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Knowledge of Health Workers in Public Health Centers of the Health District of Lomé Commune on Dengue

Background: Dengue is under-reported in the indicators and directories of health statistics in Togo and the diagnostic hypothesis of dengue during medical consultations is often not mentioned. Objective: The objective is to assess healthcare workers’ knowledge of dengue and its management in public health centers in the health district of Lomé Commune. Materials and Methods: This is a cross-sectional and descriptive study that took place from November 1, 2019 to February 29, 2020 in the health district of Lomé Commune. Results: This study involved 280 healthcare workers out of 310 concerned, i.e., a participation rate of 90.32%, distributed over the 22 public health centers of the health district of Lomé Commune. The age of the healthcare workers ranged from 18 to 58 years with an average age of 33 years (±8.14). The age group [25 - 35 years] was more represented with 53.20%. Physicians were more represented with 46.07%. The majority of healthcare professionals were aware of the existence of dengue (90.36%). The essential clinical signs were more or less known, especially by the physicians. Dengue hemorrhagic fever was the most known clinical form and represented 70%. Treatment was symptomatic according to the majority (63.21%) and was based on analgesics (71.43%) and antipyretics (65%). The existence of a vaccine is not well known and represented 16.79%; the use of impregnated mosquito net is more cited as a secondary means of prevention, 77.86%. Conclusion: Dengue is not well known by the health professionals involved in the survey. Nevertheless, physicians have a more or less good knowledge compared to paramedics. In practice, the diagnosis of dengue is often not mentioned.


Introduction
Dengue or tropical influenza is currently the main arbovirus of the tropical regions surrounding the globe [1] and is one of the neglected tropical diseases, constituting a major public health concern [2].
Arboviruses are zoonotic diseases usually transmitted from vertebrate to vertebrate via a hematophagous arthropod, which is most often a mosquito or a tick [1] [3]. A modeling estimates indicate that 390 million dengue virus infections occur annually, of which 96 million are clinically manifested (all severities) [4].
Over the past two decades, the number of dengue cases reported to WHO has increased more than eightfold, from 505,430 cases in 2000 to 4.2 million cases in 2019 [4]. Most infections are encountered in urban areas in tropical and subtropical regions, but imported dengue cases have been reported in non-tropical regions [5]. In Africa, the incidence of dengue is largely unknown due to poor surveillance and non-reporting of cases and epidemics to WHO [6].
In Togo, the first cases of dengue were reported between the years 1987 and 2000 in expatriate travelers after a stay in Togo without identification of the serotype involved [7]. In 2017, a few cases of dengue were identified and confirmed by the National Institute of Hygiene according to the Ministry of Health without any recorded deaths [8]. Two studies were conducted at the Sylvanus Olympio Teaching Hospital in 2017; one about 2 hospitalized cases of dengue hemorrhagic fever and the other concerned the search for NS1-Dengue antigen in febrile patients [9] [10]. Dengue is under-reported or almost not reported in the indicators and directories of health statistics in Togo. Moreover, the diagnostic hypothesis of dengue during medical consultations is often not mentioned. It is in this perspective that the said study was initiated in order to evaluate the knowledge of healthcare staff on this plague in order to participate in its elimination.
The main objective of this study was to evaluate the knowledge of healthcare workers on dengue and its management in the public health centers of the health district of Lomé commune.

Material and Methods
This is a descriptive and cross-sectional study from November 1, 2019 to February 29, 2020 concerning healthcare workers providing medical consultation in public health facilities in the health district of Lomé Commune. It involved general practitioners and specialists, medical assistants, nurses, midwives and birth attendants practicing in the infectious diseases, medical emergencies, internal medicine, general medicine, maternity and pediatrics departments of the Teaching Hospitals, district hospitals and medico-social centers of the health district of Lomé Commune.
The health district of Lomé commune has five health districts composed of public, private and religious healthcare facilities. The public healthcare facilities are composed of 2 Teaching Hospitals (CHU), 1 Regional Hospital (CHR), 5 The level of knowledge was judged as good, average or poor. Knowledge was good when the percentage of correct answers obtained was ≥80%; knowledge was average when the percentage of correct answers was between 50% and 79%, and poor when the percentage was <50%.
The Chi-square (χ 2 ) test was the primary statistical test used for categorical variables of interest at the 95% significance level. The significance level was set at 5%.
Participation in the study required informed verbal consent and did not require any compensation since the voluntary nature of the study was emphasized.
The directors of the various health districts were informed by a request through the hierarchy and gave their agreement by memos to the various healthcare facilities to be surveyed in their health area.

Results
The participation rate was 90.32%, i.e., 280 healthcare workers surveyed out of 310 in 22 public health facilities in the health district of Lomé Commune.

Socio-Professional Characteristics
The median age was 30 years (±12) and the age group [25 -45 years] represented 74.60%. Medical staff (physicians and medical assistants) were in the majority as was professional experience ranging from 0 to 10 years for most (Table 1).

Socio-Professional Characteristics
Healthcare professionals in Togo are relatively young as shown by the median age and their work experience of this study. This finding was made in Tanzania where a similar study conducted on the issue found that the majority of healthcare professionals (n = 86) were between 25 and 40 years old (48%) with work experience ranging from 0 to 10 years for most (n = 62) [11]. The predominance of paramedics was also noted in Burkina Faso (89% nurses) [12] and Tanzania (75.3% nurses) [11]. Paramedics still make up the majority of the health workers in Togo for several reasons. The country has several training schools for medical assistants and midwives. In addition, in peripheral health facilities outside hospitals, paramedics are the first actors who play the role of physician.

General Knowledge about Dengue
Dengue is known to most healthcare workers as a viral infectious disease and its means of transmission; however, the causal agent, which is a virus, was not well known among physicians. Sondo et al. in Burkina Faso had reported a high proportion of knowledge of dengue but 62.50% for knowledge about the causal agent [12]. In Tanzania, according to Kajeguka et al. the majority of healthcare professionals knew about dengue through the media [11]. The fact that malaria and dengue are transmitted by mosquito bite may be confusing for some who are unaware that dengue is caused by a virus. The level of knowledge is not the same among all caregivers. Physicians had a much higher level of knowledge than other socio-professional categories with a significant difference (p < 0.05).
The level of study of physicians is in favor of their better knowledge of the disease, especially since the teaching modules are not the same with paramedics.
The clinical signs of dengue were well known among physicians and medical assistants who have better knowledge because they are the ones who often provide consultations in healthcare facilities. A few years ago, a study on the detection of dengue in consultations conducted by the National Institute of Hygiene in certain health centers in the city of Lomé also enabled this good knowledge of clinical signs similar to malaria. Dengue hemorrhagic fever is the most frequently cited clinical form and this is also explained by the fact that dengue is known by most healthcare professionals as viral hemorrhagic fever.

Knowledge of Dengue Treatment and Prevention
It is well known among healthcare providers that most viral diseases such as dengue are managed symptomatically, which explains the high use of analgesics/antipyretics (81.3%) in a study in Burkina Faso [12]. This high level of use is explained by the fact that signs such as fever, headaches, aches and pains and diffuse pain are in the foreground; in addition, analgesics and antipyretics are widely used in the treatment of febrile diseases. In general, anti-inflammatory drugs were less used and the avoidance of Aspirin and Ibuprofen were mentioned in Guadeloupe [13]. This proves that the majority of caregivers are aware In terms of prevention, the existence of a vaccine against dengue is not well known among healthcare workers, because the vaccine is not widely used and because of its recent development. As the means of transmission of dengue is similar to that of malaria, other means of prevention have been well reported in our series and in Burkina Faso in high proportions [12].
The limitations of this study are that the administration of the questionnaire was not straightforward because of the workload. This situation required the interviewer to distribute the questionnaire to staff and return on another day to collect the completed questionnaire. This certainly allowed some of the respondents to go and get the answers to the questions. As a result, the actual assessment of knowledge may be biased.

Conclusions
Dengue is the most common arbovirus in the world and is considered by the World Health Organization to be an emerging disease in urban areas of tropical and subtropical regions.
This study reveals that healthcare workers in public health centers in the health district of Lomé Commune do not have good knowledge of dengue. However, this knowledge is better among physicians than among other socio-professional categories. In practice, the diagnosis or assumption of dengue is often not made, considering that dengue is relatively rare due to the absence of an epidemic in the country. Malaria is over-treated in cases of fever and cases of classical dengue would be treated as malaria. However, caution is required to diagnose severe dengue cases early and to identify outbreaks.
At the end of this study, we suggest the recommendation to the nursing staff to think of dengue during medical consultations or in case of febrile episode and especially to ask for complementary examination for its confirmation.