Monkeypox Virus Outbreak 2022: Assessment of Knowledge Among Healthcare Workers in Two Countries—India and Saudi Arabia
Abstract
Background: Healthcare workers play a crucial role in limiting the spread of the monkeypox virus. Studies show that healthcare worker’s (HCWs) understanding and communication about preventing infectious diseases can inspire various groups of individuals.
Objective: This study aimed to compare the knowledge of HCWs in India and Saudi Arabia regarding monkeypox virus infection.
Methods: A cross-sectional survey was conducted among HCWs in India and Saudi Arabia. The questionnaire was developed using information from the World Health Organization and Centers for Disease Control and Prevention websites. The validation of the questionnaire (Cronbach’s alpha = 0.87) was conducted for data collection. The mean scores between different demographic groups were compared using Student’s t-test and one-way ANOVA.
Results: A total of 848 participants responded to the questionnaire (India = 424 and Saudi Arabia = 424). The average knowledge score in India was 12.59 ± 2.49, and in Saudi Arabia, it was 13.25 ± 2.99 out of 20. The percentage of participants with good knowledge about monkeypox was 22.2% in India and 36.1% in Saudi Arabia. Participants with poor knowledge about monkeypox constituted 11% in India and 12% in Saudi Arabia.
Conclusion: HCWs in both countries had moderate to poor knowledge about the monkeypox outbreak. This might be because monkeypox is not prevalent in these countries. More education is needed to improve HCWs knowledge about monkeypox infection.
1. Introduction
Monkeypox (MPOX) is a zoonotic disease caused by the MPOX virus, an Orthopoxvirus closely related to the variola virus responsible for smallpox. First identified in 1970 in the Democratic Republic of Congo, MPOX has consistently affected marginalized communities in Central and West Africa, with notable outbreaks in countries like Nigeria and DR Congo. The disease presents with fever, rash, and lymphadenopathy and can lead to complications such as pneumonitis, encephalitis, and secondary bacterial infections. Case fatality rates vary by clade, with the Congo Basin clade exhibiting higher virulence compared to the West African clade. Transmission occurs through large respiratory droplets, direct contact with skin lesions, and contaminated fomites, with recent outbreaks linked to sexual networks, especially among men who have sex with men. The recent global MPOX outbreak in 2022, with over 3000 cases reported across over 50 countries, prompted the WHO to declare it a public health emergency. This outbreak highlighted the need for updated public health strategies, vaccination, and research into the developing transmission dynamics and clinical manifestations of MPOX [1–3]. India has reported around 22 cases and one death. Saudi Arabia (SA) has reported eight cases by July 2023 [4].
Healthcare workers (HCWs) play a proactive role in developing practical and focused initiatives to prevent the disease by educating and influencing the population to address the current MPOX situation. By effectively communicating, HCWs have the power to not only improve public understanding but also debunk misconceptions, inspire various groups to embrace preventive measures, and ultimately cultivate a sense of trust within the community. As a result, there is an increase in adherence to guidelines for preventing infectious diseases [5–8].
The knowledge about MPOX among HCWs in these two nations can be compared because they share a common characteristic; both are (rapidly) developing countries. Comparing SA and India during the MPOX outbreak assesses healthcare infrastructure, public health measures, epidemiological factors, HCW preparedness, and cultural influences and promotes international collaboration for better responses. Previous research in SA reveals that physicians have inadequate knowledge and attitudes toward MPOX infection, influenced by several factors [9]. A study in India revealed that healthcare professionals were aware of the MPOX outbreak but were unsure about recognizing its clinical signs and vaccination protocols [10].
In September 2018, a HCW became infected with the MPOX virus. The most likely transmission mechanism was contact with contaminated patient bedding [11]. HCWs should be vigilant regarding rashes that resemble MPOX, such as herpetic and vesicular–bullous lesions. The primary transmission mode of the disease occurs through contact with the patient’s belongings. Hence, disease transmission can be controlled with proper standard precautions to prevent contact and droplet infection [12]. This study aimed to evaluate and compare the knowledge of HCWs in India and SA regarding MPOX virus infection.
2. Materials and Methods
2.1. Participants and Design
This cross-sectional survey was carried out among HCWs in India and SA. The data were collected approaching hospitals, healthcare sectors, general practitioners, and educational sectors.
2.2. Eligibility Criteria
The study focused on HCWs as outlined by the World Health Organization’s international classification of health workers and included them in the study [13]. Those who gave consent to participate were included in the study, while participants who were not practicing, working, or retired were excluded.
2.3. Sample Size
A minimum sample size of 385 respondents from each participating country was required, with a 95% confidence interval, 0.5% standard deviation, and 5% margin of error.
2.4. Instrument Development
The frequently asked questions sections of the WHO [14] and CDC [15] websites served as the basis for developing the questionnaire, which consisted of three sections. The first section included consent for participation and an introduction. The second section gathered demographic details such as age, gender, years of work, and sector. The third section focused on specific questions about the MPOX virus, assessing knowledge of the virus, its spread, and typical diagnostic signs and symptoms. This questionnaire was distributed in both countries.
2.5. Validity and Reliability of the Questionnaire
Four faculty members from King Saud University, each holding a master’s degree or Ph.D. in dental public health and possessing strong research backgrounds, evaluated the content validity of the questionnaire. The primary objective of this assessment was to review the advisory panel’s responses to the questions and ensure consistency among the panelists for each question. The responses in the questionnaire yielded Cronbach’s alpha test values exceeding 0.87.
A pilot study involving a limited number of participants (n = 50) was conducted, during which they were asked to provide suggestions on how to improve the questionnaire’s clarity and reduce its length. The participants were selected from the study sample. Their feedback was carefully considered and integrated into the questionnaire, resulting in the approval of the final questionnaire consisting of 20 items. The questionnaire was then distributed to the research participants, with each participant taking approximately two to three minutes to complete it.
We assessed the test–retest reliability by collecting responses from the same respondents before and after a 2-week break. An intraclass correlation coefficient of 0.89 indicated good reliability. Based on the results of the pilot research, no additional revisions were deemed necessary, and thus, all 20 items were incorporated into the final form of the questionnaire.
2.6. Ethical Consideration
Ethical clearance was obtained from the College of Applied Medical Science, King Saud University (22/0352/IRB).
2.7. Data Collection
The data were collected by sending questionnaires via email, WhatsApp, or other social media platforms between August and November 2022.
2.8. Statistical Analysis
2.8.1. Dependent Variable
The main outcome measured was knowledge about MPOX infection. Responses of “yes” and “no” were utilized to gather data on the variables. A score of one point was assigned for each correct answer to calculate the knowledge score, while incorrect answers received zero points. Previous literature was consulted to categorize the knowledge score [16]. The knowledge score was graded as good (score 15–20, 75%–100%), moderate (score 10–14, 50%–75%), or poor (score 0–9, < 50%).
2.8.2. Independent Variables
Sociodemographic factors were treated as independent variables. Age was categorized into groups: 18–29, 30–39, 40–49, and > 50 years. Gender included male and female categories. Years of work experience were grouped into five categories: 0–5, 6–10, 11–15, 16–20, and > 20 years. The employment sector was categorized as public, private, and teaching institutes.
Descriptive statistics were used to analyze the sociodemographic data of participants from both countries. Student’s t-test and one-way ANOVA were employed to compare mean scores between different demographic groups. For analyzing categorical data, we used the chi-square test of association. The analysis was conducted using IBM SPSS Version 25 and Microsoft Excel.
3. Results
3.1. Demographic Details of the Participants
A total of 848 HCWs responded to the questionnaire, with 424 from India and 424 from SA. In India, 30% of participants were male, while 70% were female. In SA, 34% were male and 67% were female. The majority of participants in both India (78%) and SA (38%) were in the 18–29 age category. HCWs with 0–5 years of work experience constituted the largest group in both India (77%) and SA (49%). In terms of sectors, 66% of HCWs in India were from the private sector, compared to 42% in SA (Table 1).
| Demographic variables | Country | |||
|---|---|---|---|---|
| India (n = 424) | Saudi Arabia (n = 424) | |||
| Gender | Frequency | Percentage | Frequency | Percentage |
| Male | 127 | 30 | 146 | 34 |
| Female | 297 | 70 | 278 | 67 |
| Age interval in years | ||||
| 18–29 | 331 | 78 | 160 | 38 |
| 30–39 | 34 | 8 | 78 | 18 |
| 40–49 | 35 | 8 | 145 | 34 |
| > 50 | 24 | 6 | 41 | 10 |
| Years of work | ||||
| 0–5 | 329 | 77 | 209 | 49 |
| 6–10 | 25 | 6 | 19 | 4 |
| 11–15 | 18 | 4 | 41 | 10 |
| 16–20 | 18 | 5 | 72 | 17 |
| > 20 | 34 | 8 | 83 | 20 |
| Employment sector | ||||
| Public | 23 | 5 | 172 | 41 |
| Private | 280 | 66 | 163 | 38 |
| Teaching institute | 121 | 9 | 89 | 21 |
3.2. Knowledge About MPOX Infection Among the Participants
After combining both countries, the mean knowledge score regarding MPOX was 12.92 (SD = ±2.77) out of 20. The two countries exhibited a substantial disparity in mean knowledge scores (p < 0.001) (Table 2).
| Country | p value | ||||||
|---|---|---|---|---|---|---|---|
| India | Saudi Arabia | ||||||
| Mean | SD | p value | Mean | SD | |||
| Knowledge score | 12.87 | 2.29 | 0.04 ∗ | 13.24 | 2.98 | 0.001 ∗∗∗ | |
| Age in years | 18–29 | 12.45 | 2.44 | 0.14 | 12.06 | 3.11 | 0.02 ∗∗ |
| 30–39 | 13.38 | 2.60 | 13.91 | 2.65 | |||
| 40–49 | 12.83 | 2.73 | 14.03 | 2.60 | |||
| > 50 | 13.00 | 2.60 | 13.83 | 2.98 | |||
| Gender | Male | 12.41 | 2.45 | 0.22 | 14.12 | 2.47 | 0.001 ∗∗∗ |
| Female | 12.66 | 2.51 | 12.79 | 3.13 | |||
| Years of experience | 0–5 | 12.81 | 2.20 | 0.3 | 12.85 | 3.25 | 0.02 ∗∗ |
| 6–10 | 13.72 | 2.63 | 12.32 | 1.70 | |||
| 11–15 | 13.05 | 2.99 | 13.66 | 2.92 | |||
| 16–20 | 12.33 | 1.90 | 13.64 | 2.95 | |||
| > 20 | 13.00 | 2.59 | 13.90 | 2.38 | |||
| Employment sector | Public | 12.42 | 2.60 | 0.6 | 13.07 | 3.07 | 0.5 |
| Private | 12.69 | 2.51 | 13.27 | 3.07 | |||
| Teaching institute | 12.62 | 2.37 | 13.42 | 2.82 | |||
- Abbreviation: SD = standard deviation.
- ∗p < 0.05.
- ∗∗p < 0.01.
- ∗∗∗p < 0.001.
The mean knowledge score in India was 12.59 ± 2.49, while in SA, it was 13.25 ± 2.99, and these differences were statistically significant. Interestingly, both countries showed lower mean values in the young age group of 18–19 years old (India = 12.45 ± 2.44 and SA = 12.06 ± 2.99).
Out of the 20 questionnaire items, 10 were answered correctly by more than 50% of the participants in India, while 13 were answered correctly in SA. In India, 86% correctly responded to the item, “When treating suspected cases of monkeypox, all HCWs should follow standard infection control procedures,” compared to 71% in SA. Around 80% of participants in both countries correctly identified that MPOX spreads through close contact and respiratory droplets. Similarly, around 60% of participants in both India and SA responded correctly that the management of MPOX is symptomatic (Table 3).
| Question | Response | χ2 value (p value) | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Indian | Saudi Arabia | |||||||||
| Correct | Incorrect | Correct | Incorrect | |||||||
| n | % | n | % | n | % | n | % | |||
| 1 | Close contact and respiratory droplets transmit MPOX | 339 | 80 | 85 | 20 | 342 | 81 | 82 | 19 | 13.400 (0.05 ∗∗) |
| 2 | India/Saudi Arabia currently has commercially available tests to diagnose MPOX | 176 | 42 | 248 | 58 | 198 | 47 | 226 | 53 | 2.315 (0.128) |
| 3 | The risk of MPOX among homosexuals is not higher | 368 | 87 | 56 | 13 | 382 | 90 | 42 | 10 | 2.261 (0.133) |
| 4 | MPOX vesicular lesions are broad and nonitchy | 129 | 30 | 295 | 70 | 226 | 53 | 198 | 47 | 45.589 (0.001 ∗∗∗) |
| 5 | Contact lesions, body fluids, or respiratory droplets do not spread MPOX | 158 | 37 | 266 | 63 | 338 | 80 | 86 | 20 | 27.599 (0.001 ∗∗∗) |
| 6 | When treating suspected cases of MPOX, all healthcare workers should follow standard infection control procedures | 364 | 86 | 60 | 14 | 301 | 71 | 123 | 29 | 27.657 (0.001 ∗∗∗) |
| 7 | Lip and oral mucosa are not at all affected by MPOX | 379 | 90 | 45 | 10 | 337 | 80 | 87 | 20 | 15.827 (0.001 ∗∗∗) |
| 8 | MPOX can be prevented with the conventional smallpox vaccine | 122 | 29 | 302 | 71 | 221 | 52 | 203 | 48 | 47.982 (0.001 ∗∗∗) |
| 9 | MPOX does not cause lesions on the hands or eyes. | 354 | 84 | 70 | 16 | 350 | 82 | 74 | 18 | 0.134 (0.714) |
| 10 | According to the observations of recent epidemics of MPOX, lesions may develop in the genital area | 209 | 49 | 215 | 51 | 209 | 49 | 215 | 51 | 1.535 (< 0.12) |
| 11 | Compared to chickenpox, MPOX lesions are less severe | 337 | 80 | 87 | 20 | 323 | 76 | 101 | 24 | 1.340 (0.247) |
| 12 | If someone has already received a smallpox vaccination, they are more likely to acquire MPOX | 364 | 86 | 60 | 14 | 312 | 74 | 112 | 26 | 19.721 (0.001 ∗∗∗) |
| 13 | The reverse transcription-polymerase chain reaction test is advised to detect the MPOX virus in an acute infection | 214 | 50 | 210 | 50 | 186 | 44 | 238 | 56 | 3.710 (0.05 ∗∗) |
| 14 | Children under 12 years, pregnant women, and immunosuppressed individuals do not have a higher risk for MPOX | 367 | 87 | 57 | 13 | 334 | 79 | 90 | 21 | 8.962 (0.03 ∗∗) |
| 15 | MPOX is primarily managed symptomatically | 253 | 60 | 171 | 40 | 258 | 61 | 166 | 39 | 0.123 (0.72) |
| 16 | MPOX can be cured with certain antiviral medications | 334 | 79 | 90 | 21 | 319 | 75 | 105 | 25 | 1.498 (0.2) |
| 17 | Those with comorbidities may be given the smallpox vaccine for MPOX | 121 | 29 | 303 | 71 | 249 | 59 | 175 | 41 | 78.55 (0.001 ∗∗∗) |
| 18 | MPOX can be successfully prevented with passive immune globulin vaccination | 141 | 33 | 283 | 67 | 183 | 43 | 241 | 57 | 8.881 (0.03 ∗∗) |
| 19 | Vaccines against smallpox are effective in preventing MPOX and postexposure prophylaxis | 159 | 37 | 265 | 63 | 222 | 52 | 202 | 48 | 18.92 (0.03 ∗∗) |
| 20 | N95 masks and other personal protective equipment are ineffective when in close contact with a MPOX case | 338 | 80 | 86 | 20 | 326 | 77 | 98 | 23 | 0.9 (0.3) |
- Note: χ2 = chi-square value.
- ∗p < 0.05.
- ∗∗p < 0.01.
- ∗∗∗p < 0.001.
Eleven percent of HCWs in India and 12% in SA had poor knowledge of MPOX, while 22% in India and 36% in SA had good knowledge. The majority of participants in both countries exhibited moderate knowledge levels (India = 65% and SA = 58%).
Among male HCWs in India, only 21% had good knowledge about MPOX, compared to 40% in SA. The age group of 30–39 years showed the highest correct answer rate in India (35%), while in SA, it was the 40–49 age group (45%). The least experienced group (0–5 years) had a higher prevalence of poor knowledge in both countries, with 12% in India and 20% in SA.
In the Indian private sector, HCWs exhibited good knowledge (37%) compared to other sectors, whereas in SA, public sector HCWs demonstrated higher knowledge levels (54%) (Table 4).
| Variable | India (percentage) | Saudi Arabia (percentage) | |||||
|---|---|---|---|---|---|---|---|
| Good | Moderate | Poor | Good | Moderate | Poor | ||
| Gender | Male | 21 | 65 | 14 | 40 | 58 | 2 |
| Female | 23 | 67 | 10 | 34 | 50 | 16 | |
| Age (years) | 18–29 | 20 | 68 | 12 | 27 | 48 | 26 |
| 30–39 | 35 | 62 | 3 | 40 | 59 | 1 | |
| 40–49 | 23 | 66 | 11 | 45 | 52 | 3 | |
| > 50 | 33 | 54 | 13 | 34 | 61 | 5 | |
| Years of work | 0–5 | 21 | 67 | 12 | 36 | 44 | 20 |
| 6–10 | 40 | 56 | 4 | 11 | 89 | 0 | |
| 11–15 | 28 | 61 | 11 | 44 | 51 | 5 | |
| 16–20 | 11 | 78 | 11 | 38 | 60 | 3 | |
| > 20 | 26 | 62 | 12 | 37 | 59 | 4 | |
| Sector | Public | 29 | 81 | 19 | 54 | 85 | 20 |
| Private | 37 | 113 | 18 | 46 | 61 | 16 | |
| Teaching institute | 28 | 88 | 11 | 53 | 77 | 12 | |
4. Discussion
This study offers fresh insights into the knowledge about the MPOX virus among HCWs in India and SA, which have distinct healthcare delivery systems. Our findings revealed good knowledge levels (22% in India and 36% in SA) as well as moderate knowledge levels (67% in India and 53% in SA) about MPOX among HCWs. Given the pivotal role of HCWs in preventing MPOX infections, they must play a crucial role in educating the public, especially vulnerable patients. Furthermore, recent studies conducted in both countries and globally have underscored that HCWs serve as the most significant and reliable source of information on MPOX [9, 10, 17, 18]. A notable case in Brazil reported MPOX transmission to HCWs through fomites. Surfaces in the patient’s residence, their personal protective equipment (PPE), or the exterior of the specimen transport box were identified as causative for fomite transmission [19]. The higher level of good knowledge in SA compared to India may be attributed to its status as a high-income nation with better preparedness and infrastructure. However, it is crucial to note that HCWs can sometimes underestimate the risk of contracting MPOX, leading to preventable infections that can spread among staff members and patients.
The observed poor level of awareness regarding MPOX is a significant concern and should be addressed as a top priority. It may also be necessary for the Ministry of Education to include information about MPOX in the curriculum for medical and nursing students, considering it as one of the important endemic illnesses [20, 21].
The results of the present survey indicate that the majority of HCWs in both countries have poor knowledge about MPOX. A previous study among Saudi HCWs reported an average mean score of MPOX knowledge and perceptions. Notably, only 57% of HCWs were aware that MPOX could initially present similarly to COVID-19. MPOX and COVID-19 share some initial clinical features, making early differentiation challenging. Both diseases can present with symptoms such as fever, headache, chills, and fatigue in the early stages. This overlap can complicate initial diagnosis, especially in areas where both viruses are circulating [22]. Female HCWs and individuals with self-rated strong MPOX awareness showed noticeably higher knowledge scores [23]. In another study conducted in SA, physician attitudes and knowledge regarding the spread of MPOX were assessed. Approximately 55% of the respondents demonstrated good knowledge regarding MPOX [9]. The lack of awareness about MPOX among workers may suggest that local health officials have not provided formal information sufficiently. It is crucial for the government of all nations to take deliberate measures to prepare for, prevent, and mitigate the impact of MPOX.
The previous study conducted in India among HCWs indicated that 64.9% had good knowledge, while 35.1% had inadequate knowledge [10]. This study highlighted the potential impact of accessibility to scientific information in online academic journals on HCWs’ disease awareness. Similarly, another study among nursing staff and medical students in India showed unsatisfactory overall knowledge levels: 17.05% had good knowledge, 20.58% had moderate knowledge, and 65.78% had poor knowledge [18]. The Ministry of Health & Family Welfare, Government of India, provides guidelines for managing MPOX disease [24].
The participants in the current study demonstrated limited knowledge regarding various aspects of MPOX, including its clinical manifestations, the cause of lesions, the efficacy of smallpox vaccination, diagnosis, and accessible treatments. A recent study by Kaur et al. among dental professionals revealed concerning findings: 44.8% were misinformed about the similarities between MPOX and smallpox disease, 24.8% had never heard of MPOX, and only 31.2% were aware of the disease’s oral manifestations. Only 28% of participants in that study obtained high knowledge scores [25].
In our study, the majority of participants in both countries were unaware that vaccines used for smallpox could also be effective against MPOX. Similarly, a previous study conducted among Jordanian health schools revealed that only 26.2% of respondents were aware of the availability of a vaccine to prevent MPOX [26]. In previous studies, a significant number of participants were unaware of the fact that the JYNNEOS vaccine provides protection against both smallpox and MPOX, highlighting a crucial knowledge gap. Many participants mistakenly believed that the VARIVAX vaccine protected against MPOX [23, 27, 28]. JYNNEOS is approved for individuals aged 18 years and older who are at a high risk of contracting MPOX infection [29]. The lack of knowledge about vaccines like JYNNEOS may pose challenges for future vaccination campaigns and hinder efforts to contain pandemics effectively.
The findings from previous studies suggested that younger individuals are more adept at using the internet to access information about MPOX, while older doctors may rely more on their experience rather than seeking information online [30]. In our study, we observed that private-sector HCWs in India exhibited more knowledge compared to other sectors, whereas in SA, HCWs in the public institute sector had higher knowledge levels. Interestingly, unlike the previous study, we did not find a significant difference in knowledge among medical and dental practitioners based on their sector [10].
4.1. Limitations
The cross-sectional design of the current study limits its ability to track the growth of knowledge regarding MPOX infection over time. There may be a risk of selection bias during the sampling procedure. Another limitation is the lack of organization of healthcare professionals based on their categorization. Since the research was conducted in two nations with different economies and cultures, the findings may not apply universally.
4.2. Recommendations and Future Research
Vaccinating exposed personnel is a key recommendation for preventing and controlling MPOX in workplace settings. Prompt identification and isolation of infected individuals, coupled with good hygiene practices, are crucial measures. While MPOX may not spread as extensively as COVID-19, it is essential for every sector to adopt a global health policy to prevent the recurrence of zoonotic outbreaks [12, 31]. Additional research is recommended to further explore the impact of education on HCWs and its role in increasing knowledge levels. This will enhance the value and applicability of medical education in infection prevention and control efforts.
5. Conclusion
This study revealed moderate to low levels of knowledge about the MPOX virus among HCWs in both countries, which may be attributed to the low prevalence of MPOX in these regions. The lack of education and information regarding the infection is a concerning issue. It is recommended that healthcare personnel participate in workshops, seminars, and webinars focusing on clinical, preventive, and control methods to address knowledge gaps during periods of heightened risk. Medical and related science courses should emphasize nonendemic, emerging, and reemerging diseases to better prepare for pandemics.
Conflicts of Interest
The authors declare no conflicts of interest.
Funding
This study was funded by the Researchers Supporting Project number (RSP2024R31), King Saud University, Riyadh, Saudi Arabia.
Acknowledgments
This study was funded by the Researchers Supporting Project number (RSP2024R31), King Saud University, Riyadh, Saudi Arabia.
Open Research
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
