key: cord-1050410-g9z4cxtl authors: Abbag, Huda F.; El-Mekki, Awad A.; Al Bshabshe, Ali A. Ali; Mahfouz, Ahmed A.; Al-Dosry, Ahasen A.; Mirdad, Rasha T.; AlKhttabi, Nora F.; Abbag, Lubna F. title: Knowledge and attitude towards the Middle East respiratory syndrome coronavirus among healthcare personnel in the southern region of Saudi Arabia date: 2018-03-08 journal: J Infect Public Health DOI: 10.1016/j.jiph.2018.02.001 sha: db559547fcb1764632f2fd9b4c3e7da9025d0c59 doc_id: 1050410 cord_uid: g9z4cxtl INTRODUCTION: Middle East respiratory syndrome coronavirus (MERS-CoV) belongs to the family Coronaviridae, 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. The Middle East respiratory syndrome coronavirus (MERS-CoV) belongs to the family Coronaviridae. Most individuals are infected by a coronavirus at some time in their lifespan. Human coron- * Corresponding author. 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 [4] . In humans, the exact source and mode of transmission of MERS-CoV is undefined. MERS-CoV has never been isolated from bats and it is uncertain if there has been direct or indirect transmission from bats to humans. Many studies have shown a direct correlation of contact with camels and MERS-CoV infection, including exposure from ingesting unpasteurized camel milk [5] [6] [7] . MERS-CoV spreads through contact with respiratory secretions from coughing and sneezing and may also be transmitted through close personal contact, such as touching or shaking hands [8, 9] . Clinical presentation of MERS-CoV infection ranges from asymptomatic to very severe disease; The patient may also complain of shortness of breath that may progress to pneumonia, often requiring ventilator support. Around one third of all patients report vomiting, diarrhea, and other gastrointestinal symptoms [8, 10, 11] . PCR is the best confirmatory test for MERS-CoV; however, a serology test can be used for screening. In a German hospital, contacts of a treated case were screened with two immunofluorescence assays to detect antibodies to MERS-CoV, along with a serum neutralization test; result showed good sensitivity and specificity [12] . Regarding management in uncomplicated case, it is essential to isolate the patient (standard, contact, and droplet precautions) and for critically ill patients, airborne precautions are recommended in addition to the above precautions because of the high likelihood of requiring aerosol-generating procedures [13] . The purpose of this study was to assess the knowledge and attitude towards MERS-CoV among healthcare personnel in the southern region of Saudi Arabia. This study was a cross sectional study conducted over an 8month period (August 2016 through March 2017) that surveyed healthcare personnel working in tertiary and primary care centers in Ahba, Saudi Arabia (majority from the central hospital 296 and 43 from the regional primary health care centers). Using random sampling methods, 339 health personnel were selected to participate in the study. Inclusion criterion was: any healthcare personnel with at least 6 months experience. All healthcare workers, including physicians, pharmacists, nurses, and laboratory technicians, were considered eligible to participate in this study. Respondents were excluded if they were a student or failed to complete the entire questionnaire. This study was approved by the Ethical Committee of King Khalid University and Aseer Central Hospital (2016-06-05). Informed consent was obtained, and the right to withdraw from the study at any time was also conferred. Respondents completed a multiple-choice questionnaire composed of demographic information (e.g., sex, age, work experience), and questions testing the participant's knowledge about the morphology, transmission, and clinical aspects of MERS-CoV, and sources of information. The study sample included 339 healthcare personnel. A majority of the study sample was female (n = 235, 69.3%). Most respondents had less than 10 years of work experience (n = 193, 56.9%), and were working at Aseer Central Hospital (n = 296, 87.3%). More than half of respondents were between 26-to 36-years-old (n = 179, 52.8%). All demographic data are presented in Table 1 . 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 coronaviruses. On the other hand, only 23.9% (n = 81) properly identified the March-May period as the season of greatest disease transmission. Results showed a massive lack of adequate knowledge regarding prevalence of MERS-CoV among abattoir workers (5.0%, n = 17), the general population (19.5%, n = 66), and camel owners and shepherds (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 ). 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 healthcare 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 symptoms. Only one-quarter of the respondents recognized that the virus can be transmitted by close contact with infected persons, which carry a little concern in infection transmission and prevention. Two-thirds knew about the lack of vaccination and that case management is mostly supportive care. From this study, we found that healthcare workers in the southern region of Saudi Arabia had moderate knowledge of MERS-CoV. This adequate knowledge may be attributable to the educational campaign conducted by the ministry of health through the command and control center, which is dedicated to MERS-CoV infection queries from healthcare workers and all other practitioners. Limitations of the present study include the use of a questionnaire to evaluate healthcare personnel knowledge. In addition, respondents may have experienced limited exposure to patients with MERS-CoV since the number of confirmed cases of MERS-CoV in the region is low. Knowledge and attitude towards MERS-CoV infection among healthcare personnel in the southern region of Saudi Arabia were limited for microbiological and virological information, but adequate for clinical aspects. These results show that additional education on MERS-CoV may be needed for healthcare personnel in the southern region of Saudi Arabia. No funding sources. None declared. This study was approved by the Ethical Committee of King Khalid University and Aseer Central Hospital (2016-06-05). Middle East respiratory syndrome coronavirus (MERS-CoV) Summary of Current Situation, Literature Update and Risk Assessment MERS coronavirus: diagnostics, epidemiology and transmission WHO | Middle East respiratory syndrome coronavirus (MERS-CoV). WHO [Internet The emergence of the Middle East respiratory syndrome coronavirus Rooting the phylogenetic tree of Middle East respiratory syndrome coronavirus by characterization of a conspecific virus from an African bat Middle East respiratory syndrome Middle East respiratory syndrome coronavirus (MERS-CoV) RNA and neutralising antibodies in milk collected according to local customs from dromedary camels Hospital outbreak of Middle East respiratory syndrome coronavirus State of knowledge and data Gaps of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) in Humans Severe respiratory illness caused by a novel coronavirus Laboratory Testing for Middle East Respiratory Syndrome Coronavirus Clinical management of severe acute respiratory infection when Middle East respiratory syndrome coronavirus (MERS-CoV) infection is suspected Interim guidance MERS-CoV) -Version 2.1 Specimen Type and Priority Knowledge and attitude of healthcare workers about middle east respiratory syndrome in multispecialty hospitals of Qassim, Saudi Arabia