A cross-sectional questionnaire based study was done in Shyam Shah Medical College Rewa, MP over a period of 7 days from 25^th April to 1^st May 2020. An online, close ended, structured questionnaire in English language containing questions pertaining to awareness regarding COVID-19 and sources of gathering information about the disease and the participant’s confidence on these sources was designed by the team of authors after a rigorous literature review. The questionnaire was an adapted version from the information for healthcare workers published by the US Centers for Disease Control and Prevention (CDC), the information released by WHO and ICMR [12,13]. Ethical clearance was obtained from the Institutional Committee. The questionnaire was tested for validity (I-CVI=0.8; S-CVI=0.9) and reliability (Cronbach’s alpha=0.8) by means of a pilot study conducted in a small sample of the teaching faculty to assess the clarity, relevance, accessibility and time required to complete the survey.

It was then distributed to all the students of pre-final and final year MBBS course, interns and postgraduate students (Total=320) in the form of Google form (a cloud-based data management tool used for designing and developing web-based questionnaires) via a link that was shared through a cross platform messaging application namely whatsapp within their smart phones. The aim of the study was explained in a brief note and consent was obtained from the participants. The respondents’ personal information was made anonymous and the confidentiality was maintained. They were requested to fill the desired information over a time period of 7 days beginning from 25^th April 2020 after which the questionnaire was closed for any response. After the dispatch of the link of the questionnaire form, reminders in the form of whatsapp messages were sent thrice to the participants over a period of 7 days requesting their participation in the study. The questionnaire was locked after being opened and the participant had to finish the entire set of questions at one go.

Section 1 of the self administered questionnaire gathered Demographic data of the respondents like age, gender and the qualification. The section 2 measured the knowledge about the disease based on 16 questions pertaining to aetiology, clinical manifestation of the disease, risk groups, consequences, mode of transmission, prevention strategies and treatment of the disease. Awareness was assessed by giving 1 to correct answer and 0 to the wrong answer and to the unanswered question. The scale measured awareness from maximum 16 to minimum 0. Scores <9 (≤50%) were taken as poor, 9-12 (≥ 50% to ≤75%) as satisfactory and >12 (≥75%) as good awareness towards COVID-19. Section 3 contained the data about the amount of information procured from various sources regarding the disease as well as the confidence of the respondents on these sources on a likert scale of 1-5. This was adapted from a similar study by Brug J et al., on Severe Acute Respiratory Syndrome [14]. The results of medical undergraduate students of pre-final and final year were compiled together as Group A. Since interns and postgraduate students assume clinical responsibilities under supervision, their results were compiled together as Group B.

Categorical variables were measured as percentages while continuous variables were expressed as mean±standard deviation using Microsoft Office Excel version 2010. Student’s Independent t-test was used to compare mean awareness scores. A p-value of less than 0.05 was considered statistically significant.

The questionnaire was served to a total of 320 students of MBBS pre-final and final year, interns and postgraduate students and 183 individuals participated in this study (57.1% response rate). A total 112 undergraduate students (61.2% of the respondents) were categorised as Group A and 71 interns and postgraduate students (38.8% of the total respondents) constituted Group B. Hundred (54.6%) respondents were males and 83 (45.4%) were females. Majority of the participants (80.9%) belonged to 18-25 years age group and the rest to 26-35 years age group [Table/Fig-1].

COVID-19 is caused by a RNA virus was known to 88.4% participants in Group A and 92.9% participants in Group B. All the participants of both the groups (100%) were aware that outbreak started at Wuhan in China and the most common presenting symptoms are fever, dry cough and breathlessness. Majority of the respondents in Group A (95.5%) and all in Group B had an opinion that the disease is considered to be originated from wild bats [Table/Fig-2]. Both the groups presented with good awareness level towards COVID-19 and the average number of questions correctly answered by Group A were 12.31 and by Group B were 14.49. Awareness among interns and postgraduate students was found to be high in comparison to undergraduate students and the difference was statistically significant (p-value<0.001) [Table/Fig-3].

The difference in awareness of both the groups was found to be extremely statistically significant (two-tailed p-value was found to be less than 0.001).

Group A reflected that their source of maximum information was official government websites (mean=3.6). They had maximum confidence in the information procured through official government websites and through teachers (mean=3.6), for reliability. Group B also received maximum amount of information from official government websites (mean=3.7). Group B had maximum confidence in the information obtained from official government websites (mean=4.7). Overall, analysis revealed that the study population relied mainly on government official websites for amount of information received (mean=3.6) and maximum confidence (mean=3.9) regarding validity of the information [Table/Fig-4,5].

COVID-19 caused by SARS-CoV-2 is the third major coronavirus outbreak over the past 20 years [15]. The fact that causative agent of this disease is a RNA virus was correctly answered by 90.16% respondents which were higher than that reported by Olaimat AN et al., where one-third of the respondents (34.6%) believed that genetic material of the virus was DNA [16]. SARS-CoV-2 is primarily transmitted from person-to-person by droplet spread was known to 91.26% of the study population which was better than the study by Modi PD et al., who reported that 56.7% medical post-graduates residents, fellows, faculty and 70.2% medical students answered it correctly [10]. This virus has also been detected in the samples of stool, gastrointestinal tract, urine, tears and conjunctival secretions of the infected individual [17]. Virus shedding by asymptomatic and pauci symptomatic patients poses a big challenge in restricting the spread of the disease and up to 12% of transmission occurs before an index case presents with symptoms [18]. Majority of respondents (96.17%) were well-versed with this fact.

The typical presenting symptoms are severe acute respiratory illness with fever, dry cough and shortness of breath [19]. Gastrointestinal symptoms have been reported in 2-40% of patients, olfactory disorders in 53% and ocular manifestations in 32% of patients [6]. The patients can also present with anxiety, delirium, agitation, fatigue, muscle aches, and headache [20].

The mean incubation period of SARS-CoV-2 is estimated to be 6.4 days, and a median incubation period of 5.0 days (CI, 4.4 to 5.6 days) with a range of 2-14 days [21-23]. The question on incubation period was answered correctly by 95.08% respondents which was similar to other studies [16,24]. Elderly and those with co-morbidities have escalated risks of progressing rapidly into acute respiratory distress syndrome, septic shock, metabolic acidosis, and coagulation dysfunctions [4]. This was known to 49.18% participants in this study which was less than that reported by Olaimat AN et al., who found that 94.9% students were aware that elderly and 81.0% were aware that immune-compromised persons (81.0%) are at higher risk to develop severe cases of COVID-19 [16].

The Indian Council of Medical Research (ICMR) approved the empiric use of hydroxychloroquine for prophylaxis of SARS-Cov-2 infection for asymptomatic health care workers involved in care of suspected or confirmed cases of COVID-19 and asymptomatic household contacts of laboratory confirmed cases [25,26]. Concurrent administration of azithromycin may prolong QTc interval and predispose to tachyarrhythmias and sudden cardiac death [25,27]. Electrocardiography is essential prior to starting these drugs as both tend to prolong QTc.

To address the worldwide shortage of PPE, guidelines for conserving single-use PPE through extended use and reuse in the face of shortages so as to ensure continued availability have been issued by regulatory authorities and institutions [28,29]. A response rate of 57.1% was reported in this study which was comparatively high in comparison with other studies in literature which reported a response rate of 35.1% and 33.6%, respectively [10,30]. The low response rate can be attributed to the emerging reluctance in participation of web based surveys perhaps due to survey fatigue [31].

The overall percentage of correct answers in this study for awareness related questions was 82.24%. This finding was consistent with a similar study conducted on 2,083 undergraduate or postgraduate students from different Jordanian universities which reported an average knowledge score of 80.1% and a highest mean knowledge score of 82.8% for students who majored in medical science, for questions pertaining to viral sources, incubation period, mortality rate, transmission, symptoms and complications of COVID-19 [16]. Average percentage of correct answers in the present study was greater for interns and postgraduates (90.58%) in comparison with under graduates (76.95%). This finding was consistent with other studies which have emphasised the relationship of knowledge with the experience [32]. However, it was in contrast with a study, which reported a greater number of correctly answered questions by medical undergraduates (74.1%) in comparison with postgraduates (72.1%) [10].

Majority of the participants depended on official government website for procuring the maximum amount of information and they believed that the information that is being dissipated through these websites was reliable. This was in accordance with the study by Parikh PA et al., that reported that 71% healthcare professionals depended on websites for seeking information [24]. Hence, these websites should be continuously updated with authentic data. In an another study performed on pre-natal and post-natal Chinese women, it was revealed that the three major sources of obtaining information about COVID-19 were doctors, nurses/midwives, and the television, (mean reliance scores: 4.22, 4.15, 4.14, respectively) and they placed a high level of confidence in these sources. (mean confidence scores 4.22, 4.14, 4.14, respectively) [33]. Hence, it was suggested that healthcare professionals remain well-versed with the latest information and guidelines. Open forum discussions, webinars led by healthcare professionals, especially COVID-19 experts, can serve as credible information sources for the general public rather than the information procured through social media platforms. Limaye RJ et al., has emphasised that social media platforms facilitate the dissemination of misinformation about COVID-19 which can prove to be fatal and its elimination is a great public health challenge [34]. In the study done by Sharma A et al., common source of information about COVID-19 was the internet, social media and television followed by newspaper, government sources and radio [35] but in present study, most of the information was obtained through newspaper and government official sites followed by other sources. Training sessions focused on latest clinical practice guidelines, standard operating procedures and emergency response plan of the institute were conducted by the institute for all healthcare professionals including interns and postgraduate students. It is believed that this would have further enhanced their preparedness.

The low sample size and low response rate (57.1%) despite multiple reminders which is not ideal to represent the awareness level of all medical students and interns. The findings presented in this study were self-reported and partly dependent on the participants’ honesty and recall ability; thus, they may be subject to recall bias.

Health care workers at all hierarchical levels must have an unhindered access to the authentic information about the current scenario of the disease, updates in Standard Operating Procedures and the supply of personal protective equipment. The awareness of the study population reflects their state of well preparedness for their utilisation in community education, screening, and treating the disease and safeguarding themselves and others amidst their duties but the results cannot be generalised because the sample size was low which can be attributed to a drawback in attitude for online surveys.