Our paper “Rapid Assessment Zika Virus Knowledge Among Clinical Specialists in Singapore: A Cross-sectional Survey” was published in PLOS Currents Outbreaks this week. This was a collaboration between KK Women’s and Children’s Hospital, the Saw Swee Hock School of Public Health and Singapore General Hospital.
The first case of confirmed Zika virus disease in Singapore was reported in May 2016, in a patient who had recently travelled to Brazil, but local transmission of Zika virus within Singapore was documented in August 2016. For this paper, we were interested in finding out how familiar local specialists were with guidelines to diagnose, manage and prevent Zika virus disease. We felt this was important because, although guidelines had been published by WHO and the US Centers for Disease Control after the Zika epidemic in Latin America had been declared a Public Health Emergency of International Concern, these guidelines were updated several times as more information emerged. In addition, like many of its neighbours and other countries in Latin America with Zika transmission, Singapore has endemic transmission of dengue, which causes similar, but not identical, clinical symptoms to Zika. In some ways this might make clinicials more aware of signs to look for to diagnose Zika, but in other ways it might make it more likely that Zika patients could be misdiagnosed with dengue.
In June 2016, we conducted a survey among medical specialists in obstetrics, gynaecology, paediatrics and neonatology. We asked them a series of 15 multiple choice questions about clinical features of Zika virus disease, how to diagnose it, how to manage pregnant women and infants with suspected Zika virus disease, how to prevent Zika virus infection, and how to notify Zika virus disease to public health authorities. We designed the survey using Typeform, which we use for some of our projects to deliver simple questionnaires that can be completed on a mobile device, and sent a link to the survey via email.
We received 110 responses over two weeks. We found that respondents had good knowledge of clinical symptoms of Zika virus disease that resembled those of dengue, but were less likely to name symptoms such as conjunctivitis, which are less common in dengue. We also found that there was confusion around which types of diagnostic tests to use when, and other infections to rule out in suspected cases of microcephaly; diagnostics for flaviviruses like Zika and dengue are notoriously complex, and several types of infections are known to cause microcephaly and other congenital abnormalities, including rubella virus, cytomegalovirus, syphilis and toxoplasmosis.
Another area of confusion was related to recommendations for preventing Zika virus infection in pregnant women. A number of studies prior to our survey, mainly done in travellers to Zika-endemic areas, had found that Zika virus could be detected in semen for several months following infection, suggesting that sexual transmission could potentially occur over a longer period of time than initially thought possible. As a result, changes were made to recommend pregnant women and their partners returning from Zika-affected areas to abstain from sexual intercourse or use condoms throughout the duration of the pregnancy. These recommendations remain in place, but at the time of the survey only about a third of respondents were aware of this recommendation.
Our study had some limitations. The survey sample was quite modest, so we were not able to fully look at differences in knowledge between medical specialties. We also did not have many respondents practising in the private sector. Nevertheless, the survey served as a rapid assessment to gauge awareness of current guidelines among medical specialists. An important message is that in the context of a rapidly evolving epidemic, in which recommendations need to be continually updated, we need to ensure that these changes are clearly communicated to frontline medical staff. Rapid surveys such as this are a good way to monitor communication strategies, and dissemination strategies were intensified after local transmission of Zika virus was reported within Singapore.
You can read the full paper from this study here.