Introduction

Nipah Virus (NiV) is a zoonotic virus belonging to the Paramyxoviridae family. It was first identified in Malaysia and Singapore during an outbreak in 1998-1999, where it caused severe respiratory and neurological disease in human beings. The virus is named after the Malaysian village where the first outbreak occurred [1-3].

The incidence of Nipah infection in Malaysia and Singapore was very high and associated with severe encephalitis, respiratory problem. Encephalitis was a very common problem that affected people living in Malaysia and Singapore and had a high death rate. In India, this happened for the first time in the city of Kozhikode in the state of Kerala [1,2].

NiV is transmitted to humans mostly through direct contact with infected animals, especially fruit bats, which are considered natural reservoir hosts. Human-to-human transmission of the virus has also been documented, mostly through close contact with infected people. In some cases, the virus is spread through contaminated food or drink [1,2,4]. Pteropus bats (fruit-eating species, commonly known as flying foxes) are deemed the natural host of the virus [5]. The virus has been reported in Malaysia, Singapore, Philippines, Bangladesh, and India [6].

The incubation period (the time from acquiring infection to appearing symptoms) is estimated to be between 4 and 14 days. However, incubation periods of up to 45 days have been reported. Infected individuals initially develop symptoms such as fever, headache, myalgia, sore throat, and vomiting. This may be followed by dizziness, sleepiness, altered consciousness, and neurological signs indicating acute encephalitis. Some people may also develop atypical pneumonia and severe breathing problems, including acute respiratory failure. Seizures and Encephalitis happen in severe cases, and thus proceeding to coma from about 24 to 48 hours [7].

Common diagnostic tests involve cell culture, serological testing through enzyme-linked immunosorbent assay (ELISA) or indirect fluorescent antibody (IFA), and reverse transcription polymerase chain reaction (RT-PCR). The samples include nasal and throat swabs, cerebrospinal fluid, blood, and urine. In the later stages of the disease and after recovery, ELISA is used for testing antibodies [3,8].

In 1999 outbreak in Malaysia and Singapore, this outbreak caused nearly 300 human cases and over than 100 deaths, and had a significant economic impact as more than a million pigs were slaughtered to assist in controlling the outbreak [9]. From September 12 to 15, 2023, Indian Ministry of Health (MOH) reported six laboratory-confirmed cases of NiV infection, enclosing two deaths, in Kozhikode district, Kerala. Besides the first case, the source of infection is unknown, the remaining cases are all contacts at the household and hospital of the primary case. As of September 27, 2023, 1,288 contacts of positive cases have been traced, involving high-risk contacts and healthcare workers (HCWs), who are quarantined and monitored, followed up for 21 days. Since September 12, 387 samples were tested, of which six found positive for NiV and rest of samples were negative. Since September 15, no new positive cases have been identified. This is considered the sixth NiV outbreak in India since 2001 [10].

Since there is no current treatment for the disease caused by NiV, the treatment is mostly limited to supportive care and treatment of symptoms [11].

In the Kingdom of Saudi Arabia (KSA), there is no cases of NiV reported and Saudi MOH has issued a public health guide concerning with NiV infection. The guide book demonstrated the epidemiology of the disease, agent, seasonality, mode of transmission, incubation period, clinical features, treatment, case definition, infection control in healthcare facilities, diagnosis, and public health response and reporting [12]. Since Saudi MOH was concern with preparedness of the HCWs and raise their knowledge regarding the disease, and there was no study in KSA studied the knowledge towards NiV. Therefore, this study aimed (1) to assess the knowledge of HCWs towards NiV, and (2) to identify the associated factors with good knowledge.

Methods

Study design and participants

A cross sectional study conducted at the healthcare institutions affiliated with the MOH in Najran region, KSA to assess the knowledge of HCWs towards NiV. HCWs involved in this study were physicians, dentists, pharmacists, nurses, infection prevention and control (IPC) staff, and other specialties such as Laboratory staff, Respiratory therapists, Public health staff, Physiotherapists, and psychologists.

HCWs affiliated with the MOH in Najran region, KSA were included. However, administrative workers affiliated with the MOH in Najran region, KSA were excluded. Further, HCWs and administrative workers affiliated with the MOH in other regions of KSA were also excluded.

Sampling technique and sample size

A proportionate probability stratified random sampling method was employed in this study. According to a recent study conducted in Najran, KSA, the estimated overall HCWs was 6000 [13]. The involved hospitals were ten affiliated with MOH in the region. Therefore, the sample size was 362 HCWs. Raosoft online software was used to calculate the sample size.

In addition, primary healthcare centers (PHCs) are relevant to hospitals and were involved. Healthcare settings were classified to Hospitals and PHCs during data analysis.

Measurements and instrument

A validated questionnaire was used to collect the data [14]. It is consisted of two parts: The first part includes the demographic data of the study participants; Age, gender, nationality, specialty, settings (hospital or PHC), educational level (Diploma, Bachelor, Master, Doctor of Philosophy (PhD), Board and Fellowship). The study participants were categorized according to their specialties. The second part includes twenty questions to assess the knowledge of study participants in terms of clinical presentation, mode of transmission, risk factors, and methods of prevention of NiV. Cronbach’s alpha test was carried out to measure the internal consistency. It was .95, which shows a high internal consistency.

A score of ‘one’ was given for ‘correct answer’ and ‘0’ for ‘incorrect answer’. An overall score was calculated according to the responses of each participant to each item of Knowledge in the questionnaire. The overall knowledge score was 20. The 75th percentile was used as the cut-off point [13]. The cut-off point was used to classified the performance of HCWs to questions related to the knowledge as good or poor. Thus, scores that ≥ 75th percentile of the total score for knowledge indicated good knowledge, while scores that ≤ 75th percentile indicated poor knowledge.

Statistical analysis

Median (inter-quartile range) was used to present the data. Mann-Whiteny test and Kruskal Wallis test were used to compare the data. Binary logistic regression was used to identify the associated factors with good knowledge. Age, gender, nationality, cadre, Education level, place of work, and years of experience were included. In the logistic regression, we conducted univariate analysis first, and then statistically significant factors were involved in the multivariate analysis. p-value < .05 was considered a statistical significant level. SPSS version 27.0 was used for the data analysis.

Ethical consideration

The ethical approval was obtained from the Institutional Review Board at the General Directorate of Najran Health Affairs (IRB Log Number 2023-2lE).

Study participants who agree to participate in this study were informed about their participations would be voluntary and then they directed to an online questionnaire after they clicked "agree". Their responses were confidential and anonymous. However, those who refused to participate clicked "disagree" and then exit the page directly.

Results

Socio-demographic characteristics of the study participants

Of the 362 participants invited to contribute in this study, the response rate was 247 (75.7%). Socio-demographic characteristics of the HCWs present in Table 2. Since the data was not normally distributed the median (IQR) was used to present the data. Median age was 38 years (Q1= 34, Q3 =42) and 75.9% of the HCWs were male. Two third of the participants were Saudi and majority of them were nurses (35%), while solely 2.4% and 3.6% were dentists and staff of IPC, respectively. Most of the HCWs had a bachelor degree (42.9%) and the least had a Fellowship (2.8%), Board (2.4%), and PhD (0.4%). Vast majority (86.2%) of the HCWs worked at hospitals and only 13.8% of them worked at PHCC.

Responses of the participants to questions related to knowledge towards Nipah virus

The median (Q1, Q3) knowledge score of the HCWs in this study was 45% (10%–60%). Table 3 shows responses of the participants to questions related to knowledge towards Nipah virus. About 62% of the HCWs stated the symptoms of Nipah virus infection could be acute respiratory distress, convulsions, and coma. Only 36.8% of them reported no available vaccine to prevent Nipah virus infection, and more than 50% identified the main reservoir (fruit bat) of the virus, possibility of transmission from animal to human, which has been reported previously in Bangladesh. Solely 13.4% of the HCWs identified the location of first discovery of the virus. Roughly 57% of them reported that the virus can be transmitted among people through droplet. Regarding the availability of treatment, 38.9% stated yes and 42.9% didn’t know. Roughly 40% stated there are many strains of the virus and the outbreaks have been occurred in Bangladesh and Malaysia.

Regarding the common risk factor for human, most of the HCWs were not able to report it correctly. Only 19.8% stated the outbreak season is mostly during summer, and approximately 31 stated the virus does not spread through mosquitos. Above 50% of them sated that people can recover from the disease. About 25% reported the possibility of virus to cause the disease among animals. Above 50% of the HCWs stated the outbreak in Kerala had high mortality rate. Less than 40% stated the Nipah virus can cause AIDS. Approximately 30% and 28% stated the infection may be asymptomatic and the virus can be transmitted via sexual intercourse. More than 72% of them stated either there is antibiotics to cure the infection or they do know.

Correct and wrong responses to questions related to knowledge of HCWs towards Nipah virus

Table 4 shows correct and wrong responses to questions related to knowledge of HCWs towards Nipah virus. Unfortunately, responses of the HCWs to 19 items showed poor knowledge. However, their knowledge was good for only one item related to symptoms of Nipah virus infection (Q1).

Differences in overall median scores by Socio-demographic characteristics

Differences in overall median scores by Socio-demographic characteristics illustrated in Table 5. Overall median score was differed significantly by gender (p=.001), nationality (p=.001), and cadre (p=.001).

logistic regression for variables associated with good knowledge of HCWs towards Nipah virus

Univariate and multivariate analysis logistic regression for variables associated with good knowledge of HCWs towards Nipah virus is presented in Table 6. In univariate analysis, significantly associated variables with good knowledge were gender (p=.001), nationality (p=.001), cadre (p=.001), and qualification (p=.002). In multivariate analysis model, the significantly associated variable with good knowledge was only nationality (p=.002). Compared with Saudi HWCs, non-Saudi were two times more likely to have good knowledge (AOR=2.33, CI=2.28-46.77, p=.002).

Discussion

To the best of our knowledge, this study was the first study conducted in KSA to assess the knowledge of HCWs towards Nipah virus. The study discovered that the knowledge of HCWs in Najran, KSA was poor although the Saudi MOH has sent circulation to all the healthcare facilities demonstrating the key points of the disease. Such points included epidemiology of the disease, agent, seasonality, mode of transmission, incubation period, clinical features, treatment, case definition, infection control in healthcare facilities, diagnosis, and public health response. The findings indicated a lack of proper knowledge and the need for an improvement. Moreover, this study revealed HCWs who should improve their knowledge towards Nipah virus.

The median (Q1, Q3) knowledge score of the HCWs in our study was 45% (10%–60%), which reflected a poor knowledge. This could be explained by lack of effective educational programs. Similarly, a recent study in the same region, Najran, KSA reported a poor knowledge of the HCWs towards antibiotic resistance during coronavirus disease 2019 (COVID-19) [13]. Another study in Bangladesh, revealed that the knowledge of physicians towards Nipah virus was not profound [15]. In contrast, a recent study in India found a good knowledge among public [16].

The knowledge of HCWs in the present study regarding the symptoms of Nipah virus was good for 62% of them. Their knowledge regarding to main reservoir, transmission from animal to human, previous report of transmission from human to human in Bangladesh and it caused high mortality rate during 2018 in Bangladesh, the transmission among people through droplet, possibility of recovering from the Nipah virus infection, and the Nipah virus does not cause a disease in animals was good for 51%-57% of them. Unlike, in India the knowledge of HCWs regarding the symptoms of Nipah virus was good accounting for 89.5% of them. Their knowledge regarding to main reservoir, transmission from animal to human, previous report of transmission from human to human in Bangladesh with high rates of deaths in 2018, the transmission among people through droplet, and possibility of recovering from the Nipah virus infection was good for 75%-95% of them. However, their knowledge regarding the Nipah virus does not cause a disease in animals was good for only 52.3% of them [14]. Comparably, in Bangladesh, the knowledge of most physician regarding the Nipah virus infection was fair, roughly 78% reported correctly that the bat is main reservoir of Nipah virus, the human to human transmission was mention by approximately 45% of them [15].

The knowledge of HCWs in the present study regarding availability of vaccine, location of first discovery of the disease, availability of treatment, present of many strains, the outbreak that happed before in Bangladesh and Malaysia, risk factor, outbreak season, transmission the virus via mosquitos, Nipah virus can cause AIDS, can be transmitted via sexual intercourse, and the availability of antibiotics to cure the infection was poor, and less than 40% of them had good knowledge. This could reflect lack of implementation of periodic active educational program. Physicians in Bangladesh showed similarly in terms of epidemiological link of the disease [15]. Similarly, a study conducted in India revealed that the knowledge of HCWs regarding location of first discovery of the disease, present of many strains, risk factor, and outbreak season was only good for less than 45% of them. However, the study found the knowledge of the HCWs regarding the availability of vaccine, availability of treatment, the outbreak that happed before in Bangladesh and Malaysia, transmission the virus via mosquitos, Nipah virus can cause AIDS, can be transmitted via sexual intercourse, and the availability of antibiotics to cure the infection was good for about 63%-90% of them [14].

Regarding the variables associated with good knowledge of HCWs towards Nipah virus in the present study, it was only nationality. Compared with Saudi HWCs, non-Saudi were two times more likely to have good knowledge. This could be explained by the non-Saudi HCWs are originally from India, Philippines, or neighbor countries to Malaysia, Bangladesh, or Singapore. Comparably, the factors associated with knowledge of HCWs in Najran, KSA regarding antibiotic resistance during COVID-19 were nationality, cadre, qualification and working place [13]. In Bangladesh, good knowledge was associated with age group between 21 and 25 years [15]. In India, the Knowledge scores were significantly higher among physicians compared to nurses [14].

The present study has strength points. First, this is the first study conducted in KSA to assess the knowledge of HCWs towards Nipah virus. Second, the study represented the knowledge of HCWs towards Nipah virus who affiliated with governmental healthcare institutions in the whole region. Third, misclassification bias was avoided using a proportionate sampling method. Lastly, associated variable with the knowledge of HCWs was identified throughout using univariate and multivariate analyses. However, the study has some limitations. First, the study was conducted in one region and thus the generalizability of the findings to all the HCWs in KSA was not possible. Second, although the response rate of the study participation was high (75%), the responses of those who disagreed to complete the questionnaire may have differed from those included in this study. This may introduce selection bias. However, those who refused to participate in this study are not likely to differ from those who participated. Last, some cofounding variables such as years of experience of the participants may have been found irrelevant. Hence, it has not been used in the regression analysis.

Conclusions

The present study showed the poor knowledge of HCWs. The associated variable with good knowledge was nationality. Therefore, the implementation of education and training programmes are highly recommended. All decision-making processes need to incorporate research, education, practice, policy, environment, climate, and sustainability considerations. In addition, to better inform such programmes, further prospective and interventional studies are highly encouraged. Moreover, HCWs who might benefit from the these programmes were identified in the present study.

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References

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