COVID-19: Implications for Food, Water, Hygiene, Sanitation, and Environmental Safety in Africa: A Case Study in Ghana

Governments all over the world are currently grappling with the COVID-19 pandemic. While some countries were very hard hit, others were only mildly hit but all are still taking measures to mitigate the consequences. The virus emerged in December 2019 in Wuhan, China and spread to most continents by the beginning of March 2020, which led to the World Health Organization declaring it as a pandemic on the 11th of March 2020. Since it was a novel disease, there was limited information on the virus, Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) belongs to the same family as the Severe Acute Respiratory Syndrome Coronavirus 1 (SARS-CoV-1) and the Middle East Respiratory Syndrome Coronavirus (MERS-CoV). Researchers all over the world started working simultaneously to understand the virus to provide the necessary treatment regime or vaccine in order to reduce the impact of the virus on its victims. Africa and other developing countries with limited resources and poor planning and management are expected to be among the worst hit in the long run. The implications of the COVID-19 on food, water, hygiene, sanitation, and the environment in Africa have been reviewed in this paper, as well as possible implications they may pose to the population, based on the existing common practices and their immediate impacts. This information can assist policymakers in Africa to adequately plan the management of the COVID-19 in order to lessen its impact on the population.


Introduction
Governments of all countries worldwide are currently grappling with the COVID-19 pandemic.
While some countries were very hard hit and others only mildly hit but all are still taking measures to mitigate the consequences.
Most Africans thought they were immune to whatever was happening Wuhan, China, and Asia, Italy and the rest of Europe, as well as the Americas and Australia. There was a widely held perception that the disease could not survive the high temperatures in African countries.
Unfortunately, the first case of COVID-19 in Africa was recorded on the 14 th of February 2020 in Egypt. The first case in sub-Saharan Africa and at the same time, in West Africa was reported in Nigeria on the 27 th of February, 2020. The disease has since spread to other countries and the number of confirmed cases is rapidly increasing.
The fear of most experts in Africa as well is that, with limited healthcare and poor sanitation the continent will be hit harder than the rest of the world. As of the 18 th of May 2020, Ghana has recorded more than 5,735 cases with 29 deaths (Ghana Health Service, 2020), and the situation in the country as well as in other African states raises further concern about the possible burden the of COVID-19 in Africa. Economically, it has been projected by the world bank that the COVID-19 will drive sub-Saharan Africa toward its first recession in 25 years (World Bank 2020).
It has been estimated by the WHO that Africa is likely to report 199,000 deaths as a result of the COVID-19 pandemic (WHO, 2020). This estimate takes into consideration the predisposing factors, the level of preparedness, availability of healthcare systems to cater for the vulnerable population, ability to detect, isolate and treat, among several other factors.
The main objective of this review is to discuss the COVID-19 and its possible implications on food, water, sanitation, hygiene and environmental safety during the pandemic and the Surprisingly, the SARS-CoV-2 genetic material has also been detected in faeces of humans just three days after infections, unlike the nasopharyngeal samples that take 5 days or more to manifest in patients (Madema et al., 2020). This finding may be very important in most parts of Africa, since open defecation is widely practiced (Fig 1) due to lack of sanitary facilities. such products gave a leeway for unscrupulous individuals to flood the market with counterfeit or diluted disinfectants. In one instance, a producer of fake hand sanitizer was arrested by the police in Techiman, one of the regional capitals in Ghana. He was using water and some unprescribed ingredients to produce and sell substance to the public (Nyabor, 2020). Such 6 practices may produce fake disinfectants which are not effective and contribute to the wider spread of the virus, coupled with the widespread insanitary conditions.

Food safety
Food safety is complex as it involves a combination of multifaceted interdisciplinary processes. Food safety includes producing, harvesting, processing, handling, packaging, storing (freezing), transporting and distributing or selling food in an acceptable manner (by standards) that will prevent the food from changing its biological/microbiological, chemical and physical form beyond acceptable limits until it reaches the last consumer for consumption.
In food safety, there are basically three types of hazards that may be encountered. 7

Foodborne diseases and outbreaks in Africa
A foodborne disease is any disease triggered by the consumption of food and water. An outbreak occurs when the same source of food causes three or more people to be sick of the same causative agent. In the developing countries, where stringent measures are put in place to detect foodborne disease outbreaks rapidly, outbreaks or recalls occur frequently because they have effective processes in place to monitor and track when there is any problem. This makes the citizenry to have confidence in the food production chain. There is also a constant update of issues concerning food safety through various channels of communication in order to act swiftly and avert any loss of life.
Foodborne diseases and outbreaks and recalls are hardly reported in developing countries and there are virtually no effective guidelines or implementation strategies when they occur.
Africa is ranked first when it comes to deaths associated with diarrhea and related foodborne illnesses (Kirk et al., 2015). Issue of availability and accessibility to food (food security) is also a big challenge. However, an unwholesome food may kill the consumer. Food security and food safety must, therefore, go hand in hand to solve the problems of the food production and supply, as well as utilization or consumption in Africa.

Food safety on the farm
In most urban and peri-urban areas in Africa, vegetable producers are heavily dependent on irrigated water or sewage for the production of their crops (Fig 2). Some also depend on dams, dugouts, streams and rivers for water to irrigate their crops. There is a high risk of using this untreated water to irrigate crops. Already, Escherichia coli has been found on many leafy vegetables cultivated using untreated and sewage water in Africa (Seidu et al. 2014;Pesewu et al., 2017). This makes it a clear possibility for the SARS-CoV-2 to contaminate leafy 8 vegetables and allow transmission to consumers who buy and eat these products without any proper processing to eliminate or reduce microorganisms.

Food transportation and distribution
Delays in transportation as a result of lockdown restrictions may also have it toll on food safety. In cases where selected cities are locked down, alternative and probably longer routes are considered for essential food items to be transported. This increases the time and cost of transportation. The end result might be breakage in the food chain, and the food quality being compromised.
Another concern which is worthy of note is the health of the transporters, such as the driver of the vehicle, the assistant driver or those who help in offloading the food from the vehicle.
Any of the actors mentioned above could serve as a source of transmission of the disease in case they are infected and may possibly transmit it onto the food when they come into direct contact or indirectly, through the packaging materials.
The frequent disinfection of vehicles used for the transportation of food is necessary to break the chain of contamination of the virus from contact surfaces in the vehicle.
Sensitization of the actors in the food chain about the disease, as well as constantly monitoring their health status will go a long way to prevent the spread of the disease.

Food processing/cooking
In the case of the SARS-CoV-2, there are no known toxins to be released into food. However, the live virus could find its way into food when there are gaps in the processing and cooking practices. A typical example to expatiate this point is when an infected sewage or untreated water is used to irrigate a leafy vegetable such as lettuce for example, that is harvested for immediate sale on the market, without further basic processing on farm to eliminate potential pathogens. Lettuce may continue to habour the virus, until it is consumed and if the 9 appropriate receptor of the virus is found, proliferate and may result into COVID-19. This applies to other vegetables and fruits from the farm that are not processed well before consumption. The processor or cook may also be a source of the infection and may transmit the virus into the food during cooking without following good hygienic practices. Apart from the materials that are cardboard-like (e.g. old newspapers, leaves of exercise books or text books, old cement packaging bags, paper bags) and plastic-like (polyethylene bags and, plastic containers) of which the survival of the SARS-CoV-2 may be predicted or extrapolated, the survival on the leaves of trees is not known. Generally, the virus is likely to die faster on local packaging materials than the conventional ones. Unfortunately, the viability of the virus in different food products is not documented yet.
Two factors are noteworthy in food packaging: i) The ability of the packaging personnel to introduce the virus directly from him or herself into the food or on the packaging material through sneezing, coughing or with a contaminated hand and

10
ii) The ability of the personnel to introduce the virus from a contaminated contact surface either into the food directly or indirectly when touching or cleaning the material to package the food.
After sterilization of packaged product is done, the outer part of the packaging material is still vulnerable to microbial contamination. The sterilization of the outer packaging materials may not be done for most local packaging materials. Cardboard-like materials have been reported to habour the virus for just a few minutes to hours while the stainless or cans may habour them for up to 3 days based on PCR analysis (van Doremalen, 2020). Those involved in packaging food must be mindful of the good packaging practices and take precautions to avert any possible spread of the virus through the food packaging materials of the food itself.

Food retailing
Small scale retailing of fresh of cooked food is present everywhere on the African continent. This is an informal activity, commonly practiced by women in Ghana. The sanitation and hygiene levels of these retailers are generally low, due to lack of training. Some food items such as oranges, yam, water melon, cabbage etc. are generally sold from the ground, which may also harbor pathogens, possibly including the SARS-CoV-2. Some may argue that there is no problem with produce that will be cooked before consumption, but cross contamination of other food products or contact surfaces may occur and put the consumer at risk of infection. Another behavior of concern is that many people are allowed to touch directly these retail foods to check for their quality before purchase. Flies that might have landed on infected faeces may also land on such produce on the market and therefore, increase the risk of acquiring the disease. Small-scale retailers buy their stock in a well packaged form, but open the package to further retail in smaller quantity to make them affordable. This practice also predisposes the retail products to contamination. Awareness creation on these practices is needed to reduce the possible spread of COVID-19.

Street food safety
Street foods in Africa are generally ready-to-eat foods sold in stationary stalls, opened, semi closed or closed tables or by hawkers who roam about with the foods to find customers.
Hawkers are commonly found in schools, at bus stations, government work places or offices, markets, social events, at places where major construction works is going on, by the windows of vehicles in heavy traffic and from door to door. These foods are normally prepared by vendors without training and certificates. Those that are well-organized and stationary have some supervision by the local authorities intermittently, because they are charged taxes. They are generally not well regulated and operate unhygienically Saba and Gonzalez-Zorn, 2012). There has been a report in Accra, Capital of Ghana of ten street vendors at the Achimota Government Hospital who tested COVID-19 positive in a routine surveillance (Wemakor, 2020). Another street vendor, who sold peeled oranges to the public was also confirmed dead of COVID-19 in the Tamale Metropolis on the 11 th of May (More, 2020). This poses risk to the consumers of their products and any other persons who came into contact with them. Where there are enough testing centers and kits, it is recommended to test all those involved in the food production chain, especially chefs at hotels and restaurants, street food vendors, waiters, etc. This will lead to early detection and treatment to prevent the further spread of the disease.

Zoonotic potential of SARS-CoV-2 and implications in Africa
Even though most coronaviruses are zoonotic (Schoeman and Fielding, 2019), there is no evidence that the SARS-CoV-2 is zoonotic and there has been no evidence of animal to human transmission yet.
The World Organization for Animal Health (OIE) has declared that the infection of animals with SARS-CoV-2 can be considered as an emerging disease, which it described as a new occurrence in an animal of a disease, infection of infestation, causing a significant impact on animal or public health resulting from: i) a change of a known pathogenic agent or its spread to a new geographical area or species or ii) a previously unrecognised pathogenic agent or disease diagnosed for the first time. In Africa, there is no report and evidence that an animal has contracted the SARS-CoV-2.
However, a report from Egypt showed killing of their cats by several owners because of the baseless believe that cat was transmitting the disease to human beings (Jansen, 2020). So far, the closest animals that are known to carry permissible infection dose of the SARS-CoV-2 are cats (Shi et al., 2020). Cats, both domestic and wild, are delicacies of certain tribes in Ghana.
Although it has not been proven yet, eating cat meat in areas where the COVID-19 is highly endemic in Ghana may pose a considerable risk to consumers. The viral RNA of SARV-CoV-2 was detected in the faeces of two virus-inoculated subadult cats by Shi et al. (2020). Even though the live virus was not cultures from this study, it must be considered as a risk factor, especially in highly endemic areas of the diseases. There might be a risk of faecal-oral transmission through contaminated food and water. Faeces of cats must be handled with care especially in the endemic regions of COVID-19 in Ghana. However, the risk may be higher in companion cats whose owners have been infected with the virus.
As mentioned above, rabbits could be sensitive to the virus (International Society for Infectious Diseases, 2020). This may also mean that, rabbits in close contact with infected person or endemic areas must be monitored in Africa. Even though the virus has not been proven to be transmitted to human as a result of consuming rabbits, there is also a possible risk of its transmission through eating infected rabbit. One of the main issues of concern will be the way these animals are slaughtered and processed in Africa. Hygienic precautions are not normally followed during slaughtering and processing and hence, there may be a risk of cross contamination of the virus. Most of the slaughtering and processing of cats and rabbits is done in the house, but not the abattoir.
With the detection of the SARS-CoV-2 human faeces, animals, both waste water and rivers, there is also potential of animals acquiring the virus through contaminated waste water, sewage or rivers if they have the appropriate receptacle for the virus.

The role of food safety authorities and stakeholders
The role of food safety authorities is very crucial in the enforcement of stringent guidelines in order to mitigate against the spread of the disease through food. Even though the enforcement of the law is generally relaxed during ordinary times, more efforts must be put in during crisis period even if it demands employing more people. The effects of the pandemic might be more than the financial commitment to employ more hands to help educate and enforce the law effectively to prevent the spread of the disease. This calls for the authorities to redouble their efforts and if possible fast track some of the processes to respond to the demands of the of the pandemic.
The major problem of food regulation in Ghana is the centralization of activities in the headquarters in the capital, Accra. Very simple procedures and analyses that could be done by regional offices are still sent to Accra, which is very far away from some of the regions. It takes about 600 km to 800 km to get to the headquarters in Accra from some regions. Food authorities must make conscious efforts and make it a priority to decentralize their activities in order to serve the population better. They must locate subsidiary laboratories in the regions and build their capacity to be able to perform very simple but important tests to ensure basic safety.
Since samples from almost the whole Ghana must be analyzed in the central laboratory in Accra, there are unnecessary delays of test results. This can be avoided by using the tertiary institutions with laboratory facilities in the various regions. Central authorities must be ready to provide simple equipment and training to staff in those subsidiary laboratories to meet the required standards.

Water, Sanitation and Hygiene
Water, Sanitation and hygiene, collectively named WASH, have attracted a lot of attention in Until recently, it was not uncommon to see many Ghanaians washing their hands without soap. It was not also very strange to visit an eatery that is without soap, because the food vendor is reluctant to buy more when certain quantity is exhausted. The concentration of the liquid soap used in such establishments, is of concern, to ensure that the hands of customers are very clean. Food business operators tend to dilute liquid soap to increase the volume without thinking if it will enable customers to wash their hands effectively. Even though the primary action of hand washing is the mechanical removal of viable transient and resident microorganisms, the concentration of the soap is very important to achieve the needed result.
With the advent of the COVID-19, almost every street food vendor, restaurant or food business operator in Ghana provides either liquid soap or cake soap with water from the sink which is connected directly to a pipe borne water or a container filled with water with a tap fixed on it and called ''Veronica'' bucket in Ghana, after its inventor. Although the Veronica bucket concept is a very good one, there are a lot of concerns when it is publicly used.
The first concern is that, the taps expose users to contamination since everybody uses hands to open/close the tap in an attempt to wash the hands. We have worked on the prevalence

Implications for water resources for livelihood in Africa
The SARS-CoV-2 has been detected in raw waste water for up to 8 days and in rivers as well in the Milano Metropolitan Area, Italy through Polymerase Chain Reaction, however, it was not detected in treated water samples (Rimoldi et al., 2020). Traces of the SARS-CoV-2 were also found in several wastewater treatment plants in the Netherlands (Mallapaty, 2020) and Paris (Wurtzer et al., 2020) where the SARS-CoV-2 has been established to stay for few days.
Fortunately, the waste water or water from rivers in those advanced economies is not drank in the raw form. In developing countries, there is often no choice but to make use of untreated  Fig 5).
According to the WHO, from a work that was done by Casanova  there is no evidence of transmission from waste water of rivers to humans, people who utilize polluted water may be at risk when they drink water contaminated with SARS-CoV-2.

Perennial flooding in Ghana: Implication for the spread of COVID-19
Due to the poorly designed and maintained drainage systems in most cities in Ghana, flooding after seasonal rains is a common occurrence. Flood waters normally carry waste and sewage into homes of residents in the affected areas (Fig 6). Since the SARS-CoV-2 has been found in faeces, with the resultant presence in waste water and its presence in flood water cannot be ruled out. Open defecation, over flooded manholes and pit latrines may also pose risk of spreading the virus. to humans, either directly or indirectly. It is unlikely due to the small viral load that they carry but the transmission cannot be completely ruled out.

Open defecation: implications for the spread of COVID-19
Apart from treated water, which is a preserve for only a few, millions of Africans depend on other sources of largely untreated water for their livelihood (WHO and UNICEF, 2012). These sources of untreated water include but are not limited to dugouts, dams, streams, rivers, wells, as well as rain water.
In Ghana many people fetch water from possibly contaminated surface water reservoirs, such as dugouts and dams. They drink water from such sources, without any preliminary treatment (Fig 5). This water is used for many household chores such as cooking, washing

Toilet facilities and their potential role in the spread of COVID-19
Apart from the open defecation, there open and semi-opened toilet facilities exposed to flies.
The Kumasi Ventilated Improved Pit (KVIP), is commonly used in Ghana. The whole pit is covered, apart from where one eases himself/herself but an additional perforation is normally made on another side to allow for the stench to go out. Another type of toilet is a dug pit crossed with wood to squat (Fig 7). They are located in the house or a bit distant from the house -especially the open types. These types of toilets can be either public and private.
House flies normally move to and from the pits after settling on the pile of faeces. Although, the pile of faeces may generate heat that may kill the virus, flies may settle on the fresh faeces which are normally on the top and has not yet mixed with old faeces. Thus, toilet facilities as described may also pose some risk to food and water safety since they are normally expose to flies that fly in and out and may settle on food.

Environmental safety
The impact of the COVID-19 on the environment and ecosystem cannot be left out. Humans may impact negatively on the environment as a result of measures they will take to curb the spread of the disease. The positive impact of the COVID-19 has been that the lockdowns throughout the world slowed down human activities and led to the reduction of pollution in the environment (Chen et al., 2020). Moreover, African practices may have their peculiar implication on the environment as far as the disease is concerned.

Disposal of personal protective equipment in the environment
The disposal of 'supposed' infected face masks and personal protective equipment (PPE) into the environment may find their way through sewage and finally, enter the water bodies that are used by the populace. The face masks and PPE, if not disposed properly, could also directly enter such water bodies through drainage, because of improper disposal and possibly contaminate the water bodies with the SARS-CoV-2 even though it is unlikely. This is a very big issue that must be considered by all governments in Africa, where these governments are enforcing the compulsory wearing face masks in public. Most countries in Africa are already fighting a losing battle against plastic bags in the environment.
A simple analysis below may help appreciate the waste problem that will be posed by the face masks and other PPE. Assuming that the adult population of Ghana is seventeen million (17,000,000), half the total population. Half of the adult population again, eight million (8,000,000) may go to formal or informal work. If half of the eight million, four million (4,000,000) wears disposable face masks, there will be four million face masks to be disposed daily. Assuming that they work for 5 days in a week, 20 million face masks will be disposed per week. The monthly estimate of face masks to be disposed of will be approximately 80 million. The same analogy could be applied to the thousands of frontline workers who also don several PPE that are not reusable y. One could imagine the total tonnage of waste from PPE that will be generated during the time of this pandemic. Are African governments ready for this? The tasks seem daunting, since they must struggle to acquire the PPE and at the same time struggle to dispose of them.

Disposable tissue papers in the environment
The amount of waste generated by using the tissue is also alarming. The disposable tissue paper may not only cause physical nuisance in the environment but also microbiological hazard. Waste tissues of those who did not wash their hands properly and might be carrying the virus risk spreading the disease. The good news is that, research have shown that the virus may only live on cardboard for that matter tissues for only up to 24 hours. However, the virus could be washed away on to another surface where it can survive for a longer period and increases the risk of spreading the disease.

Disposal hand sanitizers containers in the environment
There is currently high demand for sanitizers, especially alcohol-based. There is also a very high demand for stock alcohol since it is the major ingredient in the production of hand sanitizers. With the massive use of hand sanitizers, the disposal of their empty plastic containers becomes a very big concern. This will significantly increase the existing burden of the disposal of plastics already overwhelming most urban environments.

Environmental contamination with detergents
Due to the increase in the frequency of the hands washing with soap and other cloths, as well as other surfaces to reduce or eliminate any possible SARS-CoV-2, there will be excessive use

Conclusion and Recommendations
COVID-19 has been present globally for the past five months and its impact is been felt throughout the world. The impact is expected to be more pronounced in developing countries, which are still struggling with the basic necessities of life. Until a vaccine or a cure is found for the disease, the direct health effects and their related issues will continue to raise concerns. It is likely that the COVID-19 has come to stay, just like HIV/AIDS that remains present for decades. There are also a lot of gaps to be filled to fully understand the behavior Africa bears further many possible predisposing factors, taking into account the current knowledge of the disease. Thus, a lot of efforts must be made by various governments to properly address the problems during and after the epidemic has subsided.
African governments must be up-to-date regarding the current trends of detecting, isolating, managing and preventing the COVID-19 in order to adapt them to what pertains in their countries, as well as share good practices among themselves in order to benefit most from the existing knowledge of the disease. At the same time, they must also invest in research and development and encourage researchers to bring out innovative ideas to tackle the disease and any impact it might have caused thereof.
It has been proven that clean water, good sanitation and hygiene and safe environment improve the living conditions of communities across the world. Efforts must be made by African governments and development partners to provide clean and affordable water to the continent's population. More homes should also be assisted to build toilets. The individuals and communities must be sensitized on the need of clean environment and water, good sanitation and hygiene and their maintenance. Culturing of microorganisms from their hands, water sources, contact surfaces and their environment could be a good way to demonstrate disease presence and to appreciate the existence of microbes and take measures needed to prevent infections.
The authorities involved should sensitize the populace to treat water from open sources and if possible, provide them with relevant materials or chemicals. This will go a long way to reduce the impact of waterborne diseases, as possibly COVID-19, if confirmed to be transmitted to humans through water.
Food safety and environmental protection authorities must be actively involved to curb the spread of the COVID-19. Food regulations must be strictly enforced not only for imported, but also local products that are put on the market without following good manufacturing practices. Environmental protection activities must be evaluated and those practices that can potentially spread the COVID-19 must be strictly regulated.