassessment of the existing norms within the national health systems. It has prioritized the importance of water, sanitation and hygiene (WASH) quality to protect human health during any infectious disease outbreak. Endorsing the best WASH and waste disposal practices on the individual, community and institutional level is crucial for preventing the spread of disease by safeguarding public health. In addition to strict social distancing norms and wearing a face mask in public places, the promotion of good hygiene, particularly handwashing with clean water and soap, is equally important. Healthcare providers are playing a critical role during the pandemic. Similarly, the increased responsibility of water utility personnel and sanitation workers, which directly enable the hygiene practices that limit the spread of the novel COVID-19 virus, is also essential.
Keywords: COVID-19, water, sanitation, hygiene, waste management, public health, environmental health
The global pandemic of coronavirus disease 2019 (COVID-19) has challenged basic hygiene behavior and related facilities. It has placed hygiene at the center of disease prevention. The intensive infectious nature of COVID-19 has led to the requirement of rigorous infection prevention and control (IPC) to reduce transmission in a healthcare facility.1 However, billions of people living in developing countries lack safe drinking water and reliable water access even for basic handwashing.2 The provision of safe water, sanitation and hygiene (WASH) with proper waste management facilities plays an essential role in the prevention of the disease. Consistent WASH and waste management practices in communities, homes, schools, marketplaces and healthcare facilities help to prevent human-to-human transmission of pathogens, including the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19.
The transmission of the disease majorly depends on the extent of contact with the infected individual. The main route of infection and transmission of the disease is the same through the respiratory tract, respiratory droplets from the infected person being the potential cause of the spread of the novel COVID-19 virus. Passive transmission pathway follows the presence of respiratory droplets on surfaces where the virus could remain viable. The immediate environment of an infected person can therefore serve as a source of transmission.3 The World Health Organization (WHO) recommends the promotion of good hygiene, especially regular handwashing with clean water and soap, to prevent the transmission of the virus.4 Frequent and correct hand hygiene is one of the most important measures to prevent infection. The practice of handwashing at the right time, using the right technique with either alcohol-based hand sanitizer or soap and water is essential.3
WATER AND COVID-19
Access to safe drinking water is among the basic human rights and is a necessity for a healthy life.5 Governments of many developing countries consider the provision of safe water supplies as one of their major responsibilities. In developing countries, most people do not have access to safe drinking water.6 Between the years 2000 and 2017, urban coverage of basic drinking water services increased from 95% to 97%, while the rural coverage increased from 69% to 81%.7
The absence of the household drinking water facility and water storage facilities increases the frequency of going to water points or boreholes. This forced the community members to collect water daily from such sources, thus increasing their risk of contracting COVID-19. Developed countries, having more resources to tackle the diseases, highly relied on their water supply system, and fought the infection and transmission of the virus. However, in developing countries, the disinfection of public places led to the problem of water supply outage, which reveals that water is a key component in tackling the spread of the pandemic in several ways.2 For some slum residents, the lockdown restrictions affected their access to clean water, which leaves the slum community vulnerable to exposure to other infectious diseases.8 It has been noted that unreliable water supplies have a relation with degraded domestic hygiene, which is tied to the increased spread of COVID-19 transmission through fomites.9
Gender and Disability
Women and girls are the primary collectors of water in the household or community. It is already known that this group is negatively impacted in terms of their education, livelihoods and personal safety. The COVID-19 pandemic has worsened the situation, and in some regions, social distancing and lockdown rules have led to a re-emergence of the role of caring for those infected with the virus falling largely on women. Additionally, members of the community that have a disability are often forgotten in water resources management. COVID-19 has brought to light the inequalities that exist in water accessibility.10
It is found that water disinfection can reduce virus load as the virus is susceptible to detergents and oxidants, like chlorine and it is inactivated faster than nonenveloped waterborne enteric viruses.4 Not only COVID-19 but other infectious diseases can also be prevented, and health benefits realized by safely managing water services.
In places where centralized water treatment and safe piped water supplies are not available, several household water treatment technologies can effectively remove or destroy viruses, such as boiling, filtration, solar irradiation and appropriately dosed chlorine products including sodium hypochlorite and sodium dichloroisocyanurate (NaDCC).3 Water disinfection is critically important as the human coronavirus can reportedly survive for several days in tap water at 4°C-25°C.4
The issues tied to water demand and supply to handle the COVID-19 pandemic have not gained serious attention. It is important to understand if there are enough water facilities in workplaces and other public places, as well as at homes for everyone for the anticipated future. This question is important since COVID-19 will likely continue for years and not just months, as per several health professionals, epidemiologists and other experts in fields related to infectious diseases. Besides the increase in the demand for water quantity, COVID-19 also poses challenges from the perspective of water quality.11
In the parts of the world with fragile governments and economies and conflicts raging, water-sharing governance arrangements can be vital in keeping doors open for dialogue between riparian nations. Cooperation over water can enhance communication when broader diplomatic tensions arise between countries.10
SANITATION AND COVID-19
Sanitation is among the most significant components of community well-being as it safeguards human health, extends life spans, and benefits the economy. Sanitation is currently deployed to treat human excreta to protect human health and the environment.12 Owing to the lack of proper sanitation and treatment of municipal wastewater, viral infections can be transmitted to the surrounding life and environment.8
Wastewater and Its Management
The detection of SARS-CoV-2 viral particles in wastewater is a potentially effective approach to identify and track the spread of the virus. Preliminary analysis indicates that monitoring wastewater influents at the community level may indicate the extent of the outbreak in certain population clusters, particularly in communities where mass testing may not be
Recently, it was reported that the SARS-CoV-2 virus was excreted in the feces of COVID-19 patients, and from municipal wastewater in many countries including Australia, India, Sweden and, the USA.8 However, the risk of transmission of SARS-CoV-2 from the feces of an infected person and the feral-oral pathway appears to be low. One of the studies identified infectious SARS-CoV-2 in the urine of one patient and viral RNA has been detected in the gastrointestinal tissue.3 Human coronavirus has been reported to survive for several days in sewage at 4°C-25°C.4
Use of more water, as well as soap and disinfectants, for washing hands in order to control the spread of COVID-19 will eventually heighten the quantity of wastewater, with possibly even poorer quality, coming from homes, workplaces and other public places. Handling and disposal of wastes related to COVID-19 often require a large quantity of water, both during and after.
The quarantine and isolation centers used for testing and treating suspected and confirmed COVID-19 patients have been found to have a common sewerage system with the communities and cities. People are hence exposed to the tendency of using water from surface water sources that might be have been contaminated with SARS-CoV-2.13 It is required to provide separate flush toilets or latrines that should be cleaned and disinfected at least twice daily by a trained cleaner wearing appropriate personal protective equipment (PPE). Places where pit latrines are used, efforts should be made to prevent contamination of the environment and groundwater with excreta.4
COVID-19 is thus bound to seriously impact the water sector, in terms of both water quantity and water quality.11 The best way to tackle this problem is by separating the sewerage systems and wastewater treatment facilities of the healthcare centers.13 All the wastewater and sludge should be contained and treated either at the site or off-site in well-designed and managed wastewater and/or focal sludge treatment plants. Water utility personnel must be informed well about COVID-19 preventive measures. They may wear masks, they may follow physical distancing between workers and with the public, and practice hand hygiene frequently.3
So, appropriate treatment of municipal wastewater and additional measures are vital to limit further disease transmission.8 This involves creating a healthy environment, reducing open defecation and encouraging hygienic practices.14
Solid Waste and Its Management
The idea of lockdown, stay-at-home policy, and other preventive measures to check the spread of COVID-19 saw an increase in production and consumption patterns of nonmedical and household-related products, including masks, gloves, thermometers, sanitizers, cleaning products, toilet papers, foodstuffs and many other things. Sudden lockdown and fear of the virus gave rise to a surge in single-use products and panic buying.
Failure to properly manage the waste generated from healthcare facilities and households may escalate the spread of COVID-19 through secondary transmission. The waste disposal practices have often been found inappropriate, and most people disposed of a used mask, gloves and other infectious wastes with household wastes instead of separate disposal. Improper management of medical waste has the potential to expose patients, health workers and waste managers to infections. Therefore, it is essential to increase the awareness level of people regarding the preventive measures of COVID-19, as well as the significance of WASH and safe practices for infectious waste disposal practices.8
Even during the COVID-19 pandemic, appropriate waste management must ensure continuity and functionality of waste services as well as workers, the safety of waste service workers, adjustment of recycling services to include measures that curb the spread in the collection, disposal and treatment of medical waste. Sustainable management of medical waste is difficult, especially in current times. Waste management is an essential public service that is needed to check the spread of COVID-19.15
HYGIENE AND COVID-19
Hygiene is important for keeping people healthy across the globe.16 Hygiene plays a vital role in disease prevention. However, there is a lack of access to the water supply that supports good hand hygiene and institutional cleaning, people’s understanding of hygiene behaviors, and access to soap in the low-, middle- and high-income countries.9 Since the transmission of COVID-19 can occur through contaminated surfaces and hands, adequate hand hygiene is essential to stop transmission.4
Practicing appropriate hand hygiene can prevent respiratory illness3 and is also known to curb the transmission of viruses and bacteria causing common colds, flu and pneumonia.4 An increase in handwashing among susceptible communities would potentially help in preventing and controlling the spread of COVID-19.8
It is recommended to wash the hands thoroughly after coughing and sneezing or disposing of tissue, after coming home from public places, before cooking, before and after eating and feeding/breastfeeding, after using the toilet, or changing a child’s diaper, and after touching animals.3 The simple handwashing method is the most effective action to prevent the spread of COVID-19.10
The optimal hand hygiene materials include water and soap, alcohol-based hand rub and ash. Where it is not possible to have alcohol-based hand rub or bar soap, liquid soap, or locally-made soapy water solutions can be used mixing water with detergent. The ratio of detergent to water is guided by the types and strengths of available products. Drying the hands after washing is an important part of effective hand hygiene. The moisture left on the hands after washing can be a major determinant of transmission of pathogens from hands to surfaces and the other way round. Washing and rubbing of hands and the amount of rinsing water determine the reduction of contamination on hands. A handwashing session with just 0.2 liters is sufficient.
Frequent and appropriate hand hygiene is one of the most important measures to prevent infection with SARS-CoV-2.3
Home Hygiene Management Practices
In case of suspected or confirmed cases of COVID-19 at home, caregivers and other family members must be protected from the risk of contact with respiratory secretions and excreta carrying the virus. Frequently touched surfaces in the patient’s care area, such as furniture, tables, etc., must be cleaned regularly. The Patient’s utensils and cutlery should be washed and dried after every use and should never be shared with others. If bathrooms are shared by COVID-19 patients and other household members, they should be thoroughly cleaned and disinfected at least once a day. Regular household soap or detergent can be used for cleaning and after rinsing, a regular household disinfectant that has 0.1% sodium hypochlorite should be applied. The person carrying out the cleaning work must wear PPE, and hand hygiene supplies should be available in households caring for COVID-19 patients.
Waste generated during home quarantine, while caring for a sick person or during the recovery period, must be put in strong bags and closed completely prior to disposal and collection by municipal waste services. Individuals collecting waste should wear PPE, including heavy-duty gloves, boots, coveralls and masks when working in confined spaces, and must have facilities that allow conducting regular hand hygiene.3
Hygiene is of crucial importance in keeping people across the globe healthy. That said, the COVID-19 pandemic has provoked radical and immediate changes in hygiene measures. It is essential to implement stricter hygiene practices now to curb COVID-19 transmission, but this increased hygiene may be tied to a microbial cost by reducing microbial acquisition and reinoculation after a loss.16
The important role that adequate WASH and waste disposal practices play in the current pandemic cannot be overemphasized.8
The current outbreak of COVID-19 calls for action from governments, industry and the people to limit its spread.17 The promotion of other COVID-19 control measures such as social distancing, self-isolation, and avoidance of public places has been a challenge in low-income countries.4 WASH practices and usage and safe disposal of safety equipment are important to fight against COVID-19.8 There is a need to act urgently to overcome deficiencies in WASH, especially provide reliable, continuous piped water on-premises for all households and settings. Hygiene promotion programs, based on behavioral science, are needed that are particularly adapted to high-risk populations, such as the elderly and to particular settings like healthcare facilities, transport hubs, workplaces, etc.9 There is an urgent need for public awareness campaigns, suburbanization of wastewater treatment facilities, use of low-cost point-of-use water treatment systems, policy interventions and community-led total sanitation (CLTS).13
The development of multifaceted artificial intelligence (AI) approaches such as Wash Karo should be encouraged for Infodemic Management. Wash Karo is driven by the inevitable need to increase awareness of WASH to curb the spread of COVID-19.18 For such technological innovations, we need better use of financing instruments that will help to extend and improve WASH services.9
Effective public health messaging is vital to obtain social support for disease containment strategies. But it must be noted that effective public health messaging, especially to convince people to limit their activities, has to be culturally and socially competent. Public health messaging regarding a disease outbreak, such as the ongoing COVID-19 outbreak, is challenging, especially in multicultural populations.19 Therefore, it becomes important to strengthen WASH facilities to prevent and fight the pandemic situation with the help of proper drinking water, hand washing, maintaining good hygiene and cleaning and self-isolating facilities. The knowledge, attitude and practice (KAP) of healthcare workers toward COVID-19 are critical to the success of COVID-19 response efforts.20 Long-term public health policy responses are required to ensure that the ongoing pandemic does not escalate health inequalities for the coming generations.21
- McGriff JA, Denny L. What COVID-19 reveals about the neglect of WASH within infection prevention in low-resource healthcare facilities. Am J Trop Med Hyg. 2020;103(5):1762-4.
- Zvobgo L, Do P. COVID-19 and the call for ‘Safe Hands’: Challenges facing the under-resourced municipalities that lack potable water access - A case study of Chitungwiza municipality, Zimbabwe. Water Res X. 2020;9:100074.
- World Health Organization. Water, sanitation, hygiene, and waste management for SARS-CoV-2, the virus that causes COVID-19. Interim guidance, 29 July 2020. Available from: https://www.who.int/publications/i/item/WHO-2019-nCoV-IPC-WASH-2020.4.
- Donde OO, Atoni E, Muia AW, Yillia PT. COVID-19 pandemic: Water, sanitation and hygiene (WASH) as a critical control measure remains a major challenge in low-income countries. Water Res. 2020;191:116793.
- Khan S, Shahnaz M, Jehan N, Rehman S, Shah MT, Din I. Drinking water quality and human health risk in Charsadda district, Pakistan. J Cleaner Product. 2013;60(1):93-101.
- Abu Amr SS, Yassin MM. Microbial contamination of the drinking water distribution system and its impact on human health in Khan Yunis Governorate, Gaza Strip: seven years of monitoring (2000-2006). Public Health. 2008;122(11):1275-83.
- World Health Organization. Progress on household drinking water, sanitation and hygiene 2000-2017. Special focus on inequalities. New York: United Nations Children’s Fund (UNICEF) and World Health Organization, 2019.
- Islam SMD, Mondal PK, Ojong N, Bodrud-Doza M, Siddique MAB, Hossain M, et al. Water, sanitation, hygiene and waste disposal practices as COVID-19 response strategy: insights from Bangladesh. Environ Dev Sustain. 2021 Jan 2:1-22.
- Howard G, Bartram J, Brocklehurst C, Colford JM Jr, Costa F, Cunliffe D, et al. COVID-19: urgent actions, critical reflections and future relevance of ‘WaSH’: lessons for the current and future pandemics. J Water Health. 2020;18(5):613-30.
- Neal MJ. COVID-19 and water resources management: reframing our priorities as a water sector. Water International. 2020;45(5):435-40.
- Sivakumar B. COVID-19 and water. Stoch Environ Res Risk Assess. 2020;1-4.
- Naughton C. Mihelcic JR. Introduction to the importance of sanitation. In: Rose JB, Jiménez-Cisneros B (Eds.). Water and Sanitation for the 21st Century: Health and Microbiological Aspects of Excreta and Wastewater Management (Global Water Pathogen Project). Part 1: The Health Hazards of Excreta: Theory and Control), Michigan State University, E. Lansing, MI, UNESCO. 2017. pp. 3-11. https://doi.org/10.14321/waterpathogens.1
- Sunkari ED, Korboe HM, Abu M, Kizildeniz T. Sources and routes of SARS-CoV-2 transmission in water systems in Africa: Are there any sustainable remedies? Sci Total Environ. 2021;753:142298.
- Akseer N, Kandru G, Keats EC, Bhutta ZA. COVID-19 pandemic and mitigation strategies: implications for maternal and child health and nutrition. Am J Clin Nutr. 2020;112(2):251-6.
- Sarkodie SA, Owusu PA. Impact of COVID-19 pandemic on waste management. Environ Dev Sustain. 2021; 23:7951-60.
- Finlay BB, Amato KR, Azad M, Blaser MJ, Bosch TCG, Chu H, et al. The hygiene hypothesis, the COVID pandemic, and consequences for the human microbiome. Proc Natl Acad Sci U S A. 2021;118(6):e2010217118.
- Kuper-Smith BJ, Korn C, Oganian Y, Doppelhofer LM, Rosenblau G. Optimistic beliefs about COVID-19. 2020.
- Pandey R, Gautam V, Pal R, Bandhey H, Dhingra LS, Sharma H, et al. A machine learning application for raising wash awareness in the times of COVID-19 pandemic. arXiv preprint arXiv:2003.07074 (2020).
- Stratton SJ. COVID-19: Not a simple public health emergency. Prehosp Disaster Med. 2020;35(2):119.
- Kanu S, James PB, Bah AJ, Kabba JA, Kamara MS, Williams CEE, et al. Healthcare Workers’ Knowledge, Attitude, Practice and Perceived Health Facility Preparedness Regarding COVID-19 in Sierra Leone. J Multidiscip Healthc. 2021;14:67-80.
- Bambra C, Riordan R, Ford J, Matthews F. The COVID-19 pandemic and health inequalities. J Epidemiology Community Health. 2020;74(11):964-8.