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Interventions to improve water supply and quality, sanitation and handwashing facilities in healthcare facilities, and their effect on healthcare-associated infections in low-income and middle-income countries: a systematic review and supplementary scoping review
  1. Julie Watson1,
  2. Lauren D'Mello-Guyett1,
  3. Erin Flynn2,
  4. Jane Falconer3,
  5. Joanna Esteves-Mills1,
  6. Alain Prual4,
  7. Paul Hunter5,
  8. Benedetta Allegranzi6,
  9. Maggie Montgomery7,
  10. Oliver Cumming1
  1. 1Disease Control, London School of Hygiene and Tropical Medicine, Faculty of Infectious and Tropical Diseases, London, UK
  2. 2Infection and Immunity, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
  3. 3Library and Archives Service, London School of Hygiene and Tropical Medicine, London, UK
  4. 4Regional Office for Western and Central Africa, UNICEF, Dakar, Senegal
  5. 5School of Medicine Health Policy and Practice, University of East Anglia, Norwich, UK
  6. 6Global Infection Prevention and Control Unit, World Health Organization, Geneva, Switzerland
  7. 7Water, Sanitation, Hygiene and Health, World Health Organization, Geneva, Switzerland
  1. Correspondence to Julie Watson; julie.watson{at}


Introduction Healthcare-associated infections (HCAIs) are the most frequent adverse event compromising patient safety globally. Patients in healthcare facilities (HCFs) in low-income and middle-income countries (LMICs) are most at risk. Although water, sanitation and hygiene (WASH) interventions are likely important for the prevention of HCAIs, there have been no systematic reviews to date.

Methods As per our prepublished protocol, we systematically searched academic databases, trial registers, WHO databases, grey literature resources and conference abstracts to identify studies assessing the impact of HCF WASH services and practices on HCAIs in LMICs. In parallel, we undertook a supplementary scoping review including less rigorous study designs to develop a conceptual framework for how WASH can impact HCAIs and to identify key literature gaps.

Results Only three studies were included in the systematic review. All assessed hygiene interventions and included: a cluster-randomised controlled trial, a cohort study, and a matched case-control study. All reported a reduction in HCAIs, but all were considered at medium-high risk of bias. The additional 27 before-after studies included in our scoping review all focused on hygiene interventions, none assessed improvements to water quantity, quality or sanitation facilities. 26 of the studies reported a reduction in at least one HCAI. Our scoping review identified multiple mechanisms by which WASH can influence HCAI and highlighted a number of important research gaps.

Conclusions Although there is a dearth of evidence for the effect of WASH in HCFs, the studies of hygiene interventions were consistently protective against HCAIs in LMICs. Additional and higher quality research is urgently needed to fill this gap to understand how WASH services in HCFs can support broader efforts to reduce HCAIs in LMICs.

PROSPERO registration number CRD42017080943.

  • health education and promotion
  • systematic review
  • prevention strategies
  • hygiene
  • public health

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  • JW and LD-G are joint first authors.

  • Handling editor Seye Abimbola

  • Contributors LDM-G, EF, JF, JE-M, AP, PH, BA, MM and OC conceived the idea for the review and contributed to the published protocol. LDM-G, JF and OC developed the search strategies. LDM-G and JF executed the searches. JF conducted screening of titles and JW, LDM-G and OC screened abstracts and full texts for inclusion. JW, LDM-G and OC extracted data from studies. JW and LDM-G conducted a risk of bias assessment and synthesised results. JW, LDM-G and OC prepared first draft of manuscript. All authors contributed to later drafts of the manuscript. The corresponding author (JW) attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. JW and LDM-G contributed equally to this paper.

  • Funding This review received funding from WHO, Unicef and DFID through the SHARE Research Programme. The funders had no institutional involvement in the study design, collection, analysis and interpretation of the data, in the writing of the report, or in the decision to submit the paper for publication. Authors from WHO (MM, BA) and Unicef (AP) contributed independently in their own right as individuals.

  • Disclaimer The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated. WHO takes no responsibility for the information provided or the views expressed in this paper.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.

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