SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES ...
Transcript of SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES ...
SCHOOL OF PUBLIC HEALTH
COLLEGE OF HEALTH SCIENCES
UNIVERSITY OF GHANA
ASSESSMENT OF KNOWLEDGE, ATTITUDES AND PRACTICES AMONG
HEALTH CARE WORKERS TOWARDS LASSA FEVER IN 5 HEALTH
FACILITIES OF FARANAH DISTRICT IN UPPER GUINEA
BY
MORY CHERIF HAIDARA
10639057
THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA,
LEGON IN PARTIAL FULFILMENT OF REQUIREMENTS TOWARDS THE
AWARD OF MASTER OF PUBLIC HEALTH DEGREE
MAY, 2019
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DECLARATION
I do hereby declare that apart from people’s knowledge that have been duly acknowledged,
this research proposal is the result of my hard work under competent supervision
I take full responsibility for any shortcomings in this work.
…………………………………… ………………………
MORY CHERIF HAIDARA DATE
10639057
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CERTIFICATION
I hereby certify that this thesis was supervised in accordance with the laid down
procedures by the University.
…………………………………… ………………………
DR. ERNEST KENU DATE
(Academic Supervisor)
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DEDICATION
This research work is dedicated to my mother, NANSIRA MAGASSOUBA and to the
memory of my Uncle, TAHIROUN CHERIF.
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ACKNOWLEDGMENT
Glory be to God almighty for giving me the strength, sagacity and grace to complete my
dissertation. My sincere appreciation goes to my supervisor for his guidance, inspiration
and support. Dr. Ernest Kenu, may God reward you abundantly. My gratitude goes to
LAROCS Project for their financial support and care. I appreciate the warm reception from
the health workers at the GENERAL Hospital, ABATTOIR, BENDOU, MARCHE, AND
TIRO HEALTH CENTRES. I am very grateful for giving me the opportunity to use your
facilities for the study I am grateful for your support. To my family and friends, thank you
for being there for me. May God bless you. This research would have been impossible to
undertake without the support.
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ABSTRACT
Introduction: Lassa fever (LF) is a zoonotic acute viral haemorrhagic fever caused by the
Lassa virus (LASV). Nosocomial infection with high case fatality rate of the disease has
been described primarily in the hospital settings in many West African countries including
Guinea. The nosocomial spread is due to the current state of the health system, leading to
poor medical practice. Hospitalized patients with LF may pose a substantial risk to health
care workers (HCWs) and to other patients (Lavergne et al., 2016). Late diagnosis and
wrong treatment are factors that can increase the likelihood of nosocomial transmission.
Therefore, it is important that health care providers working in endemic communities have
adequate knowledge on the disease, its clinical features and diagnosis (Ea, Da, Ec, Og, &
Ebhodaghe, 2013).
Objectives: The study assessed knowledge, attitudes and practices and determined factors
influencing them among health care providers working in five health facilities of Faranah
district in upper Guinea (the general hospitals, two health centres in the urban area and
another two health centres in the urban area).
Methods: A descriptive cross-sectional survey and quantitative approach was used to
collect data. Pre-coded structured questionnaire were used to conduct interviews. All health
professionals who were working in these selected health facilities were enrolled into the
study, if found eligible. Statistical analysis was done in Stata (version 14.1) Software.
Frequency distribution was done to compute proportions on good KAP, gender, religion,
educational level, and occupation. Multiple logistic regression analysis was used to assess
the strength of association between the knowledge and attitudes and each independent
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variable to assess the strength of association looking at the adjusted Odds Ratio (AOR)
with 95% confidence interval (CI).
Results: Sixty-three out of the 195 respondents (32.3%) had no idea what Lassa fever was.
Of the remaining one hundred and thirty-two, 67.7% (132/195) who had heard about Lassa
fever, their knowledge was accessed with a sixteen item questionnaire on knowledge
according to case definition. Nearly forty-nine percent (64/132) had good knowledge about
Lassa fever (p = 0.485; 95% CI = 0.4 – 0.6). Ninety-five percent of health professionals
(186/195) were found to have good attitude towards a suspected case of Lassa fever (p =
0.95; 95% CI = 0.91 – 0.97). With regards to practice, all health professionals had good
practices in dealing with a suspicious case of Lassa fever.
Conclusion: The study revealed a general low level of knowledge of LF disease among
the HCWs. Most of the HCWs had good attitudes and all of them had good practices
towards LF. Age and number of years of work were found to influence knowledge but not
attitudes and practices. There was not statistical significant difference in the KAP of HCWs
working in the general hospital compare to those working in the health centres. HCWs in
urban HC had better attitude compare to those in the rural ones. The Ministry of Health,
Guinea should plan more training on Lassa Fever with emphasis on other professionals as
much as medical doctors.
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TABLE OF CONTENTS
DECLARATION ................................................................................................................. i
CERTIFICATION .............................................................................................................. ii
DEDICATION ................................................................................................................... iii
ACKNOWLEDGMENT.................................................................................................... iv
ABSTRACT ........................................................................................................................ v
LIST OF TABLES .............................................................................................................. x
LIST OF FIGURES ........................................................................................................... xi
LIST OF ABBREVIATION ............................................................................................. xii
CHAPTER ONE ................................................................................................................. 1
INTRODUCTION .............................................................................................................. 1
1.1 Background ............................................................................................................... 1
1.1.1 Lassa Fever Burden ............................................................................................ 1
1.1.2 Lassa Virus Infection .......................................................................................... 2
1.2 Problem Statement .................................................................................................... 4
1.3 Justification of Study ................................................................................................. 6
1.4 Conceptual Framework ...................................................................................... 8
1.5 Narrative of Framework ............................................................................................ 8
1.6 Research Questions ................................................................................................... 9
1.7 Objectives ................................................................................................................ 10
General objective ....................................................................................................... 10
The specific objectives of study are .......................................................................... 10
CHAPTER TWO .............................................................................................................. 11
2.0 LITERATURE REVIEW ........................................................................................... 11
2.1 Definition ................................................................................................................ 11
2.2 Historical Account of Lassa Fever .......................................................................... 11
2.3 Properties/Strains of LASV ..................................................................................... 12
2.4 Replication of LASV ............................................................................................... 13
2.5 Epidemiology .......................................................................................................... 13
2.6 The Rodent Reservoir/Host of LASV ..................................................................... 15
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2.7 Transmission of LF ............................................................................................ 16
2.7.1 Rodents-To-Human .......................................................................................... 16
2.7.2 Human-to-human .............................................................................................. 17
2.8 Pathogenesis of LF .................................................................................................. 17
2.9 Amplification of LF ................................................................................................ 18
2.10 Clinical Presentations of LF .................................................................................. 18
2.11 Complications of LF ............................................................................................. 19
2.12 WHO Case Definition of LF for Epidemiological Surveillance ........................... 20
2.12.1 Clinical description ......................................................................................... 20
2.12.2 Laboratory criteria for diagnosis .................................................................... 20
2.12.3 Case classification .......................................................................................... 20
2.13 Prognostic Factors ................................................................................................. 21
2.14 Diagnosis of LF ..................................................................................................... 21
2.14.1 Laboratory investigations ............................................................................... 22
2.15 Treatment .............................................................................................................. 23
2.16 Prevention and Control.......................................................................................... 24
2.16.1 The individual prevention ............................................................................... 24
2.16.2 The community prevention ............................................................................. 24
2.16.3 Vaccine ........................................................................................................... 25
2.17 Knowledge attitude and practice on LF and other haemorrhagic fevers............... 25
CHAPTER THREE .......................................................................................................... 27
3.0 METHODOLOGY ..................................................................................................... 27
3.1 Study Design ........................................................................................................... 27
3.2 Study Area ............................................................................................................... 27
Figure 4: Map for the location of Faranah district ................................................. 28
3.2.1 The general hospital of Faranah district ...................................................... 28
3.2.2 Health centres.............................................................................................. 28
Urban health centres ........................................................................................... 29
3.3 Study Population ..................................................................................................... 29
3.4 Sampling Technique ................................................................................................ 29
3.4.1 Inclusion Criteria ........................................................................................ 29
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3.4.2 Exclusion Criteria ....................................................................................... 30
3.5 Study variable ..................................................................................................... 30
3.5.1 Dependent variable ..................................................................................... 30
3.5.1.1 Knowledge ................................................................................................. 30
3.5.1.2 Attitudes .................................................................................................. 30
3.5.1.3 Practices of HCWs .................................................................................. 31
3.5.2 Independent variables ................................................................................. 31
3.6 Data Collection Methods and Instruments .............................................................. 32
3.7 Data analysis ........................................................................................................... 32
3.8 Ethical consideration ............................................................................................... 33
CHAPTER FOUR ............................................................................................................. 35
4.0 RESULTS ................................................................................................................... 35
4.1 Socio-demographic characteristics of respondents ................................................. 35
4.2 Proportion of health care professionals who have good knowledge on LF ............ 36
4.3 Proportion of health care professionals with good attitude and practice ................ 37
4.4 Socio-demographic characteristics associated with knowledge ............................. 38
4.5 Factors associated with health professionals’ attitude towards LF’s suspected case
....................................................................................................................................... 41
CHAPTER FIVE .............................................................................................................. 44
5.0 DISCUSSION ............................................................................................................. 44
6.0 CONCLUSION AND RECOMMENDATION .......................................................... 49
6.1 Conclusion ............................................................................................................... 49
6.2 Recommendations ................................................................................................... 51
REFERENCES ................................................................................................................. 52
APPENDICES ..................................................................................................................... a
INFORMED CONSENT FORM ......................................................................................... a
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LIST OF TABLES
Table 1: Independent Variable .......................................................................................... 31
Table 4.1a: Socio-demographic characteristics of respondents (n=195) .......................... 35
Table 4.1b: Socio-demographic characteristics of respondents (n=195) .......................... 36
Table 5a: Factors associated with health care workers' knowledge about Lassa Fever.... 40
Table 6a: Factors associated with health care workers' attitude towards LF's suspected
case .................................................................................................................................... 42
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LIST OF FIGURES
Figure 1: Conceptual framework ........................................................................................ 8
Figure 2: Lassa fever risk map in West Africa, with the higher risk located in the red
zones ................................................................................................................................. 14
Figure 3: Mastomys natalinsis, the reservoir of Lassa fever ............................................ 16
Figure 4: Map for the location of Faranah district ............................................................ 28
Figure 5: Proportion of health care workers who have good knowledge about Lassa fever
........................................................................................................................................... 37
Figure 6: Proportion of health care workers with good attitude ....................................... 38
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LIST OF ABBREVIATION
CDC Centres for disease control and prevention
EVD Ebola virus disease
KAP Knowledge Attitudes and Practices
LASV Lassa virus
LF Lassa fever
MOH Ministry of health
NGOs Non-government organizations
PCR Polymerase chain reaction
PPE Personal protective equipment
WHO World health organization
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CHAPTER ONE
INTRODUCTION
1.1 Background
1.1.1 Lassa Fever Burden
Lassa fever (LF) is a zoonotic acute viral haemorrhagic fever caused by the Lassa virus
(LASV). It was first described in north eastern Nigeria (Lassa, in Borno state, in the
Yedseran River valley at the South end of Lake Chad) in 1969 (Ajayi et al., 2014). It is
endemic in Benin, Guinea, Liberia, Mali, Sierra Leone, and Nigeria with peaks in incidence
closely related to season. Same cases have also been reported into western countries where
LF is not endemic but was imported by returning travellers in Germany, Netherlands,
Sweden, US and UK (Ea et al., 2013). According to the World Health Organization LF
affects between 100,000 to 300,000 persons in West Africa per year and approximately
5,000 deaths (WHO, 2007). Around 80% of infected individuals are asymptomatic or have
mild symptoms while 20% progress to disease. Case fatality rate is estimated to be around
15% among those who develop severe disease. However, in 2016, the mortality rate was
reported to be above 50%. Pregnant women with LF have a high mortality rate especially
in the third trimester. Recovered LF patients may experience hearing loss as well as other
neurologic side effects (WHO, 2017). Based on prospective studies performed in four of
the most affected countries, Guinea, Sierra- Leone, Liberia, and Nigeria, Richmond and
Baglole in the year 2003, estimated that 59 million people are at risk of primary LASV
infections with an annual incidence of disease as high as 3 million and as many as 67,000
deaths per year (Lukashevich, 2012). LF affects all age-groups and gender with a seasonal
clustering around the late rainy season and dry season (Olowookere et al., 2017).
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1.1.2 Lassa Virus Infection
Lassa fever is an acute and occasionally severe rodent- borne viral haemorrhagic fever,
with cases in humans geographically constrained to sub-Saharan West Africa (Gibb,
Moses, Redding, & Jones, 2017). LASV is an arenavirus enveloped and contains two
single-stranded RNA segments of ambience polarity encoding five proteins (N. E. Yun et
al., 2012). The natural host of LASV is the multi-mammate rat, Mastomys natalensis which
is commonly found in human households and eaten as a delicacy in several African
countries and lives in close contact with humans (Olugasa et al., 2014). LF is symptomatic
in about 20% of cases when it causes an acute illness with nonspecific symptoms such as
fever and general weakness, headache, chest pain, vomiting, diarrhoea, cough, pleural
effusion, bleeding from orifices, and in the late stages, sometimes disorientation and coma
(Olowookere et al., 2017). Deaths from LF is due to the effective reduction of circulating
volume of the blood which can cause shock, and multi-organ system failure (Shaffer et al.,
2014). Presently, there is no licensed vaccine or immunotherapy available for prevention
or treatment of this disease. The antiviral drug ribavirin has been demonstrated to reduce
fatality from 55% to 5%, but only if it is administered within 6 days after the onset of
symptoms (Branco et al., 2011). LF presents with nonspecific symptoms similar to many
other endemic illnesses in West Africa, that making it difficult to diagnose clinically;
therefore, laboratory testing is needed to confirm the diagnosis (Raabe & Koehler, 2017).
Humans contract LASV primarily through contact with excreta of its natural host.
Although uncommon, secondary transmission of LASV between humans may occur
through direct contact with infected blood or bodily secretions, such as saliva, vomit, stool,
or urine (Bausch, Hadi, Khan, & Lertora, 2010). Human infections tend to be focal with
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periodic familial or village clusters with secondary cases due to person-to-person spread.
Infections peak between January and May – during the dry season, but cases are seen year
round (Gibb et al., 2017). In this second type of contamination nosocomial transmission
plays an important role. According to Lavergne et al., nosocomial infection with high case
fatality rate has been described primarily in the hospital settings in many West African
countries including Guinea. The nosocomial spread is due to the current state of the health
system, leading to poor medical practices. Hospitalized patients with LF may pose a
substantial risk to health care workers (HCWs) and to other patients (Lavergne et al., 2016).
This nosocomial hazard can be minimized by proper and timely infection-control
measures, careful management of infected patients, and, in some cases, administration of
prophylactic therapy to HCWs after exposure. Late diagnosis and wrong treatment are
factors that can increase the likelihood of nosocomial transmission (Ea et al., 2013). Since
no human vaccine exists and therapeutic options are limited to the broad-spectrum antiviral
ribavirin, rodent control and adjusting human behaviour are currently considered to be the
only options for LASV prevention (Mariën, Kourouma, Magassouba, Leirs, & Fichet-
Calvet, 2018). Late diagnosis and wrong treatment are factors that can increase the
likelihood of nosocomial transmission and adverse outcomes.
HCWs are potentially exposed to blood-borne pathogens through contact with infected
body parts, blood and other body fluids in the course of their work. It has been estimated
that each year, as many as three million HCWs all over the world experience percutaneous
exposure to blood-borne viruses Hepatitis C and B and HIV viruses. Apart from these
pathogens, LASV is fast gaining prominence as an emerging nosocomial transmitted
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pathogen with significant public health impact in the West African sub region (Ekaete
Alice, Akhere, Ikponwonsa, & Grace, 2013).
Therefore, important that health care providers working in endemic communities have
adequate knowledge of the disease through its clinical presentation and its diagnosis.
Because, when these HCWs are themselves ignorant of the disease, the tendency to
misdiagnose and treat wrongly not only puts the health worker at risk, but also endangers
the lives of the close family contacts and community at large. HCWs in the endemic area
should have comprehensive information about the virus and the disease it causes.
1.2 Problem Statement
Viral haemorrhagic fevers like Lassa fever are among the most feared diseases due to their
high case fatality rates, severe clinical presentations and ease of transmission. Unlike most
viral haemorrhagic fevers, which are recognized only when outbreaks occur. LF is endemic
in West Africa, with an estimated tens of thousands of cases annually (Shaffer et al., 2014).
Since the identification of LASV, human- to-human transmission has been documented in
several nosocomial outbreaks, leading to an initial perception that the virus was both highly
contagious and virulent (Lo Iacono et al., 2015). The availability of laboratory testing has
been limited by the designation of Lassa virus as a category (Raabe & Koehler, 2017). A
pathogen by the National Institute of Allergy and Infectious Diseases (NIAID). Biosafety
level 4 (BSL-4) precautions are recommended for handling potentially infectious
specimens (Raabe & Koehler, 2017).
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Existence of signs common to LF and other diseases such as malaria (fever, asthenia,
vomiting) which is an endemic disease, leading cause of consultation in health facilities in
Guinea (30% of consultations). It is very difficult for HCWs to identify Lassa fever’s
patient because of similarity of its signs and symptoms of another tropical diseases.
Additionally in West African towns and villages where there are no facilities for laboratory
diagnosis, most Lassa fever infections are treated as malaria (Ogbu, 2014). Therefore it is
imperative that health care workers in endemic communities are adequately sensitized on
the disease, it’s clinical features and diagnosis (Ea et al., 2013).
The difficulty of distinguishing between patients with LF and other patients suffering from
most tropical diseases due to the similarity of symptoms and clinical signs and the absence
of a diagnostic laboratory in this endemic area endanger health providers and increase the
risk of developing nosocomial infections due to LASV. Hence the need to assess the
knowledge, attitudes and practices of health providers in this community.
The reasons for choosing the city of Faranah are based on the fact that previous studies
have revealed an endemicity of LF in this city (Lukashevich et al. 2012; Klempa et al.,
2013). Between 1990 and 1992 a large epidemiological investigation into the activity of
LASV in the human populations of the Republic of Guinea was conducted by Lukashevich
et al. (2012). They sampled 25 villages, distributed in different prefectures to establish the
LASV antibody prevalence using the ELISA assay. Their results allowed to calculate the
average of seroprevalence by prefecture. Thus, the prevalence of LF in the city of Faranah
was 35% or 149/420 (Klempa et al., 2013) A second important aspect is the proven
presence of native rodents belonging to the genus Mastomys which represents both the
reservoir and the vector of LASV in some villages of Faranah. According to the study by
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Fichet-calvet et al., (2007), LASV-positive rodents were captured in the villages of Bantu,
Gbetaya and Tangaya. The prevalence of LASV in Mastomys natalensis is12.4% (51/412)
(Fichet-calvet et al., 2007).
The Regional Hospital of Faranah which is the reference hospital of all this region and
primary health centres which have been selected for this study are health facilities where
a very large number of patients is coming for health care. Thus these health facilities could
also receive any type of LF case because they are located in an endemic LASV area. Since
the load of patients is heavier, HCWs are more likely to contract the disease and so their
knowledge, attitudes and practices are critical.
1.3 Justification of Study
This study seeks to assess Knowledge, Attitudes and Practices among health care workers
towards LF in 5 health facilities of the prefecture of Faranah in Guinea.
The reasons for this study are first of all, no studies has yet been published on of health
care personnel regarding infections (nosocomial) LF in this locality of the country.
Secondly, the level of the KAP and the quality of the attitudes and practices of the
caregivers make them most vulnerable to a disease as transmissible as LF and therefore
deserves to be evaluated and known by the authorities in charge of health in the country.
In addition to significantly enriching the medical literature, this study will provide novel
empirical evidence to support efforts of previous basic research on LF in Guinea. It will
also be of great value to health care workers, medical researchers, the Governments of
other countries in sub-Saharan Africa where this disease is endemic, as it provides general
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overview of the problem. Finally, this study will serve as a resource for other researchers
who may want to undertake a similar study in other cities in the country or in other
countries.
The difficulty of clinically distinguishing patients with FL and other patients suffering from
most tropical diseases due to the similarity of symptoms and clinical signs and the absence
of a diagnostic laboratory in this endemic area, thus putting at risk the HCWs who work
there and increasing the risk of developing nosocomial infections due to LASV are among
other reasons for choosing this topic. Hence the need to assess the knowledge, attitudes
and practices of health providers in this community.
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1.4 Conceptual Framework
Figure 1: Conceptual framework
1.5 Narrative of Framework
This conceptual framework shows how individual factors (professional status, number of
years of work of health staff), factors related to interventions (Ebola disease epidemic,
training seminars and Sensitization on haemorrhagic fevers) and factors related to the
health structure through the type (General Hospital or Health centre), the location (urban
or rural), the service of work (General medicine, surgery, paediatrics etc...) Could influence
the health care staff of these different sanitary structures.
Intervention factors:
Ebola epidemic
Training on Viral
Haemorraghic Fevers
KAP
Knowledge
Attitudes
Practices
Individual factors
Age
Sex
Religion
Occupation
Number of
year of work
Facility factors
Location
Type of facility
Unit of work
Nosocomial
Transmission of
LASV
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Indeed, we assume that in a first aspect the HCWs’ KAP about LF could be influenced by
his or her professional status. In this order of thought we think that HCWs with professional
status as a doctor could have a higher level of KAP compared to other HCWs. It is also
possible that HCWs who have many years of experience have a higher level of KAP
compared to those who have less. In a second aspect of this conceptual framework, we also
assume that their KAP could also be influenced by the advent of the Ebola disease
Epidemic which occurred in the country from 2014 to 2016 in the county and with the city
of Faranah having had cases and interventions such as workshop and awareness campaigns
on Viral Haemorrhagic Fevers in general and on LF in particular.
Factors related to the health facility are factors which could directly influence the HCW’s
because we assume that a general hospital may receive more training seminars than a health
centres and urban health centres are more in a position to receive than rural ones. Otherwise
health facility factors could influence individual factors by assuming that there would be
more HCWs in urban health centres area than the rural area health centres. Which could
indirectly affect the HCWs’ KAP.
1.6 Research Questions
• What is the level of knowledge, attitudes, and practices of the health care workers
on Lassa fever in hospitals of the endemic region of Guinea?
• How does socio-demographic factors influence practices of healthcare
professionals?
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• Is there a (statistically significant) difference between the KAP of HCWs who are
working at the Regional hospital and the KAP of those who are working in the
health centres?
• Is there a (statistically significant) difference between the KAP of HCWs who are
working in the urban health centres and those who are working in rural health
centres?
1.7 Objectives
General objective
To assess knowledge, attitudes and practices of HCWs on LF in 5 health facilities of
Faranah district in upper Guinea and determine whether KAPs differ by place of work
(Rural vs Urban or Regional vs Health Centres)
The specific objectives of study are
1. To determine the proportion of HCWs having good knowledge about LF.
2. To determine the proportion of HCWs having good attitudes and good practices in
dealing with a suspected case of L.F.
3. To identify socio-demographic factors that could influence the KAP of HCWs
working in these 5 health facilities on LF.
4. To assess whether KAP of HCWs vary by type of facility (General Hospital vs
Health centres) and place of work ( Rural vs Urban)
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CHAPTER TWO
2.0 LITERATURE REVIEW
HCWs are potentially exposed to blood-borne pathogens through contact with infected
body parts, blood and body fluids in the course of their work. It has been estimated that
each year, as many as 3 million HCWs all over the world experience percutaneous exposure
to blood-borne viruses Hepatitis C and B and HIV viruses. Apart from these pathogens,
The public health impact of LASV in the West African sub region as an emerging
nosocomial transmitted pathogen requires significant response (Ekaete Alice et al., 2013).
2.1 Definition
Infection with LASV, a member of the Arenaviridae, results in a spectrum of illness from
unapparent infection to Lassa fever, a severe multisystem disease that often has
haemorrhagic manifestations (Robinson et al., 2016). Its initial clinical manifestations are
difficult to differentiate from those of other common febrile illnesses, such as malaria, and
a high index of clinical suspicion is required in the diagnosis (Akhuemokhan et al., 2017).
2.2 Historical Account of Lassa Fever
Lassa fever was first described in Sierra Leone in the 1950s but the virus responsible for
the disease was not identified until 1969 when two missionary nurses died in Nigeria, West
Africa, and the cause of their illness was found to be LASV, named after the town in
Nigeria where the first cases were isolated (Mccormick et al., 2017). Although LASV was
identified in 1969, records of haemorrhagic fever (HF) since the 1920s indicate this virus
had been circulating for at least 50 years (Zapata & Salvato, 2015). The nurse presumably
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acquired infection from an obstetrical patient residing in Lassa. She died approximately
one week after the onset of symptoms. Subsequently, two more nurses that attended the
first patient contracted the disease, which was later named Lassa fever and caused the death
of one of them. Infectious virus (LASV) was isolated from all three cases (Yunusa &
Egenti, 2015).
2.3 Properties/Strains of LASV
LASV is the causative agent of LF, belongs to the family Arenaviridae. LASV is spherical
in shape and measures between 70 and 150 nm in diameter. It has a smooth surface
envelope with T-shaped spikes measuring 7–10 nm and built with glycoprotein. The
envelope encloses the genome which has helical nucleocapsid measuring between 400 and
1300 nm in length (Yunusa & Egenti, 2015). LASV can be inactivated by exposure to
ultraviolet light, gamma irradiation, or ultrasonic vibration. The effect of these physical
factors on the virus depends on the exposure time (Ogbu, 2014).
Arenaviruses are classified as segmented negative-sense RNA (nsRNA) viruses and are
phylogenetically closely related to other segmented nsRNA viruses belonging to
Bunyaviridae and Orthomyxoviridae (Nadezhda E. Yun & Walker, 2012). Its genome
consists of two segments, L (7.3 kb) and S (3.4 kb), which encode four proteins: Z (matrix),
L (polymerase), NP (nucleoprotein), and GPC, which is post-translationally cleaved into
two peptides, GP1 and GP2, that form the transmembrane glycoprotein (Andersen et al.,
2015). Arenaviruses have an 11 kb segmented genome comprised of single-stranded RNA
with ambience coding. The naked RNA is not infectious. There is considerable sequence
heterogeneity of LASVs across West Africa, with four recognized lineages three in Nigeria
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and one in the area comprising Sierra Leone, Liberia, Guinea, and Ivory Coast (Grant,
Khan, Schieffelin, & Bausch, 2014).
2.4 Replication of LASV
Replication of Lassa fever virus forms the basis of its pathogenesis. The process starts with
adsorption of the virus on widely distributed and highly conserved cell-surface receptor
molecules. The glycoprotein of the spikes is responsible for the virus–cell interactions. The
other steps are penetration, removal of the viral envelope, and liberation of viral (Ogbu,
2014).
2.5 Epidemiology
LF accounts for an estimated 300,000 to 500,000 cases and 5000 deaths yearly in West
Africa, particularly in Sierra Leone, Nigeria, Liberia and Republic of Guinea. Serological
evidence of LF has also been found in Mali, Senegal and Central African Republic
(Ogoina, 2013). Severe and fatal disease may occur with all strains of LASV, but, other
than during the third trimester of pregnancy, in which maternal and fatal mortality are
elevated, no prognostic indicators are known that would identify, prior to disease onset
(Bausch et al., 2010).
The high seroprevelance for LASV specific antibodies in those Guinean (55%), Nigerian
(21.3%) and Sierra Leonean (52%) populations tested indicates that most infections are
mild or asymptomatic and do not require hospitalisation. This is supported by findings that
more than 80% of persons who developed antibodies have not reported recent febrile illness
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(Mylne et al., 2015). LF is seen in both genders and all age groups (Grant et al., 2014). LF
disease is commonly found in rural communities, where the over 70% and where poverty
prevails and standards of living are low of the population resides. (Ea et al., 2013).
Figure 2: Lassa fever risk map in West Africa, with the higher risk located in the
red zones (Fichet-Calvet & Roger, 2009)
The virus has also been imported into countries where it is not endemic, for example, by
returning travellers. A few imported cases have been identified in countries outside of West
Africa endemic zone suggesting a wider distribution of LASV and challenging the current
dogma of LASV endemicity. For example, in 1980, a non-fatal case of Lassa fever was
diagnosed in The Netherlands in an aid worker stationed in Burkina Faso (ref). Nearly a
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decade later a similar scenario unfolded in the United Kingdom (Sogoba, Feldmann, &
Safronetz, 2012).
In addition, LASV has been classified as a biosafety level 4 (BSL4) pathogen as a category
A bioweapon agent because of the potential for the spread this highly dangerous and
contagious pathogen (N. E. Yun et al., 2012).
2.6 The Rodent Reservoir/Host of LASV
After the first outbreaks reported in Nigeria and Sierra Leone in the seventies, identified
the reservoir in Sierra Leone, by isolating the virus in the multi-mammate rat, Mastomys
natalensis, a species indigenous to Africa (Fichet-Calvet, 2013). This distribution of
Mastomys in West Africa is highly variable and in some areas, 50% of domestic rodents
may be Mastomys. Since the rodents do not move far from their nest, and because LASV
is transmitted vertically in rodents, infection in local populations of rodents tends to cluster
(Ogoina, 2013).
A spatial survey of small mammals confirmed the multi-mammate rat, Mastomys
natalensis as the only reservoir host of LASV in Guinea (Fichet-calvet & Becker-ziaja,
2014). The 2-year longitudinal survey revealed that the reservoir host is more abundant
inside than outside of houses, especially during the dry season (Fichet-calvet & Becker-
ziaja, 2014).
The human disease, LF is definitely linked with the presence of Mastomys natalensis,
which is absent in coastal Guinea. In that region, only Mastomys erythroleucus (a local
species of the rat) was present and it has never been found to be infected by LASV,
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justifying the low endemic zone described by Lukashevich et al. in 1993 (Fichet-calvet et
al., 2009).
Figure 3: Mastomys natalinsis, the reservoir of Lassa fever (Boisen et al., 2015)
2.7 Transmission of LF
There are only two 2 modes of transmission: Rodent-to-human (the primary mode) and
human-to-human (the secondary mode).
2.7.1 Rodents-To-Human
Inhalation of aerosolized virus
Corrupt practices by staple food producers, which involve drying cassava flour
(Garry) in the open air in the daytime and sometimes at night. This enables all
types of rat including Mastomys natalensis to contaminate the flour with their
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excreta. Use of rat meat as a source of protein by people in some communities;
contamination of exposed food by rat faeces and urine(Lukashevich, 2012)
2.7.2 Human-to-human
Direct contact with blood, tissue secretions or excretion of infected humans through:
Needle stick or cut injuries from sharps used in LF cases - Airborne spread
Sexual contact with infected human. The virus maybe excreted in the urine of
patient for 3-9 weeks from the onset of illness. LASV can be transmitted via
semen for up to 3 months. Nosocomial transmission of LASV was well
described during the outbreaks that occasioned the discovery of the virus more
than 3 decades ago (Anderson, 2015).
Transplacental transmission from infected mother to unborn child is less frequently
reported but it is associated with poor prognosis for mother and foetus (Ogoina, 2013).
2.8 Pathogenesis of LF
After inoculation, LASV replicated first in dendritic cells and other local tissues, with
subsequent migration to regional lymph nodes and spread by lymph and blood monocytes
to a wide range of Tissues and organs occurs.
Thus, the pathogenesis of LF would mainly relate to the disruption of cellular function by
the virus. And most often patients die without significant bleeding and histopathological
lesions are generally not serious enough to explain the death (Grant et al., 2014). The level
of viremia is highly predictive of the disease outcome (Nadezhda E. Yun & Walker, 2012).
In a study involving 137 patients with LF, patients that presented with viremia < 103
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median tissue culture infectious dose (TCID 50)/ml on the day of hospitalization had 3.7
times greater chance of survival than those admitted with higher levels of viremia.
Similarly, the probability of fatal outcome in patients with serum titters > 103 TCID50/ml
and serum levels of aspartate aminotransferase (AST) ≥ 150 international units (IU)/L was
21 times higher than that in patients not meeting either of these criteria (Nadezhda E. Yun
& Walker, 2012). The humoral response often lags, with neutralizing antibodies typically
appearing after recovery in survivors and not at all in most fatal cases (Khan et al., 2008).
2.9 Amplification of LF
LF affects all age-groups and gender with a seasonal clustering around the late rainy season
and dry season (Olowookere et al., 2017). The highest incidence appears to be in eastern
Sierra Leone, northern Liberia, southeaster Guinea, and central and southern Nigeria.
However, the risk of exposure to LASV varies significantly in a given country and often
among regions or even villages within endemic areas (Grant et al., 2014).
A detailed systematic literature review identified nine incidents of Lassa fever cases being
imported into Europe, (including one case which was in transit in London while travelling
to the U.S.) between 2000 and 2010 (Gilsdorf, Morgan, & Leitmeyer, 2012).
2.10 Clinical Presentations of LF
LF is highly variable disease with a broad range of manifestations and many degrees of
severity. There are no firm clinical predictors or pathognomonic signs. LF presents at its
early stage with symptoms and signs indistinguishable from those of other viral, bacterial
or parasitic infections common in the tropics such as malaria, typhoid and other viral
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haemorrhagic fevers (Ea et al., 2013). Incubation periods range from 7 to 10 days, followed
by a flu-like illness that lasts 2 to 3 days, with a progressive fever, chills, malaise,
weakness, headache and myalgia in the back or the limbs (Fichet-Calvet, 2013). The
pharynx may be erythemic or even exudative, a finding which has at times led to
misdiagnosis of streptococcal pharyngitis. Gastrointestinal signs and symptoms occur early
in the course of disease and may include nausea, vomiting, epigastric and abdominal pain
and diarrhoea (Grant et al., 2014).
Clinically discernible haemorrhage is seen in fewer than 20% of cases and never in the first
few days of illness. Hematemesis, melena, haematochezia, metrorrhagia, petechiae,
epistaxis, and bleeding from the gums and venepuncture sites may develop, but
haemoptysis and haematuria are infrequent. Severe LF appears to result from an
insufficient immune response, with higher levels of viremia and lower anti- body titres in
fatal cases relative to survivors (Fichet-Calvet, 2013).
2.11 Complications of LF
Clinical complications such as pleural and pericardial effusions, facial oedema, bleeding
from mucosal surfaces, and neurological manifestations occur. Capillary lesions cause
haemorrhage in the targeted organs of the stomach, small intestine, kidneys, lungs, and
brain; and among the clinical signs, sore throat, vomiting, and bleeding are highly
correlated with poor outcome, resulting in death after a mean period of 12 days after the
onset of illness (Idemyor, 2010).
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2.12 WHO Case Definition of LF for Epidemiological Surveillance
2.12.1 Clinical description
An illness of gradual onset with one or more of the following: malaise,
fever, headache, sore throat, cough, nausea, vomiting, diarrhoea, myalgia,
chest pain, hearing loss, and
A history of contact with excreta of rodents or with a probable or confirmed
case of Lassa fever.
NB: In LF endemic regions such as Nigeria, a suspected case is defined as an illness with
onset of fever and no response to treatment of usual causes of fever in the area and at least
one of the following signs:
Bloody diarrhoea
Bleeding from gums, into skin (purpura) and into eyes
Bloody urine
2.12.2 Laboratory criteria for diagnosis
Isolation of virus (only in laboratory of biosafety level 4) from blood,
urine or throat washings or
Positive IgM serology or seroconversion (IgG antibody) in paired serum
specimens or
Demonstration of Lassa virus antigen in autopsy tissues by
immunohistochemistry or in serum by ELISA
Positive Polymerase Chain Reaction (PCR) from serum or autopsy tissues
2.12.3 Case classification
Suspected: A case compatible with the clinical description.
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Probable: A suspected case that is epidemiologically linked to a
confirmed case.
Confirmed: A suspected case that is laboratory-confirmed.
Contact: A person having close personal contact with the patient (living
with, caring for) or a person testing the laboratory specimens of a patient in
the 3 weeks after the onset of the illness.
2.13 Prognostic Factors
Prognosis depends on how early a patient presents at the clinic and better in males who
may acquire partial immunity due to the habit of patronizing food vendors. A study done
in Nigeria, the case fatality rate in males was 23% compared to women with 44%, though
males were four times more commonly affected than females (Yunusa & Egenti, 2015).
2.14 Diagnosis of LF
The signs and symptoms of LF may be difficult to distinguish from diseases that are
common in the tropics such as severe malaria, typhoid fever, yellow fever and other viral
haemorrhagic fevers, but diagnosis can be assisted with simple laboratory support but
definitive diagnosis requires testing that is available only in highly specialized laboratories.
As the symptoms of LF are so varied and nonspecific, clinical diagnosis is often difficult
especially early in the course of infection. Hence, to make accurate diagnosis of LF, clinical
manifestation, epidemiological data, and result of laboratory findings should be taken into
consideration (Yunusa & Egenti, 2015).
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Early events in LASV infection are complex and it has been difficult to design early
diagnostic tests. Consequently, there is no commercially available diagnostic assay for
early laboratory detection of LASV infection. Early diagnosis is important for case
classification, implementation of prevention measures, contact-tracing and treatment
initiation. LASV isolation is the ‘gold standard’ for LF diagnosis and must be done in a
high containment Biosafety Level-4 (BSL-4) facility, over several days (Zapata & Salvato,
2015).
2.14.1 Laboratory investigations
The signs and symptoms of LF may be difficult to distinguish from other common disease
in sub-Saharan Africa. Therefore, laboratory investigation is crucial in the diagnosis of
Lassa fever. Lassa fever can be diagnosed by:
Detection of the viral antigen, antibodies, or conventional virus culture.
The classical method used to detect LASV infection is inoculation of the
Vero cells with serum, cerebrospinal fluid, throat washing, pleural fluid, or
urine of the suspected individual patient. The specimen for laboratory
analysis should be collected as soon as the patient is suspected of being
infected. This conventional method is not affected by the variability of the
virus; however, the major disadvantage is the long turn- around time, which
may be days to weeks, for the result to be obtained.
One method of detection of the virus antigen is by enzyme-linked
immunosorbent assays (ELISAs) using Lassa virus–specific antibodies.
These tests are rapid and easy to perform. Also, they can be performed with
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inactivated specimens, which is advantageous in the field if sophisticated
equipment is not available.
Indirect immunofluorescence using virus-infected cells is commonly used
in detecting IgM and IgG anti- bodies to LASV and preferred for the
serological diagnosis of LF. However, it has its shortcomings and is not
completely specific due to cross-reactivity among African species of
arenaviruses.
The current method of choice for early and rapid diagnosis of LASV
infection is the real-time reverse-transcription PCR. Because Lassa virus is
an RNA virus, its RNA must be reverse transcribed into complementary
DNA prior to PCR (Idemyor, 2010).
2.15 Treatment
Ribavirin the antiviral drug is effective in the treatment of LF, but only if administered
early in the course of illness. In a study of LF in Sierra Leone, West Africa, it was observed
that patients with a high risk of death who were treated for 10 days with intravenous
ribavirin, begun within the first six days after the onset of fever, had a case- fatality rate of
5% (1 of 20) (p = 0.002), while patients whose treatment began seven or more days after
the onset of fever had a case fatality rate of 26% (11 of 43) (p = 0.01). The study confirmed
the efficacy of ribavirin in the treatment of LF and that it should be used at any point in the
illness, as well as for post-exposure prophylaxis. Supportive treatment is often necessary
and includes fluid replacement, blood transfusion, and administration of paracetamol,
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phylometadione, ringer lactate, haemocoel, quinine and broad spectrum antibiotics
(Yunusa & Egenti, 2015).
2.16 Prevention and Control
Prevention of primary transmission of LASV to humans can be achieved by avoiding
contact with Mastomys rodents, especially in endemic areas of the disease. Food should be
kept away from rodents and premises that are constantly cleaned to prevent rodents from
entering their homes. De-ratification with the use of rodenticides is also another way of
controlling the rodents and transmission of the disease. The illumination campaign against
Bush burn and the rat hunt for eating must be intensified in endemic areas. Trapping and
the use of rat poisons are effective in trying to reduce rodent populations. However, storage
of grains in modern silos will also help prevent contamination of the grain stored by
infected rodents (Ogbu, 2014).
2.16.1 The individual prevention
The affected person should be admitted to a special centre for the treatment of LF. Health
care providers and close associates of the patient should wear protective clothing, masks
and gloves (Personal Protective Equipment, PPE). Excreta from affected persons should
be properly disposed (Yunusa & Egenti, 2015).
2.16.2 The community prevention
Legislation is needed to prevent widowhood rites, traditional autopsies, bush burning and
unhygienic preparation of cassava flour and other staple foods. Animal husbandry and
fisheries should be encouraged in order to provide alternative sources of first-class proteins
for rat eaters. Regular and sustainable environmental sanitation is needed to prevent rat
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breeding (WHO, 2012). The public should be made aware of the mode of contact of LF
and its high case fatality rate using print and electronic media. Community involvement
and participation is necessary to provide sustainable LF control. Food vendors should be
educated on the need to prevent food contamination with LF virus. Grains, flours and left-
over foods should be adequately covered to prevent contamination by rats. Rodenticides
should be used for the destruction of rats in homes, and development of LF vaccine should
be facilitated. Regular seminars should be held for health-care providers on early diagnosis
and treatment of LF, while diagnostic kits should be made available in district hospitals.
Affected people should be referred early to the special centre in order to prevent or limit
the evolution of the disease (CDC, 2004).
2.16.3 Vaccine
LASV testing is limited to Biosecurity level 4 (BSL-4) facilities, which are scarce and
inconvenient. Genetic diversity among LASV strains requires vaccine candidates to induce
a broad cross-protective immunity. Several vaccine candidates showed protection against
LF in animal models. However, only ML29 conferred sterilizing immunity with broad pre-
and post-exposure protection and no adverse events in healthy or immuno-compromised
animals (Zapata & Salvato, 2015).
2.17 Knowledge attitude and practice on LF and other haemorrhagic fevers
In a study conducted by Ea et al., (2013), less than 20% of primary care health workers
assessed, were knowledgeable of Lassa Fever disease but 97% had heard of the disease.
A study conducted to assess knowledge of Crimean-Congo fever , another haemorrhagic
fever like Lassa fever, among health professionals in Iran found that nearly 94% had an
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idea of the disease, with just about 50% having good knowledge of the disease (Rahnarardi
et al., 2008). Another study conducted in Turkey found that over 68% of 144 primary health
workers in Turkey were found to have good knowledge of Dengue (Hidiroglu et al., 2012)
and Primary care Physicians in Singapore were found to have adequate knowledge of
Dengue fever (Lee et al., 2011).
Gloves for personal protection by majority of health workers was reported by Ea et al.,
(2013). Among nursing and midwifery students, in a study carried out in Kahramanmares,
Turkey (Ozeer et al., 2011) and among health workers in Iran ( Rahnarardi et al., 2008) it
was reported on the use of hand gloves were made, and higher than was reported in a study
carried out among healthcare personnel in Balochistan (Sheikh et al., 2004).
Hand glove is an essential component of the PPE, Standard personal protective gear for
any viral haemorrhagic fever management should include a scrub suit, gown, apron, rubber
boots, head covering, mask, eyewear, and two pairs of gloves (World Health Organisation,
1998).
In other studies, it was stated that low mention other PPE might be as a result of their
unavailability in the facility (Borchert et al., 2007; Hewlett and Hewlett, 2005) and
ignorance as to the significance of the protective gear in the prevention of infection.
In a study conducted by Ea et al., (2013), Overall knowledge of Lassa fever was poor for
51 (38.9%), and fair for 54 (41.2%) and good for 260 (19.8%). Knowledge on LF was not
significantly different across the various professions (doctors, nurses, orderlies.) at the
facility. They also reported that Sex, age and type of facility were not significantly
associated with knowledge on LF.
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CHAPTER THREE
3.0 METHODOLOGY
3.1 Study Design
The study design was a descriptive cross-sectional survey among HCWs in 5 health
facilities of Faranah district from May –June, 2018.
3.2 Study Area
This study was carried out in Faranah district. It occupies a land mass of 12,966km2 and
has a population of 78,108 (National Institute of Statistics, Guinea 2014). Faranah is a town
in upper Guinea lying by the River Niger. This district is administratively divided into 11
sub-districts. The town is mainly inhabited by Malinké and Djallonké. Islam and
Christianity are predominant. For this study we selected the general hospital, the 2 health
centres (Abattoir and Marché) which are located in the urban area and 2 health centre
(Bendou and Tiro) located in the rural area. All of them are public health facilities.
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Figure 4: Map for the location of Faranah district
3.2.1 The general hospital of Faranah district
The general hospital of Faranah district is located in the urban area of Faranah, not far from
the main market of this city and right in front of the Great Mosque. This hospital was built
in pre-colonial times, it has been rehabilitated several times to serve as a reference sanitary
structure for the entire Faranah region. This hospital has a capacity of 80-bed. It offers
general and specialized care services in all major clinical units, including General
Medicine, General Surgery, Paediatrics, Obstetrics and Gynaecology, Dental and Ocular
care. The total staff strength is about 80, of which there are 10 specialists and some 30
nurses.
3.2.2 Health centres
Health centres are structures that have a role in the health system to provide primary care
to the population and will use the general Hospital in need. These health centres include
the following services:
Faranah
Ngiehun
SorombaKomina
Bamba
Ouoma
Freetown
Bamako
Conakry
SIERRA
LEONE
MALI
GUINEA
A
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Primary curative consultation
Prenatal Consultation
Family Planning
Expanded immunization Programme
Maternity
All of the health centres are public health facilities and have the same structure.
Urban health centres
In this study, we selected the 2 health centres located at Abattoir and Marche in the urban
area.
Rural health centre
Another 2 health was selected in the rural area in the sub-district of Bendou and Tiro.
3.3 Study Population
The study population included in 5 health facilities in Faranah district. The cadre of HCWs
required for the study were doctors, nurses (trained and auxiliary), laboratory technologists,
as they were directly involved in clinical patient care or specimen collection.
3.4 Sampling Technique
All of the health care providers working in these 5 public health facilities within our
period of data collection were recruited
3.4.1 Inclusion Criteria
The selection criteria for its health providers were as follows:
A full-time employee in one of the selected health facilities of Faranah district and
having worked at least one month;
Students in clinical practice of medicine and nurses;
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Health provider who has given his informed consent.
3.4.2 Exclusion Criteria
Health workers who were absent on the day of the study were exempted and those who
did not give their consent.
3.5 Study variable
3.5.1 Dependent variable
3.5.1.1 Knowledge
The knowledge of HCWs regarding LF was knowledge acquired on its definition, signs
and symptom, the reservoir of LASV, the mode of transmission, the clinical presentation
of the infected person, the positive and differential diagnosis of LASV disease, the
measures of preventing and controlling the infection, also the case definitions. In this study,
the total score was divided into two levels for knowledge: respondents who had never heard
about LF were considered as having poor knowledge (score ≤ 50%) and good knowledge
(score > 50%).
3.5.1.2 Attitudes
The attitudes of HCWs towards LF cases were all the ways of being or postures adopted
by the care staff in the face of a suspected case of LF. For this, we asked whether the
respondent encountered a suspected case of LF in his unit of work and what his reaction
which could be was (to refer the suspected case to an isolation centre, inform health
authorities, expel the patient, and refer the suspect case to another service). For attitudes,
the total score was divided into two levels: Bad attitudes (score ≤ 50%) and Good attitudes
(score > 50%)
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3.5.1.3 Practices of HCWs
It made possible to know the individual practices carried out by the medical staff for the
prevention and control of infections in health facilities. The question was whether the
respondents were washing their hands with water and soap or chlorine solution and wearing
basic PPE. The assessment of practices made possible to know if the respondents know the
procedure and the conditions of wearing gloves. For practices, the total score was divided
into two levels: bad practices (score ≤ 50%) and good practices (score > 50%).
3.5.2 Independent variables
Table 1: Independent Variable
Variables Operational
Definition
Scale of
Measurement
Type of Variable
Age Age at last Birthday Discrete
Numerical
Gender Male or Female Nominal
Categorical
Marital status Single, Married,
Divorced or Widowed
Nominal Categorical
Number of years of work number of years to
practice this work
Continuous
Numerical
Type of facility General hospital or
health centre
Nominal
Categorical
Training on L.F
To attend a workshop
on L.F or VHF in
general
Nominal
Categorical
Location of the facility Urban or Rural Nominal Categorical
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3.6 Data Collection Methods and Instruments
All health providers who worked in any unit of each of the selected hospitals were
approached by the researcher. Researcher explained into detail, the study to be conducted
to get their approval to become participants. Only those who signed the consent form were
enrolled into the study. Interviews based on structured questionnaires were conducted by
the researcher with the respondents on one on one basis. The researcher was the one who
was allowed to fill the questionnaires. The questionnaire had four sections: the first part
collected data on individual factors and demography which influenced KAP; the second
section collected data on knowledge regarding LF; the third part elicited data on attitudes
of HCWs towards LF suspected or confirmed case; and the fourth part sought to find out
respondents’ practices on of prevention and control measures of infection. In this study,
the total score was divided into three levels for knowledge: respondents who had never
heard about LF were considered as having No knowledge (score = 0%); Poor knowledge
(score ≤ 50%) and Good knowledge (score > 50%). For attitudes and practices the total
score was divided into two levels: Bad attitudes and bad practices (score ≤ 50%); Good
attitudes and good practices (score > 50%).
3.7 Data analysis
Pre-coded data were entered into excel, cleaned and subsequently imported into Stata
(version15.1) Software for statistical analysis. Frequency distribution was done to compute
proportions on good KAP, gender, religion, educational level, and occupation. Mean age
and Mean of number of years of work and their respective standard deviations were
computed. Tests of significance on socio-demographic factors that influence knowledge
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and attitudes of HCWs was done using Chi Square, with statistical significance was set at
p-values ≤ 0.05. Multiple logistic regression analysis was used to assess the strength of
association between the knowledge and attitudes and each independent variable. This was
done by first running a bivariate analysis between knowledge and attitudes and all the
independent variables (Age, Gender, marital status, Occupation, type of facility unit of
word, location of facility, donation from MOH, Availability of PPE, training on LF,
training on VHF). Independent variables with p-values ≤ 0.05 in bivariate analysis were
fitted in the final multiple logistic regression model to assess the strength of association
looking at the adjusted Odds Ratio (AOR) with 95% confidence interval (CI).
3.8 Ethical consideration
Approval of the study was obtained from Guinea Health Service Ethical Review
Committee (GHS- N: 066/CNERS/18). After this, permission was asked for from the
hospital authorities of the health facilities before data were collected. Similarly, each
respondent was asked to express consent prior to participation. Also, before participating
to the interview, each respondent was given a consent form to read and sign. Thumbprints
of those accepted to be part of the study were taken. All respondents were given assurance
that the information they provided was strictly going to be used purely for academic
purposes and nothing else and they were assured of confidentiality. Respondents were
assured that the research that come to them at any risk or cost except their precious time
that they will use to answer the questionnaire. Privacy was ensured during the data
collection since some TB patients may also be HIV patients. Questionnaires were given on
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a one on one basis. Respondents were given the liberty to choose a place of convenience
to answer the questionnaires.
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CHAPTER FOUR
4.0 RESULTS
4.1 Socio-demographic characteristics of respondents
The results in table 4.1 below shows the socio-demographic characteristics of respondents.
The mean age of health workers was 30.4 years ± 7.7SD. The mean number of working
years of the health professional was 4.9 years ± 5.2 SD. Females were in the majority 57.4%
(112/195). Most of the health workers were married making up 64.6% (126/195) of
respondents. Muslims were the majority 80.5% (157/195). There were seventeen doctors
(8.7%), thirty-two nurses (16.4%), fifteen laboratory technologists (7.7%) and twelve
midwives (6.2%) thirty eight student professionals and other health professionals including
pharmacists, physician’s assistants, and nurse assistants constituted 41.5% of respondents
(81/195).
Table 4.1a: Socio-demographic characteristics of respondents (n=195)
Variables Frequency Percent (%)
Mean Age ± SD 30.4 ± 7.7years
Mean Number of years working ± SD 4.9 ± 5.2 years
Sex
male 83 42.6
Female 112 57.4
Marital status
Single 61 31.3
Married 126 64.6
Divorced 4 2.1
Widowed 2 1.0
co-habiting 2 1.0
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Table 4.1b: Socio-demographic characteristics of respondents (n=195)
4.2 Proportion of health care professionals who have good knowledge on LF
Sixty three (32.3%) out of the 195 respondents had no idea what Lassa fever was. Of the
remaining one hundred and thirty two, 67.7% (132/195) who had heard about Lassa fever,
their knowledge was accessed with a sixteen item questionnaire on knowledge according
to case definition. 48.5 % (64/132) had good knowledge about Lassa fever (p = 0.485; 95%
CI = 0.4 – 0.6) as shown in figure 5.
Variables Frequency Percent (%)
Religion
Muslim 157 80.5
Christian 38 19.5
Occupation
medical doctor 17 8.7
Nurse 32 16.4
laboratory technologist 15 7.7
Midwife 12 6.2
Student 38 19.5
Other 81 41.5
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Figure 5: Proportion of health care workers who have good knowledge about Lassa
fever
4.3 Proportion of health care professionals with good attitude and practice
In figure 6 below, Ninety five out of a hundred health professionals (186/195) were found
to have good attitude towards a suspected case of Lassa fever (p = 0.95; 95% CI = 0.91 –
0.97).
With regards to practice, all health professionals (100%) had good practices in dealing with
a suspicious case of Lassa fever.
51.5%48.5%poor knowledge
good knowledge
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Figure 6: Proportion of health care workers with good attitude
4.4 Socio-demographic characteristics associated with knowledge
After running a bivariate analysis (chi square and simple logistic)and multiple logistic
regression to determine the association between socio-demographic characteristics and
knowledge as shown in table 5a and 5b, a number of factors showed significant association.
The mean age of health professionals who had good knowledge was significantly higher
than those with poor knowledge. In that, a one year increase in age significantly increased
the odds of having good knowledge by 15% (cOR = 1.15; 95% CI = 1.08 – 1.22).
Marital status was significantly associated with knowledge of LF amongst health
professionals. Married health professionals had 3.6 times the odds of good knowledge on
LF compared to health professionals who were single (cOR = 3.6; 95% CI = 1.7 – 7.9).
4.6%
95.4%
poor attitude
good attitude
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This association was still significant after adjusting for other variables (aOR = 4.2; 95% CI
= 1.3 – 13.5).
Occupation was significantly associated with knowledge from a chi square test (p < 0.001).
Nurses (cOR = 0.08; 95% CI = 0.009 – 0.7), laboratory technologist (cOR = 0.06; 95% CI
= 0.005 – 0.6), student professionals (cOR = 0.03; 95% CI = 0.003 – 0.3) had significantly
lower odds on good knowledge of LF as compared to medical doctors.
A one year increase in number of working years significantly increased the odds of
knowledge on LF by 20% (cOR = 1.2; 95% CI = 1.08 – 1.3).
Type of facility, whether general hospital or health centre were significantly associated
with knowledge on LF. Logistic regression showed that health professionals who were in
health centres had significantly 70% reduction of their odds of having good knowledge on
LF as compared to health professionals in general hospital (cOR = 0.3; 95% CI = 0.2 –
0.7). This association was still significant after adjusting their odds (cOR = 0.3; 95% CI =
0.1 – 0.9).
Training of health personnel on viral haemorrhage fever (VHF) was found to be
significantly associated with health professional’s knowledge on LF in a chi square test. (p
= 0.002). Health personnel’s who had received training had significantly higher odds of
good knowledge on Lassa fever (cOR = 3.1; 95% CI = 1.5 – 6.3).
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Table 5a: Factors associated with health care workers' knowledge about Lassa
Fever
Variables Knowledge X2 cOR(95% CI) aOR(95% CI)
good
knowledge
poor
knowledge p-value
Age (mean ± sd) 35.8 ± 8.4 28.4 ± 6.2 1.15 (1.08 - 1.22) 1.2 (1.01 - 1.4)
Sex 0.6
male 33(46.5) 38(53.5) Reference
Female 31(50.8) 30(49.2) 1.2 (0.6 - 2.4)
Marital status +0.001*
Single 14(29.8) 33(70.2) Reference
Married 48(60.8) 31(39.2) 3.6 (1.7 - 7.9) 4.2 (1.3 - 13.5)
Divorced 2(50.0) 2(50.0) 2.4 (0.3 - 18.4) 7.2 (0.3 - 163.7)
Widowed 0(0.0) 0(0.0) 1 1
co-habiting 0(0.0) 2(100.0) 1 1
Religion 0.5
Muslim 49(47.1) 55(52.9) Reference
Christian 15(53.6) 13(46.4) 1.3 (0.6 - 2.9)
Occupation <0.001*
medical doctor 15(93.8) 1(6.2) Reference
Nurse 14(53.9) 12(46.1) 0.08 (0.009 - 0.7) 1
laboratory
technologist 5(45.5) 6(54.5) 0.06 (0.005 - 0.6)
0.9 (0.007 -
101.1)
Midwife 10(83.3) 2(16.7) 0.3 (0.03 - 4.2) 1
Student 7(31.8) 15(68.2) 0.03 (0.003 - 0.3) 1
Other 13(28.9) 32(71.1) 0.03 (0.003 - 0.2) 1
Number of years
working (mean
sd) 7.6 ± 5.7 4.2 ± 3.7 1.2 (1.08 - 1.3) 1.0 (0.8 - 1.3)
Location of
facility 0.5
Urban 55(47.4) 61(52.6) Reference
Rural 9(56.3) 7(43.8) 1.4 (0.5 - 4.1)
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Table 5b: Factors associated with health care workers' knowledge about Lassa Fever
Variables Knowledge X2 cOR(95% CI) aOR(95% CI)
good
knowledge
poor
knowledge p-value
Type of facility 0.003*
general hospital 42 (60.9) 27(39.1) Reference
health centre 22(34.9) 41(65.1) 0.3 (0.2 - 0.7) 0.3 (0.1 - 0.9)
Unit of work 0.3
internal medicine 19(43.2) 25(56.8) Reference
Surgery 7(36.8) 12(63.2) 0.8 (0.3 - 2.3) 0.8 (0.2 - 4.4)
laboratory 6(54.6) 5(45.5) 1.6 (0.4 - 5.9) 1
maternity 16(66.7) 8(33.3) 2.6 (0.9 - 7.4) 4.5 (0.7 - 29.4)
Other 16(47.1) 18(52.9) 1.2 (0.5 - 2.9) 2.9 (0.7 - 12.8)
Availability of
PPE 0.3+
always available 63(49.6) 64(50.4) Reference
not always
available 1(20.0) 4(80.0) 0.3 (0.03 - 2.3) 0.09 (0.003 - 2.9)
Trained LF
personnel 0.2+
No 58(46.8) 66(53.2) Reference
Yes 6(75.0) 2(25.0) 3.4 (0.7 - 17.6)
Trained VHF
personnel 0.002*
No 18(32.7) 37(67.3) Reference
Yes 46(59.7) 31(40.3) 3.1 (1.5 - 6.3) 1.8 (0.5 - 6.3)
*statistically significant (p<0.05) + Fisher’s exact
4.5 Factors associated with health professionals’ attitude towards LF’s suspected
case
None of the socio-demographic factors were found to be significantly associated with
health professionals’ attitude on Lassa fever. However, health workers in rural facilities
were found to be 80% reduction in their odds of having good attitude towards a suspected
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case of Lassa fever as compared to health workers in urban facility (cOR = 0.2; 95% CI =
0.04 – 0.6). After adjusting for other variables, rural health workers had 94% significant
reduction in their odds of having good attitude towards suspected case of lassa fever (aOR
= 0.06; 95% CI = 0.01 – 0.4)
Non availability of PPE’s sometimes in facilities significantly reduced the odds of health
professionals having good attitude towards a suspected case of lassa fever (cOR = 0.2; 95%
CI= 0.03 – 0.7). After adjusting for other variables, this association was still significant
(aOR = 0.06; 95% CI = 0.01 – 0.4). These results are shown in table 6a and 6b below.
Table 6a: Factors associated with health care workers' attitude towards LF's
suspected case
Variables Attitude COR(95% CI) AOR(95% CI)
Good attitude
n = 186
Poor attitude
n = 9
Age 0.9 (0.9 - 1.02)
Sex
male 77(92.8) 6(7.2) Reference
Female 109(97.3) 3(2.7) 2.8 (0.7 - 11.7)
Marital status
Single 57(93.4) 4(6.6) Reference
Married 121(96.0) 5(4.0) 1.7 (0.4 - 6.6)
Divorced 4(100.0) 0(0.0) 1
widowed 2(100.0) 0(0.0) 1
co-habiting 2(100.0) 0(0.0) 1
Religion
Muslim 150(95.5) 7(4.5) Reference
Christian 36(94.7) 2(5.3) 0.8 (0.2 - 4.2)
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Table 6b: Factors associated with health care workers' attitude towards LF's suspected case
Variables Attitude COR(95% CI) AOR(95% CI)
Good attitude
n = 186
Poor attitude
n = 9
Occupation
medical doctor 17(0.0) 0(0.0) 1
Nurse 30(93.8) 2(6.3) 1.2 (0.2 - 6.3)
laboratory technologist 14(93.3) 1(6.7) 1.1 (0.1 - 10.0)
Midwife 12(100.0) 0(0.0) 1
Student 38(100.0) 0(0.0) 1
Other 75(92.6) 6(7.4) 1
Number of years
working 1.0 (0.9 - 1.2)
Location of facility
Urban 166(97.1) 5(2.9) Reference Reference
Rural 20(83.3) 4(16.7) 0.2 (0.04 - 0.6) 0.06 (0.01 - 0.4)
Type of facility
general hospital 90(96.8) 3(3.3) Reference
health centre 96(94.1) 6(5.9) 0.5 (0.1 - 2.2)
Unit of work
internal medicine 64(97.0) 2(3.0) Reference
surgery 25(100.0) 0(0.0) 1
laboratory 16(94.1) 1(5.9) 0.5 (0.04 - 5.9)
maternity 36(100.0) 0(0.0) 1
other 45(88.2) 6(11.8) 0.2 (0.04 - 1.2)
Availability of PPE
always available 173(96.7) 6(3.3) Reference Reference
not always available 13(81.3) 3(18.7) 0.2 (0.03 - 0.7) 0.06 ( 0.01 - 0.4)
Trained LF personnel
no 178(95.2) 9(4.8) Reference
yes 8(100.0) 0(0.0) 1
Trained VHF personnel
no 99(96.1) 4(3.9) Reference
yes 87(94.6) 5(5.4) 0.7 (0.2 - 2.7)
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CHAPTER FIVE
5.0 DISCUSSION
Lassa fever is a disease of public health importance because it has the ability to cause
significant mortality and morbidity within the community, especially when outbreaks
occur, and also due to ability to spread in no time. It is therefore essential that health
workers in endemic communities such Faranah are conversant with the disease, its
manifestations, management and prevention. Maintaining a high alertness is dependent on
adequate knowledge of the disease. Patient counselling and community campaigns should
only be carried out by health workers who are adequately knowledgeable on the disease.
The greater ratio of female to male workers is an indication differential role of gender in
the health profession in Guinea, where females are more likely belong to health professions
such as nurses, auxiliaries and orderlies than males.
In this study, 32.3%, (63/195) had no idea what LF was. Of the remaining one hundred and
thirty two, 67.7% (132/195) who had heard about Lassa fever, their knowledge was
assessed with a sixteen-item questionnaire on knowledge according to case definition. 48.5
% (64/132) had good knowledge about Lassa fever (p = 0.5%; 95% CI = 0.4 – 0.6). In
another study conducted by Ea et al., (2013), less than 20% of primary care health workers
assessed, were knowledgeable of the disease, though 97% had heard of the disease. This
sharp deficit between the number of professionals who are aware of a disease and those
having in-depth knowledge is common phenomenon among health workers, which makes
it paramount that attention should not just be on creating awareness of the disease, but
ensuring that capacity building equips the health workers’ knowledge to effectively educate
to others. A study conducted to assess knowledge of Crimean-Congo fever, another
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haemorrhagic fever like Lassa fever, among health professionals in Iran found a similar
outcome, with nearly 94% having an idea of the disease, with just about 50% having good
knowledge of the disease (Rahnarardi et al., 2008). In terms of proportions, a similar trend
has been reported by Kakade (2012) and Kongsap (2006). In contrast, over 68% of 144
primary health workers in Turkey were found to have good knowledge of Dengue
(Hidiroglu et al., 2012) and Primary care Physicians in Singapore were found to have
adequate knowledge of Dengue fever (Lee et al., 2011). The apparent higher levels of
knowledge in the latter studies may be due to the greater attention given those disease, both
by the governments of those countries and by the academia. Lassa fever in Guinea is yet to
gain the needed political commitment it deserves by government and this should be given
a major attention if even at the local government as far as Faranah District is concern. This
is because Faranah is a border town with Sierra-Leone, the second most endemic country
in West Africa after Nigeria.
In this study, all respondents were found in this study to have good practice on Prevention
and control of infections. This finding is expected due to the numerous training and
experience gathered by all professionals during the Ebola Epidemic in 2014-2016.
Prevention and control of infection programmes were organized periodically to equip
health professionals in Guinea as part of the control mechanisms to effectively deal with
the Ebola Scare at the time.
In this study, all the health professionals new the indication for using hand gloves. Gloves
for personal protection by majority of health workers was reported by Ea et al., (2013), a
similar study. Among nursing and midwifery students, in a study carried out in
Kahramanmares, Turkey (Ozeer et al., 2011) and among health workers in Iran (Rahnarardi
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et al., 2008) similar reports on the use of hand gloves were made, and higher than was
reported in a study carried out among healthcare personnel in Balochistan (Sheikh et al.,
2004). While the hand glove is an essential component of the PPE, Standard personal
protective gear for any viral haemorrhagic fever management should include a scrub suit,
gown, apron, rubber boots, head covering, mask, eyewear, and two pairs of gloves (World
Health Organisation, 1998). All respondents, in this study, correctly selected all the above
personal protective gears as part of the component of PPE. In other studies, it was stated
that low mention other PPE might be as a result of their unavailability in the facility
(Borchert et al., 2007; Hewlett and Hewlett, 2005) and ignorance as to the significance of
the protective gear in the prevention of infection. Fortunately, that was not the case in this
study which is suggestive of availability and no ignorance of the protective gear in health
facilities in Faranah possibly due to the effective training received by the health
professional during the 2014-2016 Ebola epidemic.
In this study, socio-demographic factors found to be associated with knowledge on LF were
age, marital status, and occupation of respondents. A one year increase in age increased the
odds of having good knowledge on LF significantly. Married workers had higher odds of
having good knowledge. This findings are suggestive of the fact that older health workers
may have longer years of work experience hence their increased knowledge on the disease.
Number of working years was significantly associated with Knowledge just as occupation
in the bivariate analysis. Better knowledge was observed among doctors, since other
professions such as nurses, laboratory technologist, student professionals and other health
workers had significantly lower odd of good knowledge on LF. Similar has been reported
in other studies ( Hidiroglu et al., 2012; Ho et al. 2013; Lakhani et al., 2003; Rahnarardi et
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al, 2008; Sheihk et al., 2004) Doctors are the leaders of the health team, with higher levels
of training and exposure. It is not surprising then that they would exhibit better knowledge.
While some may argue that it may not be necessary for other professional such as orderlies
to have much information as they are not involved in making clinical decision, this claim
may be refuted on the ground that improving their knowledge makes agents of education
on LF in their communities. This finding is in contrast with what Ea et al., (2013) reported.
They reported that Knowledge was not significantly different across the various
professions.
Type of facility, whether general hospital or health centre were significantly associated
with knowledge on Lassa fever. Health professionals who were in health centres had
significantly 70% reduction of their odds of having good knowledge on LF as compared to
health professionals in general hospital. The General hospital is in the urban area of
Faranah district and have more exposure to training programs and receives more
equipment. It serves as the main referral hospital to the other health centres within the
district and is therefore expected to have higher standards.
Training of health personnel on viral haemorrhagic fever (VHF) was found to be
significantly associated with health professional’s knowledge on Lassa fever. HCWs who
had received training had significantly higher odds of good knowledge on LF. Although
failed to remain significant after adjusting for other variables, this finding gives a policy
direction to emphasise training as an approach specifically on LF and other haemorrhagic
fevers to help improve health workers knowledge.
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None of the socio-demographic factors were found to be significantly associated with
health professionals’ attitude on LF.
However, health workers in rural facilities were found to have 80% significant reduction
in their odds of having good attitude towards a suspected case of LF as compared to health
workers in urban facility.
Non availability of PPE’s sometimes in facilities significantly reduced the odds of health
professionals having good attitude towards a suspected case of LF.
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CHAPTER SIX
6.0 CONCLUSION AND RECOMMENDATION
6.1 Conclusion
The mean age of health workers was 30.4 years. The mean number of working years of the
health professional was 4.9 years. Females were in the majority. Most of the health workers
were married. Muslims formed the majority of health professionals. There were 17 doctors
32 nurses, 15 laboratory technologists, 12 midwives, 32 student professionals and 81 other
health professionals including pharmacists, physician’s assistants, and nurse assistants and
auxiliary workers.
Sixty three out of the one hundred and ninety five respondents (32.3%) had no idea what
Lassa fever was. Of the remaining one hundred and thirty two, 67.7% (132/195) who had
heard about Lassa fever, their knowledge was assessed with a sixteen item questionnaire
on knowledge according to case definition. 48.5 % had good knowledge (scored ≥8 out of
16) about Lassa fever (p = 50%; 95% CI = 40% – 60%).
Ninety five out of 100 health professionals were found to have good attitude towards a
suspected case of Lassa fever (p = 95%; 95% CI = 91% – 97%).
With regards to practice, all health professionals (100%) had good practices in Prevention
and control of infections.
Socio-demographic factors found to be associated with knowledge on LF were age, marital
status, occupation, number of working years
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The mean age of health professionals who had good knowledge was significantly higher
than those with poor knowledge. In that, a unit increase in age significantly increased the
odds of having good knowledge
Marital status was significantly associated with knowledge of Lassa fever amongst health
professionals. Married health professionals had 3.6 times the odds of good knowledge on
Lassa fever compared to health professionals who were single. This association was still
significant after adjusting for other variables. A unit increase in number of working years
significantly increased the odds of good knowledge on LF by 20%. Type of facility,
whether general hospital or health centre were significantly associated with knowledge on
LF. Health professionals who were in health centres had significantly 70% reduction of
their odds of having good knowledge on LF as compared to health professionals in general
hospital.
None of the socio-demographic factors were found to be significantly associated with
health professionals’ attitude on Lassa fever.
However, health workers in rural facilities were found to be 80% significant reduction in
their odds of having good attitude towards a suspected case of LF as compared to health
workers in urban facility Non availability of PPE’s sometimes in facilities significantly
reduced the odds of health professionals having good attitude towards a suspected case of
LF.
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6.2 Recommendations
• Ministry of Health (MOH), Guinea should plan more training on LF with emphasis
on other professionals as much as medical doctors.
• The MOH should provide adequate supply of PPE for both urban and rural health
facilities to assure there are no shortages at the facilities
• The district health management team should provide health promotion strategies
programs on LF in rural areas with emphasis on the strategy of strengthening
community action to ensure positive KAP towards LF not only in the facility nit
also within the communities.
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REFERENCES
Ajayi, N. A., Ukwaja, K. N., Ifebunandu, N. A., Nnabu, R., Onwe, F. I., & Asogun, D. A.
(2014). Lassa fever ??? Full recovery without Ribavarin treatment: A case report.
African Health Sciences, 14(4), 1074–1077. https://doi.org/10.4314/ahs.v14i4.40
Akhuemokhan, O. C., Ewah-Odiase, R. O., Akpede, N., Ehimuan, J., Adomeh, D. I.,
Odia, I., … Akpede, G. O. (2017). Prevalence of Lassa Virus Disease (LVD) in
Nigerian children with fever or fever and convulsions in an endemic area. PLoS
Neglected Tropical Diseases, 11(7), 1–17.
https://doi.org/10.1371/journal.pntd.0005711
Andersen, K. G., Shapiro, B. J., Matranga, C. B., Christian, T., Garry, R. F., Sabeti, P. C.,
… Broodie, N. (2015). Clinical Sequencing Uncovers Origins and Evolution of
Lassa Virus Clinical Sequencing Uncovers Origins. Elsevier Inc., 162(13), 738–750.
https://doi.org/10.1016/j.cell.2015.07.020
Anderson. (2015). Clinical sequencing uncovers origins and evolution of Lassa virus,
162(4), 738–750. https://doi.org/10.1016/j.cell.2015.07.020.Clinical
Bausch, D. G., Hadi, C. M., Khan, S. H., & Lertora, J. J. L. (2010). Review of the
Literature and Proposed Guidelines for the Use of Oral Ribavirin as Postexposure
Prophylaxis for Lassa Fever. Clinical Infectious Diseases, 51(12), 1435–1441.
https://doi.org/10.1086/657315
Boisen, M. L., Schieffelin, J. S., Goba, A., Oottamasathien, D., Jones, A. B., Shaffer, J.
G., … Khan, S. H. (2015). Multiple Circulating Infections Can Mimic the Early
Stages of Viral Hemorrhagic Fevers and Possible Human Exposure to Filoviruses in
Sierra Leone Prior to the 2014 Outbreak. Viral Immunology, 28(1), 19–31.
University of Ghana http://ugspace.ug.edu.gh
53
https://doi.org/10.1089/vim.2014.0108
Branco, L. M., Grove, J. N., Boisen, M. L., Shaffer, J. G., Goba, A., Fullah, M., … Garry,
R. F. (2011). Emerging trends in Lassa fever: Redefining the role of
immunoglobulin M and inflammation in diagnosing acute infection. Virology
Journal, 8(1), 478. https://doi.org/10.1186/1743-422X-8-478
Ea, T., Da, A., Ec, I., Og, U., & Ebhodaghe, P. (2013). Assessment of knowledge and
attitude towards Lassa fever among Primary care providers in an endemic suburban
community of Edo state : implications for control. Journal of Medecine and Medical
Sciences, 4(8), 311–318.
Ekaete Alice, T., Akhere, A. D., Ikponwonsa, O., & Grace, E. (2013). Knowledge and
practice of infection control among health workers in a tertiary hospital in Edo state,
Nigeria. Direct Research Journal of Health and Pharmacology (DRJHP), 1(2), 20–
27. Retrieved from
http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.407.5493&rep=rep1&typ
e=pdf
Fichet-Calvet, E. (2013). Lassa Fever: A rodent-human interaction. The Role of Animals
in Emerging Viral Diseases. Elsevier. https://doi.org/10.1016/B978-0-12-405191-
1.00005-3
Fichet-calvet, E., & Becker-ziaja, B. (2014). Lassa Serology in Natural Populations of
Rodents, 14(9), 665–674. https://doi.org/10.1089/vbz.2013.1484
Fichet-calvet, E., Lecompte, E., Koivogui, L., Soropogui, B., Doré, A., Kourouma, F., …
Meulen, J. A. N. T. E. R. (2007). Fluctuation of Abundance and Lassa Virus
Prevalence in. VECTOR-BORNE AND ZOONOTIC DISEASES, 7(2), 119–128.
University of Ghana http://ugspace.ug.edu.gh
54
https://doi.org/10.1089/vbz.2006.0520
Fichet-calvet, E., Lecompte, E., Veyrunes, F., Barrière, P., Nicolas, V., & Koulémou, K.
(2009). Diversity and dynamics in a community of small mammals in coastal
Guinea , West Africa, 139(February 2005), 93–102.
Gibb, R., Moses, L. M., Redding, D. W., & Jones, K. E. (2017). Understanding the
cryptic nature of Lassa fever in West Africa. Pathogens and Global Health, 111(6),
276–288. https://doi.org/10.1080/20477724.2017.1369643
Gilsdorf, A., Morgan, D., & Leitmeyer, K. (2012). Guidance for contact tracing of cases
of Lassa fever, Ebola or Marburg haemorrhagic fever on an airplane: Results of a
European expert consultation. BMC Public Health, 12(1), 1.
https://doi.org/10.1186/1471-2458-12-1014
Grant, D. S., Khan, H., Schieffelin, J., & Bausch, D. G. (2014). Lassa Fever. Emerging
Infectious Diseases. Elsevier Inc. https://doi.org/10.1016/B978-0-12-416975-
3.00004-2
Idemyor, V. (2010). Lassa Virus Infection in Nigeria: Clinical Perspective Overview.
Journal of the National Medical Association, 102(12), 1243–1246.
https://doi.org/10.1016/S0027-9684(15)30780-X
Khan, S. H., Goba, A., Chu, M., Roth, C., Healing, T., Marx, A., … Bausch, D. G.
(2008). New opportunities for field research on the pathogenesis and treatment of
Lassa fever. Antiviral Research, 78(1), 103–115.
https://doi.org/10.1016/j.antiviral.2007.11.003
Klempa, B., Koulemou, K., Auste, B., Emmerich, P., Thomé-Bolduan, C., Günther, S.,
… Fichet-Calvet, E. (2013). Seroepidemiological study reveals regional co-
University of Ghana http://ugspace.ug.edu.gh
55
occurrence of Lassa- and Hantavirus antibodies in Upper Guinea, West Africa.
Tropical Medicine and International Health, 18(3), 366–371.
https://doi.org/10.1111/tmi.12045
Lavergne, A., Thoisy, B. De, Tirera, S., Donato, D., Bouchier, C., Catze, F., & Lacoste,
V. (2016). Infection , Genetics and Evolution Identi fi cation of lymphocytic
choriomeningitis mammarenavirus in house mouse ( Mus musculus , Rodentia ) in
French Guiana. ELSEVIER, 37, 225–230.
https://doi.org/10.1016/j.meegid.2015.11.023
Lo Iacono, G., Cunningham, A. A., Fichet-Calvet, E., Garry, R. F., Grant, D. S., Khan, S.
H., … Wood, J. L. N. (2015). Using Modelling to Disentangle the Relative
Contributions of Zoonotic and Anthroponotic Transmission: The Case of Lassa
Fever. PLoS Neglected Tropical Diseases, 9(1), 1–13.
https://doi.org/10.1371/journal.pntd.0003398
Lukashevich, I. S. (2012). Advanced vaccine candidates for Lassa Fever. Viruses, 4(11),
2514–2557. https://doi.org/10.3390/v4112514
Mariën, J., Kourouma, F., Magassouba, N., Leirs, H., & Fichet-Calvet, E. (2018).
Movement Patterns of Small Rodents in Lassa Fever-Endemic Villages in Guinea.
EcoHealth, 1–12. https://doi.org/10.1007/s10393-018-1331-8
Mccormick, J. B., Webb, P. A., Krebs, J. W., Johnson, K. M., Smith, E. S., The, S., …
Johnson, K. M. (2017). A Prospective Study of the Epidemiology and Ecology of
Lassa Fever Published by : Oxford University Press Stable URL :
http://www.jstor.org/stable/30105053 REFERENCES Linked references are
available on JSTOR for this article : You may need to log in to JS. OXFORD
University of Ghana http://ugspace.ug.edu.gh
56
JOURNAL, 155(3), 437–444.
Mylne, A. Q. N., Pigott, D. M., Longbottom, J., Shearer, F., Duda, K. A., Messina, J. P.,
… Hay, S. I. (2015). Mapping the zoonotic niche of Lassa fever in Africa.
Transactions of the Royal Society of Tropical Medicine and Hygiene, 109(8), 483–
492. https://doi.org/10.1093/trstmh/trv047
Ogbu, O. (2014). Viruses: Lassa Fever Virus. Encyclopedia of Food Safety, 2(l), 208–
213. https://doi.org/10.1016/B978-0-12-378612-8.00128-1
Ogoina, D. (2013). Lassa Fever : a Clinical and Epidemiological Review. Niger Delta
Journal of Medicine and Medical Research, 1(1), 1–10.
Olowookere, S. A., Adegbenro, C. A., Idowu, A., Omisore, A. G., Shabi, O. M., Ikem, U.
R., … Oderinde, I. F. (2017). Knowledge attitude and practices toward lassa fever
control and prevention among residents of Ile-ife, Southwest Nigeria. International
Quarterly of Community Health Education, 37(2), 107–112.
https://doi.org/10.1177/0272684X17701261
Olugasa, B. O., Dogba, J. B., Ogunro, B., Odigie, E. A., Nykoi, J., Ojo, J. F., … Fasunla,
A. J. (2014). The rubber plantation environment and Lassa fever epidemics in
Liberia, 2008-2012: A spatial regression. Spatial and Spatio-Temporal
Epidemiology, 11, 163–174. https://doi.org/10.1016/j.sste.2014.04.005
Raabe, V., & Koehler, J. (2017). Laboratory Diagnosis of Lassa Fever. Journal of
Clinical Microciology, 55(6), 1629–1637. https://doi.org/10.1128/JCM
Robinson, J. E., Hastie, K. M., Cross, R. W., Yenni, R. E., Elliott, D. H., Rouelle, J. A.,
… Garry, R. F. (2016). Most neutralizing human monoclonal antibodies target novel
epitopes requiring both Lassa virus glycoprotein subunits. Nature Communications,
University of Ghana http://ugspace.ug.edu.gh
57
7(10), 1–14. https://doi.org/10.1038/ncomms11544
Shaffer, J. G., Grant, D. S., Schieffelin, J. S., Boisen, M. L., Goba, A., Hartnett, J. N., …
Garry, R. F. (2014). Lassa Fever in Post-Conflict Sierra Leone. PLoS Neglected
Tropical Diseases, 8(3), 1–13. https://doi.org/10.1371/journal.pntd.0002748
Sogoba, N., Feldmann, H., & Safronetz, D. (2012). Lassa Fever in West Africa: Evidence
for an Expanded Region of Endemicity. Zoonoses and Public Health.
https://doi.org/10.1111/j.1863-2378.2012.01469.x
Sweileh, W. M. (2017). Global research trends of World Health Organization’s top eight
emerging pathogens. Globalization and Health, 13(1), 1–19.
https://doi.org/10.1186/s12992-017-0233-9
Yun, N. E., Poussard, A. L., Seregin, A. V., Walker, A. G., Smith, J. K., Aronson, J. F.,
… Paessler, S. (2012). Functional Interferon System Is Required for Clearance of
Lassa Virus. Journal of Virology, 86(6), 3389–3392.
https://doi.org/10.1128/JVI.06284-11
Yun, N. E., & Walker, D. H. (2012). Pathogenesis of lassa fever. Viruses.
https://doi.org/10.3390/v4102031
Yunusa, T., & Egenti, N. (2015). Understanding Lassa Fever Virus and Diversification of
the Rodent Vector in the Tropics. International Journal of Current Medical
Research, 4(6), 372–378. Retrieved from
http://wrpjournals.com/sites/default/files/issues-pdf/1155.pdf
Zapata, J. C., & Salvato, M. S. (2015). Genomic profiling of host responses to Lassa
virus: therapeutic potential from primate to man. Future Virology, 10(3), 233–256.
https://doi.org/10.2217/fvl.15.1
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a
APPENDICES
INFORMED CONSENT FORM
Title: ASSESSMENT OF KNOWLEDGE, ATTITUDES AND PRACTICES
AMONG HEALTH CARE WORKERS TOWORDS LASSA FEVER IN 5
HEALTH FACITIES OF FARANAH DISTRICT IN UPPER GUINEA
Principal Investigator: MORY CHERIF HAIDARA
Address: SCHOOL OF PUBLIC HEALTH
DEPARTMENT OF EPIDEMIOLOGY
AND DISEASE CONTROL
UNIVERSITY OF GHANA, LEGON
Contact: 0551896623/ [email protected]
My name is Mory Cherif Haidara. I am a graduate student of University of Ghana School
of Public Health undertaking a research on assessment of knowledge, attitudes and
practices among health care workers in 5 health facilities of Faranah district. The
study seeks to find out the level of knowledge, attitudes and practices of health care workers
on Lasa fever and which sociodemographic factors could influence them. Participants are
required to share their experiences on Lassa fever by responding to questions.
Personal information that will lead to identification of participants will not be included in
the questionnaire. Questionnaire clients will respond to will be anonymous (will not
bear names of participants) so you will not be identified. You are free to be part of the
study and decide to leave at any point you want. However, be assured that your privacy
and confidentiality will be respected. Be assured that the research come at no risk and no
cost except the precious time that they will used to fill the questionnaire. You can choose
a place of convenience to answer the questions.
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b
VOLUNTEER AGREEMENT
The above document describing the benefits, risks and procedures for the research title
“assessment of knowledge, attitudes and practices among health care workers in
health facilities of Faranah district” has been explained to me.
I have read all of the above, asked questions, received answers regarding participation
in this study, and am willing to give consent to participate in this study as a volunteer.
I certify that the nature and purpose in this research have been duly explained to
the above individual.
Date Name and Signature of Person Who Obtained Consent
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c
University of Ghana
School of Public Health
Department of Epidemiology and Disease Control
I am Mory Cherif Haidara. I am a Master of Public health (MPH) student at the Department
of Epidemiology and Disease Control, University of Ghana, Legon, conducting a study
entitled: Assessment of knowledge, attitudes and practices towards Lassa fever among
health care workers in 5 health faculties in Faranah prefecture in Guinea as part of the
requirement for the award of a Master of Public health (MPH) degree. I would be very
grateful if you could spare some few minutes to answer the questions below to the best of
your ability. Please be assures that your responses are completely confidential and would
be used solely for academic purposes. Your cooperation is fully appreciated. Thank you.
Please CIRCLE the appropriate answers or provide information where necessary or write
the figure of the correct answer in the followed column.
N°00…
QUESTIONS CODING CATEGORIES SKIP
TO
COD
ES
SECTION A: SOCIO-DEMOGRAPHIC CHARACTERISTICS
1 Sex Male…………………………..….1
Female……………………...……2
SEX
2 Age (State your last
birthday age in year)
……………………………………
AGE
3 Marital status
Single ……………………….…….1
Married……………….…………...2
Divorced ………………….……....3
Widowed …………………………4
Co-habiting……………………….5
MSTA
4 Religion
Muslim……………………………..1
Christian…………………………....2
Other……………………………….3
RLG
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5 Occupation
Medical doctor …..………….…..1
Nurse …………..………….…….2
Laboratory
technologist/Scientist….………...3
Midwife………………..…….…..4
Student………………………..…5
Other..............................................6
DSGT
6 How long have you been
working in this health
facility?
NOYW
Facility factors
7 Location of the facility Urban…………………………….1
Rural………….……………….....2
LOF
8 Type of facility General hospital………………...1
Health centre…………………....2
TOF
9
Unit of work
Internal medicine………………..1
Surgery………………………….2
Laboratory………………………3
Maternity………………………..4
Other…………………………….5
UOW
Intervention factors
10 Does your facility receive
PPE from the MoH or
NGOs as donations?
Yes..................................................1
Non.................................................2
DON
11 What can you say about
the Availability of PPE?
Always available………;………....1
Not always available………..…….2
AVAIL
12 Have you received a
training on LF?
Yes..................................................1
Non.................................................2
FART
13 Have you received a
training on viral
haemorrhagic fevers like
Ebola virus disease since
you have been working in
this facility?
Yes..................................................1
Non.................................................2
TRAN
Section B: Knowledge
14 Have you heard about
Lassa fever before?
Yes..................................................1
Non.................................................2
HALF
15 If yes by which mean? In school..........................................1
During your medical practices........2
By media.........................................3
IBWM
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Never................................................
4
16 Which type of disease is
Lassa fever?
Haemorrhagic fever........................1
Chronic disease..............................2
Do not know ..................................3
WTD
17 In which country the
LASV has been
discovered?
Nigeria............................................1
Congo (Zaïre)..................................2
Do not know...................................3
WCD
18 what is the causal agent
Bacterium…..……………………1
Virus………………….……….....2
Do not know ……………...……..3
DOCA
19 To which family LASV
belongs?
Arenaviridae ……………......…….1
Filoviridae……...............……........2
Do not know....................................3
WFB
20 What are the incubation
period of LF?
2 à 21 jours…......……………….1
2 à 10 jours………….………......2
Do not know.......…..……………3
IPLF
21 what is the natural host of
the causal agent
Rodent...........……………………1
Monkey ……...………………….2
Do not know ………...…………..3
HOST
Please check all correct answers
22 What are the pathways of
Lassa Fever
transmissions?
Mosquito bites already
contaminated□
Consumption of bush meat□
Direct contact with liquids
biological contamination without
appropriate protective material □;
Direct contact with
contaminated patient's clothing or
linen □;
Airway □;
Consuming infected food by rodent
urine and faeces □;
Consuming rodent’s meat □
Correct answer................................1
Wrong answer.................................2
Do not know....................................3
PLFT
23 Knowledge of LF
symptoms and signs:
Fever □; Diarrhea □;
Vomiting □; polyuria □; Asthenia □;
Skin rash □;
Palpitation □; Bleeding □; Dyspnea
□; agitation □;
Myalgia □; Headache □; Abdominal
LFSS
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pain □ ;
Constipation □; Slimming □;
clubbing □;
Nervousness □; Cramps □;
Dizziness □
Correct answer................................1
Wrong answer.................................2
Do not know...................................3
24 With what diseases do we
do differential diagnosis
of the LF?
Malaria□; Typhoid fever □;
EVD□; Marburg fever □; Yellow
fever □ ; Cholera □; Diabetes □;
Meningitis □;
Correct answer................................1
Wrong answer.................................2
Do not know...................................3
DDLF
25 What are the elements of
difference between
malaria and LF?
Brutal Fever □; Headache □; Fever
□; Haemorrhage □; Fatigue □;
Vomiting □; GE □; TDR □; TR-
PCR □;
Correct answer................................1
Wrong answer.................................2
Do not know...................................3
EOD
26 What are the tests to
make the positive
laboratory diagnosis of
the LF?
Virus culture □; ELISA □
IFA IgM □; IFA IgG □; PCR □
Correct answer................................1
Wrong answer.................................2
Do not know...................................3
PLD
27
Do you know the definition of LF suspicious case?
1= Yes □ 2 = No □
If yes say
it.........................................................................................
Correct answer........................................................................1
Wrong answer.........................................................................2
Do not know............................................................................3
DFSC
28
Do you know the definition of LF confirmed case?
1= Yes □ 2= No □
If yes say
it............................................................................................
Correct answer...........................................................................1
Wrong answer............................................................................2
Do not know..............................................................................3
DFCC1
Please check all correct answers
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g
SECTION C: Attitudes
32 Does LF is part of the
diseases under epidemic
surveillance in your
facility?
Yes………………………………1
No……………………………….2
DUES
33 Have you been involved
in a case management of
LF patient in the past?
Yes………………………………1
No……………………………….2
LFCM
34 Will you refuse to treat a
suspected LF patient with
adequate PPE in order to
protect yourself?
Yes…………………....……………1
No……………………....………….2
RTLF1
35 Will you refuse to treat a
suspected LF patient
without adequate PPE in
order to protect yourself?
Yes…………………....…...………1
No……………………....………….2
2 RTLF2
36 Would you like to get
more information about
LF?
Yes………………………....………1
No………….....……………....…….2
MINFO
Please check all correct answers
29 What are the preventive
measures?
Health education □
Adequate hand washing □
Use of dedicated equipment for each
patient □
Personal Protective equipment □
Isolation of confirmed case □
Rodent elimination □
Correct answer................................1
Wrong answer.................................2
Do not know....................................3
PRME
30
Is there a specific treatment against LF?
Yes………………………….……1
No………………………….…….2
Do not know..................................3
If yes which antiviral is used for the treatment?
Correct answer................................1
Wrong answer.................................2
DFDIA
31 Is there a vaccine to
prevent LF?
No……………………………….1
Yes………………………………2
Do not know..................................3
PSDIA
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37 If you have a suspicious
LF case which reaction
would you adopt?
Notify hospital authorities □;
Inform the head of your unit □;
Refer the patient to another unit or
hospital □; Treat the patient □;
Sack the patient □
Correct answer................................1
Wrong answer.................................2
Do not know....................................3
SLFC
SECTION D: Practices
38 What are the products
used for hand wash?
Water only □; Water + soap; 5% □;
chlorinated water; Alcoholic hydro □;
Gel; Chlorinated water at 0.05% □;
Alcohol at 90 ° □;
Correct answer................................1
Wrong answer.................................2
Do not know....................................3
PHW
39 What are the indications
of hand washing?
Before any direct contact with a
patient □;
Immediately after removing gloves □;
Before handling an invasive device □;
After touching any biological fluid □;
After touching any object in the
patient’s environment □;
After any direct contact with the
patient □;
Correct answer................................1
Wrong answer.................................2
Do not know.....................................3
INHW
40 What are the components
of personal protective
equipment PPE?
Face Shield □; Blouse □; Bonnet □;
Glove □; Flap □; Boots □;
Correct answer................................1
Wrong answer.................................2
CPPE
41 What are the indications
of gloves using?
Before touching a patient □;
Before hand washing □;
Before touching biological fluids □;
Before touching any object in the
patient’s environment □;
Correct asnswer................................1
Wrong answer.................................2
Do not know....................................3
INGU
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