{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,19]],"date-time":"2026-03-19T17:23:17Z","timestamp":1773940997629,"version":"3.50.1"},"reference-count":19,"publisher":"MDPI AG","issue":"7","license":[{"start":{"date-parts":[[2021,3,25]],"date-time":"2021-03-25T00:00:00Z","timestamp":1616630400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000030","name":"Centers for Disease Control and Prevention","doi-asserted-by":"publisher","award":["Cooperative Agreement number [NU2GGH001659-02-00]."],"award-info":[{"award-number":["Cooperative Agreement number [NU2GGH001659-02-00]."]}],"id":[{"id":"10.13039\/100000030","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Fourteen years of civil war left Liberia with crumbling infrastructure and one of the weakest health systems in the world. The 2014\u20132015 Ebola virus disease (EVD) outbreak exposed the vulnerabilities of the Liberian health system. Findings from the EVD outbreak highlighted the lack of infection prevention and control (IPC) practices, exacerbated by a lack of essential services such as water, sanitation, and hygiene (WASH) in healthcare facilities. The objective of this intervention was to improve IPC practice through comprehensive WASH renovations conducted at two hospitals in Liberia, prioritized by the Ministry of Health (MOH). The completion of renovations was tracked along with the impact of improvements on hand hygiene (HH) practice audits of healthcare workers pre- and post-intervention. An occurrence of overall HH practice was defined as the healthcare worker practicing compliant HH before and after the care for a single patient encounter. Liberia Government Hospital Bomi (LGH Bomi) and St. Timothy Government Hospital (St. Timothy) achieved World Health Organization (WHO) minimum global standards for environmental health in healthcare facilities as well as Liberian national standards. Healthcare worker (HCW) overall hand hygiene compliance improved from 36% (2016) to 89% (2018) at LGH Bomi hospital and from 86% (2016) to 88% (2018) at St. Timothy hospital. Improved WASH services and IPC practices in resource-limited healthcare settings are possible if significant holistic WASH infrastructure investments are made in these settings.<\/jats:p>","DOI":"10.3390\/ijerph18073409","type":"journal-article","created":{"date-parts":[[2021,3,25]],"date-time":"2021-03-25T14:51:12Z","timestamp":1616683872000},"page":"3409","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":10,"title":["The Impact of Water Sanitation and Hygiene (WASH) Improvements on Hand Hygiene at Two Liberian Hospitals during the Recovery Phase of an Ebola Epidemic"],"prefix":"10.3390","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1694-9344","authenticated-orcid":false,"given":"Udhayashankar","family":"Kanagasabai","sequence":"first","affiliation":[{"name":"John F. Kennedy Medical Centre, 1000 Monrovia, Liberia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kayla","family":"Enriquez","sequence":"additional","affiliation":[{"name":"Emergency Medicine, School of Medicine, University of California, San Francisco, CA 94110, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Richard","family":"Gelting","sequence":"additional","affiliation":[{"name":"Division of Global Health Protection, Centers for Disease Control and Prevention, Atlanta, GA 30329, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4780-1361","authenticated-orcid":false,"given":"Paul","family":"Malpiedi","sequence":"additional","affiliation":[{"name":"Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA 30329, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Celina","family":"Zayzay","sequence":"additional","affiliation":[{"name":"Ministry of Health, 1000 Monrovia, Liberia"},{"name":"Academic Consortium Combatting Ebola in Liberia, 1000 Monrovia, Liberia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"James","family":"Kendor","sequence":"additional","affiliation":[{"name":"Academic Consortium Combatting Ebola in Liberia, 1000 Monrovia, Liberia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Shirley","family":"Fahnbulleh","sequence":"additional","affiliation":[{"name":"Academic Consortium Combatting Ebola in Liberia, 1000 Monrovia, Liberia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Catherine","family":"Cooper","sequence":"additional","affiliation":[{"name":"Ministry of Health, 1000 Monrovia, Liberia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Williamatta","family":"Gibson","sequence":"additional","affiliation":[{"name":"Liberian Government Hospital, 2000 Tubmanburg, Liberia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rose","family":"Brown","sequence":"additional","affiliation":[{"name":"Liberian Government Hospital, 2000 Tubmanburg, Liberia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nadoris","family":"Nador","sequence":"additional","affiliation":[{"name":"Centers for Disease Control and Prevention, 1000 Monrovia, Liberia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Desmond E.","family":"Williams","sequence":"additional","affiliation":[{"name":"Centers for Disease Control and Prevention, 1000 Monrovia, Liberia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"David","family":"Chiriboga","sequence":"additional","affiliation":[{"name":"Academic Consortium Combatting Ebola in Liberia, 1000 Monrovia, Liberia"},{"name":"University of Massachusetts Medical School, Worcester, MA 01655, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7631-8187","authenticated-orcid":false,"given":"Michelle","family":"Niescierenko","sequence":"additional","affiliation":[{"name":"Harvard Medical School, Boston, MA 02115, USA"},{"name":"Boston Children\u2019s Hospital, Boston, MA 02115, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2021,3,25]]},"reference":[{"key":"ref_1","unstructured":"WHO (2021, March 18). Water, Sanitation, and Hygiene in Health Care Facilities Practical Steps to Achieve Universal Access to Quality Care. Available online: https:\/\/apps.who.int\/iris\/bitstream\/handle\/10665\/311618\/9789241515511-eng.pdf."},{"key":"ref_2","unstructured":"WHO, and UNICEF (2019). WASH in Healthcare Facilities: Global Baseline Report 2019, WHO."},{"key":"ref_3","unstructured":"World Health Organization (WHO) (2019). Water, Sanitation, Hygiene and Health a Primer for Health Professionals, World Health Organization (WHO)."},{"key":"ref_4","first-page":"27","article-title":"Water and Sanitation Standards in Humanitarian Action","volume":"15","author":"Ersel","year":"2015","journal-title":"Turk. J. Emerg. Med."},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Mallow, M., Gary, L., Jeng, T., Bongomin, B., Aschkenasy, M.T., Wallis, P., Cranmer, H.H., Debasu, E., and Levine, A.C. (2018). WASH activities at two Ebola treatment units in Sierra Leone. PLoS ONE, 13.","DOI":"10.1371\/journal.pone.0198235"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"578","DOI":"10.3201\/eid2104.141940","article-title":"Evolution of Ebola Virus Disease from Exotic Infection to Global Health Priority, Liberia, Mid-2014","volume":"21","author":"Arwady","year":"2015","journal-title":"Emerg. Infect. Dis."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"659","DOI":"10.1016\/j.chom.2015.11.008","article-title":"Evolution and Spread of Ebola Virus in Liberia, 2014\u20132015","volume":"18","author":"Ladner","year":"2015","journal-title":"Cell Host Microbe"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"44","DOI":"10.1016\/j.midw.2016.12.005","article-title":"\u201cEbola kills generations\u201d: Qualitative discussions with Liberian healthcare providers","volume":"45","author":"Bell","year":"2017","journal-title":"Midwifery"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"2","DOI":"10.1186\/s12916-015-0548-4","article-title":"Infection prevention and control of the Ebola outbreak in Liberia, 2014\u20132015: Key challenges and successes","volume":"14","author":"Cooper","year":"2016","journal-title":"BMC Med."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"526","DOI":"10.2471\/BLT.16.175802","article-title":"Improving water, sanitation and hygiene in health-care facilities, Liberia","volume":"95","author":"Abrampah","year":"2017","journal-title":"Bull. World Health Organ."},{"key":"ref_11","unstructured":"Ministry of Health Liberia (2015). Investment Plan for Building a Resilient Health System in Liberia, Ministry of Health Liberia."},{"key":"ref_12","unstructured":"Republic of Liberia, Ministry of Health (2021, March 18). WASH and Environmental Health Package in Health Facilities. Available online: https:\/\/www.washinhcf.org\/wp-content\/uploads\/2019\/05\/Final-WASH-EH-Package-for-Health-Facilities-2015.pdf."},{"key":"ref_13","unstructured":"World Health Organization (2017). Water and Sanitation for Health Facility Improvement Tool, World Health Organization."},{"key":"ref_14","unstructured":"WHO (2009). WHO Guidelines on Hand Hygiene in Health Care First Global Patient Safety Challenge Clean Care is Safer Care, World Health Organization."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"283","DOI":"10.1086\/650451","article-title":"Systematic Review of Studies on Compliance with Hand Hygiene Guidelines in Hospital Care","volume":"31","author":"Erasmus","year":"2010","journal-title":"Infect. Control Hosp. Epidemiol."},{"key":"ref_16","unstructured":"Cronk, R. (2018). Literature Review: Water, Sanitation, and Hygiene in Health Care Facilities, WaSH Policy Research Digest."},{"key":"ref_17","unstructured":"World Health Organization, and UNICEF (2015). Water, Sanitation and Hygiene in Health Care Facilities Status in Low- and Middle-Income Countries and Way Forward, World Health Organization."},{"key":"ref_18","unstructured":"World Health Organization (2016). Water and Sanitation Health Facility Improvement Tool \u2018WASH FIT\u2019 A Field Guide to Improving Water, Sanitation, and Hygiene in Health Care Facilities in Low-Income Countries, World Health Organization."},{"key":"ref_19","doi-asserted-by":"crossref","unstructured":"Benova, L., Cumming, O., Gordon, B.A., Magoma, M., and Campbell, O.M.R. (2015). Where There Is No Toilet: Water and Sanitation Environments of Domestic and Facility Births in Tanzania. PLoS ONE, 9.","DOI":"10.1371\/journal.pone.0106738"}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/18\/7\/3409\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T05:41:04Z","timestamp":1760161264000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/18\/7\/3409"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,3,25]]},"references-count":19,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2021,4]]}},"alternative-id":["ijerph18073409"],"URL":"https:\/\/doi.org\/10.3390\/ijerph18073409","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,3,25]]}}}