Knowledge and Attitude to the 2019 Novel Coronavirus (COVID-19) pandemic: A cross sectional survey from Egypt

Background: Coronavirus disease 2019 (COVID-19) is a serious emerging public health issue and it has been identified as a major risk to human health in 2020. Egypt has more than 100 million population, of whom in poor economic conditions and with low education levels could be vulnerable to COVID-19 infection. Physicians are at the frontiers in battles against the emergence, spread


Introduction
In late December 2019, a cluster of patients with pneumonia of unknown etiology was reported in Wuhan, China [1].A new coronavirus was identified as the causative pathogen and since then, the number of cases has continued to increase spreading to all 34 regions of China [2].On 30 th January 2020, the World Health Organization (WHO) declared that the new coronavirus outbreak constitutes a Public Health Emergency of International Concern (PHEIC) [3].
The new coronavirus was initially named as 2019 novel coronavirus (2019-nCoV) by the WHO.On 11 th Feb 2020, WHO named this novel coronavirus pneumonia as Coronavirus Disease 2019 ''COVID-19'' [4].The Coronavirus Study Group (CSG) of the international committee on taxonomy of viruses recognized this virus as a close relative to Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV) and renamed it as SARS-CoV-2 [5].
The Coronaviruses family members are positive single-stranded enveloped large RNA viruses that infect humans and a wide range of animals.SARS-CoV-2 is the 7 th member of the family of Coronaviruses and like SARS-CoV and Middle East Respiratory Syndrome Coronavirus (MERS-CoV), SARS-CoV-2 is responsible for lower respiratory infection and can cause Acute Respiratory Distress Syndrome (ARDS) [6].
Compared to the 2002/2003 SARS-CoV and the 2012-2014 MERS-CoV, the SARS-CoV-2 spreads strikingly fast.While MERS-CoV needed about two and a half years to infect 1000 people, and SARS-CoV took roughly 4 months, the new SARS-CoV-2 reached that count in just 48 days [7].
Respiratory droplets are the main route of human to human transmission.Direct or indirect contact with mucous membranes of the eyes, mouth or nose, and aerosol transmission especially in a relatively closed environment are also possible routes of transmission [8].Digestive tract is recently considered a potential route of SARS-CoV-2 transmission via invasion of ACE2-expressing enterocytes [9].
All people are generally susceptible to infection with SARS-CoV-2 but the elderly and people with underlying chronic diseases are more likely to develop severe diseases [10].The incubation period is estimated to be 3-7 days (range: 2-14 days) [11].The main clinical characteristics of COVID-19 are fever, dry cough, fatigue, myalgia and dyspnea.The less common reported symptoms are sore throat, vomiting and diarrhea.Severe cases often develop dyspnea and/or hypoxemia, septic shock, ARDS, difficult-to-correct metabolic acidosis, and coagulation disorders [12,13].
Since the complete SARS-CoV-2 genome sequences are available in Gen Bank, the novel nucleic acid could be detected by RT-PCR or by viral gene sequencing of oropharyngeal and nasopharyngeal swabs [14].Suspected and confirmed cases should be treated in designated hospitals with effective isolation and protective conditions [8].
Egypt has more than 100 million population, of whom in poor economic conditions and with low education levels could be vulnerable to COVID-19 infection.On Other hand, physicians are facing multiple challenges: an abrupt outbreak of epidemic, a sudden increase work overload, a substantial risk of occupational exposure and violence, a high risk of infection of themselves and their family members, and insufficient supply of protective equipment.
Knowledge and attitude towards infectious diseases can affect control of the disease [15].Attitude, for example, underestimation; overestimation; or panic behavior can affect the battle against epidemics [16].Currently, there is no known information about the physicians' knowledge and attitude towards COVID-19 pandemic in Egypt.We therefore conducted this survey to investigate the knowledge and attitude of a convenience sample of Egyptian physicians towards COVID-19 pandemic.

Study design and participants
This multicenter cross-sectional study was conducted during March 2020.Ethical approval was obtained from Zagazig University -Faculty of Human Medicine Institutional Review Board (IRB).
Following the current recommendations to minimize face-to-face interaction, the questionnaire was electronically sent to the participants through E-mails and social networks.Only a single response to the questionnaire was permitted for each person.Consent implied by the participant completion.According to a margin of error of 5%, level of confidence of 95% and power of study of 80%, the minimal sample size required was calculated to be 256 participants.Participants' confidentiality was maintained all through the process of the research and the information collected by the study instruments contained no information that can be linked to any participant.
The online survey portal, Google Form, was created and participants were invited to complete and submit the form.The process of calling the participants to share answering the survey was conducted through convenient sampling technique including physicians from all the governorates of the country, all medical specialties, all levels of postgraduate studies, and different years of work experience.

Survey developments
A questionnaire was developed by the primary author using the frequently asked questions posted on WHO website.The final questionnaire was reviewed for validity by biostatistics expert and was pilot tested on 20 subjects of the target population, who were not included in the study.Cronbach's alpha was calculated to be 0.7.
The questionnaire consisted of four parts: (1) Basic demographic data of the participants including age, gender, and work experience; (2) Sixteen multiple choice knowledge questions that tested the following knowledge aspects in relation to SARS-CoV-2 infection: basic virology; first places of outbreak; mode of transmission; incubation period; clinical symptoms; fatality; infection in special patients population; treatment, vaccination; and protective measures against COVID-19.(3) Five questions about the physicians' attitude to COVID-19 pandemic; (4) one question about the major source of information.

Statistical analysis
Data management and analysis were performed using the Statistical Product and Service Solution (SPSS) version 25 (IBM SPSS Statistics, New York, United States).Descriptive statistics were performed by reporting the number and percentages for the different categorical variables.Percentages of responses were calculated according to the number of respondents per response with respect to the number of total responses of a question.Continuous variables are expressed as mean and standard deviation (SD).Chi square test used for comparison of the categorical variables.All tests were two-tailed, p value ≤ 0.05 was considered statistically significant.

Results
A total of 256 questionnaires were completed and were included in the study.Demographic data of the study participants are summarized in table (1).Of the respondents, 123 (48%) were males and 127 (49.6%) were females.Approximately half of the respondents (51.4%) aged between 25-29 years old.The working life of 55.1% of the participants was less than 5 years, 20.7% had work experience of 5-10 years, and 24.2% had >10 years working experience.Attitude of the studied sample of physicians towards COVID-19 pandemic is detailed in table (3).About 95% (n=243) of the participants believes that COVID-19 is currently a serious public health issue and 99.2 % (n=254) believes that educating people about COVID-19 is important to prevent the spread of the disease.Tow hundreds and sixteen physician (n=216/256, 84.4%) stated that they will not do any clinical rotation in a hospital without clear COVID-19 infection control policy.About 97% (n=248) believes that HCWs must avail themselves of all information about the virus.About 83% (n=213) thought that if COVID-19 vaccine were available, they would have it.There was no statistically significant difference between male and female participants as regard their attitude.The total score for all participants is shown in table (4) , with the mean score 19.6±2.3, the minimum score was 7 points and the maximum points for the questionnaire were 23 points obtained by 13 participants.
The impact of work experience on participants' knowledge and attitude is shown in tables (5&6).Participants with > 10 years experiences had the highest knowledge in some aspects, such as being familial with Coronaviruses before this outbreak (p=0.03) and diarrhea as a possible manifestation of COVID-19 (p=0.00).Participants with ≥ 5 working life experience were aware that seasonal influenzas vaccine is not effective against COVID-19 when compared to participants with < 5 years of experience (p value= 0.03).There is no statistically significant difference between participants' attitude based on their years of experience.[18,19].Our results also coincide with Saqlain et al. who reported 93.2% of HCWs from Pakistan to have a good knowledge and positive attitude to COVID-19 [20].These findings are also in line with a study from Bangladesh that revealed good knowledge and positive attitude of doctors towards SARS-CoV-2 pandemic [21].
This satisfactory level of knowledge reported in our study group may be attributed to widespread media coverage following the COVID-19 pandemic.The pandemic of COVID-19 is very recent and therefore there are many talks about it among the HCWs and in the community.Since, the focus is more towards symptoms and prevention; this may have increased the knowledge about the disease.
Despite the knowledge about COVID-19 is generally high, there are differences in some knowledge aspects based on sex and work experience.However, Attitude did not differ with gender or work experience.Huynh et al. also found that attitude regarding COVID-19 was not associated with gender or work experience [19].
We found that almost half of the respondents (n=130, 50.8%) gathered their information from the social media channels and only 28.5% (n=73) and 19.1 % (n=49) mentioned the MOH website [24] and college of medicine as their source of information, respectively.These disappointing results were also reported by several studies [19&22].The remaining 1.6% (n=4) of our participants mentioned TV & radio as their major source of information.
Although most of the educational materials are posted online by MOH, the HCWs are now more reliant on internet technologies to gain knowledge on emerging diseases like COVID-19 [25].Hussein et al studied the impact of social media on knowledge dissemination between physicians in Egypt during COVID-19 outbreak and confirmed our findings that physicians are active users of social media (e.g.Facebook and WhatsApp) and considered them as useful platforms to spread right data about diseases during pandemics [26].However, caution must be taken when using social networks to gain healthcare knowledge because of the information overload and it is difficult to determine authenticity of the source and one can easily be misguided.It is an important issue for the Egyptian health authorities to consider official channels to update knowledge and learning materials on COVID-19.
As SARS-CoV-2 epidemic is ongoing and continues to spread, it is important to prepare health care systems to be ready dealing with this public health emergency.Our findings could be used to plan, design, and develop educational programs to ensure continuous knowledge update for the physicians aiming at handling disastrous events efficiently.Our study found gaps in specific aspects of knowledge that should be focused on in future educational programs.The participants were less knowledgeable regarding atypical presentation of the disease and only 55% (n=141/256) recognized diarrhea as a possible clinical symptom.Such unsatisfactory results highlight the need for greater efforts to raise general awareness regarding atypical symptoms of COVID-19.The training programs should also be organized according to work experience.Health authorities could consider providing smartphone-based application to provide up to date accurate health information about COVID-19 pandemic.
It is so also important to interpret the results in the context of potential study limitations.This study has several limitations.First, there is no comparable study assessing knowledge and attitude of physicians in Egypt towards COVID-19 pandemic to compare with our study; Second, because of the disease pandemic and time constraints, we were unable to conduct face-to-face interviews; third, the results are limited by the use of convenience sampling and our sample size might not be ideal to represent the awareness of all Egyptian physicians; fourth, This cross-sectional study was conducted online among physicians during a time ( 15 th -to 25 th of March 2020) when an alarming number of cases were being reported globally; this might limit generalizations.In addition, and finally, the questionnaire we used is simple that it can only provide preliminary results; further confirmation and intervention are needed.Future research studies on larger sample size should be conducted to provide data related to reporting practice, the barriers, and the needs for training amongst Egyptian physicians.

Conclusion
This study concluded that participants have satisfactory knowledge and positive attitude towards COVID-19 pandemic and self-reported infection control practices.Incorporation of teaching courses (theories and practices) to keep updated knowledge and emergency preparedness regarding COVID-19 disastrous pandemic is advised.Further studies with larger sample sizes are required to assess HCWs preparedness at national level so that effective interventions could be designed as dealing with COVID-19 as a critical global public health issue.
(2) responses to the knowledge questions are displayed in table(2).Of the participants, 67.2% (n=172) heard of Coronaviruses before this pandemic, (n=201, 78.5%) could identify the Coronaviruses family members, and (n=193, 75.4) were aware of COVID-19 basic virology.All the participants (n=256, 100%) correctly identified the incubation period and (n=209, 81.6%) correctly identified the typical clinical symptoms.Most of the participants (n=250, 97.6%) could estimate the fatality of COVID-19.Approximately 95% of the respondents knew no vaccination and 88% correctly answered that no current specific treatment for COVID-19 available.Around 98% (n=250, 97.7%) of the participants knew the recommended general infection control precautions.

Table 1 .
Baseline demographic characteristics of all participants.

Table 2 .
Answers of all participants to the knowledge questions.

Table 3 .
Attitude responses of all the study participants.

Table 4 .
The total score of all participants.

Table 5 .
Answers to knowledge questions based on respondents' experience.

Table 6 .
Attitude answers based on respondents' experience.