Improving Community Sanitation and Preventing the Spread of Ebola in Liberia

Report highlights the link between improved sanitation practices and the spread of Ebola

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Community-Led Total Sanitation, Open Defecation Free Status, and Ebola Virus Disease in Lofa County, LiberiaAn assessment demonstrating the correlation between Community-Led Total Sanitation (CLTS) and Ebola prevention in Liberia was published in the Journal of Health Communications at the George Washington School of Public Health—Community-Led Total Sanitation, Open Defecation Free Status, and Ebola Virus Disease in Lofa County, Liberia. CLTS is an methodology that engages communities to end the practice of open defecation and become ODF (open defecation free). Global Communities has been implementing CLTS in Liberia in 2012 as part of an effective, affordable and adaptable approach to eliminate open defecation by promoting universal sanitation access while reducing community dependence on donor subsidy and fostering community buy-in and demand for safe sanitation and improved hygiene.

Abstract

"Using mixed quantitative and qualitative methods, we determined that no cases of EVD were found in ODF communities..."

The Ebola virus disease (EVD) epidemic entered Liberia through Lofa County in February 2014 and spread to two health districts where the nongovernmental organization Global Communities had been implementing community-led total sanitation (CLTS) since 2012. By December 2014 the county had 928 Ebola cases (422 of them confirmed) and 648 deaths. Before the epidemic, CLTS was triggered in 155 communities, and 98 communities were certified as Open Defecation Free (ODF). Using mixed quantitative and qualitative methods, we determined that no cases of EVD were found in ODF communities and in only one CLTS community that had not reached ODF status. No differences were found between EVD and non-EVD communities in tribe, religion, ethnic group, or major sources of Ebola information. Radio was the most common source of information for all communities, but health workers were the most trusted information sources. CLTS ODF communities attributed their avoidance of EVD to Water, Sanitation, and Hygiene behaviors, especially hand washing with soap and disposal of feces that they learned from CLTS prior to the epidemic. Communities that got EVD blamed their strong initial resistance to Ebola response messages on their distrust that Ebola was real and their reliance on friends and family for advice. A strong inverse correlation between EVD and CLTS with or without ODF emerged from the regression analysis (R = –.6).

Lofa County is the second largest county and fourth most populated political subdivision in Liberia (Government of Liberia, 2014). Global Communities, a U.S.-based humanitarian nongovernmental organization (NGO), introduced Community-Led Total Sanitation (CLTS) as part of the USAID-funded Improving Water, Sanitation, and Hygiene (IWASH) project in two of Lofa County’s six health districts in 2012. By February 2014, 98 of 115 CLTS communities had been certified as Open Defecation Free (ODF), meaning they had received independent Government of Liberia verification that they met national CLTS criteria.

Ebola virus disease (EVD) entered Liberia from Guinea through neighboring Foya District in February 2014 and quickly spread to other districts in the county. The epidemic spread quickly, and there were new cases until mid-2015. The last confirmed new EVD case in Lofa County was in November 2014, months before Liberia was declared Ebola free. By that time there had been 928 reported cases (422 confirmed), with 648 deaths in Lofa County (key informant interview [KII], Lofa County Health Team, personal communication, February 2015).

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