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Year : 2011  |  Volume : 1  |  Issue : 2  |  Page : 52-58
Knowledge and attitude towards swine influenza (2009) among dental practitioners in Nellore district of Andhra Pradesh, India

1 Department of Community Dentistry, Mamata Dental College, Khammam, Andhra Pradesh, India
2 Department of Community Medicine, Institute of Medical Sciences and SUM Hospital, Bhubaneshwar, Orissa, India
3 Department of Physiology, Institute of Medical Sciences and SUM Hospital, Bhubaneshwar, Orissa, India

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Date of Web Publication22-Nov-2012


Background: The practice of dentistry exposes dentists to a variety of micro-organisms that are transmittable via blood, oral or respiratory secretions. Recent outbreak of swine flu virus has posed a greater risk of occupational transmission to dentists as it can spread through the aerosols. In our study, we assessed the knowledge and attitude of dentists regarding swine flu (2009) in Nellore, India.
Materials and Methods: This cross-sectional survey was conducted during November and December 2009 in the south Indian district of Nellore in Andhra Pradesh. Self-administered, anonymous, multiple-choice type study questionnaire elicited information from 220 Dentists across the district.
Results: The Mean (±Standard Deviation, S.D) scores of knowledge and attitude were 37.92 (±5.63) and 11.34 (±2.51) from the maximum scores of 52 and 20 respectively. After adjusting for other variables, multivariable linear regression analysis showed gender, location and qualification of the participant contributing significantly to the knowledge score indicating a male participant, who is from urban area with higher qualification, had better knowledge. Attitude scores were not associated with any of the variables at significant level.
Conclusion: Although the knowledge level seems to be moderately high, there were some note-worthy yet disturbing gaps in knowledge. This study showed that the dentists' attitude towards swine flu was satisfactory. Emphasis during undergraduate teaching and continuous dental educational campaigns regarding infectious diseases are recommended for the dentists, as preparedness for future disease outbreaks.

Keywords: Attitude, dentists, knowledge, swine influenza

How to cite this article:
Kaipa S, Epari V, Gupta S. Knowledge and attitude towards swine influenza (2009) among dental practitioners in Nellore district of Andhra Pradesh, India. J Educ Ethics Dent 2011;1:52-8

How to cite this URL:
Kaipa S, Epari V, Gupta S. Knowledge and attitude towards swine influenza (2009) among dental practitioners in Nellore district of Andhra Pradesh, India. J Educ Ethics Dent [serial online] 2011 [cited 2022 Jan 28];1:52-8. Available from: https://www.jeed.in/text.asp?2011/1/2/52/103675

   Introduction Top

Swine influenza, a highly contagious respiratory disease has today become a major public health concern in the developing countries worldwide. Outbreaks of swine influenza date back to 1918 with the Spanish flu pandemic that caused approximately 50 million deaths. [1] Since then there have been many outbreaks, and the most recent one in April 2009 was with a new strain of virus. [2] Usually, this disease spreads from pigs or birds to humans; however, the recent form was seen to occur amongst those who haven't had any contact with pigs, and was found to be spreading from humans to humans, and affecting people of all ages. [3]

The first case of swine flu death in India occurred in a 14 year old girl, on August 03 2009. [4] Within the next 15 days, the mortality rose up to 25. As of January 31 2010, the reported mortality due to H1N1 influenza is 1229, and the number of laboratory confirmed cases (including uncomplicated cases) are 28,810. [5] New cases are still occurring, and maybe due to the following reasons: demographic factors; poultry farming structure; poultry movement; vaccine unavailability; and, geopolitical migration of birds. [6] Health care workers are at a greater risk of contacting such diseases and may also promote their transmission by occupational exposures. [7] The practice of dentistry exposes dentists to a variety of microorganisms that are transmittable via blood, oral or respiratory secretions. Recent outbreak of swine flu virus has also posed a greater risk to the dentists because of its spread through aerosols. [3] Hence, dentists should have sound knowledge on the prevalent infectious diseases, their symptoms, modes of spread and methods of prevention. The aim of this study was to assess the knowledge and attitude of dental practitioners towards swine flu in Nellore district, India.

   Materials and Methods Top

This district wide cross-sectional survey was conducted during November and December 2009, in the South Indian district of Nellore in Andhra Pradesh. Approximately 400 dentists were enrolled in the Indian Dental Association, Nellore district, and 250 of them were randomly approached by the first author requesting participation in the survey. The participation was voluntary and confidentiality was assured. A verbal consent was obtained after explaining about the aims and the objectives of the study. A self-administered, anonymous, multiple-choice type study questionnaire was administered to each participant in person, which took approximately 20minutes to complete all the three sections. Section-A, consisted of questions assessing demographic and professional characteristics like age, gender, location, qualification and years of clinical practice. Section-B included questions about knowledge of swine influenza, and section-C included attitude questions related to swine influenza. The original version of the questionnaire was pilot tested among 15 dental practitioners in order to ensure practicability, validity and interpretation of answers. Few modifications were done to improve validity.

Knowledge section (27 questions) assessed knowledge regarding communicability; symptomatology and diagnostics; at-risk individuals; prevention and treatment; and, virus characteristics of swine influenza. The responses to these questions were of multiple-choice type with four options having one correct answer, including an option of "don't know" in some of questions. Few questions also had responses in "yes/no/don't know" format. For each correct answer, 2 points, "I don't know" 1 point and any incorrect answer 0 points were assigned. The sum makes up the total score, which ranged between 0 and 52 (26 questions). Higher score indicated a greater level of knowledge. Finally, the source of the awareness was elicited in the last question. Attitude (10 questions) towards swine influenza was assessed by a series of statements and all were of "yes/no" format. Favourable attitude was given a score of 2 and for a negative attitude, 0 points were assigned.

Statistical analysis

The results were expressed in percentages. Multivariable linear regression analysis was employed to examine the association of various predictors with each of the following outcomes of interest; overall knowledge score and favorable attitude towards swine influenza. All hypotheses tests were two tailed and P values <0.05 were considered to be statistically significant. Analyses were done using the statistical package of social sciences, (SPSS) 12.0 software (SPSS Inc., Chicago II, United States of America).

   Results Top

Out of the 250 dentists who were approached to participate in the survey, 220 agreed and completed the questionnaire. The socio-demographic characteristics of the sampled population are presented in [Table 1]. Majority of the subjects belonged to the age group of25 - 35 years (52.7%), were males (74.5%) with less than 5 years of clinical practice (58.2%), had a bachelors degree in dentistry (54.5%) and belonged to urban areas (84.1%).
Table 1: Demographic and professional characteristics of the participants of the study

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Knowledge level

The mean (also the median) knowledge score of the respondents was 37.92 ± 5.63 with a narrow 95% confidence interval (37.16-38.68) [Table 1]. The responses to the knowledge questions are depicted in [Table 2].
Table 2: Responses to the knowledge questions by the participants of the study

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All the participants were aware that swine flu is an air-borne disease; however, only 51.8% of the subjects were conscious of the fact that the disease can spread even during the prodromal period and not just after one develops the symptoms.Majority (56.4%) were not aware about the period of viability of the virus (2 to 8 hours) after being deposited on inanimate objects. Close to 11% of the subjects agreed that consumption of pork can cause swine flu, though it was rare in the community. Despite the declaration by the World helath Organization (WHO) of the status of transmission of swine flu as being pandemic in nature, only 31% were aware of it. In response to the question - "what way does swine influenza concern to a dentist" almost everyone expressed their concern over spreading of the disease through aerosols (98.6%) and through direct contact (82.3%).

Symptoms and diagnosis

All were aware of fever, cough and fatigue as the symptoms of swine flu. Whereas, sneezing, runny nose and body ache as symptoms were unknown to 13.6%, 28.6% and 6.4% of the subjects respectively. Availability of a diagnostic test was known to all. Immunologically compromised, pregnant women and children below 5 years are at risk of swine flu was known to all.

Prevention and treatment

Nearly three-forth of the participants (71.4%) agreed that they are unaware of what a N95 respirator is. Most (82.3%) of the participants had the knowledge that a vaccine effective against swine influenza is available. Nearly half (43.6%) of the respondents knew about the presence of a designated government hospital in the district providing the drugs and the treatment for swine influenza. In an open ended question to name the drugs that are available and effective against swine influenza infection, 38.6% of the subjects could mention about TAMIFLU (OSELTAMIVIR) and 14.5% of the subjects mentioned about RELANZA (ZANAMIVIR).

Virus characteristics

Only 38.6% of the dentists were aware of the new virus as a genetic mixture of virus strains found in pig, human and bird. About two third (71.8%) of the respondents knew about the genotype of the current virus as H1N1; whereas, only 35.9% could exactly identify what H and N stands for. Very few respondents (19.5%) were aware of the temperature at which the virus can be destroyed.Multivariable linear regression analysis was carried out to find out the determinants of knowledge among the study participants. Of the five demographic and professional characteristics (age, gender, location, qualification and years of clinical practice) incorporated into the model, only gender, location and qualification of the participant contributed significantly to the knowledge score indicating that male participants, who are from urban areas and with a higher qualification had better knowledge (P<0.05) [Table 3].
Table 3: Multivariable linear regression analysis to study the relationship between the demographic and professional characteristics of the participants of the study with the results of the knowledge score

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Source of the knowledge
"Television" and "Newspaper" were the main sources of information followed by the "Relatives/family members", "Professional colleagues", "Friends" and "Radio" [Table 4].
Table 4: Sources of information about swine flu among the participants of the study

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Attitude level

The mean (also the median) attitude score of the respondents was 11.34±2.51 with a narrow 95% confidence interval [11.00 - 11.68] [Table 1]. The responses to the attitude questions are depicted in [Table 5].
Table 5: Responses to the attitude questions by the participants of the study

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All the participants believed that swine flu is curable and does not always lead to death. More than half (53.2%) of the respondents perceived that they are at risk of being infected by swine flu; however, a high level of risk was perceived only by 14.1% of the subjects. Contrary to the severity and high infectivity of the swine flu infection, a sizeable proportion of the respondents (71.4%) believed that swine flu is getting unnecessary public attention. All the respondents had a positive attitude towards social distancing and frequent hand-washing as an effective preventive measure, whereas 41.1% had an attitude of using an ordinary surgical mask to protect themselves. Subject to the availability of a vaccine, close to 96% of the respondents agreed to protect themselves by undergoing vaccination. While evaluating the attitude towards patients with swine flu like symptoms, nearly half (45%) of the dentists were hesitant to treat and about two thirds (64.5%) were worried about losing other patients if they do so. Multivariable linear regression analysis did not show statistically significant association between the attitude scores and the demographic and professional characteristics.

   Discussion Top

The scope of this survey on a representative random sample of dental health-care professionals across Nellore district, India, was to provide a lucid description of dentists' knowledge and attitude in this district in respect to the Swine influenza, and such an understanding is important in order to assess their effectiveness in the prevention of infectious diseases. Today, there is a considerable awareness among the dental professionals of the possibility of cross infection occurring in the dental clinics. This awareness has been heightened by the advent of human immunodeficiency virus (HIV), Hepatitis B virus and other infectious diseases. [8] Cross infection can be from a patient to dentist, from dentist to patient or from patient to patient. [9] As a care giver, they are not only at a higher risk of contracting these infectious diseases but also can help in transmitting them because of their frequent occupational exposures. Further, they play an important role in correcting misconceptions by providing accurate information to a large segment of the population, who lack access to regular medical care and to other dental practice employees and colleagues, who have concerns. [10] Hence, assessment of dentists' knowledge of infectious diseases and necessary control procedures is vital. [7]

The results of the "knowledge level test" among the respondents to our questionnaire, (which had questions pertaining to the communicability; symptoms and diagnostics; prevention and treatment; and, virus characteristics of swine flu), suggest that knowledge among the dentists was fairly good (25 th percentile value exceeded 63% of the highest knowledge score). However, there were some noteworthy yet disturbing gaps in knowledge.

It was found that males had significantly higher knowledge compared to females. This difference could be due to the fact that males usually have more interaction and socialization than females. Similar finding was found in studies conducted by Kamate et al., [11] and Leili et al. [12] Swine influenza is transmitted by droplet infection and can spread in three main ways: by direct transmission (when an infected person sneezes mucus directly into the eyes, nose or mouth of another person); the airborne route (when someone inhales the aerosols produced by an infected persons' coughing, sneezing or spitting) and through hand-to-eye, hand-to-nose, or hand-to-mouth transmission, either from contaminated surfaces or from direct personal contact such as a hand-shake. [3],[13],[14] It was interesting to note that in our survey almost all dentists could correctly identify swine flu as an airborne disease which spreads via aerosols and through direct contact. This information is crucial as not knowing about this may lead dentists to inappropriately triage patients. [7]

According to Centers for Disease Control and Prevention (CDC), the period of infectivity of swine flu virus begins the day before the onset of illness and can persist for up to 5 to 7 days; and, the virus can infect a person for up to 2 to 8 hours after being left on items like cafeteria tables, doorknobs, and desks. [3] It is of concern that in our study dentists lacked sufficient knowledge about the period of infectivity (48.2%) and duration of viability of the virus (56.4%). Contrary to the emphasis by the CDC that spread of swine flu virus (2009) is neither associated with contact with pigs nor eating pork, 11% of the subjects in our study misconceived about its spread through eating pork.

On 11 th June 2009, WHO raised Influenza A/H1N1 2009 pandemic alert to phase-6 indicating human-to-human spread of the virus causing global concern. [15] Although differences in groups of health care workers do not allow true comparison, the awareness among the participants in our study (31%) was considerably higher than among the pediatricians (14%) of Chandigarh, India. [16] Centers for Disease Control and Prevention described the symptoms of the 2009 "swine flu" H1N1 virus being similar to those of influenza and influenza-like illness in general. Symptoms include fever, cough, sore throat, body aches, headache, chills and fatigue. Baring a few, most of the respondents in our study were aware of these common symptoms. Studies have indicated that pregnant women, children below 5 years [17] and immune-compromised individuals [18] are at higher risk of contracting swine flu. Our study participants had the knowledge about these high risk individuals.

CDC also advices the use of special face masks called N95 Respirator for prevention and spread of the virus, [3] though wearing of an N95 mask had cost effectiveness concerns and would be difficult to implement over long periods of time. [19],[20] In our study, only a small proportion of the participants knew about the utility of this special mask. This finding was contrary to the observation made by Mahajan V, where 78% of pediatricians knew about the utility of N95 respirator. [16] Following the pandemic alert by WHO, Government of India provided diagnostic and treatment facilities at designated hospitals in the endemic states, primarily to provide diagnostic and curative services, and secondarily to curb the misuse of the facilities by false positive cases. [21] Being aware of the existence of such a facility would facilitate the provision of guidance to suspected cases. In our study, a substantial proportion of the subjects (43.6%) were aware of this. At the time of this study, vaccine against swine flu was not available except in the United States. [22] Further, it was reported that, the seasonal flu vaccine isn't effective against swine flu, by Richard Besser, acting head of the CDC. [3] Nevertheless, 82.3% of the participants were of the opinion that an effective vaccine is available. Two antiviral drugs, TAMIFLU (OSELTAMIVIR) or RELENZA (ZANAMIVIR) are recommended for the treatment and/or prevention of infection with swine influenza. [23] In our study, though the usage of these drugs was known to a small proportion of dentists, still it is noteworthy for the reason that the responsibility of dentist is limited to referring a suspected case to a physician.

At present, the origin of this new virus (2009) is unclear. Initially it was described as an apparent re-assortment of at least four strains of influenza A virus subtype H1N1, including one strain endemic in humans, one endemic in birds, and two endemic in swine. [24] However, subsequent analysis suggested that it was a re-assortment of just two strains, both found in the swine. [25] In this study, there were variable responses to this question, and only 10% of participants knew it as a re-assortment of just two strains, both found in swine. According to the CDC, these viruses are classified by two proteins on their surface, called H for Hemagglutinin and N for Neuraminidase. [3] In our study, abbreviations of H and N could be identified correctly by only 35.9% of the participants.

Television was the most popular source of information for swine flu followed by news paper, family members and professional colleagues. This may be due to the recent increase in the number of news channels and daily broadcasting about the spread and number of deaths across the country due to swime flu. This finding was in accordance with the study conducted by Kamate et al. and Apichaya et al., [11],[26] where television was the main source of information for the public. In this study, it is interesting to note that the family members played a significant role as source of information, and the possible explanation behind this could be that, in most of the Indian families, women yet do not work and remain confined to home looking after the domestic chores and children, which would facilitate the dissemination of information from the media to the family members. Also because the majority of the participants were males.

In our study, respondents had a favorable attitude towards the curability of swine flu. Despite of its hype in media about the death toll due to swine flu, most of the respondents believed that it is mild in nature and does not lead to death. In a recent critical review related to swine flu and dental practice, aerosol generating dental procedures were placed at high risk for acquiring swine flu by a dentist. [27] In our study, only 53.2% of respondents believed that they were at risk of developing swine flu. This low perception of risk is probably due to the minimum number of cases reported from this community. Nearly three fourths of the respondents conceived that media is creating unnecessary publicity towards swine flu. This negative perception may be related to the mild nature of virus, and minimum number of cases in the community; however, can have serious implications for pandemic preparedness.

In this study, it was interesting to note that close to half of the respondents (45%) were hesitant to treat a patient with swine flu like symptoms. This aversion among the respondents may be related to the perception of risk of infection due to transmission and occupational exposure. However a sizeable portion of the respondents (64.5%) were bothered about losing patients in the waiting room, if they perform treatment on a patient having symptoms of swine flu. The best way to prevent the spread of swine flu virus is by washing hands frequently and avoiding patients having flu like symptoms. [3] Wearing mask is also advised; however, available scientific evidence shows that the basic face masks cannot protect people from being infected. In our study, almost every one believed "frequent hand washing" and "vaccination" as effective preventive measures against swine flu, while the attitude towards the use of a surgical mask as an effective way of prevention was disheartening.

   Conclusion Top

In conclusion, our results identify that dentists' knowledge regarding swine flu was substantial, yet there were notable deficiencies regarding the virus characteristics and treatment. It was found that male participants, who are from urban areas with higher qualification, had better knowledge. Our study found that dentists' attitude towards swine flu and patients' with swine flu like symptoms was satisfactory. Emphasis during undergraduate teaching and continued dental educational campaigns on infectious diseases is recommended for the dentists, as preparedness for future disease outbreaks.

   References Top

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Correspondence Address:
Venkatarao Epari
Department of Community Medicine, Institute of Medical Sciencesand SUM Hospital, Bhubaneshwar, Orissa
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0974-7761.103675

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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