Knowledge , Attitude and Practice ( KAP ) Study about Middle East Respiratory Syndrome Coronavirus ( MERS-CoV ) among Population in Saudi Arabia

Objectives: Middle East respiratory syndrome Coronavirus (MERSCoV) is an epidemic in Saudi Arabia. This study aimed to measure the level of knowledge, attitude and practice about Coronavirus, to correlate the sociodemographic characteristics to the level of knowledge, attitude and practice about Coronavirus, and to explore awareness and health behaviors related to the prevention of Coronavirus.


Introduction
Middle East respiratory syndrome Coronavirus (MERS-CoV) is a viral respiratory disease caused by a novel coronavirus [1].The Coronavirus was first isolated in Saudi Arabia in 2012 [2].It is considered an epidemic in Saudi Arabia [3].Prevalence of the disease and mortality are higher among men compared to women.Furthermore, among people of age between 45-59 and more than 60 years have the highest mortality rate [4].From 2012 to 21 July 2017, there have been 2,040 reported laboratoryconfirmed cases and 712 deaths from MERS-CoV infection in 27 countries [5].
Knowledge of mode of disease transmission is important for developing effective control measures.The transmission of MERS-CoV is defined as sporadic between family members, often occur in health care settings, and requiring close and prolonged contact [6].The Coronavirus infection was initially thought to spread by zoonotic events via bats.It is genetically connected to Tylonycteris bat coronavirus HKU4 (BatCoV-HKU4) [7].However, an evidence indicates that Coronavirus originated from dromedary camels [2].A serological study suggests that almost 90% of all camels in Africa and the Middle East were seropositive for Coronavirus, whereas other animals such as sheep, goats and cows were found to be negative [8].A populationbased seroepidemiologic study suggests that the seroprevalence of the virus was several folds higher in people who were exposed to camels compared with that in the general population [9].Moreover, antibodies against Coronavirus were found in samples obtained from camels in Saudi Arabia in 1993, which reinforces the hypothesis that dromedary camels are most likely the main reservoirs of Coronavirus.In contrast, no seroreactivities were reported in the blood samples obtained from abattoir workers in Saudi Arabia during 2012 [10].The mode of transmission is still unknown but is suspected to be through saliva during direct contact with infected camels or through consumption of milk or uncooked meat.Secondary infection may occur through droplets or contact, and the virus could spread either via air or fomites [9].
A few recent studies on infected patients showed that the most common Coronavirus infection causes acute pneumonia, renal failure and almost every patient developed respiratory problems.In addition, at least one-third of the studied patients were also reported to have abdominal disorders.Also, there were other effects including inflammation of the pericardium, consumptive coagulopathy, increasing in leukocytes and neutrophils, and low levels of lymphocytes, platelets and red blood cells.Moreover, hyponatremia and low blood levels of albumin were detected during the case study [11,12].Coronavirus is often a lower respiratory tract disease, with the following signs and symptoms; fever with chills/rigors, cough, shortness of breath, myalgia and gastrointestinal problems (diarrhea, vomiting and abdominal pain) [13].Abnormal fin-dings of chest radiograph are very common in Coronavirus patients.The laboratory reports have shown thrombocytopenia, lymphopenia, and increase concentration of lactate dehydrogenase and aspartate aminotransferase [11].
The treatment includes first, the combination of ribavirin and interferon alfa-2b therapy.Second, mechanical ventilation and renal replacement therapy.However, in Saudi Arabia, five critically infected patients who received the ribavirin and interferon therapy have died [14].The Centers for Disease Control and Prevention (CDC) stated that infected people with MERS-CoV, who do not need to be in a hospital, may be cared and isolated in their homes.The WHO recommended that individuals who are at high risk of chronic disease (such as prolonged lung disease, immunocompromised hosts, diabetes, or renal failure) should take precautions during visiting places where camels are present (such as farms, camel coops, and barn areas).These precautions include practicing good public health measures, such as good hand hygiene, avoiding direct contact with camels, avoiding drinking raw camel milk or camel urine, avoiding eating meat that has not been perfectly cooked, and avoiding eating food that may be contaminated with animal discharge or products that are not washed appropriately [15].
Health authorities in Saudi Arabia did substantial efforts in order to control the disease through various measures.Public education is considered as one of the most important measures that can help in the control of infectious diseases.Few studies were conducted in Saudi Arabia among the public and health care workers to assess knowledge about the disease and its management.Assessment of the public general knowledge about MERS-CoV is crucial for developing health policy for the containment of the disease [3,16,17].
The main goal of the present work was to measure the level of knowledge, attitude and practice about Coronavirus, to identify sociodemographic variables associated with satisfactory level of knowled-ge, attitude and practice about Coronavirus, and to explore awareness and health behaviors related to the prevention of Coronavirus.

Design of the work
A national adaptive cross-sectional survey was conducted on 714 Saudi Arabian population aged from twenty to above sixty years old in period from March to April 2017.A standardized, confidential, Internet questionnaire (an electronic questionnaire) was used for a large randomly selected population in all regions of Saudi Arabia.

Inclusion criteria
The current study involved only Saudi Arabian population aged from 20 to above 60 years old.

Questionnaire Design
The questionnaire was designed in English and then translated to Arabic and reviewed for consistency.The questionnaire included socio-demographic characteristics of the participants, questions related to knowledge about Coronavirus, and followed by questions related to attitude and prevention practice toward MERS-CoV.

Data analysis
The recorded data were analyzed using Statistical Package for Social Sciences software (SPSS) (version 20).Descriptive statistics (frequency with percentage, cross tab) were used to summarize the study and outcome variables.Pearson's Chi-square test was used to test the differences and odds ratios were used for observing and quantifying the association between categorical outcomes.The 95% confidence intervals were calculated for odds ratios.The p value ≤ 0.05 was considered significant.
Table 2 showed sociodemographic data including marital status, level of education, occupation and level of income.Four hundred twenty-three (59%) were married and 291 (41%) were single.Majority of participants had a bachelor 570 (79.8%), and 34 (4.7%) had higher education (master and PhD degree).In addition, 309 (43%) were student, and 48 (6.7%) were working in the medical field.
The knowledge section in the survey intended to focus on the perception of the participants about MERS-CoV (general knowledge about MERS-CoV, its etiology, symptoms, transmission mode, treatment and prevention of MERS-CoV) according to the geographic regions as shown in Table 3 and 4 The results are expressed as percentages (%).F: Frequency.The results are expressed as percentages (%).N: number of participants.The results are expressed as percentages (%).N: number of participants.*:Result is significant at p ≤ 0.05.
It was found that the majority of respondents (98%) had prior knowledge about MERS-CoV.High proportion of respondents (78.7%) knew that the causative agent was a virus.More than 85% of the respondents in Qassim region knew that the MERS-CoV is contagious.Only 0.5%, 1.3% and 2.9% of the participants had experienced MERS-CoV infection in Qassim, Riyadh and other region in Saudi Arabia, respectively.In addition, the respondents' relatives in Makkah region had significant infection level (44%, p ≤ 0.01) in comparison to other geographic region in Saudi Arabia.This percentage was less in other regions; 16%, 17% and 19% in Riyadh, Qassim and east province, respectively.On comparing the Knowledge about the importance of isolation of suspected cases, the participants in Makkah region showed significantly more awareness than other regions (96%, p ≤ 0.01).On the other hand, more than 45% of respondents affirmed that MERS-CoV can't be treated at home.
It was found that more than 70% of the respondents knew that there were more than one symptoms of MERS-CoV, followed by one sign as fever (7.9%), Cough, sore throat and blocked nose (6.3%), and difficulty breathing (1.4%) in the Qassim region.However, there was a significant awareness about MERS-Cov symptoms in Makkah region (84%, p ≤ compared to other Saudi Arabia regions.Participants from Qassim region (66.7%) and East province (76.2%) reported that there was more than one way of MERS-CoV transmission.This includes coughing, touching contaminated surfaces, infected camel and bats, consuming milk and meat of infected animals and direct contact with an infected patient.Other regions in Saudi Arabia had similar knowledge about the mode of transmission.Around 60% of participant believed that Hajj and Omrah are source of MERS-Cov transmission.
Of all the participants, more than 80 % knew that the disease is prevented through wash hands, and avoid touching and contacting infected people.Regarding the knowledge of disease treatment, the fact that the disease has no specific treatment was known by only 18.6%, 16%, 32%, and 14.2% in Qassim, Riyadh, Makkah, east province, respectively.Around 40% of participants confirmed that there is a treatment for the disease.In addition, more than 85% believed that early detection, and health education could help in preventing MERS-CoV.Around 74% (P ≤ 0.001) of participants in Qassim region believed that there is no current treatment for MERS-CoV at home.Regarding va-ccine, about 48% of Riyadh region participants believed in the presence of vaccine to prevent MERS-CoV, however 40% of Makkah city participants believed there was no vaccine to prevent the disease.Supportive treatment and vaccination were described as a treatment for MERS-CoV by most participants in all regions.For example, 40% and 30.7% of participants in Riyadh region believed that supportive treatment and vaccination could help in treatment, respectively.On the other hand, it is worth mentioning that in general, there was no significant association between knowledge and geographic regions.
Figure 1 shows the association between different sources of information about MERS-CoV and the  level of participants' knowledge about MERS-CoV.Social media was the main source for providing information about MERS-CoV with (9.7%) excellent, (72.4%) fair and (17.9%) poor knowledge.As shown in Table 5, several themes gained agreement amongst the participants.About 72 .5% of male and 71.4% of female participants agreed that MERS-CoV is a dangerous disease.Around 71% of participants were afraid from someone of the families could possibly get infected.However, only 19 % of males and 23% of females were afraid from going to common places.
There was almost unanimous among participants that MERS-CoV infection is preventable.By comparing males and females, the females (91%, P ≤ 0.05) showed significantly better attitude toward the possibility of preventing of MERS-CoV infection than males (86.1%).
In addition, most participants had good attitude toward privation of camel's milk and meat if they are source of transmission of MERS-CoV.However, women had better attitude towards the privation of camel's milk and meat if they are source of transmission of MERS-CoV infection (81.6%, p ≤ 0.001) than men (66.7%).
About half of both females (54%) and males (58%) respondents felt that the information in Sau-di Society was insufficient to deal with MERS-CoV.Around 40% of females and 52% of males agreed that governmental institutions can control and prevent the disease.
Regarding whether participants consider themselves at risk of infection, males thought that they are at risk more than females by about 1.3 times [OR:1.3(0.78-2.13)].Additionally, males are less likely to visit that doctor compared to females by 0.57 time [OR:0.57(0.306-1.098)].Regarding safety precautions, the data suggested that males are significantly less than females in taking safety precautions and prevention by 0.563 time [OR: 0.563 (0.341-0.94), p ≤ 0.05] as illustrated in Table 6.In general, female participants had better attitude toward MERS-CoV compared to male participants.
As illustrated in Table 7, 74.6% of females and 78% of males take several precautions such as washing hands, avoiding touching the eyes, nose and mouth, throwing the used tissue in the trash, and using the mask to cover their nose in crowded places to avoid infection.In addition, the physician advising is the main reason for getting the vaccine (if preset) by males (59.3%) and females (34.5%) to prevent the MERS-CoV infection.

Discussion
Little studies were conducted in Saudi Arabia among the public and health care workers to assess their knowledge about MERS-CoV and its management.The survey of the present study is inclusive as it includes the evaluation of the participants' knowledge, attitude and practice about modes of transmission, clinical symptoms, risk factors, preventive measures and treatment of MERS-CoV.
The distribution of the sociodemographic characteristics of the respondents showed a high percentage of females, Bachelor and married participants.Nearly 20% of the participants did not exactly know that the causative agent of the disease is a virus.Knowledge of the etiology of the disease is considered as the first step of patient education.Once the people know the cause, they are most likely understanding how the disease is transmitted and what are the preventive measures that limit its distribution.
The current study measured public awareness about MERS-CoV in Saudi Arabia and showed that methods of delivering information and educating people need to take into account geographic loca-tion to promote health.In addition, the majority of participants depended on the social media as main source of information about MERS-CoV.However, these result different from those of previous studies, which showed television as a main source of information for participants [3].On the other hand, about half of the respondents adopted the insufficient of the information about MERS-CoV in Saudi society.
The result from the present study was expected because most of the educational materials (e.g., brochures) are posted online by the Ministry of Health (MOH), which encourages the public to use technology.However, caution must be taken when using the social media as a main source of information due to information overload and it is difficult to determine the validity of information sources, which leads to misinformation.Therefore, evaluation skills should be developed among the public with regard to carefully evaluating MERS-CoV related educational materials [2].
The current study comes in agreement with the work of Almutairi et al., (2015) who stated that a vast majority of the participants were aware of The results are expressed as percentages (%).N: number of participants the MERS-CoV in Saudi Arabia [3].Furthermore, females had more knowledge and better attitude than males.This study also showed a positive attitude and a higher level of proper hygienic practices among the population.These current results are in line with other studies' findings which showed a positive attitude of the public and among healthcare professionals specifically [3,16].Participants in Qassim (66.7%) and East province (76.2%) reported that camel is one of the sources of MERS-CoV transmission.This is due to the isolation of MERS-CoV from camels in Egypt, Qatar, and Saudi Arabia, which lead to the thinking about camels as being a source of infection of the coronavirus [14].Moreover, more than 67% of the respondents reported the humans themselves could act as a source of transmission of this disease by connecting with an infected patient, touching surfaces contaminated with virus and cough, confirming the good knowledge level about mode of transmission of MERS-CoV infection among population in Saudi Arabia.However, preventing the infection transmission should be increase by people education about the different mode of transmission of MERS-CoV.The most identified gap in knowledge among participants was related to disease treatment domain.Only 19% of participants believed that there is no treatment for MERS-CoV; however, (26.6%) agreed with using supportive treatment for MERS-CoV, and (31.1%) of the participants believed in the presence of a vaccine for preventing MERS-CoV.Actually, there is no treatment, and the infected people treatment depended on their immune system.As well as their psychology, according to a manager of public health at Ohud Hospital in Madinah (western region).He also added that MERS-Cov patients still beg for treatment, so the hospital just gives them ribavirin and interferon.They feel better because they think that it is a legitimate treatment, but it is really just a mindfulness-based treatment designed to improve their health and keep their hopes up.
The strength of the immune system is important in overcoming MERS-CoV [16].
Generally, most participants had positive attitude toward the privation of consuming camels' meat or milk if they are source of MERS-CoV infection.Furthermore, there is no study that proves that the MERS-CoV is transmitted to humans by consuming the milk or meat of camels, but prevention is better than cure.
It was found that more than 75% of respondent knew that there are many symptoms of MERS-Cov such as fever, cough, sore throat and blocked nose.This result shows that participants had a good knowledge about the symptoms of the disease.The majority of respondents (91.6%) agreed that the infected patients with MERS-Cov should be isolated.In addition, more than 70% of participants worried about infection of their family by MERS-CoV.All of these reflect the high concern about MERS-CoV infection.
In conclusion, Generally, participants have a high level of knowledge, positive attitude, and prevention practice toward MERS-CoV.Furthermore, there was no significant difference in knowledge level in different regions in Saudi Arabia.The females have better attitude toward MERS-CoV than males.The present study highlights the need to create wide-spread awareness about MERS-CoV infection among individuals who do not have access to the internet and social media through posters, television, and dissemination of information by healthcare professionals.

Figure 1 :
Figure 1: Association between information sources and the level of participant's knowledge about MERS-CoV.

Table 3 .
Knowledge about MERS-CoV according to Geographic Regions.

Table 4 .
Participants perception about causes, mode of transmission, symptoms, risk factors, treatment and prevention measures of MERS-CoV according to geographic region.

Table 5 .
Attitude toward MERS-CoV according to gender.The results are expressed as percentages (%).N: number of participants.*:Result is significant at p ≤ 0.05.

Table 6 .
Attitude towards MERS-CoV according to gender.The results are expressed as percentages (%).OR: odd ratio.CI: confidence interval.*: Result is significant at p ≤ 0.05.

Table 7 .
Practice of taking precaution and vaccination (if preset) to prevent the MERS-CoV infection.