Assessment of the hand hygiene status of internally displaced persons in Jos and environs, Nigeria

1 Department of Microbiology, Faculty of Natural Sciences, University of Jos, Plateau State, Nigeria. 2 Department of Biological Sciences, Faculty of Natural Sciences, University of Maiduguri, Borno State, Nigeria. 3 Department of Microbiology, Faculty of Natural Sciences, Plateau State University, Bokkos, Plateau State, Nigeria. 4 Department of Microbiology, College of Natural Sciences, Michael Okpara University of Agriculture, Umudike, Abia State, Nigeria.


INTRODUCTION
Internally displaced persons (IDPs) are "persons or groups of people who have been compelled to flee or leave their homes or places of customary residence, in particular as a result of, or in order to avoid the effects of armed conflicts, situations of generalized violence, violations of human rights or natural or man-made disasters, and who have not crossed an internationally recognized state border" (UNHCR, 1998). Estimates from *Corresponding author. E-mail: egbereo@yahoo.com, egbereo@unijos.edu.ng. Tel: +2348033646268.
Author(s) agree that this article remain permanently open access under the terms of the Creative Commons Attribution License 4.0 International License the Internal Displacement Monitoring Centre (IDMC) indicate that the number of people displaced annually by conflict and violence has increased globally since 2003 (IDMC, 2016). A massive 40.3 million of them were uprooted during 2016, equaling 15,000 people displaced every day in African countries alone (IDMC, 2015(IDMC, , 2016(IDMC, , 2017a. The IDMC's Global Overview (IDMC, 2015) reported that the majority of the increase in new displacement during 2015 was the result of protracted crises in the Democratic Republic of the Congo, Iraq, Nigeria, South Sudan, and Syria. In total, these five countries accounted for 60% of new displacement worldwide. In Nigeria, the insurgent activities of Jamā'at Ahl as-Sunnah lid-Da'wah wa'l-Jihād (Islamic State's West Africa Province) commonly called Boko Haram (BH) in the past decade have forced more than 2,152,000 people to flee their homes with 1,434,142 of these coming from Borno State (Nigeria IDP Figures Analysis, 2018). This has resulted in an unprecedented humanitarian crisis in the Northeastern part of the country and the Lake Chad region (IDMC, 2016).
Intercommunal clashes resulting from ethno religious disputes, between Fulani herdsmen militia and farmers have also resulted in over 700,000 people being displaced from the Middle Belt region of Nigeria (IDMC, 2016). Internally displaced persons (IDPs) are often predisposed to infectious diseases because of the temporary nature of their abode which usually does not have adequate water and hygiene facilities (Olwedo et al., 2008;Guerrier et al., 2009;Lam et al., 2015). According to Owoaje et al. (2016), there are several risk factors, working in synergy during displacement which promotes communicable diseases. These factors include the massive movement of populations and resettlement in temporary locations, overcrowding, economic, environmental degradation, poverty, inadequate availability of potable water, poor sanitation, and bad waste management. These conditions are further complicated by the absence of shelter, food shortages, and poor access to healthcare (Connolly et al., 2004). In Sub-Saharan Africa, Diarrhoeal and Urinary tract diseases are major causes of morbidity and mortality among IDPs and mainly result from substandard or inadequate sanitation facilities, poor hygiene, and poor hand washing practices due to scarcity of soap, water, sanitizers, etc. (Connolly et al., 2004;Kim et al., 2007;Getanda et al., 2015).
The hand has been recognized as the major carrier of many germs of fecal origin and body flora through the mouth, nose, eyes, etc. into the human body resulting in infectious diseases such as the current pandemic Coronavirus, diarrhea, cholera, Ebola, Lassa fever, flu, hepatitis and the likes (Greger, 2007;Gould et al., 2017;Jefferson et al., 2011;Ngene et al., 2020;Egbere et al., 2008). Hand washing has an age-long recognition among religious and cultural practices of the world. A Nigerian Egbere et al. 609 proverb which states "that it is only the child that washes his or her hands that could eat with elders" bears credence to the cultural importance of hand washing. The widespread occurrence of antibiotic resistance among thousands of people with suspected bacterial infections across 22 countries was revealed by W.H.O.'s new Global Antimicrobial Surveillance System (GLASS). The most commonly reported resistant bacteria have Escherichia coli, Klebsiella pneumoniae, Staphylococcus aureus, and Streptococcus pneumoniae, followed by Salmonella spp. (WHO, 2018). Improper or irregular Hand washing in areas starved with Hand washing facilities like internally displaced person camps can be a huge problem for antibiotic therapy (Todd, 2014). This research was therefore carried out to assess the compliance to hand washing and antibiotic susceptibility of hand-borne bacteria in the hands of internally displaced persons in Jos and environs, Plateau state, Nigeria.

Study area
The sample area for this research work is two displaced camps situated within Jos which include House of Recaps (British American junction) and Stefanos Foundation IDP camp (Bukuru).

Samples size and questionnaire type used
A total of 100 samples of hand-washed water from displaced persons (IDPs), 50 drawn from each camp were taken randomly. Randomization was done by tagging the IDPs with numbers 1-5 and the first 10 persons with numbers 5 were picked from each camp. A structured questionnaire comprising of various aspects meant to investigate the persons' knowledge, attitude, and practice (KAP), as well as compliance with proper hand washing procedures recommended by the world health organization were used.

Collection of samples
The collection of samples from the two camps was done ingeniously and aseptically using the Hand-dip technique modified from the method of Houshian et al. (2006). This involved the displaced person dipping his or her right or left hand (depending on which hand the person uses regularly) into a sterile surgical hand glove containing 50 ml of sterile water (held by the researcher) and left for 30 s. The hand of the Idp was twisted thrice in an attempt to rinse it with the water (with the researcher assisting in the process). Thereafter, the sample was carefully poured into a clean sterile bottle labeled appropriately. The collected samples were transported to the microbiological laboratory a few minutes after collection.

Cultivation and enumeration
A serial dilution of the hand-washed water was used. Each sample was serially diluted to the power of 5 by pouring 9 ml of sterile water into test tubes arranged in fives for all samples following the Serial Dilution Technique as described by Cheesbrough (2000). The last dilution (10-5) was inoculated on plates containing different media (Nutrient Agar, MacConkey agar,) for each sample and then labeled accordingly After inoculation, plates were incubated upside down at 37°C for 24 h then were observed for growth and the colonies obtained were counted using Digital Colony Counter.

Macroscopic examination of the isolates
The isolates were examined macroscopically for morphological characteristics of the bacterial isolates to include size, shape, color, margin, elevation consistency, and hemolysis according to descriptions by Cheesbrough (2000).

Microscopic examination of the isolates
Standard bacteriological methods on microscopic examination of gram stained colonies as well as the determination of biochemical characteristics of the isolates as described by Cheesbrough (2005) were followed to identify the bacterial isolates obtained from the hands of the IDPs.

Antibiotic susceptibility test
Kirby-Bauer Disk Diffusion technique of antibiotic susceptibility testing (AST) was carried out to determine according to specifications of the National Committee for Clinical Laboratory Standards (NCCLS), 2013 (Kassim et al., 2016) using standard antibiotic discs on Muller-Hinton agar. A clear zone or ring of inhibition around the antibiotic disc was measured as the Zone diameter of Inhibition by the respective bacterial isolates tested.

Statistical analysis
Data were subjected to statistical analysis using the software SPSS version 13.0 (SPSS Inc, Chicago, USA).

RESULTS
The results  The results of the morphological, microscopic and biochemical characteristics of bacterial isolates associated with the hands of Internally Displaced Persons in Jos and Environ are shown in Table 2. Six organisms were identified and they include S. faecalis (21.00%), S. aureus (31.00%), E. coli (32.00%), Salmonella sp (32.00%), P. aeruginosa (40.00%) and Proteus sp (54.00%). The results of the percentage frequency of occurrence of bacterial isolates associated with the hands of the Internally Displaced Persons in Jos and Environs are shown in Table 3. The results indicated that while Proteus sp (54.00%) had the highest occurence, the least frequently occurring organism is S. faecalis (21.00%).
The result of the antibiogram of bacterial pathogen isolated from the hands of Internally Displaced Persons in Jos and Environs are displayed in Tables 4 and 5. The result showed that while Proteus sp was the most resistant (61.1%) organism to the 10 commonly used antibiotics, S. aureus was found to be the most sensitive organism (63.9%). The results obtained from the questionnaire which were filled by the IDP's about their knowledge of pathogenic bacteria and hygienic practices and precautions taken to prevent infections such as hand washing after defecating and before eating and also use of gloves during domestic work and washing hands afterwards as well as the nature of the finger nails as to whether it is trimmed, semi trimmed, or untrimmed is represented Figures 1 to 5.

DISCUSSION
The results in Table 1 having an average mean total plate count of 2.81× 105 tallies with reports of (Okareh and Erhahon, 2015) who equally enumerated bacterial loads on the hands of food handlers in Benin city, their mean total plate count was gotten to be 3.07×105. It should be noted however that the mean bacterial count of IDPs in the Stefanos Foundation (2.90×105) was slightly higher than those in House of Recabs (2.71×105). This could be due to inadequate water supply, both in quantity and quality, poor sanitation, and overcrowded condition of the Stefanos Foundation camp. In converse, the population in House of Recabs is less than and more manageable, they also have more access to the water supply. The Table 2. Biochemical characteristics of bacterial isolates associated with hands of internally displaced persons in Jos and environs.

Gram reaction Motilty Catalase Coagulase Oxidase Spore Lactose fermentation Glucose fermentation Sucrose fermentation Suspected organisms
-    difference in mean count between the two camps could also be reflective of the different personal hygiene status of the IDPs in two camps as well.

Pseudomonas aeruginosa (%)
The results in Table 2 show that S. faecalis (21.00%), S. aureus (31.00%), E. coli (32.00%). Salmonella sp (32.00%), P. aeruginosa (40.00%) and Proteus spp  (54.00%) were isolated from hand washed samples of IDPs. All the six bacterial isolates are known to be pathogenic to man. E. coli the commonest coliform organism was isolated may be due to fecal contamination. S. aureus and S. faecalis being normal floras of the skin were isolated probably due to the use of hand to scratch wounds, pick specks of dirt from the nose, and so on. Salmonella spp which is mostly found in contaminated water indicates health hazards (Cheesbrough, 2000). P. aeruginosa which is mostly found in soil was probably isolated due to contact with soil. Microorganisms such as S. aureus, E. coli found in hand washed samples if ingested could lead to acute or chronic food poisoning or food-borne related illness such  as gastroenteritis, etc. They can cause other infections as well. The result agrees with (Tambekar and Shirsat, 2009) who isolated similar microorganisms from hand swab samples from students. (Clarence et al., 2009) isolated almost similar organisms from meat pie while (Ajao and Atere, 2009) who isolated microbes from cooked rice. (Wogu et al., 2011) also reported similar organisms from ready to eat rice sold in Benin City. The presence of indicator organisms on Hand provides a direct and relevant measure of cleaning efficiency and hygiene (Moyo and Baudi, 2004).
The result of the percentage frequency of occurrence of bacterial isolates associated with the hands of IDPs in Jos and Environs indicated that while Proteus spp has the highest frequency of occurrence (54%), the least frequently occurring organism was S. faecalis (21%). Proteus species known to be a normal microflora of the gastrointestinal tract is recorded the highest, possibly been that they probably do not wash their hands often. This is in contrast with the research carried out by  having a lower percentage of the organisms, the low results of the authors could be due to the fact that the samples were collected from the hands of students who might tend to have a general knowledge on hand hygiene.
The result showed that while Proteus spp was the most resistant (61.1%) organisms to the 10 antibiotics used, S. aureus was found to be the most sensitive (63.9%) organism. The high antibiotic resistance of Proteus spp may be an indication of resistance level among the Enterobacteriaceae. Salmonella having relatively high prevalence could be due to indiscriminate in-take of antibiotics which provides selective pressure, leading to the higher prevalence of resistant bacteria (Barrow and Feltham, 2003). Not only are these species potential causes of infections but also potential reservoirs of resistance genes that could be transferred to other bacterial pathogens. The increase in levels of Betalactamase production and multi-drug resistance of the isolates indicates an increase in the resistance menace reported by many studies (Feglo et al., 2010). The resistance of 77.85% of Proteus spp against ampicillin, cotrimoxazole, tetracycline, and chloramphenicol was reported by Feglo et al. (2010). Similar results were reported by Newman et al. (2006). These organisms are entirely preventable by practicing good sanitation and proper hand hygiene practices.
The results of the questionnaire survey showed that hand washing compliance score of the IDPs was generally poor (34.00%) with House of Recabs having a slightly higher score (35.60%) than Stefanos Foundation (32.40%) respectively. The compliance score of House of Recabs is higher than that of Stefanos Foundation possibly because the former has a lower population of children and youth with teachers who teach them hygiene and other manners. The result of the hand hygiene compliance score recorded here is slightly lower than that recorded by Odidi (2014) for students of the University of Jos (46.70%) who are obviously informed. There is a need for improvement in basic hand hygiene practices.
The following are the conclusions derived from this study; the bacterial burden of the hands of the IDPs is high, all the six organisms isolated are implicated for pathogenicity, most of the bacteria isolated have high resistance to common antibiotics used, knowledge of and compliance to hand washing by IDPs are generally low. It is recommended that effective washing agents should be provided by those in charge of the displaced camps and these agents include clean water (Tap), Antiseptic liquid, soaps, drying agents (disposable) followed by teachings about proper hand washing procedure to displaced persons.
Finally effective hand washing according to the Centre for Disease Control and Prevention (CDC) 2013 (Center for Disease Control and Prevention, 2013) should be done by wetting the hands, lather by rubbing together (back of hands, between the fingers and under the nails), scrub for at least twenty 20 s, rinse under clean running water and dry using a clean towel or air dry.