Research Article

Amit Rekhi1, Aaron F

Knowledge and Awareness of Ebola among
Gomes2, Gaurav Undergraduate Dental Students: A Cross-
Chahal3, Himani
Dadwal4, Siddharth Sectional Study
Bisht5
1
Department of Public
Abstract
Health Dentistry,
2,3
Department of Aim: In the wake of the latest epidemic of Ebola, it has become important for
Periodontics, healthcare personnel around the world to be very cautious regarding the contagious
4
Department of Oral & nature of the disease. This study was conducted among undergraduate dental students
Maxillofacial Surgery, to assess the baseline knowledge and awareness about different aspects of Ebola.
5
Department of
Endodontics and Methodology: A total of 212 students from third-year, final-year and internship were
Conservative Dentistry,
Uttaranchal Dental and
selected for the study. A pre-designed, structured and self-administered questionnaire
Medical Research was used for data collection. The first part had questions related to knowledge,
Institute, Dehradun, epidemiology and transmission of Ebola. Second part was concerned with the
Uttarakhand. symptoms, treatment and prevention aspect. Questions were close-ended with
Correspondence to: multiple-answer type.
Dr. Amit Rekhi, Public
Health Dentistry, Results: Of the total sample, 78 (36.8%) participants were from third-year, 74 (34.9%)
Uttaranchal Dental and from final-year and 60 (28.3%) from internship. The overall success rate was just
Medical Research 48.58%. It was seen that the interns answered more number of questions correctly as
Institute, Mazri Grant, compared to final-year and third-year students.
Haridwar Road,
Dehradun, Uttarakhand.
Conclusion: Level of knowledge of Indian dental students about Ebola was generally
E-mail Id: acceptable considering the fact that it is not part of their curriculum. Dental school
rekhiamit@gmail.com curriculum must also be updated in this regard.

Keywords: Ebola, Knowledge, Awareness, Dental students.

Introduction

In March 2014, the World Health Organization was notified of an outbreak of a highly
fatal communicable disease in Guinea characterized by fever, severe diarrhea, and
vomiting. Virologic investigations identified Ebola virus (EBOV; belonging to the species
Zaire ebolavirus) as the causative agent.1 Ebola virus disease (Ebola) is a rare and deadly
viral illness which is prevalent mostly in the western part of the African sub-continent.
This virus can cause acute febrile illness associated with high mortality. This illness is
characterized by multisystem involvement that begins with the abrupt occurrence of
headache, myalgias, and fever and proceeds to prostration, rash, shock and often
bleeding manifestations. Epidemics usually occur with a single case acquired from an
unknown reservoir in nature and spread mainly through close contact with sick persons
How to cite this article: or their body fluids.2,3
Rekhi A, Gomes AF,
Chahal G et al. Knowledge The first epidemics of severe hemorrhagic fever caused by Ebola virus were reported in
and Awareness of Ebola
among Undergraduate
Zaire and Sudan in 1976, which were caused by different strains. Both epidemics were
Dental Students: A Cross- associated with inter-human spread. As for the reservoir, no conclusive animal source
Sectional Study. Epidem could be elucidated but speculation has centered on a possible role of bats.4 Ebola virus
Int 2016; 1(2): 23-29. has four readily distinguishable subtypes named after the site where they were first
discovered (Zaire, Sudan, Cote d’Ivoire, and Reston). Except for sub-type ‘Reston,’ all
ISSN: 2455-7048 cause severe and often fatal disease in humans.1

© ADR Journals 2016. All Rights Reserved.

Rekhi A et al.
The Ebola virus replicates in all cell types of multiple
organs. Viral replication is associated with cellular
necrosis. Pro-inflammatory cytokines are found to be in
high levels which contribute to severity of illness. Acute
infections are associated with high levels of circulating
virus and viral antigens which may escape through small
breaks in skin or through sweat glands and may hence
contribute in its spread.3,4
The Ebola virus is spread through direct contact (broken
skin or mucous membranes) with blood and body fluids
(urine, feces, saliva, vomit and semen) of a person who
is sick with Ebola, or with objects (like needles) that
have been contaminated with the virus. Ebola is not
spread through the air, water or food.5
After an incubation period (2 to 21 days), patient
abruptly develops fever, severe headache, myalgia,
malaise, nausea and vomiting. Chest pain with cough
and severe diarrhea follow. A maculopapular rash
appears in light-skinned people around 5 to 7 days and
is followed by desquamation. Bleeding usually begins at
this time apparent from any mucosal site into the skin.
Around 10 to 12 days after the onset, fever may break
and improvement occurs. No specific treatment is
available and only symptomatic treatment can be given
but a range of blood, immunological and drug therapies
are under development. In fatal cases, death occurs
usually between 6th and 16th day after infection from
multiple organ failure.2,6
In the wake of the latest epidemic of Ebola which began
in 2014 in the West African region, which has proved to
be the deadliest so far with cases reported in far off
countries too, it has become important for the
healthcare personnel around the world to be very
cautious regarding the contagious nature of the disease.
Since no vaccination is available, effective barrier
techniques and personal protective equipments (PPE)
are the main focus now.
Community engagement is key and good outbreak
control relies on applying a package of interventions,
namely case management, surveillance and contact
tracing, a good laboratory service, safe burials and social
mobilization 6,7. Nothing is perfect and simply relying on
airport checks to control the spread of disease during
epidemics would have dire consequences. This is
especially true for large developing countries like India,
where there are multiple points of entry and all such
points would not be possibly equipped with the
infrastructure to manage such a situation. Another thing
to be considered is the lack of health infrastructure to
cater to such a huge population in case of crisis.
ISSN: 2455-7048
Epidem. Int. 2016; 1(2)
A person infected with Ebola is not considered
contagious until symptoms appear. Due to the virulent
nature of the disease, it is highly unlikely that someone
with Ebola symptoms will seek dental care when they
are severely ill but a person who is unaware about his
illness being due to Ebola may seek dental care if he has
some unavoidable painful condition. However,
according to the Centers for Disease Control and
Prevention and the ADA Division of Science, dental
professionals are advised to take a medical history,
including a travel history from their patients with
symptoms in which a viral infection is suspected. Any
person within 21 days of returning from the West
African countries may be at risk of having contacted
persons infected with Ebola and may not exhibit
symptoms.5,8
If this is the case, dental professionals are advised to
delay routine dental care of the patient until 21 days
have elapsed from their trip. Palliative care for serious
oral health conditions, dental infections and pain can be
provided, if necessary, after consulting with the
patient’s physician and conforming to standard
precautions and physical barriers.5,8
Virology as a subject is part of the curriculum of dental
students and is taught in the second year of education
under the subject of Microbiology. However, the main
focus is on the microflora related to the oral cavity.
Considering the recent advent of Ebola virus disease, it
has become important for dental graduates to learn a
bit more on such kinds of infectious diseases.
Awareness simply means that one has an idea or holds a
concept about something whereas knowledge indicates
having more detailed information or experiencing
something related. Awareness is the basis for
knowledge but should not be mistaken for knowledge.
Taking this into consideration, this study was conducted
to check the basic knowledge and awareness related to
the Ebola virus disease among three grades of dental
students.
Materials and Methods
This institution-based, cross-sectional study was
conducted among dental students and interns from
Uttaranchal Dental and Medical Research Institute,
Dehradun, India.
The sample comprised of a total of 212 students-78
from third-year, 74 from final-year and 60 interns. All
the third-year, final-year, and intern students who were
present on the day of study were considered as the
sample size for the study.
24
Epidem. Int. 2016; 1(2) Rekhi A et al.

The students who were present on the day of the study taken that the students were not aware of such a
and were willing to participate were included in the questionnaire being given to them since it would have
study and those who were not willing to participate prompted them to search for information about Ebola
were excluded and thus were not given the before hand just to score better, thus leading to
questionnaire. acquisition bias. In addition to basic demographic
characteristics, the questionnaire was divided into two
A pre-designed, structured and self-administered sections. The first part had 14 questions related to the
questionnaire was used for data collection. The knowledge, epidemiology and transmission of Ebola.
questionnaire was designed by three senior faculty The second part with 10 questions was concerned with
members based on the facts released by World Health the symptoms, treatment and prevention associated
Organization and Centre for Disease Control following with Ebola. Questions were close-ended with multiple-
the epidemic. Since no other study could be found after answer type. Most questions had a response as ‘do not
thorough literature search, the structure of the know’ also. The responses were noted and analyzed as
questionnaire was based on similar studies dealing with correct response only. The response marks as ‘do not
other infectious studies. After giving instructions and know’ were record as incorrect. The overall response
explaining the aim and objective of this questionnaire, it rate was computed for each response and presented in
was distributed among all the students of the study, percentage form. The last question asked about their
which took about 15 minutes for completion. Care was source of knowledge about Ebola (Table 1).
Table 1.Questions Asked
Is the knowledge of Ebola important for general dental practice?
When EBOLA was first discovered?
Is EBOLA an epidemic, endemic or pandemic?
Which region of the world is EBOLA prevalent in?
Source of EBOLA in humans?
What kind of microbial disease is EBOLA?
How is EBOLA transmitted?
What is the incubation period of EBOLA?
Patients with EBOLA die on an average in how many days?
What is the case fatality rate of current outbreak?
Which of the following group of people are most susceptible to EBOLA virus?
Can EBOLA be transmitted from a person who has recovered
Is susceptibility to EBOLA affected by genetic makeup?
Risk of EBOLA virus in India is?
EBOLA virus targets which system of body?
Initial symptoms of EBOLA are?
Characteristic symptom of EBOLA?
What is the most common symptom of the current outbreak?
Mortality due to EBOLA is because of ?
Is there any cure for EBOLA infection?
What kind of treatment is there for EBOLA?
Are antibiotics effective against EBOLA?
Currently, is there any vaccine available for EBOLA?
Precautions taken by health care professionals include?
What is your source of knowledge regarding EBOLA?

Senior faculty members were requested to review and
comment on the questionnaire and appropriate changes
were made. It was also pre-tested on ten students from
all years to assess the reliability and for clarity of
questions and these students were not included in the
main study. Validity of the survey was confirmed by
similar articles (with some modifications)9-12 and by bio-
statisticians. Cronbach’s alpha (0.72) showed a good
degree of internal consistency and homogeneity
between items. To check for test-retest reliability, 30
participants were asked to repeat the questionnaire
after a gap of two weeks from the time the first
questionnaire was administered. Spearman’s rank
correlation coefficient was used for the same to check
for reliability for individual items which ranged between
0.42 and 0.90. All questions were clearly understood by

25 ISSN: 2455-7048
Rekhi A et al. Epidem. Int. 2016; 1(2)

students. The anonymity of respondents was assured success rates (number of correct responses) for
and their verbal consent was obtained. The Institutional questions were calculated for the three groups of the
Ethics Committee approved the study protocol and also sample. The statistical differences between the groups
gave permission for the procedure of taking verbal were calculated using Chi-square test where <0.05 was
consent from the participants instead of a written considered to be statistically significant.
consent. It was understood that the subjects who filled
the questionnaire did so only if they wanted to and no Results
compulsion was imposed. They could even refrain from
completing the form in-between if they felt the need This cross-sectional, questionnaire-based study was
and hence quit the study without completing. Hence, a conducted among 212 dental students of Uttaranchal
separate written consent was not thought to be Dental and Medical Research Institute, Dehradun. The
necessary. Since all the participants were above the age study was conducted on the third-year, final-year
of 18 years, no consent from the parents or guardians students and interns from the institution. Out of the
was required. The research was conducted in full total sample, 78 (36.8%) participants were from third-
accordance with the World Medical Association year, 74 (34.9%) from final-year and 60 (28.3%) from
Declaration of Helsinki. internship. Majority of the sample comprised of females
(62.3%; n=132) and males formed around 37.7% (n=80)
Statistical Analysis of the sample. The questionnaire comprised a total of
25 questions with multiple choice answers. The correct
The questionnaire forms were manually checked for responses for each question were calculated. Table 2
completion of data. All data were entered in a data and Table 3 represent the distribution of the responses
entry form which was transferred to SPSS software of the participants according to their year of education,
(SPSS, version 17 for Windows). Descriptive statistics depicted as correct and incorrect.
were obtained for all variables in the study and the
Table 2.Correct Responses given by the Participants for First Part of Questionnaire
Q. No. Third year Final year Interns Total p-
value
n (%) n (%) n (%) n (%)
1. Is the knowledge of Ebola important for general 63 (80.8) 63 (85.1) 60 (100) 186 (87.7) 0.002
dental practice?
2. When EBOLA was first discovered? 9 (11.5) 4 (5.4) 21 (35) 34 (16) 0.000
3. Is EBOLA an epidemic, endemic or pandemic? 26 (33.3) 47 (63.5) 33 (55) 106 (50) 0.001
4. Which region of the world is EBOLA prevalent in? 3 (3.8) 6 (8.1) 33 (55) 42 (19.8) 0.000
5. Source of EBOLA in humans? 2 (2.6) 5 (6.8) 37 (61.7) 44 (20.8) 0.000
6. What kind of microbial disease is EBOLA? 75 (96.2) 65 (87.8) 58 (96.7) 198 (93.4) 0.058*
7. How is EBOLA transmitted? 8 (10.3) 22 (29.7) 19 (31.7) 49 (23.1) 0.003
8. What is the incubation period of EBOLA? 13 (16.7) 29 (39.2) 35 (58.3) 77 (36.3) 0.000
9. Patients with EBOLA die on an average in how 15 (19.2) 13 (17.6) 19 (31.7) 47 (22.2) 0.109*
many days?
10. What is the case fatality rate of current 34 (43.6) 20 (27) 31 (51.7) 85 (40.1) 0.011
outbreak?
11. Which of the following group of people are 54 (69.2) 60 (81.1) 54 (90) 168 (79.2) 0.010
most susceptible to EBOLA virus?
12. Can EBOLA be transmitted from a person who 41 (52.6) 27 (36.5) 50 (83.3) 118 (55.7) 0.000
has recovered?
13. Is susceptibility to EBOLA affected by genetic 47 (60.3) 37 (50) 24 (40) 108 (50.9) 0.061*
makeup?
14. What is the risk of EBOLA in India is? 20 (25.6) 19 (25.7) 12 (20) 51 (24.1) 0.686*
*Not significant

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Epidem. Int. 2016; 1(2) Rekhi A et al.

Table 3.Correct responses given by the Participants for Second Part of Questionnaire
Q. No. Third year Final year Interns Total p-value
n (%) n (%) n (%) n (%)
15. EBOLA virus targets which system of body? 45 (57.7) 40 (54.1) 35 (58.3) 120 (56.6) 0.858*
16. Initial symptoms of EBOLA are? 31 (39.7) 47 (63.5) 31 (51.7) 109 (51.4) 0.014
17. Characteristic symptom of EBOLA? 10 (12.8) 28 (37.8) 37 (61.7) 75 (35.4) 0.000
18. What is the most common symptom of the 36 (46.2) 35 (41.3) 34 (56.7) 105 (49.5) 0.422*
current outbreak?
19. Mortality due to EBOLA is because of? 19 (24.4) 25 (33.8) 29 (48.3) 73 (34.4) 0.013
20. Is there any cure for EBOLA infection? 29 (37.2) 25 (33.8) 43 (71.7) 97 (45.8) 0.000
21. What kind of treatment is there for EBOLA? 24 (30.8) 29 (39.2) 47 (78.3) 100 (47.2) 0.000
22. Are antibiotics effective against EBOLA? 48 (61.5) 53 (71.6) 42 (70) 143 (67.5) 0.367*
23. Currently, is there any vaccine available for 61 (78.2) 42 (56.8) 53 (88.3) 156 (73.6) 0.000
EBOLA?
24. Precautions taken by health care professionals 62 (79.5) 48 (64.9) 31 (51.7) 141 (66.5) 0.003
include?
*Not significant

The overall success rate was just 48.58%. It was seen
that the interns answered more number of questions
correctly as compared to final-year and third-year
students. Overall, the questions with the highest correct
responses were questions related to importance of
Ebola awareness in dentistry (Q 1) (87.7%), microbial
nature of the disease (Q6) (93.4%) and people’s
susceptibility (Q11) (79.2%). Conversely, lowest correct
responses were noted for questions related to region of
prevalence (Q 4) (19.8%), source of disease (Q 5)
(20.8%) and average days for fatality (Q 9) (22.2%).
The differences in answers between the three groups of
students were not found to be statistically significant in
case of questions asked about microbial nature of
disease (Q 6), average days for fatality (Q 9), genetic
role (Q 13), risk in India (Q 14), target system of body (Q
15), symptom of current outbreak (Q 18) and effect of
antibiotics on disease (Q 22) (p>0.05). Rest of the
questions showed a statistically significant difference in
answering when compared among the three groups
(p<0.05).
The last question asked the participants about their
source of knowledge regarding Ebola. Most respondents
reported to have learned from ‘newspapers’ (41.5%)
followed by ‘radio-television’ (35.4%). Around 23.1%
reported to have learnt from ‘other sources’ such as
internet or from doctors.
Discussion
The recent outbreak of Ebola virus in the West African
region has been the deadliest epidemic in history. The
disease has been found to be difficult to contain, and
with no specific treatment or vaccination present, focus
has shifted to prevention of its spread. The knowledge
of Ebola has become important for all health personnel
including the dentists. This study investigated the
knowledge and awareness of undergraduate dental
students and interns regarding the epidemiology,
transmission, symptoms, treatment and prevention of
Ebola virus disease.
A thorough literature search could not reveal any similar
studies conducted about Ebola among dental students
in other populations. Hence, it was difficult to compare
the results of our study with others. General
comparisons were made with some other studies
conducted on dental students only but regarding the
knowledge of other diseases.
Our study was done on third-year, final-year students
and interns. A questionnaire with 25 questions was
given to each student and correct responses were
computed. Higher correct responses were given by
interns as compared to the students of other years.
Similar result was seen in a study on dental graduates in
a college in India regarding hepatitis B where it was
seen that seniors gave more correct responses than
their junior counterparts.9
A very high number of participants (87.7%) agreed that
the knowledge of Ebola was important for general
dental practice. This is not surprising since Ebola being a
contagious disease can infect the attending dentist too.
In some studies conducted to assess knowledge about
HIV,10 Hepatitis9,11 and oral cancer,12,13 participants had
shown similar agreement.
A good number of participants knew that Ebola is an
epidemic where people susceptible include healthcare
workers, family members in close contact and also the
people handling the dead bodies of victims. It is well

27 ISSN: 2455-7048
Rekhi A et al.
known that Ebola is transmitted by direct contact with
an infected individual and viral titers also exist in
deceased individuals. Hence proper barriers should also
be maintained by people involved in disposing the dead
bodies too.5,6 Around half the subjects knew that Ebola
is a viral disease.
Very few knew about Ebola being first reported in 1976
and most of the respondents thought that it was in 2014
only. The region of prevalence was also not known to
many respondents. Most believed that Ebola is chiefly
transmitted through monkeys and not bats which
decreased the success rate.2,4 It is known that Ebola is
transmitted through direct contact with infected
individuals and their body fluids.5 Participants’ most
responses were however in favor of it being a droplet
infection. The knowledge of transmission of Ebola is of
utmost importance to the dentist since a dentist comes
in direct contact with the patient’s body fluids (saliva)
and thus may be more susceptible than a general
physician.
Current responses improved a bit in case of knowledge
regarding the incubation period and case fatality rate of
the current outbreak. Ebola has shown a case fatality
rate of around 71% for this current outbreak and its
incubation period ranges from 3 to 16 days.6
India is a densely populated country and hence has a
high risk for Ebola epidemic to occur. However, it was
thought to be such by only 24.1% of the participants.
Probably, the respondents felt that other conditions
which were needed for Ebola to spread were not
present in the country. The dentist needs to know that
India bears a decent scenario for such diseases to
spread due to its large population and densely
populated areas.
The overall percentage of correct responses improved a
lot when questions regarding the symptoms,
transmission and prevention of Ebola were asked. This
was probably due to the fact that a general knowledge
about viral diseases helped the respondents to relate it
to Ebola. Also, the stress in the electronic and the print
media was more on such factors as compared to the
general awareness of Ebola. Although a person with
Ebola will not visit a dentist, the knowledge of signs and
symptoms is of utmost importance to the dentist in case
of patients who are unaware of their illness. This would
also aid in establishing a differential diagnosis and
would act as a precautionary measure for other diseases
too.
In a Malaysian12 study on knowledge about oral cancer
and in a study among Jordanian14 dental students on the
ISSN: 2455-7048
Epidem. Int. 2016; 1(2)
knowledge about HIV, a significant difference was seen
between the answers given by different grades of
students. This is similar to our study where more
number of questions demonstrated such results.
However an Indian study15 regarding hepatitis B
knowledge reported a contradictory result, i.e., no
statistically significant differences were found between
the responses of different groups.
An overall success rate of 48.5% was seen in our study.
Similar success rates were seen in studies on students in
Iraq16 and India9 regarding Hepatitis B. Higher correct
responses were seen in a study conducted about
hepatitis B among dental students in India.11 Similarly, in
some other studies,13,16 conducted on dental graduates,
the percentage of correct responses was also high. This
might be due to the fact that Ebola as such is not part of
the curriculum like HIV and hepatitis, hence whatever
knowledge the students had, was acquired from other
sources and therefore was not complete. The role of
dentists, particularly the public health dentists can be of
prime importance here. These dentists can be trained
about the epidemiology and prevention of such diseases
since they already have a background in ‘public health’
as part of their curriculum. They can further impart such
knowledge to dental students and other dentists too.
The public health dentist can also educate the people in
both urban and rural set-ups about the various aspects
of the disease including its prevention. They can also
gather information and help conduct various research-
based studies for the same.
Conclusion
The level of knowledge of Indian dental students about
Ebola was generally acceptable considering the fact that
it is not part of their curriculum. There were, however,
some inadequacies in the students’ knowledge in some
essential aspects.
Since this study is limited by its small sample size,
studies with larger samples are recommended to
confirm the findings which may help to expand the
knowledge base for the future dentists of India. The
results of such studies can be used as a baseline for
conducting continuing dental education programs on
Ebola. The dental school curriculum may also be
updated and improved in order to enhance the
students’ knowledge about Ebola as a whole and also a
chapter on foreign and exotic infectious diseases in
general, as many other diseases may become of greater
concern over time.
Conflict of Interest: None
28
Epidem. Int. 2016; 1(2)
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Date of Submission: 29th May 2016
Date of Acceptance: 27th Jun. 2016
ISSN: 2455-7048