Behind the Paper: International Healthcare Workers’ Experiences and Perceptions of the 2022 Mpox Outbreak

In this post, we talk to the authors of a recently published paper, International healthcare workers’ experiences and perceptions of the 2022 multi-country mpox outbreak, by Vanessa Apea, Boghuma K. Titanji, Francesca H. Dakin, Rosalie Hayes, Melanie Smuk, Habiba Kawu, Laura Waters, Itsik Levy, Daniel R. Kuritzkes, Monica Gandhi, Jürgen Rockstroh, Mauro Schechter, Martin Holt, Romain Palich, Claudia P. Cortes, Silvia Nozza, Cristina Mussini, Alexandra Calmy, Brenda E. Crabtree-Ramirez, José L. Blanco, Sanjay Bhagani, Claire Dewsnap, Chloe Orkin, On Behalf of the Mpox SHARE-NET Writing Group

What led you to decide on this research question?

Being on the frontline of the mpox outbreak response, it was immediately apparent to us that we were navigating a challenging period marked by uncertainty, fear, and fatigue. We were dealing with a disease that many of us had never encountered before, and this lack of familiarity, coupled with the urgency of patient care, heightened feelings of professional unease.

Many of our team members, still recovering from the immense toll of the first two major COVID-19 waves—during which colleagues, friends, and family members were lost—were once again thrust into another global public health emergency. Just as healthcare systems and workers were beginning to regain a sense of normalcy, the mpox outbreak introduced new layers of complexity and stress.

We felt it was crucial to describe and understand the impact of the outbreak on healthcare workers (HCWs). Furthermore, having initiated and  led a large international research collaboration on clinical aspects of mpox during the mpox pandemic during 2022/23, it was clear from our interactions with international colleagues that they did not also feel prepared, that misdiagnoses had occurred,  some had no access to vaccines  and that they were under huge pressure. Having established these relationships we felt it was important to study these important questions internationally.

Beyond the clinical and logistical challenges, we were struck by the parallels between the stigma surrounding mpox and that historically associated with HIV. The early narrative of the outbreak disproportionately focused on cases among men who have sex with men, which led to palpable fear and stigmatisation within affected communities. Having to witness  these harmful patterns resurface also underscored the importance of accurately capturing and sharing the experiences of HCWS in this context.

Could you talk us through how you designed your study? What was important for your team as you created the study team?

Building a diverse and collaborative research team was essential to ensuring broad international participation. Our cross-sectional survey was designed in collaboration with colleagues across multiple WHO regions. Our team included infectious disease specialists, sexual health clinicians, and public health researchers. Our survey focused on HCWs engaged in the clinical response to mpox across Europe, the Caribbean, Central and South America, the United States, and Canada and our primary objective was to examine their experiences, focusing on workload, preparedness, training, support, vaccination, and psychological well-being.  The co-authors  reviewed and shaped the questions to ensure that the questions were relevant and sensitive to the realities of frontline workers within their health setting. We also utilised an option of free text to some questions for respondents to provide some additional insight and context. We were also very cognisant that HCWs were still in the midst of the outbreak so we worked hard to create a survey tool that was manageable and not too lengthy to support completion. Inclusivity was a definite priority, so we translated the survey into multiple languages (English, Spanish, French, and Portuguese) to maximise accessibility. 

What challenges did you encounter during your study?

One of the main challenges was the rapid pace of the mpox outbreak, which required us to design and deploy the survey quickly to capture real-time experiences. This urgency limited our ability to conduct extensive pilot testing, although we did pilot the survey with a small group of sexual health clinicians in the UK to ensure clarity and relevance. The evolution of the outbreak also impacted the pace of recruitment at times as HCWs were already overstretched. The survey covered many aspects of health care providers experiences which meant that survey fatigue occurred. However our international team worked hard to mitigate this as far as possible. The study was also unfunded so it took time to analyse and publish it in amidst other research and clinical commitments.

What did you find most striking about your results? How will this research be used?

Several findings stood out. Firstly, the knowledge gap among HCWs regarding mpox was striking—30% of respondents had never heard of mpox before the outbreak, and over a quarter initially misdiagnosed cases. This highlights the urgent need for proactive training on emerging infectious diseases and an increased focus on disease identification. Secondly, the infectious disease workforce is particularly burned out and exhausted having weathered two pandemics in close succession.The outbreak placed a significant burden on HCWs, with 41% reporting longer working hours and almost 90% stating that their existing responsibilities were not reduced to accommodate mpox-related work. This mirrored challenges faced during COVID-19 and underscored the ongoing vulnerability of frontline HCWs in outbreak responses. Thirdly, moral distress was highly prevalent—55% of respondents resonated with the term, reflecting the ethical dilemmas and emotional toll of the response. Vaccine inequities also emerged as a major concern, with HCWs in the Caribbean, Central, and South America having significantly lower access to mpox vaccination compared to their counterparts in North America and Europe.

These findings will be used to advocate for stronger support systems for HCWs, including better access to vaccines, mental health resources, and training on emerging diseases. The results also underscore the importance of integrating HCW perspectives into pandemic preparedness plans to ensure that health systems are resilient and responsive to future outbreaks.

What further research questions need to be addressed in this area?

Our study raises a number of questions that warrant more exploration; such as “What long-term psychological effects does moral distress have on HCWs, and how can health systems better support them?” Future research should prioritise qualitative studies to delve deeper into the lived realities of HCWs working in outbreaks exploring their perspectives on moral distress with a  longitudinal  design to assess the long-term impact of outbreaks on the workforce. Other key questions are: “How do experiences of HCWs in endemic African regions compare to those in non-endemic regions during mpox outbreaks?” and “How can global vaccine allocation be improved to ensure equitable access for HCWs and high-risk populations?”

Why did you choose PLOS Global Public Health as a venue for your article?

PLOS Global Public Health was a natural home for our study due to its commitment to open-access publishing and its focus on amplifying research from diverse and resource-limited settings. Given the global nature of the mpox outbreak and the disparities in healthcare access highlighted by our findings, it was important to us that the research be freely accessible to policymakers, researchers, and healthcare workers worldwide. PLOS Global Public Health’s emphasis on equity in global health aligned perfectly with our goal of addressing systemic inequities in pandemic response and HCW support. By publishing in this journal, we hope to contribute to a more inclusive and equitable approach to global health research and policy.