Perceptions of Indian Healthcare Practitioners Regarding the 2022 Outbreak of Monkeypox Disease

Introduction Although only a few cases of monkeypox have been reported in India so far, it is vital for healthcare practitioners to have sufficient knowledge about its epidemiology, clinical presentation, diagnosis, and management. Therefore, this study aimed to understand the perception of Indian healthcare practitioners regarding the 2022 outbreak of monkeypox disease. Methods A cross-sectional survey was conducted among 500 medical and dental practitioners from various regions of Kerala, India. The Chi-squared test for proportion was used to determine the significant difference in the knowledge levels of the participants. Binary logistic regression (multivariate) was used to understand the knowledge of healthcare professionals regarding the 2022 outbreak of monkeypox disease. Results A total of 424 healthcare professionals completed this survey. Overall, the level of knowledge was good in 64.9% and poor in 35.1% of the participants (p<0.01). Binary logistic regression analysis did not show any statistical significance (p > 0.05) in terms of demographic characteristics. However, in this sample, participants with 6-10 years of work experience were more likely to have improved knowledge scores (odd's ratio OR 1.764). Similarly, participants between the age of 30-40 years were also likely to have improved knowledge scores (OR: 1.065). Conclusions Indian healthcare professionals had an overall good level of knowledge regarding the 2022 outbreak of monkeypox. However, a low level of knowledge was found related to the clinical presentation and immunization of monkeypox. This may be due to the low prevalence of monkeypox in this region.


Introduction
Over the last few decades, an increase in the global population has brought advances in urbanization and has also witnessed increased cases of zoonotic diseases. Monkeypox virus disease is a zoonotic infection caused by the monkeypox virus, a member of the Orthopoxvirus group of viruses [1]. Although initial cases of human monkeypox were reported from the African continent, recent reports were also from developed countries in North America, Asia, and Europe [2]. This alarming trend led to the declaration of monkeypox as a global emergency by the World Health Organization (WHO).
The clinical presentation of monkeypox infection was similar to but less severe than smallpox. The cases reported in 2022 often presented with fever, rash, sweats, chills, lymphadenopathy, headache, stiff neck, red eyes, runny nose, sore throat, cough, wheezing, nausea and/or vomiting, abdominal pain, a scrotal lump, itchy maculopapular rashes, and confusion [3][4][5]. These cases were presented with [6,7] and without oral manifestations [8]. Generalized lymphadenopathy in monkeypox has been reported as a primary differentiating factor between monkeypox and smallpox.
Monkeypox has been reported in many cases during travel to Africa or contact with a monkeypox virus-1, 2 3 4 5 6 infected person [9]. However, many new cases in the current outbreak of 2022 do not give a travel history to Africa or exposure to an infected person [3]. Discontinuation of the smallpox vaccination policy about 30-40 years ago could have caused an overall decline in the immunity of the population to smallpox and similar Orthopoxvirus diseases [10]. This could be one significant reason for the resurgence of infections by the monkeypox virus in young adults and small children in 2022 who were unvaccinated against smallpox [11]. Some report increased hospitalization in children below 18 years of age [12].
The surveillance system of many countries took preventive steps to control the transmission of the monkeypox virus [5]. This included isolating and quarantining infected people, preparing beds in several hospitals, and installation of thermal scanning systems at various places. Such a robust system is necessary to enable frontline healthcare workers to screen these cases [5]. India receives visitors from different parts of the world annually, increasing the vulnerability to human monkeypox transmission. Although only a few cases of monkeypox have been reported in India so far, it is crucial for healthcare practitioners to have sufficient knowledge about its epidemiology, clinical presentation, diagnosis, and management. This will help to identify and manage cases of the monkeypox virus efficiently and prevent further disease transmission [13]. Hence, we aimed to understand the perception of Indian healthcare practitioners regarding the 2022 outbreak of monkeypox in terms of their knowledge score.

Materials And Methods
This cross-sectional survey was conducted among medical and dental practitioners from various regions of Kerala, India, during September 1-30, 2022, using a convivence sampling method. We sent invitations to 500 participants to take part in the survey. Members of the Indian Medical Association (IMA) and the Indian Dental Association (IDA) who were interested in participating and were practicing in Kerala, India, were included in the survey. The ethical approval was obtained from the Institutional Ethics Committee, Pushpagiri group of Institutions, Thiruvalla, Kerala, India, College, India (IRB/03/08/2022).

Survey
The questionnaire was sent to the participants through email and Whatsapp (WhatsApp LLC, Menlo Park, California, United States). The subject heading of the message described the purpose of the survey, while the main content contained the weblink to an anonymous web-based survey. Responses within a one-month time horizon were accepted for the study. Participants' response to the virtual survey was considered implicit consent. The participants were told about the time to complete the survey and data privacy.

Questionnaire
Before disseminating the survey, a questionnaire was drafted based on previous studies and frequently asked questions (FAQ) by WHO. This was pilot tested among 10 medical and dental practitioners, professors, administrators, and experts to determine its validity, following which necessary modifications were made. Cronbach's alpha equal to or more than 0.80 was considered in terms of internal consistency. The survey was finalized, taking into consideration their suggestions and comments. The study is reported based on the strengthening of the reporting of observational studies in epidemiology (STROBE) checklist.
The questionnaire consisted of two parts. The first part collected the sociodemographic details of the respondents. The second part addressed the professional knowledge of the respondents. The second part had 20 questions that could be answered as "yes", or "no".
The second section gathered the knowledge of these practitioners regarding the 2022 outbreak of monkeypox through 20 questions.

Sample size
Since no previous study evaluated the perception of healthcare practitioners about monkeypox, a power analysis was done based on the previous study by Harapan et al. in 2020 [3]. Assuming that 50% of the medical and dental practitioners would have a good knowledge of monkeypox, 382 respondents were required as the minimum sample size (5% margin of error and confidence interval of 95%).

Statistical analysis
The data was imported and analyzed using IBM SPSS Statistics for Windows, Version 20.0 (Released 2011; IBM Corp., Armonk, New York, United States). Frequencies and percentages were used as summary statistics.
The chi-squared test for proportion was used to determine the significant difference in the awareness levels of the participants. Binary logistic regression (multivariate) was used to understand the knowledge of health professionals regarding the 2022 outbreak of monkeypox.

Participants (demographics)
A total of 424 healthcare professionals completed this survey. The demographic details of the participants are shown in Table 1. It can be seen that the majority (70.3%) of the participants were between the ages of 20 and 30, followed by 13.9% who were older than 40 years. The least number of participants was below 20 years (7.8%).

Variables Categories Frequency Percent
Age (  Knowledge of health professionals regarding the 2022 outbreak of monkeypox Table 2 shows that out of the 20 questions, three were answered correctly by over 70% of participants. These questions were: (i) "All healthcare professionals should implement standard infection control precautions with suspected cases of monkeypox" (85.8% answered correctly), (ii) "Monkeypox has a very high fatality rate of above 50%" (73.8% answered correctly), and (iii) "N95 masks and other personal protective equipment (PPE) are of no value when coming into close contact with a case of monkeypox" (70.3% answered correctly).    Table 3 shows a binary logistic regression analysis's outcome when considering participants' knowledge regarding the 2022 outbreak of monkeypox in either a "Yes" or "No" answer. Statistical significance was not found (p > 0.05) in this logistic regression model in terms of demographic characteristics such as age, sex, years of work experience, specialty (medical or dental), employment sector (teaching institute or clinical practice), and the number of years after graduation/ postgraduation.

Knowledge of health professionals regarding the 2022 outbreak of monkeypox
Monkeypox disease has spread in multiple regions and was declared a "global emergency" by WHO. The regions of southeast Asia have been on high alert for monkeypox since the first case was reported in India in July 2022 [14]. It was reported by a 35-year-old man with a history of travel from the Middle East earlier that week. Since then, all countries have taken preventive measures to control the spread of monkeypox.
The perceptions of healthcare practitioners impact the healthcare sector's outlook towards it [15]. In the present study, an overall good level of awareness was seen in the majority (64.9%) of the participants. A recent study among dental professionals in India found a low level of knowledge about monkeypox [16]. They reported that 24.8% of the participants were unaware of monkeypox. In our study, 61.3% had knowledge about oral lesions of monkeypox, and 59.0% had knowledge about other clinical presentations. Contrary to our findings, only 31.2% of subjects had knowledge regarding oral manifestations of the disease in another recent study [16]. Another study also reports low levels of knowledge scores among general practitioners in Indonesia [13].
The good level of knowledge in the present study could be because the majority (70.3%) of the participants were between the ages of 20 and 30 who usually have good access to the internet and frequently used social media. A recent study showed higher education levels and working profiles increased knowledge levels [16]. In these participants, online media (internet) was the most preferred (42.2%) source of information [16].
Another study done on the general population also found that three-fourths of the participants used social media as their main source of information [17]. The availability of scientific data in online academic journals may have a better influence on healthcare professionals' knowledge regarding the disease.
It was interesting to note that most of the participants (85.8%) of the present study were aware of the need to use standard infection control procedures, including the use of N95 masks and other PPE, with a suspected case of monkeypox (70.3%). Similarly, most participants (73.8%) also knew that monkeypox does not have a high fatality rate.
A low level of knowledge was found among the present study participants related to the clinical presentations of monkeypox, the origin of lesions, the effectiveness of immunization with smallpox vaccines against monkeypox, diagnosis of monkeypox, and available treatment for monkeypox. The low prevalence of monkeypox cases in this region could be a probable reason. A recent study reported 44.8% of participants had the wrong information about the resemblance of monkeypox with smallpox disease [16]. Furthermore, only 26.2% of the respondents in a Jordanian health school survey had knowledge about the availability of vaccination to prevent monkeypox [18].
An earlier online survey conducted on general practitioners in Indonesia showed 36.5% of them had good knowledge when a 70% cutoff point for the knowledge domain was applied [13]. Within this cut-off, lower knowledge was found in those older than 30 years (adjusted OR (aOR): 0.61; 95%CI: 0.39-0.96, p = 0.033).
Our results are contrary to this study as participants between the age of 30 to 40 years were likely to have improved knowledge scores (OR: 1.065; 95%CI: 0.274-4.129, p=0.928).
Another interesting finding was that working in teaching institutes or clinical practice did not influence the knowledge levels of the participants of the present study. But an earlier study reports general practitioners working in private clinics had less knowledge compared to general practitioners in community health centers (aOR: 0.55; 95%CI: 0.31--0.99, p = 0.047) [13].
In our study, logistic regression showed that the knowledge of medical and dental practitioners regarding the 2022 outbreak of monkeypox disease was not influenced by demographic characteristics such as age, sex, years of work experience, specialty (medical or dental), employment sector (teaching institute or clinical practice), and the number of years after graduation/ postgraduation. However, in this sample, work experience of 6-10 years and age between 30 to 40 years seem to influence knowledge scores. Similarly, in a study done on students in Jordanian health schools, age was significantly associated with improved monkeypox knowledge for most of the participants [18].

Strengths and limitations of the study
This is the first study that reports the perception of medical and dental professionals regarding the outbreak of the 2022 monkeypox disease in India. However, this is a cross-sectional study. Therefore, changes in their perception over time cannot be provided. This is one of the limitations of this study. Moreover, we did not categorize medical and dental professionals based on their specialty and region of work. Since the participants were from different backgrounds, the findings of this study may lack generalizability.

Recommendations
There are certain precautions to be taken in dental and medical clinics. Transmission of the monkeypox virus can be prevented in clinical settings by taking standard infection control precautions when treating patients with monkeypox symptoms [19][20][21][22]. Proper contact and droplet infection control should also be practiced. The patient should be isolated during examination and treatment. Exposed skin lesions should be covered, and the patient's nose and mouth be covered using a surgical mask. Elective dental treatment should be postponed in patients with probable or confirmed monkeypox infection until the patient is noninfectious [23]. Oral lesions [24] and ocular lesions [25] are possible complications of monkeypox. If not careful, ocular monkeypox can potentially cause conjunctivitis and even vision loss. Good hand hygiene should be practiced to reduce the risk of auto-inoculation.
The knowledge of healthcare professionals can further be improved through educational programs and training in identifying and managing monkeypox. Health professionals should be given information regarding the clinical presentations of monkeypox, the origin of lesions, the effectiveness of immunization with smallpox vaccines against monkeypox, diagnosis of monkeypox, and available treatment for monkeypox. Based on the findings of this study, increasing the knowledge about these factors can improve the overall knowledge score of healthcare practitioners regarding monkeypox.

Conclusions
Within the study's limitations, it can be concluded that the Indian healthcare practitioners had an overall good level of awareness regarding the 2022 outbreak of monkeypox in terms of their knowledge score. There was good knowledge about oral lesions of monkeypox. However, a low level of knowledge was found related to the clinical presentation and immunization of monkeypox. This may be due to the low prevalence of monkeypox in this region. Educational programs and training in identifying and managing monkeypox disease are recommended for healthcare professionals. The vesicular lesions in mpox are broad and non-itchy.

Appendices
Mpox has a very high fatality rate of above 50%.
All healthcare professionals should implement standard infection control precautions with suspected cases of mpox.
Oral mucosa and lips are not at all affected in mpox.
The traditional smallpox vaccine is protective against mpox.
Lesions do not appear in the hand and eyes in mpox.
Lesions may originate in the genital region as per the observations of current outbreaks of mpox.
The lesions in mpox are smaller than those in chickenpox.
There is more chance of contracting mpox if an individual has already been vaccinated with the smallpox vaccine.
The reverse transcription-polymerase chain reaction test is recommended for identifying the mpox virus during an acute infection.
Immunosuppressed people, pregnant women, and children younger than 12 years do not have an increased risk for mpox.
Management of mpox is essentially symptomatic.
Specific antiviral agents are available that completely cure mpox.
Smallpox vaccine against mpox could be prescribed for patients with comorbidities.
Passive immunization with immune globulin vaccinia is successful in the case of mpox Vaccines against smallpox are effective in preventing mpox and postexposure prophylaxis.
N95 masks and other personal protective equipment (PPE) are of no value when coming into close contact with a case of mpox Mpox spreads through close contact and respiratory droplets.
Commercial tests to detect mpox are available at this point in India.
Homosexuals do not have a higher risk of mpox.

Additional Information
Disclosures Human subjects: Consent was obtained or waived by all participants in this study. Institutional Ethics Committee, Pushpagiri Group of Institutions, Thiruvalla, Kerala, India issued approval IRB/03/08/2022. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.

Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.