The human monkeypox disease, known simply as monkeypox disease, is caused by a monkeypox virus (MPXV) and is a zoonotic infectious disease, frequently found in African countries [1
]. The MPXV belongs to the “genus Orthopoxvirus, subfamily Chordopoxvirinae and family Poxviridae
”. The genomes of these viruses are ≈200 kb long, with replication characteristics, and are involved in host range determination and pathogenesis [3
The possible pathogenesis and transmission of MPXV are animal–animal, animal-human, and human-human transmission. Direct or indirect contact with bodily fluids, respiratory droplets, the skin lesions of an infected person, and patients’ contaminated possessions, bedding, clothing, and environment have been associated with inter-human transmission [4
The transmission of disease may be due to close physical, skin-to-skin, or face-to-face interaction [7
]. MPXV infection can also be transmitted through bites or scratches from infected animals, and the contamination of raw meat [9
]. Moreover, rodents and squirrels may also play a role in the transmission of MPXV to humans [9
The MPXV was first found in 1958 among a group of monkeys housed in a research institute in Copenhagen, Denmark [10
]. About 12 years later, in September 1970, the MPXV was identified for the first time in humans in the Democratic Republic of Congo [11
]. In the new millennium, in the year 2003, the first case of the MPX disease was reported from endemic to non-endemic countries [13
The World Health Organization has stated that MXPV disease is a global emergency [15
]. This year, from 1 January 2022 to 19 August 2022, MPXV has swiftly spread from non-endemic to endemic regions [16
], involving 94 countries and infecting 41,358 people; 387 cases were reported from seven endemic African countries and 40,971 cases in 87 non-endemic countries in Europe, America, Australia, and the Asian continent [14
Currently, there is no specific approved vaccine for MPXV. However, vaccination against the smallpox virus provided cross-protection against MPXV [17
]. There are three generations of vaccines used against the smallpox virus [18
]. The first-generation vaccine was used against smallpox until 2008. This vaccine was highly effective in preventing smallpox and played a vital role in the eradication of smallpox all around the world. In 1980, the WHO declared the eradication of smallpox, and this vaccine was discontinued [7
]. The second-generation vaccine, the live attenuated tissue culture-derived vaccinia virus vaccine has been used for populations who might be at high risk for orthopoxvirus. The third-generation vaccine, the modified vaccinia Ankara-Bavarian Nordic (MVA-BN), was approved for human use in Canada and Europe [7
In the present situation of global emergency, public awareness about monkeypox disease is vital to educating the people to fight against such infectious diseases. Therefore, the present study aimed to assess the public perceptions and knowledge of monkeypox in Riyadh, Saudi Arabia.
2. Subjects and Methods
2.1. Study Design and Settings
This questionnaire-based cross-sectional survey was steered in the “Department of Physiology, College of Medicine, King Saud University, Riyadh, Saudi Arabia”, from 15 May to 15 July 2022.
2.2. Study Area Demographics
The total population of Saudi Arabia is around 35.8 million; the male population is 20.70 million and the female population is 15.14 million, with a median age of 32.4 years. Riyadh is the largest city and the capital of Saudi Arabia. The city consists of five regions with a total population of about 7.54 million people, comprising 57% males and 43% females. More Saudi women are studying in universities than men; there are about 551,000 women and 513,000 men studying for bachelor’s degrees in universities.
2.3. Study Sample Size
The targeted study participants were Saudi and non-Saudi male and female residents in the capital city of Riyadh, Saudi Arabia. A power formula was used to calculate the sample size, based on a 50% population proportion, a 95% confidence interval, and a 5% margin of error. For this study, a sample size of about 800 people was required, but the number of participants who responded and were included in the study analysis was 1020.
2.4. Study Survey Procedure and Instrument
The study participants were invited to join the questionnaire survey using social media platforms (via WhatsApp and emails). The study objectives and a polite request for their consent and voluntary participation were presented at the beginning of the questionnaire. The study variables were socio-demographic characteristics, age, gender, occupation, level of education, socioeconomic status, and allied questions about knowledge, attitude, and perceptions regarding monkeypox disease. The study was based on a well-designed questionnaire [19
] issued to the targeted population of Riyadh, Saudi Arabia. The survey participants represent the entire Riyadh region of Saudi Arabia.
After receiving permission, the questionnaire [19
] was slightly modified and used for the data collection. The reliability and technical issues of the questionnaire were tested among 10 participants, and their feedback was taken in the pilot survey test. After ethical approval, the questionnaire was distributed online through email, Google, and social media platforms in Riyadh, Saudi Arabia. The questionnaire was distrusted by 1300 participants, 1020 (78.46) participants responded to the survey, and 280 (21.53%) did not respond to the survey. Among the 1020 participants, 554 (54.3%) were females, and 466 (45.7%) were males.
The names of the participants were not collected to maintain confidentiality. The invitations to participate in the online survey were distributed by the social media program WhatsApp and e-mails. To achieve a better response, one reminder was also sent as a follow-after the initial message. An introductory page consisted of information on the research objectives, demographic information, and the expected benefits. The survey was estimated to take about 10 min to complete. The duplication distribution of the questionnaire was checked, and the raw data were extracted and imported for analysis. The questionnaire consisted of 28 questions to assess the knowledge, attitudes, and perceptions regarding monkeypox. The questionnaire was developed in the national language of Arabic, and also in the English language.
2.5. Ethical Considerations
An introductory page was provided, informing the participants that they could exit the survey at any point, and before enrolling, they were asked to provide their consent to participate. This study was approved by the Ethics Committee Institutional Review Board (IRB), College of Medicine Research Centre, King Saud University, Riyadh, Saudi Arabia (Ref: 22/0466/IRB).
2.6. Statistical Analysis
The results were examined using the SPSS software, version 26.0 for Mac. The demographical variables of age, gender, occupation, education, and socioeconomic status were reported, using frequency and percentage. The response score was reported using mean and standard deviation. The comparisons between the variables were analyzed using independent sample t-tests, ANOVA, and chi-squared tests. A p-value of <0.05 was considered significant.
Since early May 2022, the human monkeypox outbreak across many countries has raised concerns about a possible change in the pattern of monkeypox transmission, and that the disease now poses a greater global threat [15
]. The transmission of monkeypox diseases is not only limited to the close contract but it can also be transmitted through respiratory droplets, direct or indirect contact with bodily fluids, certain possessions, the skin lesions of an infected person, and a contaminated patient’s environment [4
The present study findings suggest that the general population in Riyadh, Saudi Arabia has a satisfactory level of knowledge about the human monkeypox disease. The majority of participants proposed adopting preventive measures and initiating a vaccination campaign to eradicate monkeypox disease at regional and global levels. The present study findings reflect high levels of endorsement of public perceptions about the emerging monkeypox threat. Monkeypox disease was declared a global emergency on 23 July 2022 by the WHO [16
] and alarm bells began to ring worldwide, as a reminder of the similar situation that arose immediately before the spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), also known as COVID-19, which was declared a global pandemic in March 2020 [20
Meo et al. (2022) [15
] reported that the number of cases of monkeypox is now surging drastically. From what started as an endemic zoonotic disease that was restricted to Central and West African countries, it was not until earlier this year that the number of cases began to climb in countries where monkeypox had never existed before, indicating that the disease is now becoming a global health concern. Monkeypox has now spread to around 94 states across the world. With an emergency situation declared, the international community must immediately act to prepare for a possible pandemic, so that this time, the global healthcare system does not lack sufficient supplies and is not taken by surprise, as it was in 2020 when the COVID-19 pandemic first spread [20
Harapan et al. (2020) [19
] reported that knowledge regarding monkeypox among a group of general practitioners in Indonesia was low, although knowledge about monkeypox is essential to enhance the profession’s capacity to respond to human monkeypox prevalence.
In another study, Sallam et al. (2022) [21
] reported that knowledge regarding the emerging monkeypox disease among 615 university students in Jordanian health schools was unsatisfactory. About 26.0% of the respondents knew that vaccination could help to prevent monkeypox. Age was associated with better human monkeypox (HMPX) knowledge. Our study, with a sample size of 1020, had satisfactory results, with more than half of the respondents answering most questions appropriately. About 71.4% of participants knew that smallpox vaccinations can be used to protect against monkeypox. The knowledge of human monkeypox among the general population in Riyadh, Saudi Arabia, was satisfactory for all ages, genders, levels of education, and economic groups.
Riccò et al. (2022) [22
] conducted a study in Italy that involved 566 participants and reported that the knowledge status of its participants was quite unsatisfactory, with substantial knowledge gaps on all aspects of monkeypox. In our study, 71.4% of respondents were aware of the smallpox vaccine’s role in protecting against monkeypox, and only 58.6% of respondents in the Italian study were somewhat in favour of implementing variola vaccinations to prevent monkeypox.
Nonetheless, in terms of knowledge about monkeypox and a positive attitude toward future monkeypox vaccines, it is essential to educate communities about such emerging viral diseases. An important tool for dealing with a health emergency crisis is to ensure the education of the masses regarding how to approach, deal with, and protect oneself if nearby people become infected. Providing essential knowledge ensures that the public takes the necessary precautions themselves and relieves the burden on the healthcare authorities by limiting the spread and surging of the disease. These steps must be taken in adequate time before the onset of its general spread; analyzing the pre-existing knowledge level of the public is the most important way to combat infectious diseases.
4.1. Study Strengths and Limitations
The strength of this study is that this is among the first studies to correlate the public’s knowledge of the emerging monkeypox outbreak in Riyadh, Saudi Arabia. The results of this study may be helpful in providing awareness programs to further improve the public’s knowledge of virus emergence and diseases. The sample size was suitable for representing the general public’s perceptions. The limitation of this study was that the data were collected only from the capital city of the country; it would be more appropriate to collect additional data from other cities in the country.
It is essential to educate the public and provide timely advice to increase public awareness of monkeypox disease through lectures, seminars, and the involvement of electronic and print media. The implementation of a “One Health approach”, a multidisciplinary and multi-sectoral, collaborative, and transdisciplinary approach at the inland, regional, national, and global levels, with one objective of achieving ideal health outcomes and identifying the interconnection between people, animals, plants, and the environment.
Moreover, the early diagnosis of patients, rapid notification to health authorities about suspected cases of MPXV, and the implementation of public intervention measures are decisive in eradicating the disease. Furthermore, the smallpox vaccine campaign and the development of antiviral drugs to treat this neglected tropical disease are highly recommended.