Knowledge of COVID-19 infection control among healthcare workers in radiology departments in Saudi Arabia

Radiological examinations have played a crucial role in the identification and management of COVID-19 patients. Therefore, knowledge and awareness of infection control among healthcare workers in radiology departments are important to prevent disease transmission. This study aimed to assess the knowledge and practice of infection control for COVID-19 among healthcare workers in radiology departments in Saudi Arabia. A cross-sectional, online questionnaire was administered among healthcare workers in radiology departments in Saudi Arabia in May 2020. The questionnaire consisted of demographic characteristics, profession, knowledge of infection control for COVID-19, and good practice of infection control measures for COVID-19 in radiology departments. A descriptive statistical analysis and chi-square test were performed using SPSS software. A total of 234 (91%) of healthcare workers replied that they have good knowledge about the precautions needed during the examination of positive COVID-19 cases in radiology departments, and 216 (84%) replied that they knew the necessary precautions when using portable X-ray machine. Moreover, 191 (>74%) of those surveyed agreed that wearing personal protective equipment and following the CDC sequence. There was significant association between profession and good clinical practices in radiology departments regarding COVID-19. Such knowledge could limit the spread of COVID-19 among the healthcare workers in radiology departments.


Introduction
Coronaviruses (CoVs) are a large group of viruses that cause respiratory infections. In the past two decades, severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV) have emerged, causing several human diseases . The current coronavirus disease 2019  was initially defined in Wuhan, China, in December 2019, and it has spread rapidly worldwide (Huang et al., 2020). On January 30 2020, the World Health Organization (WHO) declared COVID-19 to be public health emergency of international concern (Sohrabi et al., 2020). On March 2 2020, the Ministry of Health (MOH) confirmed the first case of COVID-19 in Saudi Arabia (Ministry of health in Saudi Arabia, 0000). There is currently no effective antiviral treatment or vaccine for COVID-19. Thus, decisive precautions and infection control measures were implemented early by the MOH in Saudi Arabia to prevent spread of the disease within the country (Algaissi et al., 2020;Alshammari et al., 2020;Barry et al., 2020) (Ministry of health in Saudi Arabia, 0000).
COVID-19 is transmitted from person to person through respiratory droplets and contact routes (Backer et al., 2020;Organization WH, 2020a). The most common clinical symptoms are fever, cough, and shortness of breath Huang et al., 2020;Michelen et al., 2020;. These symptoms occur within 2-14 days after exposure based on the incubation period of COVID-19 (Backer et al., 2020). The current gold standard for the clinical diagnosis of COVID-19 is the reverse transcription-polymerase chain reaction (RT-PCR) analysis of the extract from a saliva or mucus swap sample (Corman et al., 2020;Long et al., 2020). However, previous studies have reported low sensitivity of real-time RT-PCR tests in the early detection of COVID-19 (Ai et al., 2020;Fang et al., 2020;Li et al., 2020;Yang et al., 2020). In addition, the availability of the RT-PCR test and the long processing time are major concerns during this pandemic. Therefore, radiological chest examinations such as with X-ray and computed tomography (CT) scan have been suggested in recent studies for the identification and follow-up of suspected patients with COVID-19 (Ai et al., 2020;Fang et al., 2020;Long et al., 2020;Rubin et al., 2020;Xie et al., 2020). With the increasing number of infected patients, controlling the transmission of COVID-19 infections in radiology department is the most critical intervention.
During the COVID-19 outbreak, many healthcare workers (HCWs) have been infected with COVID-19 worldwide, mainly in China Gan et al., 2020;Wang et al., 2020;Xiao et al., 2020). The reason for this transmission to HCWs is that the nature of their work puts them in close contact with infected patients during examinations and their contaminated environments (Xiao et al., 2020). Because radiological examinations play a significant role in the diagnosis and management of suspected and/or laboratoryconfirmed patients with COVID-19 (Shahzeb et al., 2020;Shi et al., 2020;Zu et al., 2020), HCWs in radiology departments are expected to be at higher risk of being infected (H-W . During the previous MERS-CoV outbreak in Saudi Arabia, it was reported that radiologic technologists had the highest infection rate in hospital units in Jeddah that treated infected patients (Alraddadi et al., 2016). The main reasons for this high rate were that they had direct contact with infected patients while obtaining portable chest radiographs and lacked infection control knowledge (Alraddadi et al., 2016;Omrani & Shalhoub, 2015). Therefore, HCWs in radiology departments should be aware of infection control measures and trained in the use of personal protective equipment (PPE) to prevent the transmission of diseases .
Recently, the focus of most radiology departments is on preparedness for COVID-19 to enable their role in the diagnosis of infected patients and to maintain the optimum utilization of radiological services for the hospital as well as ensure the safety of HCWs, patients, and the population (Mossa-Basha et al., 2020;Rubin et al., 2020;Wan et al., 2020) (Ministry of health, 0000). In this regard, the WHO and Center for Disease Control (CDC) have published guidelines for HCWs about infection prevention and control of COVID-19 (Centres for Disease Control and prevention, 0000; Organization WH, 2020b). The MOH in Saudi Arabia has also defined the standard operation procedure of radiological investigations in diagnosing and/or follow-up COVID-19 patient to ensure staff, patient, and population safety (Ministry of health, 0000). Although online materials and several training courses have been offered by the WHO to increase awareness among HCWs about preventive strategies (Organization WH, 2020c) (World Health Orgnization, 0000), it is still unclear to what extent this knowledge can be put into clinical practice to reduce the spread of COVID-19 infections in radiology departments. We conducted this study to assess the infection control knowledge and practice of HCWs in radiology departments regarding patients with COVID-19 in Saudi Arabia.

Materials and methods
An online questionnaire was designed using Question pro software to assess the knowledge of infection control for COVID-19 among HCWs in radiology departments. This survey contained 25 items and was developed utilizing WHO course materials on emerging respiratory viruses, including .
The estimation of the sample size was performed using the following formula n = P (1 − P) Z2/d2, assuming an unknown prevalence of 50%, Z = 1.96, d = 0.05, confidence level = 95% (margin of error = 5%), and 80% power of the study. The calculated sample size of this study was 256 participants. The sample size was determined according to the latest report of the General Authority for Statistics (GAS), Kingdom of Saudi Arabia, 2020.
The draft survey was distributed to five experts in different geographical regions for the comprehensive evaluation of the content domain of the questionnaire. The draft evaluation was scaled from 1 to 5 points and allowed for open commentaries. In addition, the materials utilized for developing the questionnaire were provided to allow for any necessary clarifications. The readability of the questionnaire was assessed by seven faculty members who read the questionnaire for 10 minutes and scored the ease of readability from 1 − 5 (1 very easy, 2 easy, 3 standard, 4 difficult, and 5 confusing). To assess the clarity and acceptability of the survey, a pilot survey was conducted among seven HCWs who were selected randomly. Another seven HCWs were selected randomly to assess the required time and the feasibility of answering the survey questions. These participants were not included in the study. Adjustments were made in final draft as required to ensure a good understanding of the questions and to organize them before the survey distribution. Prior to the distribution, the survey was edited to remove typographic errors and standardize the formatting. The participation period lasted 1 week, from May 24 until the end of May 2020. A URL link for the final questionnaire was created using Question pro software and distributed through e-mail and social media applications to different clinical groups in 13 different regions in Saudi Arabia.
The survey covered four sections as follows: 1) demographic and characterization of HCWs, 2) the knowledge of HCWs about infection control for COVID-19, 3) the good practice of infection control for COVID-19 during clinical investigations, and 4) the main source of information related to COVID-19 for the participant.
The questionnaire consisted of four sections and 25 questions, and all were multiple choice and were free text. The first section referred to general demographic information, such as gender, age group, region, qualification, and years of experience in diagnostic radiology. The second section asked about the participants' employment information, including their job description, the region of their institution, and if their institution was an authorized center for dealing with COVID-19. This section also included questions related to the participants' knowledge of infection control in diagnostic radiology. The third section contained questions about the participants' knowledge of the good practice of infection control measures when working with patients with COVID-19. This included questions related to following the guidelines for the center for disease control and prevention (CDC) sequence for the 'donning and doffing' of personal protective and equipment (PPE). The last section addressed the participants' source of COVID-19 information. All data were inserted into an Excel spreadsheet (Microsoft Office) for analysis.

Inclusion and exclusion criteria
The participants included male and female (Saudi and non-Saudi) employees in 13 regions of Saudi Arabia. The age of the participants ranged from 20 to 60 years. Other HCWs at hospitals such as lab technologists, pharmacists, and dentists were excluded from this study.

Statistical analysis
A descriptive cross-sectional design was adopted for this study. Descriptive statistics and graphical presentations of the survey data were expressed as frequencies and percentages. Comparisons of categorical data between groups were performed using Pearson's chisquare analysis or an exact analysis when expected cell counts were less than five. In all analyses, P < 0.05 was considered significant. All statistical analyses were performed using Package for Social Science (SPSS) statistical software, version 22.

Ethical considerations
During the study, the confidentiality of personal information was maintained by keeping the participants' information anonymous. Electronic informed consent was obtained from each participant on the first page of the survey. All participants were asked to answer the questions honestly. The participation of HCWs in this survey was completely voluntary and not compensated. This study followed the declaration of Helsinki principles revised in 2013. Moreover, it followed the checklist for reporting the results of internet E-surveys (CHERRIES) guidelines (19).

Knowledge of HCWs about COVID-19 infection control practices
Most of the responses (163, 64%) were 'yes' for the question about having previous experience in dealing with a pandemic/epidemic (Table 2). A total of 234 (91%) of the HCWs replied that they had knowledge of the precautions needed during the investigation of positive COVID-19 cases in radiology departments, and 216 (84%) reported having such knowledge when using a portable X-ray machine (Table 3). Moreover, for CT and MRI units, 172 (67%) of the radiology staff members stated they knew how to prepare the types of disinfectants, including the medium level and high level types, for disinfecting the sectional imaging rooms ( Table 3). The responses to the question about the types of contact and spray precautions needed during a radiological examination for patients with COVID-19 revealed that 199 (77%) participants knew the precaution protocols. Because facial protection instruments are vital during routine X-ray exams and in some radiology departments they are not available because of their high cost, most of the participants (159, 62%) stated they knew how to complete the exams without them (Table 3). The statistical analyses revealed there was a significant association between profession and knowledge of COVID-19. A majority of radiologic technologists agreed that they knew about the types of disinfectants and their use for the radiology equipment (p = 0.001). Moreover, they reported having sufficient knowledge about the types of contact and spray precautions needed during the radiological examination of an infected patient (p = 0.046) and the precautions needed to perform a routine X-ray examination if the safety materials were unviable (p = 0.001) ( Table 3).

The good practice of infection control of COVID-19 during clinical investigations
Overall, a high percentage of 223,(87%) of the participants responded that they followed infection control measures and precaution policies before and after each exam in their radiology department. More than 169 (66%) of the HCWs stated that they followed the rules by screening the patients at the radiology front desk and taking the appropriate precautions before, during, and after each radiology exam (Table 4). Moreover, 149 (58%) participants stated that putting on a surgical mask would be helpful to prevent COVID-19 transmission. Most of the radiographic technologists replied that they were aware of the importance of following the CDC sequence for PPE, and 191 (>74%) agreed that wearing PPE and following the CDC sequence can prevent the spread of COVID-19 from infected patients to radiology staff (Table 4). There were significant associations between profession and good clinical practices of infection control regarding COVID-19 in the radiology department (p < 0.05).

Participants' main source of information about COVID-19
This section asked the participants about their sources of information about 1) COVID-19 in general and 2) preventing the transmission of COVID-19 among professionals in radiology departments. Official media platforms and their websites (e.g., TV, radio, and newspapers) received the most responses 51(20%) about the primary source for information on the two points. Periodical medical meetings in the organization, internal newsletters, colleagues, and international organizations such as the WHO accounted for 46 (<18%) responses about the primary source of general information and information about preventing the COVID-19 pandemic (Figure 1).

Discussion
To the best of our knowledge, this is the first study to assess the knowledge and practice of COVID-19 infection control among HCWs in radiology departments in Saudi Arabia. The results of the present study indicated that there is a good knowledge of infection control measures with patients with COVID-19 among HCWs in radiology departments. In addition, there was a significant association between HCWs' profession and their knowledge of COVID-19 and good clinical practices of infection control measures. The most common sources of COVID-19 information and prevention policies were official media platforms and the websites of the hospital/MOH.
The findings of the current study demonstrate that the majority of the respondents knew the required infection control precautions needed during radiological examinations of suspected and/or positive COVID-19 cases and when using a portable unit. In the previous MERS-CoV epidemic in Saudi Arabia, HCWs had less knowledge about MERS-CoV infection control (Alsahafi & Cheng, 2016;Nour et al., 2015;Rabaan et al., 2017). In another study, Alraddadi et al (Alraddadi et al., 2016) reported that the highest infection rate was among radiographic technicians because of their lack of infection control knowledge while imaging infected patients. As a sign that a lesson was learned from the previous epidemic in Saudi Arabia, we found that most HCWs in radiology departments had attended a training course about infection prevention and control to improve their knowledge. In addition, the majority of the surveyed HCWs were working in an authorized facility for patients with COVID-19; therefore, radiology departments followed infection control measures and precaution policies for each examination.   (17) 18 (29) 23 (37) 10 ( 63 (40) 37 (23) 14 (9) 159 Radiologist 11 (17) 24 (38) 22 ( We also analyzed the association between profession and HCWs' knowledge of COVID-19 infection control in clinical practice in radiology departments. The results showed that the majority of radiographic technologists agreed that they knew about the types of disinfectant used for the radiology equipment, especially for CT and MRI scans. They also had sufficient knowledge about the precautions needed to perform a routine X-ray examination when eye protective glasses or face protective instruments were unavailable in the radiology department. This critical knowledge among radiographic technologists in our study could be explained by their work experience in dealing with different imaging modalities, clinical training for imaging patients with COVID-19, and previous experience with the MERS-CoV pandemic in Saudi Arabia. In our study, most of the surveyed HCWs were radiographic technologists, their age ranged from 25 to 50 years old, and they had more than 10 years of experience in the field. These factors could explain their sufficient knowledge of infection control. This is in line with the findings from a previous study in Saudi Arabia that indicated that age, specialty, and work experience were significantly associated with infection control knowledge of MERS-CoV among HCWs (Nour et al., 2015). Similarly, Ayinde et al (Ayinde et al., 2020) and Giao et al (Giao et al., 2020) reported that profession was significantly associated with HCWs' knowledge of COVID-19. This sufficient knowledge had a positive impact on HCWs' attitudes toward COVID-19 prevention (Ayinde et al., 2020;Giao et al., 2020).
The present study revealed good practices of infection control among radiographic technologists during the outbreak compared with other HCWs in the radiology department. We found that the majority of the radiographic technologists reported wearing the recommended PPE for each radiological examination regardless of the patient's infection status during this pandemic. This good practice indicates their high level of knowledge about the appropriate use of PPE such as isolation gowns, surgical masks, and gloves while imaging patients to protect against the new virus. These findings agree with those from a study in China showing that professional categories and work experience significantly influenced HCWs' practices regarding COVID-19 .
The results of our study also showed that most of the HCW professions agreed that their radiology departments followed the COVID-19 infection control measures and precaution policies before and after each exam. These infection control measures included screening each out-patient at the front desk of the radiology department and performing a deep cleaning of all radiology offices and workstations. These guidelines were in line with recent recommendations for infection control of COVID-19 in radiology departments (Kooraki et al., 2020;Mossa-Basha et al., 2020;Nasir et al., 2020;Wan et al., 2020;Yu et al., 2020). Thus, the sufficient COVID-19 knowledge and good practice of control measures by HCWs in radiology departments found in this study are likely related to the protection-associated materials and policies of the MOH that have aided the frontline HCWs in Saudi Arabia during this pandemic (Ministry of health, 0000). As a result, HCWs in radiology departments were more confident in their knowledge of and ability to protect against the virus.
We found that the majority of the respondents obtained their information about COVID-19 and preventive procedures through official media platforms such as TV, radio, and newspapers and their hospital and MOH websites. This finding is consistent with previous studies that assessed HCWs' knowledge and perceptions of COVID-19 (Bhagavathula et al., 2020;Giao et al., 2020;Saqlain et al., 2020). Although there is a vast amount of information currently available on the internet, a major concern during this pandemic is the worldwide spread of misinformation causing xenophobia (Bhagavathula et al., 2020). Thus, information regarding COVID-19 and prevention strategies on the MOH and hospital websites should be updated regularly to ensure the delivery of correct information to HCWs. To effectively control the spread of the disease within the country, educational training programs must be offered to all HCWs in hospitals to increase their existing knowledge.
The major strength of the present study is that our findings indicate that HCWs possess important knowledge during this outbreak and demonstrate that the major infection control procedures are followed in radiology departments in Saudi Arabia. Another strength of this study is that it included participants who are working in radiology departments during this pandemic in different regions in Saudi Arabia. However, this study has some limitations that must be considered when interpreting the results, including there has been limited research on COVID-19 infection control for comparison. It remains unclear how many HCWs have been infected with COVID-19 in radiology departments. Further analyses and data are needed to understand the specific situation of HCWs who have been infected during their work (Xiao et al., 2020). Moreover, additional studies on infection control expanded to include general HCWs in Saudi Arabia, including nurses, physicians, and doctors in other departments, are needed. The information obtained from such studies could help to design appropriate interventions at the national level.

Conclusion
There is a good knowledge and practice of infection control among HCWs in radiology departments in Saudi Arabia. The radiology staff responses showed that they are following infection control measures and precaution policies before and after each radiology exam in the department. Such knowledge could limit the spread of COVID-19 among the HCWs in radiology departments.