Healthcare workers and monkeypox: The case for risk mitigation

Potentially more at risk of contracting the monkeypox virus are healthcare workers. Most healthcare workers come into direct contact with the disease's infected people, which can spread directly and indirectly. Healthcare professionals must contact patients with the disease and any infected objects or fluids to effectively manage the disease, which further increases the risk of transmission. It is crucial to put safety measures in place and protect healthcare workers. To stop the spread of the monkeypox virus, countries must develop the necessary safeguards and countermeasures. In this emergency, healthcare systems must be strengthened. All healthcare systems should offer staff sufficient personal protective equipment (PPE) and facilitate risk assessment among those with a high risk of exposure. Any suspected case of monkeypox requires caution on the part of healthcare professionals. They must abide by infection control safety rules and protective measures.

Potentially more at risk of contracting the monkeypox virus are healthcare workers. Most healthcare workers come into direct contact with the disease's infected people, which can spread directly and indirectly. Healthcare professionals must contact patients with the disease and any infected objects or fluids to effectively manage the disease, which further increases the risk of transmission. It is crucial to put safety measures in place and protect healthcare workers. To stop the spread of the monkeypox virus, countries must develop the necessary safeguards and countermeasures. In this emergency, healthcare systems must be strengthened. All healthcare systems should offer staff sufficient personal protective equipment (PPE) and facilitate risk assessment among those with a high risk of exposure. Any suspected case of monkeypox requires caution on the part of healthcare professionals. They must abide by infection control safety rules and protective measures.
Healthcare workers are the core of health systems worldwide. Healthcare workers, including doctors, dentists, pharmacists, nurses, midwives, paramedics, administrators, support workers, laboratory technicians and community health workers, play a substantial role in responding to global health emergencies, such as the current monkeypox outbreak [1].
Monkeypox is a zoonotic disease caused by a virus that belongs to the Poxviridae family. Taking its name from an initial detection among monkeys in a Danish laboratory in 1958 [2], monkeypox was first diagnosed in humans in 1970 in the Democratic Republic of the Congo (DRC). Since then, the virus has been endemic in Western and Central Africa, but few cases were detected outside Africa in 2003 when the first monkeypox case was detected in the US. This ongoing multi-country monkeypox outbreak, which was first documented in the United Kingdom in May 2022, has quickly spread across the globe [3]. This resulted in gaining global attention and, subsequently, the WHO declaring it a Public Health Emergency of International Concern (PHEIC) [4]. As of 18 November 2022, more than 80,328 cumulative cases of monkeypox have been documented worldwide, alongside 53 deaths [5].
Healthcare workers are inextricably involved in the diagnosis, treatment, and direct management of patients with suspected or confirmed monkeypox infection. However, a significant number of healthcare workers reported a lack of confidence regarding the disease diagnosis and management [6]. This is compounded by eruptions or rashes of the suspected individual, which are often similar in appearance to measles, chickenpox and sexually transmitted diseases [7]. Monkeypox is currently diagnosed through analysis of fluid swabbed from those eruptions or rash sites. However, the capacity to diagnose the disease requires advanced laboratory infrastructure and specialised equipment such as polymerase chain reaction (PCR) assays, nucleic acid amplification tests, and GeneXpert assays [8], which may be difficult to carry out in limited-resource settings, thereby hindering the disease diagnosis, and potentially exposing healthcare workers. Furthermore, despite the vaccination recommendation of HCWs, who are considered at high risk of exposure/infection, many countries still need vaccination, thus being an additional risk factor for healthcare workers to contract the virus [4].
Many other factors render healthcare workers vulnerable to virus transmission. Monkeypox management takes a toll on healthcare workers that primarily serve populations at risk, such as men who have sex with men (MSM), the immunocompromised, and their household and workplace contacts, without necessary workplace precautions due to stigma and diminishing trust in healthcare workers [9]. In addition, protective measures such as contact tracing and adequate follow-up of suspected cases are not implemented in many countries. At the same time, medicines and vaccinations are not available across all dimensions of healthcare [4], from receptionists to doctors, medical laboratory technicians, nurses, support workers or healthcare assistants, and all those involved in patient care from admission to discharge. Studies have documented cases of monkeypox among healthcare workers. For instance, a healthcare worker contracted the monkeypox virus in September 2018 in the United Kingdom due to contact with a contaminated patient's bedding despite having personal protective equipment (PPE) [10]. Moreover, transmissions among health workers have been reported in the Central African Republic [11,12]. Interestingly, new data has reported the Monkeypox virus widespread in hospitalisation environment, furthering the disease exposure to healthcare workers [13,14]. This is a concern because the study showed the virus contamination not only in rooms but also on the PPE of healthcare workers [14].
Considering the above, implementing safeguarding measures and ensuring healthcare workers' protection is essential. It is strongly advocated that countries devise and enforce necessary precautions and measures to protect healthcare workers as part of a wider strategic response to curb the monkeypox outbreak and strengthen the capacity of health systems to address this concern while not forsaking other pressing public health concerns. Areas with a high risk of monkeypox transmission are highly encouraged to sustain the provision of adequate PPE, including gowns, gloves, fluid-repellent surgical facemasks (FRSM), eye protection, and FFP3 respirators for personnel [14,15]. This is in line with the global strategy of strengthening human resources for health towards Universal Health Coverage (UHC) and the Sustainable Development Goals (SDGs) [16], which, more broadly, aims to uphold the rights of all health workers and ensure healthcare workers, and to ensure their safety in providing care through decent working conditions [14,16]. Additionally, in case of any suspected case of monkeypox among healthcare professionals, there is a need to promote preventive action, such as through adherence to protective measures and infection control safety measures, which would greatly prevent infections among more vulnerable groups, such as staff undergoing pregnancy or are of senior age, as well as the immunocompromised.
Most importantly, protecting the high-risk population, including MSM, is critical. Every healthcare worker exposed to the virus should undergo a thorough risk assessment to ascertain their exposure. Depending on the risk level, they should also receive counselling on selfmonitoring, isolation, and the timely reporting of manifestations. Healthcare professionals should be trained to be aware of the potential threat of the monkeypox outbreak and be ready to deal with any potential outbreaks of infectious diseases.

Ethics approval statement
Not applicable.

Funding statement
The authors received no funding for this letter. All authors have read and confirmed that they meet ICMJE criteria for authorship.

Consent
Not applicable.

Registration of research studies
Not applicable.

Data availability statement
Not applicable.

Patient consent statement
Not applicable.

Permission to reproduce material from other sources
Not applicable.