KNOWLEDGE, ATTITUDE AND PRACTICE SURVEY AMONG GEORGIAN HEALTH CARE WORKERS TOWARDS BLOOD BORNE INFECTIONS.

The prevalence of viral hepatitis B and C in Georgia is among the highest in the region. US Centers for Disease Control and Prevention (CDC) has selected Georgia as a pilot country for hepatitis C elimination program. Since 2015, Georgia launched a multi-year program of HCV elimination, including treatment of infected individuals with Direct Acting Antivirals (DAAs) and implementation of prevention programs, including infection control in health care facilities. The objective of this study was to evaluate the attitude and knowledge of blood borne infections (HIV, HCV, HBV) among Georgian Health Care Workers (HCWs). HCWs were recruited from six participating multi-profile hospitals and dental care institutions in three large cities of Georgia (Batumi (Western Georgia), Rustavi (Eastern Georgia) and the capital city, Tbilisi). A self - administered questionnaire included sections regarding sociodemographic and professional characteristics; awareness of blood-borne infections; practice for transmission risk reduction and perceived educational interventions acceptable among HCWs. The selection of HCWs was done through simple random sampling from the list of staff as a sampling frame. HCW's survey results were compared to the one from Dental health care workers (DHCWs). The total number of surveyed individuals was 442. Among them, 246 (55.6%) were HCWs (physicians, nurses, physician assistants and residents) from different departments, including family medicine (38.6 %), surgery (21.7%), gynecology (23.4%) and intensive care (13.9%) and 196 DHCWs (44.6%). Only few respondents (15.6%) correctly identified the prevalence of HIV infection in Georgia. HCWs have better understanding about the prevalence of viral hepatitis compared to DHCWs (Prevalence of HBsAg was correctly identified by 33.2 % vs 22.3%; prevalence of HCV- by 18.9 % vs 17.3%). Knowledge regarding transmission risks of blood-borne infections (HIV, HCV, HBV) among HCWs is higher compared to DHCWS (for HIV 73% vs 45.3%, for HCV 49.2% vs 37.9% and for HBV 54.8% vs 33.7%) (p<0.005). Vast majority of DHCWs as well as HCWs believed that probability of transmission of blood-borne infections after contaminated needle stick is 50-70% (p<0.05). There was a poor knowledge on availability of post exposure prophylaxis (42.9% of HCWs compare to 36.1% DHCWs believed that HCV post-exposure prophylaxis is available) (p<0.005). The practice of using facemasks (81% vs 74.4% always use, respectively), protective clothes (96.8% vs 83.3% always use) and eyewears (46.9% vs 27.4% always use) was reported by DHCWs and HCWs. Some nosocomial risk events were reported by higher proportion of DHCWs, compared to HCWs and included accidental needle stick injuries (65.1% vs 45.5%) and blood splashes (48.3% vs 28.2%). Cuts with contaminated instruments was more common among HCWs compared to DCHWs (41.4% vs 35.1%) during medical procedures. The study suggests that level of knowledge on blood borne infections among both HCWs and DHCWs is not adequate. Data from this study can be utilized to design educational programs for Georgian HCWs/DHCWs to improve knowledge and practice about blood borne diseases.

A QUALITATIVE STUDY OF KNOWLEDGE, ATTITUDE AND PRACTICE TOWARDS TB IN GEORGIA.

TB remains to be the major public health concern in Georgia. TB awareness and knowledge is usually low in the general population, which leads to delayed referral to a medical facility, which in turn hinders timely initiation of diagnostic and treatment interventions. Lack of knowledge also contributes much to the widespread stigma in the society. The aim of the study was to qualitatively explore TB knowledge, attitudes and practice, as well as related barriers and facilitators by conducting FGDs among representatives of general population as well as TB risk groups. The qualitative data was collected through FGDs among different target groups: (1) TB patients; (2) TB contacts; (3) Injecting drug users; (4) health care providers and (5) students. FGD recordings were transcribed using a predefined coding scheme and followed by contextual analysis. According to the study results, there is a good level of TB knowledge and awareness among current/former TB patients, their contacts, and health care providers, which is linked to their practice and experience. IDUs receive sufficient information on the disease within the educational component of the Needle and Syringe program. A significant lack of TB knowledge was revealed in a segment of the general population such as students. Lack of TB knowledge among general population is highly linked to the stigmatized attitude towards TB patients. Accurate TB knowledge is an important prerequisite determining positive attitude towards the disease and supporting stigma reduction. Correct information on TB should be disseminated through all possible channels and the process should have permanent nature.

GENDER RELATED BARRIERS TO TUBERCULOSIS IN GEORGIA.

The morbidity and mortality burden of tuberculosis (TB) remains high in Georgia, including drug-resistant TB. A survey was conducted to identify potential gender-based barriers and contributing factors that might influence the timely diagnosis and treatment of TB among active and former TB patients. To assess TB-related stigma and discrimination, a quantitative study was conducted to identify gender-based barriers to the diagnosis and treatment of TB among current and former patients. The study subjects were selected by a simple random sampling method with a 1:1 gender ratio. Participation in the study was voluntary. Data were collected by individual, face-to-face interviews. The patients' registry of the National Center for Tuberculosis and Lung Disease was used as the sampling frame to select patients either currently on anti-tuberculous treatment as well as former TB patients, who completed or discontinued treatment. A total of 230 patients on current anti-tuberculosis treatment or former patients who have been treated for tuberculosis participated in the study. Half of the participants (115, 50%) were male. No significant gender difference was detected with respect to awareness and knowledge about tuberculosis. Stigma associated with TB was found to be higher among women than men. Compared to men, more female respondents than males reported a negative change in attitude from other people after their TB diagnosis (14.8% vs 8.7%, respectively). A higher proportion of women than men notified a family member upon deciding to visit a doctor due to TB symptoms and, similarly, more women were accompanied by a family member for the first physician visit related to tuberculosis. In Georgia, as in other countries around the world, men are more likely to be infected with TB than women. However, the stigma related to TB introduces barriers to service utilization. Barrier reduction programs should consider more comprehensive gender assessment and in-depth analysis of the epidemiological situation by economic status, living conditions, regions, employment status, and ethnicities. Effective interventions may reduce barriers and contribute to the timely diagnosis and treatment of TB.

AWARENESS OF CANCER SCREENING AMONG GEORGIAN PRIMARY CARE PHYSICIANS.

Despite the development of new diagnostic and treatment tools, cancer remains one of the leading public health challenges of developed and developing countries. According to the National Center for Disease control and Public Health (NCDC), incidence of all cancer cases in 2018 was 258.6 per 100.000 in Georgia. However, the national cancer screening program (available since 2006) has a low participation rate. In 2018, only 11.2% of eligible women were screened for cervical cancer and 8.6% had a mammogram. The coverage is even lower for colorectal cancer screening (1.5%). In 2019, NCDC launched an awareness campaign for cancer screening aiming to inform citizens about the importance of cancer screening and to provide updated information to primary care physicians to promote the cancer screening among their patients. Primary care workers (PCW) from three regions of Georgia were surveyed to assess their awareness regarding cancer and the cancer screening program before and after the educational courses. Data were collected using a self-administered questionnaire with 27 questions. The statistical software package, SPSS version 23, was used for data processing and analyses. A total of 129 primary care workers were enrolled, of whom 55.1% did not know that breast cancer screening is offered every two years by the national screening program. Only 61.1% correctly identified the eligible age groups for colorectal cancer screening. Almost half of PCWs (46.0%) did not know that low-risk HPV strains are associated with genital warts. Low engagement of PHC workers in cancer screening may explain the low participation rate in the state cancer screening program. Even though baseline knowledge was significantly improved after training courses, follow-up knowledge and practice surveys are needed to understand the long-term impact of training on the rate of referrals for cancer screening by PHC providers.

KNOWLEDGE RELATED TO THE NOVEL CORONAVIRUS (SARS-COV-2) AMONG GEORGIAN POPULATION.

Georgia confirmed its first case of SARS-COV-2 infection on February 26, 2020. Despite the government's proactive measures during the early stages of the epidemic, number of new infections of SARS-COV-2 is increasing and by March 31, a total of 110 cases have been reported. Limited understanding about epidemics can lead to panic and disrupt public health efforts to contain transmission. Thus, it is very important to understand the perceptions of the population regarding the disease and perceived level of government preparedness to fight against the spread of infection. This study reports results of a survey designed to understand attitudes and knowledge regarding SARS-COV-2 virus among Georgian population, including health care workers (HCWs). The online survey was conducted using a Facebook advertisement. The target was the whole country and the language used was Georgian. We collected information on demographic data, knowledge of symptoms and transmission modes of coronavirus, perceived differences between coronavirus and influenza, availability of antiviral medication and vaccination. We also included questions to capture the Georgian population's perceptions about government preparedness to combat the new coronavirus. The survey was open for three days (March 2-4, 2020). 5228 participants completed the survey. Of these, 40.3% were 25-45 years old and 58.2% were female. 20.7% of respondents had university degree and 10.3% were HCWs. For 25.8% of respondents, COVID-19 and influenza are the same diseases; 10.9% did not know if they are different. The majority correctly identified the transmission route and symptoms (96.9% and 98.0%, respectively). Regarding physical distancing, 13.2% indicated they would attend public events if needed even if they had COVID-19 symptoms. 19.1% think that Georgia is ready for COVID 19 epidemic, while according to 55% the county is not ready, but HCWs are trying hard to respond to this challenge properly. For 18% response is inadequate. There was no difference in knowledge between HCWs, non-HCWs and unemployed. 20% of HCWs as well as other study subjects believe that SARS-COV-2 vaccine and medications do exist but are simply not available in Georgia. One in five Georgians believe that there is a vaccine and medication to treat coronavirus, but that it is not available in the country. Given that information regarding coronavirus is changing very rapidly, the need to reach people with time-sensitive educational messages as well as prevention strategies is vital. Three months have elapsed since discovery of the novel coronavirus causing severe acute respiratory syndrome and classified as SARS-COV-2.

HEPATITIS B VACCINATION: KNOWLEDGE AND ATTITUDE AMONG WOMEN OF REPRODUCTIVE AGE IN GEORGIA.

Georgia is a country with high prevalence of hepatitis B. Based on a 2015 population serosurvey, the prevalence of hepatitis B surface antigen (HBsAg) is 2.9% and prevalence of anti-HBc is 25.5% in general population. Hepatitis B vaccine has been included in the national immunization schedule of Georgia only since 2002. Thus, most reproductive aged women were not vaccinated during young childhood. Cross-sectional study was conducted in the capital of Georgia, Tbilisi. Reproductive aged women were randomly selected and then recruited from three maternity care centers during prenatal care. The self-administered questionnaire included questions on socio-demographic information, hepatitis B vaccination status and awareness of HBV infection status. A total of 2185 reproductive aged women were enrolled in the study. The mean age was 28.5 (age range 17-46) years. Most (76.4%) had a bachelor and/or master's degree. 20.0% of respondents never heard about HBV. Very few (3.3%) knew they were infected with HBV. We could not determine if women were chronically infected or were exposed and developed antibodies. HBV knowledge was limited: 57.5% were not aware of available HBV treatment; 51.6% didn't know HBV infection could be prevented (35.8% named HBV vaccination, 29.3% named condom use). Only 10% of study participants reported being vaccinated for HBV. Awareness of HBV infection was higher among women over age 25 (72.1%) compared to women aged 25 years or less (27.9%) (P<0.0001). Among women who reported having an HBV infection, 40.6% did not name vaccine as a prevention method and 38.2% did not have information about availability of HBV treatment (P<0.05). Based on our study results, knowledge about HBV infection and vaccination is very low among reproductive aged women in Georgia. Women's health centers can be a good place to reach reproductive aged women for counseling on HBV infection and promote vaccination against hepatitis B.

DENTAL CLINICS: A RESERVOIR FOR HEPATITIS C VIRUS.

Nosocomial transmission of hepatitis C virus (HCV) is well established, however the role of dental care in HCV transmission has been speculated but particularly difficult to quantify. This study investigated the potential for nosocomial transmission of HCV in dental clinics in a high HCV prevalence, middle-income country.  Dental health care workers (DHCWs) in 13 clinics in 3 cities were invited to participate. After informed consent was obtained, the DHCWs were asked to provide a blood sample to test for anti-HCV and complete a questionnaire that included questions on risk behaviors. A second sample of dental clinics was recruited to conduct environmental testing for HCV RNA. Among the 244 DHCWs invited to participate in the study, 196 (80.3%) enrolled including 115 doctors, 49 nurses and 32 dental residents. The seroprevalence of anti-HCV among DHCWs was 4%. Of the 46 private dental clinics invited to participate, 37 (80.4%) dental clinics agreed to allow the environmental study. Overall, 23 (62.2%) clinics had HCV RNA detected in at least one location. The most frequently contaminated location was the suction unit with HCV RNA retrieved from 14 (37.8%) clinics, followed by contaminated samples from the general dental room in 9 (24.3%) clinics. Given that HCV RNA can be viable for up to six weeks, without fastidious attention to infection control procedures, patients may be exposed to contaminated dental equipment and nosocomial transmission can occur.

GENOTYPIC DISTRIBUTION OF HPV AMONG WOMEN OF REPRODUCTIVE AGE IN GEORGIA.

Of the 100 types of human papillomaviruses (HPV), approximately 35 infect the genital tract. The viruses are categorized as "high risk" and "low risk" depending on whether they are known to cause cancer or not. Cervical cancer is an important cause of cancer mortality in Georgia, and worldwide. Only limited and incomplete data are available about the epidemiology of HPV infection and related molecular and cellular changes in Georgia. Objectives of our study included the estimation of the prevalence and the distribution of HPV genotypes among women in Georgia. The study participants were women (~2000) aged 18-49 years randomly selected during a clinic appointment with a gynecologist for a regular check-up at one of the women's consultation centers (WCC) participating in the study. Venous blood (5 ml) was drawn and the prevalence of HPV evaluated by the detection of the HPV DNA. For genotyping, HPV DNA were extracted from the cervical samples, amplified first by consensus and then by primer-specific PCR, followed by a detection step on agarose gel. Of the total samples, 250 were positive for HPV DNA; these were further tested to identify the specific HPV genotype. The genotype distribution was as follows: type 6, 98 women (39.2 %); type 16, 64 (25.6%); type 18, 47 (18.8%); type 33, 23 (9.2%); type 11, 27 (10.8%); type 45, 19 (7.6%); and type 66, 9 (3.6%). In 37 women (14.8%), we found coexistence of several different HPV genotypes. The HPV genotypic profile among Georgian women is similar to data generated from studies conducted among the populations in other European countries. Presence of the subset of HPV genotypes not covered by quadrivalent anti-HPV vaccine (types 33, 45 and 66) was demonstrated among Georgian women.

ROLE OF VIRAL PATHOGENS IN INFANTS WITH SYSTEMIC INFECTION AT THE NEWBORN INTENSIVE CARE UNITS IN GEORGIA.

In Georgia, causative agents among infants with systemic infections are generally not identified and "neonatal sepsis" is usually diagnosed and treated without determining the etiology. The objective of this study was to estimate the role of viral pathogens (Herpesviridae and Enteroviruses) among neonates with generalized infections. A cross-sectional study was performed among neonates younger than <8 weeks admitted to a neonatal intensive care unit (NICU) at the two largest pediatric hospitals in Tbilisi, Georgia. Laboratory tests were performed by consensus and then by type-specific PCR methods. A total of 187 infants were recruited from the NICUs; most participants (74.9%) were of normal birth weight at admission to the NICU and half (51.3%) were younger than 7 days of age. Almost all babies (91.4%) were treated with a broad-spectrum antibiotic despite a lack of microbe identification. While the overall mortality rate of infants with a systemic infection was 21.9 %, neonatal outcomes were more favorable when the infection was due to enteroviruses (2.9% mortality rate) compared to a herpesvirus infection (16.1% mortality rate). Multivariate analyses identified independent predictors associated with neonatal mortality. These included etiology of infection, APGAR score and the type of delivery. Our investigation suggests that viral pathogens play a substantial role in systemic infections among NICU infants. Utilizing molecular-based testing in these cases could improve both the clinical management and outcomes of neonates with generalized infections.

RAPID IDENTIFICATION OF THE ETIOLOGICAL FACTORS CAUSING DIARRHEAL DISEASES.

The main objective of this investigation was to develop and pilot a real-time Polymerase Chain Reaction (rt-PCR) diagnostic system for rapid and simultaneous identification of pathogens with a particular emphasis on diarrheal disease diagnostics. The diarrheal diseases were selected as a target for the pilot because they constitute a primary public health priority in Georgia and worldwide. The product developed by our research team "Neo_PCR_Diagnostics" represents an original system for the identification of pathogens associated with gastrointestinal tract infections and diarrhea. The advantages of the proposed technology over existing conventional methods include the ability of simultaneous identification of multiple pathogens and the detection of pathogenic agents directly from the fecal samples. For the evaluation of the new diagnostic system, stool samples were collected at collaborating hospitals and clinics and analyzed by real-time PCR using the Neo_PCR_Diagnostic system. The selection of the pathogens for detection was based on their epidemiological and clinical importance. The following bacterial pathogens were targets for detection: Salmonella spp., Campylobacter spp., Shigella spp., Clostridium difficile (Toxin A/B), Escherichia coli (ETEC, STEC and O157), Yersinia enterocolitica and Vibrio cholerae. The following viral pathogens were studied: adenoviruses, rotaviruses and noroviruses. Genetic material (DNA) of the following parasites were targets in our study: Giardia lamblia, Entamoeba histolitica and Cryptosporidium spp. We also compared the results obtained by our molecular technology with the conventional methods - bacterial culture (for bacterial growth) and ELISA (for bacterial toxins). For viral and parasitic pathogens, comparison tests were performed with immunochromatographic assays for direct detection of antigens in the stool samples or with the data obtained by use of home-made end-point PCR (where available). Advantages of the proposed technology over existing conventional technologies include the ability of simultaneous identification of diarrheal infections by multiple pathogens. The proposed test system allows the detection of pathogenic agents directly from the fecal samples and can be completed within one working day. In general, the spectrum of pathogens detected by our approach was wider than those detected by the conventional methods used in the clinical setting, taking into consideration the list of pathogenic agents requisitioned by physicians within the framework of the routine clinical visit. Given these promising results, Neo_PCR_Diagnostics test performance and accuracy may be sufficient for use in molecular microbiological diagnostics in clinical and/or research settings.