Knowledge, attitude and practices regarding dengue and its vector among medical practitioners in Malakand region, Pakistan

Abstract Dengue fever (DF) is increasingly recognized as one of the world’s major mosquito borne diseases and causes significant morbidity and mortality in tropical and subtropical countries. Dengue fever is endemic in most part of Pakistan and continues to be a public health concern. Knowledge, attitude and practices can play an important role in management of the disease. Current study was aimed to determine the level of knowledge, attitude and practices regarding dengue fever among health practitioners, to study the level of knowledge and attitude with preventive practices for dengue fever. A cross sectional study was carried out in medical practitioners of the four districts of Malakand region during October to November 2019. A pre-structured questionnaire was used to collect data from medical practitioners. Data was analyzed using Graph Pad version 5. Significant value was considered when less than 0.05 (at 95% confidence of interval). The results revealed that most of participants have seen dengue vector (62%), the media being the most quoted source of information. Nearly 81.2% participants were aware from transmission of dengue fever is by mosquito bite. Practices based upon preventive measures were found to be predominantly focused towards prevention of mosquito bites rather than elimination of breeding places. Although the knowledge regarding DF and mosquito control measure was quite high among the medical practitioners but this knowledge was not put into practice. Further studies are required to aware the people about dengue and its vector in order to get prevention and control.

the Netherlands (Seixas et al., 2018) while Aedes albopictus although a less active vector than its corresponding partner, the distribution area of Aedes albopictus are greater than Aedes aegypti and currently found in Asia, Africa, Caribbean, South-America, Central America, Australia, and in a large number of European countries, mostly in Southern Europe, which possess Portugal, South of France, Spain, Greece, Italy, Albania and now it has been introduced in United Kingdom, Germany, Eastern Europe, and France.The area of the distribution of A. albopictus is rapidly increasing and has been listed in top hundred most invasive species (Semenza et al., 2014;Liu-Helmersson et al., 2016).
According to Arif et al. (2015) there are three main forms of dengue disease, the 1 st one is dengue fever 2 nd one the more severe dengue hemorrhagic fever (DHF) and 3 rd ones Dengue Shock Syndrome (DSS).Dengue has been reported to cause more illness and death than any other Arbovirus disease in the world, there are approximately 2.5 billion people at risk of infection (Guglani and Kabra, 2005) and the World Health Organization (WHO) estimates that there are about 50 to 100 million cases per year.It has become a major health problem in Pakistan, and it is likely to become an even greater health problem in the coming years (Rasheed et al., 2013).Current paper describes the knowledge, attitudes and practices regarding dengue fever and its vector among health care workers in Malakand region, Pakistan.

Materials
This cross sectional study was conducted over a period of two months from October 2019 to November 2019 in four districts of Malakand Division using the pre structured and self-explanatory questionnaire.The four districts are Lower Dir, Upper Dir, Swat and district Malakand.Samples were collected by visiting different areas and hospitals of the districts.Doctors, pharmacists and the paramedical diploma holders were included in present study.Pre-testing of the questionnaires was conducted among 20 participants and minor changes were done after pretesting.The participants were required to complete the self-administered questionnaires which took about 10-15 minutes.The questionnaire was developed after an extensive literature review and was validated for its reliability.The questionnaire comprises 31 questions.The questionnaire comprises four parts.The first part concerned with the demographic status of the medical practitioner of Malakand region Pakistan (questions 1 to 6), the second part concerned with knowledge of the respondents related to dengue vector among health practitioners of four districts of Malakand region, (questions 7 to 14), the next part dealt with knowledge of the respondents related to dengue fever among health practitioners of four districts of Malakand region, (question 15 to 24) and the last part dealt with attitude of the respondent related to practice and prevention of the dengue fever (question 25 to 31).

Introduction
Dengue fever is an epidemiological infection that is closely similar to symptoms of yellow fever (Paul et al., 1998).Dengue is a mosquito born viral infection found in tropical and subtropical regions of the globe and now continuously spreading all over the world.Dengue fever is transmitted by the bite of female mosquito caused by human viral pathogen that belongs to the genus Flavivirus of the family Flaviviridae (single-strand, non-segmented RNA viruses) which is closely similar to West Nile virus (Luqman et al., 2013).The dengue virus is divided into four serotypes .First case of epidemics of DF had reported from Asia, Africa, and North America during 1779-1780 (Qureshi et al., 2014).Outbreaks in the three continents indicate a worldwide distribution of these viruses and their mosquito vectors presence in the tropics.A pandemic situation was adopted in Southeast Asia soon after World War II and since then has spread around the world (Halstead, 1980;Halstead, 1992).
The dengue virus disease is reported to be prevalent across the whole tropical belt in more than 100 countries with about 2.5 billion residents at risk of being infected (Guglani and Kabra, 2005).According to the WHO, 50 to 390 million people are become infected each year (Semenza et al., 2014), with around 25000 deaths, mostly children (Semenza, 2015).For the first time dengue outbreak in Pakistan was reported in the industrial city, Karachi, in 1994 (Rai and Khan, 2007).In the same way the outbreak of dengue infection was reported in many areas of Pakistan for three following years 2006, 2010 and 2011 respectively (Luqman et al., 2013).In Pakistan, dengue virus is endemic, now present throughout the year with a peak incidence in the period of late time of monsoon.Flood of 2010 in Pakistan made the situation worse.All over 20864 cases had been reported in Punjab in 2011 including 17256 in Lahore with 323 deaths in the Punjab province and 279 deaths in Lahore.The three provinces in Pakistan Sindh, Punjab and Khyber Pakhtunkhwa are facing the epidemic of dengue.It was reported that Karachi is one of the supreme habitat for breading of dengue mosquito and thus for spreading the diseases (Almeida et al., 2009;Shamim, 2010).
There has been a gradual global increase in the number of dengue cases in the last decade.According to mathematical models which are established by researchers it can be demonstrated that Southern Europe are more susceptible to dengue outbreaks in the next decade due to climate changes and globalization.Any prophylactic drug or vaccine are not developed against dengue fever up to now so vector management and prevention against mosquito bites are the best preventive methods for control of the disease.
Dengue is transmitted in humans by two species of Aedes mosquitoes namely, Aedes Aegypti and Aedes Albopictus (Shuaib et al., 2010;Yboa and Labrague, 2013;Semenza et al., 2014;Liu-Helmersson et al., 2016).Currently Aedes aegypti are found in, South-east Asia, Africa, Middle-East, South-eastern United States, Pacific Islands and Northern Australia.This species is also distributed in Georgia, Madeira (Portugal) and has been introduced in Brazilian Journal of Biology, 2023, vol.83, e244966 3/9 Awareness of medical practitioners regarding dengue and its vector

Population and study sample
The targeted population was all practitioners aged over 20 years serving in various health care units in four districts of Malakand region.The study areas comprises Lower Dir, Upper Dir, Swat and district Malakand, have selected due to several outbreaks occurred in this region.

Source and collection of data
The source of the data was the population of medical practitioners of the four districts of Malakand region Pakistan.The data was collected in a form of questionnaire.One questionnaire was given to one participants for filling all the questions in the areas and then collected from them.The questionnaire was in English language and so sample, that all of the questions are easily solved by the participants.The data was collected from October 2019 to November 2019.

Data analysis
The data was analyzed by using Graph Pad version 5. Significant value was considered when less than 0.05 (at 95% confidence of interval).

Ethical consideration
The participants were informed about the advantages and risk factors of the study through distribution of an inform consent letter.All the participants were included voluntarily.Respondents had to read and approve that they had read the inform consent letter before filling the questionnaire.Only respondents who were medical practitioners and aged 20 years or over at the time of the survey were allowed to fill the questionnaire.No authorization was required from the official board of committee of the university as well as local administration of Malakand division, No Objection Certificate (NOC) as the way of collecting the data via the questionnaire while following ethical guidelines, such as respect for the participants' respect for human dignity, autonomy and freedom.

Demographic information among health practitioners
Regarding the demographic information of the respondents the age is divided into three groups ranges 21 to 40(75%), 41-60(20%) and above 60 years (5%).In the current study male and female proportion are 85% and 15% respectively.Three professions are included the finding are physician (20.4%), public health officers (27.5%) and paramedics (51.6%).The respondents were in two practice setting health centre and referral hospitals which result are 67.5% and 32.5% respectively.The respondents experience were divided into three groups which result are 1-10 years (54.1%),11-20 years (30.8%),21 and above are (15%), Zone wise division resulted hot spot and non-hot spot which results 46.2% and 53.8% respectively (Table 1).

Knowledge of the respondents related to dengue vector
Table 2 describes the knowledge of the respondents related to dengue vector among health care workers in Malakand region, Pakistan.Four districts were selected for the operation of the present study.In response to the question "have you ever seen dengue vector?"61.2%(n=147) were voted as yes.The 2 nd question" What is the cause of dengue fever?" result are (mosquito=62.0%,Bacteria=7.50%, virus=22.0%and parasite=8.33%), the 3 rd "question is "how do dengue mosquito looks like?"(small dark mosquito with white strips on legs=78.3%,marking in form of a layer on its thorax=21.7%),another question was asked about the breeding site the result are (flowing dirty water=10.8%,flowing clean water=23.3%,stagnant dirty water=15%, stagnant clean water=41.6%,puddles=6.25%,garbage=2.91%),a question was asked about the living place the results are (underneath furniture=17.1%,shelter places=65.4%,indoor=17.5%),the response to the question "what is the most frequent mosquito bite time" are (sunset/ sundown=77.1%,day time=13.3%,night=13.3%),how is dengue transmitted?the results are (an infected dengue mosquito bite=81.2%,contacting DP*=11.3%,drinking dirty water=7.50%), a question was asked "Is government responsible for controlling mosquito causing dengue" the result are (agree=88.7%,disagree=11.3%).

Knowledge of the respondents related to dengue fever
Table 3 demonstrates the knowledge of the respondents related to dengue fever.In this regard some questions were asked from the respondents who are medical practitioner in Malakand region Pakistan.In response of the question "have you ever seen dengue fever cases?" the response for yes are 76.6%, a question was asked about the symptoms of the dengue fever the finding were (prolong high fever=58.3%,muscular pain=15.0%,bleeding from nose and other areas=20.4%,rashes=4.14%,headaches, nausea and vomiting=2.08%), in response to the question "can dengue fever be prevented?"the finding are (agree=91.2%,disagree=8.75%), a question was asked about the vaccine the result was (yes=26.6% and no=73.3%), the response to the question "can dengue be treated?"n=194 (80.8%) of the respondents are voted for yes, a question was asked about the medicine for the treatment of dengue the finding are (antibiotic=15.8%,antipyretic=73.3%and pain killer=10.8%),a question was asked about the confirmation of dengue in the suspected patient from the respondents the result are (PCR=10%, ELISA=10.8%,CBC=20.4%,dengue serology=5.75% and viral culture=1.25%).

Knowledge of the respondents related to attitude, prevention and practice of dengue
Table 4 describe attitude, prevention and practice of the respondents related to the dengue fever in Malakand region Pakistan, in response to the question "are you familiar with the WHO clinical management of dengue guidelines?" 67.9% of the respondents were voted for yes, another question were asked "WHO dengue guidelines help in managing dengue fever"82.5% of the respondents are marked yes, a question were asked that are their adequate resources are available to treat dengue at local areas the results were 62.1% for yes, a question were asked about the resources that are lacking to treat patient with dengue the result are (sufficient training=46.2%,medication=37.0%,instruments=5.83% and laboratory tools=10.8%)a question were asked about the prescription of paracetamol to the dengue patient from the respondents the results were (always=62.0%,sometimes=31.2%and never=6.66%), in response to the question "how frequently do you advise DP to avoid mosquito bite?" the result were (always=79.1%,sometimes=16.2%and never=4.58%), in response to the question "how frequently do you prefer CBC lab investigation to monitor patient with suspected or confirm dengue?" the results were (always=64.5%,sometimes=16.2%and never=2.91%).

Discussion
Current study pinpoint to understand the knowledge, attitude and practices among health care workers in Malakand region, Pakistan.In this research 3 age groups (20-40, 41-60 and above 60 years) were considered.Age wise this study was comparable to the study findings of Itrat et al. (2008).While another study was conducted in Kuala Kangsar district of Malaya which are not comparable age wise to our finding in that study the proportional of >50 were quite high (47%) Hairi et al. (2003).
Sex wise almost all the study was found the same of Oriental region in literature the proportion of male was high as compare to female due to some restriction of female in society but this situation was not same in European country, current study finding of gender proportion were same with finding of Khalil et al. (2016), Arif et al. (2015), Hairi et al. (2003), Itrat et al. (2008) and Syed et al. (2010) in all these studies the proportion of male is greater than the female, while contradicted with the finding of Qureshi et al. (2014) and Siddiqui et al. (2013) in the first two study the proportion of male and female were almost similar but in Siddique study the proportion of male were less than the female (male 34% and female 66%).
Knowledge of mosquito breeding site were asses in this paragraph, according to the current study most of the participants were voted to clean water for mosquito breeding site (64.9%),dirty water 25.8%), puddles (6.25%) and garbage (2.91%) according to this data most of the medical practitioners were aware of the breeding site of mosquito, the finding of the current study were not comparable with the other study which were conducted at other areas like Khalil et al. (2016) Arif et al. (2015) and Itrat et al. (2008) this deviation may due to the selected population in the current study we are selected the health  care workers of malakand division while in the other study they were selected the general population.Question about mosquito bite time are asked in different article they were not comparable with current study, according to the current study which were conducted in the four districts of malakand division the responded were health worker in this study three timing were asked about the question sunset/sundown, day time and night time, according to the most of the respondents Aedes mosquito are crepuscular the biting time are sunset and sundown (77.1%) day time are marked by (13.3%) but some of the respondents are believed that the dengue mosquito are nocturnal there feeding time are night (9.58%) while in other study this proportion were quite different.
A question was asked in the current study about the dengue transmission most of the respondents were voted that the dengue are transmitted through bite of the mosquito which were (81.2%) 2 nd option are dinking dirty water (7.5%) and the 3 rd option is by contacting with dengue patient (11.3%) it means that knowledge about the transmission were quite high among the healthcare worker of Malakand region another study was conducted in Karachi Pakistan Itrat et al. (2008) the finding of that study were comparable to the finding of the current study, in the study of Karachi (86.9%) of the responded are also believed that mosquito bite are the main cause of dengue transmission, the same result are also found in another study Arif et al. (2015) which was (83.8%).Awareness of medical practitioners regarding dengue and its vector selected population, the Peshawar study population were the general population of rural and urban area.
In the current study a question were asked from the respondents that how you heard about the dengue so 41.6% of the respondents are marked the option of social media, 29.5% of the respondents are marked the option of print media, 14.5% are marked the option of lecture and 14.1% of the respondents are marked the option of TV/ Radio.The same study were conducted in central Punjab Pakistan Arif et al. (2015) their finding are not same with the finding of the current study, 61.4% of the respondents were voted for TV/Radio, 19.4% were voted for print media and 37.4% of the respondents were voted for lecture, this differences may be due to selected population, areas of the study, and year of the study it can be said that the use of social media is quite high in Malakand region as compare to the Punjab province of Pakistan.
In the current study a question were asked about the treatment of the dengue fever "how dengue be treated" three option are given (anti pyretic, antibiotic and pain In the current study a question were asked about the dengue fever cases seen (76.6%) are voted for yes and (23.4%) of the respondents were voted for no, the population of the current study are health care workers so most of the participants are seen dengue fever patient, the finding of the Itrat et al. (2008) are similar with the current study which are (yes=89.9%,no=10.1%)and (yes=65.7%,no=34.3%)respectively.
In the current study a question were asked about the prevention of dengue fever most of the respondents are believed that dengue fever can be prevented, 91.2% of the respondents are voted for yes and 8.2% of the respondents are voted for no, the same study was conducted in Peshawar Pakistan Khalil et al. (2016) in which the situation are not same, the finding of that study were 41.2% of the respondents were voted for yes 43.6% of the respondents were voted for no while 15.2% of the respondents are selected the not sure option meaning that not know about the question the finding of the current study and the finding of the Peshawar study were not match may be due to the killer) according to 73.3% of the respondents are believed that the dengue fever can be treated by using anti pyretic, 15.8% of the respondents are believed that the treatment of the dengue fever are antibiotic and 10.8% of the respondents are voted for pain killer.The same study were conducted in Karachi Pakistan Itrat et al. (2008) their finding are not similar with the finding of the current study may be due to the selected population their study population were general while the population of the current study are medical practitioner their finding are 22.8% of the respondents are voted for antipyretic, 8.7% of the respondents are voted for pain killer and 5.6% of the respondents are voted for antibiotic, and most of the participants are refused from that question according to them they are not know about the treatment.

Conclusions
It is concluded that the health care workers are well aware about dengue fever and its prevention, the proportion of male was quite high and most of participants have seen dengue vector (62%), the media being the most quoted source of information.Nearly 81.2% participants were aware transmission of dengue fever is by mosquito bite.A significant ratio of the respondents are believed that dengue fever can be prevented, 91.2%, however, it was noted that sufficient knowledge doesn't necessarily lead to good practice.Health educational campaigns and seminar should be conducted to improve behavior of the community about dengue.Interdepartmental collaboration is required, medical, religious and municipal corporation for stressing on adopting preventive measures and distributing low cost preventive material against dengue.The knowledge and practice will remain an important challenge for public health to dengue control, climate change including increase in temperature, precipitation and humidity is considered as main factor to increase the epidemics of dengue virus in different parts of the world.This study was conducted in Malakand region the target population are medical practitioners.Further studies are advised in various community to know the exact level of knowledge, attitude and practices about dengue and its vector in other parts of Pakistan.

Table 1 .
Demographic information among health practitioners of four districts of Malakand region, Pakistan.

Table 2 .
Knowledge of the respondents related to dengue vector among health practitioners of four districts of Malakand region, Pakistan.

Table 3 .
Knowledge of the respondents related to dengue fever among health practitioners of four districts of Malakand region, Pakistan.

Table 4 .
Knowledge of the respondents related to attitude, prevention and practice of dengue among health practitioners of four districts of Malakand region, Pakistan.