Hotel employees' knowledge of monkeypox's source, symptoms, transmission, prevention, and treatment in Egypt

Abstract

Background

The re-emerging human monkeypox virus (MPXV) poses a global threat. The rising number of confirmed MPXV cases worldwide is a significant reason for concern. This study aims to investigate (1) hotel employees' knowledge in Egypt of MPXV source, signs/symptoms, transmission, prevention, and treatment, (2) the primary sources of their information about MPXV, (3) whether or not they received information about MPXV from their hotels, and (4) the differences of employees’ knowledge in terms of gender, age, marital status, level of education, type of contract, professional category, hotel department, type of hotel, seniority in the hotel, and the number of hotel rooms.

Methods

Using a quantitative approach, we collected data from 453 employees in Egyptian hotels via a web-based questionnaire. The survey included questions regarding the MPXV source, signs/symptoms, transmission, prevention, and treatment, as well as its primary information sources. The questionnaire also included questions regarding participants’ demographics and hotel characteristics.

Results

The findings indicated that more than half of hotel employees have inadequate knowledge of MPXV. Additionally, the majority of employees selected social media as their primary source of MPXV-related information. Surprisingly, most participants reported that their hotels neglected to provide them with the MPXV's information. Age, marital status, education, professional category, and tenure in the hotel all have a significant impact on their MPXV knowledge level.

Conclusion

The current paper presents significant implications for both theory and practice. This study provides government agencies and hotels with guidelines for preventing the outbreak of MPXV. According to our knowledge, this is the first study conducted with hotel employees in the MPXV Egyptian context.

1. Introduction

The human monkeypox virus (MPXV) is currently a global concern [[1], [2], [3]] and a multi-country outbreak [[4], [5], [6]]. The World Health Organization (WHO) declared MPXV a public health emergency of international concern on July 23, 2022 [7]. According to Ortiz-Martínez, Rodríguez-Morales et al. [8], over 50 non-endemic countries reported the emergence of MPXV in May 2022.

According to WHO [9], between January 1 and June 22, 2022, 50 countries/territories reported a total of 3413 infections among humans and one death. West and Central Africa are the main endemic regions [10]. Based on WHO [11], 61,753 confirmed MPXV cases and 23 deaths were reported from 105 countries/territories/areas in all six WHO regions between January 1 and September 18, 2022. The number of confirmed cases has increased by 16.5% since the previous report on September 7, 2022.

MPXV has many signs and symptoms, including skin lesions, cervical lymphadenopathy, fever, fatigue, and anal pain, as well as perianal, genitals, mouth and trunk lesions [12]. MPXV is a dangerous pandemic since many complications are associated with MPXV, such as encephalitis, vision loss, and pneumonia [13]. The case fatality ratio is between 3% and 6% [6]. Saxena et al. [6] also demonstrated that MPXV could be transmitted to humans by direct contact with an infected individual, animal, or virus-contaminated material. MPXV could be easily transmitted from human to human [2,14]. Therefore, Peter et al. [15] recommended isolating infected persons in the human population to reduce its outbreak.

The tourism industry is the backbone of economic development [16]. Additionally, Enilov and Wang [17] illustrated that tourism is vital for developing countries’ economic growth. The travel and tourism sector contributed 10.3% to the global gross domestic product (GDP) in 2019, as reported by the World Travel and Tourism Council (WTTC) [18]. In 2019, this sector also accounted for 333 million jobs worldwide. International visitor spending accounted for US$1.8 trillion in 2019 (6.8% of total exports) [18].

Egypt has been selected as the context for the current paper in order to make a contextual contribution. Statista [19] states that the travel and tourism industry contributed approximately 389 billion EGP to the Egyptian economy in 2018. Furthermore, this industry accounted for 2.16 million employees in 2021. It is expected that this sector will contribute 601 billion EGP to the Egyptian economy by 2028 [20].

The tourism industry depends on human mobility [21] and is increasingly influenced by pandemic diseases [22]. According to WTTC [18], GDP declined from 10.3% to 5.3% in 2020 due to travel restrictions of the COVID-19 pandemic. In addition, 62 million jobs were lost in 2020, representing a drop of 18.6% compared to 2019, leaving just 271 million employed across the industry worldwide [18] and due to COVID-19, Egypt's tourism sector revenues declined by nearly 70% in 2020 [23]. COVID-19 has shut down Egypt's tourism sector, leading to monthly losses estimated at US$1 billion [24].

There is a significant global knowledge gap about MPXV [25], necessitating more efforts to provide guidelines on preventing and managing MPXV [7]. Alshahrani, Assiri et al. [7] confirmed that the lack of knowledge about MPXV among people makes this pandemic a more significant threat, and it may mutate, resulting in a shift in virulence. Jairoun et al. [26] concluded that improving knowledge of MPXV will help enhance the capacity to respond to MPXV cases and relay pertinent data to a disease surveillance system. Thus, they urgently call to assess knowledge about MPXV sources, signs/symptoms, transmission, prevention, and treatment in various regions worldwide. Sah, Alshahrani et al. [27] asserted that training, education, and prevention programs for MPXV are urgently needed.

The recommendations of Thornhill et al. [28] to contain further community spread of MPXV were the impetus for the current study. This can be achieved by increasing the awareness and knowledge of people [29], particularly hotel employees in Egypt, about MPXV's source, symptoms, transmission, prevention, and treatment. Previous scholars have assessed knowledge of MPXV among the general population [30] and physicians in Saudi Arabia [31] with a clear gap in other countries and sectors worldwide.

Our study was conducted in Egypt due to its location in Africa, which reported the highest number of deaths among MPXV confirmed cases (14/23; 60.9%) from January 1 to September 18, 2022. In addition, the south border of Egypt is Sudan which reported one death of MPXV [11]. In the midst of the COVID-19 pandemic, Uwishema et al. [32] found that a lack of public awareness and understanding of MPXV is a significant obstacle for African nations attempting to combat MPXV.

Due to its location in the Middle East, Egypt faces a challenge in preventing the spread of MPXV through the education of its population. According to WHO [9], there are confirmed cases of MPXV in Arabian and Middle Eastern nations such as Morocco, the United Arab Emirates, Lebanon, and Israel. Additionally, Bahrain reported its first case on September 16, 2022 [11]. Egypt attracts a large number of tourists each year [33] from different countries, so it remains at high risk.

Additionally, the Presidency of the Egyptian Council of Ministers [34] revealed that Egypt has one confirmed case of MPXV infection. Even though the number of MPXV cases in Egypt is not high, infections from other countries around the globe are cause for concern [7]. This necessitates urgent research to measure the awareness and knowledge of the Egyptian population regarding MPXV, particularly in the hotel industry, in order to prevent any potential transmission by providing insightful suggestions and recommendations for preventing its spread.

Given that MPXV affects primarily men with a median age of 35 years (interquartile range: 30–42) as stated by WHO [11], and the fact that the predominant gender in the accommodation and food services in Egypt is men who represent 780,800 of the total 820,000 employees [35] and range in age from 26 to 45 years old [36], it is reasonable to assume that the prevalence of MPXV in Egypt is high. This places the Egyptian lodging and food service industry in peril. Therefore, the current study is essential for enhancing hotel employees’ knowledge of MPXV and its prevention.

Since that there are no effective treatments for infected individuals of MPXV [2], it is critical to improve people's knowledge of MPXV and how they could prevent its transmission, especially in Egypt's hotel industry which is considered a labor-intensive sector that is based on the human factors. Moreover, Egypt's hotel employees contact directly with a substantial number of guests around the clock. MPXV transmission could rapidly spread and be a catastrophe for the entire Egyptian population if a single case of infection occurs in this industry. In addition, Kaler et al. [2] reported that MPXV could be transmitted between humans through respiratory droplets or direct contact with mucocutaneous lesions of an infected individual.

The current paper contributes to enhancing people's knowledge, especially hotel employees, about MPXV because the globe faces the fear of the MPXV epidemic in various regions such as COVID-19 [2] and it would appear as a pandemic like COVID-19 [37]. Moreover, the continuing outbreak of MPXV infection makes its prevention a global challenge [38].

In conclusion, the present study aims to investigate (1) hotel employees' knowledge in Egypt about MPXV's source, signs/symptoms, transmission, prevention, and treatment, (2) the primary sources of their information about MPXV, (3) whether or not they received information about MPXV from their hotels, and (4) the differences of hotel employees' knowledge in terms of gender, age, marital status, level of education, type of contract, professional category, hotel department, type of hotel, seniority in the hotel, and the number of hotel rooms. This study also provides a detailed training program and presents practical implications and recommendations for governmental authorities and practitioners.

2. Method

2.1. Procedure and sample

The researchers adopted a positivist research philosophy. Quantitative data were collected using a web-based questionnaire directed to hotel employees from different positions in Egypt. Using questionnaires for data collection is beneficial to reduce bias, accomplish reasonable response rates, collect high-quality, useable data, obtain more honest and frank answers, and yield quantitative data [39,40].

Using a web-based survey is a very efficient and effective way for data collection because it expedites data processing and analysis and eliminates the need for cumbersome and expensive transfer and tracking of forms, data entry, and verification. Further, previous scholars collected data online due to the COVID-19 pandemic restrictions in Egypt and the need for social distancing [36].

In the current study, after developing the questionnaire, ten academic experts in the medical and management fields were consulted to solve any questionnaire-related issues [36]. The authors requested that experts consider the validity of the measurement items, the questionnaire's content, and its clarity. A few modifications were made to the questionnaire format in response to their constructive comments. The authors also included questions regarding education level and seniority.

Given that Arabic is the local language of hotel employees in Egypt, the questionnaire was translated from English to Arabic by the current study's researchers. The authors also enlisted the assistance of five Arabic-English language instructors to ensure the questionnaire items were compatible. As a result, minor adjustments were made. Before collecting the final data, a pilot study was administered to 35 hotel employees to determine the instrument's validity, evaluate the Arabic translation of the questionnaire, minimize measurement error, and confirm the questionnaire's content. This method allowed the authors to make minor adjustments to the measurement items.

In September 2022, the final data were collected. First, with the assistance of the Egyptian Hotel Association [41], we gathered the email addresses of all human resources managers in Egyptian hotels. Second, the researchers emailed the managers and asked them to distribute the questionnaire as an attached URL hyperlink to their hotels, indicating the research's aim. Eventually, two follow-up emails were sent to the directors until the survey's closing to increase their response rate.

The authors employed a non-probability convenience sampling to gather the required data [42], especially since the population is substantial [36,43] and the difficulty of the Egyptian context. Previous scholars used convenience sampling to collect data in tourism and hospitality research [[44], [45], [46]]. With a high level of participation, non-probability sampling could provide reliable data and high-quality results [47].

In Egypt's accommodation and food services, there are 820,000 employees [35]. Based on Saunders et al. [48], the expected sample size is 384 if the population size ranges from 1,000,000 to 10,000,000 and the margin of error is 5%. We collected 453 questionnaires from employees in Egyptian hotels. All questionnaires were valid for the final analysis.

2.2. Measures

The participants' knowledge of human monkeypox was evaluated with 27 questions derived from Alshahrani, Alzahrani et al. [30] and Jairoun et al. [26]. First, five measurement items investigated knowledge of the source, definition, and incubation period. Second, knowledge of the mechanism of transmission of human monkeypox was examined by using three items. Third, knowledge of the signs and symptoms was assessed by seven measurement items. Fourth, knowledge of the preventative measures was also examined by seven items. Finally, five items were employed to measure knowledge of the treatment modalities. Hotel employees were requested to answer all 27 questions with one of three expected answers: “Yes, No, or I don't know” (Appendix 1).

The second section of the questionnaire consisted of a number of questions as follows: The main sources of the respondents’ information about monkeypox, receiving information about human monkeypox from the hotel, gender, age, marital status, level of education, type of contract, professional category, department, type of hotel, seniority in the hotel, and the number of hotel rooms. The questionnaire ended with two open-ended questions “please add any suggestion on how we could increase your knowledge about human monkeypox as a global pandemic” and “please feel free to write any additional comment.” The answers to the open-ended questions were carefully considered and then used to support the quantitative results.

2.3. Ethical considerations

Before collecting data, the questionnaire began with a brief introduction outlining the purpose of the study and ensuring confidentiality. In addition, the participants were not asked to record their identities. All respondents signed the informed consent, confirming that they are hotel employees or managers, and they voluntarily agreed to be a part of the current research.

2.4. Analytical approach

Based on the collected data, the research questions were investigated using SPSS (version 21.0). The adopted analyses were means, standard deviation, frequencies, percentages (for data description), t-tests, and one-way ANOVA (for testing the differences). Moreover, the level of significance was set at p < 0.05. For participants' responses to the MPXV questions, we allocated one for the correct answer, while we allocated zero for the wrong answer or the response by “I don't know.” The participants' correct responses from 80 to 100% of the total score (27) were good knowledge level, from 60 to 79% were moderate knowledge level, and from 0 to 59% were poor knowledge level.

3. Results

A sample of 453 hotel managers (26.3%), supervisors (41.3%), and entry-level employees (32.5%), with a majority of males (80.1%), participated in the current study. These participants came from various hotel departments, including reception (35.3%), food and beverage (25.2%), housekeeping (21.6%), and others (17.9%.). The majority of participants were between 25 and 45 years old. The percentage of participants with a bachelor's degree was higher than 69%. More than half of the participants were married (58.3%), followed by singles (28.5%) and those who had been divorced or widowed (13.2%). In addition, 41.1% of participants had tenure exceeding five years, followed by 37.3% of participants with tenure between one and five years. Finally, the analyzed data revealed that the participants were permanent (43.7%) and temporary (56.3%) employees working in independent (38.2%) and chain hotels (61.8%) with different room numbers, including fewer than 150 rooms (17.0%), from 150 to 300 rooms (28.7%), from 301 to 450 rooms (25.8%), and over 450 rooms (28.5%) (Table 1 ).

Table 1.

The results of ANOVA and T-test.

Variables	N	Percentages	Mean (±SD)	Homogeneity of variances	P-Value	P-value multiple comparisons
						1	2	3	4
Age
Less than 25 (1)	81	17.9%	13.25 (6.87)	<0.001*	<0.001*		0.687	0.410	<0.001*
From 25 to 34 (2)	178	39.7%	12.84 (8.19)			0.687		0.135	<0.001*
From 35 to 45 (3)	139	30.2%	14.12 (7.67)			0.410	0.135		0.002*
Over 45 (4)	55	12.1%	17.98 (6.21)			<0.001*	<0.001*	0.002*
Gender
Male	363	80.1%	13.71 (7.70)	0.846	0.240
Female	90	19.9%	14.80 (7.84)
Marital status
Single (1)	129	28.5%	12.07 (7.66)	0.043*	0.005*		0.002*	0.018*
Married (2)	264	58.3%	14.62 (7.50)			0.002*		0.796
Divorced/Widowed (3)	60	13.2%	14.90 (8.31)			0.018*	0.796
Level of education
Secondary education (1)	84	18.5%	11.58 (7.80)	0.013*	<0.001*		0.021*	<0.001*
University education (2)	313	69.1%	13.72 (7.52)			0.021*		<0.001*
MSc/PhD (3)	56	12.4%	18.63 (6.85)			<0.001*	<0.001*
Type of contract
Permanent	198	43.7%	13.34 (7.89)	0.122	0.175
Temporary	255	56.3%	14.38 (7.59)
Professional category
Manager (1)	119	26.3%	17.46 (6.55)	<0.001*	<0.001*		<0.001*	<0.001*
Supervisor (2)	187	41.3%	13.67 (7.42)			<0.001*		0.005*
Entry-level staff (3)	147	32.5%	11.39 (7.96)			<0.001*	0.005*
Hotel department
Reception(1)	160	35.3%	14.79 (7.44)	0.089	0.373		0.131	0.181	0.258
Housekeeping (2)	98	21.6%	13.29 (7.37)			0.131		0.828	0.792
Food and beverage (3)	114	25.2%	13.52 (8.12)			0.181	0.828		0.947
Other departments (4)	81	17.9%	13.59 (8.15)			0.258	0.792	0.947
Type of hotel
Independent	173	38.2%	14.27 (8.05)	0.265	0.467
Chain	280	61.8%	13.72 (7.53)
Seniority in the hotel
Less than 1 year (1)	98	21.6%	11.54 (8.29)	<0.001*	<0.001*		0.009*	<0.001*
From 1 to 5 years (2)	169	37.3%	14.09 (7.95)			0.009*		0.246
Over 5 years (3)	186	41.1%	15.04 (6.94)			<0.001*	0.246
Number of hotel rooms
Less than 150 rooms (1)	77	17.0%	13.09 (8.18)	0.082	0.134		0.896	0.186	0.120
From 150 to 300 rooms (2)	130	28.7%	12.95 (7.76)			0.896		0.095	0.051
From 301 to 450 rooms (3)	117	25.8%	14.59 (7.94)			0.186	0.095		0.814
Over 450 rooms (4)	129	28.5%	14.82 (7.14)			0.120	0.051	0.814	0.120

This study evaluated the participants' knowledge of MPXV with 27 questions regarding “the source, definition, and incubation time of MPXV,” “the mechanism of transmission of MPXV,” “the signs/symptoms,” “the preventative measures,” and “the treatment modalities.” The frequency and percentages of participants’ responses for each question with the correct answers are presented in Table 2 .

Table 2.

Knowledge dimensions’ items of human monkeypox virus with responses.

Dimensions' items	Correct answers	Yes(1)	No(2)	I don't know(3)	Correct response	Wrong response
knowledge of the source, definition, and incubation time (SDI)
SDI1	Yes	293(64.7%)	43(9.5%)	117(25.8%)	293(64.7%)	160(35.3%)
SDI2	No	100(22.1%)	158(34.9%)	195(43.0%)	158(34.9%)	295(65.1%)
SDI3	Yes	224(49.4%)	68(15.0%)	161(35.5%)	224(49.4%)	229(50.6%)
SDI4	Yes	242(53.4%)	63(13.9)	148(32.7)	242(53.4%)	211(46.6%)
SDI5	Yes	176(38.9%)	71(157%)	206(45.5%)	176(38.9%)	277(61.1%)
The mechanism of transmission of human monkeypox (T)
T1	Yes	277(61%)	48(10.6%)	128(28.3%)	277(61.1%)	176(38.9%)
T2	Yes	233(51.4%)	67(14.8)	153(33.8)	233(51.4)	220(48.6%)
T3	Yes	272(60.0%)	60(13.2%)	121(26.7%)	272(60.0%)	181(40.0%)
The signs/symptoms (SS)
SS1	Yes	182(40.2%)	88(19.4)	183(40.4)	182(40.2%)	271(59.8%)
SS2	Yes	208(45.9%)	67(14.8)	178(39.3)	208(45.9%)	245(54.1%)
SS3	Yes	242(53.4%)	54(11.9%)	157(34.7%)	242(53.4%)	211(46.6%)
SS4	Yes	264(58.3%)	50(11.0%)	139(30.7%)	264(58.3%)	189(41.7%)
SS5	Yes	271(59.8%)	57(12.6%)	125(27.6)	271(59.8%)	182(40.2%)
SS6	Yes	187(41.3%)	74(16.3%)	192(42.4%)	187(41.3%)	266(58.7%)
SS7	Yes	246(54.3%)	71(15.7%)	136(30.0%)	246(54.3%)	207(45.7%)
The preventative measures (PM)
PM1	Yes	276(60.9%)	52(11.5%)	125(27.6%)	276(60.9%)	177(39.1%)
PM2	Yes	290(64.0%)	45(9.9%)	118(26.0%)	290(64.0%)	163(36.0%)
PM3	Yes	232(51.2)	68(15.0%)	153(33.8%)	232(51.2)	221(48.8%)
PM4	Yes	285(62.9)	43(9.5%)	125(27.6%)	285(62.9)	168(37.1%)
PM5	Yes	299(66.0%)	37(8.2)	117(25.8)	299(66.0%)	154(34.0%)
PM6	Yes	306(67.5%)	39(8.6%)	108(23.8%)	306(67.5%)	147(32.5%)
PM7	Yes	312(68.9%)	43(9.5%)	98(21.6%)	312(68.9%)	141(31.1%)
The treatment modalities (TM)
TM1	Yes	188(41.5%)	61(13.5%)	204(45.0%)	188(41.5%)	265(58.5%)
TM2	Yes	297(65.6%)	42(9.3%)	114(25.2%)	297(65.6%)	156(34.4%)
TM3	Yes	115(25.4%)	87(19.2%)	251(55.4%)	115(25.4%)	338(74.6%)
TM4	No	153(33.8%)	62(13.7%)	238(52.5%)	62(13.7%)	391(86.3%)
TM5	Yes	173(38.2%)	64(14.1%)	216(47.7%)	173(38.2%)	280(61.8%)

The overall dimensions of the MPXV's knowledge had means tend to be moderate, except the dimension mean of the treatment modalities tends to be low (1.84 ± 1.40). The mean score of the 27 questions (from 0 to 27 marks) was moderate (13.93 ± 7.73) (Table 3 ). Of the entire participants, only 82 (18.1% with mean [23.67 ± 1.17]) had good knowledge about MPXV, 126 (27.8% with mean [19.10 ± 1.38]) had moderate knowledge, and more than half of hotel employees (N = 245; 54.1% with mean [8.01 ± 5.32] had poor knowledge (Table 4 ).

Table 3.

Human monkeypox virus dimensions’ scores, means and standard deviation.

Dimensions mean score	The total score	Means	Std. deviation
knowledge of the source, definition, and incubation time	5	2.41	1.62
The mechanism of transmission of human monkeypox	3	1.73	1.22
The signs/symptoms	7	3.53	2.40
The preventative measures	7	4.42	2.71
The treatment modalities	5	1.84	1.40
All dimensions' items	27	13.93	7.73

Table 4.

Knowledge levels of human monkeypox virus.

	Frequency	Percentage	Means	Std. deviation	95% CI of means
High	82	18.1%	23.67	1.17	23.41	23.93
Moderate	126	27.8%	19.10	1.38	18.86	19.35
Low	245	54.1%	8.01	5.32	7.34	8.68

Note: High = 80–100% of the correct answers, Moderate = 60–79%, Low = 0–59%.

Table 5 indicates sources of employees’ information about MPXV. The majority (77.5%) of participants selected social media as the primary information source, followed by TV and radio (48.6%), healthcare providers (47.2%), and family or friends (46.8%). In contrast, books and scholarly articles provided the least amount of information (36.4% and 31.1%, respectively). Notably, most participants (87.0%) reported that their hotels neglected to equip them with information about MPXV.

Table 5.

Sources of employees’ information about human monkeypox virus.

Sources of information	No. of selection	Percentage
Social media	351	77.5%
TV and radio	220	48.6%
Healthcare providers	214	47.2%
Family or friends	212	46.8%
Books	165	36.4%
Research articles	141	31.1%
Receiving information of MPXV from hotels
Yes	59	13.0%
No	394	87.0%

To investigate MPXV's knowledge level among hotel employees and its reasons, we measured the effects of participants' demographics and hotel characteristics on their knowledge level differences (Table 1). The results revealed no significant (p > 0.05) differences between male and female employees, as well as the participants' type of contract, hotel departments, hotel type, and hotel rooms did not affect the MPXV's knowledge level.

In contrast, hotel employees' age, marital status, level of education, professional category, and seniority had significant (p < 0.05) impacts on their knowledge level about MPXV. Regarding the participants’ age, our finding revealed that the knowledge level of the age-group over 45 years had significantly (p < 0.01) the highest knowledge level (mean = 17.98 ± 6.21), while there were no significant (p > 0.05) differences among other younger age-groups.

In terms of marital status, the findings confirmed that single employees had significantly (p < 0.05) the poorest knowledge level (mean = 12.07 ± 7.66). Nevertheless, there were no significant differences (p > 0.05) between the married participants (mean = 14.62 ± 7.50) and divorced or widowed (mean = 14.90 ± 8.31). In addition, it has been found that the three educational levels are significantly different from each other. The participants with MSc or Ph.D. had the greatest knowledge level about MPXV (mean = 18.63 ± 6.85), with significant differences followed by those with a university degree (mean = 13.72 ± 7.52). Employees who had a secondary school degree had significantly the lowest knowledge level (mean = 11.58 ± 7.80).

The knowledge level of MPXV was significantly influenced by the professional category of participants and their seniority in the hotel. The findings found that hotels’ managers, supervisors, and entry-level staff differed significantly (p < 0.01) in terms of their knowledge of MPXV. Hotel managers demonstrated the highest knowledge level (mean = 17.46 ± 6.55) with significant differences (p < 0.01), followed by supervisors (mean = 13.67 ± 7.42), while entry-level staff had the lowest (p < 0.01) knowledge level (mean = 11.39 ± 7.96). Finally, the findings associated with seniority in the hotel highlighted that participants with less than one year of work tenure had significantly the poorest knowledge level of MPXV (mean = 11.54 ± 8.29). However, there were no significant (p > 0.05) differences among hotel participants who spent one year and above in the hotel, as their knowledge level of MPXV was higher.

4. Discussion and conclusion

Our findings demonstrate that more than half of employees (54.1%) have limited knowledge about MPXV, which may be because the number of MPXV infection cases in Egypt is not high as declared by the Presidency of the Egyptian Council of Ministers [34]. This result is in line with other scholars who demonstrated that there is low MPXV knowledge among people, such as the general population in Saudi Arabia [30] and university students in the United Arab Emirates [26].

As reported by the vast majority of participants (87.0%), the majority of hotels have neglected to provide hotel employees with MPXV-related information. This is another possible explanation for the lack of MPXV knowledge among hotel staff. This result may be attributable to the fact that hospitality and tourism organizations in developed nations are more likely to have a proactive attitude than those in developing nations (such as Egypt), where a reactive attitude prevails [49].

Nowadays, in the era of the new MPXV with COVID-19 [2,37], most hotels may still be making strenuous efforts to recover from the destructive impact of the COVID-19 pandemic [50], so they are not ready to take additional actions or proactive strategies, such as providing their employees with awareness and knowledge training related to the new outbreak of MPXV. Hotels that do not provide their employees with MPXV's information may believe that MPXV is an unpredictable threat, so they do not plan and prepare to face it [51] by such actions as improving their employees' knowledge. However, prior researchers asserted that MPXV would emerge as a pandemic comparable to COVID-19 [37].

It was observed that hotel employees lacked sufficient knowledge of MPXV's source, symptoms, transmission, prevention, and treatment. Therefore, the Egyptian government should encourage and assist hotels in providing their employees with training on the origin, symptoms, transmission, prevention, and treatment of MPXV. This finding aligns with Salem et al. [36], who revealed that supporting hotels during pandemics such as COVID-19 with grants, subsidies, fiscal assistance, medical information and guidance, and protection methods is necessary for hotels to support their employees (e.g., providing training programs).

Social media is the central and first source of information about MPXV for 77.5% of hotel employees, which may be a contributing factor to their low MPXV knowledge. In general and concerning health issues, social media platforms could expose users to misinformation [[52], [53], [54]]. Therefore, government authorities should inform hotels on a regular basis about trustworthy social media sources for health information. Then, hotels could instruct their staff to enhance their knowledge of MPXV.

The present findings highlighted that the main sources of hotel employees' knowledge in Egypt about MPXV's source, signs/symptoms, transmission, prevention, and treatment are social media (77.5%), followed by TV and radio (48.6%), healthcare providers (47.2%), and family or friends (46.8%). Social media is the dominant source of hotel employees' information about MPXV because the dominant age category in Egyptian hotels is young people, as our study shows. Young people rely heavily on the internet and social media for information and news [55]. A part of our results is consistent with Jairoun et al. [26], who concluded that the major sources of university student's knowledge in the United Arab Emirates about MPXV are social media and TV. Our findings indicate that social media, TV, and radio should be one of the priorities of the Egyptian government while launching awareness campaigns about MPXV.

Additionally, hotels should publish MPXV-related information for their employees on their social media platforms (e.g., Facebook, Instagram, and Twitter) to increase employee knowledge, thereby preventing MPXV transmission. People use social media extensively to share information and as a source of news and information in both normal and pandemic situations [24,53].

It was found that family or friends (46.8%) are one of the most important sources of hotel employees' knowledge about MPXV's source, signs/symptoms, transmission, prevention, and treatment. This finding suggests the importance of enhancing social activities in hotels to foster good relationships among employees, who would then discuss and share information regarding MPXV. Elkhwesky et al. [45] suggested that organizing social activities in hotels, such as tennis tables, football, and billiards tournaments, is critical to human resources management. Our finding also indicates that hotels should provide employees with flexible working hours and allow them to contact their colleagues, friends, or families through social media [56]. This result could help acquire and transfer knowledge related to MPXV.

Concerning the control variables, it has been found that hotel employees’ knowledge of MPXV was unaffected by variances in gender, type of contract, hotel department, type of hotel, and the number of hotel rooms. Compared to employees of younger ages, employees older than 45 demonstrated a higher level of MPXV knowledge. This result can be explained by the fact that older people are afraid of diseases and pandemics [57] because they are more vulnerable [58], so they try on a regular basis to have health information and knowledge [59]. In addition, older hotel employees have past experience with COVID-19 [60] and how this pandemic affected them negatively, so they strive to maintain a good knowledge about pandemics.

It was also revealed that hotel employees who were married, divorced, or widowed had a high knowledge of MPXV than single employees. Marriage could explain this finding because spouses can build relationships and share knowledge [61]. The findings indicated that hotel employees with MSc or Ph.D. had a higher knowledge about MPXV than other educational levels. It was also found that hotel managers had high knowledge about MPXV than supervisors and entry-level staff. A significant relationship was also revealed between seniority in the hotel and employees’ knowledge of MPXV. Hotel employees who spent more than one year in the hotel had high knowledge about MPXV. These findings align with previous scholars who stated that employees with a high educational level, position, and work experience, could have high knowledge and innovative behaviors [62,63].

4.1. Theoretical contribution

The current paper, using Egypt as the research context, contributes to hotel management literature by highlighting (1) hotel employees' knowledge about MPXV's source, signs/symptoms, transmission, prevention, and treatment, (2) the main sources of their information about MPXV, (3) whether or not they received information about MPXV from their hotels, and (4) the differences of hotel employees' knowledge in terms of gender, age, marital status, level of education, type of contract, professional category, hotel department, type of hotel, seniority in the hotel, and the number of hotel rooms.

This study serves as a guideline for governmental authorities and hotels of other nations in similar contexts on measures or practices that can be adopted to prevent MPXV and other health crises that may arise in the future, in addition to providing how they could implement comprehensive training related to MPXV. Our research provides source information on MPXV-related news articles and procedures that should be implemented to prevent its spread. This study identified official pages and websites that provide an abundance of MPXV-related information that other nations can use to learn more about the virus. According to our knowledge, this is the first study conducted with hotel employees in the context of MPXV Egypt.

4.2. Managerial implications

The Egyptian authorities should regularly inform society, including hotels, about MPXV infection cases and how they could prevent its transmission through their official pages on Facebook (e.g., https://www.facebook.com/EgyptianCabinet; https://www.facebook.com/tourismandantiq; https://www.facebook.com/egypt.mohp). It is also recommended the government and hotels increase hotel employees' knowledge about MPXV by using awareness campaigns, and other approaches, including print, electronic, and social media [64]. TV channels are also crucial in enhancing knowledge about MPXV [26]. Hotels could publish MPXV's information for their employees on their social media platforms (e.g., Facebook, Instagram, and Twitter) and official websites to enhance employees' knowledge.

Governmental authorities could provide hotels with guidelines and training programs about MPXV. The ministry of health and the ministry of tourism could collaborate to perform this task. Also, hotels could present proactive training sessions for their employees to enhance their knowledge of MPXV. It is critical for governmental authorities and hotels to follow and visit in a regular basis the official pages or websites of WHO (e.g., https://www.facebook.com/WHO; https://www.who.int/emergencies/situations/monkeypox-oubreak-2022) and the Centers for Disease Control and Prevention (CDC) (e.g., https://www.facebook.com/CDCGlobal; https://www.cdc.gov/poxvirus/monkeypox/index.html) to update and develop the content of training programs and awareness campaigns about MPXV's source, signs/symptoms, transmission, prevention, and treatment.

The content of training that could be presented to hotel employees about MPXV is as follows. First, training should focus on providing information about the source, definition, and incubation time of MPXV. MPXV is a viral disease infection that primarily occurs in tropical rainforest areas of Africa and is occasionally exported to other regions [65,66]. In addition, 61,753 confirmed MPXV cases and 23 deaths were reported to WHO from 105 countries/territories/areas from January 1 to September 18, 2022, in all six WHO regions [11]. MPXV belongs to the genus of orthopoxvirus [10]. MPXV and smallpox have similar signs and symptoms. MPXV is typically a short‐term disease with symptoms lasting 2–4 weeks. The interval from infection to the onset of symptoms is usually from 6 to 13 days but can range from 5 to 21 days [6,67]. Additionally, MPXV could occur in both humans and non-human primates [66]. Many complications are associated with MPXV, such as encephalitis, vision loss, and pneumonia [13].

Second, the transmission mechanism of MPXV must be included in the training provided to hotel employees. The hotel staff should be aware that MPXV is easily transmitted from animals to humans through direct contact with an infected animal's blood, bodily fluid, cutaneous or mucosal lesions, or by consuming meat from an infected animal that has not been adequately cooked. It can also be transmitted to humans through animal bites and scratches. This virus is easily transmitted from person to person through direct contact with respiratory secretions, skin lesions, or contaminated objects (such as clothing) [10,26,30,68]. Significantly, sexual and non-sexual contact with an infected person can transmit MPXV [[69], [70], [71]].

Third, it is essential to include the signs/symptoms of MPXV in training presented to hotel employees. Examples of signs and symptoms of this virus are skin lesions, cervical lymphadenopathy, fever, fatigue, anal pain, and perianal, genitals, mouth, and trunk lesions [12]. Additionally, papules, vesicles, and pustules on the skin are some signs/symptoms of MPXV [26,30]. According to Saxena et al. [6], the distinct symptoms of MPXV at the beginning of infection (0–5 days) are fever, intense headache, back pain, muscle aches, lymphadenopathy, and intense asthenia. In addition, the skin eruption appears within 1–3 days after the fever. This disease also harmfully affects the cheeks, palms of the hands, soles of the feet, genital organs, oral mucosa, conjunctivae, and cornea.

Fourth, a critical part of training is to teach hotel employees about preventative measures against MPXV. These measures include washing hands with soap and water or alcohol, avoiding dealing with wild animals (alive or dead), avoiding handling or touching the bedding, towels, or clothing of people with MPXV, reducing sharing eating utensils or cups, proper cooking of meat, avoiding contact with objects that have been in contact with sick animals or people, avoiding dealing with people with a rash, and notifying national health authorities during the onset of symptoms of MPXV [26,30,72]. Additionally, it is crucial to educate employees that reducing rodent-human interaction is an effective MPXV prevention strategy [10]. In addition, hotel employees should understand that avoiding kisses, hugs, cuddles, and sexual contact with MPXV-infected individuals is crucial for preventing virus transmission [72].

Fifth, providing information for hotel employees about the treatment modalities could be a part of training on MPXV. Employees should be trained that MPXV is not treated with the available antiviral medications and that there is no treatment for this virus until now [26,30]. However, symptoms of this disease could be treated with supportive care and using paracetamol, tramadol, and fusidic acid cream as a topical antibiotic on the lesions skin [12]. Patients with gastrointestinal symptoms (e.g., diarrhea and vomiting) require rehydration treatment due to fluid losses in the gastrointestinal system [68].

Hotel employees could receive MPXV training in three ways: virtual reality (VR) game training [73], live demonstration, and traditional video training. Virtual reality (VR) game training and traditional video training allow trainees to share virtually without presenting on-site. Traditional video training is also appropriate for small hotels with a limited budget for training. It is advised not to use VR game training at all times in order to avoid poor knowledge retention due to the increased arousal induced by this training. However, training sessions for employees should be entertaining and engaging [74]. Icebreakers, group discussions, role play, learning games, and question-and-answer sessions can be incorporated into the training method of live demonstration. Embedded quiz questions and the adoption of animated pedagogical agents are features that could be incorporated into traditional recorded video training to be interactive [75].

Providing grants, subsidies, fiscal assistance, medical information and guidance, and protection methods [36] could be beneficial for the Egyptian government for hotels to recover from the COVID-19 pandemic and to provide training programs on MPXV for their employees to enhance their knowledge and awareness. The Egyptian government could prevent MPXV transmission by setting restrictions, given that Europe and the United States have numerous infected cases due to travel, tourism, and international trade. The government must establish an extensive disease surveillance system to detect, diagnose, quarantine, and manage MPXV cases [76].

Hotels could prevent MPXV transmission by washing clothes and linens at 60 °C and disinfecting contaminated surfaces with 0.1% sodium hypochlorite (dilution 1:50). Additionally, it is essential to limit the dissemination of dust and aerosols during routine cleaning [77]. Hotels need to consider that festivals, events, and concerts are an active environment for MPXV outbreaks because of skin-to-skin or face-to-face contact [78] among clients or employees. Therefore, awareness posters must be spread in all hotel areas, alarming clients and employees. In particular, posters on evidence-based infection control are essential [79].

If the hotel discovers a case of MPXV among its guests or employees, it is crucial to quarantine the infected individual until the rash scabs fall off. Infected individuals must also use their own clothing, bedding, towels, eating utensils, plates, and glasses. In addition, daily monitoring with medical face masks must be implemented, and rashes must be covered. The infected individual must avoid direct contact with others until the rash has completely healed. Any person in close contact with a confirmed case of MPXV must be isolated for 21 days until the infection is ruled out or confirmed [80].

5. Limitations and future research

Given that our research was performed in Egyptian hotels and using a non-probability sampling approach, generalizability cannot be ascertained. Therefore, we recommend that future scholars assess hotel employees' knowledge about MPXV's source, symptoms, transmission, prevention, and treatment in different contexts in the MENA area and worldwide. Our study is limited to hotel employees in Egypt. Therefore, it is recommended that future research investigate employees' knowledge of MPXV in the Egyptian tourism industry as a whole. Despite these limitations, the current study is the first to examine hotel employees in the MPXV Egyptian context.

Funding

“The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.”

Data availability

“The data that support the findings of this study are available from the corresponding author upon reasonable request. ”

Ethical considerations

“Before collecting data, the questionnaire began with a brief introduction outlining the purpose of the study and ensuring confidentiality. In addition, the participants were not asked to record their identities. All respondents signed the informed consent, confirming that they are hotel employees or managers, and they voluntarily agreed to be a part of the current research.”

CRediT authorship contribution statement

Zakaria Elkhwesky: Conceptualization, Methodology, Formal analysis, Data curation, Validation, Supervision, Project administration, Resources, Writing - original draft, Writing - review & editing. Neama Derhab: Conceptualization, Methodology, Visualization, Resources, Supervision, Writing - original draft, Writing - review & editing. Fady Fayez Youssif Elkhwesky: Conceptualization, Resources, Methodology, Writing - review & editing. Abuelhassan Elshazly Abuelhassan: Software, Formal analysis, Data curation, Writing – review & editing. Hamada Hassan: Investigation, Methodology, Writing - review & editing.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper (Hotel employees' knowledge of monkeypox's source, symptoms, transmission, prevention, and treatment in Egypt).

Appendix A. Supplementary data

The following is the Supplementary data to this article: