Skip to main content Skip to secondary navigation

HCF Liberia: Comparing Hospital Hand Hygiene in Liberia: Soap, Alcohol, and Hypochlorite

Main content start
Handwashing Station
Handwashing Station


Locally-made alcohol hand sanitizer as part of existing hospital infection control program,
Kolahun Hospital, Lofa County, March 2018
Handwashing station with hypochlorite solution
Handwashing station with hypochlorite solution
Handwashing Station: Phebe Hospital, Bong County
Handwashing Station:
Phebe Hospital, Bong County
Lily walking hospital ward with handwashing station
Lily and team walking a hospital ward
(Handwashing Station in background)
Handwashing Station: Borma Hospital, Foya, Lofa County
Handwashing Station:
Borma Hospital, Foya, Lofa County

Comparing Hospital Hand Hygiene in Liberia: Soap, Alcohol, and Hypochlorite



1.  To determine the most appropriate cleansing material (soap, alcohol-based hand sanitizer, or 0.05% hypochlorite) for routine hand hygiene in Liberian healthcare facilities after the 2014-2016 Ebola epidemic

2.  To determine how best to implement hand hygiene programs in Liberian health facilities



Why we care about this

The 2014-2016 Ebola epidemic in West Africa resulted in over 28,000 reported cases and 11,000 deaths. Hospitals were amplifying centers of Ebola transmission, and health workers were 20-30 times more likely to be infected with Ebola than the general population. Effective prevention required strict adherence to infection control: patient isolation, personal protective equipment, environmental decontamination, and hand hygiene. Chlorine solution was used widely at 0.05% concentration for hand hygiene and 0.5% concentration for environmental decontamination in hospitals, Ebola treatment units, community care centers, and checkpoints. After the epidemic, international and national guidelines recommended health facilities change to handwashing with soap or using alcohol-based sanitizer for hand hygiene. However, there are knowledge gaps about whether 0.05% hypochlorite could be advantageous for routine hand hygiene. 0.05% hypochlorite could be safe, effective, and easier to implement for routine hand hygiene, especially after the Ebola epidemic catalyzed institutional and individual behavior change in Liberia.

Why we see the knowledge we are generating as strategic

Handwashing is an effective and inexpensive infection control intervention, but sustainable hand hygiene interventions in low-income countries are difficult due to resource limitations, including lack of basic water and sanitation. Our study will specifically address gaps in knowledge on which hand hygiene material – soap, alcohol-based hand sanitizer, or 0.05% hypochlorite – is most appropriate for routine hand hygiene in health facilities in Liberia and how best to implement hand hygiene programs. This study’s focus is critically relevant to building a resilient health system in Liberia and to global pandemic prevention.

Stages on Stairway of Research - Stages 2, 3, and 4:

Stage 2:  Explicate causal paths that generate the problem

Stage 3.  Develop an intervention to interrupt generation of the problem

Stage 4:  Pilot the intervention


Project dates

2017 - 2022


Stage of Work

What has been accomplished so far within the project

1.  All ethical and administrative approvals have been obtained.

2.  Conducted visits to study sites and assembled Liberia-based data collection team

3.  Completed Phase 1, a cross-sectional survey of all hospitals with inpatient services in Lofa County and Bong County, Liberia. The survey included qualitative interviews with hospital workers and “spot check” observations of hand hygiene materials and behaviors.


What are we focusing on now

1.  Implementation of Phase 1B to examine community perspectives on hospital safety, trust, and health-seeking behavior during the COVID-19 pandemic.

2.  Implementation of Phase 2 to design an intervention to improve hospital hand hygiene.



Primary Contact:  Ronan Arthur

Stanford University

.   Stephen Luby, Professor of Medicine

.   Ronan Arthur, Post-Doctoral Researcher

.   Lucy Tantum, Research Assistant

Uniformed Services University for the Health Sciences (USU)

.   John Gilstad, PI

U.S. Naval Medical Research Unit No. 3 (NAMRU-3)

.   Andrew Vaughn, co-PI

.   Andrew Letizia, co-I

National Public Health Institute of Liberia (NPHIL)

.   Fatorma Bolay, Co-PI

Q&A, Inc., Liberia



Uniformed Services University (USU) Center for Global Health Engagement (CGHE), Department of Defense (DoD)

Stanford RISE COVID-19 Crisis Response Faculty Seed Grant Program