Establishment of district-led production of WHO-recommended Alcohol-Based Hand Rub (ABHR) during the COVID-19 pandemic: a model for improving access to ABHR during health emergencies

The supply of Alcohol-Based Hand Rub (ABHR) is critical to support easily accessible, quick, effective hand hygiene in healthcare settings and is an important complement to handwashing with soap in non-healthcare facilities (Pittet & Donaldson 2005; WHO 2009; CDC 2021a, 2021b). However, commercial production of ABHR in low- and middle-income countries (LMICs) is limited by the persistently high cost and limited availability of materials (Lamorde et al. 2020), which are exacerbated during public health emergencies (McMahon et al. 2020; Uganda Radio Network 2020). Before the COVID-19 pandemic, about 38–56% of hospitals in selected LMICs, which included Afghanistan, Democratic Republic of the Congo (DRC), Haiti, Nepal, and Tanzania, had access to ABHR; access was even lower in smaller, frontline healthcare facilities (HCFs) (McMahon et al. 2020). Community and public locations are likely to have had even more limited access to hand hygiene materials given the few standardized hand hygiene guidelines for those locations; however, formal assessment of ABHR coverage in these settings is limited (World Health Organization 2020).

To improve access to quality ABHR at lower cost, the World Health Organization (WHO) has published protocols for local, facility-level production of two ABHR formulations (World Health Organization 2010). Relatedly, SARS-CoV-2 – the virus that causes COVID-19 – and Ebola virus strains are susceptible to the WHO ABHR formulation, with log reductions greater than 5.9 in laboratory settings (Siddharta et al. 2017). In 2016, a cost analysis conducted in Rwanda found that locally-produced ABHR was 71% less expensive compared with commercial ABHR available for purchase (Budd et al. 2016). However, ABHR production typically is not feasible for smaller, primary facilities that may be unable to order raw materials and lack the space and technical capacity to produce ABHR (Lamorde et al. 2020). Although prior work in southwestern Uganda since 2018 suggests that ABHR production at a district scale is feasible and useful for outbreak response when established prior to outbreaks in Uganda (Tusabe et al. 2023), the establishment of new ABHR production sites, distribution, and monitoring systems during an active public health emergency or outbreak response has not been attempted. This study therefore assessed the feasibility of establishing and maintaining local production of high-quality ABHR and concurrent distribution to and monitoring at HCF and non-HCF settings at district or sub-district scale during an active outbreak in an LMIC. Results can inform considerations for and best practices in establishing local ABHR production during outbreak settings, in contrast to other methods of ABHR procurement.

During the early stages of the COVID-19 pandemic in Uganda, Amuru and Tororo Districts were identified as areas of concern for viral transmission as border districts due to high levels of use by migratory populations, including truck drivers (Berendes et al. 2022). The Population Connectivity Across Borders (PopCAB) toolkit (NCEZID 2021) was implemented to characterize population movement patterns in HCFs and community settings at high risk for COVID-19 transmission in Tororo and Amuru districts. The PopCAB results were utilized to prioritize locations for ABHR distribution in the two districts. Subsequently, Moroto and Kotido districts were identified as areas of concern for COVID-19-related challenges due to having largely pastoral populations and a semi-arid climate with challenges to water availability (Nicol et al. 2021); all public and private not-for-profit HCFs were prioritized. Locations prioritized across districts are shown in Table 1.

In each district, a technical officer with previous experience in ABHR production assessed the space proposed by the district government for ABHR production using a checklist for local production of ABHR (Supplementary material S1) adapted from the WHO protocol (World Health Organization 2010). Two WASH project officers (one for both Amuru and Kotido and the other for Tororo and Moroto) were hired and trained on the local production and quality control of the ABHR.

To promote sustainability, 12 district staff (three in each of the four districts) nominated by the District Health Officer were mentored for 3 days on the production and quality control of ABHR. The ABHR was produced by the trained WASH officers, based on the WHO guide on the local production of ABHR (World Health Organization 2010). Internal quality control (IQC) was performed immediately post production and externally at pre-distribution by measuring the alcohol content using an Economy Tralle & Proof alcoholmeter model number MT307 (Brewmaster, Pittsburg, CA) as described in Supplementary material S2. ABHR production and distribution was demand-driven based on amounts requested by HCFs and non-HCF settings monthly during consumption monitoring (see in the following).

ABHR production quantities were recorded by the producer at the production (L) and were compared with national data on confirmed positive cases recorded during the ABHR project cycle. COVID-19 disease data was provided by Uganda's Ministry of Health Public Health Emergency Operations Center.

The assignment of roles and responsibilities was consistent with those proposed when establishing ABHR production in non-outbreak settings shown in Table 2 (Tusabe et al. 2023) and as outlined in Figure 2.

Distribution in the two districts, responding to the heightened demand during the COVID-19 pandemic, used hired vehicles. Last-mile distribution of ABHR in Amuru and Tororo to HCFs and community spaces was supported through project funds given that there was no established government supply chain for hand hygiene or WASH-related materials to community locations.

ABHR consumption was monitored at the receiving locations using standardized stock cards (Supplementary material S3). At the healthcare facility, the liters of ABHR received was entered in a stock card by the person at the medical store for the HCF as received item and the remaining amount of ABHR was tracked accordingly on the stock card as the facility filled and refilled its 1-L empty ABHR containers. Similar stock cards and tracking was done by wardens at markets and places of worship, the officer in charge at police checkpoints, POEs and police stations and prisons, and the teacher in charge of health at schools.

All raw materials involved in the ABHR production were procured from local markets.

Costs included production site renovations, procurement of production equipment (buckets, mixing paddles and alcoholmeter), ingredients (distilled water, 95% ethanol, 100% glycerol, 6 and or 3% hydrogen peroxide) dispensers, distribution, and salary costs. Costs per liter of ABHR were calculated by dividing the total costs involved (raw materials, one-off supplies, staff salaries, overhead and distribution costs) by the total ABHR (L) produced (Table 3).

Once a production location was identified, it took 5–17 days for the project to establish an ABHR production site in a district, which included renovations and setup as shown in Figure 1.

In 2021, 21,600 L of quality-controlled ABHR were produced using WHO formulation 1: 7,980 and 8,720 L were produced between April and December 2021 for Amuru and Tororo, respectively, and 2,980 and 1,920 L produced between August and December 2021 for Kotido and Moroto, respectively. All ABHR batches produced (n = 535) passed IQC and external quality control (EQC) for alcohol concentration (target: 75–85%) (World Health Organization 2010) (Table 2).

Between March and December 2021, 6,420 L of ABHR were distributed to 34 locations in Amuru and 5,120 L to 36 locations in Tororo. Between August and December 2021, 1,200 L were distributed to 19 HCFs in Moroto and 1,140 L to 22 HCFs in Kotido (Supplementary material S4). Using project vehicles, the project supported last-mile delivery (Davison et al. 2021) during the first month of implementation in Kotido and Moroto. After this period, some HCFs made direct requisition requests to their respective District Health Office and, upon approval, which usually was received in less than a day. HCF representatives picked up the ABHR from the district medical stores. Direct-to-HCF distribution was facilitated by the National Medical Stores (NMS) distribution system that delivers essential drugs quarterly to public HCFs. Otherwise, ABHR distribution was coordinated by the district IPC and store person with project staff support.

The average monthly ABHR consumption for HCFs across all districts was 7.0 L for HCII, 15.0 L for HCIII, 29.8 L for HCIV, and 29.9 L for hospitals. Across community locations, which were limited to Amuru and Tororo, the average monthly consumption was 22.0 L for schools, 10.5 L for markets, 11.8 L for churches, 27.3 L for guesthouses, 21.5 L for POEs, 23.0 L for checkpoints, 13.1 L for police stations, 16.0 L for prisons and 14.2 L for truck checkpoints (Supplementary material S4).

Renovation, including air conditioning systems installation costs, ranged from $2,300 (Tororo) to $5,600 (Kotido) in USD. The average cost per liter of ABHR was $4.30 across the four districts (range: $3.50–$5.76) (Table 4a).

Increasing ABHR access and utilization is important in reducing the transmission of highly infectious diseases like COVID-19 and the Ebola virus. Similarly, providing access to multiple user-friendly hand hygiene points (functional ABHR dispenser bottles) minimizes sharing and allows for increased social distancing (Hayashi et al. 2022), which is partly a preventive measure for contagious diseases. Local production of ABHR at a district scale was feasible to establish, maintain, and adapt to new production needs during the height of the COVID-19 pandemic in Uganda, as well as in subsequent years when the pandemic was waning. Critically and uniquely, it enabled both HCFs and priority community locations to have regular and routine access to quality-assured ABHR, even during times of increased need for ABHR. The average total costs per liter of ABHR were affordable ($4.30) and similar to findings during non-pandemic times in Uganda (Tusabe et al. 2023). It was also less expensive than commercial ABHR, which was about $10/L until pandemic-driven supply limitations and inflation increased overall costs to about $60/L (Uganda Radio Network 2020). The cost difference for local production between sites is attributed to the high renovation costs of the ABHR production units and the low ABHR volumes demand for Moroto and Kotido. The low demand was attributed to the concurrent infection prevention and control programs funded by non-governmental organizations in these districts that supported the HCFs with commercial ABHR. Despite this difference, costs were less than that of commercial ABHR (Uganda Radio Network 2020). With increased production that would ensure access to lower-cost raw products, costs could significantly scale down even further compared with commercial ABHR.

ABHR consumption in frontline HCF was higher during the pandemic than during pre-pandemic, non-outbreak periods, which necessitated increased production capacity. In southwestern Uganda in 2018 and 2019, HCIIs had lower average monthly consumption of ABHR (3.0 L) prior to the COVID-19 pandemic (Tusabe et al. 2023) than during the pandemic (7.0 L). Given that primary HCFs receive fewer supplies yet are the frontline of the healthcare system (Armstrong-Hough et al. 2018), ABHR demand and subsequent consumption by healthcare workers may have been higher than pre-pandemic levels, with use increased even further due to risk perception. Notably, this study is one of the first to document locally produced ABHR consumption in community, public locations in Uganda, which will be informative as hand hygiene guidance and normative standards become more detailed in these locations (World Health Organization 2020).

The infrastructure and systems established during COVID-19 were subsequently utilized in response to the Sudan ebolavirus disease (EVD) outbreak in Uganda (CDC 2023). When the EVD outbreak was first declared on September 20, 2022, affected HCFs did not have to rush to find hand hygiene materials because many were rapidly provided with a supply of ABHR through the existing district-led program for ABHR local production built during the COVID-19 response. The project team rapidly mobilized resources to the affected districts with the EVD outbreak and produced over 17,000 L of ABHR within 7 days of the outbreak being declared. Nearby ABHR production units pivoted from district-level production to supplementary production for response to affected locations. Non-governmental organizations aiming to provide ABHR to HCFs opted to purchase raw materials for the production units to produce ABHR locally rather than purchase commercial ABHR in response to the EVD outbreak (CDC 2023). This rapid production was more sustainable than alternatives and resulted in more than enough ABHR to support every HCF in the affected districts, including the Mubende Hospital, giving healthcare workers easy access to hand hygiene resources. These investments helped the global community to support more sustainable local preparedness and response measures rather than one-off measures.

Although manually-filled standardized stock cards worked well for reporting ABHR consumption both in community locations and HCF, reliable monitoring of ABHR consumption during an emergency is complex and may require context-specific solutions to be defined and operationalized. These approaches would need to be examined during future emergency responses.

To improve sustainability and manage ramping up production during periods of peak demand, associated risks like high cost of raw materials and staff burnout, we involved government and key stakeholders from the project conception. This ensured the inclusion of ABHR to the list of medical countermeasures (MCMs) and obtained stakeholder buy-in to the contingency plan for emergency ABHR provision aligned to the national countermeasures plan. To leverage response efforts to spread expertise to partners, we developed and are piloting an online training curriculum to build ABHR production capacity in collaboration with stakeholder entities to align with the Global Health Security Agenda's call for improved global access to MCMs (Simpson et al. 2020) in a more sustainable manner. These efforts can improve future preparedness efforts; however, the approach is still primarily donor-funded, especially during response efforts. As such, there is no budget at the national level to facilitate the rapid mobilization of resources (e.g. trained producers, raw materials) when there is a public health emergency to scale up production. There is a need to establish and sustain the local ABHR production approach (including sustainable supply chain and delivery mechanisms) within emergency response support and funding measures nationally, as well as scale it for access in Ugandan HCFs and community settings during non-outbreak periods with a particular focus on addressing the gaps identified during past pandemics and epidemics (World Health Organization 2023).

Although this approach can serve as a guide, roles and responsibilities for stakeholders in production and distribution may differ in other countries and by the outbreak vs. non-outbreak production contexts. Costs were relatively low because the model capitalized on existing structures (e.g. personnel, buildings that were converted to ABHR production units, and systems/vehicles for delivery); however, if such structures were not in place, cost per liter would have been higher. District officials can support local ABHR production with space, staff, and distribution logistics, while non-governmental organizations can support renovations, initial raw materials, training, quality control, and monitoring of consumption. Country-specific optimization of roles, responsibilities, and shared costs (leveraging existing economies of scale) are important areas of future research for this model.

For cost-saving and destruction of any possible contaminating spores, WHO guidelines suggest cleaning and disinfection (reprocessing) of re-usable ABHR containers between new ABHR refills (World Health Organization 2010); however, step by step guides are limited and feasibility has yet to be assessed especially in community locations. In the current project, guidelines for reprocessing ABHR containers were developed and piloted only in HCFs. Future research is needed to identify whether these guidelines are sustainable and feasible as communicated to existing HCFs, as well as assess feasibility in non-healthcare locations.

This case study documents a feasible approach for LMICs to use to establish/leverage district-wide production and distribution of ABHR – a critical prevention measure – in the middle of the response to an outbreak. Results from this case study, combined with future research, can improve access to and use of ABHR for both future preparedness and response contexts.

We acknowledge the support of the District Health Offices of Amuru, Tororo, Kotido, and Moroto local governments who supported project activities.

The findings and conclusions of this paper are those of the authors and do not necessarily represent the official position of the U.S. Centers for Disease Control and Prevention (CDC) and Infectious Diseases Institute (IDI).

All relevant data are included in the paper or its Supplementary Information.

The authors declare there is no conflict.