Fostering a Culture of Learning in Rwanda

Written by Nazanine Scheuer, Save the Children
This post originally appeared on Aspen Network of Development Entrepreneurs

Fostering a Culture of Learning in Rwanda
How can you learn if you can’t get books in your own language? And how can that situation be remedied if 1) your nation has only three local publishers and 2) they’ve published just 12 children’s books in the language spoken by the vast majority of your country’s citizens?

That was the challenge faced by schoolchildren in Rwanda – until Save the Children stepped in to create a social enterprise partnership platform that engaged the private sector in local book publishing. By enabling the start-up and training of Rwanda-based publishers and linking them to key actors across the value chain, we strengthened the supply of locally created, quality reading materials, stimulated demand and helped local entrepreneurs build thriving businesses.

The result? By providing students with vastly improved access to books that are both culturally relevant and language-appropriate, the venture is making significant strides toward creating a culture of literacy and learning in Rwanda. We have helped local publishers produce over 1,000 stories, of which more than 600 were approved for use in schools by the Rwanda Education Board. At the same time, the project has built – and continues to build – a new industry that’s making significant contributions to the local economy.

Why Local Publishing?
As Save the Children enters our second century of creating innovative approaches to improving life for children, women and their families around the world, we are increasingly engaging in market-based, impact driven solutions to social and economic challenges. Investment in these initiatives has become a driver of our strategy to build and strengthen local market systems and underpin long-term, self-sustaining economic development.

In the case of Rwanda, it was widely recognized that a shortage of books in their mother tongue, Kinyarwanda, was preventing millions of girls and boys from building literacy skills and discovering the joy of reading. Furthermore, what was available was poorly written, edited, illustrated and designed and/or for the wrong age group. Not only did local publishers lack the skills, knowledge and experience to produce high quality children’s books, but, as a result of low demand for non-textbook materials, they lacked incentives to produce good quality reading materials.

An added hurdle to availability of appropriate books was the lack of access to or within schools, as well as a lack of the skills necessary for teachers to use the books effectively.

Traditional literacy initiatives addressed the gap in book availability by developing materials externally or facilitating the translation of foreign-sourced materials into Kinyarwanda. While that approach was somewhat effective in the short term, it did not offer a pathway to sustainable solutions. Equally important, it largely ignored the role local publishers could play in enhancing their communities’ economies by building and expanding profitable business ventures with long-term viability.

Creating an Economic Eco-System
In 2013, with an initial investment from public- and private-sector partners, we designed and implemented the Rwandan Children’s Book Initiative (RCBI). The goal was to foster a reading and learning environment to improve literacy. By developing a local publishing industry through a comprehensive, multi-pronged approach, we were able to strengthen all aspects of the book value chain, from developers to end users. We created a thriving new industry in Rwanda and also achieved our objective of improving literacy outcomes and creating a culture of reading among children. In 2016, we received an additional investment that enabled us to further expand the model, building on the eco-system already created.

We focused our model on five key activities central to success:

Skills Development

o   Provide quality, relevant training and ongoing mentoring to the publishing industry and its constituents;

o   Work in partnership with private sector, book-publishing actors to tap into resources and expertise (i.e. a partnership with Penguin Random House.)

Demand Generation

o   Support the establishment of communities of practice for each segment of the industry;

o   Invest in initiatives that established a market for the newly developed, local-language books.

Supply Strengthening:

o   Maintain a book-review committee to provide feedback to publishers, assess quality and inform procurements;

o   Establish incentive-driven agreements to encourage publishers with low capital to invest in quality materials;

o   Facilitate an understanding of quality criteria to allow negotiation of better prices/more affordability;

o   Formulate quality-assurance guidelines;

o   Create a book purchasing consortium comprised of different projects/programs/organizations.

Advocacy

o   Invest in advocacy and policy formulation work to create a conducive book-publishing environment;

o   Engage relevant decision makers and build evidence to support the importance of a local publishing industry;

o   Build coalitions around the importance of involving the private sector to develop and maintain quality materials, educational opportunities and a knowledge based society;

o   Raise awareness through meetings, conferences, campaigns and media.

Through this model, we demonstrated the value of a “whole chain” approach that connects publishers with government agencies, the private sector and local communities. In doing so, we increased collaboration between these actors to establish a self-sustaining industry that draws on the local mix of skills and expertise.

Compelling Results
Thanks to RCBI, the quality, quantity and range of local-language children’s books published and distributed in Rwanda has grown significantly. In fact, there are now more than 1,000 books for children from 0 to 9 years of age available from publishers that received our support. An added bonus of the project is that girls are increasingly likely to be the protagonists in these stories and are more often portrayed in positive roles. By 2019, almost a third of the children’s books featured girls as main characters.

As for the impact on local economies, most of the participating publishing houses have grown, often from just one person to an entire staff. Notably, a third of the active publishers are women! With a stronger capital base, these publishers are able to compete for contracts and access markets that were previously unavailable to them. Additionally, the publishers are diversifying their activities beyond Kinyarwanda children’s books and even beyond the boundaries of Rwanda. Some have begun co-publishing textbooks in foreign countries, while others have sold rights for publishing their books in additional languages or sold rights overseas.

This is important because generating income allows them to invest in the production of more books and other learning materials. For example, many publishers are investing in digital educational materials such as animations, alphabet apps and audio books and are building online e-bookstores. They’re also forming partnerships with local schools, writing books for older readers and offering books on important topics that align with national development priorities.

In all, we’ve counted more than 250 new actors contributing to the industry, whether as authors, illustrators/artists, editors, designers, booksellers or administrators, underscoring the thriving industry created by the project.

“There were no trainings for publishers and no local publishing schools. I had an interest in this field because I am a writer, and I worked in a printing company. When I started my company, I wanted to create products children would enjoy, but didn’t know which way to go to achieve that goal…. So Save the Children helped me bring my vision to life.”

– A Rwandan publisher trained by Save the Children

What’s Next?
The bottom line is that the RCBI project has exceeded its goals, helping children learn while also building a flourishing children’s book publishing industry in a nation that previously had no such aspiration. In our next phase, we plan to increase distribution across the country including in remote communities, amplify women’s empowerment and further improve literacy outcomes. Concrete examples include: establishing micro-libraries; starting women’s authorship groups; developing innovative, income-generating activities to increase book sales and incentivize reading.

Thanks to the support of our committed partners in the U.S. and Rwanda, this project has effectively changed the lives of children, women and entire communities. To learn more or get involved, please contact Nazanine Scheuer at nscheuer@savechildren.org. And do stay tuned for the next chapter!

A mother cradles her newborn baby at a hospital in Kenya.

The Unintended Consequences of COVID-19 on Mothers and Newborns

This post is part of a series authored by the BASICS (Bold Action to Stop Infections in Clinical Settings) team. BASICS is a new initiative that will transform healthcare and reduce healthcare-associated infections (HAIs) by at least 50%.

Written by the BASICS team

The unintended dangerous effects of pandemics on maternal and newborn health are not new.

During the Ebola crisis of 2015-16, more women and girls died of obstetric complications than the infectious disease itself.

For COVID-19, the situation is no different. While some emerging evidence suggests that COVID-19-infected pregnant women may be at higher risk of pre-term birth[1] and that pregnant women with pre-existing conditions may face complications, it appears that healthy pregnant women face few direct adverse effects of the virus. There is also no evidence of vertical mother-to-newborn transmission during pregnancy or via breastfeeding, and the few infants with confirmed COVID-19 have experienced mild illness.[2] Current guidance on caring for babies of mothers with COVID-19 are available here.  

However, Save the Children’s own experiences responding to disease outbreaks in low- and middle-income countries, modeling data and other evidence point to a number of worrying indirect effects the pandemic may have on mothers and newborns. The myriad complications of the COVID-19 pandemic – from overwhelmed health systems to government lockdowns that may restrict a woman’s access to health care, and to families simply being unable to afford transportation to a distant health post because of lost incomes – are conspiring to disrupt maternal and newborn care and jeopardizing hard-won progress in reducing maternal and newborn mortality.

  • Facility care may be disrupted or diminished as health staff and materials, including those necessary for infection prevention and control (IPC), are re-deployed or prioritized for departments likely to see COVID-19 patients.
    • Fear of physical proximity may limit or alter care provision. Social distancing and the fear of spreading the virus may lead health workers to deny laboring mothers an outside birth companion or to separate newborns from mothers after delivery. We are aware of such instances occurring through the country programs we support and the working groups and forums we participate in. Essential care for every newborn should include immediate skin-to-skin contact and early initiation of breastfeeding. This is especially critical for pre-term and small babies whose survival relies on the practice of Kangaroo Mother Care, which includes – among other practices – early, continuous and prolonged skin-to-skin contact between the mother and the newborn.
    • Government-ordered curfews and lockdowns may prevent or inhibit women’s access to routine antenatal care or emergency care, or to cause them to give birth at home without the support of a trained midwife or health worker.
    • Families’ economic shocks from lost jobs and livelihoods may make the cost of transportation to a health facility or facility fees prohibitive.
    • Mixed messages about how the virus can be transmitted and fear of physical closeness may reduce breastfeeding rates.

Over the past two decades, individuals, families, communities and countries have achieved significant improvements in health outcomes for mothers and newborns. Maternal death rates globally fell 38.3 percent, from 342 deaths per 100,000 live births in 2000 to 211 per 100,000 live births in 2017[3]. Newborn death rates declined by 43 percent, from 31.5 deaths per 1,000 live births in 2000 to 17.7 per 1,000 live births in 2017[4]. The increased access to safe healthcare has been one of the main reasons for these improvements. For example, the percentage of births globally that were attended by skilled personnel increased from 64% in 2000 to 81% in 2019.[5]

The impacts of COVID-19 can easily erode some of these hard-won gains in reduced mortality over the past two decades.

So what can we do? It is essential to ensure mothers feel safe going to a health facility and health providers are empowered with knowledge and tools. WHO, Save the Children and other partners recommend that health facilities: 

  • Maintain and promote essential, evidence-based maternal and newborn health services such as antenatal care for pregnant women, skilled attendance during labor and delivery and essential newborn care; 
    • Practice IPC in all departments and wards, but especially in the spaces where pregnant women, laboring mothers and newborns receive care. This includes routinely cleaning and disinfecting surfaces to help prevent the spread of disease, and practicing strict hand hygiene (handwashing) before and after contact with the mother and newborn;
    • Encourage mother-baby contactinstead ofisolation. Mothers and newborns should not be separated. Mothers should be encouraged to breastfeed and practice immediate skin-to-skin contact for low weight/preterm babies while following the appropriate protective measures. For asymptomatic and non COVID 19 exposed mothers, this means practicing respiratory hygiene, avoiding touching the mouth and face, practicing hand washing with soap and running water or using sanitizer where possible, following distancing recommendations and reporting symptoms.
    • Engage mothers and communities to understand their needs, questions and fears, which will help to tailor approaches and health messages to communicate effectively, both about the risks of COVID-19 and the benefits of essential maternal and newborn health services. 

These are basic yet powerful actions that will ensure pregnant women, mothers and their newborns continue receive quality care during the pandemic and that those caring for them will help keep them healthy and thriving. Maternity and newborn wards, in which all staff are trained in and practicing strict hygiene and IPC protocols as second nature, become safer environments and places where the risk of acquiring an infectious disease is greatly reduced.

The BASICS model ensures IPC measures are embedded in the delivery of health care to pregnant women, mothers and newborns –in the midst of COVID-19 as well as for the future so that if the next pandemic hits, health systems will be prepared.


[1] https://www.sciencedirect.com/science/article/pii/S2589933320300379?via%3Dihub

[2] https://www.healthynewbornnetwork.org/resource/covid19-interim-guidance-who/

[3] https://www.who.int/reproductivehealth/publications/maternal-mortality-2000-2017/en/

[4] https://data.unicef.org/topic/child-survival/neonatal-mortality/

[5] https://data.unicef.org/topic/maternal-health/delivery-care/

WaterAid Tanzania (Project was funded by the Canadian Government)

This post is part of a series authored by the BASICS (Bold Action to Stop Infections in Clinical Settings) team. BASICS is a new initiative that will transform healthcare and reduce healthcare-associated infections (HAIs) by at least 50%.

BASICS is built around the Clean Clinic approach, which incentivizes healthcare leadership to create a hygiene compliant health system at a low cost, and TEACH CLEAN, which empowers health care workers so that hygiene becomes second nature, are essential to reducing the number of Healthcare Associated Infections and deaths in Least Developed Countries (LDCs). But how can health workers practice the needed hygiene when there are no facilities to wash their hands or water to clean contaminated surfaces? A critical component of BASICS is to ensure Water Sanitation and Hygiene (WASH) infrastructure is available to make our efforts successful. In rural Tanzania, healthcare workers, like Regina Kasanda, experience firsthand what it is like to provide care in a maternal ward with little to no access to water. Close access to clean water means healthcare workers, who have been trained to practice hygiene, can now implement what they learnt, mothers are able to stay long enough to receive the care they need but most importantly, unnecessary and sometimes fatal infections can be avoided.

To learn more about BASICS (Bold Action to Stop Infections in Clinical Settings), visit savethechildren.org.

Disinfection You Can See

This post is part of a series authored by the BASICS (Bold Action to Stop Infections in Clinical Settings) team. BASICS is a new initiative that will transform healthcare and reduce healthcare-associated infections (HAIs) by at least 50%.

What happens when a healthcare worker or sanitation employee can’t discern whether or not surfaces, protective equipment, tools and supplies are properly disinfected after use?

BASICS partner, Kinnos Inc., is a social venture who won USAID’s Fight Ebola Grand Challenge with an innovative product. They developed Highlight, a color additive, to increase the efficiency and effectiveness of cleaning and disinfection by making chlorine visible and changing the chlorine’s liquid properties to achieve full surface coverage. The blue color fades automatically once optimal disinfection time has passed. Clean Clinics and Teach Clean (watch our videos to learn more) will employ this innovative additive to train health workers on effective cleaning and disinfection methods. See this video and you will be impressed!

To learn more about BASICS (Bold Action to Stop Infections in Clinical Settings), visit savethechildren.org.

Basics’ Partners Mobilize Global Responses to Combat Pandemic’s Impacts

This post is part of a series authored by the BASICS (Bold Action to Stop Infections in Clinical Settings) team. BASICS is a new initiative that will transform healthcare and reduce healthcare-associated infections (HAIs) by at least 50%.

With frightening speed, COVID-19 has turned the world on end. Over 1.9 million cases had been confirmed in 213 countries or territories as of April 15, according to the World Health Organization. Borders have been sealed, travel bans and lockdowns have been implemented, and health systems are under immense pressure.

All four BASICS partners have pivoted quickly to help. We have mobilized responses that put us on the front line – producing research, guidance and recommendations for governments and task forces; strengthening the ability of health systems in low- and middle-income countries to respond through training, supplies and water, sanitation and hygiene (WASH) infrastructure; and helping to directly alleviate the pandemic’s impact on vulnerable populations.

Here are highlights of the ways that Save the Children, the London School of Hygiene and Tropical Medicine, WaterAid and Kinnos are leveraging our expertise in global health – the same expertise that BASICS draws on – to react to this unprecedented crisis. 

Save the Children
Save the Children has mobilized a response unlike any other humanitarian mission in its more than 100 years of alleviating the needs of vulnerable and marginalized children. It was among the very first international aid organizations to deliver critical supplies to health workers and provide families with trusted information to reduce transmission and keep children safe.

It is supporting 500,000 community health workers and plans to support another 100,000 over the next six months by providing them with resources, tools and skills to deliver essential services to treat common childhood illnesses and malnutrition, and to recognize symptoms and prevent COVID-19. Many of its country offices are working with Ministries of Health to equip local health workers with protective equipment and medical supplies, training and emotional and professional support.

It is supporting 500,000 community health workers and plans to support another 100,000 over the next six months by providing them with resources, tools and skills to deliver essential services to treat common childhood illnesses and malnutrition, and to recognize symptoms and prevent COVID-19. Many of its country offices are working with Ministries of Health to equip local health workers with protective equipment and medical supplies, training and emotional and professional support.

  • In-country and international health staff in Kenya, Mozambique, South Sudan and Tanzania are participating in and advising national COVID-19 task forces or technical working groups.
  • In Malawi, Save the Children teams have collaborated with the Ministry of Health to develop and disseminate simple messages on handwashing and have set up sample handwashing stations at the Ministry building.
  • In Sierra Leone, Save the Children has reprised its role in the 2015-16 Ebola outbreak response by engaging in COVID-19 coordination mechanisms at the national level and in its districts of operation. National staff attend daily COVID-19 coordination meetings and have an active part in the development and dissemination of national COVID prevention messages. They are collaborating with the government on training community health workers on COVID prevention, so that they can pass accurate information to their communities.
  • In select refugee contexts where populations are extremely vulnerable and social distancing is impossible in overcrowded camps and settlements, such as camps of Rohingya refugees in Bangladesh, the agency will work with local health authorities to support isolation and treatment of those with COVID-19.

The London School of Hygiene and Tropical Medicine

LSHTM experts are involved in a diverse range of COVID-19 research initiatives and are providing technical support and guidance to governments and organizations. LSHTM has a strong track record of responding to emergencies and major outbreaks, whether through research or by providing immediate information, advice, courses and action on the ground.

There are a number of specific LSHTM COVID-19 responses directly related to the goals of BASICS. The School is hosting a massive open online course summarizing the latest evidence on COVID-19. Members of the LSHTM community are actively involved in providing expert commentary on COVID-19 response relevant to low- and middle-income countries, including the role of cleaning and the risks from hand-touch sites by Professor Wendy Graham from the BASICS team.

LSHTM experts are providing technical support to the UK government and Unilever’s Hygiene Behaviour Change Coalition. Its researchers have also developed and are coordinating the COVID-19 Hygiene Hub – a broad partnership that will provide technical resources and dedicated support to government and organizations implementing hygiene programs to combat COVID-19 transmission and provide a platform for communication and learning among partners.

Water Aid

The first phase of WaterAid’s COVID-19 response is focused on delivering key hygiene behavior change campaigns in coordination with national governments, distributing materials such as soap, water, personal protection equipment and, where possible, handwashing stations. WaterAid’s experts are providing technical support to national governments and key coordinating mechanisms.

  • In Bangladesh, WaterAid’s ‘Fight Corona’ campaign, which uses social media and radio, has reached over 3 million people. It has installed free handwashing facilities in public areas such as bus stops, railway stations, markets and shopping malls.
  • In Pakistan, 22 million people across the country have been reached through a similar WaterAid awareness campaign on the importance of handwashing with soap and social distancing. The campaign uses regional and local languages and has been broadcast over radio, local cable networks and through SMS service. WaterAid has also installed handwashing facilities in hospitals, quarantine centers and public places in Islamabad, Lahore, Multran, Muzzaffargarh, Mardan and Quetta districts in close coordination with the district administrations.
  • In Zambia, WaterAid is working with celebrities and artists to record hygiene promotion videos that are being posted on social media. For example, Pompi, a popular musician, produced a music video on handwashing and promoted a #handwashingchallenge #Kutuba2020
  • In Malawi, WaterAid has developed a pedal handwashing device to reduce contact with soap and taps.
  • In Cambodia, through the Building and Wood Workers Trade Union of Cambodia, WaterAid is providing guidance and online training for members to create simple hand hygiene facilities using local recycled materials. It is providing hand hygiene facilities and materials to hospitals and medical students for training. WaterAid and the National Institute of Public Health are also undertaking a rapid assessment of the role of cleaners during the COVID-19 response and identifying knowledge gaps.

Kinnos

Kinnos provided its Highlight® color additive technology to hospitals in China during the onset of the COVID-19 outbreak. It is now supplying various EMS/fire departments with Highlight® to help decontaminate ambulances and PPE equipment, and to hospitals for disinfecting screening rooms. Kinnos has also started manufacturing hand sanitizers to aid in the shortage and has provided them to multiple medical organizations.

Making Health Care Clean: Steve Sara, Save the Children, On How an Approach to Clean Clinics Can Be Cheap and Sustainable

This post is part of a series authored by the BASICS (Bold Action to Stop Infections in Clinical Settings) team. BASICS is a new initiative that will transform healthcare and reduce healthcare-associated infections (HAIs) by at least 50%. Tanzania is one of the four countries where BASICS’ rollout is planned

Implementing clean care and quality infection prevention and control in healthcare facilities in low-income countries can be simple, cheap and show quick progress. How can we save money for governments, the health systems and families but ensure a lower rate of infection, saved lives and saved time? WASH expert Steve Sara takes you through the power of the Clean Clinics approach.

Teaching the Science of Cleaning: Professor Wendy Graham of LSHTM on the Crucial Importance of “Basics” in Fighting Infections

This post is part of a series authored by the BASICS (Bold Action to Stop Infections in Clinical Settings) team. BASICS is a new initiative that will transform healthcare and reduce healthcare-associated infections (HAIs) by at least 50%. Tanzania is one of the four countries where BASICS’ rollout is planned

Cleaning is a science, but cleaning staff in low resourced healthcare facilities are often not equipped with the right training, supplies or the power to ask for what they need to carry out effective cleaning and effective change in behavior.

How can we make teaching the science of clean easy, practical and unforgettable for those who hold the power of ensuring hygiene in healthcare is safe, of high quality and successful? Professor Wendy Graham takes you through the power of TEACH CLEAN.

 

STRONG HEALTH SYSTEMS DON’T EXIST WITHOUT WATER, SANITATION AND HYGIENE: LESSONS FROM COVID-19

This post is part of a series authored by the BASICS (Bold Action to Stop Infections in Clinical Settings) team. BASICS is a new initiative that will transform healthcare and reduce healthcare-associated infections (HAIs) by at least 50%. Tanzania is one of the four countries where BASICS’ rollout is planned

This post originally appeared on WaterAid’s website on April 1, and is reposted with permission.

As of March 31, the World Health Organization (WHO) had reported some 719,000 confirmed cases of coronavirus (COVID19) and 33,000 deaths in 203 countries. Declared a pandemic by the WHO on March 11, infections have spread at a rapid pace, creating an unprecedented global crisis. Many countries continue with full lockdown measures to help slow transmission. Healthcare systems are overwhelmed.

The pandemic has hit Europe and North America hard, and there are fears that African countries could see a similar outbreak, which could have devastating impacts on people’s health, education and livelihoods.

The ability to protect ourselves literally falls into our own hands, as COVID-19 can spread between people through contact with droplets of an infected person. Good hygiene practices are among the key measures for preventing the spread of COVID-19 – and hand hygiene is at the forefront. Effective hand hygiene entails washing hands with soap for at least 20 seconds – this is one of the main ways to protect yourself from contracting the infection.

Handwashing with soap is simple but effective. This is because it inactivates and removes virus particles that may be on our hands. When used properly, soap effectively dissolves the fatty membrane that surrounds the virus particles, causing them to fall apart and be inactivated.

Research shows that handwashing with soap is linked to a 16-23% reduction in acute respiratory infection, substantial reductions in neonatal infections, and a 50% reduction in pneumonia (source: The Lancet).

While the WHO has called on people and governments to emphasize hand hygiene and environmental cleanliness as the most effective way to prevent the infection and spread of COVID-19, this advice is difficult in countries lacking access to clean water, decent toilets and good hygiene. Statistics from the WHO/Joint Monitoring Programme (JMP) show that one in 10 people worldwide have no access to clean water close to home, and around 1.4 billion people have no handwashing facility at all.

Water, soap, and supplies to prevent and control the spread of infections are quintessential for frontline health workers to be able to perform their jobs effectively – yet one in six healthcare facilities globally has no soap and water available for patients, doctors and nurses to wash their hands. Research has shown that over 30% of healthcare facilities in Tanzania lack access to clean water, making hand hygiene a challenge (source: Tanzania Service Provision Assessment).

Additionally, while European countries are implementing lockdown measures and social distancing, many people in low-income countries rely on day-to-day incomes and simply don’t have the option of remaining home. In these places, investing in water, sanitation and hygiene (WASH) is an effective strategy for helping people to practice good hygiene and reduce their risk of COVID-19 and other diseases.

The pandemic and other contagions underscore the practical need for Tanzania to invest in WASH in our communities, schools, public utilities (markets, bus stations) and healthcare facilities. Ensuring that communities can practice good hygiene will dramatically reduce the risk of people contracting infections and reduce the strain on the already stretched healthcare system.

In 2017, the Ministry of Health, Community Development, Gender, Elderly and Children launched the National Guidelines for Water, Sanitation and Hygiene in Healthcare Facilities. The Ministry of Education, Science and Technology also launched guidelines for WASH in schools. We must support the government to ensure these guidelines are resourced and rolled out. This will create resilience within the health and education systems and put us in a better position to deal with future disease outbreaks.

WaterAid Tanzania and our partners will continue to support the government to invest in national hygiene promotion to help equip citizens with the hand-hygiene knowledge and tools they need to protect themselves and their communities. WaterAid will also increase our investment to scale up the provision of WASH services, improve access to handwashing facilities at key locations, use mass media to share important handwashing and hygiene messages, and support healthcare and frontline workers on Infection Prevention and Control training.

In the long term, more investments in WASH are needed to accelerate access and achieve the goals of Tanzania’s Development Vision 2025 and Sustainable Development Goal 6 – universal access to water and sanitation. This means embedding WASH interventions into key national development sectors – putting it firmly at the center of national development. We must take the lessons from COVID-19 to create stronger and more effective health systems.

This is a time where we can all take action. Individuals can  practice good hygiene behaviours to protect themselves and others from the coronavirus; donors can invest in WASH as a core priority of global health security; NGOs and development partners can support the government in its efforts to strengthen hygiene behaviour change programmes and WASH interventions; and media can support getting correct information to the public.

Lastly, we are all indebted to our healthcare workers across Tanzania and across the globe, who are putting themselves at risk to save the lives of others. The best way we can support them is to ensure that they are working in a safe environment, and for that let us push to ensure all healthcare facilities have clean water, decent toilets and good hygiene.

COVID-19 AND SURFACE DISINFECTION: THE IMPORTANCE OF THE “FOUR C’S” OF DISINFECTANTS

This post is part of a series authored by the BASICS (Bold Action to Stop Infections in Clinical Settings) team. BASICS is a new initiative that will transform healthcare and reduce healthcare-associated infections (HAIs) by at least 50%.

This post originally appeared on Kinnos’ website on March 26th, and is reposted with permission.

We want to make it clear from the start that all aspects of infection prevention are crucial in the response against COVID-19: compliance with social distancing, availability of personal protective equipment (PPE), effective hand hygiene, and thorough surface disinfection, and that one isn’t necessarily more important than the other. While the media has widely reported on social distancing and (unfortunately severe deficiencies of) PPE and hand sanitizer, we feel that the nuances of surface disinfection are not frequently discussed. And having been in the disinfection space for over 5 years now, we feel pretty competent in talking about it. Kinnos has previously written about the “Four C’s of Disinfectants” in a prior blog post and we wanted to revisit some of those aspects here, which will also help people better understand how to use the EPA’s list for “Disinfectants for Use Against SARS-CoV-2”.

Before we jump into disinfection, let’s talk about COVID-19 itself. We know that COVID-19 can be transmitted through aerosolized droplets and that these droplets can land on surfaces and remain viable for hours or days depending on the surface material. We also know that COVID-19 is an enveloped virus, meaning that it’s protected by a fatty lipid bilayer. Fatty layers are easily exploited: when you wash your hands with soap, what you’re really doing is creating a fat-soluble layer for the virus’s fatty layer to bind to so that it’ll wash away with the soap. Unlike more robust pathogens like non-enveloped viruses and bacterial spores that contain layers of tough protein, fatty layers are susceptible to bonding with alcohol which causes the fat to un-bond with each other, opening up the envelope and allowing the alcohol to go in and denature proteins. Stronger oxidizing disinfectants, like bleach and hydrogen peroxide, literally rip electrons off molecules to destroy the structure of the pathogen. All of this to say that using a disinfectant to inactivate droplets on surfaces seems like a good way to prevent COVID-19 transmission.

With this context, we can look at the Four C’s of Disinfectants (Chemistry, Concentration, Contact Time, and Coverage) and why they’re important. When we talk about the first three, Chemistry, Concentration, and Contact Time, we really mean 1) what, 2) how much, and 3) how long it takes kill a specific pathogen. For example, the active ingredient in Clorox Healthcare Germicidal Bleach Wipes is 0.55% sodium hypochlorite and it claims a 3-minute contact time against C. difficile spores. In order to go to market, all disinfectants have to submit data to the EPA proving these claims. To be classified as a sanitizer, for instance, the requirement is usually conducting an AOAC- or ASTM-standard test demonstrating a minimum 3-log reduction (e.g. 99.9% reduction, 4-log would be 99.99%, and so on) within 10 minutes on a couple of pathogens. Specifically in the context of COVID-19, we can look at a recent paper that compiled data on the efficacy of disinfectants against enveloped viruses. Sodium hypochlorite at a concentration of 0.5% was able to achieve a >3.0-log reduction in human coronavirus after 1 minute, whereas a 0.06% sodium hypochlorite solution was only able to achieve a 0.4-log reduction in transmissible gastroenteritis virus after the same time period, suggesting that a longer Contact Time than 1 minute is needed for a more diluted bleach solution to effectively kill enveloped viruses or that stronger concentrations should be used in practice.

And this is the key point – all the disinfectants you see on the EPA’s disinfectant list against COVID-19 have varying concentrations of active ingredients that require a different amount of time to be effective [FN1]. So if we go into the database, we’ll see that Micro-kill Bleach Wipes have a 30 second contact time, Sani-Cloth Bleach Wipes have a 1 minute contact time, and Cavicide Bleach has a 3 minute contact time, even though they’re all sodium hypochlorite. You’ll also notice that many of the quaternary ammonium (“quat”) disinfectants (which is the active ingredient in household disinfectants like Lysol and what the media means when they say “alcohol” because quats are dissolved in alcohol) tend to have longer contact times at the 10 minute mark. As discussed above, it’s generally because alcohol breaks down the membrane by bonding and then the quats go in and denature proteins whereas bleach is ripping the virus apart more rapidly via oxidation. One of our gripes with all of the news articles saying that bleach is overkill and that alcohol is sufficient is that they completely neglect the Contact Time. Yes, alcohol can be effective, but often only if you’re letting it sit on the surface undisturbed for 10 minutes, in which time the alcohol could evaporate and you may need to reapply. But who’s actually sitting there with a timer for 10 minutes and making sure the surface stays wet for that time? For the record, this post is NOT meant to incite fear or to say that your standard quat/alcohol disinfectants can’t be effective (you’ll notice some bleach products have 10 minute contact times and some quat disinfectants are 3 minutes [FN2]) but the main message here is to help you understand that effectively disinfecting surfaces requires following a process and not just buying a product. It’s like that saying: it’s how you use it that matters.

Finally, there’s Coverage, which is pretty intuitive and ties everything back to the importance of process – cover every part of the surface and make sure the surface is covered for the correct Contact Time. Of course, this can be difficult when you’re dealing with large surface areas and using a transparent disinfectant, so just try your best to be thorough. It’s worth noting that many of the surfaces you tend to disinfect are waterproof, and when you put a liquid on a waterproof surface, it beads up. If beading occurs, you’re physically unable to achieve the contact time on every part of that surface. The good news is that more disinfectant manufacturers have been addressing this problem by adding surfactants which lower the surface tension of the liquid to allow it to spread out and cover waterproof surfaces. If you spray or wipe down a dark-colored surface, you should be able to see if your disinfectant is forming beads or not.

Normally, this is the part where we pitch you on how Kinnos has developed our Highlight® color additive to solve the Coverage and Contact Time problem, but the intent of this post is to be informational rather than promotional, so just take a look at our website if you’re interested. We hope that this post will help people use disinfectants more effectively, and that we can all work more well-informed to protect ourselves and our loved ones.


Footnote 1: You might be asking how the EPA has approved all of these disinfectants given that no one has actually been able to run tests specifically against COVID-19, and the answer is that the EPA allows disinfectants to use efficacy against the “most resistant representative virus” to claim efficacy on weaker ones. So if you have approval for a more robust non-enveloped virus, then the assumption is that you can easily kill an enveloped one. That’s why the database tells you to follow the instructions for killing things like canine parvovirus, which is a non-enveloped virus.

Footnote 2: One of the secrets of the disinfection world is that specific products are marketed for specific use cases. For example, most hospitals use bleach to kill C. difficile spores, which generally has a contact time of 3-4 minutes, and they’ll slap that number onto their marketing materials. So even if that bleach product can kill a virus in 1 minute, sometimes the manufacturer will just use a 3 minute contact time (or longer) because they know they can easily pass the required AOAC- or ASTM-standard test at that time point and they’re marketing 3 minutes already anyway. To an extent, this is why some of the bleach products may have 10 minute contact times on their EPA labels even though it’s generally known that bleach easily destroys enveloped viruses. Even so, always better to follow the instructions for Contact Time on the label of the disinfectant.

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COVID-19 Pandemic Reinforces the Need for Healthcare Facilities’ Preparedness

This post is part of a series authored by the BASICS (Bold Action to Stop Infections in Clinical Settings) team. BASICS is a new initiative that will transform healthcare and reduce healthcare-associated infections (HAIs) by at least 50%.

Written by the BASICS Team

In declaring the COVID-19 coronavirus a pandemic, World Health Organization Director-General Dr. Tedros Adhanom Ghebreyesus urged nations to “ready your hospitals” and “protect and train your health workers.”

Those two actions are at the core of what BASICS (Bold Action to Stop Infections in Clinical Settings) proposes: helping health systems to adopt simple, inexpensive measures to reduce infections at the point where care is delivered; measures supported by training platforms, upgraded water, sanitation and hygiene infrastructure, reliable supply chains and monitoring and accountability processes.

As the COVID-19 crisis has deepened worldwide, BASICS can play another role beyond reducing healthcare-associated infections and combatting antimicrobial resistance. Establishing a healthcare workforce equipped with the knowledge, training, resources and incentives needed to maintain a clean healthcare environment and the supplies is critical. Without adequate infrastructure, functional supply chains, modern training, monitoring progress and rewarding high performance, staff cannot protect themselves and their patients during routine care, let alone during high-risk events like a global pandemic.

Largely overlooked is the toll that COVID-19 is exacting on frontline healthcare workers, who are themselves becoming infected or spreading the disease because of a shortage of personal protective equipment like facemasks and gloves. A stable supply chain would help ensure that staff and facilities have vital materials. 

“Without secure supply chains, the risk to healthcare workers around the world is real … We can’t stop COVID-19 without protecting health workers first,” Ghebreyesus warned on March 3.

While frequent handwashing is one of the most effective ways of reducing tranmission of infections and a pillar of the BASICS solution, handwashing is more effective when coupled with the cleaning of high-touch surfaces. BASICS addresses handwashing alongside cleaning practices that create “safe to touch” surfaces like bedside tables, doorknobs and faucets.

BASICS Partners Responding to the Pandemic

Save the Children, the London School of Hygiene and Tropical Medicine, WaterAid and Kinnos have all mobilized responses to the pandemic.

Save the Children was among the very first international aid organizations to deliver critical supplies to health workers on the front lines of the crisis, as well as provide families with supplies and trusted information to reduce transmission and keep children safe. Its regional and country offices will be responding directly to vulnerable children and families to support their needs, with an emphasis on those in places with weakened health systems, fragile contexts or a limited capacity to respond due to other ongoing crises. 

Its global and national health teams are participating in daily conversations with the World Health Organization, the UN and other COVID-19 coordination bodies and advising the global READY consortium, which seeks to strengthen preparations among nongovernmental organizations for major disease outbreaks or pandemics.

The London School of Hygiene and Tropical Medicine’s experts are involved in many aspects of research and are providing guidance to those responding around the globe to the pandemic. Since January, teams from the School have mobilized to help slow the spread and mitigate COVID-19’s impact. Its global public health experts are working around the clock to provide accurate, measured and objective information and advice to governments, industry and the public.

The School’s mathematical modellers have been mapping the virus since the earliest days of the outbreak. Their insights into patterns of transmission, behavioural response and control measures are also informing the global response, including helping assess how many hospital beds will be needed, the stress on healthcare systems and how communities can prepare.

WaterAid is supporting the sharing of hygiene messaging and activities through social media and other media channels based on global and national recommendations, including developing materials in local language and with visuals to showcase good hygiene practices. In some countries, building off existing hygiene programs, it is working with government on promoting hygiene, predominantly handwashing, through government-supported behaviour change campaigns in response to COVID-19. This may expand beyond government to others, such as private-sector employers, and expand to include improving infrastructure where needed in line with government action.

WaterAid is committed to tackling inequalities in all aspects of WASH. This extends to COVID-19, as we know the most marginalized and discriminated against will be impacted the most. WaterAid is committed to supporting responses that are gender and socially-inclusive.

Kinnos, the social venture whose colorized decontamination technology Highlight®  will be used in BASICS to help cleaners and other healthcare workers achieve full disinfection of surfaces, has sent shipments of Highlight® to China to help with that country’s outbreak.