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\title{COVID-19: Public Health Implications among Healthcare Workers in a Tertiary Health Facility in Enugu State, Nigeria}
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             \author[1]{Nwoga Hope  O}

             \author[2]{Ajuba Miriam  O}

             \author[3]{zeoke Uche  E}

             \affil[1]{  Enugu State University}

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\date{\small \em Received: 10 December 2019 Accepted: 5 January 2020 Published: 15 January 2020}

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\begin{abstract}
        


Background: Coronavirus is one of the emerging respiratory viruses that are known to cause diseases in humans. It causes a range of illnesses ranging from the common cold to Severe Acute Respiratory Syndrome (SARS).Objectives: To assess the knowledge, attitude, and practice of healthcare workers in a tertiary health facility towards COVID 19 pandemic and also the perceived barrier to the control of the infection in a healthcare setting. Methodology:The study was a descriptive cross-sectional study that involved all the healthcare workers (HCWs); (doctors, nurses, laboratory scientists) working in a tertiary health facility. Data from the doctors and laboratory scientists were gathered with an online questionnaire formulated in Google form.

\end{abstract}


\keywords{COVID-19, healthcare workers, Enugu State, Nigeria, tertiary health facility.}

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\section[{Introduction}]{Introduction}\par
oronavirus is one of the emerging respiratory viruses that are known to cause diseases in humans. \hyperref[b0]{1} It is a zoonotic infection that can be transmitted from animal-to-human and then human-to-human. \hyperref[b1]{2} The most recent outbreak of coronavirus disease 2019 (COVID-19) in Wuhan City, Hubei Province, China, has emerged as a global outbreak and significant public health issue. \hyperref[b2]{3} Coronaviruses outbreaks have been recorded previously such as Severe Acute Respiratory Syndrome-Coronavirus (SARS CoV) and Middle East Respiratory Syndrome-Coronavirus (MERS-CoV) in 2003 and 2015, which are similar to the present novel coronavirus SARS CoV 2 (COVID- 19). COVID-19 was first reported in December 2019 among patients with viral pneumonia symptoms in Wuhan City, Hubei Province; China. \hyperref[b1]{2,}\hyperref[b3]{4} Due to the rapid spread of the virus from the source to many other countries of the world, the World Health Organization (WHO) declared it a Public Health Emergency of International Concern (PHEIC) on January 30, 2020. The first case of COVID-19 in Nigeria was recorded on 27 February 2020, and as of the 29 th of September 2020, there were about 58,647 confirmed cases with 1,111 confirmed deaths. Globally there were about 33, 249, 563 cases with 1,000,040 deaths as of 29 th September 2020. \hyperref[b4]{5} Coronavirus is most contagious during the first three days after onset of symptoms, however, spread may be possible before symptoms appear and in later stages of the disease. \hyperref[b7]{8} It can survive on surfaces for up to 72 hours. \hyperref[b7]{8} The best prevention for COVID-19 is to avoid being exposed to it. The recommended measures to achieve this include frequent hand washing, However, on the 11th of March 2020 the WHO declared COVID-19 a global pandemic due to its fast spread, increase in the number of countries affected, the severity of illness, and the continuous escalation in the number of cases and causalities. \hyperref[b5]{6} Coronavirus spreads mainly from person to person through close contact with infected person through respiratory droplets (coughs or sneezes) or by touching a surface or object with the virus on. The WHO reported that more than 80\% of COVID-19 patients showed mild symptoms and recovered without any medical intervention, approximately 20\% of infected cases had a severe illness such as shortness of breath, septic shock, and multi-organ failure while an estimated 2\% of the cases can be fatal. 6 The elderly, especially those with underlying chronic diseases are at an increased risk of having severe disease. maintaining physical distance from others (especially from those with symptoms), covering coughs and sneezes with a tissue or inner elbow, keeping unwashed hands away from the face using face masks, isolating confirmed and suspected cases. \hyperref[b8]{9} Healthcare Workers (HCWs) are primarily involved in caring for patients with this highly contagious virus (COVID- 19), and it has posed a serious occupational health risks to the HCWs owing to their frequent exposure to infected individuals in the course of their duty. \hyperref[b9]{10} Protection of HCWs and prevention of intrahospital transmission of infection are important aspects in epidemic response, and this requires that HCWs must have updated knowledge regarding the source, transmission, symptoms, and preventive measures. \hyperref[b10]{11} Literature suggests that lack of knowledge and misunderstandings among HCWs leads to delayed diagnosis, the spread of disease, and poor infection control practice. \hyperref[b11]{12} Thousands of HCWs have already been infected. Knowledge, attitude, and practice survey like the present study provide a suitable format to evaluate existing programs and protocols and to identify effective strategies for behavioral change both in the hospital setting and in the society at large. \hyperref[b12]{13} II. 
\section[{Methodology}]{Methodology}\par
The study was a descriptive cross-sectional design conducted at Enugu State University of Science and Technology, Enugu, Nigeria. It is one of the tertiary health institutions in Enugu State. It is located at the heart of Enugu town. 
\section[{a) Study population}]{a) Study population}\par
All the consenting HCWs (doctors, nurses, and laboratory scientists) in the hospital were used for the study. There were about 426 HCWs (doctors, nurses, and laboratory scientists) in the hospital as at the time of data collection and, they were reached for the study. 
\section[{b) Data collection}]{b) Data collection}\par
The data for the doctors and laboratory scientists were collected using an online questionnaire formulated with Google form. This was shared through the different doctors' and laboratory scientists' online platform (WhatsApp). The data for the nurses was collected using the same semi-structured self -administered questionnaire shared through the head nursing services to all the nurses. This was so because there was no online platform where all the nurses in the hospital belong.\par
The questionnaire was formulated after extensive literature review and, according to WHO recommendations on modes of transmission and prevention of COVID-19. \hyperref[b6]{7} The questionnaire had five sections. The first section was on socio-demographic characteristics of the HCWs, the second section was on knowledge, the third was on attitude, the fourth on practice, and the fifth on perceived barrier to control of COVID-19 in healthcare settings. Eleven questions were used to access the HCWs knowledge of COVID-19. A correct answer scores one while a wrong answer scores 0. The higher the score the, more knowledgeable the HCWS is. Twenty-one questions were used to assess the attitude of the HCWs. A correct answer scores one while an incorrect answer scored 0. Some of the questions were reversed to eliminate the bias of giving a single similar response in all the questions. Thirteen questions were used to access the practice score using\par
The perceived barrier to control of COVID-19 was accessed using nine questions. A correct answer scores one while a wrong answer scores 0. The higher the score the, more the barrier to control of COVID-19 in hospital settings 
\section[{c) Data analysis}]{c) Data analysis}\par
All the questionnaires were examined for completeness and all the completed ones were entered into SPSS version 25. All the responses in Google form were also entered into SPSS version 25. The data were edited for errors by generating frequencies. The categorical variables were summarized using frequencies and percentages. The significance level was placed at ? 0.05. The knowledge, attitude, and practice scores were categorized into good and poor. Blooms cut-off criteria 14 of 80\% were used to indicate good knowledge (?8.8), attitude (?16.8) and practice (?10.4) towards COVID-19, while less than these cut-offs were categorized as poor.  All the HCWs have heard about COVID-19, and their major source of information was mass media (93.2\%) and the internet (90.6\%). About 90.2\% of the HCWs knew the incubation period of the virus and, the majority also knew the modes of spread. However, about 27.7\% believe that the virus can be spread by goods imported from China. The majority knew the common symptoms, but only 22.6\% knew that loss of taste could be a symptom of COVID-19. About 77.0\% asserted that all COVID-19 patients develop a severe acute respiratory illness. On the knowledge of the preventive measures, all the HCWs knew that proper and regular hand washing with soap could prevent COVID-19. The majority also knew the other preventive measures like the use of hand sanitizers, social distancing, wearing of face mask, and good cough etiquette. However, 39.6\% believe that eating garlic, ginger, and other local herbs can prevent COVID-19. 
\section[{III.}]{III.} 
\section[{Results}]{Results}\par
On the categorization of knowledge scores, only 59.1\% of the HCWs had good knowledge of COVID-19. Table \hyperref[tab_5]{5} shows the perceived barrier to control of COVID-19 in a hospital settings. The major perceived barrier to effective control of COVID-19 in the hospital setting was the unavailability of PPEs like splash proof aprons (91.1\%) and goggles (89.8\%) followed by overcrowding in emergency rooms (87.7\%), clinics, and wards (88.1\%). Others were insufficient training on infection control (80.9\%) and a lack of policies on infection control (74.5\%). 
\section[{IV.}]{IV.}\par
Discussion COVID-19 is a global health problem that is affecting every aspect of human life. HCWs being at the forefront of the fight against the infection, are faced with a high likelihood of being infected with the infection than the general population. \hyperref[b14]{15,}\hyperref[b15]{16} This is one of the reasons why the WHO have recommended the adoption and use of proper prevention and control measures for HCWs. This includes the use of proper Personal Protective Equipment (PPE), such as face masks, splash-proof gowns, gloves, eye goggles, and FFP2 respirator masks in aerosol-generating procedures. \hyperref[b16]{17} In this study, about 59.1\% of the HCWs had good knowledge of COVID-19 including its incubation period, mode of transmission, common symptoms, and preventive measures. This knowledge score was not optimal as knowledge helps to form one's attitude, promote productive behaviors and affect their coping mechanisms towards specific events. \hyperref[b17]{18} The score was, however, similar to the report of a similar study in Uganda where 69\% of the HCWs had good knowledge of COVID-19 \hyperref[b18]{19} but lower than the report of other studies in China. \hyperref[b20]{20,}\hyperref[b21]{21} Better knowledge among these HCWs may be due to better training on COVID-19.\par
Further education, training, and retraining of HCWs through continuous professional education, particularly on the common symptoms, modes of transmission, and prevention will help in improving the knowledge of the HCW about COVID-19. The commonest source of information on COVID-19 was the mass media like television, radio, newspapers (93.2\%), followed by the internet (90.6\%). This indicates that such media should be used to disseminate information about COVID-19 to reach the majority of the HCWs.\par
The delivery of rapid, reliable information that addresses critical infection control measures was of key importance, e.g., poor hospital infection prevention and control measures, inadequate training in infection control processes, poor compliance with the use of personal protection equipment (PPE), exposure to highrisk procedures such as tracheal intubation and exposure to unsuspected SARS patients are known to be associated with a high risk of transmission of viral infections to healthcare workers. \hyperref[b22]{22,}\hyperref[b23]{23} The aim of information dissemination is to transfer knowledge of international best practices to the front-liners who need it most, at a rate equal to or faster than the increasing epidemic. The use of social media have shown to be a faster means as concurred by another literature. \hyperref[b24]{24} However, there has been worries about misinformation regarding COVID-19 on the internet, which can misguide HCWs because the internet is not without disadvantages. It is, therefore, necessary that before use, healthcare workers must critically appraise the information contained. \hyperref[b25]{25} In particular, health authorities and scientists have warned that widespread misinformation about COVID-19 is a serious concern causing xenophobia worldwide.  {\ref 26, 27,} In this regard, HCWs should carefully evaluate COVID-19-related information and should use scientific and authentic content as information sources.\par
The only factor that significantly affected the knowledge of COVID-19 in the present study was occupation where the nurses (64.2\%) and the laboratory scientists (63.6\%) were found to have better knowledge scores than the doctors (25.8\%). This was surprising as doctors, by their training, were supposed to have a better knowledge of COVID-19 compared to other HCWs. However, a similar study reported that doctors had better knowledge than the other HCWs. \hyperref[b21]{21,}\hyperref[b28]{28} One notable point on the HCWs knowledge of the mode of spread of COVID-19 is that about 27.7\% asserted that COVID-19 could be contacted from goods imported from China. This can affect the use of aids and other products from China for the prevention of COVID-19 and have a negative impact on the general control measures. Also, 39.6\% agree that eating ginger, garlic, and local herbs can prevent COVID-19 infection. This misconception can delay seeking medical advice and result in fatal outcomes for COVID-19 cases. Awareness of the mode of spread and prevention should be heightened among the HCWs as the general public also depend on the information given by the HCWs.\par
In the present study, only 43.4\% of the HCWs had good attitude toward COVID-19. This poor attitude of HCWs towards COVID-19 was reported in a similar studies in Uganda, where only 21\% of them had a good attitude toward COVID-19. \hyperref[b18]{19} The similarity may be because both studies were done in Africa with similar beliefs and attitudes.\par
About half (50.6\%) of the HCWs believe that the virus was initially designed as a biological weapon. This finding was similar to the report of a Nigerian study where 46.9\% of the respondents had a similar view. \hyperref[b29]{29} About 56.6\% are worried that their family member may contact COVID-19. This was lower than the report of a similar study where 79.8\% of the HCWs are worried that their family member may contact COVID-19. \hyperref[b20]{20} However, there was a good attitude towards some of the individual elements of attitude. About 95.7\% believe that self-protection is necessary for the protection of others, 90.2\% follow update about COVID-19 in Nigeria, 90.2\% are willing to attend lectures on COVID-19 if organized around them, and 96.2\% believe that COVID-19 can be controlled by following standard precautions for infection control. A similar study in Egypt reported a similar finding where 95.6\% of the studied HCWs asserted that following standard precautions can prevent infection transmission. \hyperref[b30]{30} The majority of the HCWs (93.2\%) in the present study had good preventive practices towards COVID-19. They reported to follow standard precautions for infection control and follow the WHO hand washing technique. Good knowledge and practice of standard precautions including good cough etiquette, have been shown to reduce infection transmission in hospitals. \hyperref[b31]{31} The finding in this study was, however, higher than what was reported in another study in Uganda. \hyperref[b18]{19} The commonest perceived barriers to effective infection control were overcrowding in the clinics, wards, and emergency rooms; thus, the HCWs were not able to maintain a safe distance from their patients. This will lead to an increase in infection transmission. An Egyptian study reported that crowdedness and poor ventilation were factors that make HCWs more susceptible to infection than the general population. \hyperref[b30]{30} An Iranian study reported that physicians (67\%), nurses (24\%), and operating room staff (100\%) did not keep a one-meter distance from patients due to lack of space. \hyperref[b32]{32} Other barriers were the unavailability of infection control supplies, especially the Personal Protective Equipment's (PPEs). This was reported in similar studies in Iran \hyperref[b32]{32} and China \hyperref[b33]{33} where lack of these PPEs was reported to be one of the reasons for infection of HCWs with COVID-19. A Nigerian study conducted in primary and tertiary health facilities showed that there is poor availability of infection control supplies in the studied facilities. \hyperref[b34]{34} This strengthens the finding in the present study.\par
Insufficient training on infection control and lack of knowledge on the mode of transmission of COVID-19 were also reported barriers to its control. This was not surprising as COVID-19 is a novel virus that was not well understood at the onset of the pandemic. It calls for training and retraining of HCWs on such novel diseases once they come up to reduce its transmission in hospital settings. This lack of knowledge by the HCWs has been reported in other studies as a significant factor in the transmission of infection in hospitals. \hyperref[b35]{35}  
\section[{a) Limitations}]{a) Limitations}\par
The data presented in our study were selfreported and partially dependent on the participants' integrity and recall ability; thus, they may be subject to recall bias. However, in despite of this limitation, our findings present valuable information on the knowledge, attitudes, and practice of HCWs during a peak period of COVID-19.\par
V. 
\section[{Conclusion}]{Conclusion}\par
The advancing global threat of COVID-19 indicates that greater efforts through educational campaigns that target HCWs and the wider population are highly needed. This can be done using more effective social media.\begin{figure}[htbp]
\noindent\textbf{1} \par 
\begin{longtable}{P{0.4157608695652174\textwidth}P{0.17554347826086955\textwidth}P{0.25869565217391305\textwidth}}
Variable\tabcellsep Frequency\tabcellsep Percentage\\
Age\tabcellsep \tabcellsep \\
20-29\tabcellsep 13\tabcellsep 5.5\\
30-39\tabcellsep 113\tabcellsep 48.1\\
40-49\tabcellsep 79\tabcellsep 33.6\\
50-59\tabcellsep 28\tabcellsep 11.9\\
Above 59\tabcellsep 2\tabcellsep 0.9\\
Gender\tabcellsep \tabcellsep \end{longtable} \par
 
\caption{\label{tab_0}Table 1 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{2} \par 
\begin{longtable}{P{0.85\textwidth}}
Variable\end{longtable} \par
 
\caption{\label{tab_1}Table 2 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{2} \par 
\begin{longtable}{}
\end{longtable} \par
 
\caption{\label{tab_2}Table 2}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{3} \par 
\begin{longtable}{P{0.7234261501210654\textwidth}P{0.06585956416464891\textwidth}P{0.06071428571428571\textwidth}}
Variable\tabcellsep \multicolumn{2}{l}{Yes Frequency Percentage}\\
You think you can contact COVID-19\tabcellsep 82\tabcellsep 34.9\\
Worried that a family member may contact COVID-19\tabcellsep 133\tabcellsep 56.6\\
COVID-19 infection is associated with stigma\tabcellsep 195\tabcellsep 83.0\\
Media coverage is exaggerated\tabcellsep 93\tabcellsep 39.6\\
The virus was initially designed as a biological weapon\tabcellsep 119\tabcellsep 50.6\\
It is a plague caused by sin and unbelief\tabcellsep 44\tabcellsep 18.7\\
Designed to control population\tabcellsep 47\tabcellsep 20.0\\
Designed by pharmaceutical companies to sell drugs\tabcellsep 21\tabcellsep 8.9\\
COVID-19 can be successfully controlled\tabcellsep 179\tabcellsep 76.2\\
Self-protection is necessary for the protection of others\tabcellsep 225\tabcellsep 95.7\\
Lockdown is an effective control measure\tabcellsep 183\tabcellsep 77.9\\
Nigeria can win the battle against COVID-19\tabcellsep 190\tabcellsep 80.9\\
If I contact a person infected with COVID-19 I will inform NCDC\tabcellsep 216\tabcellsep 91.9\\
If I have symptoms of COVID-19 I will inform NCDC\tabcellsep 208\tabcellsep 88.5\\
If I have contact with an infected person I agree to be isolated at home\tabcellsep 210\tabcellsep 89.4\end{longtable} \par
 
\caption{\label{tab_3}Table 3 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{4} \par 
\begin{longtable}{P{0.85\textwidth}}
Variable\end{longtable} \par
 
\caption{\label{tab_4}Table 4 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{5} \par 
\begin{longtable}{P{0.85\textwidth}}
Variable\end{longtable} \par
 
\caption{\label{tab_5}Table 5 :}\end{figure}
 			\footnote{COVID-19: Public Health Implications among Healthcare Workers in a Tertiary Health Facility in Enugu State, Nigeria} 		 		\backmatter   			 
\subsection[{Acknowledgment}]{Acknowledgment}\par
We thank all the study participants for their voluntary participation and for the provision of essential information. 			  			 \par
Authors' contributions: NHO designed the study, developed the questionnaire, collected the data, analysed the data, and prepared the manuscript. MOA also collected data, conducted the pre-test, conducted the literature review.EUE contributed to literature review and filtered the data. All the authors read and approved the final manuscript. 
\subsection[{Funding: No source of funding}]{Funding: No source of funding}\par
Competing interests: The authors declare that they have no competing interests			 			  				\begin{bibitemlist}{1}
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