Das et al.

BMC Infectious Diseases (2024) 24:295 BMC Infectious Diseases

https://doi.org/10.1186/s12879-024-09184-5

RESEARCH Open Access

Socio-demographic determinants of the

knowledge of Monkeypox Virus among the
general public: a cross-sectional study in a
Tertiary Care Center in Nepal
Santa Kumar Das1, Abhinav Bhattarai2, Kiran Paudel2,4, Sandesh Bhusal2, Sangam Shah2, Sakchhyam Timsina2,
Aastha Subedi3, Sandhya Niroula3, Najim Z. Alshahrani5, Sanjit Sah6,7, Bijaya Kumar Padhi8, Joshuan J. Barboza9,
Alfonso J. Rodriguez-Morales10,11,12, Luis A. Salas-Matta10, D. Katterine Bonilla-Aldana13* and Ranjit Sah14,15,16

Abstract
Background and objective Monkeypox virus (MPXV) is the causative agent of monkeypox’s zoonotic infection and
was declared a global emergency by the World Health Organization (WHO). Studies from different countries have
shown insufficient knowledge among the general public on MPXV. This study aimed to assess the knowledge of the
general public of Nepal on MPXV.
Methods Three hundred people were interviewed in person in October 2022, and 282 complete responses were
recorded. The questionnaire related to the knowledge of MPXV was derived from a previous study conducted among
the general population of Saudi Arabia. Twenty-two questions were included that assessed the knowledge and
attitude of Nepalese toward monkeypox. Statistical comparison between high and low knowledge was performed
using Pearson’s Chi-square test. Logistic regression models were deployed to establish the relationship between
participants’ knowledge and socio-demographic characteristics.
Results Among the total respondents, 53.8% demonstrated high knowledge of monkeypox. People aged 18–25
years, unmarried people, and those living in urban areas had significantly higher levels of knowledge. Most
respondents believed that MPXV is not a conspiracy or bioterrorism (63.1%) and agreed that it is likely to affect
people’s social and economic life as COVID-19 did (67.0%). The history of COVID-19 vaccination (aOR: 2.980; 95%CI:
1.227, 7.236) and the younger age (aOR: 2.975; 95%CI: 1.097, 8.069) were found to be significant determinants of the
knowledge of the participants on monkeypox.
Conclusion We observed that most Nepalese populations had a high knowledge of monkeypox and that social
media was the most valuable source of information.
Keywords Knowledge, Monkey pox, Nepal, Virus, MPXV, Population

*Correspondence:
D. Katterine Bonilla-Aldana
dbonilla@continental.edu.pe
Full list of author information is available at the end of the article

© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use,
sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and
the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this
article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included
in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The
Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available
in this article, unless otherwise stated in a credit line to the data.
Das et al. BMC Infectious Diseases (2024) 24:295 Page 2 of 9

Introduction inanimate objects, such as contaminated fabrics, linens

Monkeypox virus (MPXV) is a double-stranded DNA or towels, can cause an infection. Sexual contact and inti-
virus that belongs to the Poxviridae family and causes a mate social behaviours, including hugging, kissing, and
zoonotic infection. MPXV belongs to the same family as handshakes, could be sources of direct contact [10, 11].
smallpox, and symptoms of both resemble clinically [1]. Transmission via respiratory secretions has been docu-
The World Health Organization (WHO) declared mon- mented. However, the case-fatality rate is much lower
keypox (MPXV) a global health emergency, considering than smallpox (MPXV 0-11%, while smallpox is up to
monkeypox outbreaks in more than 100 countries [2]. 30%) [12, 13]. Common symptoms of MPXV are fever,
Globally, as of February 2024, the total number of MPXV body pain, headache, rashes on the skin, and lymphade-
cases reported from 118 countries has exceeded 93,000. nopathy. In particular, the rashes typically on the skin,
The highest number of cases has been reported from scalp, and genitals come to visibility, after which MPXV
the United States, with over 31,000 confirmed cases. infection is suspected. However, life-threatening com-
One hundred eleven countries where cases have been plications of MPXV, such as pneumonia, secondary skin
reported do not have a history of previous MPXV out- infections, proctitis, ocular problems, and sepsis due to
breaks and are experiencing their first outbreak. Seven bacterial superinfections, may occur [14]. Currently, the
have already had a history of sporadic outbreaks [3]. On definitive treatment for MPXV is unavailable; antiviral
November 28, 2022, WHO put forward the term ‘mpox’ drugs used for smallpox treatment and smallpox vaccines
as the preferred terminology for monkeypox [4]. are used to treat MPXV.
Today, media coverage has reported MPXV as a novel Although MPXV is not a novel virus, its outbreaks have
virus, which is a false claim. It was discovered for the been occurring for a long time. Until now, there have
first time in 1958 in a colony of Asian monkeys kept for been no cases confirmed in Nepal yet. However, the rapid
research in an animal facility at the Statens Serum Insti- incline in cases in neighbouring India is concerning [3].
tute, Copenhagen, Denmark [5]. In 1970, the first human Since the Nepal-India border is open, Nepal appears to
infection with MPXV was reported in a 9-month-old boy be at a high risk of transmission and outbreak. Nepal’s
in the Democratic Republic of Congo (then Zaire), where progress on MPXV preparedness is continuous. The
smallpox had already been eradicated. Subsequently, spo- National Public Health Laboratory (NPHL), Kathmandu,
radic outbreaks have occurred in Central and West Africa has upgraded its diagnostic tools and protocols to com-
[6]. The first monkeypox outbreak outside the African ply with WHO MPXV detection standards to avoid miss-
continent occurred in 2003 in the USA, which was attrib- ing any cases.
uted to the importation of infected pets [7]. However, Furthermore, the Ministry of Health and Population,
the largest outbreak occurred in Nigeria in 2017, with 68 Nepal, has established a hotline for reporting febrile and
confirmed cases. A Nigerian tourist reported Asia’s first pox-like symptoms doubtful of MPXV infection [15].
monkeypox infection in Singapore in 2019 [8]. Similarly, Importantly, Nepal is prone to suffering from unheal-
multiple cases of monkeypox have been reported. able health and economic crisis in case of an outbreak,
The new, unanticipated rise in monkeypox cases as observed by the COVID-19 lockdowns. Above all the
began in early May 2022, with a sharp increase in cases preparedness of health authorities against MPXV, there
in Europe, the United States, Australia, and most other has to be sufficient knowledge and comprehension of
non-endemic countries, causing a global public health every citizen on disease outbreaks, currently as MPXV.
concern. Despite the WHO’s declaration of a public Unfortunately, a decline in research and awareness has
health emergency on July 23, 2022, and the continuous resulted in illiteracy and negligence of the potentially
implementation of preventive measures to oversee the contagious infection.
outbreak, cases have not subsided and rapidly increased During the pandemic of COVID-19, MPXV could
until 2023. Until early August 2022, 30,000 cases were emerge as an additional burden to the world in terms of
confirmed; within two months, by October, the cases health and economy. In addition, the cessation of small-
doubled [3]. On the mortality side, the death rate is pox vaccination has left a significant portion of the global
lower than expected, representing 0.04% [9], significantly population susceptible to MPXV, with increasing cases
lower than the 1–3% reported during outbreaks caused in Central and West African countries [16]. Nepal’s vul-
by a similar viral strain in West Africa over the past few nerability to MPXV is a concern due to its lack of small-
decades [9]. pox vaccination program. People need to have adequate
Although the typical route of infection with MPXV is knowledge of this emerging MPXV outbreak to achieve
zoonotic, easy person-to-person transmission has been the objectives of reducing cases and preventing the
shown. Direct contact with MPXV infected person, spread of a new burden. From our COVID-19 experi-
including rashes, scabs, or body fluids, can result in the ences, inadequate awareness and increased public neg-
transmission of the disease. Furthermore, contact with ligence were two major factors responsible for the rapid
Das et al. BMC Infectious Diseases (2024) 24:295 Page 3 of 9

rise in cases despite strict preventive measures such as Ethical approval and consent to participate
lockdowns and vaccination. Reports from WHO state The Institutional Review Board (IRB) of the Institute of
that a challenge in MPXV outbreak control is citizens’ Medicine (IOM) has reviewed, revised, and provided the
lack of sufficient knowledge [17]. In this regard, many final ethical approval for the study (Approval number:
studies investigated the level of knowledge about MPXV 183 [6–11]E2). All methods were carried out in accor-
among various diminutions of people of different nations dance with declaration of Helsinki guidelines and regula-
[18]. Most of these studies have found that most of the tions. Written informed consent was obtained from the
population has inadequate knowledge of MPXV [11, 12, participants for the data collection.
19, 20]. Currently, there are no studies investigating the
knowledge of Nepalese citizens on monkeypox. There- Study participants and eligibility criteria
fore, our primary objective was to assess the level of All Nepalese over 18 years who attended TUTH as visi-
knowledge about MPXV among the general population tors were the desired inclusive population, and there-
of Nepal and establish its association with the popula- fore, a non-probability convenience sampling strategy
tion’s socio-demographics. Additionally, we investigated was utilised. Visitors at the hospital’s visitor section were
the difference in the knowledge according to different interviewed, and one visitor per patient was recruited for
sources of information. the study. Those who were willing to give their consent
were eligible to be included in this study. Likewise, sick
Methods individuals who visited the hospital for consultation were
Study design also excluded. (Fig. 1) We used a convenience sampling
A cross-sectional single-centred study was conducted technique in choosing the study participants. The sample
among people who visited Tribhuvan University Teach- size was calculated using the formula;
ing Hospital (TUTH) in Maharajgunj, Kathmandu,
Nepal, in October 2022. TUTH is one of the largest n = Z2 p (1 − p) / d2
health institutions in Nepal and is known to provide a
wide variety of disciplines and medical services for which z = standard normal variate is 1.96 at a 95% confidence
people from all around Nepal arrive for consultation and level.
treatment. The selection of this study site increased our p = expected proportion in population based on previ-
chances of inclusion of a diverse Nepalese population. ous study or pilot study.
Moreover, since all investigators had been affiliated with d = desirable error = 5%.
the study site, this site was selected for easy data acquisi- To our knowledge, this is the first study conducted in
tion. The research was performed in a qualitative cross- Nepal. Thus, considering the conservative estimate of
sectional study design. 20% with a precision error of 5% and a 95% confidence
level.

Fig. 1 Selection of study participants

Das et al. BMC Infectious Diseases (2024) 24:295 Page 4 of 9

Sample size, n = (1.96)2 × 0.2 × (1 − 0.2) / (0.05)2 Age, which was divided into categories of 18 to 25
= 246 years, 26 to 45 years, and over 46 years, gender (male
or female), marital status (single or married), region of
Considering the non-response rate as 10%, the non- residence region in Nepal (central / mid-western / far-
response rate = 10% of 246 = 24.6 25. western / western/eastern) and urban or rural area, were
Therefore, the minimum sample size = 246 + 25 = 271. explanatory variables. The employment status, the nature
of their job as healthcare workers, the presence of chronic
Data collection tool conditions, their smoking habits, and their monthly sal-
We used a structured, validated questionnaire for data ary were all asked about. The amount of income was
collection. The questions referenced a previously pub- calculated in Nepalese rupees (NR) and split into two
lished study conducted by Alshahrani et al. in Saudi Ara- ranges: equal or more than 30,000 (≥ US$227) and less
bia [19]. We modified it to make it suitable in the context than 30,000 (< US$227). The levels of education were
of Nepal. For the ease of study participants, the ques- recorded as high school and lower, bachelor’s and post-
tions were translated into the Nepali language. Initially, graduate degrees. They were asked if they had received
authors KP, SS, and AS, who held extensive experience every recommended childhood vaccination. The par-
in community interviews, tested the quality and reliabil- ticipants had to select all relevant sources from TV and
ity of this survey. Investigators ST, AS, and SB conducted radio, social media, healthcare professionals, family or
one-to-one interviews to complete the questionnaire. friends, books, studies, and articles to determine where
The questionnaire had two sections: the first covered they learned about monkeypox. Following questions
socio-demographic details and health-related questions. about monkeypox symptoms, participants were asked if
Twenty-two multiple-choice questions measuring knowl- they believed the disease would have the same social and
edge of monkeypox were included in the second portion. economic effects as the COVID-19 pandemic or if it was
They were developed based on prior research [16, 18, 20– a plot or act of bioterrorism.
24] and existing facts from the United States Centers for
Disease Control and Prevention (CDC) [25]. Each ques- Statistical analysis
tion included three options for responses: “Yes,” “No,” We used IBM SPSS Statistics, Version 26 (IBM Corp,
and “I don’t know.” To ensure the validity of this survey, it Armonk, NY, USA) for statistical analyses. Mean and
was pre-tested on 15 members of the general public. The standard deviation (SD) was used to represent continu-
pilot study results were only used to enhance the clarity ous variables, and frequency and percentages were used
of the questions. to represent categorical variables. The data, specifically
the knowledge scores, followed a normal distribution
Data collection procedure with mean and SD. Furthermore, knowledge scores were
Information from the general public was gathered via a divided into low and high levels of knowledge. As a cut-
standardised questionnaire. The investigators and vol- off point, we used the mean score of 10; a mean score > 10
unteers collected data from the respondents via an in- was considered high, and a mean score of 10 or less was
person survey. Before proceeding to the interview, each considered low. Pearson’s Chi-square test was performed
respondent was asked to consent by signing the consent to compare the explanatory and response variables. Mul-
statement. The objectives and the expected benefits of tivariable analysis was performed to analyse the associa-
the study were clearly explained. After the acquisition tion of different variables on the knowledge of MPXV.
of consent, an in-person survey was performed, where Since there are always possibilities of suppressor vari-
each question was asked to the respondent, and answers ables that could suppress the statistical significance in
were noted. Each in-person survey took approximately univariable analysis, all variables were subjected to the
8–10 min. multivariable analysis. The threshold for statistical sig-
nificance was established using the p-value < 0.05.
Study variables
Twenty-two questions with “Yes,” “No”, and “I don’t Results
know” responses were used to assess the knowledge Socio-demographic characteristics of the study
of monkeypox. Scores were assigned as ‘1’ for correct participants
answers and ‘0’ for incorrect answers. If the participant Of the 300 questionnaires distributed, 282(94%) were
selected ‘I don’t know’, the selection was assigned string completed and included in the final analysis. Most
‘NA’ and the particular question was excluded from the respondents (50.4%) were 18–25 years old. Male respon-
knowledge score evaluation. The knowledge score was dents were greater than females (55.7% and 44.3%,
classified as 0 (lowest) to 22 (highest). respectively), and most were unmarried (56.4%). Most of
the respondents (67.4%) resided in urban areas of Nepal.
Das et al. BMC Infectious Diseases (2024) 24:295 Page 5 of 9

A large proportion (69.1%) of the respondents were not (63.1%) and agreed that it is likely to affect people’s social
graduates, followed by postgraduates (25.9%) and bach- and economic life as COVID-19 did (67.0%) (Table 1).
elor’s degrees (5.0%). Most were unemployed (63.8%),
and most employed had a monthly income of less than 30 Relationship between the knowledge score and the socio-
thousand Nepalese rupees (69.1%). demographics of the respondents
Among the participants, 17.4% had an existing chronic The proportion of respondents and the answers recorded
disease, and 18.1% were smokers. More than 90% of is displayed in Table 2. The level of knowledge was clas-
all respondents had completed all childhood vaccina- sified as low and high based on the cut-off value, which
tions provided by the Nepalese government, including was 10 in our study. One hundred thirty-two individu-
the recent COVID-19 vaccination. Most respondents als (46.8%) and 150 individuals (53.2%) had low and high
believed that MPXV is not a conspiracy or bioterrorism knowledge, respectively. Age (p = 0.003), marital status
(p = 0.01), residency area (p = 0.02) and vaccination status

Table 1 Relationship between the knowledge score and the socio-demographics of the respondents
Variable N (%) Knowledge score Knowledge level (cut-off score = 10)
Mean (SD) Low (n = 132) High (n = 150) P-value
Age in Years
18–25 142 (50.4) 11.6 (3.5) 53 (37.3) 89 (62.7) 0.003*
26–45 111 (39.4) 10.0 (4.3) 60 (54.1) 51 (45.9)
45 above 29 (10.3) 8.5 (4.6) 19 (65.5) 10 (34.5)
Gender
Male 157 (55.7) 10.8 (4.1) 74 (47.1) 83 (52.9) 0.9
Female 125 (44.3) 10.5 (4.2) 58 (46.4) 67 (53.6)
Marital Status
Married 123 (43.6) 9.7 94.4) 68 (55.3) 55 (44.7) 0.01*
Unmarried 159 (56.4) 11.4 (3.7) 64 (40.3) 9 (59.7)
Residency
Urban 190 (67.4) 11.2 (3.8) 80 (42.1) 110 (57.9) 0.02*
Rural 92 (32.6) 9.7 (4.4) 52 (56.5) 40 (43.5)
Education level
High school and below 195 (69.1) 10.5 (4.1) 93 (47.7) 102 (52.3) 0.9
Undergraduate 14 (5.0) 11.1 (4.0) 6 (42.9) 8 (57.1)
Postgraduate 73 (25.9) 10.9 (4.5) 33 (45.2) 40 (54.8)
Employment
Yes 102 (36.2) 9.5 (3.6) 48 (47.1) 54 (52.9) 0.9
No 180 (63.8) 10.5 (5.4) 84 (46.7) 96 (53.3)
Monthly Income
Below 30 thousand 195 (69.1) 11.6 (3.1) 91 (46.7) 104 (53.3) 0.9
30 thousand and above 87 (30.9) 10.8 (2.6) 41 (47.1) 46 (52.99
Chronic disease
Yes 49 (17.4) 9.8 (5.4) 26 (53.1) 23 (46.9) 0.3
No 233 (82.6) 10.8 (3.8) 106 (45.5) 127 (54.5)
Health care worker
Yes 16 (5.7) 11.3 (3.7) 7 (43.8) 9 (56.2) 0.8
No 266 (94.3) 10.6 (4.1) 125 (47.0) 141 (53)
Do you ever smoke?
Yes 51 (18.1) 10.0 (3.7) 28 (54.9) 23 (45.1) 0.2
No 231 (81.9) 10.8 (4.1) 104 (45.0) 127 (55.0)
COVID-19 vaccinated
Yes 255 (90.4) 10.9 (4.0) 113 (44.3) 142 (55.7) 0.01*
No 27 (9.6) 8.3 (4.6) 19 (70.4) 8 (29.6)
Childhood vaccinated
Yes 258 (91.5) 10.8 (4.1) 115 (44.6) 143 (55.4) 0.01*
No 24 (8.5) 8.8 (3.9) 17 (70.8) 7 (29.2)
*Significant p value < 0.05
Das et al. BMC Infectious Diseases (2024) 24:295 Page 6 of 9

Table 2 Responses for knowledge questions Table 3 Relationship between the knowledge score and the
S.N Question Yes No source of information of the participants
(%) (%) Source of information Knowledge level P value
1 Is monkeypox an infectious disease? 89.5 10.5 TV and radio Low High
2 Monkeypox is a new infection that appeared in the 19.1 80.9 Yes 94 (61.4) 59 (38.6) < 0.001*
year 2022 No 38 (29.5) 91 (70.5)
3 Monkeypox is a sexually transmitted disease 48.6 51.4 Social Media
4 Chickenpox and monkeypox are the same diseases. 62.1 37.9 Yes 94 (42.5) 127 (57.5) 0.006*
5 Monkeypox is common in Middle Eastern 29.4 70.6 No 38 (62.3) 23 (37.7)
countries.
Health care provider
6 Monkeypox is common in West and Central African 49.6 50.4
Yes 34 (68%) 16 [32] 0.001*
countries.
No 98 (42.2) 134 (57.8)
7 There are many cases recorded in Nepal. 55 45
Family or friend
8 Monkeypox cases are increasing in the USA and 51 49
Europe Yes 24 (48) 26 (52) 0.8
9 Monkeypox is a contagious viral disease 69 31 No 108 (46.6) 124 (53.4)
10 Monkeypox is a contagious bacterial disease 44.7 55.3
11 Monkeypox is easily transmitted from one person 12.1 87.9
radio or other individuals, including healthcare providers
to another.
and family or friends (Table 3).
12 Monkeypox is transmitted to humans through bites 53 47
and scratches from infected animals. Table 4 shows the multiple logistic regression analysis.
13 People with monkeypox can transmit the disease 67.4 32.6 The history of COVID vaccination (aOR: 2.980; 95%CI:
to others (the disease is transmitted between 1.227, 7.236) and younger age (aOR: 2.975; 95%CI: 1.097,
humans). 8.069) were found to be significant determinants of the
14 Monkeypox is spread by droplets (coughing and 48 52 knowledge of the participants on monkeypox.
sneezing)
15 The first symptoms of monkeypox are similar to 47 53 Discussion
the flu
Our findings suggest that the general public lacks criti-
16 Monkeypox only affects males 73 27
cal knowledge and comprehension of monkeypox. More
17 Hand sanitisers and face masks are important in 64 36
preventing monkeypox than 53.2% of the study participants knew what mon-
18 There is a special treatment for monkeypox 29 71 keypox was, whereas 46.8% had never heard of the virus
19 Monkeypox is spread through bodily fluids 49 51 before. The general lack of information is unsurprising,
20 There is a monkeypox vaccine available in Nepal 54 45 given that monkeypox is a recurrent infectious disease
21 The chickenpox vaccine I got in childhood protects 46 54 and that no cases have ever been reported in Nepal. Our
me from monkeypox. study aligns with prior researches in Nepal, indicating a
22 There is a smallpox vaccine that can be used for 17 82 inadequacy of information regarding monkeypox [26,
monkeypox. 27]. Our findings differ from those of the Saudi popula-
tion, which revealed that only 48% of respondents had a
(p = 0.01) were significantly associated with the differ- high knowledge of MNXP [19]; this disparity may be due
ence in knowledge of monkeypox. Unmarried respon- to differences in study timing. In addition, our findings
dents aged 18–25, respondents living in urban areas, and contrast with those of a Malaysian study, which found
respondents with complete childhood and COVID-19 that despite their lack of knowledge of transmission and
vaccination had a significantly higher level of knowledge treatment, nearly 95% of respondents were aware of den-
(p < 0.05). Knowledge did not differ between male and gue fever, another viral infection, during its outbreak
female respondents (p = 0.9). There were no significant [28]. A pilot study carried out among hospital visitors in
differences in monkeypox knowledge in terms of edu- Karachi, Pakistan, showed that only 38.5% of participants
cational qualifications. The majority of nonsmokers had understood the viral disease well. However, 90% of them
a higher knowledge score (55.0%). Most respondents were aware of it [29]. Similarly, a Pakistani poll found
(53.8%) who agreed that monkeypox is a conspiracy or that only 35% of people in low and high-socioeconomic
bioterrorism had a lower level of knowledge (Table 1). groups were aware of the dengue outbreak [30]. For the
sake of public health, more research is required to under-
Relationship between the knowledge score and the source stand why the endemic population around the world is so
of information of the participants ignorant of a newly emerging virus [31].
Respondents who learned about the MPXV and its out- Amid this global upheaval, the word about possible
break via social media had significantly higher knowledge human monkeypox virus infections in Nepal spread
than those who knew about MPXV via television and quickly on social media. However, Nepali authorities
Das et al. BMC Infectious Diseases (2024) 24:295 Page 7 of 9

Table 4 Multiple logistic regression analysis for association Additionally, most of our study participants were
between knowledge and socio-demographic characteristics largely unaware of the history of the virus, and there is
(N = 282) typically not enough comprehension of the transmis-
Variable aOR [95% CI] P-value
sion channels. Our results corroborate the World Health
Age
Organization (WHO) study that found that one of the
18–25 Ref
challenges in preventing the re-emergence of monkeypox
26–45 2.975 [1.097, 8.069] 0.032*
was a lack of knowledge about the disease [33]. Although
45+ 1.401 [0.582, 3.372] 0.451
most survey respondents could not distinguish between
Gender
monkeypox and smallpox symptoms, practically all of
Male Ref
them were aware that monkeypox is a viral disease that
Female 1.035 [0.630, 1.699] 0.892
Education
affects them. However, due to a lack of information, the
PG Ref
Nepali population is primarily unaware of the types and
UG 1.083 [0.328, 3.570] 0.896
diversity of viruses that are widespread worldwide.
High school and below 0.907 [0.517, 1.591] 0.733 Our results also showed that people who rely on the
Employment internet or social media for information are more knowl-
No Ref 0.6 edgeable about monkeypox than their peers. That might
Yes 1.1 (0.6–2.1) result from the ease with which most people can access
Income 0.896 information that has been updated thanks to social media
<30,000 (NRs) Ref and the internet. That demonstrates the internet’s value
≥30,000 (NRs) 1.374 [0.766, 2.462] 0.286 in promoting health, particularly in pandemic situations
Marital Status [34]. Online media have become one of the most essen-
Married Ref tial and convenient means of accessing information com-
Unmarried 1.175 [0.608, 2.270] 0.630 pared to other options [35]. These results are consistent
Residence with those of further research carried out in Ethiopia [36]
Rural Ref 0.7 and Egypt [37], which identified the internet and social
Urban 1.1 [0.5, 2.0] media as the primary sources of information. Compared
Healthcare worker to other media, newspapers, local authorities, and health-
No Ref care professionals appear to be less prevalent sources of
Yes 1.5 [0.7, 2.9] 0.20 information about the disease. As a result, to effectively
Chronic disease convey knowledge to the public, the Nepali health system
No Ref may strengthen the participation of community leaders
Yes 1.4 (0.6–3.1) 0.37 and healthcare workers.
Smoking Keeping with the bulk of earlier study conducted in
No Ref the underdeveloped countries [38, 39], we found that
Yes 0.8 (0.4–1.8) 0.7 men in our study were more knowledgeable about this
History of COVID vaccination viral infection than women. As reported in earlier stud-
No Ref ies [40–42], we found that participants’ knowledge of the
Yes 2.980 [1.227, 7.236] 0.015*
transmission of this virus increased among participants
History of childhood vaccination
along with their degree of education. The finding of one
No Ref
Chinese study [43] is consistent with this finding. That
Yes 2.6 [0.9, 7.7] 0.07
may be explained by greater accessibility to media such
as television, radio, and online social networks [44]. The
denied these claims, claiming that no cases of monkey- availability of appropriate facilities to support health
pox had been discovered yet. Given that the virus is still educators, including medical experts and government
being found and people are still dying of it, it is urgent officials, may also impact the general public’s level of
to learn more about its source and how it spreads and understanding in this sector.
to provide people with the information and help they Since Nepal is a multi-ethnic country with substantially
need to protect themselves and others in various situa- divergent economic circumstances, educational attain-
tions [32]. So far as we know, this is the first survey ever ment levels, and cultural norms, it is expected that the
done in Nepal to determine how much the general public population’s levels of knowledge would also differ consid-
knows about the basics, spread, transmission, symptoms, erably [45]. Population segments without internet access
prevention, and treatment of human monkeypox virus or who live in places where the fast escalation of trans-
infection. mission is less likely will also demonstrate less knowledge
when standard and uniform education and dissemination
Das et al. BMC Infectious Diseases (2024) 24:295 Page 8 of 9

Author contributions
measures are advocated for and put into practice. That is SKD conceived the idea of research. SKD, AB, KP, SD, and SS contributed with
accurate despite a sizeable section of the sample contain- the manuscript writing. Rest of authors read and contribute with subsequent
ing good knowledge. Our study holds some limitations. versions of the manuscript. All authors read and approved the final submitted
version.
The study was conducted in just one tertiary care centre,
which limits the representativeness of the results to other Funding
settings. Likewise, we had to deploy convenience sam- APCs were covered by Universidad Continental, Huancayo, Peru.

pling due to resource constraints and could not accom- Data availability
modate a larger sample size, which might limit a more The datasets used and/or analysed during the current study available from the
comprehensive and generalisable result. corresponding author on reasonable request.

Conclusions Declarations
Although mpox is no longer a Public Health Emergency Ethics approval and consent to participate
of International Concern, it is still a differential diag- This study design and procedure were approved by the ethics committee of
nosis, and transmission occurs globally [44, 45]. Then, Institute of Medicine. All participants provided their written informed consent
for inclusion before participating in the study.
knowledge of this viral disease is necessary to correctly
approach disease prevention, control and treatment Consent for publication
among healthcare workers and the general population. Not applicable.

Around 54% of the participants had high knowledge Competing interests

of the Monkeypox virus. Unmarried respondents aged The authors declare no competing interests.
18–25 and those living in urban areas had significantly
Author details
higher knowledge. Those vaccinated for COVID-19 and 1
Department of Pulmonology and Critical Care, Tribhuvan University,
all childhood vaccines had comparatively good knowl- Institute of Medicine, 44600 Maharajgunj, Nepal
2
edge. Most people who had good knowledge received Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
3
Central Department of Public Health, Institute of Medicine, Tribhuvan
information on social media. Overall, the comprehension University, Kathmandu, Nepal
of the Nepalese population toward monkeypox is inade- 4
Nepal Health Frontiers, Tokha-5, Kathmandu, Nepal
5
quate, and our findings reveal that there lies a crucial role Department of Family and Community Medicine, Faculty of Medicine,
University of Jeddah, 21589 Jeddah, Saudi Arabia
of social media in uplifting the knowledge of the Nepalese 6
Research Scientist, Global Consortium for Public Health and Research,
population on monkeypox via extensive awareness and Datta Meghe Institute of Higher Education and Research, Jawaharlal
education so that public health safety amidst the mon- Nehru Medical College, 442001 Wardha, India
7
SR Sanjeevani Hospital, Kalyanpur-10, Siraha, Nepal
keypox health emergency can be ensured. Furthermore, 8
Department of Community Medicine and School of Public Health,
prospective studies in Nepal and the entire globe requires Postgraduate Institute of Medical Education and Research (PGIMER),
investigation into the improvement in the knowledge of Chandigarh, India
9
School of Medicine, Universidad Norbert Wiener, Lima, Peru
the population regarding monkeypox over time. 10
Faculties of Health Sciences and Environmental Sciences, Universidad
This study lays the groundwork for forthcoming inqui- Científica del Sur, 4861 Lima, Peru
11
ries that can guide the development of focused educa- Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese
American University, BeirutP.O. Box 36, Lebanon
tional initiatives, policy frameworks, and healthcare 12
Grupo de Investigación Biomedicina, Faculty of Msedicine, Fundacion
interventions. These efforts aim to enhance global pre- Universitaria Autónoma de las Américas-Institucion Universitaria Vision de
paredness and response capabilities in the face of emerg- las Americas, Pereira, Risaralda, Colombia
13
Research Unit, Universidad Continental, Huancayo, Peru
ing infectious diseases such as monkeypox. In essence, 14
Department of Microbiology, Tribhuvan University Teaching Hospital,
proactive measures are urgently needed to enhance pub- Institute of Medicine, 44600 Kathmandu, Nepal
15
lic knowledge, preparedness, and response, fostering Department of Microbiology, Dr. D. Y. Patil Medical College, Hospital
and Research Centre, Dr. D. Y. Patil Vidyapeeth, 411018 Pune, Maharashtra,
a more resilient and informed society. Future research India
should assess the long-term effectiveness of aware- 16
Department of Public Health Dentistry, Dr. D.Y. Patil Dental College and
ness campaigns in enhancing monkeypox knowledge in Hospital, Dr. D.Y. Patil Vidyapeeth, 411018 Pune, Maharashtra, India

Nepal. Understanding vaccine acceptance and cultural

Received: 28 July 2023 / Accepted: 28 February 2024
factors influencing perceptions is crucial for targeted
interventions. Comparative studies across diverse demo-
graphics and regions, exploration of integrating mon-
keypox information into school curricula, and deeper References
analysis of social media’s role in public understanding are 1. Shchelkunov SN, Totmenin AV, Babkin IV, Safronov PF, Ryazankina OI, Petrov
recommended. NA, et al. Human monkeypox and smallpox viruses: genomic comparison.
FEBS Lett. 2001;509(1):66–70.
Acknowledgements 2. Sah R, Padhi BK, Siddiq A, Abdelaal A, Reda A, Ismail Lashin B, et al.
Not applicable. Public Health Emergency of International Concern declared by the World
Das et al. BMC Infectious Diseases (2024) 24:295 Page 9 of 9

Health Organization for Monkeypox. Global Security: Health Sci Policy. workers toward human monkeypox: a cross-sectional study. Front Public
2022;7(1):51–6. Health. 2023;11:1161234.
3. 2022 Monkeypox Outbreak Global Map.| Monkeypox| Poxvirus| CDC [Inter- 27. Paudel K, Gautam K, Sujan MSH, Wickersham JA, Chaudhari PR, Shrestha
net]. [cited 2022 Oct 10]. Available from: https://www.cdc.gov/poxvirus/ R. Uncovering the knowledge gaps: a survey on human monkeypox
monkeypox/response/2022/world-map.html. infection among men who have sex with men in Nepal. Health Prospect.
4. WHO recommends new name. for monkeypox disease [Internet]. 2023;22(1):1–6.
[cited 2023 Mar 10]. Available from: https://www.who.int/news/ 28. Naing C, Ren WY, Man CY, Fern KP, Qiqi C, Ning CN, et al. Awareness of Den-
item/28-11-2022-who-recommends-new-name-for-monkeypox-disease. gue and Practice of Dengue Control among the Semi-urban Community: A
5. Multi-country monkeypox outbreak in non-endemic countries.: Update Cross Sectional Survey. J Community Health 2011. 2011;36(6):6.
[Internet]. [cited 2022 Oct 10]. Available from: https://www.who.int/ 29. Itrat A, Khan A, Javaid S, Kamal M, Khan H, Javed S, et al. Knowledge, aware-
emergencies/disease-outbreak-news/item/2022-DON388. ness and practices regarding Dengue Fever among the Adult Population of
6. Ligon BL, Monkeypox. A review of the history and emergence in the western Dengue hit Cosmopolitan. PLoS ONE. 2008;3(7):e2620.
hemisphere. Semin Pediatr Infect Dis. 2004;15(4):280. 30. Knowledge. attitudes and practices regarding dengue fever among adults by
7. Maskalyk J. Public Health: Monkeypox outbreak among pet owners. CMAJ: Madiha Syed, Taimur Saleem.
Can Med Association J. 2003;169(1):44. 31. Cheema S, Maisonneuve P, Weber I, Fernandez-Luque L, Abraham A, Alrouh
8. Yong SEF, Ng OT, Ho ZJM, Mak TM, Marimuthu K, Vasoo S, et al. Imported H, et al. Knowledge and perceptions about Zika virus in a Middle East coun-
Monkeypox, Singapore. Emerg Infect Dis. 2020;26(8):1826. try. BMC Infect Dis. 2017;17(1):1–9.
9. Spath T, Brunner-Ziegler S, Stamm T, Thalhammer F, Kundi M, Purkhauser K, et 32. WHO. WHO. 2022. Multi-country monkeypox outbreak: situation update.
al. Modeling the protective effect of previous compulsory smallpox vaccina- 33. World Health Organization. WHO Advisory Committee on Variola Virus
tion against human monkeypox infection: from hypothesis to a worst-case Research Report of the Fifteenth Meeting. 2015;(November):1–46.
scenario. Int J Infect Dis. 2022;124:107–12. 34. Budd J, Miller BS, Manning EM, Lampos V, Zhuang M, Edelstein M et al. Digital
10. Kozlov M. How does Monkeypox spread? What scientists know. Nature. technologies in the public-health response to COVID-19. Nature Medicine
2022;608(7924):655–6. 2020 26:8. 2020;26(8):1183–92.
11. Sah R, Abdelaal A, Reda A, Katamesh BE, Manirambona E, Abdelmonem H et 35. Mohamed Ahmed Ayed M, Abd Elaziem Mohamed A, Mohamed Mahmoud
al. Monkeypox and its possible sexual transmission: where are we now with T, Mohammed AbdElaziz S. Effect of Educational intervention on secondary
its evidence? Pathogens 2022, 11, Page 924. 2022;11(8):924. School Students’ knowledge, practices and attitudes regarding COVID-19.
12. Smallpox [Internet]. [cited 2022 Oct 10]. Available from: https://www.who.int/ Egypt J Health Care. 2021;12(2):58–74.
teams/health-product-and-policy-standards/standards-and-specifications/ 36. Aynalem YA, Akalu TY, Gebregiorgis BG, Sharew NT, Assefa HK, Shiferaw WS.
vaccine-standardization/smallpox. Assessment of undergraduate student knowledge, attitude, and prac-
13. Monkeypox [Internet]. [cited 2022 Oct 10]. Available from: https://www.who. tices towards COVID-19 in Debre Berhan University, Ethiopia. PLoS ONE.
int/news-room/fact-sheets/detail/monkeypox. 2021;16(5):e0250444.
14. Kozlov M. How deadly is monkeypox? What scientists know. Nature. 37. Souli D, Dilucca M. Knowledge, attitude and practice of secondary school stu-
2022;609(7928):663. dents toward COVID-19 epidemic in Italy: a cross selectional study. bioRxiv.
15. Subedi D, Acharya KP. Risk of monkeypox outbreak in Nepal. Travel Med Infect 2020. 2020.05.08.084236.
Dis. 2022;49:102381. 38. Sallam M, Al-Mahzoum K, Al-Tammemi AB, Alkurtas M, Mirzaei F, Kareem N,
16. Petersen E, Abubakar I, Ihekweazu C, Heymann D, Ntoumi F, Blumberg L, et al. Assessing Healthcare workers’ knowledge and their confidence in the
et al. Monkeypox - enhancing public health preparedness for an emerging diagnosis and management of human monkeypox: a cross-sectional study in
lethal human zoonotic epidemic threat in the wake of the smallpox post- a Middle Eastern Country. Healthcare. 2022;10(9):1722.
eradication era. Int J Infect Diseases: IJID: Official Publication Int Soc Infect 39. Nath SD, Islam AMK, Majumder K, Rimti FH, Das J, Tabassum MN et al. Assess-
Dis. 2019;78:78–84. ment of Knowledge on Human Monkeypox Virus among General Population
17. Switzerland G. WHO Advisory Committee on Variola Virus Research Report of in Bangladesh: A Nationwide Cross-sectional Study [Internet]. medRxiv; 2022
the Nineteenth Meeting. 2017. [cited 2024 Jan 27]. p. 2022.08.31.22279445. Available from: https://www.
18. Alshahrani NZ, Mitra S, Alkuwaiti AA, Alhumam MN, Altmimi SMB, Alamri medrxiv.org/content/https://doi.org/10.1101/2022.08.31.22279445v1.
MHM et al. Medical students’ perception regarding the re-emerging Mon- 40. Sallam M, Al-Mahzoum K, Dardas LA, Al-Tammemi AB, Al-Majali L, Al-Naimat
keypox Virus: an Institution-based cross-sectional study from Saudi Arabia. H, et al. Knowledge of human monkeypox and its relation to conspiracy
Cureus. 2022;14(8). beliefs among students in Jordanian Health schools: filling the knowledge
19. Rodriguez-Morales AJ, Alshahrani NZ, Alzahrani F, Alarifi AM, Algethami MR, gap on emerging zoonotic viruses. Medicina. 2022;58(7):924.
Alhumam MN et al. Assessment of Knowledge of Monkeypox Viral Infection 41. Harapan H, Setiawan AM, Yufika A, Anwar S, Wahyuni S, Asrizal FW, et
among the General Population in Saudi Arabia. Pathogens 2022, Vol 11, Page al. Knowledge of human monkeypox viral infection among general
904. 2022;11(8):904. practitioners: a cross-sectional study in Indonesia. Pathog Glob Health.
20. Harapan H, Setiawan AM, Yufika A, Anwar S, Wahyuni S, Asrizal FW, et al. 2020;114(2):68–75.
Knowledge of human monkeypox viral infection among general prac- 42. Alhummayani NM, Alobaid JM, Altamimi IM, Nuwayim TA, Alyanbaawi KK,
titioners: a cross-sectional study in Indonesia. Pathogens Global Health. Alhomayani NM et al. Awareness and Knowledge of the General Population
2020;114(2):68–75. About Monkeypox Disease in Riyadh, Saudi Arabia. Cureus [Internet]. 2023
21. Ibrahim NK, Moshref RH, Moshref LH, Walid JB, Alsati HS. Knowledge and Dec 8 [cited 2024 Jan 27];15(12). Available from: https://www.cureus.com/
attitudes towards Zika virus among medical students in King Abdulaziz articles/211080-awareness-and-knowledge-of-the-general-population-
University, Jeddah, Saudi Arabia. J Infect Public Health. 2018;11(1):18–23. about-monkeypox-disease-in-riyadh-saudi-arabia.
22. Alshahrani NZ, Algethami MR, Alari AM, Abdelaal A, Sah R, Rodriguez-Morales 43. Zheng M, Qin C, Qian X, Yao Y, Liu J, Yuan Z, et al. Knowledge and vaccination
AJ. Knowledge and attitude regarding monkeypox virus among physicians in acceptance toward the human monkeypox among men who have sex with
Saudi Arabia, a cross-sectional study. 2022. men in China. Front Public Health. 2022;10:997637.
23. Adler H, Gould S, Hine P, Snell LB, Wong W, Houlihan CF, et al. Clinical features 44. Al Ahdab S, Knowledge. Attitudes and Practices (KAP) towards pandemic
and management of human monkeypox: a retrospective observational study COVID-19 among Syrians. 2020.
in the UK. Lancet Infect Dis. 2022;22(8):1153–62. 45. Nepal Profile– Ministry of Foreign Affairs Nepal MOFA [Internet]. [cited 2023
24. Sallam M, Al-Mahzoum K, Dardas LA, Al-Tammemi AB, Al-Majali L, Al-Naimat May 8]. Available from: https://mofa.gov.np/nepal-profile-updated/.
H et al. Knowledge of Human Monkeypox and Its Relation to Conspiracy
Beliefs among Students in Jordanian Health Schools: Filling the Knowledge
Gap on Emerging Zoonotic Viruses. Medicina (Lithuania). 2022;58(7). Publisher’s Note
25. Online CDC. 2022. Monkeypox| Poxvirus| CDC. Springer Nature remains neutral with regard to jurisdictional claims in
26. Das SK, Bhattarai A, Kc S, Shah S, Paudel K, Timsina S, et al. Socio-demo- published maps and institutional affiliations.
graphic determinants of the knowledge and attitude of Nepalese healthcare