The second half of the twentieth century saw unprecedented population growth, unparalleled mobility, and unrestricted urbanization; however, with these advances came an increase in the spread of zoonotic diseases (Keusch et al., 2009). Many of these diseases begin as zoonotic and later mutate into a strain that can only infect humans, such as HIV. Others are reoccurring outbreaks, such as the Ebola virus. In recent years, SARS-CoV-2 caused the still circulating COVID-19 pandemic. Zoonotic diseases may be bacterial, viral, or parasitic and could spread to humans through drinking water, food, or direct contact(Rahman et al., 2020). The sheer versatility of these diseases represents a significant public health problem and should be monitored, studied, and prevented well in advance. Knowledge and awareness could be the deciding factors in limiting their spread before they become the next major pandemic. Monkeypox, a currently circulating zoonotic disease, could signify how our public health system has changed since the last pandemic and how physician knowledge plays a crucial role in that change.
Human monkeypox (MPX), a zoonotic infectious disease caused by the monkeypox virus (MPXV) of the genus Orthopoxvirus, causes smallpox-like symptoms in humans(Kuhn et al., 2019)(Ladnyj et al., 1972). It is a predominantly endemic disease in Western and Central Africa(Durski et al., 2018). The name, monkeypox, originates from the first reported discovery of the virus as an outbreak of a pox-like disease in monkeys at an animal research facility in Copenhagen, Denmark(Sehuminstitut, 1958). The first human MPXV case in medical history was recorded in 1970 at a hospital in the Democratic Republic of Congo, when a nine-month-old child manifested smallpox-like symptoms(Ladnyj et al., 1972). In 2003, multiple cases of MPXV were reported within the U.S., representing the first confirmed cases of MPXV outside the African continent(Bartlett, 2004). Fourteen years later, one of the most significant monkeypox outbreaks was reported in Nigeria, with 197 suspected cases and sixty-eight confirmed cases(Durski et al., 2018). In May of 2022, the largest outbreak of MPXV outside of endemic regions was confirmed by the World Health Organization (WHO)(Jamil et al., 2022). As of July 10, 2022, WHO had received reports of 8,238 confirmed cases from 57 non-endemic countries(Jamil et al., 2022)(Article et al., 2022). The 2022 outbreak marks the first time MPXV spread extensively outside of Western and Central Africa. Many of these cases have reportedly presented with a vesicular rash illness in men who have sex with men (MSM)(Article et al., 2022).
Monkeypox can be transmitted mainly via contact with respiratory secretions, infected skin lesions, or contaminated materials(Vaughan et al., 2020). The incubation period of monkeypox usually lasts from six to thirteen days but can range from five to twenty-one days(Reynolds et al., 2006). The disease is often self-limiting, with symptoms occurring spontaneously within fourteen to twenty-one days (Vaughan et al., 2020)(Ladnyj et al., 1972)(Manifestations, 2002). Symptoms can range from mild to severe, and lesions can be very itchy or painful. The animal reservoir remains unknown, although it is likely among rodents (Parker et al., 2007). Contact with live and dead animals through hunting and consumption of wild game or bush meat are known risk factors(Reynolds et al., 2007). The disease's clinical manifestations are comparable to but less severe than smallpox(Manifestations, 2002). Lymphadenopathy seems to be one of the key differentiating factors between monkeypox and smallpox(Brown & Leggat, 2016). Monkeypox's symptoms include fever, generalized headache, fatigue, lymphadenopathy, back pain, myalgia, and rash (Vaughan et al., 2020)(Manifestations, 2002). On the other hand, a study done to assess the knowledge of monkeypox among general practitioners showed that more than a third of them had good knowledge about it(Harapan et al., 2020).
Historically, vaccination against smallpox was shown to be protective against monkeypox, reported to be 85%(Fine et al., 1988). However, while one vaccine (MVA-BN) and one specific treatment (tecovirimat) were approved for monkeypox in 2019 and 2022, respectively, these countermeasures are not yet widely available, and populations worldwide under the age of 40 or 50 years no longer benefit from the protection afforded by prior smallpox vaccination programs (Volkmann et al., 2021).
The increased number of human monkeypox cases demonstrates healthcare workers' importance of prevention, early detection, and quick response/management. However, a report by the WHO showed that one of the challenges faced in preventing the reemergence of monkeypox was a lack of knowledge of monkeypox, particularly among healthcare workers(Monkeypox - United Kingdom of Great Britain and Northern Ireland, n.d.) .Therefore, healthcare workers must be knowledgeable and prepared for monkeypox cases in different regions, including the Middle East. In this region, especially in Saudi Arabia, there are the Hajj and Omrah destinations, which could increase its vulnerability to the importation of human monkeypox. Hence, we sought to assess physicians' knowledge and attitude toward monkeypox in Saudi Arabia.