Evaluation of Knowledge, Attitude, and Practices toward the Outbreak Pandemic (COVID-19) Virus Disease among Ophthalmologists: A Cross-Sectional Study.

PURPOSE: The objective was to evaluate ophthalmologists' KAP toward the outbreak of the pandemic COVID-19 disease.
METHODS: This cross-sectional study was conducted during the period of the global outbreak of COVID-19, between April 8 and April 18, 2020. A sample of 120 ophthalmologists was chosen by a stratified method. The online survey was used to obtain information about respondents' KAP toward COVID-19.
RESULTS: The study participants included 120 ophthalmologists and ophthalmologists under training out of the targeted 163 ophthalmologists who were invited to participate, giving a response rate of 73.6%. Ophthalmology residents represent 40.8%, whereas consultants represent 32.5% of them. Nearly 40.8% of the participants were aged between 31 and 40 years. Overall, the percentage of COVID-19 knowledge score ranged between 56% and 100% with a median (interquartile range [IQR]) of 80% (76%-88%). Overall, the percentage score of attitude toward COVID-19 ranged between 13.3% and 100% with a median (IQR) of 73.3% (46.7%-88.0%). Although the safety precaution attitude toward COVID-19 was highest among ophthalmologists aged over 50 years, the difference did not reach a statistical significance. Other studied factors were not significantly associated with the score of percentage of attitude toward COVID-19.
CONCLUSION: KAP among ophthalmologists in the Kingdom of Saudi Arabia toward COVID-19 are optimal. However, health education campaigns are needed to reinforce the current KAP and improve the level of understanding of the risks and prevention measures that, in turn, improve the confidence of ophthalmologists to provide the right care to their patients and protect themselves as well. Copyright:

Introduction

Several coronaviruses can infect humans; the globally endemic human coronaviruses HCoV-229E, HCoV-NL63, and others tend to cause mild respiratory disease, and the zoonotic Middle East respiratory syndrome coronavirus and severe acute respiratory syndrome coronavirus type 1 and type 2 (SARS-CoV-1 and SARS-CoV-2 [coronavirus disease 2019 (COVID-19)]) have a high case fatality rate.[1] On December 31, 2019, the World Health Organization (WHO) was notified by China's authorities about the outbreak of pneumonia that had initially an unknown etiology in Wuhan city of the Hubei province.[2] Then, the causative organism was identified in January 2020 as a novel coronavirus (2019-nCOV).[3] The genetic sequences of at least 19 strains found in infected patients have been reported.[45] Initially, it was tentatively named 2019-nCoV, then the virus was named SARS-CoV-2 by the International Committee of Taxonomy of Viruses.[6] This virus can cause a disease named COVID-19. The WHO refers to the virus as COVID-19 virus, however the current documentation will use both SARS-CoV-2 and COVID-19. Within several weeks, the outbreak became an emergency event and many countries have been affected.[7]

Till date, it has already been confirmed that COVID-19 has affected more than 1,300,000 people with more than 70,000 deaths in the USA, and over 2,500,000 cases outside of the USA, spanning 215 countries across South East Asia, Europe, North America, Australia, the Middle East, etc.[8] The route of transmission of COVID-19 is not yet fully elucidated, but is thought to be mainly of respiratory. The novel coronavirus (COVID-19) has gained the capacity for sustained human-to-human transmission, which has already infected more than 82,000 people in China, and the numbers are still growing hour to hour, leading to a huge public health challenge.[910] It is even more overwhelming that many infected persons showed no apparent respiratory symptoms and present with nonrespiratory manifestations, including conjunctivitis in the ocular tissue[11] and diarrhea in the gastrointestinal system.[12] This variable presentation makes transmission possible to people coming into contact, and special health-care providers like ophthalmologists.

SARS-CoV-2 can spread through the mucous membrane of the eye via indirect contact with droplets. Health-care providers, particularly ophthalmologists, are at high risk of SARS-CoV-2 infection in the cases of unprotected eye contact with secretions such as during routine ophthalmic examinations using direct ophthalmoscopy and slit-lamp examinations that are usually performed in a setting that has close doctor–patient contact.[13] As a result of that, more than 1700 health-care professionals have been infected with 6 deaths, including one ophthalmologist.[1415] Xia et al. found that in 21 common types and 9 severe types of novel coronavirus pneumonia patients, samples of tear and conjunctival secretions were obtained from one patient with conjunctivitis, yielding positive reverse transcription-polymerase chain reaction results.

Hence, to conclude, we speculate that COVID-19 virus may be detected in the tears and conjunctival secretions of COVID-19 pneumonia patients with conjunctivitis.[16] There is also evidence that some coronaviruses can occasionally cause conjunctivitis in humans. In fact, human coronavirus NL 63 (HCoV-NL63) was first identified in a baby with bronchiolitis and conjunctivitis.[17] Subsequently, in 28 cases of children with confirmed HCoV-NL63 infections, 17% had conjunctivitis.[18]

From all the mentioned above, ophthalmologists can be the first contact with patients, so, we would like to assess their knowledge, attitude, and practices (KAP) toward this new pandemic outbreak, as globally concern grows among ophthalmologists about the nature of the disease, risk of transmission to ophthalmologists in practice, and the ophthalmologic clinics acting as a possible source of infection. To the best of our knowledge, this is the first study representing a COVID-19 virus disease KAP survey among ophthalmologists within the first 4 months of a prolonged pandemic that lasted till the moment of writing this article.

Methods

This study was conducted in the Kingdom of Saudi Arabia (KSA), in major cities including the capital city Riyadh, Jeddah, and Dammam, among others. The study was done after obtaining approval from the ethical board committee at University of Tabuk, College of Medicine (Approval No. READ 007).

This study included a stratified sample of either board-certified ophthalmologists or ophthalmology residents under training. Those who were accepted in the ophthalmology residency program, but had not yet started training and seeing patients, were excluded from the study. This was a descriptive, cross-sectional, and survey-based study. The survey covered demographic characteristics such as age, gender, and ophthalmological position. Multiple-choice and true–false questions were framed to obtain information about respondents' awareness regarding the (outbreak pandemic COVID-19 disease), including the nature of disease, causative organism, attitude, and common daily practice of protective measures. The questionnaire used to assess the COVID-19 KAP was formed by lessons learned from similar KAP studies on other communicable diseases, especially HIV/AIDS.[1920212223]

In suitable instances (e.g., for knowledge and stigma), we adapted the questionnaire and items from the Joint United Nations Programme on HIV/AIDS, in addition to further validation by three consultants (two in ophthalmology, one in community medicine, and one in infectious disease). Data were collected using a self-administered online survey, established electronically on Google Documents.[24] The study was anonymous, targeting ophthalmologists in practice, with entire voluntary participation. The link was distributed through social networks, media, and ophthalmologist WhatsApp groups in the KSA. The script was presented in English language for easy understanding and convenience of the study participants, as English is the main language at hospitals in the KSA. It took about 8–10 min to complete the questionnaire.

Sample size

The sample size was estimated using the online Raosoft sample size calculator (www.raosoft.com) with the following assumption:

The estimated prevalence of knowledge about COVID-19 among the participants as 50%, which gives the largest sample size if there is no previous study done

Margin of errors as 5%

Confidence level as 90%

The total target population size is 407 ophthalmologists in the KSA, and as no previous study was done before, we required a minimum sample size of 163 ophthalmologists, which represents 50% of the target population.

Statistical analysis

Knowledge about COVID-19 was assessed through 25 questions. Responses to the knowledge questions were computed and the total was used for comparison across groups. Attitude toward COVID-19 was assessed through nine questions, and scored in a way that the higher the score, the more positive the attitude toward dealing with the COVID-19 pandemic. The total scores and their percentage were computed for each participant, tested for normality, and utilized for comparisons. Because both the knowledge and attitude score percentages were abnormally distributed, as evidenced by significant Shapiro–Wilk test, nonparametric statistical tests were applied: Mann–Whitney test to compare the score percentage between two different groups and Kruskal–Wallis test to compare it between more than two different groups. Median, interquartile range (IQR), and mean ranks were used for description, and P < 0.05 was considered statistically significant. IBM Statistical Package for Social Sciences, Version 25 (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp), was used for data entry and statistical analysis.

Results

The study participants included 120 ophthalmologists and ophthalmologists under training out of the targeted 163 ophthalmologists who were invited to participate, giving a response rate of 73.6%. Table 1 summarizes their demographic characteristics. Ophthalmology residents under training represented 40.8%, whereas consultants represented 32.5% of the respondents. Most of the responders to the survey were staying in Riyadh (40.8%), followed by Jeddah (21.7%) and Dammam (15.8%). Almost two-thirds of them (67.5%) were male and 40.8% were aged between 31 and 40 years.

Table 1

Demographic characteristics of the participants (n=120)

Variables	Frequency (%)
Current position
Resident	49 (40.8)
Fellow	32 (26.7)
Consultant	39 (32.5)
Place of stay
Riyadh	49 (40.8)
Jeddah	26 (21.7)
Dammam	19 (15.8)
Abha	6 (5.0)
Madinah	6 (5.0)
Tabuk	10 (8.2)
Others	4 (3.3)
Gender
Female	39 (32.5)
Male	81 (67.5)
Age (years)
≤30	48 (40.0)
31- 40	49 (40.8)
41- 50	14 (11.7)
>50	9 (7.5)

Awareness and knowledge about coronavirus disease 2019

All ophthalmologists except one (99.2%) have heard about COVID-19, as demonstrated in Figure 1.

Figure 1

The percentage of Ophthalmologists heard about coronavirus disease 2019 in the Kingdom of Saudi Arabia during disease outbreak

All the respondents could recognize that COVID-19 originated from China, and majority of them could recognize that COVID-19 is a viral infection, thermal scanners can detect people who have high temperature regardless of the cause, there is no vaccine available yet for the new coronavirus (99.2%), COVID-19 can be asymptomatic (98.3%), it is possible to survive and recover from COVID-19 (97.5%), good respiratory hygiene is coughing or sneezing by covering the mouth and nose with bent elbows (96.7%), it is possible for someone to have COVID-19 and not show any signs or symptoms (95.8%), and antibiotics are not effective for the treatment of infected persons (95%). However, only 10.8% knew that 2–10 days are needed for someone to become sick after exposure, according to the WHO. Regarding symptoms, the most frequently recognized were fever (100%) and headache (89.2%), whereas the least frequently recognized were joint pain (45%) and nausea (38.3%). The other responses are demonstrated in Table 2.

Table 2

Responses of the ophthalmologists to knowledge questions about coronavirus disease 2019

Knowledge questions	Correct answers, n (%)
Do you think it is possible for someone to have COVID-19 and not show any signs or symptoms? (Yes)	115 (95.8)
Is it possible to survive and recover from COVID-19? (Yes)	117 (97.5)
What is the cause of COVID-19? (viral infection)	119 (99.2)
Which one of the following is the number to notify any suspected cases of COVID-19? (937)	107 (89.2)
In which of the following countries did COVID-19 originate? (China)	120 (100)
How does a person get COVID-19? (by inhalation of infected droplets	110 (91.7)
The symptoms of COVID-19 are specific? (No)	95 (79.2)
According to the WHO, how many days would it take for someone to become sick after being exposed? (2- 10 days)	13 (10.8)
COVID-19 can be asymptomatic? (Yes)	118 (98.3)
What are the symptoms and signs of COVID-19?
Fever (True)	120 (100)
Headache (True)	107 (89.2)
Muscle pain (True)	82 (68.3)
Joint pain (True)	54 (45.0)
Diarrhea (True)	64 (53.3)
Nausea (True)	46 (38.3)
Conjunctivitis (True)	111 (92.5)
Sore throat (True)	107 (89.2)
How severe is COVID-19? (fatal only for people at risk like DM, old people)	89 (74.2)
If a person with COVID-19 goes immediately to health facilities, will he/she reduce the chance of spreading the disease to others? (Yes)	79 (65.8)
According to the WHO, what is the minimal distance we should keep with others to decrease the risk of getting infection from someone who is coughing or sneezing? (1 m)	75 (62.5)
What is good respiratory hygiene? (when someone is coughing or sneezing, they should cover their mouth and nose with their bent elbows)	116 (96.7)
What is the benefit of using face masks? (standard surgical masks can help prevent infected people from spreading the virus further)	110 (91.7)
Can thermal scanners detect people infected with COVID-19? (they can detect people who have high temperature, regardless of the cause)	119 (99.2)
Is there any vaccine available for the new coronavirus? (No)	119 (99.2)
Are antibiotics effective for the treatment of infected persons? (No)	114 (95.0)

COVID-19: Coronavirus disease 2019, WHO: World Health Organization, DM: Diabetes mellitus

Overall, the percentage of COVID-19 knowledge score ranged between 56% and 100% with a median (IQR) of 80% (76%–88%), as shown in Figure 2.

Figure 2

Distribution of the percentage of coronavirus disease 2019 knowledge score among ophthalmologists in Saudi Arabia

Attitude toward coronavirus disease 2019

Majority of the ophthalmologists agreed with keeping the waiting room as empty as possible, reducing the visits of the most vulnerable patients, rescheduling nonurgent appointments (99.2%), regular cleaning and disinfection of the frequently touched objects and surfaces (93.3%), and making sure that all ophthalmic instruments including slit-lamps are cleaned and disinfected between patients (89.2%) Figure 3 summarized the distribution of the percentage score of the attitude toward coronavirus disease 2019 among ophthalmologists. However, only 27.5% of them would view someone who came back into their community/neighborhood after he/she recovered from COVID-19, and 52.5% believed that they need more information on COVID-19, a summary of other altitudinal behaviors is demonstrated in Table 3.

Figure 3

Distribution of the percentage score of the attitude toward coronavirus disease 2019 among ophthalmologists in Saudi Arabia

Table 3

Responses of the ophthalmologists to questions regarding attitude toward coronavirus disease 2019

Attitude questions	Frequency (%)
Would you go to a hospital or any health facility if you suspected that you have contracted COVID-19?
Yes	79 (65.9)
May be	13 (10.8)
No	28 (23.3)
As a daily practice during encounters with patients, do you ask if the patient has respiratory symptoms?
Yes	83 (69.2)
May be	9 (7.5)
No	28 (23.3)
As a daily practice during encounters with patients do you ask if your patient recently traveled internationally?
Yes	77 (64.2)
May be	12 (10.0)
No	31 (25.8)
As a daily practice during encounters with patients, do you ask if your patient’s international travel includes a recent trip to Iran, Italy, Japan, or South Korea, or if they have family members recently back from one of these countries?
Yes	68 (56.7)
May be	17 (14.1)
No	35 (29.2)
I regularly clean and disinfect frequently touched objects and surfaces.
Agree	112 (93.3)
Don’t know/disagree	8 (6.7)
I make sure all ophthalmic instruments including slit-lamps are cleaned and disinfected between patients
Agree	107 (89.2)
Don’t know/disagree	13 (10.8)
Do you agree in keeping the waiting room as empty as possible, reducing the visits of the most vulnerable patients, and rescheduling nonurgent appointments?
Agree	119 (99.2)
Don’t know/disagree	1 (0.8)
Would you interact with someone who came back into your community/neighborhood after he/she recovered from COVID-19?
Yes	33 (27.5)
May be	24 (20.0)
No	63 (52.5)
Do you need more information on COVID-19?
Yes	63 (52.5)
May be	32 (26.7)
No	25 (20.8)

COVID-19: Coronavirus disease 2019

Discussion

To the best of our knowledge, this is the first study designed to examine the KAP toward COVID-19 virus disease, among practicing ophthalmologists. Due to the sudden pandemic situation, together with concern about the nature of the disease, there are big discussions about the attitude and practice among ophthalmologists. In our study of a well-educated population of health professionals, we found that the COVID-19 knowledge score ranged between 56% and 100% with a median (IQR) of 80% (76%–88%), indicating that most respondents are at an acceptable level of knowledge about COVID-19.

Nair et al. reported that the majority of ophthalmologists in India were not seeing patients during the COVID-19 lockdown, although the reason for that was not mentioned, may be due to compliance with lockdown or lack of knowledge about the pandemic outbreak so preferred to close the clinics. Even more, 59.1% of the respondents felt that ophthalmologists were potentially at a higher risk of contracting COVID-19, compared to other specialties while examining patients.[25] That small survey suggested a lack of knowledge and variation in practice among ophthalmologists in India. It is worth mentioning that the study was done at the beginning of the outbreak, reflecting missing knowledge compared to our research done later.

In a recent publication, a study conducted in China among medical staff in Chinese psychiatric hospitals regarding COVID-19 knowledge and attitude claims that 89.51% of the medical staff of psychiatric hospitals that were studied had extensive knowledge of COVID-19, which is higher compared to our ophthalmologists' knowledge level, which can be explained by the aspect that the medical staff of the psychiatric study was done in China, which is considered to be the origin country of the outbreak.[26] However, in one study conducted in China that investigated the KAP of Chinese general population toward COVID-19 during the rapid course of the outbreak, an overall correct rate of 90% on the knowledge questionnaire was found, indicating that most respondents are knowledgeable about COVID-19, comparatively close to our sample knowledge level.[27]

Even more, another study which aimed to examine the KAP toward COVID-19 among Tanzania residents found that the participants had scores of above 8 out of a total of 12 points, which is considered as good knowledge of COVID-19.[28] In the present study, on multiple logistic regression analyses regarding the factors of COVID-19 knowledge such as age and gender, none of them were significantly associated with the percentage of COVID-19 knowledge score of Chinese general population, in which females are more knowledgeable about COVID-19.[27]

In our survey, it was found that variables such as inquiries about the country of origin, causative organism, the fact that usage of thermal scanners is unspecific to diagnose COVID-19 infection, and symptoms of COVID-19 reached a good level of knowledge. Interestingly, only 10.8% knew that 2–10 days is needed for someone to become sick after exposure. We depend on the WHO as a reference and this response was expected as different sources have been published with different incubation periods. The WHO reported an incubation period for COVID-19 between 2 and 10 days,[29] while China's National Health Commission had initially estimated an incubation period from 10 to 14 days,[30] and the United States' Centers for Disease Control and Prevention (CDC) estimates the incubation period for COVID-19 to be between 2 and 14 days.[31] Regarding symptoms, the most frequently recognized were fever (100%), headache (89.2%), and symptoms of sore throat which were recognized by almost 90% as possible symptoms of COVID-19, reflecting later as attitude as most ophthalmologists in this study asked the patients about possible symptoms of COVID-19 before entering the clinic. When ophthalmologists were asked about the official number to notify any suspected cases of COVID-19, only 89.2% answered correctly. The WHO's advice to maintain at least 1 m (3 feet) distance to decrease the risk of getting infection, is simple but critical information that was recognized only by 62.5% of the ophthalmologists in the study.[32] This may be explained by missing the correct information, overprotection that many ophthalmologists are trying to do by keeping more distance, or different sources such as the CDC advising 6 feet distance.[33] Another cost-effective and simple step in controlling most infectious respiratory diseases is good respiratory hygiene. Not surprisingly, almost all ophthalmologists in our sample, except one, had heard about COVID-19, reflecting effective public announcements regarding the COVID-19 outbreak and good awareness.

On the other hand, regarding safety attitudinal behavior, the overall percentage score of the attitude toward COVID-19 ranged between 13.3% and 100% with a median (IQR) of 73.3% (46.7%–88.0%), which are at an acceptable level. In other countries, COVID-19 has made a significant impact in all aspects of life including medical services, whereas, in general, in Saudi Arabia, the ophthalmological clinics are not closed officially, however many protective measures have been done, including rescheduling the nonurgent follow-ups and opening of virtual clinics. Although the clinics are officially still open, more than 99% of the practicing ophthalmologists agreed with rescheduling a nonurgent appointment, decreasing the nonurgent visits to the clinic, as well as keeping the waiting rooms empty.

The American Academy of Ophthalmology has released many advisories for ophthalmologists during this pandemic situation, including taking a detailed history about any respiratory illnesses, fever, and recent visit to any of the high-risk countries.[34] These advisories reflect on practices ophthalmologists use in Saudi Arabia as more than 50% comply with that (69.2% ask if patients have respiratory symptoms and 64.2% ask if patients recently traveled internationally). On a practical point, most ophthalmologists ensure that all ophthalmic instruments including slit-lamps are cleaned and disinfected between patients and ensure regular cleaning and disinfection of the frequently touched objects and surfaces.

Compared to our results, Indian ophthalmologists, when asked about the preferred prevention strategy, regarding preoperative screening, the majority of ophthalmologists (62%) were unsure of what should be done and were awaiting guidelines. Even though 9.9% of the ophthalmologists indicated that they would want to perform testing for COVID-19, 16.6% indicated that they would prefer to use additional personal protection equipment before any elective surgery.[25] Zhou et al. found in a study that 89.7% of the surveyed health-care workers followed correct practices regarding COVID-19, which is higher compared to our study, which may be explained by the fact that the study was conducted in China which is considered the origin country of the outbreak.[35]

In a similar study done on psychiatrists, only 77.17% of the participants expressed a willingness to care for psychiatric patients suffering from COVID-19 infection.[26] Surprisingly, only 27.5% of the participants reported that they would associate with someone who came back to their community/neighborhood after he/she recovered from COVID-19, and 52.5% believed that they need more information on COVID-19.

Till now, no data is available about COVID-19 infection among ophthalmologists in Saudi Arabia, however worldwide, the number of infections and deaths due to COVID-19 among ophthalmologists are on the rise compared to that of other health workers. The American Academy of Ophthalmologist in an effort to honor ophthalmology doctors worldwide who have died from the pandemic, the academy has been collecting their name then posted that names on academy website.36ALBalawi recently published an article summarized Precautionary Guidelines for Ophthalmologists during pandemic periods. During the pandemic lockdown, it is advised that all nonurgent ophthalmic clinic visits and elective operations be re-scheduled and only urgent cases be handled. After reopening, ophthalmology clinics should be equipped with screening stations before entry to the waiting area and must take a detailed history about any respiratory illnesses, fever, recent return from high-risk areas, or contact with family members who had recently returned from one of the countries battling a COVID-19 outbreak. Standard precautions for every patient should be followed, including using a breath shield during a slit-lamp exam or any clear plastic barrier to block the transfer of breaths between the patient and the doctor. Ophthalmologists should inform their patients that they will speak as little as possible during the slit-lamp examination and request that the patients also refrain from talking. They should always use protection for the mouth, nose, and eyes when caring for patients potentially infected with COVID-19. Keeping the waiting rooms as empty as possible and keeping a safe social distance are other advisable recommendations. Standard hand hygiene is critical, including frequent hand wash with soap and water for at least 20 s before and after seeing patients. Single-use gloves should be worn when cleaning and disinfecting surfaces. All ophthalmic instruments, including slit-lamps, tonometer, and contact lenses and all places where the patients touch should be disinfected before and after consulting every patient.[37]

Conclusion

This study raises some important issues about the adequacy of knowledge of the ophthalmologists about COVID-19 during the outbreak, as well as their attitude and behavior as ophthalmologists that may be the first health-care providers to have contact with patients. There is a clear need for reinforcing current knowledge and behavior, initiating training programs to improve the level of understanding of the risks and prevention measurements among the ophthalmologists that, in turn, improves the confidence of ophthalmologists to provide the right care to their patients and protect themselves as well.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.