|Year : 2014 | Volume
| Issue : 1 | Page : 38-42
Knowledge, attitude, and practice of oral health care personnel regarding airborne spread of infection in Davangere, India
B Pai1, GM Prashant2, Ramya Shenoy3, GN Chandu2
1 Department of Public Health Dentistry, Manipal College of Dental Sciences, Manipal University, Manipal, Karnataka, India
2 Department of Community Dentistry, College of Dental Sciences, Davangere, Karnataka, India
3 Department of Public Health Dentistry, Manipal College of Dental Sciences, Manipal University, Mangalore, Karnataka, India
|Date of Web Publication||18-Aug-2014|
Manipal College of Dental Sciences, Manipal University, Manipal, Karnataka 576 104
Source of Support: None, Conflict of Interest: None
Introduction: Oral health care professionals (OHPs) are population with a high risk of infections, as they are exposed to an array of microorganisms in saliva and other body fluids during treatment. The aerosolized oral fluids during treatment may form a potent pool of infection. Objective: The objective was to assess the knowledge, attitude, and practice (KAP) about airborne infection and their precaution among OHPs in Davangere, India. Materials and Methods: A cross-sectional study was carried out in two dental teaching institutions of Davangere. The questionnaire contained questions related to KAP on airborne infection, its spread, and precaution. All the scores were summed and reported on a scale of 0-9 for knowledge, 0-4 for attitude and practice questions were scored on a 5-point Likert-Scale. Result: A response rate of 95.27% was observed. All the respondents knew that the infection was spread through aerosols during treatment. There was a significant improvement in KAP as the years in clinical practice increased. There was a linear correlation between knowledge and attitude (r = 0.171, P < 0.001), and knowledge and practice scores (r = 0.142, P < 0.00l) when all groups (dental faculty, postgraduate, and students) were combined, but there was no correlation between attitude and practice scores of individuals. Conclusion: This study reflects an increased knowledge and practice as the professionals move higher in the hierarchy. But there exists some disparity between the isolation precautions followed by the respondents of the current study and those from the recommended guidelines.
Keywords: Airborne infection, attitude, knowledge, oral health care personnel, practice
|How to cite this article:|
Pai B, Prashant G M, Shenoy R, Chandu G N. Knowledge, attitude, and practice of oral health care personnel regarding airborne spread of infection in Davangere, India. J Indian Assoc Public Health Dent 2014;12:38-42
| Introduction|| |
Standard precautions are practiced in high-income countries to protect health care workers from occupational exposure to blood and the consequent risk of infection with blood-borne pathogens. The situation is different in low-income countries especially in India,  where standard precautions are partially practiced. Oral health care professionals (OHPs) are at high risk of infections as they are often exposed to a wide range of microorganisms in saliva and other body fluids during dental treatment. Oral fluids become aerosolized during treatment and contribute to infections.  It is, therefore, critical for dental professionals to have and adopt proper infection control measures to protect themselves and their patients. The microorganisms in the afore-mentioned environment include pathogenic and nonpathogenic organisms such as Mycobacterium tuberculosis, Mycobacterium leprae, hepatitis B and C viruses, herpes simplex virus, and human immunodeficiency virus.  A number of viruses responsible for upper respiratory tract infections such as mumps, influenza, and rubella may also pose considerable health hazards to both OHPs and their patients.
These infections are transmitted through two major routes, blood, and saliva. This can occur through droplets, direct contact, or through indirect contact of instruments that has come in contact with the microorganisms. Dental unit water lines also pose an imminent risk of infection as these water lines harbor several microorganisms which may become aerosolized during dental treatment and cause life-threatening infections. 
There is a long history of transmission of infection through airborne route, the most common example is the transmission of bubonic plaque which is the pneumonic form of plaque which proved fatal and spread through aerosols during cough bouts from the infected patients.  More recently, Avian Bird Flu, a severe form of flu-like illness which primarily spreads through aerosolized droplets causing a pandemic in South East Asia has raised concerns over procedures that produce aerosols. Specific laws have been made by the American Dental Association (ADA) stating that any elective therapy should be performed on the patient with active severe acute respiratory distress syndrome. ,
The term aerosols and splatter was described by Micik et al.  in their pioneering work on the aerobiology, have described aerosols as particles <50 μm in diameter and splatter as airborne particles >50 μm in diameter.  They also stated that, these materials behaved in a ballistic manner as they are forcibly ejected from the operating site and an arc in trajectory similar to that of a bullet is followed until they contact a surface or the floor. These particles are too large to be suspended in the air and are airborne only briefly.
The airborne spread of splatter has been observed to spread for a distance of 18 inches without any visible aerosol being detected and was detected only as settled droplets on environmental surfaces, whereas the aerosols could spread for a distance of 60-150 cm ,, from the source of operation. Dental operatory is usually small rooms where air becomes stagnant due to increased humidity. The aerosols not only contain saliva, they also contain nasopharyngeal secretions, plaque, blood, and tooth materials used in dental procedures. Several factors are responsible for the spread of infection including humidity, particle size, temperature, and ventilation. These aerosols also have the capability of entering the lungs and invading the alveoli and causing infection. However, the ability of these aerosols to produce infection depends on the pathogenicity of the invading organism and the immune capacity of the host.  Hence, the objective of this study was to determine the knowledge, attitude, and practice (KAP) with regard to air borne spread of infection and precaution regarding these infections among OHPs of Davangere city, India.
| Materials and Methods|| |
The study was conducted in two dental teaching institutions of Davangere, India, using a cross-sectional study design. Ethical clearance was obtained from the Institutional Review Board. Informed consent was obtained from the study subjects. A convenient sample of subjects was selected for the study. The subjects who were willing to participate in the study were invited to complete the questionnaire. The questionnaire contained questions related to KAP on airborne infection, isolation, and its precaution. A trained instructor visited the faculty and students and distributed the questionnaire together with the necessary instructions for their completion.
Dental faculty, postgraduates of all dental specialty, undergraduate students (those who had clinical training enrolled in the 3 rd , 4 th year) and students in internship were included in the study. The information regarding age, gender, and year of study was obtained. KAP of respondents with respect to droplet and airborne precautions were measured using the questionnaire.
Knowledge and attitude were assessed at two levels (yes/no). A score value of one was given when the answer was in agreement with the guidelines and
0 for other responses. All the scores were summed and reported on a scale of 0-9 for knowledge and score of 0-4 for attitude. The practice questions were scored on a 5.point Likert.Scale response for (always, often, sometimes, seldom, never), a score of one was assigned to the answer galwaysh and a score of 0 to all other answers. The total scores ranged from 0 to 5.
The questionnaires were tested on 35 study subjects. Preliminary data were entered into the computer and STATA version 9. STATA CORP. SPSS 16.0 IBM Corporation was utilized to assess the reliability of the scales tested. Split-half reliability and Cronbach's alpha were found to be 0.78 and 0.81, respectively.
The frequency; mean; and standard deviations were computed. Analysis of variance and Tukey's post-hoc tests was performed to detect differences in KAP between all five groups (faculty members, postgraduates, and students from 3 rd year to internship). Pearson correlation was used as a measure of the strength of linear dependence between two variables that is, between knowledge and practice, knowledge and attitude, and attitude and practice. A two-sided P = 0.05 was considered significant for all statistical analyses.
| Results|| |
Of the total 402 questionnaires administered, 383 responses were obtained with a response rate of 95.27%. Among them, 283 (75.1%) were undergraduates, 66 (17.5%) were postgraduates, and 34 (8.4%) were faculty. The study included 126 (33.4%) males and 257 (66.8%) females. Of the 283 undergraduate respondents, 133 (35.5%) were from 3 rd year, 92 (24.4%) were from 4 th year, and 58 (15.4%) were interns. All the respondents knew that the infection spreads through aerosols or splatter produced during dental procedure.
Among the respondents, only 124 (33%) believed that human immunodeficiency virus (HIV) spreads through saliva. As many as 353 (92.16%) respondents used mouth mask when working on patients and of the 353 respondents only 222 (62.9%) changed their mouth mask after each patient. Of all the respondents, 275 (71.9%) wore eye protection when working on patients, and only 103 (37.4%) respondents disinfected their eye protection ever. The use of protective clothing was 247 (64.5%) when working on patients.
Only 30 (8%) knew that the aerosols spread for about 150 cm whereas 50 (13.3%) reported that aerosols did not spread from the operating site at all. About 85% of the respondents were willing to treat patients suffering from the disease spread through aerosols. The study participants were aware of the availability of vaccination against hepatitis, and 86.7% were vaccinated. About 47.9% knew that a patient suffering from the disease spread through aerosol should be treated as the last patient, and 20.2% knew that air absorbing system to disinfect the operating site contaminated through aerosols was recommended.
The mean score for knowledge was 5.86 (standard deviation [SD] 1.29). The mean attitude of the sample was 2.01 (SD 0.54) and practice was 2.32 (SD 0.89) [Table 1]. The majority of respondents showed considerable knowledge but much less scores for practice and attitude. Knowledge attitude and practice was the highest among the Faculty lowest in 3 rd year [Table 2]. There was a linear correlation between knowledge and attitude (r = 0.171, P < 0.05), and knowledge and practice scores (r = 0.142, P < 0.05). Overall, there was no correlation between attitude and practice scores of individuals [Table 3].
|Table 3: Pearson correlation's correlation coefficients between mean KAP scores |
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| Discussion|| |
The potential for airborne spread of disease has been recognized for many years. Recent studies have shown that this mode for disease transmission is capable of spreading fatal diseases. ,, Hence, it is mandatory to protect dental personnel and patients from airborne infection, by following guidelines set by Center of Diseases Control and Prevention (CDC) and Occupational Safety and Health Administration modified for dental practice by ADA for prevention of these diseases.
Infections spreading through aerosols and splatter are usually from pathogens residing in the oropharyngeal region and the respiratory regions.  Most OHPs in the present study knew the same and reported that the spread of tuberculosis through aerosols was common. Hepatitis ,,, also spreads through aerosols and only 44% of the respondents knew the same. This finding is similar to the study conducted by Mythri et al. in 2007. 
The spread of HIV through saliva is controversial. Maghlout and Yousef,  have stated that HIV spread might occur through saliva, but their spread through aerosols has not been substantiated till date, while Miller,  contradicted the presence of HIV in saliva. Most of the respondents believed that the salivary spread of HIV would not occur.
The use of mouth mask to prevent the spread of infections caused by aerosols is highly recommended and is one of the preliminary methods for prevention of the spread of infection. The study conducted by Shivakumar et al.,  showed that the area around the face is highly contaminated by microbes and during dental procedures hence, the use of face mask is mandatory according to the CDC. In the present study, mouth mask was used by 93.2% of the dental Professionals and is in contrast with the study conducted by the Askarian et al.,  where in only 57% acknowledged this practice. About 67.2% of the OHPs did not change the mouth mask after each patient which contradicts the ADA guidelines,  wherein change of mouth mask after every patient is recommended.
The use of protective eyewear is mandatory when face shields are not worn,  and majority of respondents did follow this, and this is similar to the study conducted by Ananda et al. in 2007,  cleaning of the protective eyewear after each patient was followed by only 33.4% which is in accordance with Miller who advised cleaning protective eyewear after each patient to reduce cross contamination. 
Aerosols produced in the dental setting can spread from a distance of 61 cm , to a distance of 150 cm.  Most of the participants in the study did not know this fact and about 13.3% of the respondents thought that the aerosols did not spread at all, this is in contrast to the study done by Askarian et al.,  where 97.3% of the participants knew that the aerosols spread through a distance of 150 cm and caused infection. 
The importance of vaccination in preventing the spread of diseases is well-documented. The major pathogens which cause diseases through aerosols are Mycobacterium, and Hepatitis B virus. , As these diseases can be by prevented by following suitable vaccination schedules, the CDC and Federal laws in some countries have made vaccination against hepatitis compulsory for health care workers who are susceptible for infection. In the present study, all the participants were vaccinated with BCG, which corresponds similarly to the study conducted by Askarian et al.  Although the study participants were aware of the availability of vaccination against hepatitis, only 86.7% were vaccinated. This is similar to the study conducted by Mythri et al. in Davangere  and Li,  but was in contrast to that reported by de Almeida et al. in Brazil  and Singh et al.  in India, where only 9.41% and 61.2% were vaccinated against Hepatitis B.
In the present study, 85% of the respondents were willing to treat patients suffering from the disease spread through aerosols and is nearly similar to the study conducted by Mythri et al.,  wherein 93% of oral care professionals agreed to treat patients suffering from hepatitis. Less than half of the respondents (47.9%) knew that a patient suffering from the disease spread through aerosol should be treated as the last patient, and 20.2% knew that air absorbing system to disinfect the operating site contaminated through aerosols was recommended. The standard protocol for the management of patients with infections that spread through aerosols is to isolate the patient in a separate room asking them to use mouth mask when sitting in the reception or with other patients in the waiting area,  in the present, only 26% of the dental professionals and 13% of the patients knew this practice.
The result of the present study showed similar mean levels of KAP to that of the studies of Askarian et al.  and Singh et al.  However, Singh et al. reported a much higher knowledge scores among the 3 rd year bachelor of dental surgery (BDS) students. The present study showed the least knowledge in the 3 rd year BDS students which could be attributed to their lack of clinical experience. The present study also showed an increase in the KAP scores as the students progressed in their clinical curriculum with the highest scores for Faculty. When asked about their knowledge regarding infection control practices, less than half respondents thought that their droplet and airborne isolation precaution were adequate, and 90.1% respondents wanted to upgrade their knowledge on infection control.
The present study showed that though the knowledge and attitude of isolation precautions among the OHPs were good, they showed a lack of adherence to the guidelines. Their noncompliance can be attributed as disordinance between their levels of knowledge and attitude with respect to guidelines. This finding is similar to a study conducted among dental professionals of the University of Shiraz, Iran. 
There are some limitations to the present study. The questionnaire was self-administered, and responses may not accurately reflect the true KAP. This study is restricted to OHPs practicing in dental colleges of Davangere. Hence, extrapolation should be done with caution.
| Conclusion|| |
We found that the OHPs in the present study had adequate knowledge regarding infection control and airborne isolation precautions whereas the undergraduates especially those just entering the clinics had the least knowledge. The attitude toward infectious control measures was positive, but application of these guidelines into practice was weak. This study also reflected some disparity between the isolation guidelines followed by the study participants and the recommended guidelines regarding infection control, droplet, and airborne isolation precautions.
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[Table 1], [Table 2], [Table 3]