Avian influenza knowledge among medical students, Iran.

To the Editor: Avian influenza is an infectious disease caused by type A strains of influenza virus (1). Since January 2004, Thailand and several other Southeast Asian countries have experienced outbreaks of avian influenza in poultry, and >100 million poultry have been culled or have died (www.who.int/csr/disease/avian_influenza/en). The prevalence of severe and fatal cases involving bird-to-human transmission is increasing (2). Experts fear that the avian influenza virus now circulating in Asia will mutate into a highly infectious strain and pass not only from animals to humans, but also among humans, which would lead to a pandemic (3).

During a pandemic, public health agencies and medical students will play critical roles in controlling the spread of disease (4). Therefore, medical school curricula should include specific courses in the epidemiology of avian influenza to ensure that all medical students and health care professionals will have the knowledge needed to confront a potential pandemic. In Iran, medical education comprises basic sciences (first to third year), externship (fourth to fifth year, preclinical education), and internship (sixth to seventh year). Medical students study virology during the second year of medical school. Thereafter, no additional coursework in virology is offered. Because several cases of avian influenza have been found in adjacent countries such as Turkey and Iraq, we anticipate that the virus will spread to Iran. Therefore, we designed a study to assess the knowledge of a group of Iranian medical students regarding avian influenza and to delineate the potential source of their knowledge.

The study population comprised second- and third-year medical students at the Faculty of Medicine, Tabriz University of Medical Sciences, in May 2006. We used a self-administered questionnaire that was based on information obtained from a review of the literature on avian influenza. This questionnaire (Table) comprised 3 sections: 1) demographic information, including age and sex of participants (2 items); 2) avian influenza-related questions covering general information, history, modes of transmission, clinical symptoms, and prevention (18 items); and 3) a multiple-choice question regarding the students' source of information about avian influenza (1 item). (As shown, the questionnaire used the common parlance "bird flu" for avian influenza.) Possible responses for section 2 included "yes," "no," and "! don't know." The knowledge score was calculated by giving + 1 for a correct answer, -1 for an incorrect answer, and zero for "I don't know" responses. A total of 18 points could be achieved if all questions in section 2 were correctly answered. Higher scores indicated a greater level of knowledge. We invited 2 epidemiologists and 1 statistician to qualify and examine the questions. Data were presented in mean [+ or -] standard deviation or percentage when appropriate. Statistical analysis was performed by SPSS Windows version 12.0 (SPSS Inc., Chicago, IL, USA) using the [chi square] test; p value was set at 0.05.

Two hundred thirty-four of 252 second- and third-year medical students completed the questionnaire. The mean age of the respondents was 19 [+ or -] 0.87 years (range 18-23). Twenty-nine percent (n = 68) of the students were male and 71% (n = 166) were female.

The mean knowledge score was 4.76 of 18 (total of correct and incorrect responses) (range -6 to 11). Second- and third-year students comparably responded to 16/18 questions ([chi square] test). A list of questions and the percentage of students' responses are provided in the Table.

Most of the respondents (67.2%) indicated that mass media (radio, television, and newspapers) was their major source of information about avian influenza, followed by scientific books and journals (8.3%), the Internet, (13%), and family and friends (10.4%). Only 1.1% of the medical students mentioned "school educational materials" as the source of their information.

Our study shows a relatively low level of knowledge of avian influenza among a group of Iranian medical students. Surprisingly, mass media was the main source of information in our study. Training health care professionals as well as medical students is of great importance in controlling infectious diseases. The findings of this study should be considered seriously by local health centers and disease control agencies because preparing health care professionals with sufficient knowledge is essential to confronting a potential pandemic. We believe that the low level of knowledge about avian influenza among these medical students is primarily a reflection of insufficient academic courses in the medical school curriculum. We strongly recommend improving the quality of education on this topic through access to textbooks, articles, seminars, and specific courses.

Kamyar Ghabili, * Mohammadali M. Shoja, * and Pooya Kamran *

* Tabriz University of Medical Sciences, Tabriz, Iran

References

(1.) de Jong MD, Hien TT. Avian influenza A (H5N1). J Clin Virol. 2006;35:2 13.

(2.) Perdue ML, Swayne DE. Public health risk from avian influenza virus. Avian Dis. 2005;49:317-27.

(3.) Ho G, Parker J. Avian influenza: risk, preparedness, and the roles of public health nurses in Hong Kong. Nurs Inq. 2006; 13:2-6.

(4.) Butler-Jones D. Canada's public health system: building support for front-line physicians. CMAJ. 2007;176:36-7.

Address for correspondence: Kamyar Ghabili, Tuberculosis and Lung Diseases Research Center, Tabriz University of Medical Sciences, Daneshgah St, Tabriz, Iran; email: kghabili@ gmail.com

Table. Respondents' knowledge of avian influenza (n = 234), Iran, May
2006

                                      Correct                   % Don't
Questions                             answer    % Yes   % No     know

History
  1. The first case of human
    infection with bird flu virus
    occurred in Hong Kong in 1997.      Yes     27.7     3.2     69.1

  2. Most fatal cases of bird flu
    have been reported in Vietnam.      Yes      28      2.2     69.9

General information
  3. Influenza virus occurs
    naturally among wild birds.         Yes     14.3    63.7      22
  4. Bird flu may be transmitted
    into other mammals such as
    horses and pigs.                    Yes     25.3    19.8     54.9

Transmission
  5. Transmission of the disease
    from person to person is
    possible.                           Yes     47.3    19.8      33
  6. Main modes of transmission
    are through saliva and nasal
    secretions.                         Yes     54.2    13.5     32.3
  7. Bird flu virus can be
    transmitted into persons
    through the alimentary tract.       No      74.2    15.7     10.1
  8. Bird flu is transmitted into
    humans through handling and
    cleaning of contaminated game.      Yes     41.3     37      21.7
  9. The consumption of
    contaminated chicken as
    broiler would have the risk of
    affliction.                         Yes     72.2    21.1      6.7
  10. Cooking eggs as soft-boiled
    eliminates the virus.               No      19.1    68.5     12.4

Diagnosis
  11. A laboratory test is needed
    to confirm bird flu in humans.      Yes      10      83        7

Clinical presentations
  12. Respiratory tract is the
    main infected system in the
    body.                               Yes     59.8     9.2      31
  13. The incubation period of
    bird flu is = 7 days.               Yes     13.6     2.3     84.1
  14. Symptoms of bird flu in
    humans are similar to seasonal
    influenza.                          Yes      20      11       69
  15. Bleeding from the nose and
    bleeding from the gums are
    early symptoms of bird flu.         Yes       2      13       85
  16. Bloody diarrhea (dysentery)
    is one of the manifestations
    of bird flu.                        No      30.8     8.8     60.4

Prevention
  17. Bird flu is a preventable
    infection.                          Yes      86      4.3      9.7
  18. There is a vaccine to
    protect humans from bird flu
    virus.                              No      20.9    37.4     41.8