Impact of knowledge and practices on prevention of chikungunya in an epidemic area in India

Context : Chikungunya is a re-emerging debilitating viral disease for which any specific cure or vaccine is not available. Aim : To study the impact of knowledge and practices on prevention of chikungunya. Settings and Design: Three primary health centers in rural area experiencing epidemic of chikungunya were selected for the study. Materials and Methods: The study was conducted in a coastal district of India, which was experiencing an epidemic of chikungunya during the study period. Patients above 18 years of age, attending out-patient department of three primary health centers, were included in the study. Patients diagnosed as case of chikungunya were taken as cases and those with other morbidity and having none of their relatives or friends suffering or had suffered in the last month from chikungunya were taken as controls. Sample size was 150 and controls were three times the number of cases. A pre-tested, open-ended questionnaire was used to collect information by face to face interview technique. Statistical Analysis Used: Percentage, proportions, and Chi-square were used for statistical analyses. Results: Controls who were not affected by chikungunya were having better knowledge and practices about the vector and methods of preventing the disease than the cases. Knowledge and practices were found to be skewed toward people having more number of years of schooling and higher per capita income. Striking differences between knowledge and practices were also observed among cases as well as controls. Conclusions: People who had knowledge about the vector and methods of preventing the disease and had put their knowledge into practice were less likely to be effected by chikungunya. In the absence of any specific cure or effective vaccine, health education can prove to be an important tool for the control of chikungunya epidemic.

Keywords: Chikungunya, Knowledge, Practices, Prevention

Chikungunya epidemic is not new to India. An epidemic was first reported in 1963-1965 in Kolkata, and in 1973, an epidemic was reported in Barsi-Sholapur district also. ^[1] The present epidemic was seen after 33 years in December 2005, and by the end of 2006, more than 1.39 million cases were reported from 12 states. Karnataka state of India reported the maximum of 0.76 million cases, followed by Maharashtra reporting 0.27 million cases. ^[2] This is spreading far and at a rapid rate. In 2008, Karnataka and Kerala were the worst effected states and the epidemic continued in many districts of these states. In some areas, attack rate has reached up to 45%, causing substantial morbidity and economic loss. ^[3] As there is no specific treatment or vaccine available at present for chikungunya, prevention through vector control and avoiding mosquito bites seems to be the only options available in order to break the chain of transmission. ^[4] The Government of India has initiated several public health measures to control the epidemic, including intensive IEC/Behaviour Change Communication activities through print, electronic media, inter-personal communication, outdoor publicity as well as and inter-sectoral collaboration with civil society organizations such as non-governmental organizations, self-help groups and Panchayati Raj Institutions (PRIs). ^[5] A brainstorming meeting of World Health Organization’s Southeast Asian Regional Office on the subject of “Priority areas for research in Chikungunya and Dengue” has recommended an evaluation of social, cultural and community behavioral practices leading to disease transmission, including Knowledge Attitude and Practices studies in relation to different stakeholders such as general population, decision makers, health care providers, etc. ^[6] Hence, the present study was carried out to assess the knowledge and practices concerning chikungunya, and their role in preventing the disease amongst the general population in an area experiencing epidemic of chikungunya.

The present study was conducted in a coastal district of Karnataka state of India in the month of July 2008. The area was experiencing an epidemic of chikungunya during this period of time. Patients attending the out-patient department of three primary health centers in the rural field practice area of a medical college were included in the study. After taking informed consent, patients above 18 years of age were included in the study. The patients were divided into two groups, that is, cases and controls. Those who were diagnosed as a case of chikungunya by primary health center medical officers were taken as cases. Others who were visiting the primary health centers for some other morbidity and those who had none of their relatives or friends suffering or had suffered in the last month from chikungunya were taken as controls. Sample size was 150 and number of controls was three times the number of cases. A pre-tested, open-ended questionnaire was used to collect information by face to face interview technique. Data thus obtained were compiled and analyzed using SPPS version 11.0 software. Percentage, proportions and chi-square were used as statistical methods to draw inference.

A total of 150 cases and 450 controls were interviewed during the study period. Demographic profile [Table 1] showed that more than half [78 (52%)] among the cases were males, whereas two-thirds [297 (66%)] of the controls were females. About half among the cases and controls were of age between 18 and 40 years. Majority [107 (78%)] among the cases were either having no schooling or less than 5 years of schooling. On the other hand, majority [279 (62%)] among the controls were having more than 5 years of schooling.

[Table 2] shows the knowledge of the cases and controls regarding symptoms and transmission of chikungunya and development sites (breeding places) of Aedes mosquito and the preventive measures. As the cases were having first-hand experience of the disease, they were more aware regarding the symptoms of the disease as compared to the controls. Controls were mostly aware about the chief symptoms of the fever, and joint pains only.

Majority of the cases [105 (70%)] as well as controls [378 (84%)] were aware that the disease spreads through mosquito bites, but only 30 (20%) cases and 162 (36%) controls were aware that it is spread by Aedes mosquitoes. Approximately half [216 (48%)] among the controls were aware that this mosquito bites during the day time too. On the other hand, less than one-fourth [36 (24%)] of the cases were having knowledge regarding this vital aspect about transmission of the disease. Majority (54-73%) among the controls was having correct knowledge regarding various development sites/breeding places of the Aedes mosquitoes, whereas only 13-48% of the cases were aware regarding these facts. Knowledge regarding prevention of the disease by elimination of breeding places of the mosquitoes and avoiding mosquito bites was far better among the controls than the cases. Most of the cases were aware of use of mosquito repellents in the form of mats and coils, which may not be effective against Aedes mosquitoes as they bite during day time. Only 10 (7%) cases were aware that wearing full dresses can go a long way in avoiding mosquito bites and hence prevention of chikungunya. Less than 40% cases were having knowledge regarding various anti-larval or source reduction methods. As far as putting the knowledge into practice is concerned, here too, controls were better off and the results were statistically significant [Table 3]. Approximately 90% of the controls having knowledge regarding various mosquito control measures were putting their knowledge into practice compared to less than half of the cases having similar knowledge (except spraying of insecticides which was done only after the establishment of the epidemic in the area). Similarly, majority of the controls having knowledge were using the same to prevent mosquito bites; cases were lagging in the aspect too. About one third among the study group believed that there is an effective prophylaxis against chikungunya and so they approached practioners of traditional system of medicine (Homeopathy, Ayurveda) for the same. The knowledge concerning disease and putting that knowledge into practices was found to be directly related to the number of years of schooling and per capita monthly income among the cases as well as the controls.

Chikungunya is mostly a self-limiting viral disease. While recovery is the expected outcome, convalescence can be prolonged (up to a year or more), and persistent joint pain may require analgesic and long-term anti-inflammatory therapy. ^[3] The principal vector is the Aedes mosquito. Females of this species deposit their eggs in a variety of water holding containers, such as jars used for domestic water storage, tyres and disposed off items that are filled with rain water. As a specific cure or an effective vaccine is not available, the disease control is limited to reduction of the vector population by making water holding containers unavailable for development of mosquitoes, killing the adult mosquitoes with insecticides or by interfering with mosquito human contact by screening the houses, using mosquito nets, mosquito repellents or wearing full dresses to avoid mosquito bites. ^[3] The present study has shown that people who had knowledge about the vector and methods of preventing the disease and had put their knowledge into practice were less likely to be effected by chikungunya. The study further reveals that the Government of India has succeeded to some extent in creating awareness among the people due to its efforts but the level of awareness was found to be skewed toward people having more number of years of schooling and higher per capita monthly income. Furthermore, striking differences between knowledge and practices among both the groups, that is the cases as well as controls, were also observed. Similar finding has been observed elsewhere too. ^[7],[8]

Chikungunya was believed to a non-fatal and self-limiting disease, but recently a severe form of the disease with CNS involvement and fulminating hepatitis has been reported on the Indian Ocean island of Reunion, where by March 2006, a third of the population was affected and the disease had caused 237 deaths. ^[9] The scientists at the National Institute of Virology of India reported that the outbreaks of chikungunya virus in 1963 and 1973 were of an Asian genotype, whereas the recent outbreaks are of an African genotype similar to the strains of virus found in the Reunion epidemic. ^[10] No state or central government has officially declared any deaths caused by chikungunya in India except for Gujrat, where 11 deaths out of 225 laboratory confirmed cases of the virus have been reported. ^[11] A mutation in the chikungunya virus that improves its ability to invade mosquito cells and to replicate has been reported. It has also been speculated that the virus might have acquired a higher neurovirulence leading to unusually severe cases. ^[9] Thus, apart from the present debilitating but self-limiting form of chikungunya causing substantial morbidity and economic loss, spread of perhaps more virulent form of the disease remains a possibility. Under such circumstances, India needs to further intensify its campaign of community education apart from strict vector control measures and disease surveillance program to control the disease.

The present study has proved that people who had knowledge about the vector and methods of preventing the disease and had put their knowledge into practice are less likely to be affected by chikungunya. Therefore, in the absence of any specific cure or effective vaccine, health education can prove to be an important tool for the control of chikungunya epidemic.

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1755-6783.80513

[Table 1], [Table 2], [Table 3]