Characterizing Determinants of Hand Contamination Across Public and Private Domains in Low-Income Neighborhoods of Accra, Ghana Open Access

Abstract

An estimated 72% of the urban population of Africa lives in slums, which are often characterized by poor access to sanitation and hygiene services and high rates of diarrheal disease. Limited prior data exists on the relationship between fecal contamination in the environment and fecal contamination of hands in low-income, urban settings. This study characterized hand contamination across four neighborhoods in Accra, Ghana and assessed the relationship between environmental fecal contamination and hand fecal contamination in these study neighborhoods. Handrinse samples and other environmental samples (swabs, soil, and stored drinking water) were collected from children and adults in four settings: households, public latrines, schools, and nurseries, and analyzed for fecal indicator organism concentrations (Escherichia coli and enterococci). Hand contamination levels were characterized by neighborhood and demographic factors using analysis of variance (ANOVA), and linear regression models were constructed to predict hand contamination from fecal contamination of environmental samples. Handrinse samples had a mean E. coli concentration of 2.53 log10 colony forming units (cfu)/ pair of hands (range: no detectable E. coli to 5.19 log10 cfu/ pair of hands) and a mean enterococci concentration of 3.08 log10 cfu/ pair of hands (range: no detectable enterococci to 5.85 log10 cfu/ pair of hands). Handrinse samples from public latrines had the highest concentrations of E. coli, while handrinse samples from nurseries had the highest concentrations of enterococci. There was a moderate, positive correlation between E. coli and enterococci handrinse concentrations (r=0.33), with higher enterococci concentrations across all settings. E. coli concentrations on swabs of surfaces were a significant predictor of handrinse E. coli concentrations (p-value<0.0001). Future studies should focus on determining the strength of the association between fecal contamination of environmental surfaces and hand contamination in different settings and the implications for pathogen transmission.

Table of Contents

I. BACKGROUND. 1

A. The Global Burden of Diarrheal Disease. 1

B. Urbanization and Informal Settlements. 2

C. Measuring Hand Contamination. 3

i. Microbiological Measures of Hand Contamination. 3

ii. Handrinse Samples. 4

D. Characterizing Hand Contamination in Low-Income, Urban Settings. 5

i. Determinants of Hand Contamination. 5

ii. Relationship between Hand Contamination and Environmental Contamination. 7

E. Description of Accra, Ghana. 11

i. Sanitation and Hygiene in Accra. 11

ii. Description of the Study Neighborhoods. 12

F. Study Objectives. 13

II. MANUSCRIPT. 15

A. Introduction. 15

B. Methods. 17

i. Study Setting and Context. 18

ii. Data Collection. 18

iii. Data Management. 21

iv. Laboratory Methods. 21

v. Statistical Methods. 23

C. Results. 25

i. Microbiological Contamination of Handrinse Samples. 25

ii. Relationship between E. coli and Enterococci Hand Contamination. 31

iii. Determinants of E. coli Hand Contamination. 34

D. Discussion. 35

E. Conclusions. 43

F. References. 46

G. Tables. 50

H. Figures. 61

III. LESSONS LEARNED AND FUTURE ANALYSES. 80

A. Lessons Learned. 80

B. Future Analyses. 82

IV. APPENDICES. 85

A. Handrinse Sample Collection Form. 85

B. Stored Drinking Water Sample Collection Form. 86

C. Swabs Sample Collection Form. 87

D. Particulate Sample Collection Form. 88

E. Recommended Values for Surface Area of Body Parts. 89

About this Master's Thesis

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School	Rollins School of Public Health
Department	Epidemiology
Subfield / Discipline	Global Epidemiology - MPH & MSPH
Degree	MPH
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health Health Sciences, Epidemiology
Keyword	E. coli Ghana Slums Hand contamination Enterococci Handrinse Hygiene Urban health Fecal contamination Hand rinse WASH
Committee Chair / Thesis Advisor	Moe, Christine L, Emory University
Partnering Agencies	Emory University schools, faculty or affiliated programs

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