Knowledge of Zika Virus Disease Prevention Methods, among Female Caregivers That Bring Babies for Immunization in a Teaching Hospital, Southeast Nigeria

Zika virus disease is a disease of public health importance and was declared a “Public Health Emergency of International Concern”, by the World Health Organization on February 1, 2016. It is mostly transmitted through the bite of Aedes aegypti and Aedes albopictus mosquitos. Transmission can also occur through blood transfusion and sexual intercourse. It could cause microcephaly and other neurological problems in newborns and adults, such as Guil-lain-Barre syndrome. It could also lead to abortion and stillbirth in pregnant women. Prevention methods are essentially targeted at transmission routes, which are mosquito bite, sexual intercourse, and blood transfusion. The study was of observational, descriptive, cross-sectional design, and conducted in a tertiary health institution in the Southeast geopolitical zone of Nigeria. Two hundred and fifty-six female caregivers participated in the study, with most of them being within the childbearing age group, and educated up to tertiary level. The objective was to assess the knowledge of Zika virus infection prevention methods, among female caregivers that bring babies for immunization in a Teaching Hospital, Southeast Nigeria. Out educational qualifications, generally exhibited higher knowledge level than the other respondents. Scores on questions that sought to assess their knowledge on prevention aspects related to sexual behavior, and vaccination were poor. Sensitization, or awareness creation activities for persons in this study area, ought to be designed to address the observed gaps.


Introduction
Zika virus infection has become a disease of global public health importance with its sporadic outbreaks from one region to another [1]. It was first isolated from a febrile Rhesus monkey in the Zika forest of Uganda in 1947, and named after the forest in 1952 [2]. Human infection was first documented in Uganda and the United Republic of Tanzania in 1952 [3]. Since Zika virus infection report in Uganda, there has been documented evidence of its spread to other Asian and African countries like Senegal [4], Ivory Coast, Egypt, India, Malaysia, Philippine [5], Indonesia [6] [7], Colombia, and Brazil [8]. Mosquito-transmitted Zika virus infection has been reported in 86 countries and territories around the world on 20 July, 2018 [3]. The outbreaks in 2015 and 2016 were a major challenge due to drift from its earlier known benign exanthematous spectrum to causing microcephaly in newborn [9].
Two genetically distinct isolates have been well characterized; the Asian and African strains [2] [5]. Its spread follows a bite of day-time-active Aedes specie of mosquitoes; the Aedes aegypti and Aedes albopictus, but commoner with Aedes aegypti [10]. Aedes aegypti mosquito also transmits Yellow fever, Dengue fever and Chikungunya disease [3]. Transmission of Zika virus can also occur through blood transfusion and sexual intercourse, as noted in Argentina, France, Chile, Italy, and New Zealand [11] [12]. Sexual transmission of Zika virus was initially known to be through heterosexual vaginal route, but on February 2 nd , 2016, the United States of America Center for Disease Control and Prevention (CDC) informed the world of the first case of transmission of Zika virus sexually through the anal route in a man [13]. There is also suspicion of transmission through oral sex [11]. Transmission through organ transplantation has also been documented [3]. Furthermore, Zika virus infection can equally spread by vertical transmission via mother-to-child transmission during pregnancy [11] [14] [15]. This intra-uterine infection has recently been linked to microcephaly. In addition to microcephaly in the newborn, Zika virus infection in the pregnant mother also causes other congenital malformations in the newborn, collectively known as congenital Zika syndrome. This could manifest as eye abnormalities, limb contractures, hearing loss, and high muscle tone. The infection can also lead to preterm delivery and stillbirth [3]. Infection in the adult may result in neurolog- Ndibuagu et al. ical complications such as Guillain-Barre syndrome [16]. Up to eighty percent of infections are asymptomatic, but when symptoms occur, it presents with nonspecific features like headache, mild fever, arthralgia, conjunctivitis, myalgia, and cutaneous maculopapular rash [3].

Treatment of Zika virus infection is basically symptomatic and supportive
treatment as there is no proven cure at present. The mainstay in the management of Zika virus infection lies basically in its prevention. Prevention methods are essentially targeted at transmission routes, which are mosquito bite, sexual intercourse, and blood transfusion. Organ transplant as a route of transmission is still rare, and more research work is presumably being done on it [3]. Mosquito bite protection can be achieved via the use of mosquito repellent, wearing long-sleeved shirts and long trousers, use of mosquito nets, sleeping or resting in screened or air-conditioned rooms and environmental cleanliness. Prevention of transmission through the sexual route can be done through practice of safer sex by pregnant women, which could involve use of barrier contraception such as condom, abstinence of sexual activity throughout the duration of pregnancy, and abstinence from sexual activity for at least two months for women and six months for men who are returning from areas of active Zika virus transmission [3]. The United States of America Centers for Disease Control and Prevention has recommended preventing Zika virus infection through blood in areas where there is an outbreak by screening potential blood donors [17].
The then "explosive spread with devastating neurological sequel" in the Americas, and the Caribbean, especially Brazil made the World Health Organization (WHO) to declare Zika virus disease a "Public Health Emergency of International Concern" on 1st February, 2016 [16]. The Zika virus strain in Brazil then was strongly linked to neurologic complications of congenital microcephaly, and Guillain-Barré Syndrome [18]. With increased global travels for economic, medical and social tourisms, no country of the world is spared from this virus [9]. In 1954, the first three cases of Zika virus infection in Nigeria, though detected in 1952, were reported in Oyo state [19]. With last United Nation's July

Materials and Methods
Nigeria has the highest population in Africa and is divided into thirty-six states and one federal capital territory, which like the states; is an administrative unit. It is estimated that the minimum weekly immunization coverage in the hospital was about two hundred and sixty-three (263) babies. Using a formula for sample size estimation [22], sample size for one week was estimated to be one hundred and fifty-six (156). Though the data collection was initially planned to be completed within one week, logistics issues hampered this, hence the sample collection was stretched to nine weeks. It was conducted between November 2016, and February 2017. A junior resident in the department of Community Medicine was trained as a research assistant. He used Interviewer administered questionnaire to collect information from ten randomly selected caregivers on each day of immunization. Mondays, Wednesdays, and Fridays were the usual immunization days in the hospital. An average of 88 female Caregivers brought babies for immunization on each of the three stated immunization days. During the usual health talk, just before the commencement of the immunization proper, a basket with folded pieces of paper was passed around, and the caregivers requested to pick one. The word "YES" was written on ten of those pieces of paper, while the rest had "NO" written on them. Those that picked "YES" were recruited into the study, after giving informed consent. Anyone that declined consent was replaced through repeat balloting. This meant that thirty (30) respondents were interviewed each week for eight weeks, while sixteen respondents were interviewed on the ninth week, making a total of two hundred and fifty-six

Results
The number of respondents in this study was 256 female caregivers

Discussion
Zika virus is an emerging infectious disease with attendant complications. It is a disease that constant efforts should be made to ensure that it is prevented, since it is preventable. The disease though has been reported in some parts of Americas, South East Asia, and Caribbean; is endemic in parts of Africa [23].   (Table 3). Higher educational attainment probably exposed respondents to information that made them know that excessive sunlight as a causative factor for febrile illnesses is a myth. In addition to low educational at- Knowledge on Zika virus infection prevention through, pregnant women abstaining from sex in Zika virus endemic areas was found to be almost the same score (38.3%), as that recorded on use of condom by pregnant women for prevention (37.9%). The age and educational level patterns were essentially similar ( Table 2 and Table 3). Only 35.2% of respondents knew that Zika virus infection can be prevented by men returning from endemic areas abstaining from sex for about six months. All those that gave correct response belonged to the childbearing age group (Table 2), and also had a minimum of secondary level education (Table 3). This further suggests that formal education positively contributes to improved knowledge on Zika virus prevention methods. Respondents in the childbearing age group, demonstrating better knowledge on this is encouraging, since they are really the ones that are required to put this into practice. Most of the respondents are not sure of the correct response (51.6%), while only 13.3% did not know that men returning from Zika endemic areas ought to abstain from sex for six months, since they possibly could be carrying the virus in their semen. Poor knowledge on men from endemic areas abstaining from sexual intercourse appears to also obtain in developed countries. Our finding of 35.2% is even slightly higher than the 35% found among residents in New York City of the United States of America [37]. A qualitative study conducted among women of childbearing age, also revealed very poor knowledge level, with respect to men from Zika virus endemic areas abstaining from sex for six months. Among three groups in six Focused Group Discussions that knew that Zika virus can be transmitted through the sexual route, only two women knew of the recommended six months period of abstinence for men returning from endemic areas [31]. It will be beneficial to always highlight this Zika virus prevention practice, during any health promotion activity targeted at Zika virus prevention.
More than half of the respondents (53.9%) knew that Zika virus can be prevented by avoiding unnecessary blood transfusion in endemic areas. More of the correct response came from persons in the childbearing age group (Table 2). Persons with higher educational level also recorded better knowledge on this, with postgraduate education respondents having 63.0%, and those with primary education having 20.0% (Table 3). Only 4.7% of the entire respondents did not know that avoiding unnecessary blood transfusion in Zika virus endemic areas could be infection prevention measure; while as many as 41.4% are not sure of the correct response. This finding can be considered impressive when compared with findings on the knowledge, about transmission of Zika virus through blood transfusion in some developed and developing countries. About half (51%) of the respondents in a study on "Knowledge and Prevention Practices among U.S. Pregnant Immigrants from Zika Virus Outbreak Areas" knew that Zika virus can be transmitted through blood transfusion [32]. In a study conducted in some universities in Qatar, to assess the knowledge and perceptions about Zika virus, only 22.9% of the female respondents knew that Zika virus can be transmitted through blood transfusion [38]. Again, the finding that very few (17.1%) respondents in a Zika virus study in Philippines knew that the infection can be transmitted through blood transfusion [33], is reasonably lower than our finding of 53.9% having the knowledge that Zika virus infection can be prevented by avoiding unnecessary blood transfusion in endemic areas.
Slightly more than half of the female caregivers that participated in this study (51.2%) knew that avoiding eating too many oily meals does not prevent Zika virus infection. This is an indication that many people from this study location where myths such as eating of oily meals being a causative factor for febrile illnesses exist [27] [28], stilled had good knowledge about this. It is encouraging to note that most of the correct response came from women in the childbearing age group ( Table 2). Educational level of the respondents also positively contributed to the overall knowledge score of the respondents. Nobody without formal education, or primary school level had the correct knowledge; while the highest knowledge score of 63.0% came from the postgraduate educational group (Table   3). Our finding could be considered better than findings in some developed countries such as Greece, if knowledge on transmission could be considered an indicator on prevention method knowledge; where 26.5% of respondents (pregnant women) strongly agreed/agreed that Zika virus infection can be transmitted through consumption of contaminated food [39]. Only 5.1% of respondents in our study agreed that Zika virus infection can be prevented by avoiding eating too much oily meals. Again respondents in our study demonstrated better knowledge than medical students in Saudi Arabia, where only 24.9% of them knew that Zika virus infection cannot be transmitted through food [40]. No respondent outside the childbearing age knew that Zika virus does not have vaccine for prevention, and most of the correct response came from persons aged 20 to 30 years (Table 2). Overall the knowledge level was poor (37.5%), and almost half of the respondents were not certain of which response to give (49.2%).
Higher educational qualification also appears to have enhanced the respondents' knowledge on Zika virus not having a vaccine. All the correct response came from persons who had at least secondary educational qualification (Table 3). It is important that care be taken in designing any Zika virus awareness programme for females, to incorporate simple communication methods and channels that will be easily understood by the less formally educated. Our finding about non-availability of Zika virus vaccine was reasonably better than finding in some other developing countries such as Philippines, where as few as 4.9% of pregnant women in a 2018 study knew that there is no vaccine for Zika virus prevention [35]. The very poor finding in Philippines could be indicative of inadequate Zika virus awareness creation activities in that study area.

Conclusion
Knowledge of Zika virus prevention methods is very crucial among the general population, especially females of childbearing age since the neurological effects on unborn babies of infected pregnant women are of significant public health importance. Female caregivers that brought babies for immunization at this tertiary hospital in Southeast Nigeria had good knowledge on protection against mosquito bites, and avoiding unnecessary blood transfusion in endemic areas, as Zika virus infection prevention methods. They, however, recorded poor knowledge on safer sex-related prevention methods, and no availability of Zika virus vaccine. Respondents in the childbearing age group, and those with higher educational qualifications, generally exhibited higher knowledge level than the others. Sensitization, or awareness creation activities for persons in this study area, ought to be designed to address the observed gaps.