Ocular Immunology and Inflammation

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Knowledge, Attitude, and Practice Towards

Leptospirosis among Undergraduate and
Postgraduate Medical Students in India

Sivakumar Rathinam, Radhika Thundikandy & Kandasamy Balagiri

To cite this article: Sivakumar Rathinam, Radhika Thundikandy & Kandasamy Balagiri
(2020): Knowledge, Attitude, and Practice Towards Leptospirosis among Undergraduate
and Postgraduate Medical Students in India, Ocular Immunology and Inflammation, DOI:
10.1080/09273948.2019.1705988

To link to this article: https://doi.org/10.1080/09273948.2019.1705988

Published online: 14 Feb 2020.

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OCULAR IMMUNOLOGY AND INFLAMMATION
https://doi.org/10.1080/09273948.2019.1705988

ORIGINAL ARTICLE

Knowledge, Attitude, and Practice Towards Leptospirosis among Undergraduate

and Postgraduate Medical Students in India
Sivakumar Rathinam, FAMS, PhDa, Radhika Thundikandy, DNBa, and Kandasamy Balagiri, MScb
a
Uveitis Clinic, Aravind Eye Hospital & PG. Institute of Ophthalmology, Madurai, India; bDepartment of Biostatistics, Aravind Medical Research
Foundation, Madurai, India

ABSTRACT ARTICLE HISTORY

Background: Students of medicine in India tend to follow textbooks from western authors for rural Received 27 August 2019
pathologies, zoonosis, and this geographical disconnect leads to gaps in familiarity with local diseases. Revised 6 December 2019
Aim: This study aims to assess knowledge, practices, and attitudes on leptospirosis among under- Accepted 13 December 2019
graduate and postgraduate medical students. KEYWORDS
Methods: A cross-sectional, self-administered questionnaire study was performed from June 2018 to Attitude; knowledge;
May 2019 among 778 undergraduate students from six medical colleges of Tamil Nadu and 446 leptospirosis; medical
postgraduate students from two postgraduate institutions. students; practice
Results: The survey of 1224 medical students revealed that the postgraduate medical students’ knowl-
edge of leptospirosis was better than undergraduates; however, there were important knowledge gaps
in risk factors and management of leptospiral infection.
Conclusions: Although the results of the study are encouraging, poor knowledge of risk factors and of
diagnosis of leptospirosis can significantly affect the quality of patient care. This calls for multifaceted
interventions to improve the medical curriculum.

There is a general perception among the population that
medical students have a greater knowledge of common dis-
eases and follow appropriate preventive measures when com-
pared with nonmedical personnel. Further, clear knowledge is
expected from the medical students as they are the future
“doctors,” and when they personally adopt a healthy practice,
they are likely to positively influence their patients as well.
However, studies have shown that medical students, are not
well versed in subjects such as zoonosis and their epidemio-
logical facts.1,2
Leptospirosis is a spirochetal disease caused by the bacilli
leptospires.3 This tropical disease is common among farmers and
in people who have close contact with animals. Animal species
including rats, dogs, cattle, and goats serve as maintenance hosts.
They shed millions of leptospires in their urine polluting the soil
and water reservoirs. Human infection depends on the chance of
direct or indirect contact with the urine of these infected animals.4
Leptospires can gain entry into humans through abraded skin and
through intact mucous membranes, resulting in ailments from
mild self-limiting fever to multiorgan failure and death.5 This
tropical disease is reported from all tropical countries6 and is listed
as an emerging disease by the Center for Disease Control.7
The city of Madurai has been a known endemic area for
leptospirosis for several decades.8 Infection is more common
in groups of the population such as farmers and slaughter and
sewer workers because of their frequent direct exposure to
animal excreta and to the contaminated environment.
Additionally, epidemic outbreaks are even more common in
the rainy season. Recently, a Sri Lankan study reported that in
spite of several such outbreaks, the general population was not
aware of the risk factors.9 Research regarding knowledge,
practices, and attitudes (KAP) on infectious diseases like
leptospirosis among undergraduate and postgraduate medical
students in Tamil Nadu has been lacking (pilot study). This
study aims to quantitatively collect the baseline data on their
understanding of risk factors and to reveal incorrect practice.
Materials and Methods
Study Instrument
“Gold standard” tool for assessing knowledge of leptospirosis
is not available, and hence, the preliminary version of the
questionnaire was developed on results of focus group discus-
sion and literature assessment. This pretested, structured
questionnaire was used as a study tool and piloted on
a sample of 50 students. The tool’s overall ability to assess
the knowledge, practice, and the ease of using the tool was
reviewed. The choice and wording, face content, and conver-
gent validity of the questionnaire were assessed by social
scientists and biostatistics. The questions that were misunder-
stood were corrected. Internal consistency was assessed by
using Cronbach’s alpha (α = 0.7) and was found to be within
the acceptable range.
The questionnaire addressed eight principal domains for
the assessment of knowledge of zoonoses: etiology, epidemiol-
ogy, mode of transmission, clinical symptoms, lab diagnosis,
preventive measures, treatment, and prognosis. The final

CONTACT Sivakumar Rathinam rathinam@aravind.org Uveitis Clinic, Aravind Eye Hospital & PG. Institute of Ophthalmology, 1, Anna NagarMadurai, 1, Anna
NagarMadurai 625 020, Tamil Nadu, India
© 2019 Taylor & Francis Group, LLC
2 S. RATHINAM ET AL.
questionnaire included 39 questions in four sections. Six
questions focused on demographic data and general informa-
tion. There were 19 questions to assess the knowledge of the
diseases, 8 for their practice, and 7 questions to explore the
attitude toward the disease. After validation, cross-sectional
data were collected from six medical colleges in South India.
The data obtained were cleaned and double-coded by two
data entry personals.
A scoring system was developed to score the KAP responses.
A correct/appropriate response was chosen based on current
literature and best practice. One point was given for choosing
the correct answer, while wrong or uncertain (do not know)
responses were given a score of zero points. For multiple-choice
questions with more than one correct answer, one point was
given for choosing each response.
Ethics Statement
The Institutional Review Board approved the study protocol and
consent forms (IRB no RES2012060ETI). The dean of each
medical college gave his or her permission to conduct the
study in their college. The participants were informed about
the aim of the study, its methods, and the details of their
voluntary participation. All participants signed the consent
form. Each response was anonymous, and neither the author
nor the data entry personals knew the identity of the students.
Sample Size
This observational cross-sectional study was conducted from
June 2018 to May 2019. Based on the results of a pilot study,
the percentage of awareness of leptospirosis disease was 85%
among doctors. In order to estimate with the precision of 2%,
with 95% CI, the sample size needed was determined to be
1220. A total of 1300 students were willing to give their consent
for participation and were enrolled in the study. However, we
had received a total of 1224 responses (94.2%). We did not
receive a response from 76 students as they were unavailable
due to classes/emergency ward duties/night duties or camps.
Two categories of students were chosen for the study: MBBS
final year medical students and medical postgraduates.
Statistical Analysis
The data were coded and analyzed using SPSS software ver-
sion 16.0 (SPSS Inc., Chicago, IL, USA). The differences in the
mean KAP scores between undergraduates and postgraduates
were compared using Z-test. The ordinary least squares (OLS)
regression method was used to evaluate the influence of socio-
demographic characteristics, knowledge, and attitudes about
leptospirosis on prevention practice. The OLS model is
empirically specified by:
〖PRACTICE〗_i = β_0 + β_1 AGE+ β_2 GENDER+ β_3
PLACE OF RESIDENCE+ λ_1 KNOWLEDGE+ λ_2
ATTITUDE+ ε_i, where PRACTICE is the dependent variable
that denotes the leptospirosis practice score of respondent i;
β_0 represents the constant term; AGE is a continuous vari-
able representing the age of the respondent in years; GENDER
is a dummy variable representing 1 for a male respondent and
0 for a female respondent; PLACE OF RESIDENCE is
a dummy variable representing 1 for urban and 0 for rural;
KNOWLEDGE is a continuous variable that denotes the
knowledge score of the respondent; ATTITUDE is
a continuous variable that denotes the attitude score of the
respondent; β_1 … β_3 denote the coefficients associated with
the socio-demographic characteristics of the respondents; λ_1
and λ_2 denote coefficients associated with knowledge and
attitude scores, respectively; and ε is the normally distributed
error term with mean and zero variance σ^2 ~ N (0, σ^2).
Multiple linear regression analysis was used to develop
a model predictive of the leptospirosis on prevention practice.
A plot of residuals was examined to determine if the assump-
tion linearity and homoscedasticity were met. The normality
of the residuals was tested using a probability–probability
plot. Outliers were identified by Cook’s distances and highly
influential points by their leverage. The multivariate model
was then used to calculate a predicted practice score for the
subjects assigned to the validation set. The relationship
between the predicted and the actual score was tested by
simple linear regression. The model was also fitted to the
validation set. Components of the model were considered
significant predictors of test performance in the new set if
the p value for their coefficients was less than 0.05.
Results
A total of 1224 students participated in the study, out of which 481
(39.3%) were males and 743 (60.7%) were females. The mean age
was 24.8 ± 4.7 years. Of 1224, 202 (16.5%) were from rural areas
and 1022 (83.5%) were from urban areas; 689 were undergraduates
and 535 were postgraduate students (Table 1). The results of the
knowledge about leptospirosis among undergraduate and post-
graduate students are detailed in Table 2. The practice and attitude
toward leptospirosis as found by the study among undergraduate
and postgraduate students are displayed in Tables 3 and 4,
respectively.
Knowledge, attitude, and practices of leptospirosis for all
respondents categorized by education are given in Table 5.
Urban residents' and rural residents' score is given in Table 6.
The average score for male and female is given in Table 7.
Comparison of knowledge, attitude, and practice score cate-
gorization of all students is given in Table 8. Factors which are
associated with preventive practices are given in univariate
and multivariate regression (Table 9).
Table 1. Socio-demographic details of undergraduate and postgraduate students.
Undergraduate Postgraduate Total
(n = 689) (n = 535) (n = 1224)
n (%) n (%) n (%)
Age in years
1. Above 25 years 1/689 (0.1) 431/535 (80.6) 432/1224 (35.3)
2. Up to 25 years 683/689 (99.1) 101/535 (18.9) 784/1224 (64.1)
Gender
1. Female 403/689 (58.5) 340/535 (63.5) 743/1224 (60.7)
2. Male 285/689 (41.4) 195/535 (36.4) 480/1224 (39.2)
Locality
1. Urban 526/689 (76.3) 475/535 (88.9) 1001/1224 (81.8)
2. Rural 152/689 (22.1) 50/535 (9.3) 202/1224 (16.5)
(21 missing data)
 OCULAR IMMUNOLOGY AND INFLAMMATION 3

Table 2. Knowledge toward leptospirosis among undergraduate and postgraduate students.

Total
Undergraduate (n = 689) Postgraduate (n = 535) (n = 1224)
Knowledge (yes) n (%) n (%) n (%)
Student recollected leptospirosis when asked, 70/689 (10.1) 151/535 (28.2) 221/1224 (18.1)
● Waterborne diseasea 51/689 (7.4) 99/535 (18.5) 150/1224 (12.3)
● Animal-borne diseasea
Risk factors for leptospirosis 232/689 (33.7) 343/535 (64.1) 575/1224 (47.0)
● Presence of ratsa 57/689 (8.3) 183/535 (34.2) 240/1224 (19.6)
● Agricultural worka 1/689 (0.1) 12/535 (2.2) 13/1224 (1.1)
● Rainy seasona 0/689 2/535 (0.4) 2/1224 (0.2)
● Mosquito-borne bite
Leptospirosis is a, 621/689 (90.1) 460/535 (86.0) 1081/1224 (88.3)
● Bacteriaa 10/689 (1.4) 1/535 (0.2) 11/1224 (0.9)
● Parasite 9/689 (1.3) 6/535 (1.1) 15/1224 (1.2)
● Virus 22/689 (3.2) 49/535 (9.2) 71/1224 (5.8)
● Fungus
Mode of transmission 402/689 (58.3) 320/535 (59.8) 722/1224 (59.0)
● Water bornea 161/689 (23.4) 124/535 (23.2) 285/1224 (23.3)
● Vector borne 80/689 (11.6) 64/535 (12.0) 144/1224 (11.8)
● Direct contact 10/689 (1.4) 5/535 (0.9) 15/1224 (1.2)
● Air borne
Leptospirosis can be 290/689 (42.1) 284/535 (53.1) 574/1224 (46.9)
● Endemica 248/689 (36.0) 236/535 (44.1) 484/1224 (39.5)
● Epidemica 161/689 (23.4) 131/535 (24.5) 292/1224 (23.8)
● Sporadica 42/689 (6.1) 13/535 (2.4) 55/1224 (4.5)
● Pandemic
Leptospirosis common among 360/689 (52.2) 439/535 (82.1) 799/1224 (65.3)
● Farmera 170/689 (24.7) 85/535 (15.9) 255/1224 (20.8)
● Children 56/689 (8.1) 70/535 (13.1) 126/1224 (10.3)
● Militarya 72/689 (10.4) 55/535 (10.3) 127/1224 (10.4)
● Elder persons 320/689 (46.4) 265/535 (49.5) 585/1224 (47.8)
● Animal-oriented joba 14/689 (2.0) 14/535 (2.6) 28/1224 (2.3)
● Student
It is common in 380/689 (55.1) 396/535 (74.0) 776/1224 (63.4)
● Southeast Asiaa 77/689 (11.2) 58/535 (10.8) 135/1224 (11.0)
● All over the world 55/689 (8.0) 10/535 (1.9) 65/1224 (5.3)
● Western country
It is common in 224/689 (32.5) 212/535 (39.6) 436/1224 (35.6)
● Rural areaa 134/689 (19.4) 182/535 (34.0) 316/1224 (25.8)
● Urban in rainy seasona 192/689 (27.9) 154/535 (28.8) 346/1224 (28.3)
● Sluma
Leptospirosis can cause 565/689 (82.0) 511/535 (95.5) 1076/1224 (87.9)
● Fevera 384/689 (55.7) 432/535 (80.7) 816/1224 (66.7)
● Hepatorenal failurea 378/689 (54.9) 392/535 (73.3) 770/1224 (62.9)
● Headachea 176/689 (25.5) 249/535 (46.5) 425/1224 (34.7)
● Meningisma 134/689 (19.4) 142/535 (26.5) 276/1224 (22.5)
● Chronic joint paina 80/689 (11.6) 116/535 (21.7) 196/1224 (16.0)
● Cough with blooda 65/689 (9.4) 103/535 (19.2) 168/1224 (13.7)
● Cardiac failurea 102/689 (14.8) 85/535 (15.9) 187/1224 (15.3)
● Skin ulcer 38/689 (5.5) 53/535 (9.9) 91/1224 (7.4)
● Psychosisa 33/689 (4.8) 20/535 (3.7) 53/1224 (4.3)
● Mouth ulcer
Lab test is available to confirm the diagnosis 10/689 (30.5) 352/535 (65.8) 562/1224 (45.9)
● Micro-agglutination testa 96/689 (13.9) 53/535 (9.9) 149/1224 (12.2)
● Culture 71/689 (10.3) 39/535 (7.3) 110/1224 (8.9)
● Smear 69/689 (10.0) 16/535 (3.0) 85/1224 (6.9)
● Grams stain
Prophylactic treatment available 375/689 (54.4) 408/535 (76.3) 783/1224 (63.9)
● Doxycyclinea 124/689 (18.0) 49/535 (9.2) 173/1224 (14.1)
● Penicillin 35/689 (5.1) 24/535 (4.5) 59/1224 (4.8)
● Nil needed
Leptospirosis is a self-limiting diseasea 565/689 (82.0) 488/535 (91.2) 1053/1224 (86.0)
It can kill human beingsa 465/689 (67.5) 451/535 (84.3) 916/1224 (74.8)
It can cause abortion to animal and human beingsa 257/689 (37.3) 296/535 (55.3) 553/1224 (45.2)
Leptospiral isolation from body fluids is possible in systemic leptospirosisa 349/689 (50.6) 322/535 (60.2) 671/1224 (54.8)
Once infected, rat can excrete leptospirosis throughout its lifea 436/689 (63.3) 290/535 (54.2) 726/1224 (59.3)
Any animal can be a carrier for its transmissiona 240/689 (34.8) 169/535 (31.6) 409/1224 (33.4)
a
Correct response.

Discussion reactions, zoonoses, and other disease entities.10 Several such

studies point out the need for revising the medical curriculum.
There are several KAP studies on medical students performed on
A study on Standard Isolation Precautions (SIP) among
many areas starting from standard isolation, precautions, uni-
Sri Lankan and Iranian medical students revealed the prac-
versal precautions, HIV awareness, reporting adverse drug
tice of SIP to be poor.11,12 In Sri Lanka, surprisingly, the
4 S. RATHINAM ET AL.

Table 3. Attitude toward leptospirosis among undergraduate and postgraduate students.

Undergraduate Postgraduate Total
(n = 689) (n = 535) (n = 1224)
Attitude (answer yes) n (%) n (%) n (%)
1. I will be afraid of getting infected with leptospirosis
● When I use temple tank water 407/689 (59.1) 384/535 (71.8) 791/1224 (64.6)
● When I attend water sports 326/689 (47.3) 304/535 (56.8) 630/1224 (51.5)
● When I walk in stagnant water on road in the rainy season 438/689 (63.6) 374/535 (69.9) 812/1224 (66.3)
2. I will not be afraid of getting infected after examining leptospirosis patient 469/689 (68.1) 436/535 (81.5) 905/1224 (73.9)
3. Leptospirosis is an important disease that need more elaborate coverage in the MBBS curriculum 564/689 (81.8) 491/535 (91.8) 1055/1224 (86.2)
4. Awareness about leptospirosis needs to be improved among doctors 598/689 (86.8) 506/535 (94.6) 1104/1224 (90.2)
5. Leptospirosis will get more attention if terms like rat fever or field fever come in use 566/689 (82.1) 460/535 (86.0) 1026/1224 (83.8)

Table 4. Practice toward leptospirosis among undergraduate and postgraduate students.

Undergraduate Postgraduate Total
Practice (n = 689) n (%) (n = 535) n (%) (n = 1224) n (%)
1. Do you dip in village water tank in your pilgrimage tour 390/689 (56.6) 324/535 (60.6) 714/1224 (58.3)
2. Will you take any prophylactic antibiotic to avoid waterborne diseases 13/689 (1.9) 10/535 (1.9) 23/1224 (1.9)
3. Do you do vaccination for your pet animals 200/689 (29.0) 176/535 (32.9) 376/1224 (30.7)
4. Do you elicit history of risk factors when you suspect leptospirosis in your patient 306/689 (44.4) 296/535 (55.3) 602/1224 (49.2)
5. Will you include leptospirosis in the differential diagnosis 162/689 (23.5) 173/535 (32.3) 335/1224 (27.4)
6. Will you do lab test to rule out leptospirosis when you suspect 218/689 (31.6) 163/535 (30.5) 381/1224 (31.1)
7. For 2–3 days fever, will you give empirical broad-spectrum antibiotic 216/689 (31.3) 141/535 (26.3) 357/1224 (29.2)

Table 5. Comparison of knowledge, attitude, and practice score between under- Table 7. Comparison of knowledge, attitude, and practice score between male
graduates and postgraduates. and female graduates.
S. No. Place of residence X SD Statistical inference S. No. Gender X SD Statistical inference
A Knowledge A Knowledge
1 Undergraduate 14.76 4.165 Z = −16.863 1 Male 16.40 4.957 Z = −0.937
2 Postgraduate 18.87 4.306 p < 0.05 Significant 2 Female 16.66 4.514 p > 0.05 Not significant
B Practice B Practice
1 Undergraduate 2.18 1.343 Z = −2.784 1 Male 2.10 1.414 Z = −3.666
2 Postgraduate 2.40 1.432 p < 0.05 Significant 2 Female 2.39 1.354 p < 0.05 Significant
C Attitude C Attitude
1 Undergraduate 19.04 4.030 Z = −5.587 1 Male 18.87 4.309 Z = −5.226
2 Postgraduate 20.24 3.349 p < 0.05 Significant 2 Female 20.02 3.346 p < 0.05 Significant

Table 6. Comparison of knowledge, attitude, and practice score between urban Table 8. Comparison of knowledge, attitude, and practice score categorization
and rural graduates. for all students.
S. No. Place of residence X SD Statistical inference Category N (%)
A Knowledge Knowledge (17 questions)
1 Urban 16.75 4.705 Z = 2.829 Poor (score ≤14) 391 (31.9)
2 Rural 15.73 4.642 p < 0.05 Significant Fair (score 15–20) 600 (49.0)
B Practice Good (score>20) 233 (19.0)
1 Urban 2.28 1.388 Z = 0.422 Attitude (7 questions)
2 Rural 2.23 1.368 p > 0.05 Not significant Negative (score ≤19) 481 (39.3)
C Attitude Intermediate (score 20–21) 444 (36.3)
1 Urban 19.61 3.821 Z = 1.093 Positive (score >21) 299 (24.4)
2 Rural 19.29 3.770 p > 0.05 Not significant Practice (7 questions)
Poor (score ≤1) 393 (32.1)
Fair (score 2–3) 592 (48.4)
Good (score >3) 239 (19.5)
nursing students had better knowledge, attitudes, and prac-
The cutoff value for the knowledge, attitude, and practice score was calculated
tices compared to the medical students.12 It was almost the based on the lower, middle (IQR-range), and upper quartiles.
same in the studies conducted at Saudi University and
Mangalore.13–16 The authors attributed the curriculum to
be insufficient and less effective and that the medical stu- B and C among medical students of Pakistan showed only
dents have no systematic education about universal precau- 57% of students to have adequate knowledge regarding the
tions during clinical practice. Another study on human route of spread. Seventy-six percent of students did not have
immunodeficiency virus (HIV) in Fiji17 found a negative any knowledge about the post-exposure prophylaxis for
attitude and unacceptable practices probably due to fear. hepatitis B and C.18 Tanzanian KAP study on common
Interestingly, most students believed that health profes- zoonosis among medical practitioners revealed poor knowl-
sionals have the right to know a patient’s HIV status for edge of rural medical practitioners on the transmission of
their own safety which is contradictory to the universal sleeping sickness.2 They also had poor knowledge of clinical
guidelines which promote universal precaution and rights features of anthrax, rabies, echinococcosis, and bovine tuber-
of patients to confidentiality.16 KAP regarding hepatitis culosis in humans compared to their urban counterparts.
 OCULAR IMMUNOLOGY AND INFLAMMATION 5

Table 9. Factors that are associated with preventive practices.

Model 1 Model 2 Model 3
Undergraduates Postgraduates All respondents
Variables Coeff. Std. Err. Coeff. Std. Err. Coeff. Std. Err.
Univariate regression
Age −0.018 0.053 −0.073*** 0.018 0.000 0.009
Gender 0.378*** 0.103 0.162 0.128 0.296*** 0.081
Place of residence 0.010 0.123 0.002 0.213 −0.045 0.107
Knowledge score 0.085*** 0.012 0.064*** 0.014 0.071*** 0.008
Attitude score 0.068*** 0.012 0.053*** 0.018 0.066*** 0.010
Multivariate regression
Age −0.007 0.051 −0.071*** 0.018 −0.029*** 0.009
Gender 0.286*** 0.101 0.110 0.129 0.228*** 0.079
Place of residence 0.032 0.117 0.021 0.208 0.012 0.103
Knowledge score 0.071*** 0.012 0.056*** 0.014 0.071*** 0.009
Attitude score 0.038*** 0.013 0.032 0.019 0.037*** 0.011
***Significant p-value at 0.01 level.

An Indian study on awareness of zoonosis done at private and
public medical colleges was equally poor.1 Only 10 out of the 364
(2.8%) respondents defined zoonosis accurately. Only 3.3% in
the private college and 33.7% in the public college could cor-
rectly name three common parasitic zoonoses. In the same study
by Kakkar, knowledge of recent infectious disease outbreaks
such as H1N1, SARS, dengue, and chikungunya as well as their
treatment was found to be generally lacking. Nearly 50% of the
students in the private colleges and 23% of the students in the
public colleges could not link H1NI with birds.1 The authors
strongly felt that the current medical curriculum needs to be
revised to improve the understanding of existing zoonosis and to
include common emerging diseases.1
Present Study
The present study addresses KAP on leptospirosis among under-
graduate and postgraduate medical students in Tamil Nadu.
Students were informed that the study was on “waterborne infec-
tious disease.” The term leptospirosis was introduced only during
the questionnaire. The questionnaire was purposefully designed to
be very simple and very basic; for example, it questioned whether
leptospirosis is a bacteria and waterborne illness. Questions on
genomics and proteomics and details or role of TNF-alpha in fatal
conditions were not addressed at all. Hence, we expected them to
know a minimum of 75% of the questions. We have taken good
knowledge as >75%. Although the total mean knowledge, attitude,
and practice score of postgraduates was better than that of under-
graduates which was statistically significant at 0.01 level, and over-
all knowledge was less satisfactory.
At the outset, when the students were asked to recollect few
waterborne diseases, very few (10% and 28%) of undergraduates
and postgraduates recollected leptospirosis. Similarly, when they
were questioned on animal-borne diseases, only 7.4% and 18.5%
recollected leptospirosis. However, when they learned that the
study was on leptospirosis, their response progressively
improved (Table 2).
Adequate knowledge was seen in few questions, and 86–90%
of students knew that leptospirosis is a bacterium and it causes
fever (82–95%). Postgraduate students were aware of the hepa-
torenal failure and headache and higher prevalence in farmers
when compared to undergraduates. Regarding lab diagnosis,
30% and 64% knew micro-agglutination test which was
appreciable. However, their knowledge of risk factors was
much less. It was similar to that reported by Karkar that the
familiarity with zoonosis was not up to the expectation among
medical students. In the present study, 22–24% of them also
mentioned that leptospirosis as a vector-borne disease which is
absolutely a wrong response. Zoonotic diseases are known to
veterinary doctors who are not part of human health care. As
suggested by previous authors, veterinary and medical collabora-
tion must be strengthened to enable a more effective under-
standing of zoonotic diseases.
Major areas of concern include ignorance of medical students
on important areas such as risk factors, severity of illness, mode of
transmission, and symptoms (Table 2). Common infections that
affect agricultural workers were recollected as leptospirosis only by
8% and 34% of undergraduate and postgraduate students only in
the initial set of questions. However, in the later part, as they were
asked to choose groups of people at risk of leptospirosis, they
selected farmers and animal-oriented jobs as common groups. In
general, in India, knowledge about the older zoonoses such as
plague and rabies is relatively better than that of emerging
zoonoses.1 This stresses the need for the updating of the medical
curriculum.
The epidemic potential of the disease was not known to more
than 50% of the students. Although more than 50% (58–59)
mentioned that it is a waterborne disease, only 19–34% men-
tioned that leptospirosis is common in the rainy season. Less than
30% only mentioned rural and slum areas and raining season as
risk factors. This lack of knowledge reflected in their practice.
Although nearly 59–70% of them were worried about leptospiro-
sis risk when taking bath in temple tank water, 56–60% men-
tioned that they took a dip in water tank. Less than 2% ever
thought of taking a prophylactic antibiotic before water sports
and possible exposure. Even though they had a good attitude of
being concerned about getting infected in water sports and rain-
water exposure, 2% only ever thought of prophylaxis.
The total mean knowledge, attitude, and practice score
obtained by postgraduates was significantly higher than that
obtained by undergraduates, and the scores were statistically
significant at 0.05 level (Table 5). Knowledge toward leptospiro-
sis of urban residents was slightly better than rural residents for
postgraduates (Table 6). The average score of knowledge in male
and female was almost the same. However, attitude and practice
toward leptospirosis of female students were better than male
6 S. RATHINAM ET AL.
students for both undergraduates and postgraduates (Table 7).
The majority of the students’ knowledge got categorized as either
moderate or good; however, the data strongly suggest the need
for improvement as shown in Table 8. In multivariate analysis,
model 1 shows that higher leptospirosis prevention practice score
among undergraduate students was significantly associated with
male respondents and higher knowledge and attitude scores.
Model 2 shows that higher leptospirosis prevention practice
score among postgraduate students was significantly associated
with younger age and higher knowledge scores (Table 9).
More than 80% felt that the medical curriculum should
include more about this disease. They, in addition, felt that if
leptospirosis is called as rat fever or field fever, it will get more
attention (Table 3). The current study shows the knowledge
gaps in medical students which can result in underdiagnosis
and hence underreporting of zoonotic diseases. This as well as
practice scores points toward a need for an increased focus on
zoonosis in India’s medical curriculum.
Conclusion
Leptospirosis is a zoonotic disease, unlike major communic-
able diseases (HIV, TB, and malaria); India does not have any
organized program for zoonosis awareness, prevention, and
control. While leptospirosis is well covered in veterinary edu-
cation, it is not addressed in the human medical curriculum,
and the focus of veterinary institutes is limited to animal
health. Veterinary doctors are not considered as a part of
the human “health workforce.” As there is little interdisciplin-
ary communication, there is a lack of adequate knowledge of
zoonosis among the doctors who treat human patients. To
diagnose, report, and control zoonotic diseases more effec-
tively, doctors who treat human patients need a better under-
standing of these diseases. There are increasing concerns from
several countries on improving the medical curriculum on
zoonosis to avoid underreporting.1,2,14 The KAP of medical
students are particularly important since they will be the
future leaders in clinical practice and responsible for treat-
ment. Proper curriculum development will enhance both
undergraduate and postgraduate education.
Declaration of interest
The authors report no conflicts of interest. The authors alone are
responsible for the content and writing of the paper.
Funding
This work was supported by the Indian Council of Medical Research
[Laptos/24/2013-ECD-I].
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