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Knowledge and Attitudes about Zika Virus Infection and Vaccine Intent among Medical Students in Costa Rica

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  • 1 Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, North Carolina;
  • 2 Department of Mathematics, Manipal Institute of Technology, Manipal, India;
  • 3 Universidad de Ciencias Medicas (UCIMED), San José, Costa Rica

ABSTRACT

Zika virus (ZIKV) infection is a public health problem in the Americas. We assessed ZIKV knowledge, attitudes, and future ZIKV vaccine intent among medical students. In this cross-sectional study, a convenience sample of medical students in San José, Costa Rica, were surveyed to assess knowledge, attitudes, vaccine intent, and sources of information about ZIKV. Knowledge and attitude scores were calculated. Factors associated with vaccine intent were determined by bivariate analysis using a chi-square test. Of 468 participants surveyed, majority were females (299, 63.8%) and lived in urban areas (411, 87%). The participant mean knowledge score was 12.2 (SD: 3.65) out of a possible 20. Students residing in suburban or rural areas (odds ratio [OR]: 0.432; CI: 0.24–0.78), first- or second-year students (OR: 0.423; CI: 0.27–0.67), and aged < 20 years (OR: 0.586; CI: 0.36–0.97) had significantly lower knowledge scores. The participant mean attitude score was 30.2 (SD: 4.76) on a scale of 13–65, with lower numbers indicating a concern for ZIKV severity. A majority of the participants indicated they would be likely or extremely likely to receive a ZIKV vaccine (420, 89.7%) and recommend the vaccine to their patients (439, 93.8%). Vaccine intent was not influenced by demographics, total knowledge, and attitude scores. Students (388, 83%) identified the Internet as their primary source of ZIKV information. A majority of students demonstrated a positive attitude toward ZIKV and willingness to accept and recommend a vaccine. Low knowledge scores underscore the need for ZIKV education, especially in the early years of medical school. Use of the Internet should be considered in dissemination of ZIKV education.

INTRODUCTION

Over the last several years, Zika virus (ZIKV) has become a major public health concern.1,2 Zika virus is a single-stranded RNA flavivirus transmitted by the Aedes mosquito vector. Originally identified in rhesus monkeys in Uganda in 1947 with few cases in humans, the disease led to little public concern for several decades after its discovery. Human outbreaks were reported from Yap island, Micronesia, Pacific, in 2007 and French Polynesia, Pacific, in 2013–2014.3 In most people, Zika infection is usually a mild illness. However, ZIKV emerged in 2015 in Pernambuco, Brazil, and rapidly spread to many countries in Latin America and other regions of the Americas.2,3 In 2016, the WHO declared an international public health emergency after the discovery of a link between ZIKV and neurological disorders such as Guillain–Barré syndrome and microcephaly in the children born to infected pregnant women.4 Efforts to minimize the impact of Zika must target women who are or may become pregnant and other at-risk populations by providing reproduction information and services.5

Although there is no current outbreak, there were 1,920 reported cases of Zika in Costa Rica as of epidemiologic week 33 of 2017.6 Analyzing the awareness of and preparedness for Zika is essential to address the public health concern, even in areas without known ongoing Zika outbreaks. As there is currently no vaccine or antiviral treatment for ZIKV, it is important to control the disease via preventative measures. Healthcare providers need to be equipped with not only the appropriate information to manage their patients infected with ZIKV but also the information to educate their patients about prevention and decision-making. Governing bodies can play a key role in community education. For example, in Costa Rica in 2016, the Ministry of Health, the Ministry of Public Education, and the Pan American Health Organization organized a campaign titled “Small Creatures, Big Threats” aimed to educate the public about various mosquito-borne diseases.

Efforts are currently underway in the development of a Zika vaccine.7 If an effective vaccine is produced, a key obstacle to overcome will be the willingness of individuals to receive the vaccine, particularly in the absence of a continued epidemic or in an area where an epidemic has not yet occurred. Medical students in their role as future healthcare providers need specialized knowledge on diagnosing and treating ZIKV infection as well as how to educate their patients on the risk of ZIKV and prevention strategies (e.g., a vaccine when available). To our knowledge, no knowledge, attitude, and practice (KAP) data among medical students exist for Zika in Costa Rica. This study aimed to assess ZIKV KAP of medical students in Costa Rica, an area where ZIKV exists but has not yet made a widespread impact. We also evaluated factors which may influence the intention to receive a future ZIKV vaccine, given the importance of healthcare provider recommendation for vaccine acceptability in the community. We hope our findings will identify gaps in ZIKV knowledge among medical students. The study results could be applied to medical education in communities where the virus has not yet been identified.

MATERIALS AND METHODS

Study design, setting, and participants.

Using a cross-sectional study design, we assessed knowledge and attitudes toward ZIKV and intention to receive a future ZIKV vaccine among medical students enrolled in Universidad de Ciencias Medicas (UCIMED) in Costa Rica over a 5-week period from July 2017 through August 2017. Costa Rica is a rugged, rain-forested Central American country with coastlines on the Caribbean and Pacific. It is a country known for its beaches, volcanoes, and biodiversity, and the capital, San José is home to several cultural institutions.

Universidad de Ciencias Medicas is a nonprofit medical school located in San José, Costa Rica, and is recognized as one of the best medical schools in Latin America. The university is located in close proximity to the four largest private hospitals in the country. In total, there are eight medical schools in Costa Rica (one public and seven private), each of which offers a 6-year program resulting in a degree in medicine and surgery. Students may enter medical school directly after high school, and the exact curriculum throughout the next 6 years varies between institutions. At UCIMED, students begin to study infectious diseases in their histology course during the first year. The topic is expanded on during a microbiology course in the second year. The final year of the curriculum is an internship during which students work only in the hospital as opposed to traditional classrooms. However, direct interactions with patients are integrated into the curriculum with classwork beginning during the third year. After medical school, students complete a general examination and an examination tailored to the specialty in which they plan to attend a residency program on graduation.

Medical students aged 18 years and older were recruited in our study by using a convenience sampling method. Exclusion criteria included students who were not enrolled in school in San José or those who did not give consent to take part in the study. Study subjects were solicited to participate on a volunteer basis in student lounge areas and classrooms. The study was implemented during the weekdays of the summer term while classes were in session. Surveys were completed by students in between class time or during class if permission was granted to the surveyors by the professor. The purpose of the study was explained to the participants by a trained research assistant conversant in English and Spanish. Students were not provided with compensation for their participation. The interviews were conducted in a private setting, and participation was voluntary. This study received approval of the Institutional Review Boards at both Wake Forest School of Medicine (WFSM) and UCIMED. Informed consent was obtained from all subjects before participation in the study.

Survey measure.

A self-administered, semi-structured, anonymous questionnaire was designed and adapted based on previous studies and, in part, based on a question bank generated by the WHO.5,8,9 The WHO questionnaire is a bank of questions developed for governments and response partners to use to obtain information to guide their responses to the ZIKV emergency.9 The survey instrument was then reviewed by a panel of three WFSM and UCIMED faculty with expertise in infectious diseases, maternal and newborn health, vaccinology, public health, and clinical trials. The survey was modified following feedback from the reviewers. The questionnaire was pilot tested among 20 medical students for qualitative validity and comprehensibility before initiation of the study. The translation of the English version of the questionnaire to Spanish and back translation to English were performed by trained interpreters associated with professional translation services at UCIMED. The internal consistency of the measure during pilot testing measured with Cronbach’s alpha was 0.721 and 0.672 corresponding to knowledge and attitude statements, respectively.

The survey was divided into the several sections: 1) demographic characteristics of student responders; 2) 20 knowledge (true/false/I do not know) statements regarding ZIKV symptoms, transmission, risks, prevention, and relationship to other endemic diseases such as dengue and chikungunya; 3) 13 attitude statements about ZIKV to which students respond on a 1–5 Likert scale from “strongly agree” to “strongly disagree” regarding ZIKV severity, importance, or stigma; 4) three statements regarding practices, training, and awareness of ZIKV national policy questions with yes/no/I do not know as responses; 5) ZIKV vaccine intent and recommendation to others; and 6) sources of information regarding ZIKV.

Knowledge and attitude scores.

The knowledge scores were calculated with a possible range of 0–20 points where one point was awarded for each correct knowledge answer and 0 points were awarded for each incorrect response or “I do not know” response. The knowledge score was categorized as low (0–6), moderate (7–13), or high (14–20). The attitude score range was 0–65, but the minimum score obtained by study participants was 13 and maximum was 65. Thus, the attitude scores were calculated on a possible scale of 13–65 based on student responses to 13 statements on a 1–5 Likert scale. Lower scores correspond to a greater concern about ZIKV. The lower scores indicated a more positive attitude toward the importance of ZIKV education and the severity of the disease. The attitude scores were categorized as positive attitude (13–39) or negative attitude (≥ 40) toward ZIKV.

Outcome measures.

The primary outcome measure was to assess the intent of the participant to receive a future ZIKV vaccine, assessed by the question: “If there were a vaccine available against ZIKV, how likely would you get that vaccine?” (The possible responses included strongly agree, agree, neutral, disagree, and strongly disagree.) The secondary outcome measure was to assess the intent of the participant to recommend the ZIKV vaccine to others, assessed by the question: “If there were a ZIKV vaccine, how likely would you recommend the vaccine to your patients?” (The possible responses included were strongly agree, agree, neutral, disagree, and strongly disagree.)

Statistical analysis.

The data were analyzed using the Statistical Package for the Social Sciences, version 20.0, IBM (Armonk, NY). Demographic characteristics are depicted as frequencies and percentages. Descriptive statistics were used to summarize the data. Because the variables were categorical, bivariate analysis was performed using the chi-squared test for independence of attributes to check for the association of one variable with another. A variable with P-value of P < 0.05 was considered to be significant.

The chi-square test for independence of attributes was initially done to determine if any of the demographic variables (gender, age, school year, location, and housing type) were significant predictors of knowledge and attitude scores. Variables that were found to be significant on bivariate analysis were then considered for multivariate analysis using binary logistic regression to determine which of these variables cause significant differences in the knowledge and attitude scores.

Bivariate analysis using the chi-square test for independence of attributes was carried out on the demographic variables, the knowledge, and attitude scores, and the receipt of ZIKV training and practices was carried out for the dependent variable (student intent to accept a future ZIKV vaccine and the likelihood to recommend the vaccine to their patients). The odds ratios and 95% CIs are presented.

RESULTS

Sociodemographic characteristics.

A total of 480 participants were approached; 12 students were excluded (e.g., inconsistent or incomplete information, unwilling to participate, and did not reside in the San José area). A total of 468 students completed the survey. A majority were females (299, 63.8%) and lived in an urban setting (411, 87.8%). Demographic and other baseline characteristics of the participants are presented as frequencies and their corresponding percentages in Table 1.

Table 1

Demographic characteristics of study respondents (n = 468)

CharacteristicNumberPercentage
Gender
 Male16535.3
 Female29963.8
 Missing040.9
Age (years)
 < 2018339.1
 20–2322347.7
 > 23255.3
 Missing377.9
Medical school year
 First10622.7
 Second17938.3
 Third6313.5
 Fourth9420.1
 Fifth and Sixth265.4
Location
 Rural255.3
 Suburban296.2
 Urban41187.8
 Missing030.7
Housing type
 Individual37780.6
 Collective8919.2
 Missing020.2

Knowledge of ZIKV.

Table 2 summarizes the knowledge statements of medical students toward ZIKV. Student responses yielded a mean knowledge score of 12.2 (SD: 3.65) on a possible scale of 0–20. A majority of students (261, 55.8%) earned moderate ZIKV knowledge scores (7–13 out of 20). One hundred seventy-nine participants (38.2%) received high knowledge scores (14–20 out of 20), and 28 (6%) received low knowledge scores (0–6 out of 20). The results are shown in Supplemental Table 2a.

Table 2

Knowledge statements of ZIKV (n = 468)

StatementTrue, n (%)False, n (%)I do not know, n (%)Correct answerCorrect answer, n (%)
1ZIKV infection can affect individuals of any age447 (95.5)05 (1.1)14 (3.0)True447 (95.5)
2A person can get ZIKV infection from eating contaminated food30 (6.4)329 (70.3)106 (22.6)False329 (70.3)
3A person can get ZIKV infection by the bite of infected mosquitoes461 (98.5)03 (0.6)02 (0.4)True461 (98.5)
4A women can get ZIKV infection by having sexual intercourse with an infected man151 (32.3)207 (44.2)108 (23.1)True151 (32.3)
5ZIKV is spread by the same type of mosquitoes that spread dengue and chikungunya336 (71.8)50 (10.7)80 (17.1)True336 (71.8)
6The mosquito that spreads ZIKV bites primarily during the nighttime73 (15.6)135 (28.8)258 (55.1)False135 (28.8)
7Pregnant women with ZIKV infection can pass the virus to their babies325 (69.4)49 (10.5)92 (19.7)True325 (69.4)
8Zika virus infection can be transmitted via saliva43 (9.2)257 (54.9)166 (35.5)False257 (54.9)
9If a person does not show symptoms, they are not infected with Zika virus30 (6.4)352 (75.2)83 (17.7)False352 (75.2)
10Fever, rash, and conjunctivitis are common symptoms of ZIKV infection308 (65.8)15 (3.2)143 (30.6)True308 (65.8)
11Symptoms of Zika are similar to dengue and chikungunya362 (77.4)30 (6.4)74 (15.8)True362 (77.4)
12ZIKV is a serious problem for an infected pregnant women’s unborn child358 (76.5)31 (6.6)77 (16.5)True358 (76.5)
13ZIKV is primarily a problem for healthcare workers196 (41.9)172 (36.8)98 (20.9)False172 (36.8)
14If a pregnant women gets Zika, her baby is at risk of developing eye defects124 (26.5)43 (9.2)299 (63.9)True124 (26.5)
15If a pregnant women gets Zika, her baby is at risk of developing brain abnormalities283 (60.5)18 (3.8)165 (35.3)True283 (60.5)
16ZIKV can cause diabetes06 (1.3)203 (43.4)257 (54.9)False203 (43.4)
17ZIKV can cause Guillain–Barre syndrome (GBS)112 (23.9)58 (12.4)296 (63.2)True112 (23.9)
18Serologic diagnosis of ZIKV infection is problematic because of cross-reactivity with dengue and chikungunya150 (32.1)57 (12.2)259 (55.3)True150 (32.1)
19Antiviral agents are effective against ZIKV infection102 (21.8)120 (25.6)244 (52.1)False120 (25.6)
20There is currently no vaccine for ZIKV infection225 (48.1)95 (20.3)146 (31.2)True225 (48.1)

ZIKV = Zika virus.

Table 3

Attitude statements of ZIKV (n = 468)

StatementStrongly agree, n (%)Agree, n (%)Neutral, n (%)Disagree, n (%)Strongly disagree, n (%)
1ZIKV infection is a serious global health problem206 (44.0)214 (45.7)40 (8.5)6 (1.3)0
2I believe there is a significant risk of ZIKV infection where I live?35 (7.5)84 (17.9)193 (41.2)124 (26.5)30 (6.4)
3I am concerned about getting ZIKV infection83 (17.7)165 (35.3)170 (36.3)34 (7.3)14 (3.0)
4The thought of someone I know getting ZIKV infection scares me107 (22.9)172 (36.8)119 (25.4)38 (8.1)30 (6.4)
5ZIKV is a serious health condition for pregnant women and babies328 (70.1)111 (23.7)26 (5.6)0 (0)01 (0.2)
6Personal protective measures (e.g., wear long-sleeved clothes, insect repellants, and cover water receptacles) are appropriate to prevent mosquito bites252 (53.8)155 (33.1)44 (9.4)13 (2.8)2 (0.4)
7It is important for the government to spend money fighting ZIKV and develop treatments or vaccine219 (46.8)195 (41.7)48 (10.3)3 (0.6)1 (0.2)
8I know where to get accurate information about ZIKV92 (19.7)117 (25)169 (36.1)65 (13.9)23 (4.9)
9I would like more education about ZIKV138 (29.5)238 (50.9)84 (17.9)4 (0.9)2 (0.4)
10There is stigma surrounding Zika or ZIKV transmission54 (11.5)171 (36.5)219 (46.8)14 (3)6 (1.3)
11Patients with ZIKV disease may avoid seeking treatment for fear of judgment or discrimination30 (6.4)94 (20.1)144 (30.8)132 (28.2)66 (14.1)
12I am comfortable in making a diagnosis of ZIKV disease82 (17.5)137 (29.3)177 (37.8)40 (8.5)29 (6.2)
13I will not travel to countries where many cases of ZIKV disease have occurred39 (8.3)54 (11.5)175 (37.4)126 (26.9)72 (15.4)

ZIKV = Zika virus.

The chi-squared test for independence of attributes was performed to determine whether any of the demographic variables were significant predictors of knowledge (Table 4). Age and school year were found to be highly significant in influencing the knowledge score (P-value < 0.001) (Table 4). On adjusted analysis by binary logistic regression, students residing in suburban or rural areas, first- or second-year students, and aged less than 20 years had significantly lower knowledge scores with P-values 0.005, < 0.001, and 0.037, respectively (Table 5).

Table 4

Association of demographic variables with knowledge and attitude scores (analysis by the chi-squared test for independence of attributes)

VariableN (%)Knowledge score (mean ± SD)P-valueAttitude score (mean ± SD)P-value
Gender
 Male165 (35.3)12.44 ± 3.790.31030.83 ± 4.710.313
 Female299 (63.8)12.10 ± 3.4429.92 ± 4.76
Age (years)
 < 20183 (39.1)10.62 ± 3.21< 0.001*30.03 ± 4.890.103
 20–23223 (47.7)13.33 ± 3.4830.23 ± 4.57
 > 2325 (5.3)12.80 ± 3.5730.44 ± 4.94
School year
 First and second285 (61)11.33 ± 3.21< 0.001*30.33 ± 4.970.021*
 Third and fourth157 (33.6)13.82 ± 3.8830.05 ± 4.46
Location
 Rural25 (5.3)10.64 ± 4.810.82031.48 ± 5.770.347
 Suburban/urban440 (94)12.27 ± 3.5630.17 ± 4.69
Housing type
 Individual377 (80.6)12.25 ± 3.650.71830.30 ± 4.790.290
 Collective89 (19.2)12.17 ± 3.2129.98 ± 4.63

Indicates highly significant result.

Table 5

Demographic factors associated with differences in knowledge scores toward ZIKV and vaccination (binary logistic regression analysis)

Predictors of knowledge of ZIKV and vaccination
VariableBeta coefficientStandard errorP-valueAdjusted OR95% CI for OR
Location (suburban or rural)−0.840.3010.005*0.432(0.24, 0.78)
Medical school year (1st or 2nd year)−0.860.234< 0.001*0.423(0.27, 0.67)
Age (below 20 years)−0.530.2560.0370.586(0.36, 0.97)

ZIKV = Zika virus.

Indicates highly significant result.

Indicates significant association.

Attitudes toward ZIKV.

Table 3 summarizes the attitude statements of medical students toward ZIKV. Student responses yielded a mean attitude score of 30.2 (SD: 4.76) on a possible scale of 13–65. Lower scores correspond to a greater concern about ZIKV and to a more positive attitude toward the importance of ZIKV education and the severity of the disease. A majority of students (446, 95.3%) indicated a positive attitude score (13–39 out of 65). Few students (17, 3.6%) had negative attitude scores (40–65), indicating that those students did not view ZIKV as an important or relevant topic for their education. Data were missing for five students (1.1%). The results are shown in Supplemental Table 5a.

The chi-squared test for independence of attributes was performed to determine whether any of the demographic variables were significant predictors of attitude scores (Table 4). Of all the demographic variables, only school year significantly influenced the attitude score; students in their third and fourth years of medical school reported stronger positive attitude scores toward vaccination than their schoolmates in the first and second years (P-value 0.021) (Table 4). On adjusted analysis, none of the demographic variables were significantly associated with attitude scores (data not shown).

Vaccine acceptability and recommendation.

If a ZIKV vaccine were to become available, 420 (89.7%) of the students agreed or strongly agreed they would receive the ZIKV vaccine and 439 (93.8%) agreed or strongly agreed they would recommend the vaccine to their patients. Table 6 shows the results of the bivariate analysis of the demographic variables, the knowledge and attitude scores, the receipt of ZIKV training and practices with the student intent to accept the ZIKV vaccine, and the likelihood to recommend the vaccine to their patients. None of the variables were found to be significant predictors of vaccine intent or recommendation of the vaccine to others (Table 7).

Table 6

Acceptability of ZIKV vaccine among students and recommendation of the vaccine to the society (analysis by the chi-squared test for independence of attributes)

Extremely likely or likely to receive the vaccine, n (%)P-valueExtremely likely or likely to recommend the vaccineP-value
Gender
 Male150 (90.9)0.743156 (94.5)0.917
 Female269 (90.0)282 (94.3)
Age (years)
 < 20170 (92.9)0.176177 (96.7)0.097
 20–23195 (87.4)207 (92.8)
 > 2322 (88)22 (88)
School year
 1st and 2nd275 (89.3)0.651291 (94.5)0.399
 3rd and 4th145 (90.6)148 (92.5)
Location
 Rural21 (84)0.29123 (92)0.627
 Suburban/urban399 (90.50)416 (94)
Housing type
 Individual338 (89.7)0.481353 (93.6)0.277
 Collective82 (92.1)86 (96.6)
Knowledge score
 Low (0–6)25 (89.3)0.97225 (89.3)0.503
 Moderate (7–13)235 (90)247 (94.6)
 High (14–20)160 (89.4)167 (93.3)
Attitude score
 Positive (13–39)400 (89.7)0.854420 (94)0.138
 Negative (40–65)20 (90.9)19 (86.4)
Student receipt of ZIKVtraining
 Yes96 (90.6)0.75197 (91.5)0.265
 No324 (89.5)342 (94.5)

ZIKV = Zika virus.

Table 7

Predictors of intention to receive a future ZIKV vaccine among medical students and recommendation to others

Intent to receive a future ZIKV vaccineRecommendation of the vaccine to patients
VariableSubject in analysisN (%)P valueOR (95% CI)Subject in analysisN (%)P valueOR (95% CI)
Gender466419 (89.9)0.741.12 (0.58, 2.14)466438 (94)0.921.05 (0.46, 2.4)
Age467420 (90)0.241.47 (0.77, 2.83)467439 (94)0.191.70 (0.76, 3.76)
Medical school year467420 (90)0.650.86 (0.45, 1.64)467439 (94)0.401.39 (0.65, 2.98)
Location467420 (90)0.830.90 (0.37, 2.24)467439 (94)0.421.84 (0.42, 7.85)
Housing467420 (90)0.480.74 (0.32, 1.71)467439 (94)0.280.51 (0.15, 1.74)
Knowledge score467420 (90)0.850.90 (0.50, 1.76)467439 (94)0.970.99 (0.45, 2.17)
Attitude467420 (90)0.081.89 (0.91, 3.92)467439 (94)0.331.59 (0.62, 4.05)
Practices467420 (90)0.063.43 (0.88, 13.41)467420 (90)0.103.59 (0.73, 17.20)

CI = confidence intervals; OR = odds ratio; ZIKV = Zika virus.

Practices, training, and awareness of ZIKV national policy.

Despite living in an endemic area, 362 (77.4%) of the students reported not receiving formal training on diagnosis and prevention regarding ZIKV. However, 288 (61.5%) of the students did not feel a need to change medical practices, such as increased screenings and patient education, despite ZIKV prevalence. In addition, a majority of the students (276, 58.9%) were not aware whether their local government had taken action to protect citizens from ZIKV. A small number (42, 9%) reported that the government had not taken any action to protect people from ZIKV, whereas 150 (32.1%) participants reported that the government had taken action (most frequently in the form of educational campaigns) to protect people from ZIKV.

Sources of information.

The Internet was identified most frequently by students (388) (83%) as a primary source of information regarding ZIKV. Scientific articles were identified most frequently as a trusted source of public health information (348, 74.7%), followed by personal physicians (306, 65.7%).

DISCUSSION

The present study of ZIKV awareness and preparedness among medical students in Costa Rica was aimed to inform medical school administrators to improve educational strategies surrounding ZIKV and inform communities where ZIKV is not endemic but has the potential to create a large impact in the future. In this study, most students demonstrated moderate knowledge scores regarding ZIKV, with students later in school scoring, on average, 2.5 points higher than their peers (13.82 versus 11.33 out of 20), similar to other medical student survey findings in Saudi Arabia.10 This indicates students are learning about ZIKV during their time in medical school, but this knowledge may not be a result of preclinical education, and there may be room for improvement to increase overall knowledge. Specifically, the younger group of medical students may be a key target group for improving ZIKV knowledge for diagnosis, treatment, and patient education because infectious disease education is introduced in the first year of medical school and students begin applying their education to clinical practice as early as their third year.

In our study, nearly all respondents knew that ZIKV is transmitted to human via bite of infected mosquitoes, and over two-thirds accurately stated that ZIKV is transmitted by the same type of mosquito that carry dengue and chikungunya. However, only 32% of the students indicated that ZIKV can spread via sexual route. In a survey of medical students from Saudi Arabia, about half of the respondents accurately identified mosquito bites and vertical route as transmission modes of ZIKV; however, a majority of students did not recognize that ZIKV can spread via sexual transmission.10 Knowledge gaps regarding modes of transmission and risks of ZIKV have similarly been reported among healthcare workers in Columbia, Indonesia, Mexico, and India.1115 Limited studies on ZIKV knowledge among nursing students also indicate the need for intensive education and promoting awareness of ZIKV in nursing schools and hospitals.16,17

In the present study, most students demonstrated a positive attitude toward ZIKV education, and students in the later years of their medical education were more likely to report a positive attitude. This difference is small, but statistically significant, and may indicate that students are recognizing the importance and severity of the disease as they advance in their medical education. Other studies have reported similar findings to support this theory.10

Students identified the Internet as their primary source of information regarding ZIKV and scientific articles as their most trusted source of public health information. Facebook was similarly cited as the most common source of ZIKV information reported by medical students from Saudi Arabia.10 In a study from India, nearly two-fifths of the surveyed dental practitioners reported that Internet was their primary source of information about ZIKV.15 It is possible that students and practitioners are turning to Internet sources because of lack of direct information gathered in their training. Although improving the educational curriculum around these topics is important, it seems likely that medical students will continue to refer to the Internet for the most up-to-date information. Therefore, it may be important to use these resources in future health promotion and effective educational efforts regarding ZIKV and other emerging and reemerging infectious disease threats. Medical schools may incorporate Internet resources into the curriculum by allowing time for students to engage in organized discussions and critical review of real-time news and online articles as they become available.

In our study, over half of students were unaware of the activities of the local government to protect people against ZIKV. Thus, there is a need for active collaboration between local government, medical school administrators, and public health officials to increase awareness among students regarding ZIKV prevention and control in the community.

A large majority of students agreed or strongly agreed they would receive a ZIKV vaccine and recommend the vaccine to their patients, indicating that students are aware of safety precautions regarding ZIKV, and therefore are likely to respond well to improved educational efforts. In the current study, no demographic, knowledge, or attitude factors were found to be significant influencers of vaccine acceptability. In many instances, no association has been noted in increased disease knowledge among individuals translating to change in behavioral intent to receive a future vaccine.18,19

The present study has many limitations. Given the cross-sectional study design, the results do not infer the temporal relationship of these associations. The participants were surveyed by convenience sampling. Study participants were medical students from a private teaching hospital in one locale, limiting generalization of our study results to other settings. In our study, the scale reliability (Cronbach’s alpha) was assessed using a sample group of student respondents at WFSM. The measures used to evaluate ZIKV knowledge and attitudes were not validated in other studies. In addition, the ZIKV question bank developed by the WHO was not primarily targeted toward healthcare providers. This limits the potential to compare the present results with other studies. As a part of demographic measures, responders were asked to define their living environment as urban, suburban, or rural in relation to central San José. No clear boundaries were defined by the study, and thus, responders were given the freedom to define their views of their environment. However, this limits the inter-responder comparability of the results. Despite these limitations, the findings from the current study highlight the need for integration of ZIKV education into the curriculum, especially in the early years of medical school. Use of reliable sources of information on the Internet should be considered in implementation of the educational curriculum in medical schools because students identified the Internet as the primary means of information. Continued training of healthcare workers regarding ZIKV is key to early diagnosis and management of ZIKV in pregnant women in endemic areas.

This study highlights the need to develop an educational curriculum for medical students regarding ZIKV and other major global health infectious disease threats (such as influenza). Internet resources (e.g., real-time news and Web-based online articles) with organized student discussions should be incorporated into the curriculum to disseminate education about ZIKV.

Supplemental tables

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Author Notes

Address correspondence to Avinash K. Shetty, Department of Pediatrics, Global Health Wake Forest School of Medicine and Brenner Children’s Hospital, Medical Center Blvd. Meads Hall, 3rd Floor, Winston-Salem, NC 27103. E-mail: ashetty@wakehealth.edu

Disclosure: All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest.

Financial support: Funding for this study was received by the Wake Forest School of Medicine (internal medicine) Medical Student Research Program.

Authors’ addresses: Morgan Stafford and Avinash K. Shetty, Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC, E-mails: mmstafo@wakehealth.edu and ashetty@wakehealth.edu. Sumathi Prabhu, Department of Mathematics, Manipal Institute of Technology, Manipal, India, E-mail: k.sumathi@manipal.edu. Sabrina Acosta Egea and Maria Del Carmen Garcia Gonzalez, Department of Medical Education, Universidad de Ciencias Medicas (UCIMED), San José, Costa Rica, E-mails: sabir.ae@gmail.com and garciagm@icimed.cr.

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