Keywords

Crimean-Congo hemorrhagic fever CCHF; Descriptive statistics; Cross tab; Chi squares

Introduction

Crimean-Congo hemorrhagic fever (CCHF) is described as a fatal viral infection in about 30 countries with reported mortality rate of 3-30%. Being a tick borne viral disease, humans become infected through tick bites, by crushing the infected tick, contact with CCHF patient during acute phase of infection or by contact with blood and tissues of virulent stock. The disease was first characterized in Crimea in 1944 thus given the name Crimean hemorrhagic fever [1]. CCHF virus has been named “the Asian Ebola virus”, a soubriquet that identifies the clinical similarity of CCHF and Ebola hemorrhagic fever [2].

Severity of the disease depends on route of transmission and viral load in the inoculum and these two factors correspond to CCHF incubation period; ranging from a few days to 1 week. Compared to nosocomial infections the length is shorter through tick bite or livestock contact. Death rate for nosocomial transmitted infections is much higher than infections developed by tick bites. This may be due to viremia in nosocomial infections [3].

About one out of five humans infected with CCHF develop mild to severe clinical symptoms as the disease progresses. Symptoms include headache, high fever, back pain, joint pain, stomach pain, vomiting, red eyes, a flushed face, large areas of severe bruising and severe nosebleeds [4].

Laboratory tests used for diagnosis of CCHF include antigen-capture enzyme-linked immune-sorbent assay (ELISA),real time polymerase chain reaction (RT-PCR), virus isolation attempts, and detection of antibody by ELISA (IgG and IgM).

Treatment regimen is based primarily on supportive care due to the fact that CCHF has multiple aspects and the maintenance and transmission of virus and pathogenesis of the disease in humans remains inadequately understood. Septic workup is done after which broad spectrum antibiotics are used. Hemostasis is improved through RBC’s, FFP/thrombocyte solutions [5].

Currently Pakistan is one of five countries with clear evidence of CCHF presence. In endemic areas, CCHF is an occupational disease for butchers, slaughter house workers, livestock workers, animal husbandry workers, veterinarians and healthcare workers. Hence, it is of paramount importance that knowledge of at-risk occupational groups should be assessed periodically.

Knowledge, Attitude and Practices (KAP) of Health Care Practitioners are of great importance when it comes to maintaining the disease. The proposed framework of this study is to develop and validate a self-administered questionnaire to evaluate KAP towards Congo virus, to determine knowledge, attitude and practices of Healthcare Professionals (HCP) towards Congo virus in Pakistan.

Methodology

Study was carried out in the twin cities of Pakistan, Islamabad and Rawalpindi. Data was collected from pharmacist and medical students and professionals. A cross sectional survey was conducted in the Riphah International University, Riphah Institute of Pharmaceutical Sciences, Islamabad,duringJan - May, 2017. The sample size was determined using EPI info stat calculator with error of 5% and level of confidence 95%.

Population Size (N)

Since the sample size does not changemuch for populations larger than 20,000, therefore 20,000 was taken as total population.

The statistically significant sample size was calculated to be 384. Adding 20% of non-response or missing data values the final sample size was 465 subjects.

Study tool

The study questionnaire was adapted from similar studies conducted previously and pre-tested. It was a two page questionnaire providing information about the knowledge, attitude and practices of Congo virus. The answers were used to assess the participants' level of knowledge and attitude FDI.

Study Questionnaire

Content validity was assessed by distributing questionnaire to 40 pharmacist recruits to complete the validation process. Initial draft was mailed to pharmacists to help review the structure of questionnaire and to amend it, if needed. After its assessment and pilot testing on 40 respondents, validation of questionnaire was done through corn batch alpha.

The final form of questionnaire consisted of pharmacist’s demographic data, and a total of 36 questions that covered main areas of interest; assessment of pharmacist’s knowledge regarding Congo virus and their attitude towards Congo virus

Statistical Analysis

The data was collected and analyzed using Statistical Package for Social Sciences (SPSS) version 16. Non parametric tests were applied including chi-square tests to identify associations amongst variables. The data was analyzed using frequency tables, chi-squares and cross tabulation among different variables.

Results

General Characteristics of Respondents

A total 437 pharmacists and doctors have participated in this study out of which 187 are male and 250 are female (Table1)

Table 1: General characteristics of respondents.

Mean percentage knowledge of respondents came out to be 66.33 (Table 2).

Table 2: Mean percentage knowledge.

Frequency of knowledge range

As elucidated in table 3 majority of pharmacists (Professionals/Students) and Doctors (Professionals/Students) i.e. 263 (60.2%) have average knowledge, 43 (9.8%) have good knowledge while 131 (30.0%) pharmacists have poor knowledge.

Table 3: Frequency of knowledge range.

As p value is greater than 0.05 therefore, difference between knowledge among male and female gender, Age, working experience and source of information is in significant. While occupation, level of education and type of facility has p value less than 0.05 hence, difference among knowledge is significant.

Association of different variables with knowledge

Majority responses for K₁ (3.4%), K₂ (13.0%), k₄ (43.7%), k₆ (23.8%), k₇ (32.5%), k₈ (22.7%), k₁₀ (41.0%), k₁₁ (41.0%), k₁₂ (33.9%) were correct. From table 4 we can conclude that difference between responses to K₂ and occupation along with experience is statistically significant as p value is less than 0.05. Difference between responses to K₃ and age, occupation, experience is statistically significant as p value is less than 0.05. Difference between responses to K₄ and occupation, level of education, experience and source of information is statistically significant as p value is less than 0.05. Difference between responses to K₆ and occupation, type of facility is statistically significant as p value is less than 0.05. Difference between responses to K₇and occupation, level of education, experience, type of facility and source of information is statistically significant as p value is less than 0.05. Difference between responses to K₈ and type of facility is statistically significantaspvalue is less than 0.05. Difference between responses to K₁₀ and occupation, level of education and experience is statistically significant as p value is less than 0.05. Difference between responses to K₁₁ and age, occupation, level of education and source of information is statistically significant as p value is less than 0.05.

Majority responses for K₅ were wrong i.e. 19.9%, 87 answers were correct. From table we can conclude that difference between responses to K₅ and age is statistically significant as p value is less than 0.05. Majority responses for K₉ were wrong i.e. 41.2%, 180 answers were correct. From table we can conclude that difference between responses to K₉ and occupation is statistically significant as p value is less than 0.05. Majority responses for K₁₂ were correct i.e. 33.9%, 148 answers were wrong. From table 4 it can be conclude that difference between responses to K₁₂ and occupation, level of education and type of facility is statistically significant as p value is less than 0.05.

Table 4: Association of different variables with individual knowledge questions.

Association of different variables with average attitude

15.3% negative responses were observed for A₁, 79.2% positive while 4.3% responses were neutral. From table we can conclude that difference between responses to A₁ and gender, age, occupation, working experience and source of information is statistically significant as p value for these three is less than 0.05.

Majority responses for A₂ were positive i.e. 80.3%, 13.5% were neutral while 5.3% were negative. From table we can conclude that difference between responses to A₂ and age, occupation, level of education, working experience and source of information is statistically significant as p value is less than 0.05. 40.7% responses were positive, 27.9% were negative while only 30.4% were neutral for A₃. From table we can conclude that difference between responses for A₃ and gender is statistically significant as p value is less than 0.05.

For A₄ 53.1% responses were positive, 24.3% were neutral while 21.7% were negative. P value shows that difference between response for A₄ and occupation, experience, type of facility and source of information is statistically significant as it is less than 0.05. Majority responses i.e. 70.9% for A₅ were negative, 11.0% were positive while 17.2% were neutral. P value shows that difference between response for A₅ and gender, experience, level of education and type of facility is statistically significant as it is less than 0.05.

Majority responses i.e. 79.4% for A₆ were positive, 12.6% were neutral while 7.1% were negative. P value shows that difference between response for A6 and age, occupation, Level of education, experience and type of facility is statistically significant as it is less than 0.05. Majority responses i.e. 51.7% for A₇ were positive, 11.7% were negative while 35.7 % were neutral. P value shows that difference between response for A₇ and gender, age, occupation and working experience is statistically significant as it is less than 0. Majority responses i.e. 59.0 % for A₈ were negative, 21.5% were neutral while 18.5% were positive. P value shows that difference between response for A8 and occupation, experience and type of facility is statistically significant as it is less than 0.05.

Majority responses i.e. 49.4% for A₉ were negative, 26.8% were positive while 22.9% were neutral. P value shows that difference between response for A₉ and age, occupation, experience is statistically significant as it is less than 0.05. In A₁₀ most of the pharmacists showed positive attitude i.e. 78.9% while 9.6% was neutral and 10.3% showed negative attitude. As p value is less than 0.05, we can conclude that difference between response for A₁₀ and gender, occupation, experience and level of education is statistically significant. In A₁₁ most of the pharmacists showed positive attitude i.e. 84.9% while 2.1% was negative and 12.1% showed neutral attitude. As p value is less than 0.05, we can conclude that difference between response for A₁₂ and level of education and type of facility is statistically significant.

In A₁₂ most of the pharmacists showed negative attitude i.e. 64.1% while 17.8% was positive and 17.2% showed neutral attitude. As p value is less than 0.05, we can conclude that difference between response for A₁₂ and age, occupation, level of education, experience, type of facility and source of information is statistically significant. For A₁₃ 70.0% responses were positive, 19.2% were neutral while 9.8% were negative. P value shows that difference between response for A₄ and age, occupation, experience, level of education and experience is statistically significant as it is less than 0.05. For A₁₄ 62.5% responses were positive, 19.0% were neutral while 17.6% were negative. P value shows that difference between responses for A₄ and age and occupation, is statistically significant as it is less than 0.05.

Table 5: Association of different variables with individual attitude questions.

Discussion

The present study was a questionnaire based study which included pharmacists and doctors from twin cities of Pakistan. This is the first study in Rawalpindi/Islamabad that evaluated the KAP of pharmacists/doctors regarding CCHF. Questionnaire development was based upon extensive literature review and focus group discussions. The present study was successful in evaluating the knowledge and attitude of CCHF among pharmacists and doctors. Overall, the KAP scores of the pharmacists was average.

Our aim was to develop a questionnaire which could be used for future studies and assessment of HCP’s, to assess knowledge of pharmacists and doctors (professional and students) and to identify key variables affecting their knowledge. The total sample size for our study was 437 among which 42.8% were male while 57.2% were female. The average respondent in our study were interested in increasing their knowledge about the disease and further surveys might be needed to explore the reasons for this.

Pharmacists and doctors should have sufficient knowledge about CCHF as they are a part of healthcare team and are responsible for patient safety. Compared to another study where about 177 students (34.3%) knew that Congo is a viral fever [6]. These results show that although most of the respondents are aware of CCHFV, that why they may take precautionary measures to save themselves from this fever. It is a non-specific febrile illness that has a dramatic progression [7]. Most of (77.6%) respondents said that symptoms appear suddenly that means they do not have adequate knowledge about the onset of disease.

In our study most of the respondents orderlies reference books/articles (54.5%) as key bases of CCHF information, while radio and television about (17.8%) as key bases of CCHF information, possibility for poorer knowledge. Compared to the study done in Iranian HCW’s they have cited radio and television as the major sources of CCHF information [8].

(56.3%) participants were aware of the transmission of disease, as it is a tick borne disease and tick bite prevention may control the disease transmission [9]. This result was important as people couldn’t have able to protect themselves against the disease by not knowing the mode of transmission [10-16]. While in another study done in turkey among public it was found that most of the adults knew about mode of transmission of disease [7,17].

Presenting symptoms of CCHF in our study were hemorrhage by (76.2%) respondents and CNS involvement by (67.5%) participants [18-20]. These results have showed that most of the individuals know about sign and symptoms of CCHF, seminar to another study done on healthcare professional reported hemorrhage as a symptom of CCHF by 57% of doctors (6).This data might have been showed that this knowledge is valuable in initial diagnosis and treatment of CCHF [21].

By directing this study knowledge and attitude of pharmacists and doctors is assessed which comes out to be average, therefore one of the better methods to improve the knowledge of pharmacists is to conduct KAP concerning CCHF precautions and conducting educational programs, seminars and workshops [22,23]. Educational intervention is suggested to expand knowledge of forthcoming HCP’s, and also in addition to infectious diseases CCHF should be included into the curriculum. Professional study courses should include training programs and sessions about CCHF among healthcare professionals to avoid its outbreaks [24]. It is also suggested that in future more studies should be directed that evaluate the KAP of pharmacists and doctors (professional and students), both before and after an educational intervention [25].

Conclusion

In conclusion, the knowledge and attitude of the HCWs is found to be average regarding CCHF. Pharmacists and doctors surveyed in this study showed an intermediate or an average knowledge about CCHF while occupation, source of information and level of education were key variables found in this study affecting knowledge of pharmacist and doctors. Pharmacists and doctors have an important role in providing pharmaceutical care to patients. In order to improve HCW’s’ attitude boost them to use academic materials and to increase the knowledge of less educated HCWs, professional by starting different educational campaigns in Pakistan. An education campaign comprising of seminars, pamphlets and workshops would be useful in dispersal of information, an important factor of this approach. The extent and nature of gaps in knowledge, attitudes and practices of HCW’s needs to be documented and require further studies. Findings of this study have supported the need to remain updated and improve practices.

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