- Email: [email protected]
Ebola virus disease: awareness among junior doctors in England
Journal of Hospital Infection xxx (2015) 1e3 Available online at www.sciencedirect.com
Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin
Short report
Ebola virus disease: awareness among junior doctors in England B. Fazekas a, *, J. Fazekas b, M. Moledina c, B. Fazekas d, K. Karolyhazy e a
Whipps Cross University Hospital, London, UK St George’s, University of London, London, UK c Imperial College London, London, UK d University of Heidelberg, Heidelberg, Germany e Semmelweis University, Budapest, Hungary b
A R T I C L E
I N F O
Article history: Received 23 December 2014 Accepted 27 March 2015 Available online xxx Keywords: Awareness Ebola England Junior doctors
S U M M A R Y
The current Ebola virus epidemic continues to pose a threat to the UK. Junior clinicians are often at the frontline of medical care in hospitals and their awareness of the clinical features and management of the Ebola virus disease (EVD) may significantly influence the timely implementation of infection control measures. In view of this, we carried out a cross-sectional survey of 119 junior doctors across four different hospitals in England in order to assess their level of knowledge of EVD. We demonstrate that there is currently a deficiency of knowledge about critical aspects of EVD in this population. ª 2015 Published by Elsevier Ltd on behalf of the Healthcare Infection Society.
Introduction The current Ebola epidemic in West Africa has been declared an ‘Emergency of International Concern’ by the World Health Organization (WHO) and this crisis has put pressure on healthcare systems across the globe.1,2 In England, to date we are unaware of any scientific analysis that has been carried out to evaluate the preparedness of healthcare services for dealing with Ebola virus disease (EVD). Public health experts assure us that England is ready, especially in view of recent successfully implemented mock emergencies
* Corresponding author. Address: Whipps Cross University Hospital, Whipps Cross Road, London E11 1NR, UK. Tel.: þ44 (0)20 3416 5000. E-mail address: [email protected] (B. Fazekas).
organized by the Department of Health and the effective management of several confirmed cases of EVD.3 In contrast to these optimistic views, previous responses to a viral haemorrhagic fever (VHF) similar to Ebola, namely Lassa fever, have highlighted the need for improvement in the recognition of these groups of viruses and the timely implementation of infection control strategies.4 Our research was aimed at evaluating the level of preparedness of the health system in England to Ebola by assessing the awareness of junior doctors to the main features of EVD by means of a questionnaire. This group of clinicians was specifically selected for this study as they are regularly the first to medically assess patients in hospitals and, as such, would be at the frontline of caring for EVD cases. A poor understanding of EVD among these clinicians may put the lives of patients, doctors and the general public at risk. To our knowledge, this
http://dx.doi.org/10.1016/j.jhin.2015.03.007 0195-6701/ª 2015 Published by Elsevier Ltd on behalf of the Healthcare Infection Society. Please cite this article in press as: Fazekas B, et al., Ebola virus disease: awareness among junior doctors in England, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.03.007
2
B. Fazekas et al. / Journal of Hospital Infection xxx (2015) 1e3
study is the first attempt to quantitatively evaluate the level of understanding among medical staff in England; a comparable study by Lakhani et al. investigated the baseline understanding about VHFs among healthcare personnel, but this was carried out in Pakistan in 2002.5
Methods To ascertain the level of knowledge about Ebola among junior doctors, we devised a questionnaire and distributed printed copies during teaching sessions in four educational hospitals around England between September 2nd and November 8th, 2014. The questionnaire was completed by a total of 119 junior doctors comprising of first-year, secondyear, and junior trainee doctors. Three of the four participating hospitals were in the London catchment area, namely Northwick Park Hospital (N ¼ 30), Whipps Cross Hospital (N ¼ 36), and Ealing Hospital (N ¼ 27); the fourth participating hospital was Leicester Royal Infirmary (N ¼ 26), which is located w150 km north of London. In each case, permission to distribute the questionnaires was obtained and all of the attempted questionnaires were included in our analysis. The questionnaire focused on the demographics of EVD, its clinical presentation, the key investigations, and the immediate management of infected patients. A comprehensive mark scheme was devised using multiple information sources including the WHO, US Centers for Disease Control (CDC), Public Health England (PHE), and the local hospital protocols. The questions were scored by one of the authors, the results were then summarized in tabular form and analysed using descriptive statistical methods.
Results The results of the marked questionnaires are summarized in Table I. Knowledge of the immediate management of patients
with EVD was better than that of many other matters. However, it is concerning that there was rather less knowledge of information that would be important to identify that a patient might have EVD; there was poor knowledge of the countries affected by EVD and of the incubation period, whereas there was also relatively poor knowledge of the presenting clinical features.
Discussion The relatively small sample size of our study, both in terms of the number of junior doctors and the number of participating hospitals, limits the validity of our results. Furthermore, despite our best efforts to use trusted sources to create the marking criteria (WHO, CDC, PHE), the short-answer format of the questionnaire introduced a classification bias, as some ambiguous answers were marked as correct according to our mark scheme, whereas others were marked as incorrect. Despite these limitations, this study suggests that there is currently a lack of knowledge about important aspects of EVD among junior doctors. The participating clinicians scored an average of <60% in four of the seven questions, including those focusing on the signs and symptoms, the diagnostic methods, and the demographics of the epidemic. If these scores are truly representative of the junior clinician population in England, this could have adverse consequences for both the patients and the dynamics of a potential outbreak. First, this apparent lack of knowledge could lead to a failure to diagnose patients with EVD promptly, or at all, which in turn would delay the initiation of appropriate treatment. Second, an inability to recognize infected patients could delay the implementation of necessary confinement measures and personal protective equipment, which would be necessary to effectively contain the spread of the imported Ebola virus. Based on models about epidemics in Africa, Whitty et al. argued that these types of delays could
Table I Summary of the marking scheme used and scores achieved in an Ebola virus disease questionnaire completed by 119 junior medical staff Question Topic tested Total no. of no. (total no. of marks available) marks available
1
4
3
Countries affected by current Ebola outbreak Transmission route of the Ebola virus Incubation period of EVD
4 5
Mortality rate Signs and symptoms of EVD
1 5
6
Diagnostic methods of EVD
2
7
Immediate management
3
2
2 2
Marks allocated for specific answers
Average mark achieved by all junior doctors for question
Answer(s)
Marks
Guinea, Sierra Leone, Liberia, Mali, Nigeria, Senegal, USA, Spain Bodily secretions/fluids Fomites, large droplets 2e21 days Within 2e21 day range 50e90% Fever, headache, myalgia, fatigue, diarrhoea and vomiting, haemorrhage, sore throat, rash RTePCR, ELISA, viral antigen detection Serology, blood tests, microscopy ID seniors/microbiology/PHE Isolation and universal precautions, e.g. personal protective equipment Rehydration
1
1.8 (46%)
2 1 2 1 1 1
1.3 (66%)
2 1 1
0.8 (38%) 0.7 (71%) 2.7 (54%)
1.1 (56%) 2.0 (66.7%)
EVD, Ebola virus disease; RTePCR, reverse transcriptionepolymerase chain reaction; ELISA, enzyme-linked immunosorbent assay; ID, infectious diseases; PHE, Public Health England. Please cite this article in press as: Fazekas B, et al., Ebola virus disease: awareness among junior doctors in England, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.03.007
B. Fazekas et al. / Journal of Hospital Infection xxx (2015) 1e3 potentially lead to an increased burden of EVD in case of an outbreak.6 There may be several explanations for the apparent lack of knowledge about Ebola among junior clinicians. Since the beginning of the outbreak, the agencies have invested a significant amount of resources to educate medical staff and to make information about the epidemic publicly available. The discrepancy between their efforts and the apparent lack of understanding may possibly be explained by the fact that resources have primarily targeted accident and emergency and primary care staff.7 It could also be that the flow of information about the EVD situation that is being generated centrally is not being disseminated locally. However, each of the participating hospitals in our study had sent educative e-mails to their employees, and all had detailed information about Ebola on their intranet pages. Our findings therefore suggest that current hospital information systems are not an effective way of transmitting important information to junior clinicians, who may not have sufficient time or access to hospital computers. Our findings should be useful to healthcare educators and hospitals in England and other countries. It has highlighted a deficit in the level of knowledge among junior clinicians, a problem that needs to be addressed in order to better prepare medical systems for EVD. This study could be used as a platform to initiate a more extensive survey to assess awareness of EVD among clinicians of all grades, as well as nurses and allied healthcare professionals. If these findings are confirmed by other similar studies, educational resources such as e-learning modules, active real-time course, or simulation scenarios may be useful to the relevant groups in order to improve the recognition and the management of EVD. With these additional measures, a better awareness of Ebola might be achieved among the medical staff.8 In conclusion, this study suggests that junior doctors in England do not currently have sufficient knowledge about the clinical features and the epidemiology of EVD. In view of the
3
continuing crisis in West Africa, this apparent lack of understanding may put both patients and healthcare professionals at risk, if imported infected patients were to seek medical help in hospitals in England. In light of the limitations of this study, we recommend a more extensive evaluation of the understanding among healthcare professionals of EVD. Furthermore, we actively encourage the use of educational resources, such as e-learning modules, to increase awareness among medical staff. Conflict of interest statement None declared. Funding sources None.
References 1. World Health Organization. Ebola virus disease. Fact Sheet No. 103. Media Centre: September 2014; Available at: http://www.who.int/ mediacentre/factsheets/fs103/en/. 2. Briand S, Bertherat E, Cox P, et al. The international Ebola emergency. N Engl J Med 2014;371:1180e1183. 3. Coombes R, Arie S. Ebola: how well is the UK prepared? BMJ 2014;349:g6288. 4. Crowcroft NS, Meltzer M, Evans M, et al. The public health response to a case of Lassa fever in London in 2000. J Infect 2004;48:221e228. 5. Lakhani A, Mahmood H, Laeeq A, et al. Viral hemorrhagic fever in Pakistan: awareness among health care personnel. J Pak Med Assoc 2002;52:214e217. 6. Whitty CJ, Farrar J, Ferguson N, et al. Infectious disease: tough choices to reduce Ebola transmission. Nature 2014;515:192e194. 7. Public Health England. Ebola virus disease: clinical management and guidance. London: PHE; 2014. 8. Tosh PK, Sampathkumar P. What clinicians should know about the 2014 Ebola outbreak. Mayo Clin Proc 2014;89:1710e1717.
Please cite this article in press as: Fazekas B, et al., Ebola virus disease: awareness among junior doctors in England, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.03.007
Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin
Short report
Ebola virus disease: awareness among junior doctors in England B. Fazekas a, *, J. Fazekas b, M. Moledina c, B. Fazekas d, K. Karolyhazy e a
Whipps Cross University Hospital, London, UK St George’s, University of London, London, UK c Imperial College London, London, UK d University of Heidelberg, Heidelberg, Germany e Semmelweis University, Budapest, Hungary b
A R T I C L E
I N F O
Article history: Received 23 December 2014 Accepted 27 March 2015 Available online xxx Keywords: Awareness Ebola England Junior doctors
S U M M A R Y
The current Ebola virus epidemic continues to pose a threat to the UK. Junior clinicians are often at the frontline of medical care in hospitals and their awareness of the clinical features and management of the Ebola virus disease (EVD) may significantly influence the timely implementation of infection control measures. In view of this, we carried out a cross-sectional survey of 119 junior doctors across four different hospitals in England in order to assess their level of knowledge of EVD. We demonstrate that there is currently a deficiency of knowledge about critical aspects of EVD in this population. ª 2015 Published by Elsevier Ltd on behalf of the Healthcare Infection Society.
Introduction The current Ebola epidemic in West Africa has been declared an ‘Emergency of International Concern’ by the World Health Organization (WHO) and this crisis has put pressure on healthcare systems across the globe.1,2 In England, to date we are unaware of any scientific analysis that has been carried out to evaluate the preparedness of healthcare services for dealing with Ebola virus disease (EVD). Public health experts assure us that England is ready, especially in view of recent successfully implemented mock emergencies
* Corresponding author. Address: Whipps Cross University Hospital, Whipps Cross Road, London E11 1NR, UK. Tel.: þ44 (0)20 3416 5000. E-mail address: [email protected] (B. Fazekas).
organized by the Department of Health and the effective management of several confirmed cases of EVD.3 In contrast to these optimistic views, previous responses to a viral haemorrhagic fever (VHF) similar to Ebola, namely Lassa fever, have highlighted the need for improvement in the recognition of these groups of viruses and the timely implementation of infection control strategies.4 Our research was aimed at evaluating the level of preparedness of the health system in England to Ebola by assessing the awareness of junior doctors to the main features of EVD by means of a questionnaire. This group of clinicians was specifically selected for this study as they are regularly the first to medically assess patients in hospitals and, as such, would be at the frontline of caring for EVD cases. A poor understanding of EVD among these clinicians may put the lives of patients, doctors and the general public at risk. To our knowledge, this
http://dx.doi.org/10.1016/j.jhin.2015.03.007 0195-6701/ª 2015 Published by Elsevier Ltd on behalf of the Healthcare Infection Society. Please cite this article in press as: Fazekas B, et al., Ebola virus disease: awareness among junior doctors in England, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.03.007
2
B. Fazekas et al. / Journal of Hospital Infection xxx (2015) 1e3
study is the first attempt to quantitatively evaluate the level of understanding among medical staff in England; a comparable study by Lakhani et al. investigated the baseline understanding about VHFs among healthcare personnel, but this was carried out in Pakistan in 2002.5
Methods To ascertain the level of knowledge about Ebola among junior doctors, we devised a questionnaire and distributed printed copies during teaching sessions in four educational hospitals around England between September 2nd and November 8th, 2014. The questionnaire was completed by a total of 119 junior doctors comprising of first-year, secondyear, and junior trainee doctors. Three of the four participating hospitals were in the London catchment area, namely Northwick Park Hospital (N ¼ 30), Whipps Cross Hospital (N ¼ 36), and Ealing Hospital (N ¼ 27); the fourth participating hospital was Leicester Royal Infirmary (N ¼ 26), which is located w150 km north of London. In each case, permission to distribute the questionnaires was obtained and all of the attempted questionnaires were included in our analysis. The questionnaire focused on the demographics of EVD, its clinical presentation, the key investigations, and the immediate management of infected patients. A comprehensive mark scheme was devised using multiple information sources including the WHO, US Centers for Disease Control (CDC), Public Health England (PHE), and the local hospital protocols. The questions were scored by one of the authors, the results were then summarized in tabular form and analysed using descriptive statistical methods.
Results The results of the marked questionnaires are summarized in Table I. Knowledge of the immediate management of patients
with EVD was better than that of many other matters. However, it is concerning that there was rather less knowledge of information that would be important to identify that a patient might have EVD; there was poor knowledge of the countries affected by EVD and of the incubation period, whereas there was also relatively poor knowledge of the presenting clinical features.
Discussion The relatively small sample size of our study, both in terms of the number of junior doctors and the number of participating hospitals, limits the validity of our results. Furthermore, despite our best efforts to use trusted sources to create the marking criteria (WHO, CDC, PHE), the short-answer format of the questionnaire introduced a classification bias, as some ambiguous answers were marked as correct according to our mark scheme, whereas others were marked as incorrect. Despite these limitations, this study suggests that there is currently a lack of knowledge about important aspects of EVD among junior doctors. The participating clinicians scored an average of <60% in four of the seven questions, including those focusing on the signs and symptoms, the diagnostic methods, and the demographics of the epidemic. If these scores are truly representative of the junior clinician population in England, this could have adverse consequences for both the patients and the dynamics of a potential outbreak. First, this apparent lack of knowledge could lead to a failure to diagnose patients with EVD promptly, or at all, which in turn would delay the initiation of appropriate treatment. Second, an inability to recognize infected patients could delay the implementation of necessary confinement measures and personal protective equipment, which would be necessary to effectively contain the spread of the imported Ebola virus. Based on models about epidemics in Africa, Whitty et al. argued that these types of delays could
Table I Summary of the marking scheme used and scores achieved in an Ebola virus disease questionnaire completed by 119 junior medical staff Question Topic tested Total no. of no. (total no. of marks available) marks available
1
4
3
Countries affected by current Ebola outbreak Transmission route of the Ebola virus Incubation period of EVD
4 5
Mortality rate Signs and symptoms of EVD
1 5
6
Diagnostic methods of EVD
2
7
Immediate management
3
2
2 2
Marks allocated for specific answers
Average mark achieved by all junior doctors for question
Answer(s)
Marks
Guinea, Sierra Leone, Liberia, Mali, Nigeria, Senegal, USA, Spain Bodily secretions/fluids Fomites, large droplets 2e21 days Within 2e21 day range 50e90% Fever, headache, myalgia, fatigue, diarrhoea and vomiting, haemorrhage, sore throat, rash RTePCR, ELISA, viral antigen detection Serology, blood tests, microscopy ID seniors/microbiology/PHE Isolation and universal precautions, e.g. personal protective equipment Rehydration
1
1.8 (46%)
2 1 2 1 1 1
1.3 (66%)
2 1 1
0.8 (38%) 0.7 (71%) 2.7 (54%)
1.1 (56%) 2.0 (66.7%)
EVD, Ebola virus disease; RTePCR, reverse transcriptionepolymerase chain reaction; ELISA, enzyme-linked immunosorbent assay; ID, infectious diseases; PHE, Public Health England. Please cite this article in press as: Fazekas B, et al., Ebola virus disease: awareness among junior doctors in England, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.03.007
B. Fazekas et al. / Journal of Hospital Infection xxx (2015) 1e3 potentially lead to an increased burden of EVD in case of an outbreak.6 There may be several explanations for the apparent lack of knowledge about Ebola among junior clinicians. Since the beginning of the outbreak, the agencies have invested a significant amount of resources to educate medical staff and to make information about the epidemic publicly available. The discrepancy between their efforts and the apparent lack of understanding may possibly be explained by the fact that resources have primarily targeted accident and emergency and primary care staff.7 It could also be that the flow of information about the EVD situation that is being generated centrally is not being disseminated locally. However, each of the participating hospitals in our study had sent educative e-mails to their employees, and all had detailed information about Ebola on their intranet pages. Our findings therefore suggest that current hospital information systems are not an effective way of transmitting important information to junior clinicians, who may not have sufficient time or access to hospital computers. Our findings should be useful to healthcare educators and hospitals in England and other countries. It has highlighted a deficit in the level of knowledge among junior clinicians, a problem that needs to be addressed in order to better prepare medical systems for EVD. This study could be used as a platform to initiate a more extensive survey to assess awareness of EVD among clinicians of all grades, as well as nurses and allied healthcare professionals. If these findings are confirmed by other similar studies, educational resources such as e-learning modules, active real-time course, or simulation scenarios may be useful to the relevant groups in order to improve the recognition and the management of EVD. With these additional measures, a better awareness of Ebola might be achieved among the medical staff.8 In conclusion, this study suggests that junior doctors in England do not currently have sufficient knowledge about the clinical features and the epidemiology of EVD. In view of the
3
continuing crisis in West Africa, this apparent lack of understanding may put both patients and healthcare professionals at risk, if imported infected patients were to seek medical help in hospitals in England. In light of the limitations of this study, we recommend a more extensive evaluation of the understanding among healthcare professionals of EVD. Furthermore, we actively encourage the use of educational resources, such as e-learning modules, to increase awareness among medical staff. Conflict of interest statement None declared. Funding sources None.
References 1. World Health Organization. Ebola virus disease. Fact Sheet No. 103. Media Centre: September 2014; Available at: http://www.who.int/ mediacentre/factsheets/fs103/en/. 2. Briand S, Bertherat E, Cox P, et al. The international Ebola emergency. N Engl J Med 2014;371:1180e1183. 3. Coombes R, Arie S. Ebola: how well is the UK prepared? BMJ 2014;349:g6288. 4. Crowcroft NS, Meltzer M, Evans M, et al. The public health response to a case of Lassa fever in London in 2000. J Infect 2004;48:221e228. 5. Lakhani A, Mahmood H, Laeeq A, et al. Viral hemorrhagic fever in Pakistan: awareness among health care personnel. J Pak Med Assoc 2002;52:214e217. 6. Whitty CJ, Farrar J, Ferguson N, et al. Infectious disease: tough choices to reduce Ebola transmission. Nature 2014;515:192e194. 7. Public Health England. Ebola virus disease: clinical management and guidance. London: PHE; 2014. 8. Tosh PK, Sampathkumar P. What clinicians should know about the 2014 Ebola outbreak. Mayo Clin Proc 2014;89:1710e1717.
Please cite this article in press as: Fazekas B, et al., Ebola virus disease: awareness among junior doctors in England, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.03.007