key: cord-0793906-kq86yous authors: Mumu, S. B.; Aktar, M. N.; Nahar, Z.; Sharmin, S.; Mostaid, M. S. title: Medical Doctors Awareness, Perception, and Attitude towards COVID-19 in Bangladesh: A Cross sectional study date: 2020-05-19 journal: nan DOI: 10.1101/2020.05.14.20101659 sha: 6733fbbb97ae40295e4ba3a01f1e8faf6ed1c046 doc_id: 793906 cord_uid: kq86yous Objective: COVID-19 has emerged as a pandemic and during the first week of May Bangladesh has reported more than 10,000 cases. A lack of awareness and poor understanding of the disease may result in rapid transmission of the disease in Bangladesh. This study aimed to investigate the awareness, perception, and attitude towards COVID-19 among Bangladeshi medical doctors. Method: This cross sectional, web-based study was conducted with the help of an online questionnaire and sent to the doctors which comprised of a series of questions regarding demographics of the participants, symptoms and incubation period of COVID-19, mode of transmission, measures to prevent transmission, availability of training and personal protective equipment in Bangladeshi hospitals, and attitude of doctors towards the treatment of suspected patients with COVID-19. Results: Of 800 medical doctors, a total 545 completed the survey (response 68.13%). Among the participants, 52.3% were females, 72.8% were below 30 years of age, and majority (52.8%) were working outside the cities in the villages and rural areas. A total of 404 (74.1%) doctors reported the correct incubation period of COVID-19. Majority doctors were aware of the symptoms with mode of transmission of COVID-19, measures to prevent hospital transmission, along with ways of identifying suspected patients with COVID-19. However, more than 90% of the doctors reported of inadequate intensive care unit and ventilator facilities along with extreme scarcity of personal protective equipment in the hospitals. 65.7% doctors prefer avoid working with a COVID-19 patient and more than 50% doctors have expressed that they would send the suspected COVID-19 patients to designated hospitals without providing treatment. Conclusion: The health authorities should take appropriate training measures to increase the awareness of the medical doctors along with providing sufficient amount of personal protective equipment for the medical doctors and supporting staff before deploying them in hospitals. The COVID-19 disease has become a pandemic affecting almost all the countries in the world. Since December, 2019 and as of 24 th April, 2020 approximately 2,719,897 COVID-19 patients have been reported including 187,705 deaths [1] . COVID-19 seems more contagious than its counterparts SARS (severe acute respiratory syndrome) and MARS (middle-east acute respiratory syndrome) and this highly infective disease may transmit from person to person contact via respiratory droplets [2] , fecal-oral transmission [3] , vertical transmission [4] . Majority of patients with this disease have experienced high fever with dry cough while others showed symptoms like shortness of breath, fatigue, muscle pain along with confusion, headache, sore throat, diarrhea, and vomiting [5] . On the contrary, up to 25% of COVID-19 patients remain asymptomatic and do not manifest any clear clinical symptoms are therefore remains unidentified but carry a high risk of transmitting the infection to their family members and society [6, 7] . So, it is difficult to identify and quarantine these patients on time. Moreover, patients in the recovering phase of COVID-19 are also potential sources of transmission. As a result, social and physical distancing has been suggested as an efficient tool to control the transmission of COVID-19 [8] . Frequent washing of hands using alcohol-based hand sanitizer or soap and water, use of face mask and covering mouth and nose with elbow or disposable tissues while coughing and sneezing are recommended measures to prevent the spread of COVID-19 [9] . [10] . Although people of all ages are generally susceptible to this infective disease but those who are in close contact with patients with COVID-19 including health care workers and patients in the hospital are at excessive risk of getting infected with this deadly virus. Bangladesh government claims that it started taking preparation to control the COVID-19 pandemic in the country since January 2020 based on the guidelines of the World Health Organization (WHO). While the first COVID-19 patient was detected on March 08, 2020, the national guidelines for the prevention of COVID-19 in health care setting was first published by the Directorate General of Health Services under the Ministry of Health and Family . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 19, 2020. . https://doi.org/10.1101/2020.05.14.20101659 doi: medRxiv preprint on March 30, 2020 [12] . It is of utmost importance to have proper knowledge, awareness and perceptions regarding COVID-19 for all health care workers. Proper training of all the health care workers especially medical doctors is mandatory before posting them to treat COVID-19 patients in designated hospitals as well is all other clinics during the pandemic situation. According to the ministry of health and family welfare HRH data sheet 2014, there are 75,514 registered medical doctors and 38,452 registered diploma nurses in Bangladesh [13] and as of 20 th April, 2020 only 3,625 medical doctors and 1,314 nurses have received video training on COVID-19 hospital management and hospital infection prevention and control [14] . So, there is a clear shortage of training on COVID-19 for health care workers in Bangladesh which may result in lack of knowledge with incorrect perception and attitude regarding COVID-19 among health care workers especially medical doctors. Protection of health care workers is vital as they are at the highest risk of getting infected with COVID-19 due to continuous exposure to the infected patients at various clinics and hospitals [15] . Adequate amount of medical resources is required during this pandemic with adequate healthcare infrastructures. Proper personal protective equipment (PPE) is also compulsory to prevent the transmission of the virus from patients to doctors and allied health care workers. Inadequate personal protection, long time exposure to the infected patients, lack of proper PPE, inadequate training are some reasons for the rapid spread of the COVID-19 infection among health care workers [16] . With all the recommendation and management protocols provided by the World Health Organization and government initiatives, all the medical doctors are expected to gain proper knowledge, awareness, and clear perceptions about COVID-19. Hence, our study aimed to assess the level of awareness, perception and attitude regarding COVID-19 and infection control among the Bangladeshi doctors who are working at various hospitals at both city and rural areas. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 19, 2020. . https://doi.org/10.1101/2020.05.14.20101659 doi: medRxiv preprint The study population comprised of registered medical doctors who are currently working in Bangladesh, both in private hospitals and public hospitals including armed forces. This survey was conducted in April 2020. Here we developed an online questionnaire using Google Forms that was used to collect the data. Within the groups, 800 doctors were randomly selected and invited to participate in the study by their Facebook profiles. However, each participant randomly selected was contacted individually to make sure that he/she was a doctor and currently working in Bangladesh. Confidentiality of information was maintained throughout the study by making the participants' information and responses anonymous. All the doctors participated voluntarily and had to sign an electronic consent form. The study was conducted following the Helsinki Declaration as revised in 2013 [17] and the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) guidelines [18] . Ethical approval was obtained from the Institutional Review Board at BRAC University. The survey questions were developed based on reviewing relevant literature and the international guidelines [6, 19- . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 19, 2020. . https://doi.org/10.1101/2020.05.14.20101659 doi: medRxiv preprint Data were analyzed using SPSS. Descriptive statistical analysis was used to describe items included in the survey. Mean and standard deviation or median and range were used to describe the continuous variables, and percentages were used to describe the categorical data. Table 1 . Majority of the medical doctors in Bangladesh are aware on many aspects of the COVID-19 infection. 404 (74.1%) doctors reported the correct incubation period (1-14 days) of COVID-19. But it is a concern that almost 25% are still not aware of this critical information. When asked about the symptoms, over 90% of the doctors pointed out fever, dry cough, shortness of breath, and sore throat ( Table 2 ). Runny nose, and diarrhea were reported by more than 50% of the doctors. Meanwhile, 394 (72.3%) doctors said that COVID-19 could be asymptomatic. Only a small percentage expressed that skin rash, vomiting, and joint or muscle pain are symptoms of this disease. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 19, 2020. . https://doi.org/10.1101/2020.05.14.20101659 doi: medRxiv preprint The medical doctors could correctly point out the mode of transmission of COVID-19 (Table 2 ). When they were asked about how to identify suspected COVID-19 patients, 527 (96.7%) mentioned presence of fever, coughing, sneezing along with difficulty in breathing, 530 (97.3%) expressed close contact with a COVID-19 patient, 504 (92.5%) mentioned coming from an area already infected with COVID-19. Bangladeshi doctors were found to be well aware of the necessary measures that are required for preventing the Table 3 . A vast majority of doctors (515, 94.5%) perceived that COVID-19 is very dangerous and 498 (91.9%) doctors believed that it is a serious public health issue. Majority of the doctors 508 (93.2%) agree that at present, lockdown of cities is the best possible method for preventing the transmission of COVID-19. According to our survey, most of the doctors' reported that the patient care facilities and availability of PPEs for the proper care of COVID-19 patients in Bangladesh is very low and nowhere near sufficient compared to the overwhelming requirement at this current pandemic situation. More than 90% of the doctors' reported that there were not enough ventilators, and intensive care units (ICUs) in the hospitals. Moreover, 499 (91.5%) doctors reported that they were not provided with sufficient amount of high quality PPEs. In addition to that doctors were . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 19, 2020. . https://doi.org/10.1101/2020.05.14.20101659 doi: medRxiv preprint not provided with training on COVID-19 and rational use of PPEs before being posted in hospitals. The details percentage are given in Table 4 . More than 75% of the doctors (409) Our study provides an overview on the level of awareness, perception and attitude of Bangladeshi medical doctors regarding COVID-19 at the time of pandemic in 2020. Moreover, it gives an insight on the hospital facilities and availability of PPE for doctors in Bangladesh who are at the forefront to fight this contagious disease. Majority of the doctors participated in this study were below 30 years of age. Moreover, the number of the female doctors participated were higher than the male doctors (54.3% vs 45.7%) which is in support of the fact that the number of female doctors (52%) in Bangladesh is slightly higher than the number of male doctors (48%) [22] . Most of the doctors (74.1%) in our study had the correct knowledge about the incubation period (up to 14 days) of COVID-19 [23] , but it becomes a concern that almost 25% are still not aware of this critical information. It is . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 19, 2020. . https://doi.org/10.1101/2020.05.14.20101659 doi: medRxiv preprint essential to know the right incubation period of COVID-19 because of its role in determining the safe period to treat suspected patients [23] . Prime symptoms of COVID-19 include fever, dry cough, shortness of breath, sore throat, diarrhea [24, 25] . Most of the doctors in our study could identify the major symptoms of COVID-19. Knowledge of the symptoms would help the doctors to identify the suspected patients and take the necessary steps to prevent spreading of the disease to other patients, and health care workers in the hospital. Doctors' awareness of measures for preventing the transmission of COVID-19 was up to the satisfactory level according to our study. The most recommended measure is frequent sanitization of hands by using alcohol-based hand rub or soap and water along with wearing personal protective equipment while at the hospital [9] . At present, there is no specific treatment for COVID-19. Measures like hand sanitization and social distancing to control infection transmission, testing of all suspected patients, isolation, mandatory quarantine are some of the steps taken by several countries including Bangladesh. Providing adequate ICU and ventilation support to the critical patients with COVID-19 is also an important step to reduce the number of deaths [24] . Regarding the perception of COVID-19, 94.5% of our participants believe that COVID-19 is very dangerous and lockdown, quarantine, social distancing, isolation of the patients are effective ways to prevent the transmission of infection. Quarantine had been used to contain or minimize infectious disease outbreaks, particularly in the developing world [26, 27] . However, it can also be very effective in protecting or restoring public health. As a result, with the outbreak of the COVID-19, various quarantine policies have been implemented by most of countries in order to reduce transmission of the disease. Doctors need sufficient amount of proper personal protective equipment to protect themselves from being infected while providing treatment to the COVID-19 patients. Doctors have also reported that the amount of ICU and ventilator facilities in Bangladeshi hospitals are extremely low to meet the need of its large population. This is supported by the data provided by Directorate General of Health services of Bangladesh Government which reports that only 3302 oxygen cylinders and 49 ventilators are available for COVID-19 treatment till 08 May 2020. Moreover, only 757 physicians and 693 nurses have been posted for COVID-19 treatment all over Bangladesh [28] , which is insufficient by all means. A somewhat similar scenario was observed even in developed countries where the hospitals fell short of providing ventilator and ICU support to meet the overwhelming demand of the COVID-19 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 19, 2020. . https://doi.org/10.1101/2020.05.14.20101659 doi: medRxiv preprint patients [29] . Moreover, doctors have expressed that they were not provided with sufficient training and PPEs before being deployed in the hospitals in Bangladesh. As, a result more than 250 doctors got infected with COVID-19 [30] and thus got isolated which is creating extra burden on an already fragile health care system. Approximately, 75% doctors believe that the symptoms of COVID-19 resolve with time and so the patients should remain at home and get symptomatic treatments. 84.6% doctors have expressed that all patients should use mask and gloves while coming to the hospital for any sort of emergency treatment to prevent nosocomial transmission of COVID-19. However, 65.7% doctors (n=358) would prefer not working with a COVID-19 patient which may be due to the lack of PPEs and insufficient training which increases their risk of being infected. If a patient comes with coughing and sneezing, almost half of the doctors (n=273, 50.1%) would suggest them to go to the designated COVID-19 hospitals, 44.2% (n= 241) would provide treatment with an advice to go to the COVID-19 designated hospitals and 5.7% (n= 31) would totally refuse to provide treatment. This scenario shows an overall tensed condition that exists among the medical doctors regarding COVID-19 in Bangladesh. Our study had some limitations. The number of participants were of moderate size. This might be due to a relatively short period of data collection. Many of the doctors might be occupied with getting latest COVID-19 information on television and internet while taking care of their nearest and dearest ones. Also, they might be busy to their duties in this current pandemic situation of COVID-19. So, only the medical doctors who were available on the social media within the short period of data collection, participated in this survey. This could result in sampling error and selection bias and so caution should be taken before generalization of our results. To conclude, Bangladeshi doctors were well aware of COVID-19 symptoms, mode of transmission, infection control and measures for preventing the transmission of COVID-19 in hospitals which may be attributed to their own efforts of acquiring knowledge by themselves through television, internet and other sources rather than government initiatives. But considering the severity of COVID-19 pandemic situation they were not provided with sufficient training and quality PPEs which are very essential for protecting the doctors while treating the COVID-19 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 19, 2020. . https://doi.org/10.1101/2020.05.14.20101659 doi: medRxiv preprint patients. So, the government of Bangladesh should try to increase hospital facilities, provide training, and supply enough PPEs to all medical doctors and supporting staff for proper management of COVID-19. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 19, 2020. . . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 19, 2020. . . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 19, 2020. . . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 19, 2020. . https://doi.org/10.1101/2020.05.14.20101659 doi: medRxiv preprint . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 19, 2020. . https://doi.org/10.1101/2020.05.14.20101659 doi: medRxiv preprint Coronavirus disease 2019 (COVID-19) Situation Report -96 The epidemiology and pathogenesis of coronavirus disease COVID-19: Gastrointestinal Manifestations and Potential Fecal-Oral Transmission The outbreak of COVID-19: An overview A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster Presumed Asymptomatic Carrier Transmission of COVID-19 The effect of control strategies to reduce social mixing on outcomes of the COVID-19 epidemic in Wuhan, China: a modelling study Stopping the Spread of COVID-19 Bangladesh: Institute of Epidemiology, Disease Control and Research Guideline for Health Care Provider On Infection Prevention and Control of COVID-19 Setting: Directorate General of Health Services, Ministry of Health and Family Welfare, Government of the Peoples' Republic of Bangladesh Covid-19) Dhaka: Government of the Peoples' Republic of Bangladesh HRH Data Sheet 2014 of MOHFW: Ministry of Health and Family Welfare, Government of the Peoples' Republic of Bangladesh Coronavirus disease (COVID-2019) Bangladesh situation reports-08 World Health Organization COVID-19: protecting health-care workers Reasons for healthcare workers becoming infected with novel coronavirus disease 2019 (COVID-19) in China Association Declaration of Helsinki: ethical principles for medical research involving human subjects Improving the quality of Web surveys: the Checklist for Reporting Results of Internet E Surveys (CHERRIES) Clinical management of severe acute respiratory infection when COVID-19 is suspected: World Health Organization Community Transmission of Severe Acute Respiratory Syndrome Coronavirus 2 Feminization' of physician workforce in Bangladesh, underlying factors and implications for health system: Insights from a mixed-methods study The Incubation Period of Coronavirus Disease 2019 (COVID-19) From Publicly Reported Confirmed Cases: Estimation and Application Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study Measuring the impact of Ebola control measures in Sierra Leone Quarantine, isolation and the duty of easy rescue in public health Government of the Peoples' Republic of Bangladesh Covid-19: how doctors and healthcare systems are tackling coronavirus worldwide Hundreds of doctors in Bangladesh infected with coronavirus Qatar: Al Jazeera The authors are thankful to the medical doctors who participated in the survey voluntarily. The authors would also like to thank the collaborators of the Bangladesh Medical Association who helped to carry out the research work. The authors declare no conflicts of interest.