Healthcare workers knowledge and diagnostic practices: a need for dengue and chikungunya training in Moshi Municipality, Kilimanjaro Tanzania

Dengue and chikungunya virus diseases are becoming an increasingly important global health threats and are continuously expanding their geographical range. The study aims to investigate knowledge and diagnostic practice of dengue and chikungunya fever among healthcare workers in Moshi Municipality. Most of healthcare workers heard of chikungunya and dengue 146 (71.2%) and 203 (99%) respectively. Ninety-five (46.3%) and 152 (74.1%) had good knowledge regard chikungunya and dengue respectively. One hundred and twenty-two of HCWs 122 (59.5%) reported that there is no vaccination for dengue virus. Most HCWs 199 (97.0%) reported that the absence of diagnostic tool for dengue virus lead to difficult in managing the infection. The finding of this study showed that there is insufficient knowledge regarding chikungunya while knowledge regarding dengue is relatively fair. This calls for training regarding these infections.


Introduction
Chikungunya and dengue are currently among the important Arbovirus. Chikungunya fever is caused by the chikungunya virus of the family Togaviridae and genus Alphavirus and dengue fever is caused by the virus of the genus Flavivirus the family Flaviviridae. Both infections are transmitted between human by the bite of infected Aedes aegypti and to a less extent Aedes albopictus [1][2][3]. Dengue has rapidly spread in all World Health Organization (WHO) regions in recent years [4]. It is estimated that over 50% of the world's population is at risk of dengue infection [4], with prediction of almost 400 million dengue infections occurring each year [5]. Notwithstanding increasing reports of chikungunya infections in different parts of the world, detailed information on the global population at risk remains sparse, however it is estimated that 1.5 billion of the world population is at risk of chikungunya infection [6], with 2 million infections annually [7].
Given the time when dengue-like illness were detected, one would expect adequate knowledge on diagnostic practices of this disease among health care workers (HCWs). However, studies indicate that understanding and diagnosing dengue vary considerably. For example, a study done in government and private hospitals as well as clinics in Karachi indicated that 100% of the doctors were aware about dengue viral infection but lack knowledge about its diagnosis (72%) and management, while 50% of doctors wanted to isolate the patient [8]. Another study reported that a large number of physicians lacked knowledge of the probable diagnosis of dengue and the appropriate time to discharge the patients [9]. A recent systematic review found that risk perceptions, attitudes, and knowledge of chikungunya among the public and health professionals vary across populations and countries and knowledge is higher in areas that have experienced an outbreak [10]. Although dengue and chikungunya are reported to prevail in Tanzania [11][12][13][14], challenges in diagnosing dengue and chikungunya are still reported in Tanzania [13,[15][16][17][18]. Previous research focused on status of exposure to dengue and chikungunya viruses; however, there have been few attempts to date to better understand the knowledge, attitude and practices among HCWs. These studies have been conducted mainly in Kilosa Morogoro [19] and Hai Kilimanjaro [20]; to our knowledge, no studies to date have been conducted in Moshi, Kilimanjaro.

BMC Research Notes
Tanzania has seen a surge of dengue infections since 2010, therefore, there is increasing need for skilled HCWs in managing dengue. Understanding how HCWs manage suspected cases of dengue is crucial to improving patient outcomes. HCWs who interact directly with patients have an important role in both treating and preventing the spread of dengue [21]. Therefore, the aim of this study was to determine knowledge and diagnostic practices regarding dengue and chikungunya among HCW in health facilities in Moshi Municipality. The sampling technique for this study was non-probability convenience sampling. In this technique the HCWs that were present in particular health facility at the time of data collection were interviewed after consultation with the head of heath facility.

Material methods
Face to face interviews were conducted using structured questionnaires with questions specifically designed for HCWs. Interviews were conducted in English and Swahili language.
The study instrument was developed following an extensive review of the literature. The questionnaire was pretested among two separate groups of 5 residents in Kilimanjaro Christian Medical University College and nurses who were excluded from the main study. Inputs from the residents were then used to refine the questionnaire. The questionnaire covered the following areas: (1) demographic information (facility, sex, age and occupation), (2) health information relating to whether the respondent had heard chikungunya and dengue disease or not, (3) knowledge about chikungunya and dengue symptoms, signs, and transmission modes, (4) diagnosis and treatment of chikungunya and dengue.
Knowledge of dengue and chikungunya was quantified using knowledge score as described by Itral et al. and Al-zurfi et al. with few modifications [22,23]. For HCWs, good knowledge was assessed as participants answered questions correctly pertaining to signs, symptoms, and diagnostic practices for dengue and chikungunya. Correct answers for knowledge item were coded as "10" while incorrect answers were coded as "0". The total knowledge ranged from 0 to 100 with scores of ≥ 40 or higher being considered as "good" and < 40 and below being considered as "poor".

Statistical analyses
Data were analysed using Statistical Package for Social Sciences 20.0 software (SPSS Inc., Chicago, USA). Descriptive statistics are presented as proportions for categorical data. Mean knowledge score was calculated using student t test. Univariate analysis was performed by logistic regression. A significance level of ≤ 0.05 was used throughout.

Knowledge score difference regarding dengue and chikungunya among HCWs in Moshi Municipality
Among the HCWs, few participants (95/205; 46.3%) had good knowledge with regarding to chikungunya fever (knowledge score of 40 and above) with the mean knowledge score of (Mean ± SD) 31.7 ± 18.9. Also 152 (74.1%) had good dengue knowledge score with the mean knowledge score of (Mean ± SD) 43.6 ± 13.2 Fig. 1.

Diagnostic practices regarding chikungunya and dengue
HCWs were asked several questions concerning diagnostic practices of chikungunya and dengue in the health facilities. Most of HCWs (123/205; 60%) didn't know if there is vaccine for chikungunya virus while (77/205 37.6%) reported absence of vaccine for chikungunya. Two (1.0%) reported that there diagnostic tools for chikungunya and almost all HCWs (195/205; 95.1%) reported that the absence of diagnostic tools for chikungunya virus lead to difficulties in managing the infection (Table 2).
One hundred and twenty-two of HCWs (59.5%) reported that there is no vaccine for dengue virus. One  Table 2).

Analysis of the association between chikungunya knowledge score and Socio-demographic characteristics
The results of univariate analysis of the selected predictors and chikungunya or dengue knowledge score are shown in Additional file 1: Table S1. None of the selected predictors were associated with chikungunya or dengue knowledge.

Discussion
This study aimed to assess knowledge and diagnostic practices regarding dengue and chikungunya among HCWs in Moshi Municipality. This study identified knowledge gaps among HCWs that should be targeted to improve the HCWs ability to practice and manage dengue and chikungunya infections. For control and management of diseases a good knowledge about aetiology, mode of transmission, management and control is needed. This study found that the good knowledge regarding chikungunya was 46.3%. This level of knowledge was not satisfactory among HCWs. HCWs are expected to be knowledgeable about diseases as this knowledge could have been obtained in medical schools. Findings of this study was higher as compared with the study conducted in other District but the same Kilimanjaro region, which reported a overall knowledge to be 2.4% [20]. Slightly higher knowledge in this could be due to several reports of the disease in Tanzania [11,13,15,17], and outbreak in nearby country where outbreaks of chikungunya had occurred at Lamu and Mombasa in 2004 [24]. A current study reported high dengue knowledge as compared by a study conducted by Kajeguka et al. [20]. The high knowledge of dengue among HCWs could be due to knowledge after the outbreak in the capital city Dar es Salaam in 2014 [25]. The outbreak created awareness to most of people in Tanzania. The same scenario has been reported in Singapore [26].
It is important to note that while majority of the HCWs were aware of dengue, a proportion of the respondents hold wrong notions about the cause, symptoms, transmissions and treatment of dengue. The HCWs didn't know the treatments of the infections as most of them reported the treatments of infections as antiviral or antimalarial drugs. In a study of hospitalised febrile patients in northern Tanzania, most febrile illnesses like dengue and chikungunya were treated as malaria and some cases with antibacterial [13].

Conclusion
There is insufficient knowledge regarding chikungunya fever among HCWs in Moshi Municipality. In view of this result, government and other non-government organizations should revisit the medical school curriculum especially in areas where vector borne diseases are prevalent. Refresher training of HCWs should be conducted regularly to improve their technical skills and build their capability.

Limitation
Our results have some limitations. It is possible that some respondents might have provided desirable responses to some questions, since the study was a face to face interview. The study included a number of HCWs from Moshi Municipality, Small sample size which is limited only to HCWs from Moshi Municipality, hence finding are not nationally representative and cannot be generalized across the country.

Additional file
Additional file 1: Table S1. Factors associated with good or poor knowledge regarding chikungunya and dengue infection.

Abbreviations
HCW: Health Care Workers; WHO: World Health Organization.
Authors' contributions SS: conceived the study, design and performed the study, participated in the field, contributed to interpretation of results and drafted the manuscript. DCK: contributed to the overall study, interpretation of data and critical review of manuscript; DDK: participated in the field and revised the manuscript; MRM and BE: contributed to overall study design, analysis of data and critical review of the manuscript. All authors read and approved the final manuscript.