Smallpox vaccines: current and future

Crucial choices in a global health crisis: Revealing the demand and willingness to pay for a hypothetical monkeypox vaccine - the PREVENT study

Background

The latent monkeypox outbreak has become the most emergent public health challenge globally. This study was conducted to assess the acceptability, and willingness to take and pay for a hypothetical Monkeypox vaccine among the Vietnamese general public as well as investigate preference for individual vaccine attributes.

Methods

An online cross-sectional study was conducted using snowball sampling among 842 respondents in Vietnam in 2022. A Discrete choice experiment (DCE) on preference for six major attributes of vaccine: effectiveness, immunity duration, side effects, mortality rate, restriction, and the cost was applied.

Results

Fear of the impact of monkeypox on public health and the economy, vaccine service satisfaction and responsibility to the community were the most weighted factors in the decision to take a hypothetical monkeypox vaccine. Two-thirds of participants were willing to take the vaccine, while insufficient information on monkeypox and the vaccine were the main reasons for vaccine hesitancy. For vaccine attributes, the mortality rate after seven days of vaccination was the most weighted while cost was the least influential attribute. Factors associated with willingness to take and to pay for the monkeypox vaccine included knowledge of transmission, geographical location, service satisfaction, and risk of infection, while financial burden and fear of vaccine were major drivers of hesitancy.

Conclusion

Our findings underline an urgent need for effective information dissemination through social media and counseling. The implementation of nationwide monkeypox vaccination requires prioritization and support for high-risk groups as well as consideration for the country's financial resources.

Low-Temperature Multiple Micro-Dispensing on Microneedles for Accurate Transcutaneous Smallpox Vaccination

Smallpox is an acute contagious disease caused by the variola virus. According to WHO guidelines, the smallpox vaccine is administrated by scarification into the epidermis using a bifurcated needle moistened with a vaccine solution. However, this invasive vaccination method involving multiple skin punctures requires a special technique to inoculate, as well as a cold chain for storage and distribution of vaccine solutions containing a live virus. Here, we report a transcutaneous smallpox vaccination using a live vaccinia-coated microneedle (MN) patch prepared by a low-temperature multiple nanoliter-level dispensing system, enabling accurate transdermal delivery of live vaccines and maintenance of bioactivity. The live vaccinia in hyaluronic acid (HA) solutions was selectively coated on the solid MN tips, and the coating amount of the vaccine was precisely controlled through a programmed multiple dispensing process with high accuracy under low temperature conditions (2–8 °C) for smallpox vaccination. Inoculation of mice (BALB/C mouse) with the MN patch coated with the second-generation smallpox vaccine increased the neutralizing antibody titer and T cell immune response. Interestingly, the live vaccine-coated MN patch maintained viral titers at −20 °C for 4 weeks and elevated temperature (37 °C) for 1 week, highlighting improved storage stability of the live virus formulated into coated MN patches. This coated MN platform using contact dispensing technique provides a simple and effective method for smallpox vaccination.

Genomic expression libraries for the identification of cross-reactive orthopoxvirus antigens

Increasing numbers of human cowpox virus infections that are being observed and that particularly affect young non-vaccinated persons have renewed interest in this zoonotic disease. Usually causing a self-limiting local infection, human cowpox can in fact be fatal for immunocompromised individuals. Conventional smallpox vaccination presumably protects an individual from infections with other Orthopoxviruses, including cowpox virus. However, available live vaccines are causing severe adverse reactions especially in individuals with impaired immunity. Because of a decrease in protective immunity against Orthopoxviruses and a coincident increase in the proportion of immunodeficient individuals in today's population, safer vaccines need to be developed. Recombinant subunit vaccines containing cross-reactive antigens are promising candidates, which avoid the application of infectious virus. However, subunit vaccines should contain carefully selected antigens to confer a solid cross-protection against different Orthopoxvirus species. Little is known about the cross-reactivity of antibodies elicited to cowpox virus proteins. Here, we first identified 21 immunogenic proteins of cowpox and vaccinia virus by serological screenings of genomic Orthopoxvirus expression libraries. Screenings were performed using sera from vaccinated humans and animals as well as clinical sera from patients and animals with a naturally acquired cowpox virus infection. We further analyzed the cross-reactivity of the identified immunogenic proteins. Out of 21 identified proteins 16 were found to be cross-reactive between cowpox and vaccinia virus. The presented findings provide important indications for the design of new-generation recombinant subunit vaccines.

Statistical approach to estimate vaccinia-specific neutralizing antibody titers using a high-throughput assay

Because of the bioterrorism threat posed by agents such as variola virus, considerable time, resources, and effort have been devoted to biodefense preparation. One avenue of this research has been the development of rapid, sensitive, high-throughput assays to validate immune responses to poxviruses. Here we describe the adaptation of a beta-galactosidase reporter-based vaccinia virus neutralization assay to large-scale use in a study that included over 1,000 subjects. We also describe the statistical methods involved in analyzing the large quantity of data generated. The assay and its associated methods should prove useful tools in monitoring immune responses to next-generation smallpox vaccines, studying poxvirus immunity, and evaluating therapeutic agents such as vaccinia virus immune globulin.

Smallpox as a Weapon for Bioterrorism

Smallpox, the only disease ever eradicated, is one of the six pathogens considered a serious threat for biological terrorism (Henderson et al., 1999; Mahy, 2003; Whitley, 2003). Smallpox has several attributes that make it a potential threat. It can be grown in large amounts. It spreads via the respiratory route. It has a 30% mortality rate. The potential for an attack using smallpox motivated President Bush to call for phased vaccination of a substantial number of American health care and public health workers (Grabenstein and Winkenwerder, 2003; Stevenson and Stolberg, 2002). Following September 11, 2001, the United States rebuilt its supplies of vaccine and Vaccinia Immune Globulin (VIG), expanded the network of laboratories capable of testing for variola virus, and engaged in a broad education campaign to help health care workers and the general public understand the disease (Centers for Disease Control and Prevention, 2003a). This chapter summarizes the scientific and theoretical bases for use of smallpox as a bioweapon and options for preparation for defense against it.

A novel, killed-virus nasal vaccinia virus vaccine

Live-virus vaccines for smallpox are effective but have risks that are no longer acceptable for routine use in populations at minimal risk of infection. We have developed a mucosal, killed-vaccinia virus (VV) vaccine based on antimicrobial nanoemulsion (NE) of soybean oil and detergent. Incubation of VV with 10% NE for at least 60 min causes the complete disruption and inactivation of VV. Simple mixtures of NE and VV (Western Reserve serotype) (VV/NE) applied to the nares of mice resulted in both systemic and mucosal anti-VV immunity, virus-neutralizing antibodies, and Th1-biased cellular responses. Nasal vaccination with VV/NE vaccine produced protection against lethal infection equal to vaccination by scarification, with 100% survival after challenge with 77 times the 50% lethal dose of live VV. However, animals protected with VV/NE immunization did after virus challenge have clinical symptoms more extensive than animals vaccinated by scarification. VV/NE-based vaccines are highly immunogenic and induce protective mucosal and systemic immunity without the need for an inflammatory adjuvant or infection with live virus.

T-Cell epitope discovery for variola and vaccinia viruses

Variola major, the causative agent of smallpox, afflicted mankind throughout history until the worldwide World Health Organisation WHO vaccination campaign successfully eradicated the disease. Unfortunately, recent concerns about bioterrorism have renewed scientific interest in this virus. One essential component of our biodefense and preparedness efforts is an understanding of poxvirus immunity. To this end a number of laboratories have sought to discover T- and B-Cell epitopes from select agents such as variola virus. This review focuses on the efforts to identify CD8(+) T-Cell epitopes from poxviruses as a means to develop new vaccines and therapeutics. A wide variety of techniques have been employed by several research groups to provide complementary information regarding cellular immune responses to poxviruses. In the last several years well over 100 T-Cell epitopes have been identified and the work rapidly continues. The information gleaned from these studies will not only give us a greater understanding of immunity to variola virus and other viruses, but also provide a foundation for next generation vaccines and additional tools with which to study host-pathogen interactions.

An update on smallpox vaccine candidates and their role in bioterrorism related vaccination strategies

The threat of using variola virus in a bioterrorist attack urged different countries to renew the production of traditional vaccines and develop new generations of smallpox vaccines. Manufacturers try to combine smallpox vaccine past experience with technological advances in vaccine development to achieve protection similar to that of the traditional vaccines with a higher level of safety and fewer contraindications. In light of the reported immunogenicity and reactogenicity of the stockpiled smallpox vaccines employed in the last immunization campaigns of "first responders", we review recently accumulated data on the assessment of new smallpox vaccine candidates and discuss their role in possible vaccination policies.

The smallpox vaccine

BACKGROUND

A heightened awareness of the potential for bioterrorist attacks in the United States has led to the expansion of the nation's supply of smallpox vaccine and the institution of procedures to distribute this vaccine in the unlikely event of a release of this potentially deadly agent.

METHODS

The authors conducted a review of the relevant smallpox literature through a MEDLINE search. They also reviewed the Web site of the Centers for Disease Control and Prevention and numerous other Web sites.

RESULTS

The authors considered for inclusion more than 100 articles discussing smallpox, the smallpox vaccine and the role of the dental professional in a bioterrorist attack.

CONCLUSIONS

Dentists may detect the initial signs of a smallpox infection, provide information concerning the disease to the public and potentially assist in the administration of smallpox vaccine.

CLINICAL IMPLICATIONS

Should an intentional release of smallpox occur, the dental professional may play an important role in its treatment and prevention.

Smallpox

The WHO declared smallpox eradicated in 1980. However, concern over its potential use by terrorists or in biowarfare has led to striking growth in research related to this much-feared disease. Modern molecular techniques and new animal models are advancing our understanding of smallpox and its interaction with the host immune system. Rapid progress is likewise being made in smallpox laboratory diagnostics, smallpox vaccines, and antiviral medications. WHO and several nations are developing stockpiles of smallpox vaccine for use in the event the disease is reintroduced. National and international public-health agencies have also drawn up plans to help with early detection of and response to a smallpox outbreak. These plans hinge on physicians' ability to recognise the clinical features of smallpox and to distinguish it from other illnesses characterised by rashes.

Poxvirus tropism

Despite the success of the WHO-led smallpox eradication programme a quarter of a century ago, there remains considerable fear that variola virus, or other related pathogenic poxviruses such as monkeypox, could re-emerge and spread disease in the human population. Even today, we are still mostly ignorant about why most poxvirus infections of vertebrate hosts show strict species specificity, or how zoonotic poxvirus infections occur when poxviruses occasionally leap into novel host species. Poxvirus tropism at the cellular level seems to be regulated by intracellular events downstream of virus binding and entry, rather than at the level of specific host receptors as is the case for many other viruses. This review summarizes our current understanding of poxvirus tropism and host range, and discusses the prospects of exploiting host-restricted poxvirus vectors for vaccines, gene therapy or tissue-targeted oncolytic viral therapies for the treatment of human cancers.

Poxvirus host range varies markedly ? some viruses, such as variola and molluscum contagiosum virus (both of which are human-specific), exhibit strict species tropism, whereas others such as cowpox virus are able to infect multiple host species.

Members of four of the eight genera of chordopoxviruses can zoonotically infect man. For example, monkeypox virus can cause severe smallpox-like disease in humans that clinically resembles variola virus.

The species tropism that is exhibited by many poxviruses in terms of causing disease is frequently quite different from the range of cultured cells that can be infected by these viruses.

Specific host-cell receptors do not mediate the distinction between cells that are permissive as opposed to non-permissive for poxvirus infection. Rather, restrictive host cells fail to support the full replication cycle of the infecting poxvirus at a point downstream of binding and entry.

A variety of poxviral host-range genes have been identified that contribute to the control of permissive versus non-permissive infection of cultured mammalian cells. The gene products of these host-range genes regulate the ability of the virus to complete its cytoplasmic replication cycle.

The development of host-restricted vaccines, like modified vaccinia Ankara (MVA), that do not replicate in humans but that retain potent immunogenicity, will provide safer platforms for recombinant vaccines.

Another advance has been the development of poxvirus-based oncolytic vectors that replicate preferentially in human tumour cells.

Emerging viral infections

"Emerging infections" have been defined as infections that have newly appeared, that have appeared previously but are expanding in incidence and geographic range, or that threaten to increase in the near future. This article focuses on nine emerging viral infectious agents. These viruses illustrate how such agents emerge: by encroaching on previously unvisited habitats (eg, hantaviruses), by air travel (eg, SARS), and by accidental importation (eg, monkeypox). Additionally, the example of SARS demonstrates not only how quickly emerging viral infections can spread but also how quickly they can be identified and contained with motivated cooperation.