PUBLIC HEALTH CRITICAL THINKING 6

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ournal of Infection and Public Health (2016) 9, 259—266

s the Saudi public aware of Middle East espiratory syndrome?

mar A. Al-Mohrej a, Sarah D. Al-Shirian a, alman K. Al-Otaibi a, Hani M. Tamim b, Emad M. Masuadi c, ana M. Fakhoury d,∗

College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, audi Arabia Clinical Research Institute, Faculty of Medicine, American University of Beirut, eirut, Lebanon Research Unit, Department of Medical Education, College of Medicine, King Saud Bin bdulaziz University for Health Sciences, Riyadh, Saudi Arabia Department of Basic Sciences, College of Science and Health Professions, King Saud in Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

eceived 9 July 2015 ; received in revised form 21 September 2015; accepted 5 October 2015

KEYWORDS Coronavirus; MERS; Public awareness; Saudi Arabia

Summary To limit the spread of Middle East respiratory syndrome coronavirus (MERS-CoV) in Saudi Arabia, the Ministry of Health tried to raise public awareness using different public campaigns. We aimed to measure public awareness of MERS in Saudi Arabia.

A cross-sectional study was conducted between May and June 2014 using a newly designed Arabic questionnaire that was distributed and completed online.

We analyzed the response of 1149 respondents across Saudi Arabia. We found that 97% of the participants were aware of MERS. In addition, 72% realized that cough- ing and sneezing could spread the infection. Furthermore, 83% thought that some patients with MERS could be cured. Moreover, 62% knew that no vaccine can pre- vent the disease. However, only 36% realized that taking antibiotics will not stop the infection, and only 41% recognized that no medication has yet been manufactured

to treat it. Regarding protection measures, 74% used hand sanitizers, 43% avoided crowded places, and 11% wore masks in public places. Moreover, only 47% knew

that bats and camels are the primary source of the virus. As anticipated, this level

of awareness varied between the different categories of the studied population. Female, married, older, and more educated participants were significantly more knowledgeable about the disease.

∗ Corresponding author at: Basic Sciences Department, College of Science and Health Professions, Female Branch, King Saud Bin bdulaziz University for Health Sciences, P.O. Box 3660, Riyadh 11481, Saudi Arabia. Tel.: +966 11 8011111x47127.

E-mail address: [email protected] (H.M. Fakhoury).

dx.doi.org/10.1016/j.jiph.2015.10.003

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260 O.A. Al-Mohrej et al.

Public awareness of MERS is generally sufficient. However, some false beliefs about treatment were fairly common. In addition, almost half of the population remains unaware that bats and camels are the most likely sources of the virus. © 2015 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier

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A e awareness was used to determine the sample size. Consequently, a sample of 1066 subjects was needed to calculate a 95% confidence interval with

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Introduction

The first case of Middle East respiratory syndrome (MERS) was reported in Saudi Arabia in June 2012 [1]. Since then, 1564 cases of MERS have been reported through the 11th of September 2015, with a fatality rate of approximately 35% [2]. The disease is caused by a novel betacoronavirus of the Coro- naviridae family [3]. Initially, scientists suspected that the virus might be transmitted from bats [4,5]. However, more recent studies have shown a strong link between the virus and camels [6—8]. It is now generally accepted that both species serve as nat- ural reservoirs for this virus [9].

The modes of transmission between animals and humans and humans-to-humans remain unclear [10]. However, it is believed that close contact with infected individuals causes transmission. According to the WHO, a large number of MERS cases seem to occur among health care workers, secondary to close contact with primary infected patients [11].

Flu like symptoms and dyspnea are among the signs and symptoms of the initial presen- tation. Gastrointestinal tract disturbances have also been reported in some patients [12]. In severe cases, acute respiratory failure, acute kid- ney injury, lymphocytopenia, thrombocytopenia, coagulopathy, and multi-organ failure have been described [12]. These critical presentations are usually associated with senior and/or comorbid patients [13].

To limit the spread of the infection, the Min- istry of Health quickly turned to public awareness campaigns to educate the community regarding the possible modes of transmission of this novel virus. The campaign was one of the largest campaigns launched by the Ministry of Health. It included tele- vision advertisements that introduced the virus to the public and discussed ways to avoid contracting the infection. It also used text messages to update

the public on new developments; these were sent via mobile phones and different social media plat- forms.

As public awareness is highly important to con- rolling the disease, this study aimed to measure ublic awareness toward MERS in Saudi Arabia.

aterials and methods

thical approval was obtained from the Institutional eview Board at King Abdullah Medical International esearch Centre, National Guard Health affairs, iyadh, Saudi Arabia. A cross-sectional study was onducted between May and June 2014. The study arget population was current residents of Saudi rabia, regardless of their nationality.

An English questionnaire was designed and trans- ated to Arabic. The Arabic version was pretested n students of King Saud Bin Abdulaziz University for ealth Sciences. The questionnaire was uploaded as

Google document and distributed to the Twitter ccounts of Saudi celebrities who have more than 1 illion followers. The celebrities included writers, oliticians, TV presenters, sports personnel, and eligious leaders. The celebrities were contacted ia email, and nearly all of them agreed to post he survey link. Additionally, they encouraged their ollowers to participate.

The questionnaire included a section on demo- raphic and socioeconomic factors. However, ersonal information of the participants, such as ames and full addresses, was not gathered, making he data anonymous. Another section of the survey overed general awareness of the infection and pro- ective measures, while the final section addressed nowledge of the disease epidemiology.

Because there were no previous studies in Saudi rabia regarding MERS awareness among the gen- ral population, a conservative choice of 50%

margin of error of 3%. Every day, 200 questionnaires were selected ran-

omly and added to the dataset. This systematic

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ublic awareness of MERS-CoV in Saudi Arabia

pproach was followed until the intended number as reached. Data analysis was performed using the Statisti-

al Package for Social Sciences (SPSS, version 20). escriptive statistics were used to assess the base-

ine demographics and socioeconomic factors. A otal score of awareness/knowledge was calculated s the percentage of most acceptable answers. ne-way ANOVA and two-independent sample t- est were used to examine the differences in the otal score between different categories of baseline haracteristics.

esults

aseline characteristics of the respondents

he questionnaire was completed by 1149 respon- ents. Table 1 summarizes the baseline charac- eristics of the respondents. Almost half (52%) of he questionnaire respondents were female. The

ajority (95%) were Saudi and young, with only 3%

bove the age of 50. The respondents came from ix different provinces, with the highest response f 59% from the Central region. Almost half (44%)

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Table 1 The baseline characteristics of the respondents.

Variable Categories

Gender Female Male

Nationality Non-Saudi Saudi

Age 11—20 years old 21—30 years old 31—40 years old 41—50 years old 51 or more

Province of residency

Northern region Southern region Central region Eastern region Western region Outside Saudi Arabia

Marital status Unmarried Married

Education level

Secondary school or less University degree Postgraduate degree (Master,

Monthly incomea

Less than 7000 SR 7000 to less than 12,000 SR 12,000 to less than 18,000 SR 18,000 SR or more

a In Saudi Riyals (1US$ = 3.75 SR).

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f the questionnaire respondents were married. s for educational levels, 29% of the respondents ad secondary school certificates or less, 62% had ndergraduate degrees, and only 9% had postgrad- ate degrees. The monthly income varied among he respondents, with a majority (60%) earning less han 7000 SR.

ERS awareness scores

able 2 is divided into three sections: a score of eneral awareness of the infection, a score of pro- ective measures against the virus, and a score of nowledge of the disease epidemiology.

An overwhelming majority (97%) of the ques- ionnaire respondents were aware of MERS, with 9% being familiar with its signs and symptoms. oreover, 72% realized that coughing and sneezing ould spread the infection, and 74% knew that the nfection is transmitted via close contact. Among he respondents, 64% knew that coronavirus is the

ause of MERS. Furthermore, 83% thought that some atients with MERS could be cured. However, 62% new that no vaccine can prevent the disease. nly 36% recognized that taking antibiotics will not

N %

596 51.9% 553 48.1%

55 4.8% 1094 95.2%

245 21.3% 492 42.8% 259 22.5% 119 10.4% 34 3%

52 4.5% 37 3.2%

682 59.4% 122 10.6% 224 19.5% 32 2.8%

646 56.2% 503 43.8%

336 29.2% 707 61.5%

Doctorate) 106 9.2%

690 60.1% 218 19.0%

137 11.9% 104 9.0%

262 O.A. Al-Mohrej et al.

Table 2 The frequency of the awareness/knowledge of the infection, protective measures against the virus, and awareness of the epidemiology of the disease items as well as the corresponding scores.

Questions Total sample, N = 1149

Most acceptable answer N %

Awareness, knowledge of the infection score Are you aware of MERS? Yes 1116 97.1% Are you aware of the MERS signs and symptoms? Yes 1021 88.9% Coughing and sneezing do NOT spread MERS-CoV False 826 71.9% There is a vaccine that can stop adults from

getting MERS False 711 61.9%

A person will NOT contract MERS if she or he is taking antibiotics

False 409 35.6%

Corona and MERS are commonly used to refer to the same thing

True 618 53.8%

Some infected people can be cured True 950 82.7% MERS-CoV is the cause of MERS True 734 63.9% A person with MERS can look and feel healthy False 391 34.0% MERS has been shown to spread from person to

person via close contact, but without sustained community transmission

True 853 74.2%

Some drugs have been made for the treatment of MERS

False 474 41.3%

Protective measure against virus score Did you start to avoid crowded places to stop

yourself from contracting MERS? Yes 491 42.7%

Did you start to avoid going to hospitals/clinics to stop yourself from contracting MERS?

Yes 471 41.0%

Did you start to wash your hand and use hand sanitizers to stop yourself from contracting MERS?

Yes 848 74.0%

Did you start to wear masks to protect yourself from contracting MERS?

Yes 125 10.9%

Awareness of the epidemiology of the disease score Do you know the primary source of MERS-CoV? Bats/camels 541 47.1% What areas of the body can MERS-CoV infect? Respiratory system 897 78.1%

How common is MERS in Saudi Arabia? Uncommon 237 20.6%

Which population is at greater risk of developing MERS?

Elderly 547 47.6%

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What is the fatality rate caused by MERS?

prevent the infection, and only 41% realized that no new medication has been manufactured to treat MERS.

Regarding protection measures, 74% used hand sanitizers, 43% avoided crowded places, 41% avoided going to clinics and hospitals, and 11% wore masks in public places.

Concerning knowledge of the disease epidemiol- ogy, only 47% knew that both bats and camels are the primary sources of coronavirus. In addition, 78%

knew that MERS-CoV primarily attacks the respira- tory system. On the other hand, a small minority (21%) knew that MERS is not a very common dis- ease. A similar percentage (23%) realized that the

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30% 261 22.7%

atality rate was approximately 30%. Finally, almost alf of the respondents knew that the elderly have he highest risk of developing MERS.

ERS awareness scores in relation to the aseline characteristics of the respondents

e studied the awareness scores in relation to he baseline characteristics of the respondents as

epicted in Table 3. Interestingly, female indi- iduals scored significantly better than males or the questions related to protective meas- res (p = 0.004). Moreover, married individuals

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Table 3 The association between the knowledge, protective measures, and awareness scores (considering scores as percentages) and the baseline characteristics.

Variable Categories N Awareness, knowledge of the infection score

Protective measure against virus score

Awareness of the epidemiology of the disease score

Total score

Mean SD Mean SD Mean SD Mean SD

Gender Female 596 64.4 19.6 44.4 27.8 42.8 20.2 57.9 16.1 Male 553 63.8 23.0 39.6 28.9 43.7 24.6 56.8 19.2 P-value 0.673 0.004 0.466 0.309

Nationality Non-Saudi 55 66.1 19.0 46.4 26.1 45.5 22.9 60.0 15.6 Saudi 1094 64.0 21.4 41.9 28.5 43.1 22.4 57.2 17.7 P-value 0.475 0.254 0.449 0.255

Age 11—20 years old 245 61.7 20.1 40.1 30.7 39.3 22.6 54.5 17.2 21—30 years old 492 64.0 22.5 43.1 28.0 42.6 23.2 57.3 18.5 31—40 years old 259 65.5 20.8 43.9 26.8 44.9 21.0 59.0 16.8 41—50 years old 119 65.9 18.9 39.7 29.2 49.1 20.0 59.4 15.5 51 or more 34 66.0 22.2 36.0 25.5 47.6 24.1 58.4 19.2 P-value 0.259 0.255 0.001 0.035

Province of residency

Northern 52 66.1 22.0 39.9 32.9 45.4 22.4 58.6 19.7 Southern 37 60.7 25.6 39.2 29.8 41.1 20.0 54.2 18.1 Central 682 64.9 20.3 42.3 28.1 43.8 21.8 58.0 16.8 Eastern 122 61.8 22.6 40.4 26.6 42.1 22.5 55.3 18.2 Western 224 63.8 22.1 44.9 28.3 42.2 24.0 57.5 18.8 Outside Saudi Arabia 32 59.9 25.5 31.3 31.1 40.0 26.4 51.8 19.1 P-value 0.417 0.156 0.743 0.212

Marital status Unmarried 646 63.2 21.4 40.7 28.6 41.1 23.4 56.0 17.9 Married 503 65.2 21.2 43.9 28.1 45.9 20.9 59.1 17.1 P-value 0.117 0.053 <0.005 0.003

Education Secondary school or less 336 58.5 21.6 39.6 29.1 40.4 24.0 52.9 18.8 University degree 707 66.1 20.7 42.5 27.7 44.1 21.7 58.8 16.9 Postgraduate degree 106 68.4 21.3 47.6 30.4 46.2 21.4 61.8 16.2 P-value <0.005 0.033 0.016 <0.005

Monthly incomea

Less than 7000 690 62.3 21.4 41.4 29.0 41.6 22.2 55.7 18.0 7000 to less than 12,000 218 63.3 21.8 45.0 27.3 42.8 23.7 57.4 18.3 12,000 to less than 18,000 137 69.7 19.0 42.9 26.1 47.3 21.4 61.9 14.9 18,000 or more 104 70.6 19.8 39.9 29.7 49.4 21.0 62.3 15.6 P-value <0.005 0.338 0.001 <0.005

a In Saudi Riyals (1$ = 3.75 SR).

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had a significantly higher total score in com- parison to unmarried individuals (p = 0.003). Of great interest was the finding that knowledge was significantly correlated with age. Indeed, older individuals had a significantly higher total score (p = 0.035). On the other hand, both educa- tional attainment and monthly income impacted the level of knowledge. As expected, more edu- cated individuals scored significantly higher than others (p < 0.005). In addition, individuals with higher income had significantly higher scores (p < 0.005).

Discussion

This study reached a wide range of Twitter users in the Saudi community to measure their MERS aware- ness. We used Twitter, one of the best social media networks and a fast-growing platform for data col- lection. Participation in this study was completely voluntary, which makes the statistical data valid and reliable. The expected percentage, as analyzed by the statistical software of public awareness, was 50%, and the actual percentage revealed by this study was much higher.

One might conclude from this study that MERS awareness among the Saudi public is generally satis- factory. Female, married, older, and more educated participants were significantly more knowledgeable about the disease. However, some false beliefs about treatment were fairly common, as demon- strated by the fact that only 36% of the respondents could recognize that antibiotics cannot treat the infection and only 41% knew that doctors do not have an antiviral drug for MERS.

Moreover, heightened anxiety was noted, espe- cially in that only 21% knew that MERS is not a very common disease. In addition, lack of information about the source of the virus was quite com- mon, with almost half of the population remaining unaware that bats and camels are the most sus- pected sources of the virus.

In comparison with two studies regarding the knowledge of MERS among French and Australian pilgrims [14,15], our study demonstrates that the Saudi public is much more aware of the disease. Approximately 65% of the French and only 35% of the Australian pilgrims were aware of the MERS epi- demic in Saudi Arabia. However, according to the French study, the French pilgrims were more seri- ous about taking protective measures. Most French

pilgrims (90%) used hand sanitizers and wore masks in comparison to 74% of our study participants who used hand sanitizers and only 11% who wore masks in public places.

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One could argue that some of the questions ddressed were not truly dichotomous and might ave constituted a bipolar trap for the respondents. owever, it is important to note that the question- aire was designed and offered in Arabic and that n English translation might have conveyed some nevitable inaccuracy.

Although the efficacy of the protective measures escribed in this questionnaire, such as facemasks, s not fully established [16], these measures are mong the very few readily available methods that he general public can use for protection.

It is noteworthy that new findings have been bserved since the time that the study was onducted. For instance, the presence of asymp- omatic carriers of the disease was not well stablished previously. However, it is now evident hat asymptomatic health care workers can spread he illness among hospitalized patients, making the isease nosocomial [17].

The results of this study should be interpreted earing in mind its limitations. Our studied pop- lation consisted mainly of Twitters users, who end to be more educated and younger individ- als in the Saudi community, and therefore, our ndings are limited to this subpopulation. In addi- ion, most of the participants were from the Central rovince. This limitation might be because the Cen- ral region is highly populated and includes the apital City of Riyadh, where most of the celebri- ies reside. Our questionnaire did not address the ource of information that the public used to ecome informed about MERS. Therefore, we could ot determine which method is most effective in ducating the Saudi public. A further limitation is ot addressing the issue of the avoidance of pil- rimage and visiting crowded places, such as the oly Mosques of Makkah and Medina. The ques- ionnaire included a vague question on avoidance f crowded places without any further description. nother shortcoming is the lack of information on he consumption of camel products. Drinking raw amel milk and consuming camel meat are Saudi raditions. Additionally, using camel urine as an lternative medicine is still practiced by some Saudi ndividuals. This is of high significance, especially s more studies are linking the consumption of raw amel products with MERS-CoV infection [18].

MERS remains a serious threat that has a large mpact on public health in the Kingdom. As the isease continues to evolve, vaccine and specific ntiviral agents are urgently needed. In the mean-

ime, promoting protective measures among the ublic will enhance safety and help reduce the pread of the infection. Based on the present ndings, we recommend a more rigorous public

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ublic awareness of MERS-CoV in Saudi Arabia

wareness campaign to correct misconceptions. his can be done by addressing the public through lear television advertisements, mobile messages, nd different social media modalities. Alterna- ively, campaigns carried out in schools, colleges, nd malls can also educate the public. More essen- ially, site visits to camel farms by veterinary r infection control officers are important strate- ies for preventing MERS-CoV transmission between amels and humans. The Saudi public must be learly instructed to avoid direct contact with amel body fluids until the eradication of the infec- ion is made possible. In addition, the consumption f raw camel products must be avoided. More mportantly, persons with frequent contact with amels should be targeted in future MERS educa- ion campaigns. The Ministry of Agriculture should nd a method for educating those individuals and onvincing them of the health hazard that camels ose. These health education messages should be onveyed without creating anxiety and fear in he community to avoid irrational and unnecessary emands on health services.

In light of the latest Riyadh outbreak, one cannot tress the role of health care workers in containing he infection enough. Implementing strict infec- ion control measures under all circumstances is xtremely important. In this regard, continuous raining and contingency measures are needed in ll health care settings to prevent such outbreaks.

unding

o funding sources.

onflicts of interest

he authors have declared that no competing inter- sts exist.

thical approval

ot required.

cknowledgements

he authors would like to thank Prof. Ali H. Hajeer or his supervision of this student research project. dditionally, the study would not have been pos- ible without the constructive help of Dr. Noura

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. Al-Ayedh, who offered support in collecting the tudy data.

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