Knowledge, perception and attitude about Crimean Congo Hemorrhagic Fever (CCHF) among medical and pharmacy students of Pakistan

Crimean Congo Hemorrhagic Fever (CCHF), a zoonotic viral hemorrhagic fever is a cause of significant morbidity and mortality; especially in underdeveloped countries. CCHFV is a member of the genus Nairovirus in the family Bunyaviridae. Basically, this disease is transmitted to humans by domestic animals and bite of an infected tick or via aerosol generated from infected animals’ excreta. Human to human transmission occurs following contact with an infected person’s blood, tissue or fluid discharge [1]. The vectors of this arthropod-borne disease are generally hard ticks of Ixodidae family, including some species of Rhipicephalus, Boophilus, Dermacentor and Hyalomma (in particular Hyalomma marginatum). Some species of Argasand Ornithodoros in Argasidae family have been reported to be infected The highly lethal virus is known for producing devastating outbreaks in humans which are very common in areas with developing healthcare systems such as in Africa, Middle East Asia, and Balkans. CCHF outbreaks constitute a threat to public health services because of its prolonged and intense course of infection. It has epidemic potential, high case fatality ratio (10–40%), and difficulties in treatment and prevention. The Hyalomma tick bite infection has a high rate of nosocomial transmission especially due to direct human to human contact [2]. In Pakistan, sporadic outbreaks have been reported frequently, mostly due to contact with viremic livestock blood and nosocomial transmission. The hospital-borne spread has been associated with a lack of, or improper use of personal protective equipment when dealing with infected patients. It mostly occurs during early contact with an undiagnosed patient before taking appropriate protective measures [3]. The first case of CCHF in Pakistan was reported in 1976 and since then continuous cases of CCHF have been emerging throughout the country. In Pakistan 2010, outbreak in Khyber Pakhtunkhwa (KPK) province precipitated and 100 cases were reported and had a 10% fatality rate. Similarly on 11 July 2014, in Hayatabad Medical Complex (HMC), Kpk, 8 patients died, out of which 6 were Afghan nationals and a nurse [4]. Figure 1 Illustrates the prevalence of CCHF, from 2012 to 2016. In accordance with the ministry of the national institute of health, a total of 323 cases were confirmed [5]. Baluchistan remains the most affected province followed by KPK and Punjab. As Pakistan shares, a long border with Afghanistan so large number of patients from Afghanistan come to Pakistani hospitals especially in Peshawar, Quetta, and Islamabad making Congo infection of particular danger in these areas. Figure 1, shows that since the last 5 years about 47% of cases were reported from Baluchistan followed by 17% from Punjab 15% from KPK. Whereas, 14% cases were reported from Sindh followed by 4% from Islamabad and 2% from Federally Administered Tribal Areas (FATA) and lastly 1% from Azad Jammu and Kashmir (AJK) [6].

In Pakistan, the overall environmental cycles are continuously subjected to major changes partly due to the effect of global warming. Such climatic changes affect the initiation and spread of disease outbreaks [7]. A similar trend of CCHF spread has been observed. During extremely hot weather the spread of CCHF experiences, a fall back followed by a subsequent rise during average weather. CCHF is an occupational disease for livestock workers, butchers, slaughterhouse workers, health care workers, animal husbandry workers and veterinarians who belong to a group of people at high risk of the disease in the endemic areas of CCHF [8]. The incidence rate increases by many folds during Eid ul Adha, a religious festival during which millions of animals are slaughtered [6, 9]. As CCHF is a viral contagious endemic disease, cases of spread of this disease in healthcare professionals have also observed. In Quetta, a doctor died due to CCHF [10]. Another doctor died of Congo fever in Abbottabad [11]. A Surgeon and nurse from Bahawalpur hospital died of CCHF at Agha Khan University Hospital (AKUH) in 2016 [12].

Healthcare professionals are a high-risk group and the primary custodians for the provision of health-related treatments. Although education campaigns have increased their awareness regarding CCHF yet it remains unclear to what extent this knowledge can be put into practice and to what extent this practice actually reduces CCHF infection spread. Knowledge, attitude, and perception survey provide a suitable format to evaluate existing programs and to identify effective strategies for behavior change in society [13]. Therefore, it is necessary to evaluate the knowledge, attitude, and perceptions of future medical and pharmacy graduates. The main purpose of this study was to identify the knowledge, attitude, and perceptions of medical and pharmacy students about CCHF so a questionnaire assessing these aspects was designed and validated.

To the best of our knowledge, there is no reported study that has evaluated thoroughly knowledge, attitude, and perceptions of medical and pharmacy students about CCHF in Pakistan. In order to effectively deal with CCHF patients with minimum risks, healthcare professionals need to have good knowledge about precautionary measures like wearing of gloves, masks, protective clothing, goggles, disposables gowns and face shields before visiting patients. Transmission can occur through direct contact with infected blood, needle stick injuries, and contact with infected abraded skin and during disposal of infected waste. In Pakistan, a qualified general surgeon died of CCHF while dealing with CCHF patient due to nosocomial transmission. Many other examples of this type can be observed frequently throughout the world [12].

The previous such study conducted in students of a single college in Pakistan concluded that students have poor knowledge even about cause and source of transmission of CHF because respondents were nonhealthcare students like a business and social science students. The results of our study are batter to this study as the participants in our case are related to health care students [14]. When the results of our study were compared with the study conducted in healthcare professionals of Iran, similar results were found. But Iranian study demonstrated more knowledge of participants [15]. According to Iranian study when question CCHF can be transmitted through percutaneous contact from an infected individual was asked, 89.5% provided a correct answer while in our study 71% participants provided the correct answer. Similarly, in Turkish study 98.2% healthcare provided a correct answer to this question [15, 16]. Furthermore, in our study, 53% of participants provided the wrong answer about vaccine availability. These results are confirmed with the similar study conducted previously in healthcare professionals of Baluchistan, Pakistan [17]. Baluchistan study also highlighted the major lacks of knowledge, especially in preventive and burial procedures. Knowledge about the causes of disease was good but major deficiency was observed in transmission, epidemiology, and treatment of disease. Table 3, overall female healthcare students have more knowledge then male participants. The reason might be the hard work and more interest of female students in health care practices. Knowledge of healthcare students increased with age and married students are quite good in this as they might attend number of clinical rounds, conferences, and workshops. so they have more knowledge about the disease [18]. Medical students knowledge was significantly better than that of pharmacist students [19]. This could be possibly explained by the current health care system in Pakistan where medical students are seen as more clinically oriented professionals than other professionals because of their in-depth clinical training and more opportunities for professional development. However, it is equally important to educate Pharmacist, as they are at equal risk of acquiring and transmitting infections such as CCHF. There is a need to encourage these workers to educate themselves with an updated knowledge of infections and other healthcare issues by participating in educational and related programs.

More than 70% healthcare professionals favored there should be an isolated room for the CCHF confirmed patients. These results are consistent with the studies previously done in healthcare professionals in Iran. These results were also consistent with the results of a study conducted in rural Georgian village [20]. However, in one question highly negative attitude was observed like commenting on the statement ‘is healthcare system of Pakistan is effectively equipped with the treatment facilities or not’ only about 34% participants agreed with the statement while the majority of participants opposed the statement with a negative attitude. This result is consistent with these studies [16, 21]. Findings of these results revealed that with huge positive attitude if healthcare professionals equip themselves with the basic knowledge of CCHF disease, better treatment of patients can be done with limited resources.

Among the participants 59% agreed on to follow standard procedures to minimize the risk of infections,57% students agreed that they are effectively equipped with necessary observing skills, 57% participants agreed with the use of preventive medicine and 56% showed positive response about whether they have valuable sources of information. These results are somewhat similar to the studies conducted previously in different countries [20, 22]. Majority of participants agreed that animal herders and pets increased the risk of CCHF infection just like Turkish study [23]. The mean attitude and perceptions of the participants were positive. The attitudes and perceptions of the physician students were more positive than that of pharmacist students. This finding could be interpreted to mean that physician students are more aware of their patient’s clinical condition and are responsible for counseling patients, which reflects positivity in their attitudes and perceptions about the disease.

Although the national institute of Health (NIH), Pakistan has already advised that healthcare professionals are at increased risk of contracting the disease. Despite the welcoming and positive attitude and perceptions of students towards CCHF, knowledge of students about CCHF was very poor. Possible reasons include lack of educational programs necessarily dealing the outbreak of disease.

The current study has its implications in relation to policy and practice as it provides a current snapshot of the knowledge, attitude, and perception about a life-threatening zoonotic endemic among future health care professionals. The findings of this study indicate that the student HCWs’ knowledge about CCHF was not optimal; however, their attitudes about CCHF were positive. Future studies should be conducted nationwide to validate these results. Interventions should be customized to target areas where participants showed a lack of knowledge and negative attitudes. Study results demonstrate that it is crucial to evaluate current curriculum and there is dire need of awareness seminars, conferences, and workshops about current endemic diseases to future health care professionals.