medRxiv preprint doi: https://doi.org/10.1101/2020.06.03.20120196; this version posted June 5, 2020. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 1 2 3 4 5 6 Prevention of COVID-19 in Ghana: Compliance audit of 7 selected transportation stations in the Greater Accra region 8 of Ghana 9 Harriet Affran Bonful,1 Adolphina Addo-Lartey,1 Justice MK Aheto2, John Kuumouri Ganle3, 10 Bismark Sarfo1, Richmond Aryeetey3* 11 1. Department of Epidemiology and Disease Control, University of Ghana School of Public 12 Health 13 2. Department of Biostatistics, University of Ghana School of Public Health 14 3. Department of Population and Family Health, University of Ghana School of Public Health 15 16 17 18 19 * Corresponding Author 20 Email: [email protected] (RA) 21 22 23 1 NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice. medRxiv preprint doi: https://doi.org/10.1101/2020.06.03.20120196; this version posted June 5, 2020. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 24 25 Abstract 26 Globally, as little evidence exists on transmission patterns of COVID-19, recommendations to 27 prevent infection include appropriate and frequent handwashing plus physical and social 28 distancing. We conducted an exploratory observational study to assess compliance with these 29 recommendations in selected transportation stations in Ghana. A one-hour audit of 45 public 30 transport stations in the Greater Accra region was carried out between 27th and 29th March 2020. 31 Using an adapted World Health Organization (WHO) hand hygiene assessment scale, the 32 availability and use of handwashing facilities, social distancing, and ongoing public education on 33 COVID-19 prevention measures were assessed, weighted and scored to determine the level of 34 compliance of stations. Compliance with recommendations was categorized as “inadequate” 35 “basic”, “intermediate” and “advanced” based on the overall score. The majority (80%) of 36 stations in Accra have at least one Veronica Bucket with flowing water and soap but the number 37 of washing places at each station is not adequate. Only a small minority (18%) of stations were 38 communicating the need to wash hands frequently and appropriately, and to practice 39 social/physical distancing while at the station. In most stations (95%), hand washing practice was 40 either not observed or only infrequently. Almost all stations (93%) did not have alcohol-based 41 hand sanitizers for public use, while social distancing was rarely (only 2%) practiced. In over 42 90% of the stations, face masks were either not worn or only worn by a few passengers. 43 Compliance with COVID-19 prevention measures was inadequate in 13 stations, basic in 16 44 stations, intermediate in 7 stations, and advanced in 9 stations. Compliance with COVID-19 45 prevention measures in public transportation stations in the Greater Accra region remains a 46 challenge. Awareness creation should aim to elevate COVID-19 risk perception of transportation 2 medRxiv preprint doi: https://doi.org/10.1101/2020.06.03.20120196; this version posted June 5, 2020. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 47 operators and clients. Transport operators and stations need support and guidance to enforce 48 hand washing and social distancing. 49 Keywords: Coronavirus; COVID-19; Prevention; Hand washing; Veronica bucket; Social 50 distancing, Compliance; Transportation; Ghana. 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 3 medRxiv preprint doi: https://doi.org/10.1101/2020.06.03.20120196; this version posted June 5, 2020. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 66 67 Introduction 68 Coronavirus disease 2019 (COVID-19) is an infectious disease caused by coronaviruses, 69 specifically, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [1,2]. From the 70 time when the disease was first reported in the Wuhan Province in China in December 2019 [2], 71 it has affected more than three million people globally, with over two hundred thousand deaths in 72 212 countries and territories [3]. The World Health Organization (WHO) declared COVID-19 as 73 a pandemic on 11th March 2020 [4]. COVID-19 is a highly transmissible disease with a basic 74 reproductive number estimated to be higher than that of Severe Acute Respiratory Syndrome 75 (SARS), which only affected 26 countries and caused about 8,000 deaths in 2002 [5,6]. 76 COVID-19 is transmitted from person to person through small droplets from the nose or mouth, 77 which are expelled when a person with COVID-19 coughs, sneezes, or speaks and also via 78 contact with fomites [2,7]. The virus has been shown to survive outside a host for durations that 79 depend on the nature of the surface. It can survive in the air for up to 3 hours, on copper surfaces 80 for up to 4 hours, on cardboard for up to 24 hours, and plastic and stainless steel, for up to 72 81 hours [8]. Common symptoms of COVID-19 include fever, cough, colds, headaches, and 82 difficulty in breathing. Available evidence suggests that the pathogenicity of SARS-COV2 83 depends on host factors such as age and other comorbidities[9–12]. There is, currently, no 84 approved treatment for COVID-19. Neither is there any vaccine for prevention in vulnerable 85 populations [2]. 86 The first two cases of COVID-19 in Ghana were identified on the 12th of March 2020 [13]. By 87 April 19th, more than 1,000 confirmed cases of COVID-19 and nine deaths had been reported. 4 medRxiv preprint doi: https://doi.org/10.1101/2020.06.03.20120196; this version posted June 5, 2020. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 88 To reduce person-to-person transmission, the Government of Ghana adopted and promoted the 89 WHO’s recommendations[14], which include avoiding or limiting physical contact (including 90 handshake and other forms of usual contact), regular handwashing with soap under running 91 water, rubbing of hands with alcohol-based sanitizers with 70% alcohol strength, and 92 reducing/limiting large gatherings among the general populace. Coughing into the elbow or 93 tissue and disposing it immediately into a bin have also been recommended. Preventive 94 behavioral change messages have been developed and are being disseminated through various 95 media (radio, television, social media, and print media), nation-wide. 96 Emphasis has been placed on ensuring adequate handwashing and social distancing in all public 97 places, including markets and transport terminals. This was partly because the majority of urban- 98 dwelling Ghanaians rely on open markets for groceries and informal public transportation for 99 daily commuting. Public transportation stations in many parts of the Greater Accra Region 100 (GAR) including Accra and Tema are usually not spacious and are characterized by high 101 vehicular and human density, especially during rush- hours. Also, they are mostly owned and 102 managed by private individuals, resulting in little or no risk management by city authorities. 103 The public transport system is essentially informal and privately-managed by independent 104 operator unions, and designed to convey intra-city commuters using Mini-buses and Taxis. The 105 city is also served by large capacity buses for travel between cities. Irrespective of the category 106 of transportation, passengers often need to converge at crowded stations to access transportation. 107 During rush hours (6-9am in the morning and 4-7pm in the evening), many commuters 108 congregate at stations, and often have to wait in queues to access public transportation to various 109 destinations in Accra, Tema, and other administrative capitals in the region. This arrangement 110 creates large crowded situations that limit the ability to effectively practice social distancing. 5 medRxiv preprint doi: https://doi.org/10.1101/2020.06.03.20120196; this version posted June 5, 2020. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 111 While onboard the vehicles, passengers usually sit or stand very close to each other, largely, 112 because of overloading. This situation further creates a fertile environment for spread of COVID- 113 19 transmission. 114 With recognition of the government’s recommendations to limit the spread of COVID-19, it is 115 critical to assess public responses to these preventive measures. At the time of our study, 116 compliance with these preventive measures, especially in urban spaces where intense human 117 interaction takes place, had not been systematically evaluated.