WATER KNOWLEDGE NOTE Water Supply, Sanitation, and Hygiene (WASH) and COVID-19 Critical WASH Interventions for Effective COVID-19 Pandemic Response Safely managed water supply, sanitation, and hygiene potential for further disease outbreaks, such as cholera, (WASH) services are an essential part of preventing where the disease is endemic. disease and protecting human health during infectious disease outbreaks, including the current COVID-19 According to a WHO/UNICEF technical brief on WASH pandemic. One of the most cost-effective strategies for and waste management for COVID-19:1 increasing pandemic preparedness, especially in resource- constrained settings, consists of investing to strengthen core • Frequent and proper hand hygiene is one of the public health infrastructure, including water supply and most important measures to prevent infection with the sanitation systems. Good and consistently applied WASH COVID-19 virus. WASH practitioners should work and waste management practices serve as essential barriers to enable more frequent and regular hand hygiene by to human-to-human transmission of the COVID-19 virus improving facilities and using proven behavior change in communities, homes, health care facilities, schools, and techniques. other public spaces. • WHO guidance on the safe management of drinking water and sanitation services applies Provision of safely managed WASH services is also to the COVID-19 outbreak. Measures that go critical during the recovery phase of a disease outbreak above and beyond these recommendations are not to mitigate secondary impacts on community livelihoods needed. and well-being. These secondary impacts, which could • Many co-benefits will be realized by safely include disruptions to supply chains, inability to pay managing water supply and sanitation services and bills, or even panic buying, have negative impacts on the applying good hygiene practices. Such efforts will continuity and quality of water supply and sanitation prevent many other infectious diseases, which cause services; the ability of affected households to access and millions of deaths each year. pay for WASH services and products (e.g., soap, point- • There have been no reports of fecal-oral of-use water treatment, menstrual hygiene products); and transmission of COVID-19 to date. Therefore, the ability of schools, workplaces, and other public spaces the risk of catching COVID-19 from the feces of to maintain effective hygiene protocols when they reopen. an infected person appears to be low. The two main If not managed, secondary impacts can lead to the risk routes of transmission of COVID-19 are respiratory of increased spread of waterborne diseases, including a and contact. What is COVID-19? COVID-19 is caused by a unique group of viruses transmitted from animal to human. While similar to the flu, there are distinct differences, most notably a dry cough and shortness of breath. According to the World Health Organization (WHO), common signs of the infection include “respiratory symptoms, fever, cough, shortness of breath, and breathing difficulties. In more severe cases, it can cause pneumonia, severe acute respiratory syndrome (SARS), kidney failure, and even death.”  COVID-19 has a case fatality rate of about 3 percent to 4 percent. The highest risk of death is among those with underlying risk factors and the elderly (especially those above 80 years old).a,b Sources: a.World Health Organization. (2020, March 9). Q&A on coronaviruses (COVID-19). Retrieved April 8, 2020, from https:// www.who.int​/­news-room/q-a-detail/q-a-coronaviruses. b.Wilson N, Kvalsvig A, Telfar Barnard L, Baker MG. Case-fatality estimates for COVID-19 calculated by using a lag time for fatality. 2020. Emerg Infect Dis. (published March 13, 2020). https://doi.org/10.3201/eid2606.200320. • While there is no evidence, to date, on the SARS- promotion, food hygiene, and safe water CoV-2 survival in water or sewage, the virus is practices. Materials for handwashing and likely to become inactivated significantly faster than hygiene may include provision of fixed and nonenveloped human enteric viruses with known portable handwashing facilities, purchase of waterborne transmission (e.g., adenovirus, norovirus, soap and alcohol-based hand rubs, provision rotavirus, and hepatitis A). Heat, high or low pH, of water supplies for handwashing, and point- sunlight, and common disinfectants (e.g., chlorine) all of-use water treatment. Schools, workplaces, facilitate die-off. markets, transport stations, and other areas where people gather all require easy access This brief provides a menu of options on critical WASH to water and soap for handwashing. Proven interventions for effective COVID-19 pandemic response behavior change techniques can help increase the and building resilience to future risks. frequency and improve the practice of critical hygiene behaviors. Resources such as the Global 1. Preparedness and emergency response. Support Handwashing Partnership can be tapped to affected, at-risk, and low-capacity countries to secure mobilize private, public, and civil society actors infection prevention and control in health facilities to support the development of messaging and and communities. materials to respond to COVID-19 outbreaks. 1.1. Safe WASH services and medical waste 1.3. Provide rapid, low-cost water service for management in health care facilities are communities, health care facilities, and schools essential to deliver quality health services; protect that currently lack access to reliable and safe patients, health workers, and staff; and prevent water supply is critical to enable handwashing, further transmission. During an infectious disease hygiene, and disinfection. Local government or outbreak, services should meet minimum quality other actors must provide quick, just-in-time standards and should be separated for infected and water access points or water kiosks (potentially noninfected patients. Support is required to ensure including provision of soap) in unserved urban services are not disrupted and products such as and rural areas, and for unserved health care soap and alcohol-based hand rubs are available. facilities and schools. These would include Temporary health care facilities and quarantine (i) provision and operation of compact water sites also need to provide these services. treatment plants; (ii) construction and operation 1.2. Communication and preparedness related of water points to deliver water in strategic urban to handwashing behavior change and or rural points; and (iii) provision and operation WATER GLOBAL PRACTICE | WATER SUPPLY, SANITATION, AND HYGIENE (WASH) AND COVID-19 2 of trucks for water delivery (bottled, sachets) and care facilities and to avoid disruption of community water tankers, including adequate water storage livelihoods and well-being. to service operators. 2.1. Provide financial support to water supply 1.4. Safely manage shared and institutional and sanitation utilities to monitor and support sanitation facilities to ensure that users of cash reserves, availability of water supply and shared sanitation facilities and sanitation wastewater treatment chemicals, availability of workers (toilet attendants, sanitation staff) are electricity fuel for pumping and treating water, not exposed to the COVID-19 virus spread. appropriate staffing levels, and routine or capital Critical steps to help protect the 700 million maintenance. people globally who are estimated to use shared 2.2. Provide technical assistance to governments sanitation as their primary form of sanitation to strengthen country systems, including include (i) maintaining and cleaning shared (i) agile service delivery mechanisms that may sanitation facilities frequently, (ii) providing turn to local private sector to delivery safe water soap and water for handwashing, and through turnkey solutions under design-build- (iii) following guidance on social distancing operate contracts; (ii) enhanced water quality and related behavioral changes. In addition, assurance and monitoring; (iii) preparation of providing sanitation workers with personal utility emergency plans (absenteeism may be a protective equipment, strengthening support for serious risk); (iv) safely managing wastewater them to seek health care services, and providing and fecal sludge; (v) emptying latrines and safe trainings and guidance on related COVID-19 disposal of excreta; (vi) monitoring of secondary risks can further minimize COVID-19-related impacts. exposure. 2.3. Provide financial support to beneficiaries to 1.5. Emergency support to water supply and ensure continuity of WASH services, such sanitation utilities and providers to ensure as financing for fee waivers to mitigate service continuity of water supplies, enhanced disruption for households and institutions monitoring, staffing levels, equipment and (e.g., schools, health care centers, government spare parts, and worker safety. Governments agencies). Ensure funding for WASH services should support additional emergency measures and related products (e.g., soap) is included in to ensure that water supply and sanitation social protection operations targeting poorer utility staff and service providers have protective households. For fragile countries that lack social equipment, priority for testing, and salary safety nets and whose fiduciary arrangements supplements to compensate for the additional do not allow for development policy operations workload and risk. (DPOs), in-kind distribution is necessary 1.6. Emergency response to fragility, conflict, to vulnerable, most at-risk populations and violence situations. The main principle (e.g., distribution hygiene and cleaning kits, of an emergency WASH response is to ensure water distribution). consideration of WASH at the site selection and 2.4. Ensure viability of critical supply chains, such planning stages while coordinating the response as for hygiene product availability in markets closely with physical planning, public health, and (e.g., soap, disinfectant, point-of-use water the environment. Governments and associated treatment supplies) as well as import and export agencies should follow the multisectoral needs restrictions on critical equipment needed by assessment for refugee emergencies, followed by a utilities or households. more detailed initial WASH rapid assessment of local WASH-related resources in relation to the 3. Build resilience against future diseases. Safely needs and demand.2 This includes assessment of managed WASH services are needed to support water resources (quantity and quality) for water affected, at-risk, and low-capacity countries to build sources and distribution options. resilience against future pandemics, as well as against diseases that afflict poor populations in low-income 2. Mitigate secondary impacts. WASH services and countries on a more routine basis, such as diarrhea. products are essential for well-functioning health In 2016, the WHO estimated that poor WASH was WATER GLOBAL PRACTICE | WATER SUPPLY, SANITATION, AND HYGIENE (WASH) AND COVID-19 3 responsible for 829,000 deaths from diarrheal disease, • The Water GP is seeking to leverage existing systems equivalent to 1.9 percent of the global burden of through (i) activating contingent emergency response disease. Cholera, an acute diarrheal disease linked components; (ii) providing additional financing to to contaminated water, which can kill within hours existing WASH programs; or (iii) developing new if untreated, infects up to 4 million people each emergency response programs, including DPOs and year, killing an estimated 21,000 to 143,000 people. investment project financing. Other diseases, such as typhoid and measles, increase • The Water GP practice managers are reaching out precipitously in low-income countries when domestic to their respective country management units for water supply outages occur. In some individuals these coordinating efforts. diseases are fatal, and in many others their burden • The Water GP country-focused staff members are reduces labor productivity and wages. If the burden is reaching out to their respective counterparts for high, repeated illnesses for family members can trap coordinating efforts. households in a poverty cycle. • The Water GP management is working with UNICEF, 3.1. Provide safely managed WASH. the WHO, other UN agencies, and the US Centers 3.2. Basic WASH services and medical waste for Disease Control to provide coordinated support to management in health care facilities are our client countries. essential for safe and quality care. 3.3. Basic WASH services in schools are essential for • The Water GP Task Force is preparing material for safe and quality care. informing the practice’s responses. 3.4. Strengthen multisector, national institutions and platforms for policy development and coordination of prevention and preparedness, NOTES including for antimicrobial resistance. 1. WHO/UNICEF. 2020. “Water, Sanitation, Hygiene and Waste Management for the COVID-19 Virus.” Technical What is the Water GP’s current response? Brief, March 19, WHO/UNICEF, Geneva, Switzerland. 2. See the UNHCR website, https://emergency.unhcr.org​ • The Water GP assembled a Task Force with thematic /­entry/38439/wash-needs-assessment. and regional focal points for identifying and 3. Angola, Bangladesh, Burkina Faso, Côte d’Ivoire, Djibouti, responding to requests for WBG support. Eswatini, Ethiopia, Haiti, the Lao People’s Democratic • The Water GP assessed the portfolio with ongoing Republic, Mauritania, Nigeria, Senegal, Tajikistan, WASH activities in Health and Education Tanzania, Vietnam, and Yemen. sectors: (i) 22 World Bank projects across 16 4. Burkina Faso, Côte d’Ivoire, Eswatini, Ethiopia, Ghana, countries3 have activities that contribute to WASH in Guinea, Haiti, India, Indonesia, Kenya, the Kyrgyz Republic, health care facilities; and (ii) 32 World Bank projects the Lao People’s Democratic Republic, Liberia, Mauritania, across 24 countries4 have activities that contribute to Mozambique, Nicaragua, Niger, Nigeria, Solomon Islands, WASH in schools. Tajikistan, Tanzania, Timor-Leste, Uganda, and Vietnam. CONNECT WITH THE WATER GLOBAL PRACTICE www.worldbank.org/water ­ worldbankwater@worldbank.org @worldbankwater blogs.worldbank.org/water © 2020 International Bank for Reconstruction and Development / The World B reserved. 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