UMMS Affiliation

Department of Medicine, Division of Cardiovascular Medicine

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Document Type



Environmental Public Health | Infectious Disease | International Public Health | Virus Diseases


Fourteen years of civil war left Liberia with crumbling infrastructure and one of the weakest health systems in the world. The 2014-2015 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.


Ebola, infection prevention and control (IPC), low-resource setting, water sanitation and hygiene (WASH)

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Copyright © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (

DOI of Published Version



Kanagasabai U, Enriquez K, Gelting R, Malpiedi P, Zayzay C, Kendor J, Fahnbulleh S, Cooper C, Gibson W, Brown R, Nador N, Williams DE, Chiriboga D, Niescierenko M. The Impact of Water Sanitation and Hygiene (WASH) Improvements on Hand Hygiene at Two Liberian Hospitals during the Recovery Phase of an Ebola Epidemic. Int J Environ Res Public Health. 2021 Mar 25;18(7):3409. doi: 10.3390/ijerph18073409. PMID: 33806086; PMCID: PMC8037341. Link to article on publisher's site

Journal/Book/Conference Title

International journal of environmental research and public health

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Creative Commons License

Creative Commons Attribution 4.0 License
This work is licensed under a Creative Commons Attribution 4.0 License.