Knowledge and Awareness-based Survey of COVID-19 within the Eye Care Profession in Nepal: Misinformation is Hiding the Truth.

Abstract Background: Nepal is currently under lockdown due to the COVID-19 pandemic with misinformation circulating on social media. This study aimed to analyse the knowledge and awareness of COVID-19 amongst eye care professionals in Nepal. Methodology: We invited 600 participants from 12 ophthalmic centres across Nepal to complete a qualitative, anonymous online survey. Results: Of the 600 eye care professionals invited, 310 (51%) participated in the survey. The symptoms of COVID-19 were known to 94%, whilst only 49% were aware of disease transmission. 98% of participants recognised the World Health Organization (WHO) awareness message, yet 41% of participants felt that consumption of hot drinks helps to destroy the virus. 41% disagreed that PPE should be mandatory for eye care practitioners. Conclusion: There is still considerable scope to improve the knowledge of COVID-19 amongst ophthalmic professionals in Nepal. Opinion is also split on measures to prevent transmission, with misinformation potentially fuelling confusion.

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(which was not certified by peer review)
The copyright holder for this preprint this version posted June 8, 2020. . On 31 January 2020, the WHO characterised the outbreak as a public health emergency of international concern. 6 Although the exact origin of the virus still remains elusive, the natural host of the virus is believed to be a species of bat. 7 Initially, it was thought to be transmitted only as a zoonotic infection from animal to human, but subsequent research . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 8, 2020. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 8, 2020. questions for all the participants. These were categorised as "excellent" (if the average of correct responses was 80% or above), "satisfactory" (if the average of correct responses was 65% or above), or "poor" (if the average of correct responses was below 55%), in a similar way to academic grading.

Results
The survey was completed by 310 (51%) individuals (55.5% male). The majority of participants (83.9%) were in age group 20-30. The demographic details are presented in Table 1.
The responses to questions are given in Table 2.
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(which was not certified by peer review)
The copyright holder for this preprint this version posted June 8, 2020.  . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted June 8, 2020.  . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
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The copyright holder for this preprint this version posted June 8, 2020. The free text question 'Being an eye care practitioner, what do you think is wise to do during this period of lockdown?' The descriptive answers were categorised into different sub-categories, illustrated in Figure 1.
The calculated knowledge performance score was 69.75%, falling into the "satisfactory" category.
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(which was not certified by peer review)
The copyright holder for this preprint this version posted June 8, 2020. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted June 8, 2020.  20 The PPE in the guidelines includes essentials to cover the mouth, nose (N95 mask preferably), eyes (goggles), face (visors), hands (gloves), and breath shields attached to the slit . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted June 8, 2020. Half of the participants were not aware that the detection of novel SARS Cov-2 was confirmed by RT-PCR. 22 One third of the participants felt that drinking things such as hot water, ginger-garlic mix, vitamin C or soup kills the virus directly or indirectly.
There is no evidence to support this statement, which has been frequently circulating around social media as misinformation. 23,24 Approximately half of the participants were unaware of the lifespan of the virus on different surfaces. 13,14 Knowledge of this can help clinicians to appropriately disinfect surfaces and equipment. Several participants were not sure if they should clean their masks daily, while others did not wear masks, and a few washed it once every two days. The WHO recommends using a mask whilst in clinic, and importantly, there is a high risk of the infection being transmitted if the mask is not disposed of or sterilised properly on a daily basis, especially in susceptible areas. 15,25 The CDC and WHO recommends at least 20 seconds should be spent while washing hands. 26 . Most participants said they follow this recommendation.
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(which was not certified by peer review)
The copyright holder for this preprint this version posted June 8, 2020. The CDC recommends 70% ethanol to be used as a multipurpose disinfectant in ophthalmology clinics and other surface cleaning activities. 22 More than half of participants (59.0% (n=183)) believed other less-potent disinfectants were adequate, which highlights an area that can be improved on by further education of clinic staff.
Cases of conjunctivitis have been reported. 17 Conjunctival secretions and tears from infected patients may contain viral RNA, whilst those with conjunctival symptoms may pose a higher risk in terms of transmission. 27 However, it is a rare symptom of COVID-19. In a recent study, of the total reported cases of ocular manifestations of COVID-19, only 0.8% had conjunctivitis; this is in keeping with other coronaviruses which are also known to (infrequently) cause conjunctivitis. 12, 28 Clinicians therefore need to be cautious while examining conjunctivitis patients as there is a risk they may be sources of SARS-CoV-2 infection. Knowledge of this is therefore important to ophthalmic practitioners. The majority of the participants knew that conjunctivitis was the most common ocular manifestation of COVID-19, which is reassuring.
As a knowledge assessment on ocular emergency within the context of COVID-19, 5% of the participants felt blurred vision was an emergency, which in our view . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
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(which was not certified by peer review)
The copyright holder for this preprint this version posted June 8, 2020.

Conclusion
Our study shows that knowledge amongst eye care practitioners is classed as satisfactory. We therefore recommend ophthalmic practitioners to enhance and develop this knowledge as a priority. There are abundant, free webinars on COVID-19 and eye care from which individuals can benefit. The views expressed within the awareness questions are concerning, as some of these responses highlight a degree of misinformation, which may be of concern for institutions and local government. Further work must be carried out by employers, as well as local and national governments in Nepal, in order to prevent the spread of misinformation, and support practitioners to carry out eye care during this . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted June 8, 2020. With rumours spreading quickly during crises, there has been an increasing amount of "fake news" or misinformation circulating in Nepal during this pandemic, and this study highlights some of these issues. It is crucial that clinicians remember to check the scientific evidence before altering their practice or recommending interventions to their patients.
Contributing authorship statement: SD, SK, and PC conceived the design. SD and SK collected the data. All authors analysed the data and have approved the final manuscript.

Conflict of Interest:
Authors do not have any conflict of interest to declare.

Funding:
No funding was received for this study.
Data sharing statement: Data can be shared on reasonable request to the corresponding author by bone fide researchers.
. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 8, 2020. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 8, 2020. . https://doi.org/10.1101/2020.06.06.20123505 doi: medRxiv preprint