Abstract
Background
The outbreak of monkeypox in several nonendemic countries has been reported since May 2022. In the context of the COVID-19 pandemic, it is important to examine how healthcare workers (HCWs) respond to the monkeypox epidemic. Having been involved in the fight against COVID-19 resurgence for nearly 3 years, how HCWs in China respond to the oversea monkeypox outbreak remains unclear.
Objective
To investigate the awareness, perceived risk, attitude and knowledge about monkeypox among HCWs in China.
Design
A cross-sectional survey.
Participants
Physicians and nurses from 13 hospitals in Suizhou, China, were contacted through membership of the Physicians’ and Nurses’ Association.
Main Measures
Responses regarding their awareness, risk perception, attitude, behavior, and knowledge about the outbreak of monkeypox were collected anonymously during the second month of the outbreak between 15 and 21 June 2022.
Key Results
Of the 395 physician and 1793 nurse respondents, most had heard of the oversea monkeypox outbreak (physicians 93%, nurses 88%). More than 30% thought there existed an infection risk for themselves or family members (physicians 42%, nurses 32%). Most agreed that HCWs should pay attention to the outbreak (physicians 98%, nurses 98%). More than half had actively sought expertise (physicians 62%, nurses 52%). Approximately half believed that monkeypox may be transmitted through sexual activity or respiratory droplets, or from mother to fetus in utero (physicians 50%, 62%, 55%; nurses 40%, 60%, and 48%, respectively). Some believed that mask-wearing, hand-washing, and glove-wearing can prevent monkeypox transmission (physicians 78%, 89%, 83%; nurses 77%, 86%, 76%, respectively).
Conclusions
This study identified high awareness, high perceived risk, and pro-prevention attitudes among HCWs in China at the onset of the oversea multi-country monkeypox outbreak, but low levels of monkeypox-related knowledge. Immediate efforts are needed to fill in their knowledge gap, particularly regarding the transmission routes and prevention measures.
KEY WORDS: monkeypox, awareness, risk perception, healthcare workers, knowledge
INTRODUCTION
In May 2022, the transmission of monkeypox virus was reported in many non-endemic countries. As of 15 June 2022, a cumulative total of 2103 laboratory-confirmed cases have been reported to the World Health Organization (WHO) from 42 countries across all five WHO regions, with 98% being identified since May[1].
For decades, monkeypox has been considered endemic to Central and West African countries despite several documented travel-associated outbreaks in non-African countries in the past decade (i.e., USA and Israel in 2003 and 2021, UK in 2018, Singapore in 2019)[2, 3]. It is the first time in human history that the monkeypox outbreaks grow on a global scale. Given the abnormally large scale and the high speed of spreading in nonendemic countries, alerts have been issued by the WHO since May 11[4].
Healthcare workers (HCWs) are on the frontline combating monkeypox and need to get prepared. However, in the context of the ongoing COVID-19 pandemic, it is difficult to predict how HCWs react to another emerging epidemic of monkeypox. On one hand, they are under extraordinary strain from COVID-19 and need psychological support[5–10]. On the other hand, the recent lessons learned from COVID-19 may keep them vigilant of pathogen infections[11]. Understanding how the HCWs respond to this monkeypox outbreak is essential for prioritizing health policy decisions and developing public health strategies. Empirical research is lacking in this regard. We thus performed a time-sensitive study among HCWs in China, who have been in the long fight against COVID-19 resurgence for nearly 3 years, to investigate their awareness, perception, attitude, related behavior, and knowledge at the onset of the monkeypox outbreak.
METHODS
Enrollment
A sample of physicians and nurses from 13 hospitals in Suizhou, China, was contacted through membership of the Physicians’ Association and Nurses’ Association. After being informed of the study purpose, they filled out the online questionnaire and recommended the survey to colleagues working in the same department/division. To improve the response rate, efforts were made to solicit HCWs by staff interviewers in the same hospital. Inclusion criteria were full-time employees in any hospital/medical center in Suizhou. Exclusion criteria were lack of a smartphone that would preclude the ability to complete the online questionnaire, or completing the online survey ≤ 60 s (n = 11). All survey data were collected anonymously. Respondents consented to participate the study by voluntarily answering the survey questions. The institutional review board at Jinzhou Medical University approved the survey (approval number JZMULL2022112). Data were collected from 15 through 21 June 2022, during which a global total of 1310 incident cases and one death being reported to WHO, of which none were from China[12].
Instrument Development and Measures
A multidisciplinary group developed an original questionnaire after literature review. All survey responses were captured using a Likert scale of strongly agree, agree, disagree, strongly disagree, and not sure, unless otherwise specified for a few other items. Using an iterative design process, cognitive pretesting with 4 physicians, 4 nurses, 4 undergraduate students majoring in clinical medicine, and 4 undergraduate students majoring in nursing was performed and revisions were made to the corresponding questionnaire items accordingly.
Demographic characteristics were collected using fixed categories, including gender (male, female), age (< 35, 35–50, ≥ 50 years), job title (senior title, middle title, primary title), education (graduate degree, bachelor degree, junior college, and below), years of working (< 5, 5–10, 10–15, ≥ 15 years), hospital grade (tertiary grade A, tertiary grade B, secondary grade A, secondary grade B, primary), and region (municipal, county).
Awareness of monkeypox was assessed using 2 items that asked whether participants had ever heard of the current multi-country monkeypox outbreak, or whether they had heard of monkeypox before the current multi-country outbreak (yes/no).
Perceived risk for monkeypox was evaluated using 3 items that asked whether they thought monkeypox will someday be transmitted into China, whether there was a risk of infection for themselves or their family members, or whether there would be a pandemic of monkeypox. To understand the impact of COVID-19 on their perceived risk of monkeypox transmission, participants were asked whether COVID-19 promote global transmission of monkeypox (promote, inhibit, or not related).
Attitude of HCWs was assessed using 4 items that asked whether they thought HCWs should pay attention to the monkeypox epidemic, whether immediate action was needed to develop monkeypox vaccines and therapy, and whether their relatives/friends should be isolated if exposed to monkeypox.
Behaviors were assessed with 2 items asking whether participants had actively sought knowledge regarding monkeypox by themselves, and whether they expect the hospital organize seminar/lectures regarding monkeypox.
Knowledge was assessed with 7 items asking the participants to select appropriate length for incubation period (1–3, 5–21, or ≥ 60 days); whether monkeypox can be transmitted through sexual activity, through respiratory droplets, or directly from mother to fetus; and whether hand-washing, mask-wearing, and glove-wearing can prevent monkeypox transmission.
Statistical Analysis
Descriptive statistics, counts, and percentages were generated for each item. For simplicity of presentation, agree and strongly agree, disagree and strongly disagree, were grouped together. The difference in the response pertaining to perceived risk of infection for themselves and family members, which was dichotomized as strongly agree or agree versus others, according to binary characteristics including gender and region through Pearson chi-square test and trend across ordered characteristics including education, job title, and years of working was examined through Wilcoxon-type rank sum test[13]. All tests were two-sided. P values < 0.05 were considered statistical significance. All analyses were performed using the SAS software, version 9.4 (SAS Institute, Cary, NC).
RESULTS
A total of 395 physicians and 1793 nurses were included for analyses. Female gender accounted for about half (54%) among physician respondents and majority in nurse respondents (98%). Most physicians were from department of Internal Medicine (n = 136, 34.4%), Surgery (n = 72, 18.2%), Outpatient (n = 48, 12.2%), and Emergency Medicine (n = 43, 10.9%). Most physician and nurse respondents were < 35 years of age, were of primary title, were from tertiary hospitals, were living in municipal city, and had bachelor degree (Table 1).
Table 1.
Respondent demographics
| Characteristic | Category | Physician (n = 395) | Nurse (n = 1793) |
|---|---|---|---|
| Gender | Female | 215 (54.4) | 1764 (98.4) |
| Male | 180 (45.6) | 29 (1.6) | |
| Age, years | < 35 | 209 (52.9) | 1255 (70.0) |
| 35–50 | 146 (37.0) | 381 (21.3) | |
| ≥ 50 | 40 (10.1) | 157 (8.8) | |
| Title | Senior | 66 (16.7) | 123 (6.9) |
| Middle | 155 (39.2) | 693 (38.7) | |
| Primary | 174 (44.1) | 977 (54.5) | |
| Education | Graduate degree | 102 (25.8) | 9 (0.5) |
| Bachelor degree | 247 (62.5) | 1267 (70.7) | |
| Junior college and below | 46 (11.7) | 517 (28.8) | |
| Years working | < 5 | 111 (28.1) | 457 (25.5) |
| 5–10 | 100 (25.3) | 588 (32.8) | |
| 10–15 | 74 (18.7) | 367 (20.5) | |
| ≥ 15 | 110 (27.9) | 381 (21.3) | |
| Hospital grade | Tertiary, grade A | 267 (67.6) | 825 (46.0) |
| Tertiary, grade B | 11 (2.8) | 137 (7.6) | |
| Secondary, grade A | 91 (23.0) | 749 (41.8) | |
| Secondary, grade B | 21 (5.3) | 77 (4.3) | |
| Primary | 5 (1.3) | 5 (0.3) | |
| Region | Municipal city | 324 (82.0) | 1193 (66.5) |
| County | 71 (18.0) | 600 (33.5) |
Awareness
Most respondents had heard of the outbreak of monkeypox (physicians 93%, nurses 88%, Table 2). In contrast, less than one-third had heard of monkeypox before the current multi-country outbreak (physicians 31%, nurses 27%).
Table 2.
Awareness, perceived risk, attitude, and behaviors regarding monkeypox outbreak
| Survey question and response | Physician(n = 395) | Nurse (n = 1793) |
|---|---|---|
| Awareness | ||
| Have you ever heard of the current multi-country monkeypox outbreak? | ||
| Yes | 368 (93.2) | 1583 (88.3) |
| No | 27 (6.8) | 210 (11.7) |
| Have you ever heard of monkeypox before the current outbreak? | ||
| Yes | 121 (30.6) | 492 (27.4) |
| No | 274 (69.4) | 1301 (72.6) |
| Perceived risk | ||
| Do you think monkeypox will someday be transmitted into China? | ||
| Yes | 284 (71.9) | 1052 (58.7) |
| Not sure | 82 (20.8) | 532 (29.7) |
| No | 29 (7.3) | 209 (11.7) |
| Is there a risk of infection for you or your family members? | ||
| Yes | 167(42.3) | 567(31.6) |
| Not sure | 108(27.3) | 591(33.0) |
| No | 120(30.4) | 635(35.4) |
| Do you think there will be a pandemic of monkeypox? | ||
| Yes | 91 (23.0) | 502 (28.0) |
| Not sure | 155 (39.2) | 651 (36.3) |
| No | 149 (37.7) | 640 (35.7) |
| Do you think COVID-19 promote monkeypox global transmission? | ||
| Promote | 122 (30.9) | 582 (32.5) |
| Inhibit | 63 (16.0) | 278 (15.5) |
| Not related | 210 (53.2) | 933 (52.0) |
| Attitude | ||
| Do you think HCW should pay attention to the monkeypox epidemic? | ||
| Yes | 387 (98.0) | 1760 (98.2) |
| Not sure | 7 (1.8) | 22 (1.2) |
| No | 1 (0.3) | 11 (0.6) |
| Do you think immediate action needed to develop monkeypox vaccines? | ||
| Yes | 355 (89.9) | 1679 (93.6) |
| Not sure | 25 (6.3) | 67 (3.7) |
| No | 15 (3.8) | 47 (2.6) |
| Do you think immediate action needed to develop monkeypox therapies? | ||
| Yes | 346 (87.6) | 1678 (93.6) |
| Not sure | 31 (7.9) | 68 (3.8) |
| No | 18 (4.6) | 47 (2.6) |
| If your relatives/friends exposed to monkeypox, should they be isolated? | ||
| Yes | 360 (91.1) | 1663 (92.8) |
| Not sure | 28 (7.1) | 115 (6.4) |
| No | 7 (1.8) | 15 (0.8) |
| Behaviors | ||
| Have you sought actively knowledge regarding monkeypox? | ||
| Yes | 243 (61.5) | 927 (51.7) |
| No | 152 (38.5) | 866 (48.3) |
| Do you expect the hospital organize seminar/lecture on monkeypox? | ||
| Yes | 353 (89.4) | 1630 (90.9) |
| Not sure | 33 (8.4) | 116 (6.5) |
| No | 9 (2.3) | 47 (2.6) |
Perceived Risk
More than half thought monkeypox will someday be transmitted into China (physicians 72%, nurses 59%, Table 2). More than 30% thought there was a risk of infection for themselves or family members (physicians 42%, nurses 32%). About a fourth thought there may be a pandemic of monkeypox (physicians 23%, nurses 28%). About a third thought COVID-19 pandemic promoted the global transmission of monkeypox (physicians 31%, nurses 33%).
Differences in the perceived risk of infection by monkeypox virus for themselves or family members are depicted in Fig. 1. For physician respondents, it was non-significantly higher in female than male (47% vs. 37%, P = 0.06, Fig. 1A), younger age group (44%, 42%, and 35% for < 35, 35–50, and ≥ 50 years, P for trend = 0.40), higher education (43%, 44%, 28% for graduate, undergraduate, and junior college and below, P for trend = 0.21). There were no substantial differences according to title, years of working or region (Fig. 1A). For the nurse respondents, it was higher in longer years of working (36%, 30% for ≥ 15 and < 15 years, P = 0.04), municipal city than county (33% vs. 28%, P = 0.03), higher title (35%, 34%, 30% for senior, middle, and primary title, P for trend = 0.06), and higher education (44%, 33%, 29% for graduate, undergraduate, and junior college and below, P for trend = 0.08); in terms of age, it was higher in the middle age group (30%, 36%, 32% for < 35, 35–50 and ≥ 50 years, P = 0.11, Fig. 1B).
Figure 1.
The percent of perceived a risk of infection for themselves or family members according to sex, age, job title, education, years of working, and region among A physicians and B nurses. * Statistical significance for trend analysis at P value of 0.05
Attitude
Majority of respondents thought that HCWs should pay attention to the monkeypox outbreak (physicians 98%, nurses 98%, Table 2), and immediate actions were needed to develop vaccines (physicians 90%, nurses 94%) and to develop therapies (physicians 88%, nurses 94%). Majority of respondents agreed that their relatives/friends should be isolated if exposed to monkeypox (physicians 91%, nurses 93%).
Behaviors
More than half had actively sought relevant knowledge regarding monkeypox by themselves (physicians 62%, nurses 52%, Table 2). Most respondents expected the hospital organize seminar/lectures regarding monkeypox (physicians 89%, nurses 91%).
Knowledge
Most respondents selected the correct time interval for monkeypox incubation period (physicians 80%, nurses 84%, Table 3). About half knew that monkeypox can be transmitted through sexual activity (physicians 50%, nurses 40%), respiratory droplets (physicians 62%, nurses 60%), or directly from mother to fetus (physicians 55%, nurses 48%).
Table 3.
Knowledge about the incubation, transmission and prevention for monkeypox
| Survey question and response | Physician (n = 395) | Nurse (n = 1793) |
|---|---|---|
| Incubation length | ||
| The incubation period is | ||
| 1–3 days | 65 (16.5) | 225 (12.6) |
| 5–21 days | 317 (80.3) | 1507 (84.1) |
| ≥ 60 days | 13 (3.3) | 61 (3.4) |
| Transmission routes | ||
| Can monkeypox be transmitted through sexual activity? | ||
| Yes | 199 (50.4) | 726 (40.5) |
| Not clear | 146 (37.0) | 809 (45.1) |
| No | 50 (12.7) | 258 (14.4) |
| Will monkeypox be transmitted through respiratory droplets? | ||
| Yes | 243 (61.5) | 1071 (59.7) |
| Not clear | 106 (26.8) | 604 (33.7) |
| No | 46 (11.7) | 118 (6.6) |
| Will monkeypox be transmitted from mother to fetus in utero? | ||
| Yes | 218 (55.2) | 863 (48.1) |
| Not clear | 131 (33.2) | 748 (41.7) |
| No | 46 (11.7) | 182 (10.2) |
| Prevention measures | ||
| Is hand-washing one of the ways to prevent monkeypox transmission? | ||
| Yes | 350 (88.6) | 1535 (85.6) |
| Not clear | 37 (9.4) | 215 (12.0) |
| No | 8 (2.0) | 43 (2.4) |
| Is mask-wearing one of the ways to prevent monkeypox transmission? | ||
| Yes | 306 (77.5) | 1386 (77.3) |
| Not clear | 70 (17.7) | 334 (18.6) |
| No | 19 (4.8) | 73 (4.1) |
| Is glove-wearing one of the ways to prevent monkeypox transmission? | ||
| Yes | 327 (82.8) | 1355 (75.6) |
| Not clear | 56 (14.2) | 355 (19.8) |
| No | 12 (3.0) | 83 (4.6) |
Regarding methods of prevention, three-fourths knew that mask-wearing can prevent monkeypox transmission (physicians 78%, nurses 77%). Less than 90% knew that hand-washing (physicians 89%, nurses 86%) and glove-wearing (physicians 83%, nurses 76%) can prevent monkeypox transmission.
DISCUSSION
In this survey, we found high awareness, high perceived risk, and pro-prevention attitudes among the HCWs in China at the onset of the multi-country monkeypox outbreak, but knowledge regarding transmission and prevention for monkeypox was lacking among all HCWs. These findings provide a foundation for intervention programs that helps engage HCWs in the control, prevention, and treatment of monkeypox.
This survey showed that HCWs in China had high awareness of the monkeypox outbreak outside China. Furthermore, most respondents displayed pro-prevention attitude, and actively sought relevant expertise by themselves. Of note, this survey was performed from 15 through 21 June, before the convening of an Emergency Committee on June 23[4] and the PHEIC announcement on July 23 by the WHO[14], and there had been no imported monkeypox cases yet in China during the time of this survey. The reasons for the observed high susceptibility of Chinese HCWs to the early phase of oversea monkeypox outbreak are unknown, but may be related to the hypersensitivity to pathogen infections induced by the successive waves of the SARS-CoV-2 infections worldwide[11]. The present study provided empirical evidence that HCWs in China displayed pro-prevention attitude advocating actions to contain the potential epidemic of another infectious disease. It is noteworthy that China has adopted Dynamic COVID-Zero strategy against COVID-19 resurgence since 2021 [15]. With this policy, HCWs have been bearing a high workload and stress for nearly 3 years[16–21]. In view of their devotion to the fight against the ongoing COVID-19 pandemic and none of the monkeypox cases having been imported yet during the period of this survey, the present findings that they exhibited pro-prevention attitude are assuring.
This survey identified that a considerable portion of physician and nurse respondents perceived the threat of monkeypox infection for themselves or family members. The underlying drivers for the risk perception remain unknown, but it may be related to the years of born. It is recognized that smallpox vaccination confers indirect protection against other poxviruses to some degree, including monkeypox[22–26]; smallpox vaccination program was terminated in the 1970s in China. Those HCWs born after the termination of smallpox vaccination program and thus not been vaccinated are more likely to believe they are at risk. Indeed, this survey identified a decreasing trend in the perceived risk with increasing age among physician respondents, although not in nurse respondents who showed highest perceived risk among middle age group. Higher education appears to be another important driving factors for risk perception among both physician and nurse respondents.
This survey identified big gap in the knowledge regarding monkeypox among HCWs in China. Despite high awareness and pro-prevention attitude, a considerable proportion of HCWs did not know the transmission routes (e.g., sexual activity, respiratory droplet, vertical transmission) or the most commonly used methods of prevention for monkeypox (e.g., masking, hand-washing, glove-wearing). Several previous small studies also reported low knowledge in terms of symptoms, diagnosis, and treatment among health professionals[27, 28]. The reasons for the knowledge gap are unknown, but may be due to the fact that China is not an endemic country for monkeypox. As cases of monkeypox are rising in both endemic and nonendemic countries, it is urgent to educate HCWs to reduce their chance of exposures. Furthermore, well-educated HCWs play an important role on disseminating prevention and control methods to the public[29].
LIMITATIONS
This study has several limitations. First, this survey was performed in one city in central China. The respondents of the present survey were not probabilistic sampled and thus not representative of the general population in China. The generalizability of the present findings may be thus limited. Second, it is possible that some respondents may have randomly selected responses to complete the survey in a shorter time. However, it is unlikely to be an importance source of bias because only 11 responses used ≤60 s and were excluded from analyses, and there was no monetary incentive associated with this survey. Third, it is also possible that some of the responses may be obtained after online searching for correct answer. To minimize this source of bias, respondents were informed that this survey would be collected anonymously. Fourth, this survey was rapidly implemented at the onset of the outbreak with close-ended questions, and the depth of analyses of underlying mechanisms for these reactions was limited. Fifth, the survey captured the initial awareness, perceived risk, attitude, and knowledge at the second month of the outbreak, which may have evolved with the outbreak.
CONCLUSIONS
This survey at the onset of the monkeypox outbreak revealed high awareness, high perceived risk, and pro-prevention attitude toward monkeypox outbreak among HCWs in China. Despite these, profound knowledge gap exists, including the transmission route and preventions. Actions are needed to ensure that HCWs are adequately educated, particularly the transmission and prevention of monkeypox, so that they are able to protect themselves and provide correct message to the public as the epidemic of monkeypox sustains.
Author Contribution
Z.-J.Z. concepted study, analyzed data, drafted manuscript; H.-C.Z. collected data, analyzed data, drafted manuscript.
Data Availability
The datasets analyzed for this study are available from the corresponding author upon reasonable request.
Declarations
Conflict of Interest
The authors declare no conflicts of interest.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets analyzed for this study are available from the corresponding author upon reasonable request.