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Journal of Clinical Medicine Research

Original Article

Volume 6, Number 3, June 2014, pages 197-204

Knowledge Levels Regarding Crimean-Congo Hemorrhagic Fever Among Emergency Healthcare Workers in an Endemic Region

Crimean-Congo hemorrhagic fever (CCHF) was first described in 1944 [1]. The CCHF virus is transmitted to humans via the bites of infected ticks or by direct contact with the secretions or blood of infected animals or humans. CCHF is a potentially fatal infection. It is endemic in over 30 countries around the Black Sea and in the Middle East and Africa [2]. CCHF infections were first reported in Turkey in 2003 among individuals who became sick in 2002 [3, 4].

In endemic regions, individuals who have occupational contact with livestock and wild animals, including shepherds, farmers and veterinarians, are at high risk for CCHF [5, 6].

Similarly, healthcare workers (HCWs) caring for CCHF patients are the second major group at risk for infection [7]. In Turkey, the neighboring cities of Sivas and Yozgat are endemic sites for CCHF. The climate of these cities is suitable for the survival of ticks, and the first cases of CCHF virus infection in Turkey were reported in this region [3].

HCWs are at risk for blood- and secretion-borne pathogens. Beltrami et al reported that at least 20 pathogens can be transmitted by needle sticks or sharps injuries. These pathogens can be transmitted to HCWs via blood and secretions [8]. Emergency HCWs are also at risk for these infectious diseases [9]. Outbreaks of CCHF among HCWs have been frequently reported and have a high mortality. The highest risk of transmission is from percutaneous exposure [10-14].

In this study, we aimed to determine knowledge levels regarding CCHF among emergency service (ES) HCWs in the cities of Sivas and Yozgat, where CCHF is endemic.

After approval by the local ethics committee, the study was conducted at the Sivas Numune Hospital Emergency Service, the Sivas Government Hospital Emergency Service and the Yozgat Government Hospital Emergency Service. A total of 109 HCWs (54 doctors, 39 nurses and 16 paramedics) received a questionnaire. Data regarding the age, gender and occupation (in the ES) of the participants were recorded. The questionnaire consisted of 28 questions about the workers’ knowledge levels regarding CCHF and their approaches to CCHF (Table 1).

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Table 1. Questions Asked to Participants

The participants’ answers were recorded.

STATA 11.0 (College Station, TX, USA) was used for statistical analyses. The data are reported in terms of percentages. Comparisons of answers given by doctors, nurses and paramedics were performed with the program used for statistical evaluation. Data were considered with percentage calculation. Comparison of doctors, nurses and paramadics answers were performed with Chi-square test or Fisher’s exact test, as appropriate. Values of P < 0.05 were considered statistically significant.

This study included 37 (33.9%) males and 72 (66.1%) females, for a total of 109 ES workers. Mean age was 29.6 ± 6.5 (range 19 - 45). Fifty-four (49.54%) participants were doctors, 39 (35.78%) were nurses and 16 (14.68%) were paramedics. All of the participants (100%) had heard of CCHF.

Eighty-six (78.9%) of 109 participants answered that they believed they had adequate knowledge of CCHF. The general knowledge distribution of the HCWs regarding CCHF is shown in Table 2.

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Table 2. General Knowledge Distribution of HCWs About CCHF

Thirty-three (61.1%) doctors and 30 (76.9%) nurses declared that they used protective equipment (masks, gloves, and so on) during interventions for patients who were admitted to the ES with active hemorrhage. Thirty (64.8%) doctors, nine (23.1%) nurses and five (21.2%) paramedics were unaware that 1/10 diluted bleach is sufficient for disinfecting environments that are contaminated with the blood and secretions of a patient with suspected CCHF. Seventeen (40.7%) doctors, 22 (56.4%) nurses and 11 (69.7%) paramedics did not know that CCHF may be asymptomatic. Seventeen (15.6%) participants did not know that adhered ticks on the human body should not be removed by pouring a substance that kills ticks on the bitten area. The knowledge level distributions of these HCWs in terms of transmission prevention and the approach to CCHF patients are shown in Table 3. Seventy (64.2%) HCWs said that positive blood cultures are a laboratory finding in CCHF. Details regarding the HCWs’ answers regarding the symptoms and laboratory findings of CCHF are provided in Table 4. Fifty (45.9%) of the participants said that CCHF can be transmitted by inhalation. The HCWs’ knowledge level distribution regarding methods of transmission and populations at risk for CCHF is detailed in Table 5.

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Table 3. Distribution of Participants Who Answered “Yes” to Questions About Prevention of Transmission and Approach to Patients

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Table 4. Distribution of Participants Who Answered “Yes” to Questions About Symptoms and Laboratory Findings of CCHF (Q20)

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Table 5. Knowledge Level Distribution of HCWs Regarding Transmission Methods and At-Risk Populations for CCHF

Ten (9.2%) participants did not think that CCHF was associated with a transmission risk for hospital-borne infections. One hundred (91.7%) HCWs believed that caring for a CCHF patient created risk at their job, and 62 (56.9%) declared that they would prefer not to work with CCHF patients if that were an option. The personnel approach distribution of HCWs (as hospital workers) for CCHF is displayed in Table 6.

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Table 6. Distribution of Participants Who Answered “Yes” to Questions About the Approach to CCHF as a Hospital Worker

Among 86 (78.9%) HCWs who believed that their knowledge about CCHF was sufficient, 50 (58.1%) declared that they would prefer not to follow patients with CCHF (P = 0.608).

HCWs are an important risk group for CCHF infection in endemic areas. Infected patients should be isolated, and barrier nursing techniques should be used. Strict universal precautions are necessary, and health care workers should wear protective clothing such as disposable gowns, gloves and masks, as well as goggles or face shields. During procedures that may produce aerosols, an N95 mask should be worn. Human infections are mainly caused by direct contact with blood or tissues of viremic hosts, as well as by tick bites or crushing infected ticks with unprotected hands. In endemic areas, high-risk groups include persons who have occupational contact with livestock and other animals, such as farmers, livestock owners, abattoir workers and veterinarians. Recreational activities such as hiking and camping in endemic areas are also risk factors for tick bites. As the CCHF virus is destroyed by tissue acidification and does not survive cooking, meat consumption is safe. The ratio of subclinical to clinical CCHF cases is approximately 5:1, and 80% of infections are asymptomatic. The nosocomial route is an important transmission mechanism for CCHF. HCWs caring for patients with CCHF are a major risk group. Direct transmission is thought to occur through contact of broken skin with viremic blood or other body fluids. Interventions for gastrointestinal bleeding, surgery on patients with occult disease, needle stick injuries and unprotected handling of infected materials are high-risk activities. Case fatality rates among nosocomial cases tend to be higher than in community-acquired cases, which may be related to the viral inoculums [15].

Emergency room HCWs constitute a high-risk group for blood- and secretion-borne infections [9]. For many emergency room patients, it is often difficult to obtain a detailed medical history because of time constraints. For example, when a patient is admitted to the emergency room with hemorrhage, contact with the patient begins before laboratory evaluations can be obtained. Therefore, emergency room physicians, nurses and other HCWs must begin care before having definitive information about a patient’s previous health history and current diagnosis. Despite these complicating factors, HCWs are responsible for protecting themselves against infectious diseases. Therefore, knowledge of infectious diseases and their transmission methods, especially in endemic regions, is important for HCWs. A young emergency resident physician died in October 2012 due to a needle stick injury while caring for a CCHF patient in Turkey [16]. There are a limited number of studies regarding CCHF knowledge levels among HCWs in the literature. In this study, we aimed to investigate CCHF knowledge levels among emergency department HCWs in an endemic region.

In Rahnavardi et al’s cross-sectional study, 209 HCWs from three hospitals in a region where CCHF was common were included. In this study, 11 (5.8%) participants had heard of CCHF. In our study, all of the participants (100%) had heard about CCHF. These findings suggested that being a physician and relying on academic material rather than local media were independently and significantly associated with higher knowledge levels. Education levels and laboratory staff attitudes were also significant factors. Forty-four percent of the study group wore gloves and masks for contact with CCHF patients, and 22% failed to observe any safety measures [17]. In our study, 86 (78.9%) of 109 participants believed that their knowledge levels regarding CCHF were sufficient.

Fifty-four (49.54%) participants were doctors, 39 (35.78%) were nurses and 16 (14.68%) were paramedics. Thirty-three (61.1%) doctors and 30 (76.9%) nurses declared that they used protective equipment (masks, gloves, and so on) during interventions for patients who were admitted to the emergency department with active hemorrhage. Thirty (64.8%) doctors, nine (23.1%) nurses and five (21.2%) paramedics were unaware that 1/10 diluted bleach is adequate for disinfecting environments that are contaminated with the blood and secretions of a suspected CCHF patient. Seventeen (40.7%) doctors, 22 (56.4%) nurses and 11 (69.7%) paramedics were unaware that CCHF may be asymptomatic. Seventy (64.2%) HCWs said that positive blood cultures are a laboratory finding in CCHF. Fifty (45.9%) of the participants said that CCHF can be transmitted by inhalation. Paramedics were more compliant than doctors and nurses with preventative measures.

Ten (9.2%) participants did not think that CCHF could be transmitted nosocomially. One hundred (91.7%) HCWs believed that caring for a CCHF patient created workplace risk, and 62 (56.9%) declared that they would prefer not to work with CCFH patients if possible.

Yilmaz et al attempted to determine knowledge levels, attitudes and practices regarding CCHF in people visiting a tertiary care hospital in an endemic city in Turkey. They provided questionnaires to the relatives or guardians of patients who were admitted to pediatric outpatient clinics and studied 1,034 participants. According to these authors, the media are the most useful source of information on this disease. They also described insufficient knowledge regarding CCHF in the normal population and suggested that the health, agriculture and media sectors can improve public knowledge and awareness of CCHF [18].

In the 10th year after the first CCHF outbreaks in Turkey, we demonstrate that ES HCWs in endemic regions have insufficient knowledge about this disease. We believe that seminars and education about CCHF and its transmission methods may be helpful for ES HCWs; furthermore, undergraduate curricula for all health-related courses should be reviewed to ensure effective education on this topic. Most CCHF patients first present in the emergency room. Therefore, techniques that protect against transmission of this disease, including gloves (especially baricidal gloves), face masks, face visors and box coats, should be explained to ES HCWs, and the use of these techniques should be encouraged.

This report describes the first study of CCHF knowledge levels among emergency room HCWs in an endemic region. In the future, comprehensive studies may be helpful to prevent the deaths of HCWs due to this disease.

Acknowledgments

This study was performed with the local ethics committee approval

Conflict of Interest

All authors declare that they have no conflict of interest.

Author Contributions

SY, CK and AE carried out the conception and design of the study. SO and AEK acquised, analyzed and interpreted the data. AE carried out the statistical analyse. SY and AE drafted the article and revised it critically for important intellectual content. All authors read and approved the final manuscript.

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