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Knowledge, attitude and practice of health care providers toward Ebola virus disease in hotspots in Khartoum and White Nile states, Sudan, 2014
American Journal of Infection Control xxx (2015) 1-4
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Major article
Knowledge, attitude and practice of health care providers toward Ebola virus disease in hotspots in Khartoum and White Nile states, Sudan, 2014 Musaab M. Alfaki MBBS a, *, Alaaddin M.M. Salih MBBS a, Daffalla A’lam Elhuda MBBS, MIH, MPH, MD a, b, Mohammad S. Egail MBBS a a b
Academy of Health Sciences Research Group, Federal Ministry of Health, Khartoum, Sudan Department of Community Medicine, Faculty of Medicine, University of Khartoum, Khartoum, Sudan
Key Words: Ebola virus disease Health care providers Knowledge, attitude and practice Sudan
Background: Ebola virus disease (EVD) is an infectious disease associated with a high fatality rate. Health care providers (HCPs) are frequently infected while treating patients with suspected or confirmed EVD. Knowledge of, attitudes toward, and practices of HCP toward EVD, especially in hot spots, is an essential element to control the disease. Materials and methods: In this descriptive, cross-sectional, health facilityebased study, 258 HCPs were interviewed in different health facilities in hot spots in the targeted states, including district and federal hospitals and health centers, using a self-administrated questionnaire. Results: The majority of respondents were house officers (40.7%), followed by nurses (26.4%). The remaining respondents were registrars, medical officers, and allied health professionals. All participants had heard about EVD. There were significant differences in the knowledge of doctors and allied health care providers regarding modes of transmission and clinical manifestations. Some false information, such as airborne transmission (53.1%) and insect transmission (20.2%), was reported by respondents. The majority of respondents (81.3%) claimed that they would treat patients with suspected EVD while taking a safe approach, 83.5% said they would notify health authorities about cases of suspected EVD, and 91.1% reported not attending any training sessions about EVD. Conclusion: The media plays an important role in increasing awareness about EVD. Regardless, however, researchers recommend more in-service training for HCPs to increase their knowledge about EVD. Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Ebola virus disease (EVD) is a serious acute illness that is often fatal if untreated.1 It is caused by infection with a virus of the family Filoviridae, genus Ebola virus.2 The first cases of EVD were reported in 1976 in 2 simultaneous outbreaks, one in Anzara, Sudan (currently the Republic of South Sudan) and the other in Yambuku village, Democratic Republic of Congo. The virus was named after the Ebola River, which runs close to that village.1 Ebola hemorrhagic fever outbreaks constitute a major public health issue in sub-Saharan Africa.3 Multiple outbreaks occurred between 1976 and 2014. In Sudan, cases were reported in 1976 and 2004. A total of 301 people were infected in the 2 outbreaks.4
* Address correspondence to Dr Musaab M. Alfaki, MBBS, Academy of Health Sciences, Federal Ministry of Health, Baladiya Street, Khartoum, Sudan. E-mail address: [email protected] (M.M. Alfaki). Conflicts of interest: None to report.
On August 8, 2014, the World Health Organization (WHO) declared an EVD outbreak in West Africa (Guinea, Liberia, Sierra Leone, and Nigeria) as an extraordinary event and a public health emergency of international importance.5 By January 29, 2015, a total of 22,101 cases and 8818 deaths had been reported.6 By August 25, 2014, more than 240 health care workers had developed the disease, of whom 120 had died.7 In Sierra Leone, the confirmed EVD incidence was 103-fold higher among health care providers (HCPs) than in the general population.8 During epidemics, the virus is transmitted through direct human-to-human contact. HCPs are frequently infected while treating patients with suspected or confirmed EVD. This occurs through close contact with patients when infection control precautions are not strictly followed.1 HCPs’ detailed knowledge of EVD is an essential preventive tool, given that multiple infectious diseases that are endemic in sub-Saharan Africa, like malaria and typhoid fevers, mimic the
0196-6553/$36.00 - Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2015.07.035
2
M.M. Alfaki et al. / American Journal of Infection Control xxx (2015) 1-4
initial symptoms of EVD. In addition, neither doctors nor the public are familiar with the disease. Moreover, patients infected with these diseases will often need emergency care, and treating personnel may see no reason to suspect EVD and thus might not take recommended safety precautions. Meanwhile, adherence to such precautions has been associated with a dramatic drop in cases among medical staff.7 This finding highlights the importance of assessing HCPs’ knowledge, attitude, and practice related to controlling EVD. As a result of conflicts in South Sudan, the site of a previous EVD outbreak, more than 635,000 refugees flooded into neighboring countries, including Sudan.9 This situation underscores the importance of instituting and maintaining preventive measures against EVD. The Sudan Ministry of Health has declared that the country is free of the disease. On top of that, a strategy for preventing EVD outbreaks was established, including instituting a notification system, increasing general awareness of EVD, and training HCPs in how to handle suspected cases.10
Table 1 Characteristics of the sample, Khartoum and White Nile states, Sudan, 2014 Main category and subcategories Sex Male Female Age 20-24 y 25-29 y 30-34 y 35-39 y >39 y Job Registrar Medical officer House officer Nurse Other HCP Level of health facility Health center District hospital Federal hospital
n
%
73 185
28.3 71.7
84 96 33 16 29
32.6 37.2 12.8 6.2 11.2
14 22 105 68 49
5.4 8.5 40.7 26.4 19.0
35 127 96
13.6 49.2 37.2
MATERIALS AND METHODS Study area This study was conducted in hospitals and health centers in hot spots located in Khartoum and White Nile States. Khartoum State is divided into 6 localities. We selected 3 hot spots in the outskirts of Khartoum: Jabl Awlia, Sharg Alnil, and Umbada. Collectively, these 3 localities contain approximately 3.5 million residents who came from different parts of Sudan because of conflicts and drought.11 In White Nile State, we selected Kosti, the largest city in the state, which represents the crossroads of the north, east, and south of Sudan and is the main portal of connection between Sudan and South Sudan,12 where the first cases were reported. Health facilities in Sudan are divided into 3 levels: primary (health centers), secondary (district hospitals), and tertiary (federal hospitals). We selected 3 health centers and 1 district hospital from each of aforementioned localities in Khartoum State. In addition, we chose a federal hospital at random. In White Nile State, we also chose3 health centers and 1 district hospital in Kosti, but no federal hospital, because these are no such hospitals in the state.
Table 2 Respondents’ knowledge of nature of the disease, incubation period, diagnostic tests, and outcomes, Khartoum and White Nile States, Sudan, 2014 Main category Know Know Know Know Know Know
that EVD is a viral disease that EVD is zoonotic the incubation period the investigations of choice that EVD is fatal the mortality rate
n
%
242 161 114 141 238 79
93.8 62.4 44.2 54.7 92.2 30.6
individual responses and identity would be treated confidentially, and honest answers were anticipated. Statistical analysis SPSS version 20.0 (IBM, Armonk, NY) was used for statistical analyses. Significance was assessed using the c2 test. A P value <.05 was considered to indicate statistical significance.
Study design
RESULTS
This cross-sectional study was conducted among HCPs, including consultants, senior specialists, specialists, registrars, medical officers, house officers, nurses, and other allied health professionals, working in the selected health facilities using convenient sampling. The single federal hospital selected for the study, Central Police Hospital, is the referral hospital for cases of suspected EVD detected at border crossing points. Each locality had a district hospital selected. Health centers were elected using simple random sampling. The study was conducted in November and December 2014. Data were collected using a pretested, self-administrated questionnaire written in Arabic comprising 44 questions divided into 6 sections. The first section solicited demographic data, the second section evaluated knowledge of the nature of the organism, and the third and fourth sections assessed knowledge regarding modes of transmission and symptoms of EVD. The fifth section concentrated on safety precautions, and the last section included questions about the respondent’s attitude toward patients with suspected EVD and on efforts of health authorities against EVD. The respondents were given sufficient time to read, comprehend, and answer all questions. They were informed that their
Of the 258 respondents (response rate, 78.3%), the majority were house officers (40.7%), followed by nurses (26.4%). The remaining respondents were registrars, medical officers, and allied health professionals (medical assistants, midwives, and laboratory technicians). The majority of the respondents were females (71.7%), and 69.8% of the respondents were under age 30 years. Characteristics of the study participants are summarized in Table 1. In multiple response questions, 68.6% of HCPs reported hearing about EVD from classical media (ie, television, radio, and newspapers), whereas 25.2% did so from new media (social networks), and 23.3% from medical websites. Only 19% gained information from medical books, and 8.5% learned about EVD from other sources, such as training sessions and other persons. The respondents’ knowledge of EVD was assessed in terms of nature of the disease, incubation period, diagnostic tests, and outcomes. The data are presented in Table 2. In terms of HCPs’ knowledge of modes of transmission, clinical manifestations, and prevention, the responses were rated as poor (<50%), average (50%-60%), good (60%-80%), or very good (>80%) for each of the aforementioned domains depending on the number of correct answers. Significant differences in knowledge of modes of
M.M. Alfaki et al. / American Journal of Infection Control xxx (2015) 1-4 Table 3 Scores achieved by doctors and allied health personnel, and significance of the difference, Khartoum and White Nile States, Sudan, 2014 Job Main category and Subcategories
Doctors
Table 4 Attitudes toward and practices with patients with suspected EVD, Khartoum and White Nile States, Sudan, 2014 Main category
Allied health personnel
Performance on transmission questions, % Poor 33.1 Average 25.1 Good 13.0 very good 28.8 Performance on clinical manifestations questions, % Poor 13.0 Average 38.4 Good 23.2 very good 25.4 Performance on prevention questions, % Poor 37.5 Average 7.80 Good 25.9 very good 28.9
3
P value
46.2 22.2 20.5 11.1
.002
35.0 41.9 11.1 12.0
.001
43.2 12.8 24.7 19.3
.241
transmission and clinical manifestations were found between doctors (house officers, registrars and medical officers) and allied health care providers (nurses, laboratory technicians, and others Table 3). False information reported by respondents included airborne transmission (53.1%) and insect transmission (20.2%). In addition, 16.7% reported believing that a licensed vaccine is available (at time of data collection), and 8.5% believing that there is a specific EVD treatment. The majority of respondents (83.5%) claimed that when encountering a patient with suspected EVD, they would break patient confidentiality by informing contact personnel to take safety precautions, and inform health authorities after exclusion of other common differential diagnoses. In addition, the majority (81.3%) claimed that they would treat patients with suspected EVD taking a safe approach, 93.5% would isolate these patients from others in a special ward, and 78% would allow relatives visits. Table 4 presents details about respondents’ approach to dealing with the body of a deceased EVD patient, including to whom it should be delivered and where to prepare it in the widely practiced Islamic manner in Sudan, which involves close contact with all parts of the body. In terms of the susceptibility of Sudan to an EVD outbreak, 87.6% of respondents considered Sudan at risk, among whom 56.6% ranked it as a high-risk country. Despite this, 91.1% never attended any training sessions on EVD. Many respondents characterized health authorities’ efforts against EVD as absent (41.7%) or weak (38.1%) (Fig 1).
DISCUSSION A previous Knowledge, Attitude and Practice (KAP) study regarding EVD done among HCPs in a tertiary care referral hospital in central Karnataka, India, found that 41.2% got their knowledge about EVD from electronic media and 44.5% did so from classical media, including television, radio, and newspapers.13 In comparison, in the present study, 68.6% of respondents learned about EVD from classical media. In a recent cross-sectional KAP study on EVD conducted by the World Health Organization among 1413 individuals from multiple households in 9 districts in Sierra Leone, only 39% of respondent knew that it is a viral illness.14 In contrast, in the present study, 93.8% knew the correct answer. The Indian study used a similar grading system as ours to evaluate knowledge of EVD, and found that the majority of doctors
Announce/notify Yes No Don’t know Treat patient (under safety precautions) Yes No Don’t know Allow relative visits Yes No Don’t know Place of patient Quarantine General ward Don’t know To whom to deliver deceased body Relatives Health authority for burial Health authority for burning Don’t know Allow ritual Islamic washing of deceased body Allow Not allow Don’t know
n
%
197 13 26
83.5 5.5 11
192 15 29
81.3 6.4 12.3
184 32 20
78 13.5 8.5
232 0 16
93.5 0 6.5
22 108 52 65
8.9 43.7 21 26.4
49 152 45
19.9 61.5 18.6
45
41.7 38.1
40 35 30 25 20 15
10.9
10 5
6.5 2.8
0 excelent
Good
moderate
week
absent
Fig 1. Respondents assessment of health authorities efforts against Ebola virus disease Khartoum and White Nile States, Sudan, 2014.
achieved good (38.4%) or average (30.7%) grades.13 In contrast, in the present study, doctors predominately achieved poor (27.85%) or very good (27.7%) grades. Among allied health personnel, 41.5% achieved poor grades concerning knowledge about modes of transmission, clinical manifestations, and means of prevention. We found significant differences in knowledge of modes of Ebola virus transmission and clinical features between doctors and allied health personnel. One possible explanation for this difference is that doctors are more educated in microbiology and infectious diseases because of their continuous professional development. Misconceptions regarding modes of EVD transmission were evident among respondents in the KAP study of households in Sierra Leone, with 29.7% believing that EVD is transmitted by the airborne route and 30.4% believing that transmission can occur through mosquito bites.14 In our study, nearly 50% of respondents cited airborne transmission, and approximately 20% identified insects as a mode of EVD transmission. This misinformation can be attributed to lack of training about EVD in the majority (91.1%) of respondents. Consequently, 79.8% of respondents characterized efforts by local health authorities against EVD as weak or absent. This study has several limitations. Self-reported responses might not always reflect the individual’ actual practice. In addition, it was difficult to collect data from consultants, most of whom were either busy or unavailable.
4
M.M. Alfaki et al. / American Journal of Infection Control xxx (2015) 1-4
CONCLUSION Classical media and the new emerging social media play important roles in increasing awareness of EVD. Nonetheless, the present study demonstrates a lack of knowledge among HCPs, especially among allied health personnel. In addition, it is evident that the vast majority of HCPs do not receive specific training regarding EVD. Thus, we recommend more in-service training for HCPs to provide updated scientific knowledge regarding EVD and caring for patients with EVD. References 1. World Health Organization. Ebola virus disease: fact sheet 103. Available from: http://who.int/mediacentre/factsheets/fs103/en/. Accessed March 5, 2015. 2. Centers for Disease Control and Prevention. About Ebola virus disease. Available from: http://www.cdc.gov/vhf/ebola/about.html. Accessed February 23, 2015. 3. World Health Organization. Ebola strategy: Ebola and Marburg virus disease epidemics: preparedness, alert, control, and evaluation. Available from: http:// www.who.int/csr/disease/ebola/manual_EVD/en/. Accessed March 5, 2015. 4. Centers for Disease Control and Prevention. Outbreaks chronology: Ebola virus disease. Available from: http://www.cdc.gov/vhf/ebola/outbreaks/history/ chronology.html. Accessed March 25, 2015. 5. World Health Organization and the Governments of Guinea, Liberia, and Sierra Leone. Ebola virus disease: outbreak response plan in West Africa. Available
6.
7.
8.
9.
10. 11. 12.
13.
14.
from: http://www.who.int/csr/disease/ebola/evd-outbreak-response-plan-westafrica-2014. pdf/. Accessed March 6, 2015. Centers for Disease Control and Prevention. 2014 Ebola outbreak in West Africa: case counts. Available from: http://www.cdc.gov/vhf/ebola/outbreaks/ 2014-west-africa/case-counts.html. Accessed March 5, 2015. World Health Organization. Unprecedented number of medical staff infected with Ebola. Available from: http://www.who.int/mediacentre/news/ebola/ 25-august-2014/en. Accessed February 28, 2015. Kilmarx PH, Clarke KR, Dietz PM, Hamel MJ, Husain F, McFadden JD, et al, Centers for Disease Control and Prevention. Ebola virus disease in health care workersdSierra Leone, 2014. MMWR Morb Mortal Wkly Rep 2014;63: 1168-71. United Nations High Commissioner for Refugees. South Sudan situation: information sharing portal. Available from: http://data.unhcr.org/SouthSudan/ regional.php. Accessed February 13, 2015. Sudan News Agency. Ebola and precautionary measures to prevent it. Available from: http://suna-sd.net/suna/showTopics/3227/ar. Accessed November 12, 2014. Khartoum State Government. About [homepage on the Internet]. Available from: www.khartoum.gov.sd/index.php?pag¼20. Accessed April 15, 2015. White Nile State Government. Localities [homepage on the Internet]. Available from: http://www.whitenilestate.gov.sd/index.php/localti/kosti. Accessed April 17, 2015. Raghavendra Vailaya CG, Kumar S, Moideen S. Ebola virus disease: knowledge, attitude, practices of health care professionals in a tertiary care hospital. J Pub Health Med Res 2014;2:13-8. UNICEF, FOCUS 1000, and Catholic Relief Services. Study on public knowledge, attitudes, and practices relating to Ebola virus disease (EVD) prevention and medical care in Sierra Leone. Available from: http://newswire.crs.org/wpcontent/uploads/2014/10/Ebola-Virus-Disease-National-KAP-Study-Final-Report_ final.pdf. Accessed April 5, 2015.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Major article
Knowledge, attitude and practice of health care providers toward Ebola virus disease in hotspots in Khartoum and White Nile states, Sudan, 2014 Musaab M. Alfaki MBBS a, *, Alaaddin M.M. Salih MBBS a, Daffalla A’lam Elhuda MBBS, MIH, MPH, MD a, b, Mohammad S. Egail MBBS a a b
Academy of Health Sciences Research Group, Federal Ministry of Health, Khartoum, Sudan Department of Community Medicine, Faculty of Medicine, University of Khartoum, Khartoum, Sudan
Key Words: Ebola virus disease Health care providers Knowledge, attitude and practice Sudan
Background: Ebola virus disease (EVD) is an infectious disease associated with a high fatality rate. Health care providers (HCPs) are frequently infected while treating patients with suspected or confirmed EVD. Knowledge of, attitudes toward, and practices of HCP toward EVD, especially in hot spots, is an essential element to control the disease. Materials and methods: In this descriptive, cross-sectional, health facilityebased study, 258 HCPs were interviewed in different health facilities in hot spots in the targeted states, including district and federal hospitals and health centers, using a self-administrated questionnaire. Results: The majority of respondents were house officers (40.7%), followed by nurses (26.4%). The remaining respondents were registrars, medical officers, and allied health professionals. All participants had heard about EVD. There were significant differences in the knowledge of doctors and allied health care providers regarding modes of transmission and clinical manifestations. Some false information, such as airborne transmission (53.1%) and insect transmission (20.2%), was reported by respondents. The majority of respondents (81.3%) claimed that they would treat patients with suspected EVD while taking a safe approach, 83.5% said they would notify health authorities about cases of suspected EVD, and 91.1% reported not attending any training sessions about EVD. Conclusion: The media plays an important role in increasing awareness about EVD. Regardless, however, researchers recommend more in-service training for HCPs to increase their knowledge about EVD. Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Ebola virus disease (EVD) is a serious acute illness that is often fatal if untreated.1 It is caused by infection with a virus of the family Filoviridae, genus Ebola virus.2 The first cases of EVD were reported in 1976 in 2 simultaneous outbreaks, one in Anzara, Sudan (currently the Republic of South Sudan) and the other in Yambuku village, Democratic Republic of Congo. The virus was named after the Ebola River, which runs close to that village.1 Ebola hemorrhagic fever outbreaks constitute a major public health issue in sub-Saharan Africa.3 Multiple outbreaks occurred between 1976 and 2014. In Sudan, cases were reported in 1976 and 2004. A total of 301 people were infected in the 2 outbreaks.4
* Address correspondence to Dr Musaab M. Alfaki, MBBS, Academy of Health Sciences, Federal Ministry of Health, Baladiya Street, Khartoum, Sudan. E-mail address: [email protected] (M.M. Alfaki). Conflicts of interest: None to report.
On August 8, 2014, the World Health Organization (WHO) declared an EVD outbreak in West Africa (Guinea, Liberia, Sierra Leone, and Nigeria) as an extraordinary event and a public health emergency of international importance.5 By January 29, 2015, a total of 22,101 cases and 8818 deaths had been reported.6 By August 25, 2014, more than 240 health care workers had developed the disease, of whom 120 had died.7 In Sierra Leone, the confirmed EVD incidence was 103-fold higher among health care providers (HCPs) than in the general population.8 During epidemics, the virus is transmitted through direct human-to-human contact. HCPs are frequently infected while treating patients with suspected or confirmed EVD. This occurs through close contact with patients when infection control precautions are not strictly followed.1 HCPs’ detailed knowledge of EVD is an essential preventive tool, given that multiple infectious diseases that are endemic in sub-Saharan Africa, like malaria and typhoid fevers, mimic the
0196-6553/$36.00 - Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2015.07.035
2
M.M. Alfaki et al. / American Journal of Infection Control xxx (2015) 1-4
initial symptoms of EVD. In addition, neither doctors nor the public are familiar with the disease. Moreover, patients infected with these diseases will often need emergency care, and treating personnel may see no reason to suspect EVD and thus might not take recommended safety precautions. Meanwhile, adherence to such precautions has been associated with a dramatic drop in cases among medical staff.7 This finding highlights the importance of assessing HCPs’ knowledge, attitude, and practice related to controlling EVD. As a result of conflicts in South Sudan, the site of a previous EVD outbreak, more than 635,000 refugees flooded into neighboring countries, including Sudan.9 This situation underscores the importance of instituting and maintaining preventive measures against EVD. The Sudan Ministry of Health has declared that the country is free of the disease. On top of that, a strategy for preventing EVD outbreaks was established, including instituting a notification system, increasing general awareness of EVD, and training HCPs in how to handle suspected cases.10
Table 1 Characteristics of the sample, Khartoum and White Nile states, Sudan, 2014 Main category and subcategories Sex Male Female Age 20-24 y 25-29 y 30-34 y 35-39 y >39 y Job Registrar Medical officer House officer Nurse Other HCP Level of health facility Health center District hospital Federal hospital
n
%
73 185
28.3 71.7
84 96 33 16 29
32.6 37.2 12.8 6.2 11.2
14 22 105 68 49
5.4 8.5 40.7 26.4 19.0
35 127 96
13.6 49.2 37.2
MATERIALS AND METHODS Study area This study was conducted in hospitals and health centers in hot spots located in Khartoum and White Nile States. Khartoum State is divided into 6 localities. We selected 3 hot spots in the outskirts of Khartoum: Jabl Awlia, Sharg Alnil, and Umbada. Collectively, these 3 localities contain approximately 3.5 million residents who came from different parts of Sudan because of conflicts and drought.11 In White Nile State, we selected Kosti, the largest city in the state, which represents the crossroads of the north, east, and south of Sudan and is the main portal of connection between Sudan and South Sudan,12 where the first cases were reported. Health facilities in Sudan are divided into 3 levels: primary (health centers), secondary (district hospitals), and tertiary (federal hospitals). We selected 3 health centers and 1 district hospital from each of aforementioned localities in Khartoum State. In addition, we chose a federal hospital at random. In White Nile State, we also chose3 health centers and 1 district hospital in Kosti, but no federal hospital, because these are no such hospitals in the state.
Table 2 Respondents’ knowledge of nature of the disease, incubation period, diagnostic tests, and outcomes, Khartoum and White Nile States, Sudan, 2014 Main category Know Know Know Know Know Know
that EVD is a viral disease that EVD is zoonotic the incubation period the investigations of choice that EVD is fatal the mortality rate
n
%
242 161 114 141 238 79
93.8 62.4 44.2 54.7 92.2 30.6
individual responses and identity would be treated confidentially, and honest answers were anticipated. Statistical analysis SPSS version 20.0 (IBM, Armonk, NY) was used for statistical analyses. Significance was assessed using the c2 test. A P value <.05 was considered to indicate statistical significance.
Study design
RESULTS
This cross-sectional study was conducted among HCPs, including consultants, senior specialists, specialists, registrars, medical officers, house officers, nurses, and other allied health professionals, working in the selected health facilities using convenient sampling. The single federal hospital selected for the study, Central Police Hospital, is the referral hospital for cases of suspected EVD detected at border crossing points. Each locality had a district hospital selected. Health centers were elected using simple random sampling. The study was conducted in November and December 2014. Data were collected using a pretested, self-administrated questionnaire written in Arabic comprising 44 questions divided into 6 sections. The first section solicited demographic data, the second section evaluated knowledge of the nature of the organism, and the third and fourth sections assessed knowledge regarding modes of transmission and symptoms of EVD. The fifth section concentrated on safety precautions, and the last section included questions about the respondent’s attitude toward patients with suspected EVD and on efforts of health authorities against EVD. The respondents were given sufficient time to read, comprehend, and answer all questions. They were informed that their
Of the 258 respondents (response rate, 78.3%), the majority were house officers (40.7%), followed by nurses (26.4%). The remaining respondents were registrars, medical officers, and allied health professionals (medical assistants, midwives, and laboratory technicians). The majority of the respondents were females (71.7%), and 69.8% of the respondents were under age 30 years. Characteristics of the study participants are summarized in Table 1. In multiple response questions, 68.6% of HCPs reported hearing about EVD from classical media (ie, television, radio, and newspapers), whereas 25.2% did so from new media (social networks), and 23.3% from medical websites. Only 19% gained information from medical books, and 8.5% learned about EVD from other sources, such as training sessions and other persons. The respondents’ knowledge of EVD was assessed in terms of nature of the disease, incubation period, diagnostic tests, and outcomes. The data are presented in Table 2. In terms of HCPs’ knowledge of modes of transmission, clinical manifestations, and prevention, the responses were rated as poor (<50%), average (50%-60%), good (60%-80%), or very good (>80%) for each of the aforementioned domains depending on the number of correct answers. Significant differences in knowledge of modes of
M.M. Alfaki et al. / American Journal of Infection Control xxx (2015) 1-4 Table 3 Scores achieved by doctors and allied health personnel, and significance of the difference, Khartoum and White Nile States, Sudan, 2014 Job Main category and Subcategories
Doctors
Table 4 Attitudes toward and practices with patients with suspected EVD, Khartoum and White Nile States, Sudan, 2014 Main category
Allied health personnel
Performance on transmission questions, % Poor 33.1 Average 25.1 Good 13.0 very good 28.8 Performance on clinical manifestations questions, % Poor 13.0 Average 38.4 Good 23.2 very good 25.4 Performance on prevention questions, % Poor 37.5 Average 7.80 Good 25.9 very good 28.9
3
P value
46.2 22.2 20.5 11.1
.002
35.0 41.9 11.1 12.0
.001
43.2 12.8 24.7 19.3
.241
transmission and clinical manifestations were found between doctors (house officers, registrars and medical officers) and allied health care providers (nurses, laboratory technicians, and others Table 3). False information reported by respondents included airborne transmission (53.1%) and insect transmission (20.2%). In addition, 16.7% reported believing that a licensed vaccine is available (at time of data collection), and 8.5% believing that there is a specific EVD treatment. The majority of respondents (83.5%) claimed that when encountering a patient with suspected EVD, they would break patient confidentiality by informing contact personnel to take safety precautions, and inform health authorities after exclusion of other common differential diagnoses. In addition, the majority (81.3%) claimed that they would treat patients with suspected EVD taking a safe approach, 93.5% would isolate these patients from others in a special ward, and 78% would allow relatives visits. Table 4 presents details about respondents’ approach to dealing with the body of a deceased EVD patient, including to whom it should be delivered and where to prepare it in the widely practiced Islamic manner in Sudan, which involves close contact with all parts of the body. In terms of the susceptibility of Sudan to an EVD outbreak, 87.6% of respondents considered Sudan at risk, among whom 56.6% ranked it as a high-risk country. Despite this, 91.1% never attended any training sessions on EVD. Many respondents characterized health authorities’ efforts against EVD as absent (41.7%) or weak (38.1%) (Fig 1).
DISCUSSION A previous Knowledge, Attitude and Practice (KAP) study regarding EVD done among HCPs in a tertiary care referral hospital in central Karnataka, India, found that 41.2% got their knowledge about EVD from electronic media and 44.5% did so from classical media, including television, radio, and newspapers.13 In comparison, in the present study, 68.6% of respondents learned about EVD from classical media. In a recent cross-sectional KAP study on EVD conducted by the World Health Organization among 1413 individuals from multiple households in 9 districts in Sierra Leone, only 39% of respondent knew that it is a viral illness.14 In contrast, in the present study, 93.8% knew the correct answer. The Indian study used a similar grading system as ours to evaluate knowledge of EVD, and found that the majority of doctors
Announce/notify Yes No Don’t know Treat patient (under safety precautions) Yes No Don’t know Allow relative visits Yes No Don’t know Place of patient Quarantine General ward Don’t know To whom to deliver deceased body Relatives Health authority for burial Health authority for burning Don’t know Allow ritual Islamic washing of deceased body Allow Not allow Don’t know
n
%
197 13 26
83.5 5.5 11
192 15 29
81.3 6.4 12.3
184 32 20
78 13.5 8.5
232 0 16
93.5 0 6.5
22 108 52 65
8.9 43.7 21 26.4
49 152 45
19.9 61.5 18.6
45
41.7 38.1
40 35 30 25 20 15
10.9
10 5
6.5 2.8
0 excelent
Good
moderate
week
absent
Fig 1. Respondents assessment of health authorities efforts against Ebola virus disease Khartoum and White Nile States, Sudan, 2014.
achieved good (38.4%) or average (30.7%) grades.13 In contrast, in the present study, doctors predominately achieved poor (27.85%) or very good (27.7%) grades. Among allied health personnel, 41.5% achieved poor grades concerning knowledge about modes of transmission, clinical manifestations, and means of prevention. We found significant differences in knowledge of modes of Ebola virus transmission and clinical features between doctors and allied health personnel. One possible explanation for this difference is that doctors are more educated in microbiology and infectious diseases because of their continuous professional development. Misconceptions regarding modes of EVD transmission were evident among respondents in the KAP study of households in Sierra Leone, with 29.7% believing that EVD is transmitted by the airborne route and 30.4% believing that transmission can occur through mosquito bites.14 In our study, nearly 50% of respondents cited airborne transmission, and approximately 20% identified insects as a mode of EVD transmission. This misinformation can be attributed to lack of training about EVD in the majority (91.1%) of respondents. Consequently, 79.8% of respondents characterized efforts by local health authorities against EVD as weak or absent. This study has several limitations. Self-reported responses might not always reflect the individual’ actual practice. In addition, it was difficult to collect data from consultants, most of whom were either busy or unavailable.
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CONCLUSION Classical media and the new emerging social media play important roles in increasing awareness of EVD. Nonetheless, the present study demonstrates a lack of knowledge among HCPs, especially among allied health personnel. In addition, it is evident that the vast majority of HCPs do not receive specific training regarding EVD. Thus, we recommend more in-service training for HCPs to provide updated scientific knowledge regarding EVD and caring for patients with EVD. References 1. World Health Organization. Ebola virus disease: fact sheet 103. Available from: http://who.int/mediacentre/factsheets/fs103/en/. Accessed March 5, 2015. 2. Centers for Disease Control and Prevention. About Ebola virus disease. Available from: http://www.cdc.gov/vhf/ebola/about.html. Accessed February 23, 2015. 3. World Health Organization. Ebola strategy: Ebola and Marburg virus disease epidemics: preparedness, alert, control, and evaluation. Available from: http:// www.who.int/csr/disease/ebola/manual_EVD/en/. Accessed March 5, 2015. 4. Centers for Disease Control and Prevention. Outbreaks chronology: Ebola virus disease. Available from: http://www.cdc.gov/vhf/ebola/outbreaks/history/ chronology.html. Accessed March 25, 2015. 5. World Health Organization and the Governments of Guinea, Liberia, and Sierra Leone. Ebola virus disease: outbreak response plan in West Africa. Available
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from: http://www.who.int/csr/disease/ebola/evd-outbreak-response-plan-westafrica-2014. pdf/. Accessed March 6, 2015. Centers for Disease Control and Prevention. 2014 Ebola outbreak in West Africa: case counts. Available from: http://www.cdc.gov/vhf/ebola/outbreaks/ 2014-west-africa/case-counts.html. Accessed March 5, 2015. World Health Organization. Unprecedented number of medical staff infected with Ebola. Available from: http://www.who.int/mediacentre/news/ebola/ 25-august-2014/en. Accessed February 28, 2015. Kilmarx PH, Clarke KR, Dietz PM, Hamel MJ, Husain F, McFadden JD, et al, Centers for Disease Control and Prevention. Ebola virus disease in health care workersdSierra Leone, 2014. MMWR Morb Mortal Wkly Rep 2014;63: 1168-71. United Nations High Commissioner for Refugees. South Sudan situation: information sharing portal. Available from: http://data.unhcr.org/SouthSudan/ regional.php. Accessed February 13, 2015. Sudan News Agency. Ebola and precautionary measures to prevent it. Available from: http://suna-sd.net/suna/showTopics/3227/ar. Accessed November 12, 2014. Khartoum State Government. About [homepage on the Internet]. Available from: www.khartoum.gov.sd/index.php?pag¼20. Accessed April 15, 2015. White Nile State Government. Localities [homepage on the Internet]. Available from: http://www.whitenilestate.gov.sd/index.php/localti/kosti. Accessed April 17, 2015. Raghavendra Vailaya CG, Kumar S, Moideen S. Ebola virus disease: knowledge, attitude, practices of health care professionals in a tertiary care hospital. J Pub Health Med Res 2014;2:13-8. UNICEF, FOCUS 1000, and Catholic Relief Services. Study on public knowledge, attitudes, and practices relating to Ebola virus disease (EVD) prevention and medical care in Sierra Leone. Available from: http://newswire.crs.org/wpcontent/uploads/2014/10/Ebola-Virus-Disease-National-KAP-Study-Final-Report_ final.pdf. Accessed April 5, 2015.