Local production of WHO-recommended alcohol-based handrubs: feasibility, advantages, barriers and costs

Bull World Health Organ 2013;91:963–969 | doi: http://dx.doi.org/10.2471/BLT.12.117085 Lessons from the field 963 Local production of WHO-recommended alcohol-based handrubs: feasibility, advantages, barriers and costs Joanna Bauer-Savage,a Didier Pittet,b EunMi Kimc & Benedetta Allegranzid Problem Health-care-associated infections are the most frequent adverse events during the delivery of health-care worldwide.1–3 Since the hands of health-care workers are the primary source of health- care-associated pathogens,4 good hand hygiene is an important factor in the reduction of such infections. In most health-care set- tings, alcohol-based handrubs (ABHs) are currently the preferred method for hand cleansing because they offer a broad antimicro- bial spectrum, a rapid antimicrobial effect and good skin tolerance, and can be made available at the point of care.5 However, problems in market availability, distribution and affordability severely limit the use of such handrubs in low- and middle-income countries.6,7 In 2005 – as part of its “Clean Care is Safer Care” programme – the World Health Organization (WHO) developed and tested two ABH formulations that complied with the relevant European norms for hand antisepsis and were suitable for local production in different settings.5,8 One of these formulations had ethanol – at 80% v/v – as its active component while the other had isopropanol – at 75% v/v. In a randomized cross-over trial, both formulations dem- onstrated excellent skin tolerability and acceptability among health- care workers.9 In 2011, we evaluated the feasibility, advantages and costs of the local production of the two formulations – and the barriers to such production – in an online survey. The methods that we used and the results that we obtained are outlined in this paper. Approach The survey was based on a questionnaire – on the local produc- tion of the WHO formulations – that had already been tested in a pilot study.5 The questionnaire consisted of 58 open and closed questions. Twenty of the questions were compulsory. The questionnaire was divided into two parts. Part I was de- signed to collect general information on the survey site and participants while Part II was designed to collect technical information on ABH preparation and storage, ingredient and dispenser procurement, quality control, tolerability, accept- ability and promotion. The questionnaire was made available online – in English, Khmer, Mongolian and Spanish – using the SurveyMonkey survey tool (SurveyMonkey, Palo Alto, United States of America). Through WHO regional focal points, country contacts and stakeholders, 125 potential local producers of either of the two WHO-recommended ABH formulations were identified and invited to complete the questionnaire. The survey was kept open for 9 months and up to four reminders were sent to the nonrespondents. Results Local setting Of the 125 potential survey sites, 100 (80%) responded to our invitation to participate. Of the 100 respondents, 56 stated that they were not currently producing either of the WHO formulations, three did not wish to participate, one could not participate because the respondent could not understand any of the survey’s languages, and one was excluded from the final analysis because the data provided were incomplete. Thirty- nine sites from 29 countries were therefore included in the Problem Reduction of health-care-associated infections in low- and middle-income countries is hampered by inadequate supplies of soap and water and the lack or high cost of alcohol-based handrubs (ABHs). Approach In 2005, the World Health Organization (WHO) developed and tested two formulations for ABHs that were suitable for production in health-care facilities. In 2011, the feasibility, advantages and costs of the local production of the two formulations – and the barriers to such production – were evaluated in an online survey. Local setting The survey included 34 health-care facilities and 5 private companies in 29 countries. Relevant changes Local production of one of the WHO formulations was feasible in every participating site. Twenty-one (54%) of the sites had replaced a previously used ABH with one of the WHO formulations. In 32 sites, the WHO formulation that had been produced was well tolerated and accepted by health-care workers. The WHO formulations were found to be less expensive than marketed ABHs. Barriers to local production included difficulty in identifying staff with adequate skills, the need for staff training, and constraints in ingredient and dispenser procurement. Lessons learnt The WHO formulations can be easily produced locally at low cost. They are well tolerated and accepted by health-care workers. Potential barriers to their local production – such as their smell and problems in the procurement of ingredients and dispensers and in performing quality control – require further investigation. a Institute of Tropical Medicine and International Health at Charité – Universitätsmedizin, Berlin, Germany. b Infection Control Programme and World Health Organization Collaborating Centre on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, 4 Rue Gabrielle Perret-Gentil, 1211 Geneva 14, Switzerland. c Harvard School of Public Health, Boston, United States of America. d Patient Safety, World Health Organization, Geneva, Switzerland. Correspondence to Didier Pittet (e-mail: didier.pittet@hcuge.ch). (Submitted: 27 December 2012 – Revised version received: 24 June 2013 – Accepted: 25 June 2013 – Published online: 30 September 2013 ) Bull World Health Organ 2013;91:963–969 | doi: http://dx.doi.org/10.2471/BLT.12.117085964 Lessons from the field Local production of alcohol-based handrubs Joanna Bauer-Savage et al. final data analysis (Fig. 1). According to the World Bank classification,10 seven (24%) of the 29 countries included in the final analysis were low-income, 16 (55%) were middle-income and the remaining six (21%) were high-income. The 39 survey sites were health-care facilities (n = 34) or private companies (n = 5). The five private companies were either selling one of the WHO ABH formulations on the local market (n = 3) or were contracted to produce one of the formulations by the national govern- ment (n = 2). Human resources The WHO formulations were produced only by pharmacists in 18 (46%) of the survey sites, jointly by pharmacists and technicians in six (15%) of the sites, only by technicians in four (10%) of the sites and by “other professionals” in the remaining 11 sites (28%). Sixteen (41%) of the survey sites had initial difficulty in identifying staff who had adequate skills for the local production of the WHO formulations, and the respon- dents representing 29 (74%) of the sites reported that staff had had to be trained in the production of such formulations (Table 1). Formulation Twenty-one (54%) of the survey sites had been using a different ABH before they had started producing one of the WHO formulations. At the time of the survey, 30 (77%) of the survey sites were using the formulation based on ethanol. The ethanol (96% v/v) being used came either from the chemical industry (16 sites) or had been produced – from sugar cane, maize, manioc, mahogany or walnut – by agro-industry (14 sites). The remaining nine sites (23%) used the WHO formulation based on isopropa- nol. The isopropanol (99.8% v/v) came from the chemical industry (eight sites) or from agro-industry (one site). The alcohol used was procured locally in 28 (72%) of the survey sites (Table 1). Glycerol and hydrogen peroxide (H2O2) were procured locally by 55% and 49% of the sites that used these chemicals, re- spectively. Difficulty in procuring ingre- dients of adequate quality for the ABHs was reported by 51% of the respondents – and attributed to local shortages and price fluctuations (Table 1). Nine of the survey sites reported using handrubs based on slight modi- fications of the WHO-recommended formulations. These modifications comprised: the exclusion of H2O2 (n = 3); the exclusion of glycerol (n = 1) or a reduction in its concentration (n = 1) to increase the moisturizing qualities of the final product; an increase in the concen- tration of glycerol (n = 1) to reduce the stickiness of the final product; or the addition of perfume (n = 3). Equipment and dispensers Respondents representing 24 of the survey sites reported information on the equip- ment that had been required for the local production of one of the WHO-recom- mended ABHs. Of the 24 sites, 11 (46%) had purchased equipment specifically for the production of ABHs; 10 (42%) of the sites – six in Cambodia and one each in Kenya, Mali, Saudi Arabia and Sen- egal – had had the necessary equipment donated; and three (12%) of the sites – in Malawi, Mongolia and the Philippines – already had adequate equipment. Information on the source of handrub dispensers was available for 36 of the survey sites. Dispensers were only sourced locally by 20 sites, only imported by nine sites and both sourced locally and imported by three sites. The necessary dispensers were donated to three of the survey sites in Cambodia, while one survey site in Mongolia re- used shampoo and soap bottles. Just over half of all respondents reported problems with the procurement of dispensers that were both affordable and of adequate quality (Table 1). In Kenya, ABH dispensers had often been stolen until they were wall-mounted and made too large to be easily portable. Of the 39 survey sites included in the final analysis, 26 (67%) – in Belgium, Brazil, Ethiopia, Indonesia, Jordan, Kenya, Malawi, Mali, Mongolia, Nigeria, Oman, the Philippines, Saudi Arabia, Senegal, Sudan, Thailand and Uganda – reused dispenser bottles and 27 (69%) reused the caps. One site in Nigeria bought dispensers in bulk, to reduce costs. Three sites reported that reused dispensers often developed problems as the result of pump or cap damage. Of the 24 health- care facilities that reused dispensers, 11 simply washed the empty dispensers; one thermally disinfected dispensers by submerging them in boiling water before air drying them and storing them with their caps tightly fitted; three only subjected them to chemical disinfection and the rest used various combinations of these three procedures (Table 1). Quality control The ABHs produced by 33 (87%) of the survey sites were subjected to quality control. Quality was assessed at the survey site (24 sites), elsewhere in the same country (5 sites), in both the survey site and elsewhere in the same country (2 sites) or only in an- other country (2 sites). The only type of quality control followed at 17 sites was the evaluation of alcohol concen- tration – using an alcoholmeter. Four sites only used filtration – to check for microbial contamination5 – and two only used gas chromatography. Vari- ous combinations of alcoholmetry, gas chromatography, filtration and H2O2 titrimetry were used in another seven sites. Lack of equipment at the survey sites hampered attempts at quality control in Cambodia, Ethiopia, the Islamic Republic of Iran and Pakistan. However, in Pakistan this barrier was overcome by sending samples of ABHs abroad for testing. Donation of testing equipment to five of the survey sites in Cambodia enabled the quality of the ABHs produced at these sites to be checked at the same sites. Acceptability and promotion Data on the acceptability of the WHO formulations were available for 38 of the survey sites. Of these 38 sites, 31 (82%) reported that their ABH was well toler- ated by their health-care workers. Work- ers at the other seven sites complained about one or more of the following: the smell or the stickiness of the handrub and skin damage or soreness resulting from its use (Table 1). Acceptability studies were performed in 20 of the survey sites – mostly by following the relevant WHO protocol (16 sites).11 ABH distribution was accompanied by training sessions in 31 (94%) of the health-care facilities included in the final data analysis. Use of the handrubs was promoted using WHO posters (33 health-care facilities) and locally pro- duced educational materials (25 health- care facilities). A multimodal approach to the improvement of hand hygiene among health-care workers – including the promotion of ABH – was reportedly being implemented in 30 (88%) of the 34 health-care facilities included in the final data analysis. One of the private compa- nies included in the survey also offered training in hand hygiene and locally- produced posters on the same topic. Bull World Health Organ 2013;91:963–969 | doi: http://dx.doi.org/10.2471/BLT.12.117085 965 Lessons from the field Local production of alcohol-based handrubsJoanna Bauer-Savage et al. Fi g. 1 . M ap sh ow in g th e lo ca tio ns o f s ite s t ha t r es po nd ed to su rv ey o n th e lo ca l p ro du ct io n of th e W HO -re co m m en de d al co ho l-b as ed h an dr ub fo rm ul at io ns , 2 01 1 Co un try w ith on e o r m ore su rve y s ite s Co un tri es an d t err ito rie s w ith no su rve y s ite s No t a pp lic ab le On e c om pa ny On e h ea lth fa cil ity Tw o h ea lth fa cil itie s Six he alt h f ac ilit ies N ot e: T he re w as o ne si te e ac h in A rg en tin a, B an gl ad es h, B el gi um , C hi na (P ro vi nc e of Ta iw an ), Co lo m bi a, E th io pi a, Is la m ic R ep ub lic o f I ra n, It al y, Ja pa n, Jo rd an , K en ya , L eb an on , M al aw i, M al i, M on go lia , O m an , P ak ist an , P hi lip pi ne s, Sa ud i A ra bi a, Se ne ga l, T ha ila nd , T un isi a, Tu rk ey a nd U ga nd a; tw o sit es e ac h in B ra zi l, I nd on es ia a nd S ud an ; t hr ee in N ig er ia ; a nd si x in C am bo di a. So ur ce : P ub lic H ea lth In fo rm at io n an d G eo gr ap hi c In fo rm at io n Sy st em s, W or ld H ea lth O rg an iz at io n. Bull World Health Organ 2013;91:963–969 | doi: http://dx.doi.org/10.2471/BLT.12.117085966 Lessons from the field Local production of alcohol-based handrubs Joanna Bauer-Savage et al. Costs Reliable information on the costs of the ingredients in the ABH and the salary costs of producing the handrub was available for 16 of the survey sites. Thirteen of these sites used ethanol- based handrubs; the remainder used the isopropanol-based formulation. The mean costs per 100 ml of the ethanol- and isopropanol-based formulations – including salaries but excluding the costs of dispensers – were 1.4 (range: 0.3–4.5) and 0.8 (range: 0.1–1.3) United States dollars (US$), respectively. Additional data on dispenser costs were available from only nine sites. Seven of these sites used ethanol-based handrubs, while the remainder used the isopropanol-based formulation. At these nine sites, the mean total costs of the ethanol- and isopropanol-based formulations – including salaries and dispensers – were US$ 2.2 (range: 0.9–4.8) and US$ 1.6 (range: 0.9–2.3) per 100 ml, respectively. Lessons learnt Our survey provided valuable insight on field experience in the local production of WHO-recommended ABH formula- tions globally and – particularly – in low- and middle-income countries. Lo- cal production of these handrubs has been rolled out over a wide range of geographical and economic settings by both health-care facilities and private companies. Ease of production com- bined with affordable cost and good product acceptability and tolerability appear to be the main advantages of the WHO formulations – despite the frequent, initial challenge of identifying staff with the skills required to produce them (Box 1). More than half of our survey sites reported that they had switched from a commercially marketed ABH to an ABH that they had produced themselves –in accordance with one of the WHO-recommended formulations. To promote hand hygiene, an overwhelming majority of the health- care facilities that we investigated used a multimodal approach that included training, the display of WHO and locally-adapted posters and other edu- cational approaches. Such multimodal strategies have been found to improve hand hygiene in many regions and Table 1. Advantages of – and potential barriers to – the local production of alcohol-based handrubs, 2011 Advantages and barriers No. of sites/total that provided data (%) Countries (no. of sites) Advantages Less expensive than marketed alcohol-based handrubs 7/9 (78) Brazil (1), Cambodia (3), Islamic Republic of Iran (1), Mongolia (1), Pakistan (1) Excellent tolerance and acceptability 31/38 (82) Argentina (1), Bangladesh (1), Brazil (2), Cambodia (3), China (Province of Taiwan) (1), Colombia (1), Ethiopia (1), Indonesia (2), Italy (1), Japan (1), Jordan (1), Kenya (1), Lebanon (1), Malawi (1), Mali (1), Mongolia (1), Nigeria (3), Oman (1), Pakistan (1), Saudi Arabia (1), Senegal (1), Sudan (1), Thailand (1), Tunisia (1), Turkey (1) Used in health facility as part of a multimodal approach to improve hand hygiene 30/34 (88) Argentina (1), Brazil (1), Cambodia (6), Colombia (1), Ethiopia (1), Indonesia (2), Islamic Republic of Iran (1), Italy (1), Japan (1), Kenya (1), Lebanon (1), Malawi (1), Mali (1), Mongolia (1), Nigeria (1), Pakistan (1), Philippines (1), Saudi Arabia (1), Senegal (1), Sudan (2), Tunisia (1), Turkey (1), Uganda (1) Manufactured from locally- sourced alcohola 28/39 (72) Argentina (1), Brazil (2), Cambodia (6), China (Province of Taiwan) (1), Colombia (1), Ethiopia (1), Indonesia (2), Italy (1), Japan (1), Kenya (1), Lebanon (1), Malawi (1), Mali (1), Nigeria (2), Philippines (1), Saudi Arabia (1), Sudan (1), Tunisia (1), Turkey (1), Uganda (1) Barriers to production Staff needed training on production process 29/39 (74) Argentina (1), Bangladesh (1), Belgium (1), Brazil (1), Cambodia (6), Colombia (1), Ethiopia (1), Indonesia (1), Islamic Republic of Iran (1), Italy (1), Jordan (1), Kenya (1), Lebanon (1), Malawi (1), Mali (1), Mongolia (1), Nigeria (2), Oman (1), Pakistan (1), Saudi Arabia (1), Sudan (1), Tunisia (1), Turkey (1) Occasional difficulty in procuring ingredients locally 20/39 (51) Brazil (1), Cambodia (6), China (Province of Taiwan) (1), Colombia (1), Ethiopia (1), Indonesia (1), Japan (1), Kenya (1), Malawi (1), Mali (1), Mongolia (1), Nigeria (1), Senegal (1), Sudan (1), Turkey (1) Difficulty in procuring appropriate dispensers 19/37 (51) Brazil (2), Cambodia (4), Ethiopia (1), Indonesia (1), Kenya (1), Malawi (1), Mali (1), Mongolia (1), Nigeria (2), Pakistan (1), Philippines (1), Saudi Arabia (1), Senegal (1), Uganda (1) to quality control Suboptimal reprocessing of dispensersb 11/24 (46) Brazil (2), Cambodia (4), Colombia (1), Ethiopia (1), Nigeria (1), Saudi Arabia (1), Sudan (1) Quality control not performed on site (mainly due to lack of equipment) 11/24 (46) Argentina (1), Ethiopia (1), Islamic Republic of Iran (1), Japan (1), Lebanon (1), Malawi (1), Nigeria (2), Pakistan (1), Sudan (1), Turkey (1) to acceptability Unpleasant smell 4/38 (11) Belgium (1), Cambodia (1), Philippines (1), Uganda (1) a Alcohol produced from sugar cane, maize, manioc, mahogany or walnut. b The simple washing of used dispensers, with no attempt at disinfection or sterilization. Bull World Health Organ 2013;91:963–969 | doi: http://dx.doi.org/10.2471/BLT.12.117085 967 Lessons from the field Local production of alcohol-based handrubsJoanna Bauer-Savage et al. thereby reduce the incidence of health- care-acquired infections.5,12–14 Excellent product acceptability and tolerability were reported in most sur- vey sites. The most common complaint about the locally produced ABHs was that they had an unpleasant smell – probably because of the H2O2 content. In an attempt to resolve this issue, some survey sites had either stopped adding H2O2 to their handrubs or had tried to mask the unpleasant smell with a fragrance. Further studies are needed to assess how the exclusion of H2O2 – which is currently not recommended by the international experts who developed the WHO guidelines on hand hygiene in health care5 – affects the risk of handrub contamination. The mean costs of a commercially- produced ABH – typically US$ 2.5 to 8.5 for a 100-ml dispenser (unpub- lished data, 2012) – appear higher than the mean costs that we evaluated for ABHs that were locally produced according to the WHO formulations. Similar observations have been made previously.5,12,13 The costs of the salaries of the heath-care workers who make ABHs are relatively low and many of our study sites were buying relatively cheap alcohol locally – particularly ethanol from agro-industrial sources – but the cost of the dispensers was high. At several sites, reuse of dispensers helped overcome difficulties caused by local shortages and the relatively high costs of new dispensers. Such reuse may, how- ever, lead to handrub contamination, especially when empty dispensers are reprocessed by simple washing before being refilled. Increased awareness of the WHO recommendations for the reprocessing of handrub dispensers8 and improvements in the availability of appropriately-priced, single-use dis- pensers of good quality could help avoid such contamination. Encouragingly, most of our survey sites performed some form of quality con- trol on the ABHs that they produced. The purchase or donation of additional alco- holmeters would facilitate such checks. Government contracts for the large-scale commercial production of the WHO formulations could make it possible to globally market low-cost ABHs. However, more related research – on market share, competitiveness and product quality, tolerability and accept- ability – is needed. Our survey had limitations. Al- though sites from all WHO regions participated, the Americas, the East- ern Mediterranean and Europe were underrepresented, perhaps because of language restrictions and because most European countries can afford to use commercially-produced ABH. Limited internet access posed a challenge for several of the low-income countries that were invited to participate in the online survey – although this issue was partially overcome by faxing the questionnaire to and from some potential survey sites. In summary, the local production of WHO-recommended ABH formula- tions provides a feasible alternative to the use of relatively expensive, com- mercially-produced ABH. It appears to be a particularly attractive option for low- and middle-income countries. This survey confirms earlier data that indi- cated that both WHO formulations are well tolerated and accepted by health- care workers. However, improvements are needed in quality control, the supply of dispensers and the procurement of ABH ingredients. Information on the sourcing of affordable dispensers of good quality and increased awareness of the WHO-recommended methods for the reprocessing of used dispensers are likely to reduce the overall production costs of ABH and the risks of handrub contamination. Large-scale production of the WHO-recommended formula- tions and the development of produc- tion networks and partnerships may both be beneficial. ■ Acknowledgements We thank all of our respondents and WHO focal points for their help with the survey, and our colleagues for technical editorial and translation assistance and other support. Competing interests: None declared. Box 1. Summary of main lessons learnt • Local production of alcohol-based handrubs based on the formulations recommended by the World Health Organization (WHO) is feasible and provides a low-cost alternative to commercially-produced handrubs that may be unavailable or unaffordable – particularly in low- and middle-income countries. • The handrub formulations recommended by WHO already have good product acceptability and tolerability but improvement of their smell could increase their acceptability even more. • Quality control issues and difficulties in the local availability of ingredients and dispensers are potential barriers that could be partially overcome by increasing awareness of the optimal methods for dispenser reprocessing and improving the availability of cheaper, single-use dispensers of good quality. صخلم فيلاكتلاو تابقعلاو ايازلماو ىودلجا :ةيلماعلا ةحصلا ةمظنم ابه صيوت يتلا ةيلوحكلا يديلأا تارهطلم ليحلما جاتنلإا صقنو ءالماو نوباصلا نم تادادملإا ةيافك مدع لقرعت ةلكشلما ضفخ اهتفلكت عافترا وأ )ABHs( ةيلوحكلا يديلأا تارهطم ةطسوتلماو ةضفخنلما نادلبلا في ةيحصلا ةياعرلاب ةطبترلما ىودعلا .لخدلا )WHO( ةيلماعلا ةحصلا ةمظنم تروط ،2005 ماع في بولسلأا ينتبسانم اتناك ةيلوحكلا يديلأا تارهطلم ينتبيكرت تبرتخاو مييقت مت ،2011 ماع فيو .ةيحصلا ةياعرلا قفارم في جاتنلإل تابقعلاو – ينتبيكترلل ليحلما جاتنلإا فيلاكتو ايازمو ىودج .تنترنلإا لىع ةيئاصقتسا ةسارد في – جاتنلإا اذه نود لوتح يتلا ًايحص ًاقفرم 34لىع ةيئاصقتسلاا ةساردلا تلمتشا ةيلحلما عقاولما .ًادلب 29 في ةصاخ تاكشر 5و يتبيكرت نم ةبيكترل ليحلما جاتنلإا ناك ةلصلا تاذ تا ّريغتلا دحاو لدبتساو .كراشم عقوم لك في ًايدمج ةيلماعلا ةحصلا ةمظنم ًاقباس مدختسلما ليوحكلا يديلأا رهطم )% 54( ًاعقوم نوشرعو تناك ،ًاعقوم 32 فيو .ةيلماعلا ةحصلا ةمظنم يتبيكرت ىدحإب ثيح نم ةديج اهجاتنإ مت يتلا ةيلماعلا ةحصلا ةمظنم ةبيكرت ينبتو .ةيحصلا ةياعرلا لامج في ينلماعلا لوبقب تيظحو لمحتلا تارهطم نع ةيلماعلا ةحصلا ةمظنم يتبيكرت ةفلكت ضافخنا يتلا تابقعلا تلمشو .قاوسلأا في ةحاتلما ةيلوحكلا يديلأا تاراهلما يوذ ينلماعلا ديدتح ةبوعص ليحلما جاتنلإا نود تلاح Bull World Health Organ 2013;91:963–969 | doi: http://dx.doi.org/10.2471/BLT.12.117085968 Lessons from the field Local production of alcohol-based handrubs Joanna Bauer-Savage et al. ةزهجأو تانوكلما ءاشر دويقو ينلماعلا بيردتل ةجالحاو ةمئلالما .عيزوتلا ةحصلا ةمظنم يتبيكرت جاتنإ ةلوهسب نكمي ةدافتسلما سوردلا ثيح نم ناتديج اهمو .ةضفخنم ةفلكتب ليحلما ديعصلا لىع ةيلماعلا بلطتتو .ةيحصلا ةياعرلا لامج في ينلماعلا لوبقب نايظتحو لمحتلا – ليحلما ديعصلا لىع ماهجاتنإ نود لوتح يتلا ةلمتحلما تابقعلا عيزوتلا ةزهجأو تانوكلما ءاشرب ةصالخا تلاكشلماو ماهتحئار لثم .يرحتلا نم ًاديزم – ةدولجا ةبقارم قيبطتو 摘要 世界卫生组织推荐的含酒精洗手液的本地生产 ：可行性、优势、障碍和成本 问题 减少中低收入国家卫生保健相关的感染因肥皂和 水的供应不足以及含酒精洗手液（ABH）的缺乏或成 本高而受阻。 方法 在 2005 年，世界卫生组织（WHO）研发并测试 了两种 ABH 配方，且这两种配方适合在医疗保健设 施中生产。在 2011 年的一次在线调查中，对这两种配 方本地生产的可行性、优势和成本以及这种生产的阻 碍进行了评价。 当地状况 此调查包含 29 个国家的 34 个卫生保健设施 和 5 家私营公司。 相关变化 本地生产世卫组织某一种配方在每个参与 点都是可行的。其中 21（54%）个点用其中一种世卫 组织配方代替了之前使用的 ABH。在 32 个点中，医 疗工作者可以很好地承受并接受已生产的世卫组织配 方。据发现，世卫组织配方比市场上的 ABH 更加便宜。 本地生产的障碍包括难以确定有足够技能的员工，需 要进行员工培训以及原料和洗手液瓶采购的限制。 经验教训 世卫组织配方可以轻松以低成本在本地生 产。医疗工作者也能很好地承受并接受这些产品。本 地生产的潜在障碍（例如其气味以及成分和洗手液瓶 的采购问题，以及质量控制问题）有待进一步的调查。 Résumé Production locale de produits pour friction hydro-alcooliques recommandés par l’OMS: faisabilité, avantages, obstacles et coûts Problème La réduction des infections liées aux soins de santé dans les pays à revenu faible et moyen est entravée par l’approvisionnement insuffisant en savon et en eau et par la pénurie ou le coût élevé des produits hydro-alcooliques. Approche En 2005, l’Organisation mondiale de la Santé (OMS) a développé et testé deux formulations de produits pour friction hydro- alcoolique, qui convenaient à une production dans les établissements de soins de santé. En 2011, la faisabilité, les avantages et les coûts de la production locale des 2 formulations – ainsi que les obstacles à une telle production – ont été évalués dans une enquête en ligne. Environnement local L’enquête incluait 34 établissements de soins de santé et 5 sociétés privées dans 29 pays. Changements significatifs La production locale de l’une des formulations de l’OMS était réalisable dans tous les sites participants. Vingt-et-un (54%) sites ont remplacé un des produits hydro-alcooliques utilisés auparavant par l’une des formulations de l’OMS. Dans 32 sites, la formulation de l’OMS qui a été produite a bien été tolérée et acceptée par les travailleurs de santé. Les formulations de l’OMS se sont révélées moins chères que les produits hydro-alcooliques commercialisés. Les obstacles à la production locale comprenaient la difficulté à identifier le personnel disposant des compétences adéquates, l’obligation de formation du personnel et les contraintes d’approvisionnement des ingrédients et des flacons doseurs (distributeurs). Leçons tirées Les formulations de l’OMS peuvent être facilement produites localement et à bas coût. Elles sont bien tolérées et acceptées par les travailleurs de santé. Les obstacles potentiels à leur production locale, comme leur odeur et les problèmes en termes d’approvisionnement des ingrédients et des flacons doseurs et en matière de contrôle de qualité, exigent des investigations complémentaires. Резюме Местное производство спиртосодержащих дезинфицирующих средств, рекомендованных ВОЗ: осуществимость, преимущества, препятствия и стоимость Проблема Дальнейшему сокращению числа инфекций, связанных с оказанием медицинской помощи, в странах с низким и средним уровнями доходов препятствует недостаточное снабжение мылом и водой и отсутствие или высокая стоимость жидких спиртосодержащих дезинфицирующих средств (ABH - alcohol- based handrubs). Подход В 2005 году Всемирная организация здравоохранения (ВОЗ) разработала и провела испытания двух составов ABH, пригодных для самостоятельного изготовления в медицинских учреждениях. В 2011 г. в интернет-опросе производилась оценка осуществимости, преимуществ и стоимости местного производства двух составов, а также препятствий к подобному производству. Местные условия В опросе участвовало 34 медицинских учреждения и пять частных компаний в 29 странах. Осуществленные перемены Местное производство одного из составов, разработанных ВОЗ, было возможным в каждом учреждении, принявшем участие в опросе. Двадцать одно учреждение (54%) из этого числа перешло на использование ABH с одним из составов ВОЗ. В 32 учреждениях произведенный состав ВОЗ хорошо переносился и был одобрен медицинскими работниками. Составы ВОЗ оказались менее затратными, чем ABH, реализуемые на рынке. Препятствия к местному производству включали трудность нахождения персонала с соответствующей квалификацией, необходимость в обучении персонала, ограничения по составу и поставке дозаторов. Выводы Составы ВОЗ могут легко изготавливаться на местном уровне по низкой стоимости. Они легко переносятся и одобрены медицинскими сотрудниками. Потенциальные препятствия к их местному производству – такие как запах составов, проблемы с поставками компонентов и дозаторов и осуществлением контроля качества – требуют дальнейшего исследования. Bull World Health Organ 2013;91:963–969 | doi: http://dx.doi.org/10.2471/BLT.12.117085 969 Lessons from the field Local production of alcohol-based handrubsJoanna Bauer-Savage et al. Resumen La preparación local de los desinfectantes para manos a base de alcohol recomendados por la OMS: viabilidad, ventajas, dificultades y costes Situación La reducción de las infecciones relacionadas con la atención sanitaria en países con ingresos medios y bajos se ve obstaculizada por el suministro inadecuado de jabón y agua y la falta o costes elevados de los desinfectantes para manos a base de alcohol. Enfoque En el año 2005, la Organización Mundial de la Salud (OMS) desarrolló y sometió a prueba dos fórmulas de desinfectantes para manos a base de alcohol que podrían prepararse en los centros sanitarios. En el año 2011 se evaluaron por medio de una encuesta en línea la viabilidad, las ventajas, los costes y las dificultades de la preparación local de ambas fórmulas. Marco regional La encuesta incluyó 34 centros sanitarios y 5 compañías privadas de 29 países. Cambios importantes La preparación local de una de las fórmulas de la OMS fue factible en todos los emplazamientos que participaron en la encuesta. Veintiuno (54 %) de ellos había sustituido el desinfectante para manos a base de alcohol empleado anteriormente por una de las fórmulas de la OMS. En 32 sitios, la aceptación y tolerancia entre los trabajadores sanitarios de la fórmula de la OMS preparada fue buena. Se descubrió que las fórmulas de la OMS eran más baratas que los desinfectantes comerciales. Las trabas para la preparación local incluyeron la dificultad de identificar el personal con las capacidades necesarias, la necesidad de formación del personal y las restricciones para la adquisición de ingredientes y dosificadores. 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