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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 6  |  Page : 278-282

Knowledge, attitudes, and practice toward multisystem inflammatory syndrome in children among pediatrician in Eastern India: An online cross-sectional survey


1 Department of Pediatrics, Kalinga Institute of Medical Sciences, KIIT University, Bhubaneswar, Odisha, India
2 Department of Research and Development, Kalinga Institute of Medical Sciences, KIIT University, Bhubaneswar, Odisha, India

Date of Submission11-Aug-2021
Date of Decision01-Oct-2021
Date of Acceptance21-Oct-2021
Date of Web Publication19-Nov-2021

Correspondence Address:
Dr. Mukesh Kumar Jain
Department of Pediatrics , Kalinga Institute of Medical Sciences, Bhubaneswar - 751 024, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpcc.jpcc_69_21

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  Abstract 


Background: Multisystem inflammatory syndrome in children (MIS-C) associated with severe acute respiratory syndrome-coronavirus-2 is a new life-threatening entity whose diagnosis and management warrant awareness and in-depth knowledge. This study intends to estimate the knowledge, attitudes, and practice toward MIS-C among pediatricians of eastern India.
Subjects and Methods: A descriptive, web-based cross-sectional survey was conducted among pediatricians of eastern India between January 1 and March 31, 2021, where they were invited to participate irrespective of their experience in treating COVID-positive children.
Results: The majority of pediatricians (≥95%) are aware of the terminology MIS-C, its clinical features, presence of raised inflammatory markers, its treatment, and follow-up. Although 75% were aware of the vulnerable age group, only 50% knew the exact timing of occurrence. Fever as a mandatory criterion for diagnosis was known to 62.6%. The majority (75%) agreed that positivity of any of the tests (reverse transcription polymerase chain reaction, antigen, or antibody) or history of contact with COVID is necessary for diagnosis. Kawasaki Disease and Toxic Shock Syndrome as a common differential diagnosis of MIS-C were agreed upon by 86%. Pediatricians working in COVID hospital were more confident in managing MIS-C than who are not working (72.8% vs. 38.6%). Steroid and intravenous immunoglobulin used as first-line treatment by 94% and 72%, respectively.
Conclusion: Although the majority of pediatricians are now aware of MIS-C, still there is need for continuing medical education (CME) and interactive sessions with experts, to make them suspect, detect early and manage it more effectively.

Keywords: Multisystem inflammatory syndrome in children, pediatricians, severe acute respiratory syndrome-coronavirus-2, steroid


How to cite this article:
Sahu SK, Patnaik S, Behera JR, Jain MK, Pathak M. Knowledge, attitudes, and practice toward multisystem inflammatory syndrome in children among pediatrician in Eastern India: An online cross-sectional survey. J Pediatr Crit Care 2021;8:278-82

How to cite this URL:
Sahu SK, Patnaik S, Behera JR, Jain MK, Pathak M. Knowledge, attitudes, and practice toward multisystem inflammatory syndrome in children among pediatrician in Eastern India: An online cross-sectional survey. J Pediatr Crit Care [serial online] 2021 [cited 2021 Nov 27];8:278-82. Available from: http://www.jpcc.org.in/text.asp?2021/8/6/278/330730




  Introduction Top


Multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19 is a highly fatal entity in children that usually develops 4–6 weeks after acute COVID infection. Due to the presence of serologic evidence of infection with severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) in these children, it is hypothesized to be temporally associated with COVID-19.[1] The clinical manifestations include unremitting fever, abdominal pain, and hypotension with features of cardiac dysfunction. The inflammatory markers are highly elevated in these children, which indicate an ongoing cytokine storm. The clinical features are indistinguishable from Kawasaki's disease and toxic shock syndrome (TSS).[2] MIS-C will be a tough task for all pediatricians during the post COVID period due to its nonspecific case definition, absence of definite diagnostic tests, varying management protocols, and ambiguity regarding long-term consequences. As it is a new clinical condition and can be life-threatening; exhaustive knowledge about this disease is required. This study intends to estimate the knowledge, attitudes, and practice toward MIS-C among pediatricians in eastern India.


  Materials and Methods Top


Study area, study design, and study period

A prospective, descriptive, web-based cross-sectional survey was conducted among Pediatricians of eastern India by Google form between January 1 and March 31, 2021. The survey was open to all pediatricians, regardless of their experience in treating COVID-positive children. The Institutional Ethical Committee (KIT/KIMS/IEC/545/2021 dated: 12/01/201) has approved the study protocol.

Study instrument

The questionnaire was developed as per the case definitions given by the WHO.[3] The questionnaire has 32 items and was designed to gather information on respondents' knowledge, attitudes, and practises regarding MIS-C. The questionnaire comprised two parts. Part (1) the socio-demographic characteristics of participants such as age, sex, degree, place of working, years of working experience, and experience of treating COVID-19 patients. Part (2) had questions to evaluate the respondents' knowledge (14 items) and attitude and practice toward MIS-C (13 items). After preparing the questionnaire, it was validated by sending it to three subject experts who made minor modification. Then, it was pilot tested on five subjects. Based on the pilot study, improvements were made to the final survey to enable a better understanding of the questions by the participants, and the question arrangement was analyzed to ensure its efficiency. It took about 8 min to complete the questionnaire.

Data collection

This online survey was conducted using a google form, circulated by WhatsApp and e-mail. Participants could access and answer the questions by just clicking on the link. Between the of January 1 and the March 31, 2021, 147 pediatricians completed the survey. All aspects pertaining to the pediatricians' knowledge, attitude, and practise regarding MIS-C were documented along with demographic variables.

Statistical analysis

All the statistical analyses were performed using a Statistical Package for the Social Sciences (SPSS Inc., Chicago, Illinois, USA) version 26.0. Pearson Chi-square test and Fisher's exact test were used to compare variables among who had work experience with COVID-19 and who did not. All the tests were considered significant at 5% level of significance. Stata 15.1 was used for analysis.


  Results Top


Of 400 invitations sent, 147 pediatricians responded; among them, 105 (71.42%) were faculty/consultant and 25% were postgraduates. Pediatricians of all age group (<30 to more than 60 years) with variable experience (5–30 years) participated in this study. Almost three-quarter (70%) of participants were male. Doctors having experience of working in COVID hospital were 103 (70%). Pediatricians working in medical colleges (government or private) were 66%, whereas 15% worked in PHC/CHC/DHQ hospital, 10% in corporate hospital, and 10% were full-time practitioner.

The majority of pediatricians were aware of this new terminology MIS-C. Three-fourth of the respondents were also aware of the most common age group affected but 5% thought it to be under-five diseases and 20% thought, 5–15 years was the most common age group. About the timing of MIS-C, 53% knew that it took place 4–6 weeks after acute COVID, but 5% thought it to happen during acute COVID and 12% said it took place immediately after acute COVID. About one-third thought that MIS-C might occur at any time. Fever was a mandatory criterion for diagnosis of MIS-C was agreed upon by 62.6%, but 27% disagreed and 10% were not sure about it. About 95% were well versed with clinical features of MIS-C such as mucocutaneous manifestation (rash and conjunctivitis), gastrointestinal symptoms (pain abdomen, vomiting, and diarrhea), cardiac dysfunction (hypotension and shock), and coagulopathy.

For diagnosis of MIS-C, 6% of pediatricians thought that either reverse transcription polymerase chain reaction or antigen should be positive, whereas 17% said the presence of antibody to be mandatory. However, majority (75%) of pediatricians agreed that the presence of anyone of the tests or history of contact with a case of COVID is sufficient. Most of pediatricians were aware of raised inflammatory markers such as C-reactive protein, procalcitonin, and ferritin in case of MIS-C. Abnormal echocardiography findings such as left ventricular dysfunction and coronary abnormalities were known to 70% of pediatricians, but about 10% had no idea about this. Majority of pediatricians (86%) believed that Kawasaki disease and TSS were close differential diagnosis of MIS-C.

Most of them (96%) were aware that immunotherapy (Intravenous immunoglobulin (IV Ig) and steroid) was cornerstone for the treatment of MIS-C, and antibiotics and antiviral had no role. The role of anticoagulant in the management of MIS-C was known to 77%, but 20% either disagreed or had no idea about this.

For managing MIS-C, 60% were confident, whereas 20% were not confident, and the rest 20% had mixed response. About the referral of such cases 10% said, they would always refer to higher center, whereas 45% said they would refer sometime depending on the patient's condition, the rest one-third was confident in managing such cases and would never refer. Most of them (98%) thought that follow-up would be an essential part of MIS-C management, and they would always advise for it. The majority (90%) were interested to participate in training programs or Continue Medical Education related to MIS-C, and they would also like to promote awareness about this disease.

Although 76% of pediatricians had seen a case of MIS-C, only 65% were confident to manage such cases. Three-fourth of pediatricians had seen <10 cases and managed it, whereas 10% had seen more than 20 cases and managed successfully. About 94% of pediatricians used steroid, out of which 70% used only when the patient was not sick or IV Ig was not available or not affordable, but 30% used it in all cases. IVIG and anticoagulant both were used by 70%.

[Table 1] compares the knowledge, attitude, and practices (KAP) between pediatricians having no experience and those having experience of working in COVID hospital. Statistically significant lacunae in knowledge were found regarding the timing of onset, fever as a mandatory criterion for diagnosis, coagulopathy as clinical manifestation, necessary diagnostic tests, key management options, and role of anticoagulation in the treatment of MIS-C.
Table 1: KAP on multisystem inflammatory syndrome in children among paediatricians and comparison between those having no experience of working in COVID hospital with those who had experience of working in COVID hospital

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In the field of attitude and practice, the number of cases seen, confidence of management, and referral to a higher center were statistically significant.


  Discussion Top


The pediatric population is substantially spared in the current pandemic of SARS-CoV-2, contributing for only 2.1%–7.8% of overall cases.[4] The disease load in this age group is underestimated due to milder degree of sickness and lesser requirement of intensive care as compared to adults.[5],[6] In April 2020, the National Health Service in the UK confirmed many children manifesting with fever, multisystem involvement (gastrointestinal, cardiovascular, and mucocutaneous), raised inflammatory markers with recent or concurrent SARS-CoV-2 infection or exposure in the absence of other plausible etiology. They coined this entity as pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2. Subsequently, World Health Organisation and Center for disease control termed this as MIS-C.[2],[7] This is completely a novel entity evolved during this pandemic and now an uphill task is waiting for pediatriacian, all over the world to tackle. Although MIS-C is a global phenomenon now, the KAP to handle this disease are not uniform.

In our study, we found that the majority of pediatriacian had good knowledge about the terminology MIS-C, its diagnostic criteria and clinical features. Many respondents were not sure about the age group affected, timing of MIS-C, and which test to be done for diagnosis. Hence, awareness in these areas should be created. Pediatriacians are also aware of high inflammatory marker in MIS-C, which differentiate it from other viral illness like dengue. Cardiac dysfunction is a known entity to majority of pediatricians, but some were unsure about the need for echocardiography. A clear message should be given to do an echocardiography in all cases of MIS-C irrespective of the clinical status. Immunotherapy is the cornerstone in the management of MIS-C, and no specific role of any antiviral or antibiotics was pretty clear to the participants.

Practice in MIS-C is not uniform because it is relatively a new entity, a lack of definite guideline for the management with rapidly changing facts and knowledge about it. Miss or wrong diagnosis of MISC can be attributed to close resemblance with other diseases such as dengue and scrub typhus.[8],[9] Although immunotherapy is the first choice in management of MIS-C, the use of IVIG was less as compared to steroid because of many factors such as availability, affordability, and lack of experience.

The gap in knowledge among pediatricians can be attributed to a lack of awareness regarding new developments in medical science. The key differences in attitude and practice are likely due to a lack of awareness, fear, and/or lack of infrastructure. CME, webinar, and training of pediatricians will have a definite impact on knowledge, attitude, and practice of MIS-C.


  Conclusions Top


Although the majority of pediatricians are now aware of MIS-C, still there is need for continuing medical education and interactive sessions with experts, to make them suspect, detect early and manage it more effectively.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Royal College of Pediatrics and Child Health. Pediatric Multisystem Inflammatory Syndrome Temporally Associated with COVID-19 (PIMS) – Guidance for Clinicians. Available from: https://www.rcpch.ac.uk/resources/paediatric-multisystem -inflammatory-syndrome-temporally-associated-COVID-19-pims -guidance. [Last accessed on 2020 Sep 15].  Back to cited text no. 1
    
2.
Riphagen S, Gomez X, Gonzalez-Martinez C, Wilkinson N, Theocharis P. Hyperinflammatory shock in children during COVID-19 pandemic. Lancet 2020;395:1607-8.  Back to cited text no. 2
    
3.
Multisystem Inflammatory Syndrome in Children and Adolescents with COVID-19. Scientific Brief: World Health Organisation. Available from: https://www.who.int/publications-detail/multisystem inflammatory- syndrome-in-children-andadolescents-with-COVID-19. [Last accessed on 2020 May 15].  Back to cited text no. 3
    
4.
Jiang L, Tang K, Levin M, Irfan O, Morris SK, Wilson K, et al. COVID-19 and multisystem inflammatory syndrome in children and adolescents. Lancet Infect Dis 2020;20:e276-88.  Back to cited text no. 4
    
5.
World Health Organization. Multisystem Inflammatory Syndrome in Children and Adolescents Temporally Related to COVID-19. Available from: https://www.who.-int/news-room/commentaries/detail/multisystem-inflammatory-syndrome-in-children-and-adolescents-with -covid-19. [Last accessed on 2021 Apr 07].  Back to cited text no. 5
    
6.
Sanna G, Serrau G, Bassareo PP, Neroni P, Fanos V, Marcialis MA. Children's heart and COVID-19: Up-to-date evidence in the form of a systematic review. Eur J Pediatr 2020;179:1079-87.  Back to cited text no. 6
    
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Jones VG, Mills M, Suarez D, Hogan CA, Yeh D, Segal JB, et al. COVID-19 and Kawasaki disease: Novel virus and novel case. Hosp Pediatr 2020;10:537-40.  Back to cited text no. 7
    
8.
Gupta A, Gill A. Multisystem inflammatory syndrome in a child with scrub typhus and macrophage activation syndrome. J Trop Pediatr 2021;67:fmab021.  Back to cited text no. 8
    
9.
Samprathi M, Narayanappa S, Sridhar M, Ramachandra P, Vemgal P. Multisystem inflammatory syndrome in children: A mimicker of severe dengue. Indian J Pediatr 2021;88:486-7.  Back to cited text no. 9
    



 
 
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