Awareness regarding Nipah infection among health-care workers in a Medical College Hospital in Kerala

Aby Dany Varghese; Geethu Mathew; Sruthy C S. Kumar; Anoop Ivan Benjamin

doi:10.4103/jcrsm.jcrsm_45_18

ORIGINAL ARTICLE

Year : 2019 | Volume : 5 | Issue : 1 | Page : 33-38

Awareness regarding Nipah infection among health-care workers in a Medical College Hospital in Kerala

Aby Dany Varghese¹, Geethu Mathew², Sruthy C S. Kumar², Anoop Ivan Benjamin²
¹ Department of Paediatrics, Believers Church Medical College, Thiruvalla, Kerala, India
² Department of Community Medicine, Believers Church Medical College, Thiruvalla, Kerala, India

Date of Submission	18-Dec-2018
Date of Acceptance	31-Jan-2019
Date of Web Publication	19-Jun-2019

Correspondence Address:
Geethu Mathew
Department of Community Medicine, Believers Church Medical College, Thiruvalla - 689 103, Kerala
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/jcrsm.jcrsm_45_18

Abstract

Background: Nipah is a highly infectious viral zoonotic disease with documented human-to-human transmission and high case fatality rate. An outbreak of Nipah infection occurred in Kerala in May 2018. Considering that this is the first encounter for health professionals dealing with Nipah outbreak in this part of India, awareness intensification among health-care workers is of paramount importance.
Objectives: The objective of this study is to find out the awareness regarding Nipah infection among health-care workers at a medical college hospital in Kerala and also to find out the factors associated with level of awareness.
Methodology: The present cross-sectional study was conducted at a medical college hospital of Kerala during the period from June 2018 to August 2018. All health-care workers from different categories who were working for a period of >1 month in the medical college were included in the study. The study tool included a structured questionnaire which collected information regarding sociodemographic details, awareness regarding causes, modes of transmission, clinical features, diagnostic investigations, and preventive measures of Nipah. A scoring pattern was developed and any respondent scoring <50% was considered as poor and ≥50% as having good awareness. After taking the written informed consent from the participants, data were collected.
Results: In this study, 204 health-care workers were enrolled. The mean age of the participants was 30.01 ± 6.7 years. Majority of the participants were nurses followed by the laboratory staff and doctors. Nearly 41% of the study population had a working experience of ≥5 years. Among the staff, 65.7% was found to have good and 34.3% had poor awareness regarding Nipah infection. The highest level of awareness was observed in Category 3 (investigations) and poorest in Category 4 (prevention). Higher age, work experience, and male gender were the factors associated with better awareness about Nipah. The highest level of awareness was observed among doctors (89.2%) followed by laboratory staff (83.3%) and nurses (61%).
Conclusion and Recommendations: The overall awareness about Nipah infection among health-care staff was found to be satisfactory, with 65.7% of them having good awareness even during the initial days of the outbreak. Since it was the first outbreak in Kerala, there were some deficiencies in the knowledge of all categories of the health-care staff. Primary prevention approach aimed at spreading adequate awareness and refreshing knowledge among all health-care staff, including nonmedical staff should be practiced, and thereby they can serve as educators of the community at large.

Keywords: Awareness, health care workers, Nipah

How to cite this article:
Varghese AD, Mathew G, S. Kumar SC, Benjamin AI. Awareness regarding Nipah infection among health-care workers in a Medical College Hospital in Kerala. J Curr Res Sci Med 2019;5:33-8

How to cite this URL:
Varghese AD, Mathew G, S. Kumar SC, Benjamin AI. Awareness regarding Nipah infection among health-care workers in a Medical College Hospital in Kerala. J Curr Res Sci Med [serial online] 2019 [cited 2023 May 30];5:33-8. Available from: https://www.jcrsmed.org/text.asp?2019/5/1/33/260641

Introduction

Nipah is a viral zoonotic disease caused by the Nipah virus (NiV) belonging to Henipa genus of the Paramyxoviridae family. First identified in Kampung Sungai Nipah village of Malaysia in 1998, three other countries, including India have reported human cases of NiV infection since then. In the Malaysian outbreak, NiV was introduced into the pig population, and most of the human cases got the infection from exposure to ill pigs. In that outbreak, 265 encephalitis cases, primarily among pig farmers, and a 40% death rate were reported. The outbreak was contained by the mass culling of >1 million pigs, and since then, no other outbreak of NiV has been reported in Malaysia. In Singapore, 11 cases and 1 death were reported among abattoir workers who slaughtered pigs imported from affected areas of Malaysia.^[1],[2] Pteropus bats (fruit-eating species, popularly known as flying foxes) are believed to be the natural reservoirs and pigs are the likely amplifier hosts for this virus. The emergence of NiV into the pig population and subsequently into the human population is believed to be due to changes in ecological conditions. Urbanization, deforestation, and drought resulting in a shortage of resources for bat populations could have compelled bats to move from their natural habitats to other areas.^[3] Human-to-human transmission of NiV was also documented during the outbreak in Bangladesh and India with a high case fatality rate of 40%–75%.^[4]

An outbreak of Nipah infection occurred in Kerala in May 2018 resulting in 17 deaths. Thefirst case occurred in Calicut district, North Kerala, and the infection spread to the neighboring district, Malappuram as well. Human-to-human transmission was documented in this outbreak. In the absence of vaccine and specific treatment, this disease needs to be prevented at the community level by restraining certain social habits and animal farming practices, including food habits, so that bat-pig-human cycle is severed, thereby preventing spread of the disease. Awareness intensification through information and communication among at-risk population and health-care workers is of paramount importance. Outbreak preparedness and season-specific surveillance for acute encephalitis syndrome and acute lower respiratory infection cases of unknown etiology are obligatory by the formation of multi-sectoral team with holistic approach to mitigate impending surge.^[5] Since the virus is highly infectious and spreads rapidly through close contact, one of the strategies to prevent or control the spread of infection is through spreading proper awareness regarding the infection. Considering that this is thefirst encounter for health professionals dealing with Nipah outbreak in this part of India, and the influence of social media among the general population generating misinformation about the disease, disseminating the correct awareness regarding the infection is the need of the hour. In this scenario knowing about the level of awareness in people regarding the cause, modes of transmission and methods of prevention are important and more so among health-care providers to whom people look for correct advice and guidance. Hence, the following study was carried out with the following objectives:

Objective

Primary objective – To find out the awareness regarding Nipah infection among health-care workers at a medical college hospital in Kerala
Secondary objective – To find out the factors associated with the level of awareness regarding Nipah infection among the health-care workers.

Methodology

The present cross-sectional study was carried out among health-care workers at a medical college in central Kerala from June 2018 to August 2018. Institutional Ethical and Review Board approval were obtained before the study.

Sample size calculation

No previous studies have been done on this topic before. Therefore, taking into consideration the awareness rate of 69.6% (awareness study regarding a similar disease among health-care staff),^[5] 10% precision, and adjusting for an expected nonresponse rate of 20%, the minimum sample size was calculated to be 204. All health-care staff from different categories working in the selected medical college hospital for a period of ≥1 month who consented to participate were included in the study using the convenience sampling. The study tool included a structured interview schedule which collected the following information.

Part A: Sociodemographic profile of the respondents
Part B: Knowledge regarding the cause of Nipah infection, past and present outbreaks, incubation period, modes of transmission, clinical features and severity of infection, investigations needed for the diagnosis and the various preventive measures to be taken for the control of infection. For the purpose of quantifying the awareness, a scoring pattern was developed. Major categories identified were awareness regarding the causes and modes of transmission of Nipah (category 1), awareness regarding the clinical features of Nipah (category 2), awareness regarding the investigations for the diagnosis of Nipah (category 3), and awareness regarding the preventive measures for Nipah infection (category 4). Each correct answer was given a score. An overall awareness score was also developed after adding up the category scores. Any respondent scoring <50% was considered as poor, and ≥50% as having good awareness in that particular category. The questionnaire was pilot-tested and necessary modifications were incorporated. After obtaining the written informed consent from the participants, the questionnaire was administered, and data were collected.

Data entry and analysis

The collected data were entered in a database in Excel with the help of a data entry expert. Statistical analysis was performed using Epi-info software. Sample characteristics were described by the mean (standard deviation) and percentage (N) for continuous and categorical variables, respectively. Appropriate tests like chi-square test, Independent t-test, ANOVA, paired t-test, and Pearson's correlation coefficient were used. A value of P < 0.05 was considered to be statistically significant.

Results

A total of 204 health-care workers from different departments were included in the study. The mean age of the participants was 30.01 ± 6.7 years. Majority of the respondents were in the age group of 25–35 years. Nearly 41% of the study population had a working experience of ≥5 years [Table 1].

Table 1: Distribution of respondents based on sociodemographic information

Click here to view

Awareness regarding Nipah infection

Awareness regarding Nipah infection was determined based on the respondent's knowledge on the causes, modes of transmission, symptoms, diagnostic tests, and the preventive measures.

Causes and modes of spread

All 204 (100%) respondents had heard about Nipah infection. Newspapers were the major source of information about Nipah among the respondents, followed by television and Internet. Only 57 (27.9%) knew about previous Nipah epidemics in India. Nearly 80% of them knew that there were Nipah outbreaks outside India in the past. Regarding the cause of infection, 191 (93.6%) knew that this was caused by a virus. Only 125 (61.3%) were aware that it can be transmitted by handling the dead bodies of Nipah victims. Based on the scoring pattern, nearly 75% of the respondents had good awareness about cause and modes of transmission.

Symptoms and diagnostic tests

Among respondents, 185 (90.7%) said that it is a serious disease. Only 83 (40.7%) of the participants knew about the mortality rate of Nipah infection. Majority of the respondents were aware of the clinical features and diagnostic tests of Nipah Infection. The highest level of awareness was observed in category 3 (investigations). Nearly 88% had good awareness regarding investigations done to diagnose the Nipah infection.

Details regarding awareness are given in [Table 2].

Table 2: Distribution of respondents based on awareness about Nipah infection

Click here to view

Prevention of Nipah

Awareness regarding the prevention of Nipah infection was found to be poor among respondents compared to other domains. Nearly 90% of them reported that the usage of personal protective devices can prevent the spread of infection. Among the health-care staff, 85% knew that maintaining proper hand hygiene can also help to limit the spread. Majority of the respondents told that using mosquito nets and growing larvivorous fish does not help in the prevention of Nipah infection. Among the respondents, 113 (55.4%) were aware that currently there is no effective vaccine against Nipah.

The overall and domain-wise awareness level about Nipah infection are shown in [Table 3].

Table 3: Distribution of participants based on awareness regarding Nipah

Click here to view

Factors associated with overall awareness

Nearly 80% of the respondents in the age group of ≥30 years showed good awareness level compared to the respondents who were <30 years old. Similarly, 87.8% of the health-care staff who had work experience of 5 years or more showed better awareness level compared to the others. There was a significant difference in the awareness level of health-care staff working in different departments. The highest level of awareness was observed among doctors (89.2%), followed by laboratory staff (83.3%), and nurses (61%). No statistically significant gender difference was found in the level of overall awareness. There was a statistically significant positive correlation between level of awareness and factors such as age (r = 0.317, P < 0.0001) and work experience (r = 0.281, P < 0.0001) [Table 4]. Factors associated with awareness in each category were age, gender, experience, and occupation. Significant gender differences were observed in the awareness level in Category 1 with male staffs having good knowledge compared to the female staffs.

Table 4: Factors associated with awareness of Nipah infection

Click here to view

Discussion

This study describes the awareness level about Nipah infection and its associated factors among health-care workers in a medical college in Kerala. This study was done during the initial days after reporting thefirst couple of cases, and when the illness and its origins were still being speculated. A total of 204 health-care staff working in the different departments were included in the study. The mean age of the participants was 30.01 ± 6.7 years. All the health-care workers had heard about the disease Nipah. Majority of the present study population were from the Department of Nursing as their proportion is high compared to other health-care workers in any institution. The major source of information for the study participants was from the newspapers followed by television and Internet. This finding is similar to other studies done where the major source of information reported was the media.^[6] This highlights the role of newspapers and media in spreading information regarding the newly emerging public health issues. Even though they had heard about Nipah only one-third of them knew that there had been a previous outbreak of Nipah in India. Most of them believed that this is thefirst outbreak in India. Nearly 80% knew that there were Nipah out breaks outside the country. The majority (93.6%) knew that the infection was caused by a virus. Only 65% were aware about the incubation period of Nipah. Nearly 75% of the respondents had good knowledge regarding the cause and modes of transmission of Nipah. In spite of some misconceptions, the majority of the health-care workers (62%) were aware that Nipah can be transmitted through contact with dead bodies of Nipah victims. Among staff, 70% said that it can be transmitted by just traveling to the area which reported an outbreak, without contact with the infected person. The above answers can be explained, as the study was done during thefirst couple of days of the outbreak and this being thefirst outbreak of relatively new emerging diseases in Kerala, the awareness had not percolated down to all health-care professionals in the initial couple of days of the outbreak. Majority of the respondents had good awareness about the clinical features (category 2) and the diagnosis (category 3) of Nipah infection. Most of them knew that it is a serious disease. The highest level of awareness was observed in the 3^rd category regarding the investigations done to diagnose the Nipah infection. Nearly 90% of them had good awareness about the investigations to be done. The majority (80%) were aware that it can be diagnosed through blood tests. However, only one-fourth knew that cerebrospinal fluid also can be used to diagnose the Nipah virus [Table 5].

Table 5: Factors associated with awareness of Nipah infection (category wise)

Click here to view

As expected with any outbreak of any new illness, the lowest level of awareness was observed in the awareness regarding the prevention of Nipah virus. Nearly two-thirds of the respondents had poor knowledge in that category. The majority were aware about the personal protective equipments to be used to prevent the spread of infection. Moreover, there were uncertainties regarding the protective effect using mosquito net and larvivorous fishes. Majority of the respondents knew that there is no effective vaccine against Nipah infection.

The overall awareness regarding Nipah among health staff was good and acceptable considering the time when this study was conducted. Among the staff, 65.7% found to have good awareness and 34.3% had poor awareness regarding Nipah. The highest level of awareness was observed in Category 3 (investigations) and poorest in Category 4 (prevention). As the age of the participants increased the level of awareness regarding Nipah increased. Similarly, staff who had >5 years' experience were found to have better awareness compared to others. There was no gender difference in the level of awareness of Nipah except in Category 1. Regarding the occupation, doctors were found to have better awareness followed by laboratory staffs and nurses. Most of the misconceptions regarding prevention were reported by the staff working in reception and pharmacy who are not directly involved in the treatment process. We have also included nonmedical staff like receptionist working in the Medical College in this study so that by increasing their knowledge about the disease they can be considered as a useful resource for educating the community they live in. Preventive aspect should be given more importance in community level control measures. A sound knowledge regarding the prevention of a deadly disease can be a powerful tool in preventing future outbreaks of the disease in the community. In spite of extensive literature search, we could not find similar studies done to assess the level of awareness about Nipah among health-care workers. Hence, it was not possible to compare our findings. However, our findings are comparable with the awareness level of other similar illness like H1N1 among health-care workers with 69.6% reported having good knowledge. The factors associated were increasing age and education which is similar to the findings of this study.^[5] Another study was done among health-care workers in Turkey to assess the knowledge level of H1N1 influenza found that 31.55% of workers had poor knowledge and nearly 68% had either moderate or good knowledge regarding H1N1 which is comparable with our results.^[7] Considering Nipah being a relatively new emerging disease and the fact that this was thefirst outbreak in Kerala, this study helps in understanding the extent and level of awareness among health-care professional at the baseline in the initial part of the outbreak.

Conclusion

The awareness about Nipah infection among health-care staff was found be satisfactory, with 65.7% of them having good awareness even during the initial days of the outbreak. The highest level of awareness was observed in Category 3 which dealt with the diagnostic tests, and poorest observed in Category 4 which contained awareness regarding prevention. Increasing age and work experience were found to be associated with better awareness about Nipah. Doctors were found to have better awareness followed by laboratory staffs and nurses.

Recommendations

Primary prevention approach by creating proper awareness and reinforcing knowledge regarding newly emerging diseases among health-care professionals through house CME sessions is necessary. The content of the CME sessions should be relevant to the category of health-care worker and sessions should give importance to preventive measures. All staff working in the hospital should be included, and hence that they may also serve as educators of the community at large.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Rahman M, Chakraborty A. Nipah virus outbreaks in Bangladesh: A deadly infectious disease. WHO South East Asia J Public Health 2012;1:208-12.
2.	Hsu VP, Hossain MJ, Parashar UD, Ali MM, Ksiazek TG, Kuzmin I, et al. Nipah virus encephalitis reemergence, Bangladesh. Emerg Infect Dis 2004;10:2082-7.
3.	Kulkarni DD, Tosh C, Venkatesh G, Senthil Kumar D. Nipah virus infection: Current scenario. Indian J Virol 2013;24:398-408.
4.	Chadha MS, Comer JA, Lowe L, Rota PA, Rollin PE, Bellini WJ, et al. Nipah virus-associated encephalitis outbreak, Siliguri, India. Emerg Infect Dis 2006;12:235-40.
5.	Yap J, Lee VJ, Yau TY, Ng TP, Tor PC. Knowledge, attitudes and practices towards pandemic influenza among cases, close contacts, and healthcare workers in tropical singapore: A cross-sectional survey. BMC Public Health 2010;10:442.
6.	Priyadarsini S, Nayeem RA, Kannan C. Study on awareness and prevention of dengue fever in a selected rural area, Salem, Tamil Nadu-descriptive longitudinal study. Int J Health Sci Res 2014;4:14-20.
7.	Aslan S, Gulsun S, Citak EC, Oncul A, Pirinccioglu H. An inquiry of knowledge, attitudes and practices against pandemic H1N1 influenza among Turkish health care workers: Experience of a single center in Southeast of Turkey. Afr J Microbiol Res 2010;4:2363-70.