Awareness of MERS-CoV among Staff Members of Prince Sultan Military Medical City in Riyadh, Saudi Arabia

Background The Middle East respiratory syndrome coronavirus (MERS-CoV) developed infections that caused serious epidemics. Special priority of awareness and prompt initiative involvement of health workers (HW) during such intensified health situation necessitated an assessment of their preparedness, appropriate attitudes and protective strategies for better efficiency modes and acceleration during emergency. Methods HW of Prince Sultan Military Medical city in Riyadh, Saudi Arabia were reviewed through specifically designed questionnaires to acquire the demanded data. It included clinical and demographic information about the viral diseases, associated signs and symptoms, transmission and protection, and attitudes about the MERS-CoV disease. Results The study was accomplished between August and November, 2017 and 477 participants of the medical city, successfully completed the study questionnaire (Appendix I). Females represented a majority and there was an indirectly proportional decrease with the increasing age. Gradual educational increase levels reflected dominance of the university degree holders. Jobs were dominated by nurses and non-Saudis were a majority whilst, the highly experienced, (>10 years) were a minority. A majority recognized the viral transmission methods, popular information sources of MERS-CoV and associated medical terms. Highest scores were observed in dealing with protective aids and recognizing symptoms of disease. High adherence to hand hygiene protocols and correct washing steps were recorded. Correct and high levels were observed in taking preventive measures and avoiding infection. Participants responded correctly to negative and wrong actions that patients should refrain from. High scores were observed in taking appreciable attitudes towards oneself and towards others. Conclusions Expatriates were majority and nurses were dominant which, necessitates Saudization of this sector. Ministry of health pamphlets and seminars were of less impact in invigilating HW, hence, more attention and efforts are demanded. HW were quite aware of the basic and emergent health policies during epidemic episodes of MERS-CoV.


Introduction
The coronavirus that causes acute respiratory infection in humans is known as the Middle East Respiratory Syndrome (MERS-CoV) and was discovered in 2012 [1].
Reports indicate that two-thirds of the infection that effect humans are not related to camels. Kharma and colleagues thus suggested that another species could act as an intermediary to human infection. Since fragments of the human MERS-CoV RNA sequence was isolated in a Taphozous bat [2], [3] they have since been suspected as a possible source of viral transmission to humans. However, the rare contact between humans and bats implies hypothetically that they are the least responsible for the human infection. For deeper investigation to find the role that bats play as MERS-CoV risk factor of viral transmission, more research is needed [4].
Human-to-human transmission is an increasingly public health concern since more than fifty percent of the confirmed secondary cases have been identified within hospitals and healthcare center boundaries [2]. Most of this coronavirus infections reported in Saudi Arabia were transmitted through human interactions within the health center boundaries, that might have been due to inadequate infection control within these areas [5].
Usually the incubation period of MERS-CoV after infection is within two weeks [6].
According to recommendations of the WHO and CDC, individuals who had visited the Middle East region within the previous 14 days should be screened for MERS-CoV [7]. In a hospital outbreak in September 2012, the first cases of pneumonia that were caused by the new coronavirus (MERS-CoV) were reported by the World Health Organization [8]. The reported symptoms in patients included fever, cough, shortness of breath and gastrointestinal symptoms, associated with a mortality rate of 65% [6]. Most patients infected with MERS-CoV show signs of pneumonia and ARDS, as well as acute kidney injury in some of the cases [9]. Whether the severity of MERS-CoV in patients depends on other conditions is still not clear [10]. One study in Saudi Arabia reported that an overwhelming majority of patients with MERS-CoV had underlying comorbidities [6]. Previous studies suggest that patients with diabetes, chronic lung diseases, renal failure, or immunocompromised are prone to greater risk of severe coronavirus onsets, however, there is little evidence to suggest that such underlying comorbidities contributed to disproportionate infection of MERS-CoV [8]. The WHO estimated the mortality rate of the coronavirus to be approximately 30% [2], [11]. Currently, the treatment is rather non-specific and there are no recommended antiviral agents [2]. Though, Nitazoxanide which is a broad-spectrum antiviral drug is being tested against influenza and other viral respiratory infections and it exhibited appreciable activity against MERS-CoV and other viruses by inhibiting their N protein expression [12], [13]. Since human-to-human transmission is said to occur in more than 60% of the total infections, mostly involving medical staffs, inpatients prone to and are at an increased risk of MERS-CoV infection. The WHO suggested that infection in healthcare settings were due to overcrowding and insufficient control measures [14]. Secondly, it would be necessary for the patients to avoid contact with camels or to eat properly cooked camel meat [15]. Sufficient knowledge of the etiology and prevention of the Middle East respiratory syndrome coronavirus among healthcare professionals is essential in combating the virus.
Significant improvement in patients administered with a combination of ribavirin and interferon alfa-2a was seen, in comparison with controls that received only supportive medical care [16]. However, further evaluation of the therapy regimen is required to enable the conclusive use of the therapy in the management of the disease.
Several preventive measures to control infections in healthcare settings, to expedite management of the disease is essential, such as developing of an emergency department visual triage scores for early detection of the MERS-CoV [17]. It has been shown that the use of triage for early detection of various types of disease had positive outcomes. Earlier studies had speculated this and suggested that it might play major roles in the early detection of this disease [18], [19]. People who are patients with diabetes, lung diseases, renal failure, or immunocompromised should avoid contact with camels or areas where camels are most likely to be found [5], [8]. In addition, the WHO recommends such patients to avoid undercooked camel meat, raw milk, and urine in addition to practicing proper hygiene.
Finally, screening for coronavirus at border points as well as the issuing travel advisories and human/ camel movement restrictions are recommended to avoid cross-border spreading and infection. Also, high levels of vigilance should be implied to prevent infection from persons returning from the middle east region [2].
This study aims at exploring the level of awareness about MERS-CoV among the Staff at Prince Sultan Military Medical City in Saudi Arabia. The knowledge generated from this study is

Research Design
This study is a cross-sectional Study that used a survey to assess the awareness level of MERS-CoV among staff members of Prince Sultan Military Medical city in Riyadh, Saudi Arabia. A structured questionnaire on the disease was prepared in both English and Arabic, based on a review of the literature and consultation with regional community health teams in Saudi Arabia.

Methods
The questionnaire was administered through the various departments in the health city and was distributed through manual approaches. The participants of this study were selected from the whole staff of the medical city, including all groups of staff workers. All participants in this manuscript has given written informed consent, approved by the IRB (Institutional Research Board and Research Ethics Committee) to publish this research study.A total of 570 responses were targeted to increase the reliability and validity of this study.

Statistical analysis
The data collected from the participants were entered into SPSS software (version 20) for analysis. A range of descriptive and inferential statistics were carried out to explore the awareness of the staff about MERS-CoV.

Results
There were 477 responders (with a response rate of 82.7%) of all participants who successfully completed the required information data required in this study questionnaire (Appendix I ). These data were collected and compiled in tables. Non-HW (8, 1.7%) and the least were Pharmacists (4, 0.8%), consecutively, with 3(0.6%) missing records.
The educational level reflected a gradual increase approaching higher learning degrees.

Discussion
The levels of awareness concerning MERS CoV has been assessed in staff workers of PSMMC, whose demographic profile reflected similar combinations and responses of the participants, compared with previous studies [23]. Ratios of different groups of HW characteristics like gender, jobs and educational levels reflected a gradual increase approaching higher learning degrees, with Bachelors as a majority, whilst fresh employees were a majority but, the most experienced (>10 years) were the least in number. This situation of demographic group counts order had been noticed before [23], [24].
With respect to information about the viral diseases, the participants' knowledge regarding basic terminologies like MERS-CoV and viral transmission, the majority got the right answer (Middle east respiratory syndrome). Whilst, the highest score recorded by participants, regarding their multiple choice answer about viral transmission of MERS was the unhygienic spread of coughing and sneezing droplets. Other methods of spread of this virus were also highly appreciated, as has been reported by previous studies [8].
The spreading of information about MERs-COV in society by HW was affirmed by the majority, whilst, spreading of information through internet/social and traditional medias like TV, radio and newspapers were of similar, second option. Ministry of health pamphlets and seminars were of less impact, a situation that demands more attention by the ministry of health in this field.
A majority of the participants stated that wearing a protective mask was one of the measurements to prevent getting infected by MERS-CoV in the waiting area. Whilst, the most effective method to deal with this situation was to avoid the patients until they recover. Other options were also found to be useful measurements with less variable grades. Investigators and other workers in this field found these measures also useful [25].
In evaluating knowledge about associated signs and symptoms of MERS-CoV infection, a majority of the participants chose 'Diarrhea' as an answer. On this point, the answer with such an appreciable majority, shouldn't be overlooked, without some attention. Diarrhea with fever was said to be one of the symptoms of MERS-CoV infection when people were immunocompromised or organ transplanted, a situation where these patients might not experience the usual route respiratory symptoms [26].
The participants got it quite right in dealing with their protective equipment and showing the right order of putting them on, whilst , they were also correct in taking them off. This reflects that participants were very careful in doing the routine steps before entering their duties in epidemics of seriously infected fields; they were also careful when they completed their jobs and abandoning these protective equipment [22].
Another challenge for these participants assessing their skills abilities in showing the proper way to wear an n-95 mask, specifically used during MERS-CoV infections. In dealing with this type of mask, they were correct in choosing the right steps, which reflects their seriousness and carefulness in entering infected zones, but, they were that quite careful in taking it off, as they put this choice as a second step. Whilst, Attention must be paid to this point, as it might reflect some unjustified hastiness practiced by professionals [20]. Also assessment of the participants reflected their high awareness of infection transmission and protection as precautionary steps for having good hand hygiene experience and practice during rush hours and epidemics. Majorly stating the right timing use reflects the strict adherence to hand hygiene which, is an essential and a basic practice and regime in health fields [20].
In choosing the correct steps in applying and practicing hand wash, the participants were able to get the highest scores which, meant that they understand and are well aware of correct and full hand wash, infection transmission and protection. Appropriate choices and proper practice preferences in medical and hygienic media and fully correct hand wash policy affirms and guarantees healthiness and safety [2], [27].
With respect to additional preventive methods to avoid getting infected with corona virus, they chose five ones with high records. They adhered to the basic rule of hand washing throughout the day, before and after every action whilst, they also preferred to avoid infected patients and their contaminated belongings, their own eyes, ears and nose and to eat fruits only after thoroughly washing them. It was important to mention to use proper compensatory methods to prevent cross infection when sneezing or coughing. Keeping always clean and avoiding sources of infection is always a hygienic routine that guarantees awareness and gratifies with success in health media [2].
Attitudes and actions evaluation of the participants towards themselves and towards others reflected high levels of awareness and knowledge. In certain cases of being sick, generally, people commit serious mistakes and decisions, even within the health field workers. Decision to stay at home with such obvious symptoms of, at least common colds, is a serious one. Also to have your prescription such as antipyretics over the counter and join work is not at all advisable.
It is a double hazard and a dangerous behavior, to the patient himself and to his colleagues at the same time. It is an appreciable level of knowledge and good practice that the participants responded correctly to these queries, whilst, few ones might have not understood the rest of queries correctly. With seriously infective viruses such as MERS-CoV, it is mostly crucial to get access to the right treatment and avoid spreading the virus in the vicinity [2].
During serious episodes of community viral infections like MERS-CoV, people should take precautionary steps and build good protective attitudes and actions, towards oneself and towards others in the community. It is quite convincing that participants in the health field have built good and correct awareness to take attitudes of taking lots of fluids, having healthy foods and taking sufficient and beneficial body rest.
Whilst, to help in cutting the vicious circuit of infective body contacts, it is always best attitude towards others to clean hands routinely, use disposable tissues to mask coughing and sneezing, and evade shaking hands. It is highly appreciated that participants in health media should stick to building and adhering to such attitudes [27].

Conclusions
The majority of the hospital staff was expatriates and the nursing group was the largest which, If you suspect that you are infected, choose the correct answer. You can choose more than one answer.

1.
Your action towards yourself should include Take antipyretics and pain killers. Take antibiotics. Drink lots of fluid. Rest enough. Eat healthy food.

2.
Your action towards others should include Wash your hands routinely. Use disposable tissues when coughing and sneezing. Avoid hand shaking. Not to share personal equipment like mobile phones. Recommend direct contacts to get medications against MERS---CoV when you are infected with it.