Assessment of water, sanitation, and hygiene practices and associated factors in a Buruli ulcer endemic district in Benin (West Africa)

Neglected tropical diseases (NTDs) include 17 tropical diseases that are prevalent in Africa, Asia and South America. They mostly affect the poor rural populations, especially in areas with low coverage of hygiene and sanitation. These diseases are important causes of morbidity, and sometimes generate significant disabilities as well as stigmatization of affected populations, perpetuating poverty [1]. Control of NTDs requires multiple strategic approaches such as preventive chemotherapy; intensive case management; surgery and chronic care; transmission control; information, education and communication and water and sanitation [1]. Indeed, sustainable water, sanitation, and hygiene (WASH) services are essential for the prevention, long-term control, and even elimination of five of the NTDs: soil-transmitted helminthiasis, trachoma, schistosomiasis, lymphatic filariasis (LF), and Guinea worm disease [2]. Reducing levels of these WASH-preventable NTDs not only improves health and alleviates suffering, but can also lead to improved educational outcomes for children and increased economic progress for communities and nations. The WASH sector can significantly affect health and development by targeting WASH activities where NTDs occur and by incorporating behavioral change messages relevant to specific NTDs into existing hygiene promotion efforts [1].

Buruli ulcer (BU), one of the 17 NTDs, is caused by a germ, Mycobacterium ulcerans, that mainly affects the skin but that can also affect the bones. It has been reported in over 30 countries. Most of those affected are children under 15 years of age who live in poor, rural communities. Late diagnosis can result in long and costly hospitalizations with significant morbidity and disability [3]. The disease is endemic in eight departments of southern Benin, with among one of the highest levels seen in the district of Lalo [4]. Whether the relationship between the WASH is clearly demonstrated for the five NTDs cited above [2], the link between WASH and BU is still little studied and the results of different studies on a possible association between BU and WASH need further investigations [5]. There is strong evidence that the endemic foci of BU almost always organized around an aquatic ecosystem [3]. However, the WASH sector is vital for the management of BU: BU patients need water for wound care, scar management after skin grafts, taking medications, and for good personal hygiene to prevent complications and secondary infections. Washing the skin lesions with clean water and soap could be protective for those exposed to BU [6]. Indeed, studies on wound care (an important component of the management of BU) have shown that washing wounds daily with clean water and soap is effective in reducing the risk of contamination by various microorganisms [7]. In addition to the above mentioned observations, Buruli ulcer control strategies as well as the community-led total sanitation (CLTS) strategy recommended for WASH in rural settings require significant community mobilization. Community based activities, as a cross-cutting interventions, can therefore be implemented alongside these for efficient use of resources in BU endemic communities where WASH services are poor. Given the growing importance of WASH in controlling NTDs [1], we report here on the first study in Benin to evaluate the level of WASH and associated factors in one of the most BU-endemic communes, to assess the baseline for future community-based cross-cutting interventions.

Numerous aspects of the control of NTDs require individuals to have good access to WASH services. This may include water to practice good skin hygiene as well as access to good sanitation for those affected [1]. As far as Buruli ulcer is concerned, contrary to the WASH preventable NTDs [2], there are currently few studies on the WASH and BU. A study conducted in Cameroon show persistence of M. ulcerans specific DNA sequences over a period of more than two years at a water contact location of BU patients in an endemic village of Cameroon. At defined positions in a shallow water hole used by the villagers for washing and bathing, detritus remained consistently positive for M. ulcerans DNA. The result of real-time PCR indicated M. ulcerans, which cause human disease, persisted in this environment after successful treatment of all local patients. Underwater decaying organic matter may therefore represent a reservoir of M. ulcerans for direct infection of skin lesions or vector-associated transmission [9]. In the same line, in a study conducted in Benin, a total of 416 participants were enrolled including 104 cases and 312 controls. BU history in the family (p < 0.001), adjusted by daily contact with a natural water source (p < 0.007), was significantly associated with higher odds of having BU (OR; 95 % CI = 5.5; 3.0–10.0) [10]. In addition to these considerations, as we explain in the background of our study, the WASH sector is vital for the management of BU patients need water for wound care, scar management after skin grafts, taking medications, and for good personal hygiene to prevent complications and secondary infections. Washing the skin lesions with clean water and soap could be protective for those exposed to BU [6]. Studies on wound care (an important component of the management of BU) have shown that washing wounds daily with clean water and soap is effective in reducing the risk of contamination by various microorganisms [7]. In the fight against HIV/AIDS, good access to WASH services can prevent opportunistic infections and improve patients’ lives [11, 12]. Adequate access to WASH services is therefore a challenge for both healthy and non-healthy populations in many countries and communities with high levels of NTDs [1].

This first study in a district in Benin where BU is endemic is very timely, and provides an inventory of WASH indicators in the study area. The average (mean) age of household heads interviewed was 45 years, with a mode of 35 and a standard deviation of 10.42. Heads of households were mostly farmers and their ethnicity is Adja (60.50 %). Other ethnicities (7 %) identified were Yoruba, Fon, Mina and some Bariba. These data are consistent with figures from the municipality showing that the population of the town is dominated by the Adja ethnic group, which together with Fon makes up 95.3 % of the population [13].

The population of Lalo uses three sources of water for drinking purposes: borehole (46.67 %), rainwater tank (4 %); and surface water (49.33 %). Generally, people had experience of using disinfection techniques such as chlorination, but did not implement them, for various reasons, probably the extra work or additional costs required This cross-sectional study was not able to assess the functionality of boreholes throughout the year, nor did it investigate the quality of water from them. However, in many poor countries, studies have shown that the water supplied by the water distribution systems may be poor quality [8]. A study conducted by our team in another municipality of Benin corroborates these findings [14]. Similarly, a study carried out in the municipality of Abomey Calavi in Benin demonstrated that the water from the aquifer was contaminated by various microorganisms including Escherichia coli, Klebsiella pneumoniae, Staphylococcus aureus, Salmonella spp, Clostridium perfringens and fecal streptococci [15]. In some localities in Lalo, such as the villages of Djibahoun and Assogbahoué, there is no system for supplying improved water for the population. Households there use only unimproved water sources. The results from this study therefore show that 53.33 % of households use unimproved water (surface water and rainwater tank) for drinking purposes. This proportion is higher than that in the WHO and UNICEF report published in 2013 [8] on Benin, which suggested that about 43 % of rural households had access to improved water sources.

There was low latrine coverage for households: only 8.67 % of those surveyed. This low rate is in line with official data from Lalo, which reveal that there are almost no household latrines in the majority of villages in the commune [13]. A study by Reiff et al. for the Global Sanitation Fund and Water Supply and Sanitation Collaborative Council established an evacuation of excreta rate of about 30.21 % in the Atlantique region [16].

As well as the questionnaire survey, which revealed a very low rate of hand-washing, we also made a count of latrines equipped with hand-washing facilities, to obtain an indirect estimate of the frequency of this practice. We found no latrines with hand-washing devices. This exposes people to the risk of disease, because the lack of hand-washing facilitates the transmission of fecal diseases. For example, Judah et al. reported that 28 % of frequent travelers had fecal bacteria on their hands [17].

Observation of maternal practices in handling children’s feces shows that often, no precautions are taken. This situation encourages the transmission of fecal diseases. Gil et al. [18] showed that improper disposal and unsanitary handling practices of children’s feces were associated with an increase of 23 % in the risk of diarrhea, which may encourage people to increase hand-washing [19, 20]. Despite this, our study showed that systematic hand-washing after defecation remains marginal. This is not without consequences for health, as our field survey found that children had suffered from diarrhea in 11.67 % of households. This could be explained by the behavior of children, who defecate on the floor and frequent uncontrolled garbage dumps. Studies in other African countries have shown a strong link between exposure to solid waste released into the environment and diarrheal diseases. For example, Dikassa et al. [21] demonstrated that in Kinshasa, the children of families living in very poor hygienic and sanitary conditions were at 70 % greater risk of suffering from severe diarrhea.

Wastewater is poorly managed in the district of Lalo. All the households surveyed lacked home cesspools, which are recommended by the Ministry of Health [22]. Wastewater, as well as solid waste, is released untreated by 98.17 % of households. These practices pose a risk to public health. In some villages, households use garbage as fertilizer on family plantations. These waste management methods should be encouraged in rural areas.

Several factors can influence the sanitation status such as level of education, type of housing, hygiene practices, and water availability [8]. In our multivariate model, the type of housing as an indicator of socioeconomic status was identified as the main factor positively associated with improved sanitation. The lack of soap and the absence of hand-washing were the main factors associated with low sanitation level. We found no link between sanitation and the level of education of the household head, in contrast to a study conducted in Ethiopia, which showed that children’s hygiene practices at school were dependent on the parents’ level of education [23]. The same observation was made by Schmidt et al. in Kenya, who showed that hand-washing practices were dependent on level of education [24].

Measured as the proportion of people living on less than $ 1 a day, half of the departments in Benin are severely affected by poverty, including Couffo, where this study was conducted. There, the proportion of the population affected by this extreme poverty is estimated to be between 61 % and 75 % [25]. Our results are consistent with those of the Water and Sanitation Program, which also showed a disparity between rich and poor in terms of access to sanitation in Benin [26]. It is therefore clear that the municipality of Lalo lacks individual and collective sanitation, has a shortage of improved water supply infrastructure and poor hygiene practices.

It would be helpful to plan and implement targeted interventions to correct this situation. UNICEF and WHO recommended a strategy called community-led total sanitation, to gradually move villages to zero open defecation [27]. This strategy requires strong community mobilization, but our results suggest that it would be relevant in Lalo. Community programs for early detection of Buruli ulcer and other neglected tropical diseases of the skin could benefit from this social mobilization. Wound care and management of scars after skin grafts can also be taken into account in these WASH programs.

In the commune of Lalo, one of the four districts in Benin where levels of BU are highest, water hygiene and sanitation levels indicators are very low. This has obvious effects on health, especially for children. This study provides baseline information for future interventions in the WASH sector in this municipality. Those treating BU and other NTDs can use the WASH platform to share resources to make interventions more efficient for communities, partners and the health system.