1 Introduction

The Marburg virus (MARV), a member of the Filoviridae family, is well known for causing severe viral hemorrhagic fever in humans with a fatality rate of up to 90% [1, 2]. The genus Marburgvirus comprises a single species—Marburg marburgvirus, which contains two different viral entities—Marburg virus (MARV) and Ravn virus (RAVV). These viruses are genetically similar to the infamous Ebola virus (EBOV) [3]. The Centres for Disease Control and Prevention (CDC) lists both viruses as Category A viruses with the potential to be used as a biohazard weapon while the World Health Organisation (WHO) labels them as Risk Group 4 diseases, necessitating biosafety level 4 containment [2, 4]. To date, the Marburg virus outbreak has been reported in Germany, Belgrade, Serbia, and mostly in African regions [5, 6] of the World. India hasn’t reported any Marburg virus cases thus far; however, the country has borne the immense brunt of earlier fatal outbreaks. Of note are the numerous fatalities caused by the Nipah virus epidemic (2018) in Kerala [7], Monkeypox virus outbreak in 2022 [8] and the coronavirus pandemic that began in early 2020 and has killed millions people and yet continues to infect others nationwide [9]. These outbreaks highlight the importance of being vigilant and prepared for the unprecedented emergence of infectious diseases [10].

MARVD is zoonotic in origin and often spreads to humans through direct contact with the body fluids of fruit bats (Rousettus aegyptiacus), which act as the virus's biological reservoir [2]. Most primary infections in MARV outbreaks that occurred naturally have been attributed to bat-inhabited cave exploration and mining activities. Once contracted, MARVD can be disseminated by direct contact with the infected body fluids (blood, urine, semen, vomit, feces, sweat, breast milk), infected surfaces, or needlestick wounds [4]. Furthermore, direct contact with the bedding, clothes, and body fluids of the deceased during funeral rituals also contributes to the propagation of MV [2]. MARVD symptoms, which frequently resemble those of other viral illnesses [2, 4], include fever, headache, rash, vomiting, bleeding, and confusion. Although medicines and vaccine trials are in the developing stage, there is currently no specific cure for MARVD, therefore supportive care and infection prevention is still the preferred approach [2, 5].

Rapid globalization, swift worldwide travel, as well as additional risk factors might contribute to the spread of the Marburg virus in India from regions experiencing virus outbreaks, thus, it is imperative to take adequate countermeasures [11]. Healthcare workers (HCWs), who are frequently the first point of contact for infectious disease patients, are at an increased risk of contracting infection due to various factors including a failure to recognize prospective cases, poor adherence to infection control practices, and inadequate healthcare infrastructure [12, 13]. A recent review showed that 1%–10% of all exposed health workers become infected while handling MARVDMARVD-infected cases [14]. Another study conducted in Sierrra Leone shows a lack of knowledge about differences in Ebola and MARVD symptoms among the healthcare professionals indicating a knowledge gap that may lead to the misdiagnosis of of cases during the outbreak onset [15]. Thus, assessing HCWs’ knowledge of the disease’s clinical manifestations, risk factors, and epidemiology is critical particularly in India, where the healthcare system is underfunded and understaffed and already has an immense burden of infectious illnesses [16, 17].

The recent Marburg virus outbreaks in Equatorial Guinea and Tanzania in March 2023 have sparked fears about potential worldwide spread due to greater globalization and cross-border travel [18, 19]. As a result, it is critical that HCWs must be prepared to respond to emerging threats [2]. However, there is a significant lack of data regarding MARVD awareness among HCWs in India [20]. Therefore, this study aimed to investigate the Marburg virus knowledge, attitudes, and practices (KAP) among healthcare workers in India. This critical step towards identifying and addressing knowledge gaps among healthcare workers will assist in strengthening the country’s preparedness for possible outbreaks. The findings of this study will identify areas for developing effective training programs and preparedness methods, improve infection control measures, and ultimately protect both HCWs and the larger community.

2 Methods

2.1 Study design and study participants

We conducted a cross-sectional study using an online survey with healthcare professionals from various backgrounds. The study protocol follows the recommendations given in the Declaration of Helsinki [21]. The survey was designed for healthcare professionals such as nurses, physicians, and pharmacists employed in any part of India in a health facility at the time of the survey. Healthcare professionals who were aged > 18 years, Indian residents able to independently read and respond to self-administered online survey, and consented to participate were included. The Google survey form was used to circulate the survey form online. The participants were prompted to log in by email to begin the survey. Before revealing the questions, the participants were briefed about the purpose of the survey. In addition, participants were made aware of their right to voluntary involvement and right to withdraw from the survey at any point in time, and the privacy of all personally identifiable data. The participants were then requested to provide their digital consent for participation by responding in Yes or No. The survey excluded healthcare practitioners who declined to provide their consent for participation. Multiple responses from one respondent were disabled. All elements in the survey were made mandatory to respond to, and submissions were not permitted if any item was missing.

2.2 Sample size

The sample size was determined using the modified Cochran Formula [22]. A population of healthcare professionals equal to 5.76 million in India [23], considering a 5% margin of error, a hypothetical response distribution of 50% (p), and a design effect equal to 1, the minimum sample size required was determined to be 385. The sample size was calculated using an open-source calculator-OpenEpi software, Version 3.

2.3 Study tool piloting

The content of the Google survey form was developed in both Hindi and English language based on the in-depth review of the relevant literature. A pilot survey was done among 10 healthcare professionals who were conveniently chosen to ensure the questionnaire’s content validity among healthcare professionals and none of the pilot responses were included in the study. The pilot survey results were analyzed for internal consistency using Cronbach’s alpha, which gave a value of 0.84. Based on the pilot response, we solicited feedback from expert professionals in the field to create the final questionnaire. The questionnaire consisted of three separate sections. The first section collects details about the respondents’ demographic characteristics their job roles. The second section inquires about knowledge, attitudes, and practices (KAP) regarding the epidemiological features of Marburg virus infection. Nine specific items or questions were included in this section, and checkboxes were provided for multiple-choice responses to each item. The third part of the survey examines respondents’ knowledge, attitudes, and practises (KAP) on MARVD prevention and management and consists of eight questions. Similar to the preceding section, these questions have checkboxes for multiple-choice answers. For each correct response, a score of 1 was assigned whereas for wrong answers or “uncertain/do not know” answers, a score of 0 was given. A cut-off of 50% was set, hence those who scored below 50% were considered as having poor knowledge, and those above 50% were considered as having good knowledge.

2.4 Data collection method

The healthcare professionals were asked to complete a self-administered survey to gather information. The Google survey link was sent through emails to participants. To recruit participants, a convenience sample technique was utilised with no constraints on gender, age, or experience. We obtained consent online before acquiring any data. The purpose of the study and participant permission were described on the opening page. Participants were made informed that participation was entirely voluntary, and no compensation were offered.

2.5 Statistical analysis

The data was entered and analyzed using the Statistical Package for Social Sciences (SPSS) for Windows, Version 28.0. (Armonk, NY: IBM Corp) Confidence intervals were set at 95%, and a p-value ≤ of 0.05 was considered statistically significant. Descriptive statistics (numbers and percentages) were generated for each response along with a 95% confidence interval indicating the range where the true percentage likely falls. Statistical significance was determined at p ≤ 0.05. A binary logistic regression model was applied to find crude and adjusted odd’s ratio for association of independent variables with knowledge scores.

2.6 Ethical considerations

Ethical approval was obtained from the institutional review board of Athar Institute of Health and Management Studies (AIHMS/IRB/Vll/56) prior to the conduct of survey. All respondents provided written informed consent before the survey began.

3 Results

Only 300 responses were received during the study data collection period. Of the 300 respondents, 58.8% worked in healthcare facilities in urban regions and 41.2% in rural region; nearly half of the respondents were men. Aside from physicians, the two vocations most frequently stated by respondents were pharmacist (30.6%) and state registered nurse (22.5%). The majority (75.4%) of respondents had worked in a healthcare institution for more than a year (Table 1).

Table 1 General characteristics of patients
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Table 2 displays the participant responses to inquiries measuring knowledge of Marburg virus infections, sign and symptoms, related modes of transmission and prevention. The majority of people (93.3%) had heard of the Marburg viral illness,. 35.3% identified it as a hemorrhagic disease whereas nearly half (48%) denied so and 16.6% were unsure. The most common clinical symptom of MARVD was bleeding as cited by 53.3% of participants followed by fever (20%). Regarding the mode of transmission, 64.6% of respondents knew that MARVD could be spread through physical contact with an infected person, compared to 11% who believed it could be spread by mosquito bites, 16% who believed it could be spread through the air, 50.6% who mentioned it could be spread through semen or sexual contact, and 53% who knew it could be spread through breast milk from an infected person. A total of 62.6% (188/300) claimed to be aware of the methods for controlling and preventing MARVD; 53% (159/300) stated that avoiding sick people, 39.3% (118/300) stated that avoiding animal interaction, and 11% (33/300) stated that a vaccine might be used. The survey results show that respondents had differing opinions regarding the spread of the Marburg virus. Significantly more respondents—64.6%—think that carriers of the Marburg virus can still spread the illness. Nonetheless, 3.33% expressed uncertainty and 31.3% disagreed with this idea. Opinions on the possibility of transmission by sexual fluids were more divided: 50% thought it feasible, 37.6% did not think so, and 11.7% were unsure. In reference to the likelihood of contracting the illness from breast milk, 53% of respondents support this notion, compared to 38.6% who oppose it and 8.3% who are uncertain. 65% of respondents consider the possibility of transmission by physical contact, such as handshakes compared to 31.3% who do not consider it a concern and 3.6% who are unclear.

Table 2 Participants’ response to the knowledge and perception questionnaire about the Marburg Virus
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The attitudes of healthcare professionals towards the Marburg virus are reflected in Table 3. According to 97.3 percent of HCWs, a MARVD survivor would be treated as a patient or welcomed back to their neighborhood, however, 19.8% of respondents believed that an HCW who had survived viral hemorrhagic fever (VHF) posed a risk to their hospital. This was especially apparent when comparing HCW from rural facilities to urban facilities (31.0% vs. 13.3%; p = 0.006). Despite the fact that the vast majority of HCWs (99%) claimed they would accept an approved vaccine for themselves, the readiness to receive experimental treatments in the event of a Marburg infection was less certain. Only 37.3% of respondents said that they would be open to using an experimental drug on themselves. In this study, participants from rural institutions were more likely to provide their consent to receiving experimental therapy. The sentiments of HCW were not distinguishable from those of urban and rural areas other than that. (Table 3).

Table 3 Attitude of Health workers towards Marburg virus
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Out of 300 respondents, 50.9% were classified as aware of Marburg virus disease, and 60.5% as having a favorable attitude towards Marburg virus disease control and prevention. The average percentage ratings for knowledge and attitude were respectively 54.3 (95% CI 53.4–57.9) and 68.9 (95% CI 67.8–72.1) (Table 4).

Table 4 Survey results on awareness and attitude toward MARVD among respondents
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Table 5 displays the findings from the logistic regression model on the predictors of knowledge about MARVD. Among genders, males demonstrate a higher level of good KAP (70.5%) compared to females (26.3%), with females being 2.8 times more likely to have poor KAP. Regarding occupation, junior physicians show a good KAP of 60% but are slightly more likely to have poor KAP compared to senior physicians, with a crude odds ratio of 1.7 and an adjusted odds ratio of 1.4. On the other hand, Nurses exhibit a significantly lower level of good KAP (41.1%), indicated by a crude odds ratio of 7.8 and an adjusted odds ratio of 8.3. Similarly, Pharmacists, with 65.2% good knowledge, also show a higher tendency towards poor KAP compared to senior physicians, with a crude odds ratio of 4.1 and an adjusted odds ratio of 3.4. Overall, there is a significant difference in KAP with senior physicians having better KAP as compared to other healthcare professionals.

Table 5 Logistic regression analysis
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4 Discussion

Health workers particularly, doctors, nurses, and pharmacist works closely with infected patients or their body fluids while performing their daily duties. Therefore, this baseline assessment establishes their level of preparedness for MARVD. According to our knowledge, this is the first KAP research on MARVD carried out among Indian healthcare professionals. The study revealed variations in knowledge, attitudes, and perceptions among healthcare workers in India regarding MARVD. While a majority had heard of MARVD, there were gaps in understanding the disease’s symptoms and transmission methods. Attitudes towards MARVD patients were generally positive, with a willingness to welcome survivors. However, the acceptance of experimental treatments was relatively low.

Firstly, the study indicates that roughly 50% of healthcare professionals have a good understanding of MARVD. This was discovered to be consistent with the findings of Raab et al. [12]. The higher percentage may reflect the fact that a greater number of healthcare workers are generally knowledgeable about infectious illnesses as a result of a greater public understanding of recent outbreaks due to social media. This is consistent with research on the Ebola virus disease (EVD), which demonstrated that healthcare personnel had a reasonably high preliminary knowledge of these illnesses and utilized the media and social media for information [12, 24, 25]. Nevertheless, the study finds that notwithstanding this awareness, a significant majority of HCWs lacked a thorough understanding of certain elements of MARVD, such as case identification, signs and symptoms, and source and route of transmission. Notably, bleeding was regarded as a key warning sign of Marburg virus disease (MARVD) by 50% of study participants. However, it is essential to stress that haemorrhagic symptoms often appear in the later stages of the illness, denoting an advanced and frequently fatal stage of the condition [4, 26]. This underlines the vital need to make sure professionals have an understanding about the disease's clinical course. Early signs of filovirus MARVD, closely resemble those of other common infectious illnesses, and thus are frequently misdiagnosed, resulting in delayed diagnosis and treatment [26]. Thus, mechanisms for early detection must be put in place within healthcare settings to aid in preventing the neglect of MARVD cases, particularly while medical personnel are watching for more obvious hemorrhagic symptoms. It is noteworthy that a sizeable number of those who took part in the survey named animal-to-animal transmission as the most common form of transmission, followed by contact with contaminated bodily fluids, exposure to infected corpses, and needlestick wounds. This knowledge among health workers aids health authorities in efficiently initiating control and prevention measures during epidemics. However, only a small percentage of the individuals claimed that MARVD is spread through the air or by mosquitoes. This is consistent with findings from related studies on Ebola research, which show that medical professionals frequently have misunderstandings about specific illness features [25, 27]. Fighting MARVD requires an understanding of the condition’s onset, method of transmission, and methods of prevention. This accentuates the necessity of focused educational initiatives to enhance their knowledge of the condition and ensure that HCWs are well-equipped to identify, manage, and halt the spread of novel infectious illnesses like MARVD.

Furthermore, the study reveals a favorable attitude toward MARVD patients and the vaccine. This positive attitude is an indispensable tool in infectious disease management during outbreaks because it enhances the quality of care for patients, minimizes prejudice, and enables community reintegration [28]. Similar results have been noticed in studies pertaining to other infectious illnesses such as Ebola virus disease (EVD), where HCWs frequently demonstrate empathetic behaviors towards patients and prioritize their welfare over their own [28,29,30,31]. This demonstrates the vital role that healthcare professionals play in the fight against infectious diseases as both providers and advocates. In contrast, the study reveals skepticism among HCWs regarding novel treatments for MARVD, with just 37.3% of respondents willing to use such medications on themselves in the event of an infection. This result is consistent with findings from studies on several infectious diseases, such as EVD and COVID-19, where HCWs have been observed to be hesitant or uneasy about experimental drugs or vaccines that did not undergo extensive clinical trials [32,33,34]. This scepticism might be attributed to worries about the safety effectiveness, and potential adverse effects associated with experimental interventions. It reinforces how crucial transparency, comprehensive investigation, and ethical issues are when implementing experimental therapies in outbreak events.

Finally, better knowledge scores were found to be linked to factors such as male gender and occupation. This is consistent with previous research suggesting that healthcare workers' understanding and perceptions of infectious diseases are influenced by their educational qualifications, job titles, and personal experiences. For instance, Mohamud et al. [35] discovered lesser Ebola understanding among lower-income healthcare workers, nurses, and laboratory workers. Similarly, Ahmad et al. [36] showed increased Awareness among doctors or employees with extensive experience when compared to their respective groups. This is in congruence with our findings where men and senior physicians were found to have better knowledge scores as compared to their counterparts. These variations highlight the significance of tailoring instructional programs to the individual needs of various subsets within the field of health care.

Our work has some significant limitations that should be carefully considered. To begin, it used a cross-sectional survey approach done via an internet portal with convenience sampling. This method may introduce bias because it relies on the self-selection of participants who may have felt confident in their ability to participate in the survey. Furthermore, this study relied significantly on self-reporting, which might be impacted by respondents’ sincerity and subject to recall bias. Furthermore, unlike several African countries where outbreaks have taken place, India has not faced a significant real threat of being exposed to Marburg virus disease (MARVD) risk factors. Because of this context, our study’s findings may be largely theoretical instead of grounded in real-life situations. In addition, statistical power of our study may be lowered due to the smaller sample size than the calculated sample size needed, which could lead to the omission of some minor but significant patterns in the data. Despite these limitations, it is critical to emphasize that our findings provide useful insights into healthcare workers’ knowledge, attitude, and perception of the Marburg virus in India. While responses may be influenced by the aforementioned variables, they provide critical details that can add to the wider body of knowledge and preparedness initiatives, especially in nations where the threat of MARVD remains concerning.

5 Conclusion

This online survey shows that although there was a high degree of awareness about MARVD, there were notable knowledge gaps and differences in attitudes among healthcare professionals. This underlines the importance of customized training programs for each group to increase healthcare workers’ knowledge of MARVD. By understanding the symptoms, modes of transmission, and preventative measures of the disease better, they will be better able to control and manage outbreaks of the Marburg virus disease. Efforts should also be made to alleviate concerns and boost the acceptance of experimental treatments among healthcare professionals.