Journal of Infection and Public Health
Journal of Infection and Public Health
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Journal of Infection and Public Health 11 (2018) 720–722
Contents lists available at ScienceDirect
Journal of Infection and Public Health
j ourna l h om epa ge: ht tp : / / www.elsev ier .com/ locate / j iph
nowledge and attitude towards the Middle East respiratory yndrome coronavirus among healthcare personnel in the southern egion of Saudi Arabia
uda F. Abbaga,∗, Awad A. El-Mekkib, Ali A. Ali Al Bshabshec, Ahmed A. Mahfouzd, hasen A. Al-Dosrya, Rasha T. Mirdada, Nora F. AlKhttabia, Lubna F. Abbaga
College of Medicine, King Khalid University, Abha, Saudi Arabia Department of Microbiology & Clinical Parasitology, College of Medicine, King Khalid University, Abba, Saudi Arabia Department of Internal Medicine, College of Medicine, King Khalid University, Abha, Saudi Arabia Department of Family and Community Medicine, College of Medicine, King Khalid University Supervisor Joint Program, Saudi Board of Community edicine, Abha, Saudi Arabia
r t i c l e i n f o
rticle history: eceived 14 September 2017 eceived in revised form 25 January 2018 ccepted 18 February 2018
eywords: nowledge ttitude iddle East respiratory syndrome
oronavirus ealthcare personnel
a b s t r a c t
Introduction: Middle East respiratory syndrome coronavirus (MERS-CoV) belongs to the family Coron- aviridae, and is named for the crown-like spikes on its surface. The clinical presentation of MERS-CoV infection ranges from asymptomatic to very severe disease, and the classical presentation includes fever, cough chills, sore throat, myalgia, and arthralgia. Methods: A cross-sectional study of 339 healthcare personnel was conducted over an 8-month period in the Aseer region of Saudi Arabia using a structured survey that included demographic information and questions testing participant’s knowledge. Results: Approximately two-thirds of the respondents properly identified the causative agent of MERS- CoV as an RNA virus (66.4%, n = 225) that is enveloped (68.1%, n = 231). On the other hand, few respondents identified the proper number of strains or the genus (16.5% and 17.4%, respectively). More than half of the study sample identified the disease as zoonotic (57.2%, n = 194). Similarly, 89.1% (n = 302) identified that camels and bats are prone to infection with coronaviruses. Only 23.9% (n = 81) properly identified March through May as the season with the highest transmission rate. There was a massive lack of adequate knowledge regarding prevalence of antibodies. Only 18.3% (n = 62) of respondents identified PCR as the proper diagnostic confirmatory test for MERS-CoV infection. Regarding MERS-CoV clinical features, 76.4%
(n = 259) recognized the presence of sub-clinical infection, 64.7% (n = 218) indicated that cases should be immediately isolated, and 46.9% (n = 159) identified the main cause of mortality as respiratory failure. Conclusions: There is limited microbiological and virological knowledge of MERS-CoV infection among healthcare personnel in the southern region of Saudi Arabia, although the clinical aspects are known.
. Publ Scien
© 2018 The Authors for Health
ntroduction
The Middle East respiratory syndrome coronavirus (MERS-CoV)
elongs to the family Coronaviridae. Most individuals are infected y a coronavirus at some time in their lifespan. Human coron-
∗ Corresponding author. E-mail addresses: Huda-fuad@hotmail.com (H.F. Abbag), aaelmekki@gmail.com
A.A. El-Mekki), albshabshe@icloud.com (A.A.A. Al Bshabshe), ahfouz2005@gmail.com (A.A. Mahfouz), ahasen199344@gmail.com
A.A. Al-Dosry), rashamirdad1995@hotmail.com (R.T. Mirdad), ora9fahad@gmail.com (N.F. AlKhttabi), fu.lubna@gmail.com (L.F. Abbag).
ttps://doi.org/10.1016/j.jiph.2018.02.001 876-0341/© 2018 The Authors. Published by Elsevier Limited on behalf of King Saud Bi C BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
ished by Elsevier Limited on behalf of King Saud Bin Abdulaziz University ces. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
aviruses usually cause mild-to-moderate upper respiratory tract illness.
SARS-CoV and MERS-CoV are zoonotic diseases which can infect both humans and animals, including camels and bats [1].
The first case of MERS-CoV was retrospectively reported at a hospital in Jordan. Subsequently, the first publicly reported case was from Jeddah in the Kingdom of Saudi Arabia. Thereafter, from September 2012 to March 31, 2017, around 1917 cases (684 deaths) of Middle East respiratory syndrome coronavirus (MERS-CoV) were
reported to the World Health Organization [2,3]. MERS-CoV is endemic in six countries in the Middle East: Saudi Arabia, United Arab Emirates, Qatar, Jordan, Oman, and Kuwait. A few travel-
n Abdulaziz University for Health Sciences. This is an open access article under the
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on and Public Health 11 (2018) 720–722 721
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Table 1 Demographic characteristics of survey respondents.
Descriptive data Characteristic Healthcare workers
N %
Gender Male 104 30.7% Female 235 69.3%
Age 18–25 77 22.7% 26–35 179 52.8% 36–45 46 13.7% 46–55 23 6.8% +56 14 4.0%
Profession Physician 94 27.7% Nurse 197 58.1% Other 48 14.2%
Work experience Interns 60 17.7% Less than 10 years 193 56.9%
H.F. Abbag et al. / Journal of Infecti
elated cases have been identified in Tunisia, the United Kingdom, rance, Germany, and Italy [4].
In humans, the exact source and mode of transmission of MERS- oV is undefined. MERS-CoV has never been isolated from bats and
t is uncertain if there has been direct or indirect transmission from ats to humans. Many studies have shown a direct correlation of ontact with camels and MERS-CoV infection, including exposure rom ingesting unpasteurized camel milk [5–7].
MERS-CoV spreads through contact with respiratory secretions rom coughing and sneezing and may also be transmitted through lose personal contact, such as touching or shaking hands [8,9].
Clinical presentation of MERS-CoV infection ranges from asymp- omatic to very severe disease; The patient may also complain of hortness of breath that may progress to pneumonia, often requir- ng ventilator support. Around one third of all patients report omiting, diarrhea, and other gastrointestinal symptoms [8,10,11].
PCR is the best confirmatory test for MERS-CoV; however, a erology test can be used for screening. In a German hospital, con- acts of a treated case were screened with two immunofluorescence ssays to detect antibodies to MERS-CoV, along with a serum neu- ralization test; result showed good sensitivity and specificity [12].
Regarding management in uncomplicated case, it is essential to solate the patient (standard, contact, and droplet precautions) and or critically ill patients, airborne precautions are recommended in ddition to the above precautions because of the high likelihood of equiring aerosol-generating procedures [13].
The purpose of this study was to assess the knowledge and ttitude towards MERS-CoV among healthcare personnel in the outhern region of Saudi Arabia.
aterials and methods
This study was a cross sectional study conducted over an 8- onth period (August 2016 through March 2017) that surveyed
ealthcare personnel working in tertiary and primary care centers n Ahba, Saudi Arabia (majority from the central hospital 296 and 3 from the regional primary health care centers). Using random ampling methods, 339 health personnel were selected to partici- ate in the study. Inclusion criterion was: any healthcare personnel ith at least 6 months experience. All healthcare workers, including hysicians, pharmacists, nurses, and laboratory technicians, were onsidered eligible to participate in this study. Respondents were xcluded if they were a student or failed to complete the entire uestionnaire.
This study was approved by the Ethical Committee of King halid University and Aseer Central Hospital (2016-06-05).
nformed consent was obtained, and the right to withdraw from he study at any time was also conferred.
tudy tools
Respondents completed a multiple-choice questionnaire com- osed of demographic information (e.g., sex, age, work experience), nd questions testing the participant’s knowledge about the mor- hology, transmission, and clinical aspects of MERS-CoV, and ources of information.
esults
The study sample included 339 healthcare personnel. A majority f the study sample was female (n = 235, 69.3%). Most respondents
ad less than 10 years of work experience (n = 193, 56.9%), and were orking at Aseer Central Hospital (n = 296, 87.3%). More than half
f respondents were between 26- to 36-years-old (n = 179, 52.8%). ll demographic data are presented in Table 1.
10–20 years 67 19.8% 20–30 years 19 5.6%
Respondent knowledge of coronaviruses
Regarding the general virology of MERS-CoV, two-thirds of the survey respondents properly identified the causative agent as an RNA virus (66.4%, n = 225) and enveloped (68.1%, n = 231). Few respondents identified the proper number of strains or the genus (16.5% and 17.4%, respectively).
More than half of the study sample correctly identified the disease as zoonotic (57.2%, n = 194). Similarly, 89.1% (n = 302) identified that camels and bats are prone to infection with coron- aviruses. On the other hand, only 23.9% (n = 81) properly identified the March–May period as the season of greatest disease transmis- sion.
Results showed a massive lack of adequate knowledge regard- ing prevalence of MERS-CoV among abattoir workers (5.0%, n = 17), the general population (19.5%, n = 66), and camel owners and shep- herds (31.6%, n = 107). Only 18.3% (n = 62) identified PCR as the proper diagnostic confirmatory test for MERS-CoV infection. An estimated 76.4% (n = 259) recognized the presence of sub-clinical infection, 64.7% (n = 218) indicated that cases of MERS-CoV should be immediately isolated, and 46.9% (n = 159) identified the main cause of mortality as respiratory failure (Table 2).
Discussion
Middle-East respiratory syndrome (MERS) was first reported in the Kingdom of Saudi Arabia (KSA) in September 2012 and found to be caused by the novel beta coronavirus MERS-CoV [14]. Since then, more than 1400 cases have been reported from KSA, with a mortality rate of about 40%. We conducted this study to assess knowledge and attitude towards MERS-CoV among health- care workers in Saudi Arabia. It is the first study conducted in the southern region of KSA, and the second in KSA overall; the first study, by Khan et al., was conducted over a 2-month period in two multispecialty hospitals of the Al-Qassim region in 2014. They found that the respondents had good knowledge of and positive attitude towards MERS-CoV. Specifically, healthcare workers were less educated about the management and consequences of MERS-
CoV, while a majority were well aware of hallmark symptoms, precautionary measures, and hygiene issues [15].
In our study, respondents had good knowledge about virus type and structure, the zoonotic nature of the disease, and the main
722 H.F. Abbag et al. / Journal of Infection and Public Health 11 (2018) 720–722
Table 2 Respondent knowledge of coronavirus virology and epidemiology (n = 339).
Knowledge item Number Percent
It is an RNA virus 225 66.4 It is an enveloped virus 231 68.1 There are 6 strains of the coronaviruses 56 16.5 MERS-CoV belongs to gamma genus of corona viruses 59 17.4 MERS-CoV is a zoonotic disease 194 57.2 MERS-CoV is transmitted by close contact 80 23.6 Camels and bats can be infected with MERS-CoV 302 89.1 March–May is season of maximum transmission 81 23.9 Main symptoms are respiratory and gastrointestinal 327 96.7 Occurrence of subclinical infection 259 76.4 The highest prevalence of anti MERS-CoVIgG is found among abattoir workers 17 5.0 The prevalence of anti MERS-CoV IgG among general population is 0.2% 66 19.5 The prevalence of anti MERS-CoV IgG among camel owners and shepherds is 2.3% 107 31.6 The main cause of mortality is respiratory failure 159 46.9 Cases should be immediately isolated 218 64.7
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The confirmatory diagnostic test is PCR There is no available vaccine Management is supportive
ymptoms. Only one-quarter of the respondents recognized that he virus can be transmitted by close contact with infected persons, hich carry a little concern in infection transmission and preven-
ion. Two-thirds knew about the lack of vaccination and that case anagement is mostly supportive care. From this study, we found that healthcare workers in the south-
rn region of Saudi Arabia had moderate knowledge of MERS-CoV. his adequate knowledge may be attributable to the educational ampaign conducted by the ministry of health through the com- and and control center, which is dedicated to MERS-CoV infection
ueries from healthcare workers and all other practitioners. Limitations of the present study include the use of a ques-
ionnaire to evaluate healthcare personnel knowledge. In addition, espondents may have experienced limited exposure to patients ith MERS-CoV since the number of confirmed cases of MERS-CoV
n the region is low.
onclusions
Knowledge and attitude towards MERS-CoV infection among ealthcare personnel in the southern region of Saudi Arabia were
imited for microbiological and virological information, but ade- uate for clinical aspects. These results show that additional ducation on MERS-CoV may be needed for healthcare personnel n the southern region of Saudi Arabia.
unding
No funding sources.
ompeting interests
None declared.
thical approval
This study was approved by the Ethical Committee of King halid University and Aseer Central Hospital (2016-06-05).
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http://www.who.int/csr/disease/coronavirus_infections/WHO_interim_recommendations_lab_detection_MERSCoV_092014.pdf?ua=1
http://www.who.int/csr/disease/coronavirus_infections/WHO_interim_recommendations_lab_detection_MERSCoV_092014.pdf?ua=1
http://www.who.int/csr/disease/coronavirus_infections/WHO_interim_recommendations_lab_detection_MERSCoV_092014.pdf?ua=1
http://www.who.int/csr/disease/coronavirus_infections/WHO_interim_recommendations_lab_detection_MERSCoV_092014.pdf?ua=1
http://www.who.int/csr/disease/coronavirus_infections/WHO_interim_recommendations_lab_detection_MERSCoV_092014.pdf?ua=1
http://www.who.int/csr/disease/coronavirus_infections/WHO_interim_recommendations_lab_detection_MERSCoV_092014.pdf?ua=1
http://www.who.int/csr/disease/coronavirus_infections/WHO_interim_recommendations_lab_detection_MERSCoV_092014.pdf?ua=1
http://apps.who.int/iris/bitstream/10665/178529/1/WHO_MERS_Clinical_15.1_eng.pdf
http://apps.who.int/iris/bitstream/10665/178529/1/WHO_MERS_Clinical_15.1_eng.pdf
http://apps.who.int/iris/bitstream/10665/178529/1/WHO_MERS_Clinical_15.1_eng.pdf
http://apps.who.int/iris/bitstream/10665/178529/1/WHO_MERS_Clinical_15.1_eng.pdf
http://apps.who.int/iris/bitstream/10665/178529/1/WHO_MERS_Clinical_15.1_eng.pdf
http://apps.who.int/iris/bitstream/10665/178529/1/WHO_MERS_Clinical_15.1_eng.pdf
http://apps.who.int/iris/bitstream/10665/178529/1/WHO_MERS_Clinical_15.1_eng.pdf
http://apps.who.int/iris/bitstream/10665/178529/1/WHO_MERS_Clinical_15.1_eng.pdf
http://apps.who.int/iris/bitstream/10665/178529/1/WHO_MERS_Clinical_15.1_eng.pdf
http://apps.who.int/iris/bitstream/10665/178529/1/WHO_MERS_Clinical_15.1_eng.pdf
http://apps.who.int/iris/bitstream/10665/178529/1/WHO_MERS_Clinical_15.1_eng.pdf
http://apps.who.int/iris/bitstream/10665/178529/1/WHO_MERS_Clinical_15.1_eng.pdf
http://apps.who.int/iris/bitstream/10665/178529/1/WHO_MERS_Clinical_15.1_eng.pdf
http://apps.who.int/iris/bitstream/10665/178529/1/WHO_MERS_Clinical_15.1_eng.pdf
http://apps.who.int/iris/bitstream/10665/178529/1/WHO_MERS_Clinical_15.1_eng.pdf
http://apps.who.int/iris/bitstream/10665/178529/1/WHO_MERS_Clinical_15.1_eng.pdf
http://www.cdc.gov/coronavirus/mers/case-def.html
http://www.cdc.gov/coronavirus/mers/case-def.html
http://www.cdc.gov/coronavirus/mers/case-def.html
http://www.cdc.gov/coronavirus/mers/case-def.html
http://www.cdc.gov/coronavirus/mers/case-def.html
http://www.cdc.gov/coronavirus/mers/case-def.html
http://www.cdc.gov/coronavirus/mers/case-def.html
http://www.cdc.gov/coronavirus/mers/case-def.html
http://www.cdc.gov/coronavirus/mers/case-def.html
http://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-14-1281
http://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-14-1281
http://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-14-1281
http://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-14-1281
http://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-14-1281
http://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-14-1281
http://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-14-1281
http://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-14-1281
http://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-14-1281
http://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-14-1281
http://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-14-1281
Knowledge and attitude towards the Middle East respiratory syndrome coronavirus among healthcare personnel in the southern…
Introduction
Materials and methods
Study tools
Results
Respondent knowledge of coronaviruses
Discussion
Conclusions
Funding
Competing interests
Ethical approval
References
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