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Abstract
At first glance, a multi-country outbreak of monkeypox in 2022 seems unusual. However, the re-emergence and expansion of this viral disease beyond its endemicity in West and Central Africa had previously been predicted as a possible consequence of a decline in population immunity following smallpox eradication. Since the 13th of May 2022, cases of monkeypox have been reported in at least 28 WHO member states from within 4 regions (the Americans, European, Eastern Mediterranean and Western Pacific regions). This summary describes the multi-country outbreak to date, with an emphasis on patient demographics, common symptoms and signs, clinical management (including infection prevention measures) and clinical outcomes of the cases in the United Kingdom, which has so far reported the largest number of laboratory confirmed cases. The future implications of this outbreak, including preventative measures to curb the current outbreak, prevent future outbreaks and the likelihood of the disease becoming endemic in the UK are also discussed.
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Abdelaal A, Reda A, Lashin BI, Katamesh BE, Brakat AM, AL-Manaseer BM, Kaur S, Asija A, Patel NK, Basnyat S, Rabaan AA, Alhumaid S, Albayat H, Aljeldah M, Shammari BRA, Al-Najjar AH, Al-Jassem AK, AlShurbaji ST, Alshahrani FS, Alynbiawi A, Alfaraj ZH, Alfaraj DH, Aldawood AH, Sedhai YR, Mumbo V, Rodriguez-Morales AJ, Sah R. Preventing the Next Pandemic: Is Live Vaccine Efficacious against Monkeypox, or Is There a Need for Killed Virus and mRNA Vaccines? Vaccines (Basel) 2022; 10:1419. [PMID: 36146497 PMCID: PMC9500691 DOI: 10.3390/vaccines10091419] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/18/2022] [Accepted: 08/26/2022] [Indexed: 11/27/2022] Open
Abstract
(1) Background: The monkeypox virus (MPV) is a double-stranded DNA virus belonging to the Poxviridae family, Chordopoxvirinae subfamily, and Orthopoxvirus genus. It was called monkeypox because it was first discovered in monkeys, in a Danish laboratory, in 1958. However, the actual reservoir for MPV is still unknown. (2) Methods and Results: We have reviewed the existing literature on the options for Monkeypox virus. There are three available vaccines for orthopoxviruses-ACAM2000, JYNNEOS, and LC16-with the first being a replicating vaccine and the latter being non- or minimally replicating. (3) Conclusions: Smallpox vaccinations previously provided coincidental immunity to MPV. ACAM2000 (a live-attenuated replicating vaccine) and JYNNEOS (a live-attenuated, nonreplicating vaccine) are two US FDA-approved vaccines that can prevent monkeypox. However, ACAM2000 may cause serious side effects, including cardiac problems, whereas JYNNEOS is associated with fewer complications. The recent outbreaks across the globe have once again highlighted the need for constant monitoring and the development of novel prophylactic and therapeutic modalities. Based on available data, there is still a need to develop an effective and safe new generation of vaccines specific for monkeypox that are killed or developed into a mRNA vaccine before monkeypox is declared a pandemic.
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Affiliation(s)
- Abdelaziz Abdelaal
- Postgraduate Medical Education, Harvard Medical School, Boston, MA 02115, USA
- School of Medicine, Boston University, Boston, MA 02118, USA
- Tanta Research Team, Tanta 31527, Egypt
- Faculty of Medicine, Tanta University, Tanta 31527, Egypt
| | - Abdullah Reda
- Faculty of Medicine, Al-Azhar University, Cairo 11884, Egypt
| | | | - Basant E. Katamesh
- Tanta Research Team, Tanta 31527, Egypt
- Faculty of Medicine, Tanta University, Tanta 31527, Egypt
| | - Aml M. Brakat
- Faculty of Medicine, Zagazig University, Ash Sharqia Governorate, Zagazig 44519, Egypt
| | - Balqees Mahmoud AL-Manaseer
- Jordan University Hospital, Amman 11942, Jordan
- School of Medicine, University of Jordan, Amman 11733, Jordan
| | - Sayanika Kaur
- Department of Internal Medicine, West Virginia University, Morgantown, WV 26506, USA
| | - Ankush Asija
- Department of Internal Medicine, West Virginia University, Morgantown, WV 26506, USA
| | - Nimesh K. Patel
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA 23284, USA
| | - Soney Basnyat
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA 23284, USA
| | - Ali A. Rabaan
- Molecular Diagnostic Laboratory, Johns Hopkins Aramco Healthcare, Dhahran 31311, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
- Department of Public Health and Nutrition, The University of Haripur, Haripur 22610, Pakistan
| | - Saad Alhumaid
- Administration of Pharmaceutical Care, Al-Ahsa Health Cluster, Ministry of Health, Al-Ahsa 31982, Saudi Arabia
| | - Hawra Albayat
- Infectious Disease Department, King Saud Medical City, Riyadh 11564, Saudi Arabia
| | - Mohammed Aljeldah
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, University of Hafr Al Batin, Hafr Al Batin 39831, Saudi Arabia
| | - Basim R. Al Shammari
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, University of Hafr Al Batin, Hafr Al Batin 39831, Saudi Arabia
| | - Amal H. Al-Najjar
- Drug & Poison Information Center, Pharmacy Department, Security Forces Hospital Program, Riyadh 11564, Saudi Arabia
| | - Ahmed K. Al-Jassem
- Drug & Poison Information Center, Pharmacy Department, Security Forces Hospital Program, Riyadh 11564, Saudi Arabia
| | - Sultan T. AlShurbaji
- Outpatient Pharmacy, Dr. Sulaiman Alhabib Medical Group, Diplomatic Quarter, Riyadh 91877, Saudi Arabia
| | - Fatimah S. Alshahrani
- Department of Internal Medicine, College of Medicine, King Saud University, Riyadh 11362, Saudi Arabia
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, King Saud University, Riyadh 11451, Saudi Arabia
| | - Ahlam Alynbiawi
- Infectious Diseases Section, Medical Specialties Department, King Fahad Medical City, Riyadh 12231, Saudi Arabia
| | - Zainab H. Alfaraj
- Department of Nursing, Maternity and Children Hospital, Dammam 31176, Saudi Arabia
| | - Duaa H. Alfaraj
- Department of Nursing, Maternity and Children Hospital, Dammam 31176, Saudi Arabia
| | - Ahmed H. Aldawood
- Molecular Diagnostic Laboratory, Dammam Regional Laboratory and Blood Bank, Dammam 31411, Saudi Arabia
| | - Yub Raj Sedhai
- Division of Pulmonary Diseases and Critical Care Medicine, University of Kentucky, Bowling Green, KY 40292, USA
| | - Victoria Mumbo
- Coast General Teaching and Referral Hospital, Mombasa P.O. Box 90231-80100, Kenya
| | - Alfonso J. Rodriguez-Morales
- Latin American Network on Monkeypox Virus Research (LAMOVI), Pereira 66001, Colombia
- Institución Universitaria Visión de las Américas, Pereira 12998, Colombia
- Grupo de Investigación Biomedicina, Faculty of Medicine, Fundación Universitaria Autónomade las Américas, Pereira 66003, Colombia
- Master of Clinical Epidemiology and Biostatistics, Universidad Científica del Sur, Lima 4861, Peru
| | - Ranjit Sah
- Postgraduate Medical Education, Harvard Medical School, Boston, MA 02115, USA
- Latin American Network on Monkeypox Virus Research (LAMOVI), Pereira 66001, Colombia
- Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu 44600, Nepal
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Chakraborty S, Chandran D, Mohapatra RK, Alagawany M, El-Shall NA, Sharma AK, Chakraborty C, Dhama K. Clinical management, antiviral drugs and immunotherapeutics for treating monkeypox. An update on current knowledge and futuristic prospects. Int J Surg 2022; 105:106847. [PMID: 35995352 PMCID: PMC9533875 DOI: 10.1016/j.ijsu.2022.106847] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 07/29/2022] [Accepted: 08/11/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Sandip Chakraborty
- Department of Veterinary Microbiology, College of Veterinary Sciences and Animal Husbandry, R.K. Nagar, West Tripura, Tripura, 799008, India
| | - Deepak Chandran
- Department of Veterinary Sciences and Animal Husbandry, Amrita School of Agricultural Sciences, Amrita Vishwa Vidyapeetham University, Coimbatore, 642109, Tamil Nadu, India
| | - Ranjan K Mohapatra
- Department of Chemistry, Government College of Engineering, Keonjhar, 758002, Odisha, India.
| | - Mahmoud Alagawany
- Poultry Department, Faculty of Agriculture, Zagazig University, Zagazig, 44511, Egypt
| | - Nahed A El-Shall
- Department of Poultry and Fish Diseases, Faculty of Veterinary Medicine, Alexandria University, Edfina, El-Beheira, 22758, Egypt
| | - Anil K Sharma
- Department of Biotechnology, Maharishi Markandeshwar University (Deemed to be University) Mullana-Ambala, 133207, Haryana, India
| | - Chiranjib Chakraborty
- Department of Biotechnology, School of Life Science and Biotechnology, Adamas University, Kolkata, West Bengal, India
| | - Kuldeep Dhama
- Division of Pathology, ICAR-Indian Veterinary Research Institute, Bareilly, Izatnagar, Uttar Pradesh, 243122, India.
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O’Shea J, Filardo TD, Morris SB, Weiser J, Petersen B, Brooks JT. Interim Guidance for Prevention and Treatment of Monkeypox in Persons with HIV Infection - United States, August 2022. MMWR. MORBIDITY AND MORTALITY WEEKLY REPORT 2022; 71:1023-1028. [PMID: 35951495 PMCID: PMC9400540 DOI: 10.15585/mmwr.mm7132e4] [Citation(s) in RCA: 74] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
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Abstract
Recently, monkeypox has become a global concern amid the ongoing COVID-19 pandemic. Monkeypox is an acute rash zoonosis caused by the monkeypox virus, which was previously concentrated in Africa. The re-emergence of this pathogen seems unusual on account of outbreaks in multiple nonendemic countries and the incline to spread from person to person. We need to revisit this virus to prevent the epidemic from getting worse. In this review, we comprehensively summarize studies on monkeypox, including its epidemiology, biological characteristics, pathogenesis, and clinical characteristics, as well as therapeutics and vaccines, highlighting its unusual outbreak attributed to the transformation of transmission. We also analyze the present situation and put forward countermeasures from both clinical and scientific research to address it.
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Kmiec D, Kirchhoff F. Monkeypox: A New Threat? Int J Mol Sci 2022; 23:7866. [PMID: 35887214 PMCID: PMC9321130 DOI: 10.3390/ijms23147866] [Citation(s) in RCA: 93] [Impact Index Per Article: 46.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 07/13/2022] [Accepted: 07/16/2022] [Indexed: 02/04/2023] Open
Abstract
The global vaccination programme against smallpox led to its successful eradication and averted millions of deaths. Monkeypox virus (MPXV) is a close relative of the Variola (smallpox) virus. Due to antigenic similarity, smallpox vaccines cross-protect against MPXV. However, over 70% of people living today were never vaccinated against smallpox. Symptoms of monkeypox (MPX) include fever, head- and muscle ache, lymphadenopathy and a characteristic rash that develops into papules, vesicles and pustules which eventually scab over and heal. MPX is less often fatal (case fatality rates range from <1% to up to 11%) than smallpox (up to 30%). MPXV is endemic in sub-Saharan Africa, infecting wild animals and causing zoonotic outbreaks. Exotic animal trade and international travel, combined with the increasing susceptibility of the human population due to halted vaccination, facilitated the spread of MPXV to new areas. The ongoing outbreak, with >10,000 cases in >50 countries between May and July 2022, shows that MPXV can significantly spread between people and may thus become a serious threat to public health with global consequences. Here, we summarize the current knowledge about this re-emerging virus, discuss available strategies to limit its spread and pathogenicity and evaluate its risk to the human population.
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Affiliation(s)
- Dorota Kmiec
- Institute of Molecular Virology, Ulm University Medical Center, 89081 Ulm, Germany;
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Pandey P, Al Rumaih Z, Kels MJT, Ng E, Kc R, Chaudhri G, Karupiah G. Targeting ectromelia virus and TNF/NF-κB or STAT3 signaling for effective treatment of viral pneumonia. Proc Natl Acad Sci U S A 2022; 119:e2112725119. [PMID: 35177474 PMCID: PMC8872766 DOI: 10.1073/pnas.2112725119] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 01/13/2022] [Indexed: 12/14/2022] Open
Abstract
Viral causes of pneumonia pose constant threats to global public health, but there are no specific treatments currently available for the condition. Antivirals are ineffective when administered late after the onset of symptoms. Pneumonia is caused by an exaggerated inflammatory cytokine response to infection, but tissue necrosis and damage caused by virus also contribute to lung pathology. We hypothesized that viral pneumonia can be treated effectively if both virus and inflammation are simultaneously targeted. Combined treatment with the antiviral drug cidofovir and etanercept, which targets tumor necrosis factor (TNF), down-regulated nuclear factor kappa B-signaling and effectively reduced morbidity and mortality during respiratory ectromelia virus (ECTV) infection in mice even when treatment was initiated after onset of clinical signs. Treatment with cidofovir alone reduced viral load, but animals died from severe lung pathology. Treatment with etanercept had no effect on viral load but diminished levels of inflammatory cytokines and chemokines including TNF, IL-6, IL-1β, IL-12p40, TGF-β, and CCL5 and dampened activation of the STAT3 cytokine-signaling pathway, which transduces signals from multiple cytokines implicated in lung pathology. Consequently, combined treatment with a STAT3 inhibitor and cidofovir was effective in improving clinical disease and lung pathology in ECTV-infected mice. Thus, the simultaneous targeting of virus and a specific inflammatory cytokine or cytokine-signaling pathway is effective in the treatment of pneumonia. This approach might be applicable to pneumonia caused by emerging and re-emerging viruses, like seasonal and pandemic influenza A virus strains and severe acute respiratory syndrome coronavirus 2.
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Affiliation(s)
- Pratikshya Pandey
- Viral Immunology and Immunopathology Group, Tasmanian School of Medicine, University of Tasmania, Hobart, TAS 7000, Australia
| | - Zahrah Al Rumaih
- Department of Immunology, John Curtin School of Medical Research, Australian National University, Canberra, ACT 2601, Australia
| | - Ma Junaliah Tuazon Kels
- Department of Immunology, John Curtin School of Medical Research, Australian National University, Canberra, ACT 2601, Australia
| | - Esther Ng
- Department of Immunology, John Curtin School of Medical Research, Australian National University, Canberra, ACT 2601, Australia
| | - Rajendra Kc
- Viral Immunology and Immunopathology Group, Tasmanian School of Medicine, University of Tasmania, Hobart, TAS 7000, Australia
| | - Geeta Chaudhri
- Department of Immunology, John Curtin School of Medical Research, Australian National University, Canberra, ACT 2601, Australia
| | - Gunasegaran Karupiah
- Viral Immunology and Immunopathology Group, Tasmanian School of Medicine, University of Tasmania, Hobart, TAS 7000, Australia;
- Department of Immunology, John Curtin School of Medical Research, Australian National University, Canberra, ACT 2601, Australia
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Shareef FI, Abdulla ML, Ibrahim AE, Subbaram K. Resurgence of Monkeypox: Transmission, Clinical Features with Emphasis on Countermeasures and Treatment. PHARMACOPHORE 2022. [DOI: 10.51847/4ubxvhhdma] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Ali RN, Rubin H, Sarkar S. Countering the potential re-emergence of a deadly infectious disease-Information warfare, identifying strategic threats, launching countermeasures. PLoS One 2021; 16:e0256014. [PMID: 34415941 PMCID: PMC8378755 DOI: 10.1371/journal.pone.0256014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 07/28/2021] [Indexed: 01/04/2023] Open
Abstract
Objectives Eradicated infectious diseases like smallpox can re-emerge through accident or the designs of bioterrorists, and cause heavy casualties. Presently, the populace is largely susceptible as only a small percentage is vaccinated, and their immunity is likely to have waned. And when the disease re-emerges, the susceptible individuals may be manipulated by disinformation on Social Media to refuse vaccines. Thus, a combination of countermeasures consisting of antiviral drugs and vaccines and a range of policies for their application need to be investigated. Opinions regarding whether to receive vaccines evolve over time through social exchanges via networks that overlap with but are not identical to the disease propagation networks. These couple the spread of the biological and information contagion and necessitate a joint investigation of the two. Methods We develop a computationally tractable metapopulation epidemiological model that captures the joint spatio-temporal evolution of an infectious disease (e.g., smallpox, COVID-19) and opinion dynamics. Results Considering smallpox, the computations based on the model show that opinion dynamics have a substantial impact on the fatality count. Towards understanding how perpetrators are likely to seed the infection, we identify a) the initial distribution of infected individuals that maximize the overall fatality count; and b) which habitation structures are more vulnerable to outbreaks. We assess the relative efficacy of different countermeasures and conclude that a combination of vaccines and drugs minimize the fatalities, and by itself, drugs reduce fatalities more than the vaccine. Accordingly, we assess the impact of increase in the supply of drugs and identify the most effective among a collection of policies for administering of drugs for various parameter combinations. Many of the observed patterns are stable to variations of a diverse set of parameters. Conclusions Our findings provide a quantitative foundation for various important elements of public health discourse that have largely been conducted qualitatively.
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Affiliation(s)
- Rex N. Ali
- Department of Electrical and Systems Engineering, University of Pennsylvania, Philadelphia, PA, United States of America
- * E-mail:
| | - Harvey Rubin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Saswati Sarkar
- Department of Electrical and Systems Engineering, University of Pennsylvania, Philadelphia, PA, United States of America
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Russo AT, Grosenbach DW, Chinsangaram J, Honeychurch KM, Long PG, Lovejoy C, Maiti B, Meara I, Hruby DE. An overview of tecovirimat for smallpox treatment and expanded anti-orthopoxvirus applications. Expert Rev Anti Infect Ther 2020; 19:331-344. [PMID: 32882158 PMCID: PMC9491074 DOI: 10.1080/14787210.2020.1819791] [Citation(s) in RCA: 98] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction Tecovirimat (TPOXX®; ST-246) was approved for the treatment of symptomatic smallpox by the USFDA in July of 2018 and has been stockpiled by the US government for use in a smallpox outbreak. While there has not been a reported case of smallpox since 1978 it is still considered a serious bioterrorism threat. Areas covered A brief history of smallpox from its proposed origins as a human disease through its eradication in the late 20th century is presented. The current smallpox threat and the current public health response plans are described. The discovery, and development of tecovirimat through NDA submission and subsequent approval for treatment of smallpox are discussed. Google Scholar and PubMed were searched over all available dates for relevant publications. Expert opinion Approval of tecovirimat to treat smallpox represents an important milestone in biosecurity preparedness. Incorporating tecovirimat into the CDC smallpox response plan, development of pediatric liquid and intravenous formulations, and approval for post-exposure prophylaxis would provide additional health security benefit. Tecovirimat shows broad efficacy against orthopoxviruses in vitro and in vivo and could be developed for use against emerging orthopoxvirus diseases such as monkeypox, vaccination-associated adverse events, and side effects of vaccinia oncolytic virus therapy.
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Affiliation(s)
- Andrew T Russo
- Poxvirus Research Group, SIGA Technologies, Inc, Corvallis, OR, USA
| | | | | | | | - Paul G Long
- Regulatory Affairs, SIGA Technologies, Inc, Corvallis, OR, USA
| | - Candace Lovejoy
- Program Management, SIGA Technologies, Inc, Corvallis, OR, USA
| | - Biswajit Maiti
- Drug Metabolism & Pharmacokinetics, SIGA Technologies, Inc, Corvallis, OR, USA
| | - Ingrid Meara
- Clinical Research, SIGA Technologies, Inc, Corvallis, OR, USA
| | - Dennis E Hruby
- Chief Scientific Officer, SIGA Technologies, Inc, Corvallis, OR, USA
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IMVAMUNE ® and ACAM2000 ® Provide Different Protection against Disease When Administered Postexposure in an Intranasal Monkeypox Challenge Prairie Dog Model. Vaccines (Basel) 2020; 8:vaccines8030396. [PMID: 32698399 PMCID: PMC7565152 DOI: 10.3390/vaccines8030396] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/13/2020] [Accepted: 07/14/2020] [Indexed: 02/07/2023] Open
Abstract
The protection provided by smallpox vaccines when used after exposure to Orthopoxviruses is poorly understood. Postexposu re administration of 1st generation smallpox vaccines was effective during eradication. However, historical epidemiological reports and animal studies on postexposure vaccination are difficult to extrapolate to today’s populations, and 2nd and 3rd generation vaccines, developed after eradication, have not been widely tested in postexposure vaccination scenarios. In addition to concerns about preparedness for a potential malevolent reintroduction of variola virus, humans are becoming increasingly exposed to naturally occurring zoonotic orthopoxviruses and, following these exposures, disease severity is worse in individuals who never received smallpox vaccination. This study investigated whether postexposure vaccination of prairie dogs with 2nd and 3rd generation smallpox vaccines was protective against monkeypox disease in four exposure scenarios. We infected animals with monkeypox virus at doses of 104 pfu (2× LD50) or 106 pfu (170× LD50) and vaccinated the animals with IMVAMUNE® or ACAM2000® either 1 or 3 days after challenge. Our results indicated that postexposure vaccination protected the animals to some degree from the 2× LD50, but not the 170× LD5 challenge. In the 2× LD50 challenge, we also observed that administration of vaccine at 1 day was more effective than administration at 3 days postexposure for IMVAMUNE®, but ACAM2000® was similarly effective at either postexposure vaccination time-point. The effects of postexposure vaccination and correlations with survival of total and neutralizing antibody responses, protein targets, take formation, weight loss, rash burden, and viral DNA are also presented.
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Abstract
Forty years after the last endemic smallpox case, variola virus (VARV) is still considered a major threat to humans due to its possible use as a bioterrorism agent. For many years, the risk of disease reemergence was thought to solely be through deliberate misuse of VARV strains kept in clandestine laboratories. However, recent experiments using synthetic biology have proven the feasibility of recreating a poxvirus de novo, implying that VARV could, in theory, be resurrected. Because of this new perspective, the WHO Advisory Committee on VARV Research released new recommendations concerning research on poxviruses that strongly encourages pursuing the development of new antiviral drugs against orthopoxviruses. In 2018, the U.S. FDA advised in favor of two molecules for smallpox treatment, tecovirimat and brincidofovir. This review highlights the difficulties to develop new drugs targeting an eradicated disease, especially as it requires working under the FDA "animal efficacy rule" with the few, and imperfect, animal models available.
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Russo AT, Berhanu A, Bigger CB, Prigge J, Silvera PM, Grosenbach DW, Hruby D. Co-administration of tecovirimat and ACAM2000™ in non-human primates: Effect of tecovirimat treatment on ACAM2000 immunogenicity and efficacy versus lethal monkeypox virus challenge. Vaccine 2020; 38:644-654. [PMID: 31677948 PMCID: PMC6954297 DOI: 10.1016/j.vaccine.2019.10.049] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 10/08/2019] [Accepted: 10/17/2019] [Indexed: 02/06/2023]
Abstract
Naturally occurring smallpox has been eradicated but research stocks of variola virus (VARV), the causative agent of smallpox, still exist in secure laboratories. Clandestine stores of the virus or resurrection of VARV via synthetic biology are possible and have led to concerns that VARV could be used as a biological weapon. The US government has prepared for such an event by stockpiling smallpox vaccines and TPOXX®, SIGA Technologies' smallpox antiviral drug. While vaccination is effective as a pre-exposure prophylaxis, protection is limited when administered following exposure. Safety concerns preclude general use of the vaccine unless there is a smallpox outbreak. TPOXX is approved by the FDA for use after confirmed diagnosis of smallpox disease. Tecovirimat, the active pharmaceutical ingredient in TPOXX, targets a highly conserved orthopoxviral protein, inhibiting long-range dissemination of virus. Although indications for use of the vaccine and TPOXX do not overlap, concomitant use is possible, especially if the TPOXX indication is expanded to include post-exposure prophylaxis. It is therefore important to understand how vaccine and TPOXX may interact. In studies presented here, monkeys were vaccinated with the ACAM2000TM live attenuated smallpox vaccine and concomitantly treated with tecovirimat or placebo. Immune responses to the vaccine and protective efficacy versus a lethal monkeypox virus (MPXV) challenge were evaluated. In two studies, primary and anamnestic humoral immune responses were similar regardless of tecovirimat treatment while the third study showed reduction in vaccine elicited humoral immunity. Following lethal MPXV challenge, all (12 of 12) vaccinated/placebo treated animals survived, and 12 of 13 vaccinated/tecovirimat treated animals survived. Clinical signs of disease were elevated in tecovirimat treated animals compared to placebo treated animals. This suggests that TPOXX may affect the immunogenicity of ACAM2000 if administered concomitantly. These studies may inform on how vaccine and TPOXX are used during a smallpox outbreak.
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Affiliation(s)
- Andrew T Russo
- Poxvirus Research Group, SIGA Technologies Inc., Corvallis, OR, United States.
| | | | | | - Jon Prigge
- Southern Research Institute, Frederick, MD, United States
| | | | - Douglas W Grosenbach
- Poxvirus Research Group, SIGA Technologies, Inc., Corvallis, OR 97333, United States.
| | - Dennis Hruby
- SIGA Technologies, Inc., Corvallis, OR 97333, United States
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Avril A. Therapeutic Antibodies for Biodefense. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1053:173-205. [PMID: 29549640 DOI: 10.1007/978-3-319-72077-7_9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Diseases can be caused naturally by biological agents such as bacteria, viruses and toxins (natural risk). However, such biological agents can be intentionally disseminated in the environment by a State (military context) or terrorists to cause diseases in a population or livestock, to destabilize a nation by creating a climate of terror, destabilizing the economy and undermining institutions. Biological agents can be classified according to the severity of illness they cause, its mortality and how easily the agent can be spread. The Centers for Diseases Control and Prevention (CDC) classify biological agents in three categories (A, B and C); Category A consists of the six pathogens most suitable for use as bioweapons (Bacillus anthracis, Yersinia pestis, Francisella tularensis, botulinum neurotoxins, smallpox and viral hemorrhagic fevers). Antibodies represent a perfect biomedical countermeasure as they present both prophylactic and therapeutic properties, act fast and are highly specific to the target. This review focuses on the main biological agents that could be used as bioweapons, the history of biowarfare and antibodies that have been developed to neutralize these agents.
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Affiliation(s)
- Arnaud Avril
- Département des maladies infectieuses, Unité biothérapies anti-infectieuses et immunité, Institut de Recherche Biomédical des Armées, Brétigny-sur-Orge, France.
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Grosenbach DW, Honeychurch K, Rose EA, Chinsangaram J, Frimm A, Maiti B, Lovejoy C, Meara I, Long P, Hruby DE. Oral Tecovirimat for the Treatment of Smallpox. N Engl J Med 2018; 379:44-53. [PMID: 29972742 PMCID: PMC6086581 DOI: 10.1056/nejmoa1705688] [Citation(s) in RCA: 213] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Smallpox was declared eradicated in 1980, but variola virus (VARV), which causes smallpox, still exists. There is no known effective treatment for smallpox; therefore, tecovirimat is being developed as an oral smallpox therapy. Because clinical trials in a context of natural disease are not possible, an alternative developmental path to evaluate efficacy and safety was needed. METHODS We investigated the efficacy of tecovirimat in nonhuman primate (monkeypox) and rabbit (rabbitpox) models in accordance with the Food and Drug Administration (FDA) Animal Efficacy Rule, which was interpreted for smallpox therapeutics by an expert advisory committee. We also conducted a placebo-controlled pharmacokinetic and safety trial involving 449 adult volunteers. RESULTS The minimum dose of tecovirimat required in order to achieve more than 90% survival in the monkeypox model was 10 mg per kilogram of body weight for 14 days, and a dose of 40 mg per kilogram for 14 days was similarly efficacious in the rabbitpox model. Although the effective dose per kilogram was higher in rabbits, exposure was lower, with a mean steady-state maximum, minimum, and average (mean) concentration (Cmax, Cmin, and Cavg, respectively) of 374, 25, and 138 ng per milliliter, respectively, in rabbits and 1444, 169, and 598 ng per milliliter in nonhuman primates, as well as an area under the concentration-time curve over 24 hours (AUC0-24hr) of 3318 ng×hours per milliliter in rabbits and 14,352 ng×hours per milliliter in nonhuman primates. These findings suggested that the nonhuman primate was the more conservative model for the estimation of the required drug exposure in humans. A dose of 600 mg twice daily for 14 days was selected for testing in humans and provided exposures in excess of those in nonhuman primates (mean steady-state Cmax, Cmin, and Cavg of 2209, 690, and 1270 ng per milliliter and AUC0-24hr of 30,632 ng×hours per milliliter). No pattern of troubling adverse events was observed. CONCLUSIONS On the basis of its efficacy in two animal models and pharmacokinetic and safety data in humans, tecovirimat is being advanced as a therapy for smallpox in accordance with the FDA Animal Rule. (Funded by the National Institutes of Health and the Biomedical Advanced Research and Development Authority; ClinicalTrials.gov number, NCT02474589 .).
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Affiliation(s)
| | | | | | | | | | | | | | | | - Paul Long
- From SIGA Technologies, Corvallis, OR
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Melamed S, Israely T, Paran N. Challenges and Achievements in Prevention and Treatment of Smallpox. Vaccines (Basel) 2018; 6:vaccines6010008. [PMID: 29382130 PMCID: PMC5874649 DOI: 10.3390/vaccines6010008] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 01/15/2018] [Accepted: 01/26/2018] [Indexed: 01/17/2023] Open
Abstract
Declaration of smallpox eradication by the WHO in 1980 led to discontinuation of the worldwide vaccination campaign. The increasing percentage of unvaccinated individuals, the existence of its causative infectious agent variola virus (VARV), and the recent synthetic achievements increase the threat of intentional or accidental release and reemergence of smallpox. Control of smallpox would require an emergency vaccination campaign, as no other protective measure has been approved to achieve eradication and ensure worldwide protection. Experimental data in surrogate animal models support the assumption, based on anecdotal, uncontrolled historical data, that vaccination up to 4 days postexposure confers effective protection. The long incubation period, and the uncertainty of the exposure status in the surrounding population, call for the development and evaluation of safe and effective methods enabling extension of the therapeutic window, and to reduce the disease manifestations and vaccine adverse reactions. To achieve these goals, we need to evaluate the efficacy of novel and already licensed vaccines as a sole treatment, or in conjunction with immune modulators and antiviral drugs. In this review, we address the available data, recent achievements, and open questions.
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Affiliation(s)
- Sharon Melamed
- Department of Infectious Diseases, Israel Institute for Biological Research, P.O. Box 19, Ness-Ziona 74100, Israel.
| | - Tomer Israely
- Department of Infectious Diseases, Israel Institute for Biological Research, P.O. Box 19, Ness-Ziona 74100, Israel.
| | - Nir Paran
- Department of Infectious Diseases, Israel Institute for Biological Research, P.O. Box 19, Ness-Ziona 74100, Israel.
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Shchelkunova GA, Shchelkunov SN. 40 Years without Smallpox. Acta Naturae 2017; 9:4-12. [PMID: 29340212 PMCID: PMC5762823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The last case of natural smallpox was recorded in October, 1977. It took humanity almost 20 years to achieve that feat after the World Health Organization had approved the global smallpox eradication program. Vaccination against smallpox was abolished, and, during the past 40 years, the human population has managed to lose immunity not only to smallpox, but to other zoonotic orthopoxvirus infections as well. As a result, multiple outbreaks of orthopoxvirus infections in humans in several continents have been reported over the past decades. The threat of smallpox reemergence as a result of evolutionary transformations of these zoonotic orthopoxviruses exists. Modern techniques for the diagnostics, prevention, and therapy of smallpox and other orthopoxvirus infections are being developed today.
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Affiliation(s)
- G. A. Shchelkunova
- State Research Center of Virology and Biotechnology VECTOR, Koltsovo, Novosibirsk region, 630559 , Russia
| | - S. N. Shchelkunov
- State Research Center of Virology and Biotechnology VECTOR, Koltsovo, Novosibirsk region, 630559 , Russia
- Novosibirsk State University, Pirogov Str. 2, Novosibirsk, 630090, Russia
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You SH, Kim T, Choi JH, Park G, Lee KN, Kim B, Lee MH, Kim HS, Kim SM, Park JH. Coinjection of a vaccine and anti-viral agents can provide fast-acting protection from foot-and-mouth disease. Antiviral Res 2017; 143:195-204. [PMID: 28454913 DOI: 10.1016/j.antiviral.2017.04.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 04/03/2017] [Accepted: 04/03/2017] [Indexed: 12/21/2022]
Abstract
Foot-and-mouth disease (FMD) is the cause of an economically devastating animal disease. With commercial inactivated FMD vaccines, the protection against FMD virus (FMDV) begins a minimum of 4 days post vaccination (dpv). Therefore, antiviral agents could be proposed for rapid protection and to reduce the spread of FMDV during outbreaks until vaccine-induced protective immunity occurs. In previous studies, we have developed two recombinant adenoviruses that simultaneously express porcine interferon-α and interferon-γ (Ad-porcine IFN-αγ) and multiple siRNAs that target the non-structural protein-regions of FMDV (Ad-3siRNA), and we have shown that the combination of the two antiviral agents (referred to here as Ad combination) induced robust protection against FMDV in pigs. In an attempt to provide complete protection against FMDV, we co-administered Ad combination and the FMD vaccine to mice and pigs. In the C57BL/6 mice model, we observed rapid and continuous protection against homologous FMDV challenge from 1 to 3 dpv-the period in which vaccine-mediated immunity is absent. In the pig experiments, we found that most of the pigs (five out of six) that received vaccine + Ad combination and were challenged with FMDV at 1 or 2 dpv were clinically protected from FMDV. In addition, most of the pigs that received vaccine + Ad combination and all pigs inoculated with the vaccine only were clinically protected from an FMDV challenge at 7 dpv. We believe that the antiviral agent ensures early protection from FMDV, and the vaccine participates in protection after 7 dpv. Therefore, we can say that the combination of the FMD vaccine and effective antiviral agents may offer both fast-acting and continuous protection against FMDV. In further studies, we plan to design coadministration of Ad combination and novel vaccines.
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Affiliation(s)
- Su-Hwa You
- Foot-and-Mouth Disease Vaccine Research Center, Animal and Plant Quarantine Agency, 177 Hyeoksin 8-ro, Gimcheon-City, Gyeongsangbuk-do, Republic of Korea; Veterinary College of Chungnam National University, 99 Daehak-ro, Yuseong-gu, Daejeon, Republic of Korea
| | - Taeseong Kim
- Foot-and-Mouth Disease Vaccine Research Center, Animal and Plant Quarantine Agency, 177 Hyeoksin 8-ro, Gimcheon-City, Gyeongsangbuk-do, Republic of Korea
| | - Joo-Hyung Choi
- Foot-and-Mouth Disease Vaccine Research Center, Animal and Plant Quarantine Agency, 177 Hyeoksin 8-ro, Gimcheon-City, Gyeongsangbuk-do, Republic of Korea
| | - Gundo Park
- Foot-and-Mouth Disease Vaccine Research Center, Animal and Plant Quarantine Agency, 177 Hyeoksin 8-ro, Gimcheon-City, Gyeongsangbuk-do, Republic of Korea
| | - Kwang-Nyeong Lee
- Foot-and-Mouth Disease Vaccine Research Center, Animal and Plant Quarantine Agency, 177 Hyeoksin 8-ro, Gimcheon-City, Gyeongsangbuk-do, Republic of Korea
| | - Byounghan Kim
- Foot-and-Mouth Disease Vaccine Research Center, Animal and Plant Quarantine Agency, 177 Hyeoksin 8-ro, Gimcheon-City, Gyeongsangbuk-do, Republic of Korea
| | - Myoung-Heon Lee
- Foot-and-Mouth Disease Vaccine Research Center, Animal and Plant Quarantine Agency, 177 Hyeoksin 8-ro, Gimcheon-City, Gyeongsangbuk-do, Republic of Korea
| | - Hyun-Soo Kim
- Veterinary College of Chungnam National University, 99 Daehak-ro, Yuseong-gu, Daejeon, Republic of Korea
| | - Su-Mi Kim
- Foot-and-Mouth Disease Vaccine Research Center, Animal and Plant Quarantine Agency, 177 Hyeoksin 8-ro, Gimcheon-City, Gyeongsangbuk-do, Republic of Korea.
| | - Jong-Hyeon Park
- Foot-and-Mouth Disease Vaccine Research Center, Animal and Plant Quarantine Agency, 177 Hyeoksin 8-ro, Gimcheon-City, Gyeongsangbuk-do, Republic of Korea.
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Kleinkind mit Ulkus am Oberschenkel. Monatsschr Kinderheilkd 2016. [DOI: 10.1007/s00112-016-0139-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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