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Community-Led Total Sanitation, Open Defecation Free Status, and Ebola Virus Disease in Lofa County, Liberia

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).

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