Emergence of human monkeypox in west Africa

Molecular evolution of 2022 multi-country outbreak-causing monkeypox virus Clade IIb

The monkeypox virus (Mpoxv) Clade IIb viruses that caused an outbreak in 2017-18 in Nigeria and its genetically related viruses have been detected in many countries and caused multi-country outbreak in 2022. Since the pandemic-causing Mpoxv Clade IIb viruses are closely related to Clade IIa viruses which mostly cause endemic, the Clade IIb Mpoxv might have certain specific genetic variations that are still largely unknown. Here, we have systematically analyzed genetic alterations in different clades of Mpox viruses. The results suggest that the Mpoxv Clade IIb have genetic variations in terms of genomic gaps, frameshift mutations, in-frame nonsense mutations, amino acid tandem repeats, and APOBEC3 mutations. Further, we observed specific genetic variations in the multiple genes specific for Clade I and Clade IIb, and exclusive genetic variations for Clade IIa and Clade IIb. Collectively, findings shed light on the evolution and genetic variations in the outbreak of 2022 causing Mpoxv Clade IIb.

The prevalence of mpox and its association with sexual behavior among Chinese men who have sex with men in early August 2023

Study investigating mpox infection and its association with sexual behavior among men who have sex with men (MSM) in China was lacking. This observational survey aimed to provide evidence on detail characteristics of mpox cases and sexual behavior, then analyze their relationship among MSM in China to help formulate prevention and control policies. An anonymous cross-sectional study was conducted in 27 MSM social organizations across 21 provinces, municipalities, and autonomous regions from July 31 to August 4, 2023. A safe sexual behavior index was constructed based on three risky sexual behaviors in the last month, including condomless anal intercourse, commercial sex and group sex. High safe sexual behavior indicated that the participant engaged in none of the three, and low safe sexual behavior indicated that they engaged in all three behaviors; otherwise, moderate safe sexual behavior was indicated. Among 7538 MSM, the prevalence of mpox was 0.73% (55/7538). The proportion of high safe sexual behavior was 79.64% (6003/7538). The crude prevalence of mpox was lower in the high safe sexual behavior group (0.35%, 21/6003), compared with the low (12.12%, 8/66) and moderate safe (1.78%, 26/1469) sexual behavior group. In the multivariable-adjusted analysis, after adjusting for all covariates, compared with low safe sexual behavior group, moderate safe sexual behavior group (aOR = 0.21; 95% CI = 0.08, 0.54) and high safe sexual behavior group (aOR = 0.04; 95% CI = 0.02, 0.12) both had lower risk of mpox. Of three sexual behaviors, MSM who reported no commercial sex had the lowest risk of mpox (aOR = 0.23; 95% CI = 0.13, 0.41), compared with those who reported commercial sex in the last month. The other two safe sexual behaviors both were associated with lower risk of mpox (no group sex vs. group sex: aOR = 0.15; 95% CI = 0.08, 0.28; no condomless anal intercourse vs. condomless anal intercourse: aOR = 0.23; 95% CI = 0.13, 0.41). The prevalence of mpox virus infection was nearly 1% among MSM in China. Strengthening mpox surveillance, emphasizing safe sexual behavior in health education are essential for the control of mpox among MSM in China.

Entropy-Driven, Integrative Bioinformatics Approaches Reveal the Recent Transmission of the Monkeypox Virus from Nigeria to Multiple Non-African Countries

Monkeypox virus (mpox) has currently affected multiple countries around the globe. This study aims to analyze how the virus spread globally. The study uses entropy-driven bioinformatics in five directions to analyze the 60 full-length complete genomes of mpox. We analyzed the topological entropy distribution of the genomes, principal component analysis (PCA), the dissimilarity matrix, entropy-driven phylogenetics, and genome clustering. The topological entropy distribution showed genome positional entropy. We found five clusters of the mpox genomes through the two PCA, while the three PCA elucidated the clustering events in 3D space. The clustering of genomes was further confirmed through the dissimilarity matrix and phylogenetic analysis which showed the bigger size of Cluster 1 and size similarity between Clusters 2 and 4 as well as Clusters 3 and 5. It corroborated with the phylogenetics of the genomes, where Cluster 1 showed clear segregation from the other four clusters. Finally, the study concluded that the spreading of the mpox is likely to have originated from African countries to the rest of the non-African countries. Overall, the spreading and distribution of the mpox will shed light on its evolution and pathogenicity of the mpox and help to adopt preventive measures to stop the spreading of the virus.

Mpox Vaccination Hesitancy and Its Associated Factors among Men Who Have Sex with Men in China: A National Observational Study

More than 400 confirmed mpox cases have been reported in China. The mpox vaccination is crucial to mitigate mpox transmission, especially for at-risk populations. This study aimed to determine mpox vaccination hesitancy and its associated factors in Chinese men who have sex with men (MSM). This nationwide cross-sectional study was conducted among 7538 Chinese MSM in 27 MSM social organizations from 21 provinces, municipalities, and autonomous regions of China from 31 July to 4 August 2023. Of them, the rate of mpox vaccination hesitancy was 5.59% (421/7538). The most common reason for mpox vaccination hesitation was concerns of safety and side effects (62.71%, 264/421), followed by concerns of privacy (38.24%, 161/421), thoughts of impossible infection (37.53%, 158/421), no effectiveness in preventing reinfection (30.88%, 130/421), and no worry about infection (12.35%, 52/421). Regarding the concerning characteristics of the vaccines, concerns of vaccine safety ranked first (71.74%, 5408/7538), followed by vaccine effectiveness (14.05%, 1059/7538), vaccine costs (7.35%, 554/7538), and the continuity of vaccine effectiveness (3.91%, 295/7538). The highest odds ratio of mpox vaccination hesitation was seen in MSM who were infected with mpox virus (aOR = 2.38; 95%CI = 1.08, 5.23), followed by those aged ≥60 years (aOR = 2.25; 95%CI = 1.31, 3.88), those who were unemployed (aOR = 1.66; 95%CI = 1.25, 2.19), and those who had an education level of postgraduate and above (aOR = 1.55; 95%CI = 1.01, 2.37). However, MSM who had a higher level of mpox-related knowledge (moderate: aOR = 0.53; 95%CI = 0.36, 0.77; high: aOR = 0.30; 95%CI = 0.23, 0.40) had a lower odds ratio of mpox vaccination hesitation. MSM in China had low hesitancy toward mpox vaccination. The safety and effectiveness of the vaccine and privacy were important aspects of hesitancy. Health education on mpox-related knowledge should be encouraged to promote future vaccination plans.

Trends in the Baidu Index in Search Activity Related to Mpox at Geographical and Economic Levels and Associated Factors in China: National Longitudinal Analysis

BACKGROUND

Research assessing trends in online search activity related to mpox in China is scarce.

OBJECTIVE

We aimed to provide evidence for an overview of online information searching during an infectious disease outbreak by analyzing trends in online search activity related to mpox at geographical and economic levels in China and explore influencing factors.

METHODS

We used the Baidu index to present online search activity related to mpox from May 19 to September 19, 2022. Segmented interrupted time-series analysis was used to estimate trends in online search activity. Factors influencing these trends were analyzed using a general linear regression (GLM) model. We calculated the concentration index to measure economic-related inequality in online search activity and related trends.

RESULTS

Online search activity was highest on the day the first imported case of mpox appeared in Chongqing compared to 3 other cutoff time points. After the day of the first imported mpox case in Taiwan, the declaration of a public health emergency of international concern, the first imported mpox case in Hong Kong, and the first imported mpox case in Chongqing, national online search activity increased by 0.642%, 1.035%, 1.199%, and 2.023%, respectively. The eastern regions had higher increases than the central and western regions. Across 31 provinces, municipalities, and autonomous regions, the top 3 areas with higher increases were Beijing, Shanghai, and Tianjin at 3 time points, with the exception of the day of the first imported mpox case in Chongqing (Chongqing replaced Tianjin on that day). When AIDS incidence increased by 1 per 100,000 people, there was an increase after the day of the first imported mpox case in Chongqing of 36.22% (95% CI 3.29%-69.15%; P=.04) after controlling for other covariates. Online search activity (concentration index=0.18; P<.001) was more concentrated among populations with a higher economic status. Unlike the central area, the eastern (concentration index=0.234; P<.001) and western areas (concentration index=0.047; P=.04) had significant economic-related disparities (P for difference <.001) in online search activity. The overall concentration index of changes in online search activity became lower over time.

CONCLUSIONS

Regions with a higher economic level showed more interest in mpox, especially Beijing and Shanghai. After the day of the first imported mpox case in Chongqing, changes in online search activity were affected by AIDS incidence rate. Economic-related disparities in changes in online search activity became lower over time. It would be desirable to construct a reliable information source in regions with a higher economic level and higher AIDS incidence rate and promote public knowledge in regions with a lower economic level in China, especially after important public events.

Human monkeypox: history, presentations, transmission, epidemiology, diagnosis, treatment, and prevention

Human monkeypox is a zoonotic infection that is similar to the diseases caused by other poxviruses. It is endemic among wild rodents in the rainforests of Central and Western Africa, and can be transmitted via direct skin contact or mucosal exposure to infected animals. The initial symptoms include fever, headache, myalgia, fatigue, and lymphadenopathy, the last of which is the main symptom that distinguishes it from smallpox. In order to prevent and manage the disease, those who are infected must be rapidly diagnosed and isolated. Several vaccines have already been developed (e.g., JYNNEOS, ACAM2000 and ACAM3000) and antiviral drugs (e.g., cidofovir and tecovirimat) can also be used to treat the disease. In the present study, we reviewed the history, morphology, clinical presentations, transmission routes, diagnosis, prevention, and potential treatment strategies for monkeypox, in order to enable health authorities and physicians to better deal with this emerging crisis.

Mpox Virus in Pregnancy, the Placenta, and Newborn

CONTEXT.—

Before its eradication, the smallpox virus was a significant cause of poor obstetric outcomes, including maternal and fetal morbidity and mortality. The mpox (monkeypox) virus is now the most pathogenic member of the Orthopoxvirus genus infecting humans. The 2022 global mpox outbreak has focused attention on its potential effects during pregnancy.

OBJECTIVE.—

To understand the comparative effects of different poxvirus infections on pregnancy, including mpox virus, variola virus, vaccinia virus, and cowpox virus. The impact on the pregnant individual, fetus, and placenta will be examined, with particular attention to the occurrence of intrauterine vertical transmission and congenital infection.

DATA SOURCES.—

The data are obtained from the authors' cases and from various published sources, including early historical information and contemporary publications.

CONCLUSIONS.—

Smallpox caused maternal and perinatal death, with numerous cases reported of intrauterine transmission. In endemic African countries, mpox has also affected pregnant individuals, with up to a 75% perinatal case fatality rate. Since the start of the 2022 mpox outbreak, increasing numbers of pregnant women have been infected with the virus. A detailed description is given of the congenital mpox syndrome in a stillborn fetus, resulting from maternal-fetal transmission and placental infection, and the potential mechanisms of intrauterine infection are discussed. Other poxviruses, notably vaccinia virus and, in 1 case, cowpox virus, can also cause perinatal infection. Based on the historical evidence of poxvirus infections, mpox remains a threat to the pregnant population, and it can be expected that additional cases will occur in the future.

Extensive ITR expansion of the 2022 Mpox virus genome through gene duplication and gene loss

Poxviruses are known to evolve slower than RNA viruses with only 1-2 mutations/genome/year. Rather than single mutations, rearrangements such as gene gain and loss, which have been discussed as a possible driver for host adaption, were described in poxviruses. In 2022 and 2023 the world is being challenged by the largest global outbreak so far of Mpox virus, and the virus seems to have established itself in the human community for an extended period of time. Here, we report five Mpox virus genomes from Germany with extensive gene duplication and loss, leading to the expansion of the ITR regions from 6400 to up to 24,600 bp. We describe duplications of up to 18,200 bp to the opposed genome end, and deletions at the site of insertion of up to 16,900 bp. Deletions and duplications of genes with functions of supposed immune modulation, virulence and host adaption as B19R, B21R, B22R and D10L are described. In summary, we highlight the need for monitoring rearrangements of the Mpox virus genome rather than for monitoring single mutations only.

Mpox virus Clade IIb detection in the air

Mpox is a viral zoonotic disease endemic in Central and West Africa that is caused by the Mpox virus, which belongs to the Orthopoxvirus genus and Poxviridae family. The clinical manifestations of mpox infection are milder than those of smallpox, and the incubation time of mpox varies from 5 to 21 days. Since May 2022, the mpox outbreak (formerly known as monkeypox) has suddenly and unexpectedly spread in non-endemic countries, suggesting that there may have been some undetected transmissions. Based on molecular analysis, there are two major genetic clades that represent the mpox virus: Clade I (formerly the Congo Basin clade OR the Central African clade) and Clade II (formerly the West African clade). It is believed that people who are asymptomatic or paucisymptomatic may spread the mpox virus. Infectious viruses cannot be distinguished by PCR testing; therefore, virus culture should be carried out. Recent evidence regarding the detection of the mpox virus (Clade IIb) in air samples collected from the patient's environment during the 2022 mpox outbreak was reviewed. Further studies are needed to evaluate the extent to which the presence of mpox virus DNA in the air could affect immunocompromised patients in healthcare facilities, and further epidemiological studies are crucial, especially in Africa.

Virus Identification for Monkeypox in Human Seminal Fluid Samples: A Systematic Review

Public health officials around the world are extremely concerned about the global outbreak of monkeypox (MPX), which has been claimed to have originated in Africa. As a result, studies into the origins and reasons behind the outbreak’s rapid spread have been sped up. The goal of the current investigation is to determine whether the monkeypox virus (MPXV) is present in seminal fluid samples from MPX cases that have been verified. Up until 6 January 2023, PubMed, Scopus, Web of Science, Embase, and ScienceDirect databases were used to conduct a thorough evaluation of the literature. The search technique returned a total of 308 items. Fourteen studies reporting the presence of MPXV in the seminal fluid of MPX-confirmed cases were included after the duplicates (n = 158) and searches by title, abstract, and full text were eliminated. In 84 out of the 643 confirmed MPX cases (13.06% or n = 643), MPXV was discovered in seminal fluid. Reverse transcriptase polymerase chain reaction (RT-PCR) was used to identify MPXV, and samples taken from skin lesions (96.27%), pharynx or oropharynx (30.48%), and blood all had higher positivity rates than other samples (12.44%). Additionally, 99.85% of respondents were male with a mean age of 36, 98.45% engaged in MSM (men who have sex with men) sexual conduct, and human immunodeficiency virus (HIV) accounted for 56.9% of all STD cases. This study offers proof that MPXV can be found in the seminal fluid of MPX sufferers. Our data imply that MPXV transmission is a possibility in these samples and that MSM are more vulnerable to it. The creation of hygienic standards is essential for the early identification of MPX cases.

Trends in Online Search Activity and the Correlation with Daily New Cases of Monkeypox among 102 Countries or Territories

Research assessing the trend in online search activity on monkeypox (mpox) and the correlation with the mpox epidemic at the global and national level is scarce. The trend of online search activity and the time-lag correlations between it and daily new mpox cases were estimated by using segmented interrupted time-series analysis and Spearman correlation coefficient (rs), respectively. We found that after the declaration of a Public Health Emergency of International Concern (PHEIC), the proportion of countries or territories with increasing changes in online search activity was lowest in Africa (8.16%, 4/49), and a downward trend in online search activity was highest in North America (8/31, 25.81%). The time-lag effect of global online search activity on daily new cases was significant (rs = 0.24). There were eight countries or territories with significant time-lag effect; the top three countries or territories were Brazil (rs = 0.46), United States (rs = 0.24), and Canada (rs = 0.24). Interest behavior in mpox was insufficient, even after the declaration of PHEIC, especially in Africa and North America. Online search activity could be used as an early indicator of the outbreak of mpox at the global level and in epidemic countries.

Development of highly accurate digital PCR method and reference material for monkeypox virus detection

Human monkeypox has attracted attention recently. Monkeypox virus (MPXV) keeps evolving as it spreading around the world rapidly, which may threaten the health of more and more people. Here, we have developed a high order reference method based on digital PCR (dPCR) for MPXV detection, of which the limits of quantification (LoQ) and detection (LoD) are 38 and 6 copies/reaction, respectively. Pseudovirus reference materials (RM) containing the conserved F3L gene has been developed, and the homogeneity assessment showed that the RM was homogeneous. The reference value with its expanded uncertainty determined by the established dPCR is (2.74 ± 0.46) × 10³ copies/μL. Six different MPXV test kits were accessed by the RM. Four out of six test kits cannot reach their claimed LoDs. The poor analytical sensitivity might cause false-negative results, which lead to incorrect diagnosis and treatment. The establishment of a high order reference method of dPCR and pseudovirus RM is very useful for improving the accuracy and reliability of MPXV detection.

Global Epidemiological Features of Human Monkeypox Cases and Their Associations With Social-Economic Level and International Travel Arrivals: A Systematic Review and Ecological Study

Objectives: We aimed to evaluate global epidemiological features of human monkeypox (mpox) cases and their associations with social-economic level and international travel arrivals. Methods: We estimated the pooled value by random-effects models. Then, we conducted an ecological study to evaluate the relationship of confirmed cases with social-economic indices and international travel arrivals using correlation analyses. Results: The average age (2022: 35.52, 95% CI [28.09, 42.94] vs. before 2022: 18.38, 95% CI [14.74, 22.02]) and comorbidity rate (2022: 15.7%, 95% CI [8.9%, 22.4%] vs. before 2022: 14.9%, 95% CI [8.5%, 21.3%]) of mpox cases in the 2022 human mpox outbreak were significantly higher than those of cases before 2022. During the 2022 mpox outbreak, the proportion of men who have sex with men (MSM) was high (79.8%, 95% CI [65.5%, 94.2%]). The number of confirmed mpox cases in 2022 significantly correlated with high social-economic levels and international travel arrivals (all p < 0.05). Conclusion: Our findings highlighted the importance of early surveillance and timely detection in high-risk populations, including older people, MSM, and travelers, which is crucial to curb the wide transmission of mpox.

Evolution of monkeypox virus from 2017 to 2022: In the light of point mutations

Monkeypox virus (MPXV) causing multi-country outbreak-2022 is related to viruses caused outbreak-2017-2018 in West Africa. Still not fully understood which proteins of the MPXV discovered in Nigeria in 2017 have mutated through different lineages to the extent that it could cause a multi-country outbreak in 2022; similarly, codon usage bias, host adaptation indices, and the role of selection or mutation pressure in the mutated genes are also not fully studied. Here we report that according to the available sequence data this monkeypox virus acquires point mutations in multiple proteins in each period, and these point mutations accumulate and become a virus that can root outbreak-2022. Viruses exported from Nigeria to Singapore, Israel, and the United Kingdom in 2018-2019 were developed as evolutionary ancestors to B.1 viruses (MPXVs causing multi-country outbreak-2022) through MPXV/United States/2021/MD virus. Although these exported viruses have different amino acid mutations in different proteins, amino acid mutations in 10 proteins are common among them. The MPXV-United Kingdom-P2 virus evolved with only mutations in these 10 proteins and further evolved into MPXV/United States/2021/MD with amino acid mutations in 26 (including amino acid mutations in 10 proteins of the MPXV-United States-P2) proteins. It is noteworthy that specific amino acid mutations in these 22/26 (presence in MPXV/United States/2021/MD) proteins are present in B.1 viruses. Further, analysis of Relative Synonymous Codon Usage (RSCU), Synonymous Codon Usage Fraction (SCUF), and Effective Number of Codons (ENc) revealed codon usage bias in genes that exhibited nucleotide mutations in lineage B.1. Also, host adaptation indices analyzes such as Codon Adaptation Index (CAI), Expected-CAI (eCAI), Relative Codon Deoptimization Index (RCDI) and Expected value for the RCDI (eRCDI) analyzes reveal that the genes that demonstrated nucleotide mutations in lineage B.1 are favorable for human adaptation. Similarly, ENc-GC3s plot, Neutrality plot, and Parity Rule 2 (PR2)-bias plot analyzes suggest a major role of selection pressure than mutation pressure in the evolution of genes displaying nucleotide mutations in lineage B.1. Overall, from 2017 to 2022, MPXV's mutation and spread suggests that this virus continues to evolve through point mutation in the genes according to the available sequence data.

The current emergence of monkeypox: The recurrence of another smallpox?

Since its first confirmation in London on 12 May 2022, many monkeypox cases have been reported worldwide. Noticeably, the epidemiology, pathology, and clinical features of the current emergence have been compared to those of smallpox, a severe contagious disease historically epidemic worldwide for nearly 3,000 years. However, some characteristics of the present outbreak differed from those of previous monkeypox outbreaks. Herein, we ask if this emergence of monkeypox could cause another global pandemic similar to smallpox or influenza or if it is only the re-emergence of a new strain. To address these questions, we reviewed its virology, transmission, clinical characteristics, experimental diagnosis, and prevention and intervention, giving our commentary along the way.

Animal Models Used in Monkeypox Research

Monkeypox is an emerging zoonotic disease with a growing prevalence outside of its endemic area, posing a significant threat to public health. Despite the epidemiological and field investigations of monkeypox, little is known about its maintenance in natural reservoirs, biological implications or disease management. African rodents are considered possible reservoirs, although many mammalian species have been naturally infected with the monkeypox virus (MPXV). The involvement of domestic livestock and pets in spillover events cannot be ruled out, which may facilitate secondary virus transmission to humans. Investigation of MPXV infection in putative reservoir species and non-human primates experimentally uncovered novel findings relevant to the course of pathogenesis, virulence factors and transmission of MPXV that provided valuable information for designing appropriate prevention measures and effective vaccines.

Early Estimates of Monkeypox Incubation Period, Generation Time, and Reproduction Number, Italy, May-June 2022

We analyzed the first 255 PCR-confirmed cases of monkeypox in Italy in 2022. Preliminary estimates indicate mean incubation period of 9.1 (95% CI 6.5-10.9) days, mean generation time of 12.5 (95% CI 7.5-17.3) days, and reproduction number among men who have sex with men of 2.43 (95% CI 1.82-3.26).

Evaluating the risk of transfusion and transplant-transmitted monkeypox infections

The recent emergence of monkeypox virus (MPXV) in the UK and elsewhere is of urgent public health concern. Several aspects of MPXV epidemiology and pathogenesis, including its systemic spread and viraemia during acute infection, furthermore represent an important potential threat to the safety of blood transfusion and organ transplantation. Reported infections in the UK have been exponentially increasing over the last 2 months, with 1552 reported cases in the UK by 7th July 2022. This is likely to be considerable underestimate given current limitations in diagnostic capacity and clinical diagnoses hampered by its similar disease presentations to other causes of rash and genitourinary disease. While MPXV infections are currently most widespread in gay, bisexual or other men who have sex with men, wider spread of MPXV outside defined risk groups for infection may prevent identification of infection risk in donors. While typically mild disease outcomes have been reported in UK cases, case fatality rates ranging from 1% to over 10% are reported for different MPXV strains in its source area in sub-Saharan Africa. Recipients of blood components and organs transplant, especially those who are immunosuppressed, may reproduce the greater systemic spread and morbidity of those infected through percutaneous routes. There is a potential risk of MPXV transmission and severe disease outcomes in blood and transplant recipients. In addition to current risk assessments performed in the UK and exclusion of donors with recent MPXV exposure, determining viraemia frequencies in donors and directly evaluating transmission risk would be of considerable value in assessing whether MPXV nucleic acid screening should be implemented.

When a Neglected Tropical Disease Goes Global: Knowledge, Attitudes and Practices of Italian Physicians towards Monkeypox, Preliminary Results

Monkeypox (MPX) has been regarded as a neglected tropic disease of Western and Central Africa since the early 70s. However, during May 2022, an unprecedent outbreak of MPX has involved most of European Countries, as well as North and South America. While the actual extent of this outbreak is being assessed by health authorities, we performed a pilot study on specific knowledge, attitudes, and practices (KAP) in a sample of Italian medical professionals (24–30 May 2022; 10,293 potential recipients), focusing on Occupational Physicians (OP), Public Health Professionals (PH), and General Practitioners (GP), i.e., medical professionals more likely involved in the early management of incident cases. More specifically, we inquired into their attitude on the use of variola vaccine in order to prevent MPX infection. From a total of 566 questionnaire (response rate of 5.5%), 163 participants were included in the final analyses. Knowledge status was quite unsatisfying, with substantial knowledge gaps on all aspect of MPX. In turn, analysis of risk perception suggested a substantial overlooking of MPX as a pathogen, particularly when compared to SARS-CoV-2, TB, HIV, and HBV. Overall, 58.6% of respondents were somehow favorable to implement variola vaccination in order to prevent MPX, and the main effectors of this attitude were identified in having been previously vaccinated against seasonal influenza (adjusted Odds Ratio [aOR] 6.443, 95% Confidence Interval [95%CI] 1.798–23.093), and being favorable to receive variola vaccine (aOR 21.416; 95%CI 7.290–62.914). In summary, the significant extent of knowledge gaps and the erratic risk perception, associated collectively stress the importance of appropriate information campaigns among first-line medical professionals.

Vaccinia Virus Activation and Antagonism of Cytosolic DNA Sensing

Cells express multiple molecules aimed at detecting incoming virus and infection. Recognition of virus infection leads to the production of cytokines, chemokines and restriction factors that limit virus replication and activate an adaptive immune response offering long-term protection. Recognition of cytosolic DNA has become a central immune sensing mechanism involved in infection, autoinflammation, and cancer immunotherapy. Vaccinia virus (VACV) is the prototypic member of the family Poxviridae and the vaccine used to eradicate smallpox. VACV harbors enormous potential as a vaccine vector and several attenuated strains are currently being developed against infectious diseases. In addition, VACV has emerged as a popular oncolytic agent due to its cytotoxic capacity even in hypoxic environments. As a poxvirus, VACV is an unusual virus that replicates its large DNA genome exclusively in the cytoplasm of infected cells. Despite producing large amounts of cytosolic DNA, VACV efficiently suppresses the subsequent innate immune response by deploying an arsenal of proteins with capacity to disable host antiviral signaling, some of which specifically target cytosolic DNA sensing pathways. Some of these strategies are conserved amongst orthopoxviruses, whereas others are seemingly unique to VACV. In this review we provide an overview of the VACV replicative cycle and discuss the recent advances on our understanding of how VACV induces and antagonizes innate immune activation via cytosolic DNA sensing pathways. The implications of these findings in the rational design of vaccines and oncolytics based on VACV are also discussed.

Human monkeypox - After 40 years, an unintended consequence of smallpox eradication

Smallpox eradication, coordinated by the WHO and certified 40 years ago, led to the cessation of routine smallpox vaccination in most countries. It is estimated that over 70% of the world's population is no longer protected against smallpox, and through cross-immunity, to closely related orthopox viruses such as monkeypox. Monkeypox is now a re-emerging disease. Monkeypox is endemic in as yet unconfirmed animal reservoirs in sub-Saharan Africa, while its human epidemiology appears to be changing. Monkeypox in small animals imported from Ghana as exotic pets was at the origin of an outbreak of human monkeypox in the USA in 2003. Travellers infected in Nigeria were at the origin of monkeypox cases in the UK in 2018 and 2019, Israel in 2018 and Singapore in2019. Together with sporadic reports of human infections with other orthopox viruses, these facts invite speculation that emergent or re-emergent human monkeypox might fill the epidemiological niche vacated by smallpox. An ad-hoc and unofficial group of interested experts met to consider these issues at Chatham House, London in June 2019, in order to review available data and identify monkeypox-related research gaps. Gaps identified by the experts included:The experts further agreed on the need for a better understanding of the genomic evolution and changing epidemiology of orthopox viruses, the usefulness of in-field genomic diagnostics, and the best disease control strategies, including the possibility of vaccination with new generation non-replicating smallpox vaccines and treatment with recently developed antivirals.