Re-Emerging Viral Infections: An Appraisal of Monkeypox Knowledge and Perception Among Staff of a Tertiary Hospital in Central, Nigeria

Re-Emerging Viral Infections: An Appraisal of Monkeypox Knowledge and Perception Among Staff of a Tertiary Hospital in Central, Nigeria

Akwaras Nndunno Asheku¹, Pitmang Simon L², Gyuse Abraham Ngueikyor³,Daniel Aondona David¹, De-kaa Niongun Lawrence Paul¹, Rimamnunra Grace Nwunuji⁴, Swende Laadi Terrumun¹, Ornguga Bamidele Ohiozoje¹, Nwagbo Ambrose Nnaemeka⁵.

¹Department of Family Medicine, Federal Medical Centre, Makurdi, Benue State, Nigeria

²Department of Family Medicine, Jos University Teaching Hospital, Plateau State, Nigeria.

³Department of Family Medicine, University of Calabar Teaching Hospital, Calabar, Nigeria.

⁴Department of Epidemiology and Community Health, College of Health Sciences, Benue State University Makurdi, Benue State, Nigeria.

⁵Department of Public Health, Ahmadu Bello University, Zaria, Kaduna State, Nigeria.

DOI: https://doi.org/10.51244/IJRSI.2024.1115006P

Received: 08 August 2024; Accepted: 13 August 2024; Published: 15 September 2024

ABSTRACT

Background

Monkeypox is one of the re-emerging viral diseases caused by the monkeypox virus and global outbreaks have occurred recently. The awareness of monkeypox and its prevention is important. The aim was to elucidate the awareness about transmission, prevention, symptoms and perceptions of the participants about monkeypox disease at the Federal Medical Centre, Makurdi, Nigeria.

Methods: The study was a descriptive cross-sectional study of hospital staff. The sample size was 386 at 50% prevalence and a random sampling technique was employed. A self-administered questionnaire was used. All statistical analysis was done using SPSS version 20 and were significant at p< 0.05 and a 95% confidence interval.

Result:  The mean age of the participants was 41.1 ± 13.0 years, females 215(56.6%) and graduates 202(53.2%). Health workers were 177(46.6%), their mean work experience was 12.1 ± 10.1 years. Those who had heard about monkeypox disease were 283(74.5%), and of these 176 were health workers. Participants who thought that monkeypox disease was caused by a virus or a public deception were 175(61.6%) and 8(2.8%) respectively. Those who knew the mode of transmission were 298(78.4%). Those who were aware of the monkeypox vaccine and were willing to take the vaccine if available were 73(19.2%) and 271(71.3%) respectively. Some responses to prevention were avoiding close contact with infected persons (51.3%) and vaccination (36.3%). Few health workers had training on monkeypox (22, 12.4%) and knew salient information such as the incubation period (32,8.4%)

Conclusion: Monkeypox awareness was not satisfactory and few healthcare workers knew salient information about the virus.

Keywords: Knowledge, monkeypox, monkeypox vaccine, perception, re-emerging viral diseases.

INTRODUCTION

Monkeypox is a zoonotic disease caused by the monkeypox virus which is of the orthopoxvirus genus (WHO, 2023a; Alakunle et al., 2020). The first case of monkeypox was recorded in 1970 and since then cases have been reported in several central and western African countries. Following eradication of smallpox in 1980 and the end of smallpox vaccination worldwide, monkeypox steadily emerged in Central, East and West Africa (CDC, 2023). In 2022, there was an outbreak of monkeypox in countries without a prior history of the disease (CDC, 2023). The World Health Organization on July 23, 2022, declared the global outbreak of monkeypox to be a public health emergency of international concern and reiterated same on August 14, 2024 (Dong, 2023; WHO, 2024).

The animal reservoir is unknown, small mammals such as rope and sun squirrels, giant-pouched rats and African dormice are thought to harbour the virus in the environments of West and Central Africa (CDC, 2024). Monkeypox can be transmitted by direct contact with infected monkeypox rash, scab or body fluids (CDC, 2022; CDC, 2023). Other transmission routes are contact with infected materials, such as contaminated sheets, clothes or needles, ccontact with infected respiratory secretions, sexual contact and in-utero ttransmissions (CDC, 2022; Dasraath et al., 2023). In a Nigerian study, some of the known transmission routes were via contact with contaminated surfaces (32.83%), close contact with infected people (42.68%), through sexual intercourse (24.48%) and 24.48% knew that hunting and contact with wildlife could transmit the disease to humans (Awoyomi et al., 2023).⁸

The incubation period of monkeypox is usually from 6 to 13 days but can range from 5 to 21 days (WHO, 2022a). The symptoms of monkeypox include rash, fever, sore throat, headache, muscle aches and swollen lymph nodes. Detection of viral DNA by polymerase chain reaction (PCR) is the preferred laboratory test for monkeypox (WHO, 2023a).

Awareness, knowledge and perception of monkeypox can impact the spread of the disease. An online cross-sectional survey of monkeypox among 822 Nigerians showed that 89% of the participants were aware of the 2022 monkeypox outbreak and obtained information mostly from internet sources (33.4%), social media platforms (28.6%) and television (25.6%) (Al-Mustapha et al., 2023).  In a study among medical and health sciences students across the media space in Nigeria, 94.1% had heard about monkeypox before, 59.1% believed that monkeypox could be treated, 80.8% believed that monkeypox is zoonotic but can be transmitted from human to human, and the majority (60.1%) were aware of the symptoms of monkeypox (Ugwu et al., 2022). A web-based assessment of the perception and knowledge of monkeypox among Nigerian healthcare workers, academics and tertiary students reported that 33.9% knew the incubation period of monkeypox disease (Awoyomi et al., 2023). They were aware of prodromal symptoms such as high fever (51.7%), and fatigue (26%) (Awoyomi et al., 2023).

Avoiding contact with infected animals and persons, infected material and monkeypox vaccine are used to prevent monkeypox infection.  Monkeypox vaccine is recommended for people at high risk of getting infected such as health workers at risk of exposure, men who have sex with men, people with multiple sex partners and sex workers. Two types of vaccines are used. These are the replication-deficient modified vaccinia Ankara (MVA) vaccine and the replication-competent vaccinia virus vaccine (CDC, 2023). Vaccine hesitancy has been observed in recent times, especially following the COVID-19 outbreak. Vaccine hesitancy can hinder efforts aimed at prevention, especially during an outbreak of a vaccine-preventable disease like monkeypox. In an online study in Indonesia among Internal Medicine residents, 77.3% were willing to be vaccinated against monkeypox (Salim et al., 2022). This was higher than that obtained among Algerian health workers, where 38.7% of the respondents indicated willingness to receive human monkeypox vaccination if given for free with COVID-19 vaccine uptake as a determinant factor of acceptance (Lounis et al., 2023). In a multinational survey of 11 countries, 77.3% were willing to be vaccinated against monkeypox (Swed et al.,2023).

There is paucity of data on monkeypox research in Benue State, Nigeria. Therefore, the aim of this study was to raise awareness about transmission, prevention, symptoms and perceptions of the participants about monkeypox disease and to enable them to prepare if the disease occurs.

METHODOLOGY

The study was conducted at the  Federal  Medical  Centre,  Makurdi, Benue State, North Central Nigeria. It is a tertiary hospital. This was a cross-sectional study, carried out from January to May 2023.

The participants included health and non-health staff of the hospital. The health staff  were Community Health Extension Workers, doctors, laboratory scientists, nurses and pharmacists. The non-health staff were administrative staff, messengers, cleaners, drivers and maintenance officers. Every consenting adult aged 18 years and above among them were included in the study.

Single proportion population formula was used to determine the minimum sample size for the study (Araoye, 2004).

N = Z²pq/δ² where,

N  =  Minimum  sample  size,  Z  =  constant  at  95% confidence   level   =1.96,

p   =   Proportion   in   the   target population estimated to have a particular characteristic (awareness of monkeypox) of interest where 50% was used.

50 % was used because the prevalence of awareness of monkeypox in the area of study was not found on literature search. This also gave a good sample size.

q =1-p (i.e. 1 –0.5) = 0.5

δ = desired precision at 5%=0.05

N = (1.96)²× (0.5 × 0.5)/ (0.05)²

N = 384.

Random sampling technique was used. A pretested, self-administered closed ended, structured questionnaire was employed. The response rate was 98% (380). The questionnaire had two parts. The first part was answered by all the participants and enquired about the details found on tables 1, 2 and figures 1, 2, 3, 4. The second part was answered by only the health workers and contained the questions found in tables 3 and 4. Data analysis was done using SPSS version 20. All statistical analysis were significant at p< 0.05 and a 95% confidence interval.

RESULTS

Table 1: Sociodemographic characteristics of the respondents.

Variable	Health-workers n(%) n=177	Non health workers n(%) n= 203	Total
Age, mean=41.1 ± 13.0 years ≤ 20 21 – 40 41 – 60 61 – 80 ≥ 81	1(0.6) 78(48.4) 81(50.3) 1(0.6) 0(0.0)	15(6.8) 88(40.2) 92(42.0) 23(10.5) 1(0.5)	16(4.2) 166(43.7) 173(45.5) 24(6.3) 1(0.3)
Gender Male Female	79(49.1) 82(50.9)	86(39.3) 133(60.7)	165(43.4) 215(56.6)
Marital status Single Married Divorce/separated Widow/widower	50(31.1) 89(55.3) 6(3.7) 16(9.9)	53(24.2) 160(73.1) 5(2.3) 1(0.5)	103(27.1) 249(65.5) 11(2.9) 17(4.5)
Ethnic group Tiv Idoma Igede Others	101(62.7) 23(14.3) 11(6.8) 26(16.1)	158(72.1) 29(13.2) 1(0.5) 31(14.2)	259(68.2) 52(13.7) 12(3.1) 57(15.0)
Religion Christianity Islam Others	153(95.0) 7(4.4) 1(0.6)	212(96.8) 6(2.7) 1(0.5)	365(96.1) 13(3.4) 2(0.5)
Level of education Informal Primary Secondary Graduate/Diploma Postgraduate	0(0.0) 0(0.0) 11(6.8) 85(52.8) 65(40.4)	5(2.3) 9(4.1) 77(34.8) 117(52.9) 13(5.9)	5(51.3) 9(2.4) 86(22.6) 202(53.2) 78(20.5)
Years of practice of health worker ≤10 years 11 – 20 21 – 30 31- 40 ≥41 years	106(65.8) 40(24.8) 12(7.5) 3(1.9) 0(0.0)	115(52.5) 52(23.7) 24(11.0) 26(11.9) 2(0.9)	221(58.2) 92(24.2) 36(9.5) 29(7.6) 2(0.5)
Average monthly income <30,000 30,000 to 99,000 >100,000	14(8.7) 31(19.3) 116(72.0)	113(51.6) 73(33.3) 33(15.1)	127(33.4) 104(27.4) 149(39.2)

The mean age of the participants was 41.1 ± 13.0 years. Those aged 21-40 years (n=166, 43.7%) and 41-60 years (n=173, 45.5%) made up over four-fifths of the respondents.  Females were slightly more (n=215, 56.6%). Nearly two-thirds were married (n=249, 65.5%) and 103 (27.1%) were single. Slightly above half were graduates (n=202,53.2%). The health workers were 177(46.6%), their work experience was 12.1 ± 10.1 years and 221(58.2%) had worked for less than 10 years (Table 1).

Figure 1: Prevalence of respondents who had heard about monkeypox.

Those who had heard about monkeypox disease were 284(74.7%), and out of these 177 (ie 46.57%) were health workers (Figure 1).

Table 2: Responses to awareness about monkeypox causes, symptoms, transmission, prevention and willingness to receive monkeypox vaccine.

Variable	Frequency	Percent
Cause of monkeypox (mpox) disease (n=284)* Caused by virus Caused by a bacteria Not a real disease, but a public deception I don’t know	175 24 8 77	61.6 8.5 2.8 27.1
Time of first information about mpox disease (n=284)* Within the year earlier than this year	122 162	43.0 57.0
First source of information (n=284)* Social media/television/radio Family/friend Market/schools/church	225 45 14	79.2 15.8 4.9
Contact with monkeypox patient (n=280)* Yes No	40 240	10.5 63.2
Knowledge of symptoms of monkeypox (n=380) Yes No	208 172	54.7 45.3
Symptoms mentioned (multiple responses, n=380) Body rash Fever Headache Lymph node swelling Muscle pain Respiratory symptom	187 153 118 102 78 55	49.2 40.3 31.1 26.8 20.5 14.5
Knowledge of transmission (multiple responses, n=380) Contact with infected monkeys and rats Contact with infected rashes Contact with infected respiratory droplets Contact with infected materials Contact with infected body fluids Mother to unborn child I don’t know	116 350 149 257 302 69 30	30.5 92.1 39.2 67.6 79.5 18.2 7.8
Knowledge of prevention (n=380) Not sure Protecting food from contact with infected rats and monkey Avoiding close contact with infected surface/materials   Vaccination Avoiding close with infected person	6   162   292   276 374	1.6   42.6   76.8   72.6 98.4
Perception of being at risk of mpox infection (n=380) Yes No	163 217	42.9 57.1
Awareness of monkeypox vaccine(n=380) Yes No	73 307	19.2 80.8
Willingness to take vaccination for monkeypox (n=380) Yes No	271 109	71.3 28.7

n= number of  responses, *not all participants responded to this question

Table2 shows that one hundred and seventy-five (61.6%) knew that monkeypox was caused by a virus, while some did not know the cause (n=77, 27.1) and few thought that it was not a real disease but a public deception (n=8, 2.8%). The first source of information of the disease was via media (n=225, 79.2%) and fourteen (n=14, 4.9%) obtained their information from market/schools/church.  The most known symptoms of monkeypox were body rash, fever and headache, while the least known was respiratory symptoms. Few respondents knew transmission via respiratory droplets and from mother to unborn child. Preventive measures known by the respondents included avoiding contact with infected person and avoiding contact with infected surfaces/materials. Willingness to receive monkeypox vaccine was reported by 271 (71.3%).

Table 3: Knowledge and perception of health-workers about monkeypox

Variable	Frequency (n=177)	Percent
I was taught monkeypox in school. Yes No	64 113	36.2 63.8
As medical personnel, I have you had training on monkeypox Yes No	22 155	12.4 87.6
Knowledge of the incubation period of monkeypox 1-10 days 6-13 days >30 days Don’t know	32 60 20 65	18.0 33.7 11.2 36.7
Knowledge of prodromal symptoms (multiple response, n=435) Fever Lymphadenopathy Malaise Myalgia Headache Not sure	110 86 91 61 69 18	75.3 58.9 62.3 41.8 47.3 12.3
Monkeypox is prevalent in West and Central Africa Yes No Not sure	122 42 13	68.9 23.7 7.3
Monkeypox is transmitted from human to human Yes No Not sure	132 33 12	74.6 18.6 6.8
Monkeypox and smallpox have similar signs and symptoms Yes No	123 54	69.5 30.5
Diagnosis of monkeypox can be confirmed by Serology ELISA# Real-time PCR* Immunohistochemistry Not sure	50 24 36 9 58	28.2 13.6 20.3 5.1 32.8
Lymphadenopathy is used to differentiate between monkeypox and smallpox Yes No Don’t  know	102 53 22	57.6 29.9 12.4
An antiviral used in the management of monkey pox is Sotrivimat Tecoviramat Molnupiravir Don’t know	18 33 9 117	10.2 18.6 5.1 66.1
Skin lesion of monkeypox include (multiple response, n=256) Macules Papules Vesicle Pustule Don’t_know	59 72 53 67 5	47.6 58.1 42.7 54.0 4.0
The case fatality had been around 3-6% Yes No Don’t know	79 25 73	44.6 14.1 41.2
I think there are currently enough preventive measures for monkey pox Yes No	74 103	41.8 58.2
I am worried monkeypox may become a world pandemic. Yes No	115 62	65.0 35.0
I think regular protocol for handling pandemic like monkeypox should be made routine Yes No	161 16	91.0 9.0
Judging from COVID-19 pandemic, I am prepared to handle monkeypox pandemic Yes No	91 86	51.4 48.6
I think the government is responding swiftly and adequately to curb the spread of monkeypox Yes No	83 94	46.9 53.1

Only 64 (36.2%) of the health-workers had been taught about monkeypox while at school and 22 (12.4%) had received training on monkeypox during their working experience. Fever was the most known prodromal symptom (75.3%). Only 36 (20.3%) knew that PCR was the confirmatory test. Over two-fifths knew all the range of exanthems of monkeypox disease, however few did not know any of them (n=5, 4%). Only 18 (10.2%) knew an antiviral (sotrivimat) used for the treatment. Most of the health-workers were worried that monkeypox could become a world pandemic (n=115, 65%) and thought that regular protocol for handling pandemics should be made routine for monkeypox (n=161, 91.0%).  Over half of the respondents thought that currently the preventive measures were not enough (n=103, 58.2%) and that the government response was not adequate (n=94, 53.1%). Ninety-one (51.4%) felt they were prepared to handle the monkeypox pandemic.

Table 4: Association between sociodemographic characteristics and awareness of monkeypox disease

Variables	Have you heard about monkeypox		p value
	Yes	No
Age in years ≤ 20 21 – 40 41 – 60 61 – 80 ≥ 81	7(43.8) 129(77.7) 135 (78.0) 11 (45.8) 1 (100.0)	9(56.3) 37 (22.3) 38 (22.0) 13 (54.2) 0 (0.0)	0.000*
Gender Male Female	133 (80.6) 150 (69.8)	32 (19.4) 65 (30.2)	0.016*
Marital status Single Married Divorced/separated Widower/widower	74 (71.8) 184 (73.9) 9 (81.8) 16 (94.1)	29 (28.2) 65 (26.1) 2 (18.2) 1 (5.9)	0.243
Tribe Tiv Idoma Igede Others	182 (70.3) 42 (80.8) 12 (100.0) 47 (82.5)	77 (29.7) 10 (19.2) 0 (0.0) 10 (17.5)	0.063
Religion Christianity Islam Others	269 (73.7) 12 (92.3) 2 (100.0)	96 (26.3) 1 (7.7) 0 (0.0)	0.226
Level of education Informal Primary Secondary Graduate/Diploma Postgraduate	3 (60.0) 1 (11.1) 34 (39.5) 168 (83.2) 77 (98.7)	2 (40.0) 8 (88.9) 52 (60.5) 34 (16.8) 1 (1.3)	0.000*
Average monthly income ≤29,999 30,000 to 99,000 ≥100,000	60 (47.2) 78 (75.0) 145 (97.3)	67 (52.8) 26 (25.0) 4 (2.7)	0.000*
Type of job Health worker Non health worker	176 (99.4) 107 (52.7)	1 (0.6) 96 (47.3)	0.000*

*Statistically significant

There was statistically significant relationship between age (p<0.05), gender (p=0.016), level of education (p<0.05), average monthly income (p<0.05) and type of job (p<0.05) and awareness of monkeypox disease (Table 4).

Table 5: Association between willingness to take monkeypox vaccine and other variables

Variables	Willingness to take monkeypox vaccine		p Value
	Yes	No
Age ≤ 20 21 – 40 41 – 60 61 – 80 ≥ 81	11 (68.8) 122 (73.5) 126 (72.8) 11 (45.8) 1 (100.0)	5 (31.3) 44 (26.5) 47 (27.2) 13 (54.2) 0 (0.0)	0.070
Gender Male Female	119 (72.1) 152 (70.7)	46 (27.9) 63 (29.3)	0.761
Marital status Single Married Divorced/separated Widow/widower	74 (71.8) 178 (71.5) 7 (63.6) 12 (70.6)	29 (28.2) 71 (28.5) 4 (36.4) 5 (29.4)	0.953
Ethnic group Tiv Idoma Igede Others	181 (69.9) 39 (75.0) 12 (100.0) 39 (68.4)	78 (30.1) 13 (25.0) 0 (0.0) 18 (31.6)	0.129
Religion Christianity Islam Others	260 (71.2) 9 (69.2) 2 (100.0)	105 (28.8) 4 (30.8) 0  (0.0)	0.659
Level of education Informal Primary Secondary Graduate/Diploma Postgraduate	3  (60.0) 3  (33.3) 50  (58.1) 156  (77.2) 59  (75.6)	2  (40.0) 6  (66.7) 36  (41.9) 46  (22.8) 19  (24.4)	0.001*
Type of job Healthworker Non-health worker	142 (80.2) 129 (63.5)	35 (19.8) 74 (36.5)	0.000*
Average monthly income <30,000 30,000 to 99,000 >100,000	79 (62.2) 78 (75.0) 114 (76.5)	48 (37.8) 26 (25.0) 35 (23.5)	0.020*
Have you heard of monkeypox? Yes No	220 (77.7) 51 (52.6)	63 (22.3) 46 (47.4)	0.000*
What do you think causes monkeypox? Caused by virus Caused by bacteria It is not a real disease, but a public deception Not sure	135 (77.1) 18 (75.0) 4 (50.0) 64 (83.1)	40 (22.9) 6 (25.0) 4 (50.0) 13 (16.9)	0.172
Do you know symptoms of monkeypox? Yes No	165 (79.3) 106 (61.6)	43 (11.3) 66 (38.4)	0.000*
Do you think you are at risk of having monkeypox? Yes No	129 (79.1) 142 (65.4)	34 (20.9) 75 (34.6)	0.003*
Are you aware of monkeypox vaccine? Yes No	65 (89.0) 206 (67.1)	8 (11.0) 101 (32.9)	0.000*

*Statistically significant

Having heard about monkeypox, education, type of job, monthly income, knowing the symptoms, being aware of the vaccine and feeling at risk of the disease had statistically significant (p<0.05) relationship with willingness to take monkeypox vaccine (Table 5).

DISCUSSION

A new incidence of monkeypox is continually being recorded. As at the 11th of September 2023, the WHO received a report of 1131 newly diagnosed cases and five deaths in the preceding 21 days (WHO, 2022b). This an increase compared to 1020 cases and three deaths over the preceding days as at 9^th August, 2023 (WHO, 2023b). Nigeria recently reported a surge in cases this year. More studies can help in instituting preventive measures.

In this study, the mean age of the participants was 41.1 ± 13.0 years. Those aged 21-40 years (n=166, 43.7%) and 41 – 60 years (n=173, 45.5%) made up over four-fifths of the respondents. In a Nigerian online national survey on monkeypox the mean age of the respondents was 35.2±10.9 years, 43.6% were aged between 30 – 44 years (Awoyomi et al., 2023). The present study shows that, those within the ages of 41 – 60 had the highest proportion of awareness of monkeypox disease compared to all other age groups. In addition, younger age groups (≤ 20, 21 – 40 years) had higher proportion of awareness compared to older age groups.  Age showed a statistically significant relationship with awareness of monkeypox. This finding may be because younger persons may have more interest with electronic media and hence more contact with information compared to older age groups. Therefore, health education should be channelled through means that target both the younger and older individuals.

Females were slightly more (n=215, 56.6%) unlike in another study where males were more (Awoyomi et al., 2023). Although the females were more than the males, the proportion of awareness of monkeypox disease was higher among the males and was statistically significant. The reason for this is unclear since they were all working in the same environment, but may be attributed to women being more involved in domestic chores after work and may not keep abreast with information on trending issues. Most of the participants were married (n=249, 65.5%) and more than half were graduates (n=202,53.2%) while five (1.3%) had no formal education. There was a statistically significant relationship between the level of education and awareness of monkeypox. The awareness increased as the educational level progressed with those having postgraduate education (98.7%) being the highest. Similarly, Awoyomi et al., found that students and academics were quite aware of monkeypox disease. Non health-workers were 203 (53.4%). Healthcare workers were 177(46.6%), their work experience was 12.1 ± 10.1 years and 221(58.2%) had worked for less than 10 years. The type of job (health related/not health related). Health workers were also found to be more aware of monkeypox disease in another study (Awoyomi et al., 2023). The average monthly income showed a statistically significant relationship with awareness of monkeypox with people who had high income (> 100,000 naira) having the highest proportion of awareness. Interventions to increase awareness may be effective if people of lower educational and socio-economic status are being targeted with educational aids such as pictures, jingles in local dialects on radio and television, community awareness programmes and school talk shows to enable them get a good grasp of information on monkeypox.

Those who had heard about monkeypox disease were 284 (74.7%), and out of these 177 (46.57%) were health workers. This present finding aligns with observations reported by Al-Mustapha and colleagues in an online cross-sectional survey where majority of the study participants (89%) were aware of monkeypox outbreak (Al-Mustapha et al., 2023). Though majority in these studies knew about the disease, it is still obvious that awareness strategies still need to be intensified. This may be achieved by health education at schools, markets and hospitals.

Most of the participants, (61.6%) knew that monkeypox was caused by a virus, some did not know the cause (27.1%) and few thought that it was not a real disease but a public deception (n=8, 2.8%). Participants obtained information of monkeypox from media (59.2%) and fourteen (n=14, 4.9%) obtained their information from market/schools/church. In another study, information about the monkeypox were obtained from internet sources (33.4%), social media platforms (28.6%) and television (25.6%) (Al-Mustapha et al., 2023).  The notable point of this finding is that media, social and educational institutions are very relevant mediums in passing information to people in a bid to curbing monkeypox. Misinformation and spread of myths during disease outbreaks can render preventive measures ineffective. Therefore, interaction with the public should address such misinformation.

The most known symptoms of monkeypox were body rash (89.9), fever (73.6%) and headache (56.3%) while the least known was respiratory symptoms (26.4%). In another study, the participants were mostly aware of the prodromal symptoms such as high fever (51.7%), and fatigue (26%), while for the more specific symptoms, rashes (52%) and swollen lymph nodes (33.1%) were most known symptoms (Al-Mustapha et al., 2023).

Majority (68.9%) of the health workers knew that monkeypox was prevalent in West and Central Africa. Only about one-third of the healthcare workers (33.7%) knew the incubation period of monkeypox. For each of the exanthems which included macules, papules, vesicles, and pustules the healthcare workers knew at least two-fifths for each of the exanthems, however few did not know any of them (4%). These skin lesions are one of the most recognizable symptoms of monkeypox and health workers are supposed to know them to enable them have high index of suspicion whenever such presents. This can help in identifying the patients early for treatment and may prompt the health worker pay more attention to preventive measures that can mitigate transmission of the disease to themselves or others.

Contact with infected rashes (49.4%) and infected body fluids (42.7%) were the commonest responses to modes of transmission and is consistent with other studies (Al-Mustapha et al., 2023). Few respondents knew transmission via respiratory droplets (21.0%) and from mother to unborn child (9.8%). Toeing a similar line, Al-Mustapha and colleagues found that less than half were aware of the less known sexual route of transmission (Al-Mustapha et al., 2023). Preventive measures known by the respondents included avoiding contact with infected persons, and avoiding contact with infected surfaces/materials while responses to ‘not sure’ were 37.3%. Proper hygiene and vaccination are also top on preventive measures in another study (Silas & Ikechukwu, 2019; Al-Mustapha et al., 2023; Awoyomi et al., 2023). During outbreaks, it is important to tackle all possible routes of transmission and if some of the less reported routes are not known, this may hinder preventive measures. The knowledge of preventive measures is important in mitigating the spread.

Prevention of monkeypox is also achieved by use of vaccination against the disease (Salim et al., 2022; CDC, 2023). In this study few respondents (n=73, 19.2%) were aware of this. One hundred and sixty-three respondents (42.9%) felt they were at risk of the disease. A remarkable proportion (n=271, 71.3%) expressed willingness to take vaccination against monkeypox. This is close to observation in Indonesia among Internal Medicine residents where 77.3% were willing to be vaccinated against monkeypox (Salim et al., 2022), but higher than that obtained among Algerian health-workers, where 38.7% of the respondents indicated willingness to receive human monkeypox vaccination if given for free with COVID-19 vaccine uptake as a determinant factor of acceptance (Lounis et al., 2023). There was statistically significant relationship between level of education (p=0.001), occupation (0.002), type of job (p<0.05) and average monthly income (p=0.02) and willingness to receive monkeypox vaccine. Those who had heard about monkeypox and knew the symptoms had the highest proportion of willingness to receive monkeypox vaccine and it was statistically significant (p<0.05). In addition, there was also statistically significant relationship between feeling at risk of contracting monkeypox (p=0.003) and being aware of the monkeypox vaccine (p< 0.05). In an online Nigerian study among health care workers, the determinants of monkeypox vaccine confidence were being single, having a higher education level and absence of chronic disease (Ghazy et al., 2022).  In a Bangladeshi study, there was statistically significant association between monkeypox knowledge score with gender, age group, educational qualification, monthly family income, job position at the hospital, total length of service, duration of service at the current place of posting and attendance of any monkeypox seminar/symposium/workshop in last 6 months (Nurul et al., 2022).

Few of the health-workers had been taught about monkeypox while at school (n=64, 36.1%) and 22 (12.4%) had received training on monkeypox during their working experience. This low proportion is comparable to 40.6% who had learnt about monkeypox during schooling in a study among health care professionals in Bangladesh (Nurul et al., 2022). About one-third knew the incubation period of monkeypox (n=60, 33.7%) and 79 (44.6%) knew the case fatality rate. This concurs with low awareness of monkeypox of less than 10% reported among general practitioners in Indonesia (Harapan et al., 2020). These findings are quite low as it would have been expected that healthcare workers are supposed to be conversant with details of an outbreak such as monkeypox.  Fever was the most known prodromal symptom among the healthcare workers (75.3%). Majority knew that monkeypox could be transmitted from human to human (n=132, 74.6%), had similar signs and symptoms with small pox (n= 123, 69.5%) but could be differentiated from smallpox by presence of lymphadenopathy (n=102, 57.6%). Only 36 (20.3%) knew that PCR was the confirmatory test. Over two-fifths knew all the range of exanthems of monkeypox disease, however few did not know any of them (n=5, 4%). Only 18 (10.2%) knew an antiviral (tecoviramat) used for the treatment though it is still under trial (Harapan et al., 2020) and is quite close to 13.3% among Internal Medicine residents in Indonesia who knew the medication used for treatment (Salim et al., 2022). Among doctors in Calabar, Nigeria, 72% were confident to clinically diagnose monkeypox in their clinics (Iwuafor et al., 2022). These specific knowledge of information about monkeypox disease among the healthcare workers is insufficient. It is essential for national health agencies in Nigeria to expeditiously train and retrain health-workers immediately an outbreak of any disease occurs. Health care workers can then have vast information to disseminate to the populace.

Most of the health-workers were worried that monkeypox could become a world pandemic (n=115, 65%) and thought that regular protocol for handling pandemics should be made routine for monkeypox (n=161, 91.0%). A multinational survey done among healthcare workers in Egypt, Saudi Arabia, Yemen, Syria, Libya, Algeria, Tunisia, Iraq, Palestine, Jordan, and Sudan. reported that 8.8% of participants were concerned that monkeypox might generate an epidemic like COVID-19 (Swed et al., 2023). In agreement with the current findings, 79.6% also felt that healthcare workers should apply more infection control measures (Swed et al., 2023). Over half of the respondents thought that currently the preventive measures were not enough (n=103, 58.2%) and that the government response was not adequate (n=94, 53.1%). Ninety-one (51.4%) felt they were prepared to handle monkeypox pandemic. It is crucial that government should support training of health staff, institute and monitor protocols for universal precautions including provision of personal protective equipment. This can boost the confidence of health care workers in handling monkeypox when patients present.

In conclusion, awareness of monkeypox was not satisfactory and few healthcare workers knew salient information about the disease, hence more needs to be done on the aspects of health education and staff training on monkeypox. Our findings buttress the need for policymakers to institute health education on monkeypox, especially for the elderly and those of lower educational and economic status and ensure that personal protective equipment is provided for health workers at risk and train health workers on how to identify and manage cases. Clinicians should be able to identify cases of monkeypox, provide information on prevention to patients, relatives and their communities and have the necessary knowledge to treat monkeypox disease.

Acknowledgements: The authors are grateful to the participants and management of the hospital for their cooperation in carrying out this study.

Declarations

Funding: None

Conflict of interest: None declared

Ethical approval: Ethical clearance was obtained from the Hospital Research and Ethical Committee.

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