Prevention of monkeypox with vaccines: a rapid review

Structural and molecular investigation of the impact of S30L and D88N substitutions in G9R protein on coupling with E4R from Monkeypox virus (MPXV)

Understanding the pathogenesis mechanism of the Monkeypox virus (MPXV) is essential to guide therapeutic development against the Monkeypox virus. In the current study, we investigated the impact of the only two reported substitutions, S30L, D88N, and S30L-D88N on the G9R of the replication complex in 2022 with E4R using structural modeling, simulation, and free energy calculation methods. From the molecular docking and dissociation constant (KD) results, it was observed that the binding affinity did not increase in the mutants, but the interaction paradigm was altered by these substitutions. Molecular simulation data revealed that these mutations are responsible for destabilization, changes in protein packing, and internal residue fluctuations, which can cause functional variance. Additionally, hydrogen bonding analysis revealed that the estimated number of hydrogen bonds are almost equal among the wild-type G9R and each mutant. The total binding free energy for the wild-type G9R with E4R was -85.00 kcal/mol while for the mutants the TBE was -42.75 kcal/mol, -43.68 kcal/mol, and -48.65 kcal/mol respectively. This shows that there is no direct impact of these two reported mutations on the binding with E4R, or it may affect the whole replication complex or any other mechanism involved in pathogenesis. To explore these variations further, we conducted PCA and FEL analyses. Based on our findings, we speculate that within the context of interaction with E4R, the mutations in the G9R protein might be benign, potentially leading to functional diversity associated with other proteins.Communicated by Ramaswamy H. Sarma.

Clade Ib: a new emerging threat in the Mpox outbreak

Monkeypox, a zoonotic virus in the Orthopoxvirus genus, has drawn global attention for its impact on public health. In the current Mpox outbreak, a novel clade, Ib, has emerged as a significant and potentially fatal threat. This review examines the dynamics of MPXV transmission, person-to-person spread, and infection mechanisms, highlighting key risk factors. We explore the clinical features of Mpox, focusing on symptomology, illness duration, and the distinguishing characteristics of clade Ib compared to other clades. A critical analysis addresses diagnostic techniques and emphasizes the need for robust surveillance, particularly for clade Ib detection. We review recent prevention and treatment strategies, including antiviral drugs and vaccines, with a focus on clade Ib containment. The conclusion underscores the urgency of global collaboration to prevent and prepare for emerging threats like clade Ib and identifies crucial research paths and knowledge gaps. This review offers a comprehensive overview of clade Ib, covering its emergence, genetic traits, epidemiological impact, transmission patterns, clinical features, the role of Artificial Intelligence (AI) in outbreak management, detection challenges, and implications for public health response.

Understanding the Epidemiology of Monkeypox Virus to Prevent Future Outbreaks

Monkeypox (Mpox) is an infectious disease caused by the Mpox virus belonging to the Orthopoxvirus genus in the Poxviridae family and has been declared by the WHO as a global health emergency owing to its rapid spread during 2022 and 2023. All patients diagnosed with Mpox who were confirmed by PCR between July 2022 and April 2023 were included in this study. In total, 405 patients in whom clade 2 was identified were included. Notably, 99% of included patients were men, with 82% of them aged 20-39 years. Furthermore, 71% were men who had sex with men, and 34% were HIV carriers. Regarding the morphology of the lesions, approximately 63% presented with papulonecrotic rash, which sometimes alternated with pustules depending on the stage they were in. All patients presented with systemic symptoms. Five patients required hospital admission, one of whom died, and presented with HIV and severe immunosuppression. Clinical findings suggest that contact during sexual intercourse is the most likely transmission mechanism and genital involvement is the most frequent clinical form. HIV was the primary comorbidity. Genital lesions were common, especially in vulnerable populations such as those who engage in high-risk sexual behaviors.

Challenges in Global Distribution and Equitable Access to Monkeypox Vaccines

The monkeypox outbreak has grown beyond the regions in which it was considered endemic. It has spread from central and west Africa to non-endemic regions like Europe, America, and other parts of the world. It has recently been classified as a public health emergency of international concern. This study evaluated the challenges faced globally and equitable access to monkeypox vaccines. Global competition has been observed in the race to obtain vaccines, with low- and middle-income countries being disadvantaged. Great inequity exists in the distribution of vaccines globally through advance purchase agreements, vaccine stockpiling, vaccine nationalism, the inequitable distribution of existing resources, and insufficient surveillance and reporting mechanisms. To address some of these challenges, there is a need for strengthening the global vaccine manufacturing capacity, targeting countries with elevated risk profiles and limited resources, strengthening surveillance systems, and addressing vaccine hesitancy.

Mpox-Specific Immune Responses Elicited by Vaccination or Infection in People With HIV

In the recent mpox outbreak, people with human immunodeficiency virus (PWH) were at high risk both for contracting infection and for a more severe disease course. We studied cellular and humoral immune responses elicited by mpox infection (n = 5; n = 3 PWH) or smallpox vaccination (n = 17; all PWH) in a cohort of men who have sex with men. All PWH were successfully treated, with stable CD4 counts and undetectable HIV viral loads. Eleven of 17 vaccinated individuals had received childhood smallpox vaccination. In this group of individuals, both 2-dose modified vaccinia Ankara (MVA) vaccination and natural infection evoked mpox-specific immune responses mediated by B cells as well as CD4 and CD8 T cells. This study improves our understanding of smallpox vaccination-mediated cross-reactivity to other orthopox viruses, and long-lasting durability of childhood smallpox vaccination-mediated immune responses, including in PWH.

Knowledge, Attitude, and Behavior of the Pakistani Population Toward the Monkeypox Pandemic and the Associated Factors

Background Monkeypox (Mpox) is a virulent disease caused by orthopoxvirus. Mpox is emerging as a major global health threat. Currently, more than 100 countries are facing outbreaks. Pakistan, too, is witnessing the spread of this virus, with 11 confirmed cases and one death since its first detection in April 2023. Mpox infection can be diagnosed using polymerase chain reaction (PCR) and treated with antiviral agents. The smallpox vaccine is also proven to be effective against Mpox. Methodology This cross-sectional survey aimed to evaluate the knowledge, attitude, and behaviors (KAB) of the Pakistani population toward the Mpox pandemic and determine the factors affecting it. Data were collected through Google Forms using a validated questionnaire to assess the population's KAB. In total, 1,511 individuals were included in the final analysis. Results Study participants had good knowledge of the disease, poor attitude toward Mpox risk and severity, and poor behavior with low adherence to recommended protocols. Overall, 58% (n = 888) of the participants were male, and most of the respondents were aged between 18 and 30 years (n = 743, 49.2%). Most participants were married (n = 983, 65.1%), from urban areas (n = 837, 55.4%), and living in shared households (n = 876, 58%). Age showed a significant relationship with knowledge level and behavior, but not with attitude. The 18-30-year age group demonstrated higher knowledge levels (p = 0.007), regardless of gender. Shared households were significantly associated with a higher incidence of good knowledge (p < 0.05) compared to independent households (p = 0.038). Additionally, higher income was linked to better attitudes and behaviors. KAB outcomes also varied significantly based on marital status, individual education level, and parents' education levels. Conclusions Population dynamics such as cultural norms, religious beliefs, misperceptions about the disease associated with sexual behavior, health literacy, education level, rural and urban division of the population, gender role, migrant and refugee population, poverty, cost-seeking healthcare, and distrust in the government and healthcare system should be considered when constructing a public health policy because the behavior of the population is important for the implementation of preventive measures.

Efforts made, challenges faced, and recommendations provided by stakeholders involved in mpox prevention and control in China: a qualitative study

OBJECTIVES

Mpox continues to spread in China, and stakeholders' experiences may help inform prevention and control strategies.

STUDY DESIGN

Qualitative study.

METHODS

A qualitative study across 14 Chinese cities recruited stakeholders from Centers for Disease Control and Prevention (CDCs), community-based organizations (CBOs), and hospitals involved in curbing mpox. Semi-structured interviews were conducted by telephone and analyzed using Colaizzi's phenomenological method.

RESULTS

15 CBOs workers, 14 CDCs staff, and 13 healthcare workers were recruited. Three theme categories were identified: "Efforts to curb mpox epidemic", including CDCs' epidemic management and health education, hospitals' diagnosis, treatment, and care, CBOs' counseling, publicity, and referrals. "Challenges to curb mpox epidemic", including negative impacts of hospital-based quarantine, lack of specific antiviral drugs, gay identity disclosure concerns, psychological problems, contact tracing difficulties, and inadequate communication and collaboration. "Recommendations for curbing mpox epidemic", including prioritizing supervised home-based quarantine, incorporating HIV-related indicators into hospital quarantine criteria, reducing the cost of hospital quarantine, accelerating the development of vaccines and drugs, enhancing patient privacy protection, psychological training for stakeholders, establishing a task force that comprises personnel who are experienced in contact tracing and strengthening communication and collaboration.

CONCLUSIONS

Effective control of mpox spread requires strengthening collaboration with CBOs and community healthcare centers (CHCs) and working out a flexible and contextualized mechanism. It also needs to reinforce patient privacy protection and integrate stigma reduction into strategies. Additionally, it is important to include HIV-related indicators in the quarantine evaluation and provide psychological training for stakeholders to help them manage their mental health and improve counseling skills.

The Peculiar Emergence of Mpox (Monkeypox): Directions for the Search for the Natural Reservoir and Vaccination Strategies

Background/Objectives: Mpox (monkeypox) is a zoonosis with origins in a currently unknown African reservoir. The first epidemiological accounts of mpox date back to the early 1980s, yet mpox only emerged as a pandemic threat in 2022-2023, more than 40 years later. This scenario is very different from those of other emerging diseases such as HIV and SARS, which immediately spread globally, in fully susceptible populations, starting from patients zero. Methods: We use mathematical modeling to illustrate the dynamics of mpox herd immunity in small communities in touch with the mpox natural reservoir. In particular, we employ an SEIR stochastic model. Results: The peculiar emergence of mpox can be explained by its relationship with smallpox, which was eradicated through universal mass vaccination in 1980. Mpox first emerged in small rural communities in touch with mpox's animal reservoir and then spread globally. The relative isolation of these communities and their herd-immunity dynamics against mpox worked to delay the introduction of mpox in large urban centers. Conclusions: Mathematical modeling suggests that the search for the mpox animal reservoir would be most fruitful in communities with high mpox seroprevalence and small outbreaks. These are communities is tight contact with the mpox natural reservoir. We propose vaccinating individuals in communities in these communities to severely reduce the importation of cases elsewhere.

Strategic vaccine stockpiles for regional epidemics of emerging viruses: A geospatial modeling framework

Multinational epidemics of emerging infectious diseases are increasingly common, due to anthropogenic pressure on ecosystems and the growing connectivity of human populations. Early and efficient vaccination can contain outbreaks and prevent mass mortality, but optimal vaccine stockpiling strategies are dependent on pathogen characteristics, reservoir ecology, and epidemic dynamics. Here, we model major regional outbreaks of Nipah virus and Middle East respiratory syndrome, and use these to develop a generalized framework for estimating vaccine stockpile needs based on spillover geography, spatially-heterogeneous healthcare capacity and spatially-distributed human mobility networks. Because outbreak sizes were highly skewed, we found that most outbreaks were readily contained (median stockpile estimate for MERS-CoV: 2,089 doses; Nipah: 1,882 doses), but the maximum estimated stockpile need in a highly unlikely large outbreak scenario was 2-3 orders of magnitude higher (MERS-CoV: ∼87,000 doses; Nipah ∼ 1.1 million doses). Sensitivity analysis revealed that stockpile needs were more dependent on basic epidemiological parameters (i.e., death and recovery rate) and healthcare availability than any uncertainty related to vaccine efficacy or deployment strategy. Our results highlight the value of descriptive epidemiology for real-world modeling applications, and suggest that stockpile allocation should consider ecological, epidemiological, and social dimensions of risk.

The transmission dynamics of an infectious disease model in fractional derivative with vaccination under real data

The resurgence of monkeypox causes considerable healthcare risks needing efficient immunization programs. This work investigates the monkeypox disease dynamics in the UK, focusing on the impact of vaccination under real data. The key difficulty is to correctly predict the spread of the disease and evaluate the success of immunization efforts. We construct a mathematical model for monkeypox infection and extend it to the fractional case considering the Caputo derivative. The analysis ensures the positivity, boundedness, and uniqueness of the solution for the non-integer system. We conduct a local asymptotical stability analysis (LAS) at the disease-free equilibrium (DFE) D0, showing the result for R0<1. Additionally, we demonstrate the existence of multiple endemic equilibria and provide conditions for backward bifurcation, which are illustrated graphically. Using real case data from the UK, we estimate model parameters via the nonlinear least square method. Our results show that, without vaccination, R2≈0.8, whereas vaccination reduces it to R2v=0.48. We perform sensitivity analysis to identify key parameters influencing disease elimination, presenting the outcomes through graphs. To solve numerically the fractional model, we outline a numerical scheme and provide detailed results under various parameter assumptions. Our findings suggest that high vaccine efficacy, a low waning rate of the vaccines, and increased vaccination of the infected people can significantly reduce the future cases of monkeypox in the UK. The present study offers a comprehensive framework for monkeypox dynamics and informs public health strategies for effective disease control and prevention.

Monkeypox: A Comprehensive Review of Virology, Epidemiology, Transmission, Diagnosis, Prevention, Treatment, and Artificial Intelligence Applications

Monkeypox (Mpox), an uncommon zoonotic Orthopoxvirus, is commonly manifested by blisters on the skin and has a mortality rate of approximately 0-10%. Approximately two decades after the cessation of global smallpox vaccination, the number of confirmed cases of Mpox has been growing, making it the most common Orthopoxvirus infection. Therefore, in this narrative review, we aimed to shed light on recent advancements in the pathophysiology, transmission routes, epidemiology, manifestations, diagnosis, prevention, and treatment of Mpox, as well as the application of artificial intelligence (AI) methods for predicting this disease. The clinical manifestations of Mpox, including the onset of symptoms and dermatologic characteristics, are similar to those of the infamous smallpox, but Mpox is clinically milder. Notably, a key difference between smallpox and Mpox is the high prevalence of lymphadenopathy. Human-to-human, animal-to-human, and animal-to-animal transmission are the three main pathways of Mpox spread that must be considered for effective prevention, particularly during outbreaks. PCR testing, as the preferred method for diagnosing Mpox infection, can enhance early detection of new cases and thereby improve infection control measures. JYNNEOS and ACAM2000 are among the vaccines most commonly recommended for the prevention of Mpox. Brincidofovir, Cidofovir, and Tecovirimat are the primary treatments for Mpox cases. Similar to other viral infections, the best approach to managing Mpox is prevention. This can, in part, be achieved through measures such as reducing contact with individuals displaying symptoms, maintaining personal safety, and adhering to practices commonly used to prevent sexually transmitted infections.

Global knowledge and attitudes towards mpox (monkeypox) among healthcare workers: a systematic review and meta-analysis

BACKGROUND

The recent increase in human mpox (monkeypox) cases emphasizes the importance of early detection, prompt response and preventive management to control the spread of the disease. Healthcare workers (HCWs) play a crucial role in this process. This study aimed to determine the global knowledge and attitudes towards mpox among HCWs.

METHODS

This study searched multiple databases, including Google Scholar, Scopus, PubMed/MEDLINE, Science Direct, Web of Science, Embase, Springer and ProQuest, to locate various publications. The search was limited to English-language articles published between May 2022 (when the increase in mpox incidence was reported) and August 2023. The Joanna Briggs Institute (JBI) quality checklist was utilized to evaluate the quality of the included studies. Data were obtained using a Microsoft Excel spreadsheet and subsequently scrutinized through STATA software, version 14. The heterogeneity of the studies was assessed using the inverse variance and Cochran Q statistics based on the I2 test statistics. The Dersimonian and Liard random effects models were used where heterogeneity existed. Subgroup analysis and univariate and multivariable metaregression techniques were used to examine the causes of heterogeneity.

RESULTS

A total of 22 studies, including 22 studies for knowledge (27 731 HCWs) and 6 studies for attitudes (14 388 HCWs), were included in the meta-analysis. The pooled estimates for good knowledge and positive attitudes among HCWs were 26.0% (95% confidence interval [CI] 17.8 to 34.2) and 34.6% (95% CI 19.0 to 50.2), respectively. Moreover, the knowledge was 34.8% (95% CI 24.1 to 45.6) among HCWs with <5 y of work experience and 41.6% (95% CI 33.1 to 50) among individuals possessing >5 y of professional background.

CONCLUSIONS

Good knowledge of HCWs is at a low level. It is suggested that training sessions should be tailored towards younger HCWs with less healthcare experience. Additionally, it is essential to identify strategies on how to improve the knowledge and attitudes for better practice about the disease in HCWs worldwide.

The Mpox Vaccine Hesitancy Scale for Mpox: Links with Vaccination Intention among Men Who Have Sex with Men in Six Cities of China

BACKGROUND

Vaccine hesitancy is a significant barrier to achieving high vaccination rates, particularly among men who have sex with men (MSM), a group at increased risk for Mpox. This study aimed to develop and validate a Mpox vaccine hesitancy scale specifically tailored for Chinese MSM, grounded in the protection motivation theory (PMT).

METHODS

An online survey through snowball sampling was conducted from October 2023 to March 2024, collecting 2403 valid responses across six representative regions in China. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were conducted to evaluate the scale's construct validity, while reliability was assessed using Cronbach's α coefficient. The predictive validity of the scale was analyzed using Receiver Operating Characteristic (ROC) analysis.

RESULTS

EFA ultimately retained 22 items in the Mpox vaccination scale and identified four distinct dimensions: Maladaptive Rewards (seven items), Self-efficacy (seven items), Response Efficacy (four items), and Response Costs (four items). These dimensions were confirmed by CFA, which demonstrated satisfactory model fit indices (χ²/df = 4.382, RMSEA = 0.053, SRMR = 0.048, GFI = 0.935, CFI = 0.967, NFI = 0.958, TLI = 0.963, and IFI =0.967). All indices were within acceptable ranges. The scale exhibited good internal consistency, with a Cronbach's alpha of 0.906, and strong content validity, with an S-CVI/Ave of 0.952. The scale's predictive accuracy was evaluated using Receiver Operating Characteristic (ROC) analysis. When used to evaluate the scale's predictive accuracy, it yielded an area under the curve (AUC) of 0.854 after adjustments, indicating good predictive ability between high and low hesitancy.

CONCLUSIONS

This scale provides a reliable and valid tool for assessing Mpox vaccine hesitancy among MSM and can be used to gauge Mpox vaccination intention within this group.

Mpox treatment evolution: past milestones, present advances, and future directions

An underestimated worldwide health concern, Monkeypox (Mpox) is becoming a bigger menace to the world's population. After smallpox was eradicated in 1970, Mpox was found in a rural region of Africa and quickly spread to other African countries. The etiological agent of the Mpox infection, the Mpox virus, is constantly evolving, and its capability for cross-species transmission led to a global outbreak in 2022 which led to several deaths throughout the world. This review aims to showcase the progressive treatment methods and emerging innovations in the diagnostic and prevention strategies for controlling Mpox. The clinical trial data for antiviral drugs were systematically collected and analyzed using statistical tests to determine the most effective antiviral treatment. Emerging viral protein inhibitors that are under investigation for Mpox treatment were also scrutinized in this review. Additionally, modern diagnostic methods, such as the Streamlined CRISPR On Pod Evaluation platform (SCOPE) and graphene quantum rods were reviewed, and the efficacy of mRNA vaccines with traditional smallpox vaccines used for Mpox were compared. The statistical analysis revealed that tecovirimat (TCV) is the most effective antiviral drug among the other evaluated drugs, showing superior efficacy in clinical trials. Similarly, mRNA vaccines offer greater effectiveness compared to conventional smallpox vaccines. Furthermore, emerging nanomedicine and herbal drug candidates were highlighted as potential future treatments for Mpox. The findings underscore the effectiveness of TCV in treating Mpox and highlight significant advancements in preventive treatments. The review also points to innovative approaches in vaccine technology and potential future therapies, including nanomedicine and herbal remedies, which may enhance Mpox management.

Mpox: what sexual health physicians need to know?

Monkeypox virus (MPXV) is another zoonotic virus spilled over to the man and resulted in pandemic. World Health Organization declared it as a 'Public Health Emergency of International Concern (PHEIC) on July 22, 2022. Mpox affected over 95226 individuals among them claimed the lives of 185. Despite the fact that Mpox is generally mild and self-limited, immunocompromised people with low CD4 counts may experience severe disease course. Management of Mpox patients has three pillars. First symptomatic approach includes pain management, prophylaxis for secondary infections and when needed effective treatment of superinfections. Second, vaccines developed against smallpox can be used in preexposure or postexposure prophylaxis strategies against Mpox. Third, current antiviral options include tecovirimat, cidofovir and birincidofovir all of which have been recommended relying on experience from animal studies, clinical case reports or case series. Results of well-planned randomized control trials are not available. Occupational exposure to MPXV is especially a manageable risk for health care workers. Prevention of Mpox also requires risk communication with vulnerable population and their involvement in mitigation efforts.

A novel multi-epitope peptide vaccine targeting immunogenic antigens of Ebola and monkeypox viruses with potential of immune responses provocation in silico

The emergence or reemergence of monkeypox (Mpox) and Ebola virus (EBOV) agents causing zoonotic diseases remains a huge threat to human health. Our study aimed at designing a multi-epitope vaccine (MEV) candidate to target both the Mpox and EBOV agents using immunoinformatics tools. Viral protein sequences were retrieved, and potential nonallergenic, nontoxic, and antigenic epitopes were obtained. Next, cytotoxic and helper T-cell (CTL and HTL, respectively) and B-cell (BCL) epitopes were predicted, and those potential epitopes were fused utilizing proper linkers. The in silico cloning and expression processes were implemented using Escherichia coli K12. The immune responses were prognosticated using the C-ImmSim server. The MEV construct (29.53 kDa) included four BCL, two CTL, and four HTL epitopes and adjuvant. The MEV traits were pertinent in terms of antigenicity, non-allergenicity, nontoxicity, physicochemical characters, and stability. The MEV candidate was also highly expressed in E. coli K12. The strong affinity of MEV-TLR3 was confirmed using molecular docking and molecular dynamics simulation analyses. Immune simulation analyses unraveled durable activation and responses of cellular and humoral arms alongside innate immune responses. The designed MEV candidate demonstrated appropriate traits and was promising in the prediction of immune responses against both Mpox and EBOV agents. Further experimental assessments of the MEV are required to verify its efficacy.

Knowledge and attitude towards mpox: Systematic review and meta-analysis

BACKGROUND

The increase in mpox incidence underscores the crucial need to understand and effectively address prevention, early detection, and agile response to this disease. Therefore, the present study aims to determine the knowledge and attitude towards mpox.

METHODS

A systematic review and comprehensive literature meta-analysis were conducted using prominent databases such as PubMed, Scopus, Web of Science, Embase, and ScienceDirect, with an updated search until June 25, 2023. The quality of the included observational studies was assessed using the Joanna Briggs Institute's Statistical Meta-Analysis Review Instrument. The collected data were recorded in a Microsoft Excel spreadsheet, and analyses were conducted using R software version 4.2.3. Additionally, Cochran's Q statistics were applied to assess the heterogeneity of the included studies.

RESULTS

A total of 299 articles were retrieved from 5 databases. This study included 27 cross-sectional articles with a total sample of 22,327 participants, of which 57.13% were women. The studies were conducted in 15 countries through an online survey. All studies had a moderate level of quality. The combined prevalence of a good level of knowledge about mpox was 33% (95% CI: 22%-45%; 22,327 participants; 27 studies; I2 = 100%), and the combined prevalence of a positive attitude towards mpox was 40% (95% CI: 19%-62%; 2,979 participants; 6 studies; I2 = 99%). Additionally, as a secondary outcome, the combined prevalence of the intention to vaccinate against mpox was 58% (95% CI: 37%-78%; 2,932 participants; 7 studies; I2 = 99%).

CONCLUSION

Good knowledge and a positive attitude towards mpox were found to be low. The findings of this study highlight the need to identify gaps and focus on implementing educational programs on mpox.

TERMS USED

Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI), Prospective International Registry of Systematic Reviews (PROSPERO), and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

History of smallpox vaccination and marked clinical expression of mpox among cases notified in France from May to July 2022

OBJECTIVES

The aim was to estimate the effect of reported history of smallpox vaccination prior to 1980 on clinical expression of mpox.

METHODS

We included all confirmed mpox cases identified by the national mpox surveillance system in France between May and July 2022. Cases tested positive for monkeypox virus or orthopoxviruses by PCR. Cases were interviewed by phone using a questionnaire documenting demographics, symptoms and exposures. To estimate the effect of smallpox vaccination on the presence of marked mpox symptoms (association of fever, lymphadenopathy and extensive mucocutaneous lesions), we estimated prevalence ratios (PRs) and 95% CIs using Poisson regression models with robust standard errors.

RESULTS

There were 1888 confirmed mpox cases with date of symptom onset between 7 May and 31 July 2022. Overall, 7% (93/1394) presented marked mpox symptoms. Among patients who provided information about their vaccination status, 14% (207/1469) reported smallpox vaccination prior to 1980. The proportion of cases with marked symptoms was 2% (3/170) among those reporting smallpox vaccination prior to 1980 and 8% (76/974) among those who reported no vaccination. The proportion of marked symptoms was four times lower among cases reporting previous smallpox vaccination than in cases reporting no vaccination (PR, 0.24; 95% CI: 0.08-0.76). There was no evidence of an effect of smallpox vaccination on development of complications (PR, 0.65; 95% CI: 0.35-1.22) or hospitalization due to mpox (PR, 0.64; 95% CI: 0.23-1.80).

DISCUSSION

Our results suggest that smallpox vaccination during childhood attenuated the clinical expression of monkeypox virus infection, but there was no evidence of an effect on complications or hospitalization.

Mpox in people with HIV: A narrative review

OBJECTIVE

The 2022 global mpox outbreak disproportionately impacted people living with HIV. This review explores recent evidence on mpox in this group, focusing on clinical presentation, complications, treatment modalities and vaccine strategies.

RECENT FINDINGS

Recent studies have suggested that people with HIV diagnosed with mpox have a greater risk of proctitis and hospitalization compared with people without HIV. In addition, those with advanced immunosuppression face an elevated risk of severe mpox infection, which can lead to mortality. Comprehensive and prompt supportive care using antiretrovirals and mpox antivirals is crucial in this group. Although results from randomized clinical trials are still forthcoming, recent studies suggest that early initiation of tecovirimat can prevent disease progression in people with HIV. The non-replicative attenuated smallpox vaccine is well tolerated and effective in preventing monkeypox virus infections in people with HIV. Further studies are needed regarding long-term vaccine effectiveness for this population.

CONCLUSION

Evaluating the risk of severe mpox in people living with HIV requires assessing the level of immune suppression and viral control. Universal access to vaccination is imperative to prevent the resurgence of future outbreaks.

Serologic responses to the MVA-based JYNNEOS mpox vaccine in a cohort of participants from the District of Columbia (D.C.)

We assessed early antibody responses after two doses of JYNNEOS (IMVANEX) mpox vaccine in the District of Columbia (D.C.) in persons at high risk for mpox without characteristic lesions or rash. Participants with PCR mpox negative specimens (oral swab, blood, and/or rectal swab) on the day of receipt of the first vaccine dose and who provided a baseline (day 0) serum sample and at least one serum sample at ∼28, ∼42-56 days, or 180 days post vaccination were included in this analysis. Orthopoxvirus (OPXV)-specific IgG and IgM ELISAs and neutralizing antibody titers were performed, and longitudinal serologic responses were examined. Based on participants' IgG and IgM antibody levels at baseline, they were categorized as naïve or non-naïve. Linear mixed effects regression models were conducted to determine if IgG antibody response over time varied by age, sex, HIV status, and route of administration for both naïve and non-naïve participants. Among both naïve and non-naïve participants IgG seropositivity rates increased until day 42-56, with 89.4 % of naïve and 92.1 % of non-naïve participants having detectable IgG antibodies. The proportion of naive participants with detectable IgG antibodies declined by day 180 (67.7 %) but remained high among non-naïve participants (94.4 %). Neutralizing antibody titers displayed a similar pattern, increasing initially post vaccination but declining by day 180 among naïve participants. There were no significant serologic response differences by age, sex, or HIV status. Serologic response did vary by route of vaccine administration, with those receiving a combination of intradermal and subcutaneous doses displaying significantly higher IgG values than those receiving both doses intradermally. These analyses provide initial insights into the immunogenicity of a two-dose JYNNEOS PEP regimen in individuals at high risk of mpox exposure in the United States.

Orthopox viruses: is the threat growing?

BACKGROUND

Smallpox was a major cause of human mortality until its eradication, but the threat of orthopox viruses has not disappeared. Since the eradication of smallpox and the cessation of the related vaccination campaigns, the threat has been growing, as evidenced by the currently ongoing worldwide Mpox outbreak. In addition to threats of an evolving Mpox, we must also be aware of a myriad of other threats that remain. Many countries still lack biosecurity regulations reflecting the recent technological advances, and the threat of bioterrorism remains ever present. Reconstruction of smallpox is a distinct possibility, as are other scenarios whereby other orthopox viruses may be made more fit for transmission in humans.

OBJECTIVES

To outline and discuss potential biosafety and biosecurity threats posed by orthopox viruses.

SOURCES

Published scientific literature, news articles, and international agreements.

CONTENT AND IMPLICATIONS

It would be wise to take steps to mitigate these threats now. Vaccination campaigns should be considered in areas with frequent orthopox outbreaks, and more efforts must be made to put a final end to the Mpox outbreak. In many countries, national biosafety and biosecurity regulations may need to be revised and strengthened to better reflect the threats posed by new technologies, including controls on synthesis of smallpox sequences. Furthermore, more international cooperation and aid is needed. The present global Mpox outbreak could likely have been prevented had areas where Mpox is endemic not been neglected. Future outbreaks could be much worse.

Polyvalent mpox mRNA vaccines elicit robust immune responses and confer potent protection against vaccinia virus

The 2022 mpox outbreak led the World Health Organization (WHO) to declare it a public health emergency of international concern (PHEIC). There is a need to develop more effective and safer mpox virus (MPXV)-specific vaccines in response to the mpox epidemic. The mRNA vaccine is a promising platform to protect against MPXV infection. In this study, we construct two bivalent MPXV mRNA vaccines, designated LBA (B6R-A29L) and LAM (A35R-M1R), and a quadrivalent mRNA vaccine, LBAAM (B6R-A35R-A29L-M1R). The immunogenicity and protective efficacy of these vaccines alone or in combination were evaluated in a lethal mouse model. All mRNA vaccine candidates could elicit potential antigen-specific humoral and cellular immune responses and provide protection against vaccinia virus (VACV) infection. The protective effect of the combination of two bivalent mRNA vaccines and the quadrivalent vaccine was superior to that of the individual bivalent mRNA vaccine. Our study provides valuable insights for the development of more efficient and safer mRNA vaccines against mpox.

Insights into the emergence and evolution of monkeypox virus: Historical perspectives, epidemiology, genetic diversity, transmission, and preventative measures

In 2022, just before the COVID-19 pandemic ended, many countries noticed a viral monkeypox outbreak. Monkeypox virus, a zoonotic pathogen, causes a febrile illness in humans and resembles smallpox. Prevention strategies encompass vaccination, strict infection control measures, and avoiding contact with infected persons. As monkeypox and related poxviruses continue to pose challenges, ongoing surveillance, early diagnosis, prompt isolation, and effective control measures are crucial for limiting transmission and mitigating the impact of outbreaks on public health. This review provides valuable insights into the evolution of the monkeypox virus and its various modes of transmission, including postmortem transmission, and offers an overall perspective on the guidelines issued by the Government of India to prevent and effectively control the spread of this disease.

"Mpox in MSM: Tackling stigma, minimizing risk factors, exploring pathogenesis, and treatment approaches"

Mpox is a zoonotic disease caused by the monkeypox virus (MPV), primarily found in Central and West African countries. The typical presentation of the disease before the 2022 mpox outbreak includes a febrile prodrome 5-13 days post-exposure, accompanied by lymphadenopathy, malaise, headache, and muscle aches. Unexpectedly, during the 2022 outbreak, several cases of atypical presentations of the disease were reported, such as the absence of prodromal symptoms and the presence of genital skin lesions suggestive of sexual transmission. As per the World Health Organization (WHO), as of March 20, 2024, 94,707 cases of mpox were reported worldwide, resulting in 181 deaths (22 in African endemic regions and 159 in non-endemic countries). The United States Centers for Disease Control and Prevention (CDC) reports a total of 32,063 cases (33.85% of total cases globally), with 58 deaths (32.04% of global deaths) due to mpox. Person-to-person transmission of mpox can occur through respiratory droplets and sustained close contact. However, during the 2022 outbreak of mpox, a high incidence of anal and perianal lesions among MSMs indicated sexual transmission of MPV as a major route of transmission. Since MSMs are disproportionately at risk for HIV transmission. In this review, we discusses the risk factors, transmission patterns, pathogenesis, vaccine, and treatment options for mpox among MSM and people living with HIV (PLWH). Furthermore, we provide a brief perspective on the evolution of the MPV in immunocompromised people like PLWH.

Molecular Evolution of Protein Sequences and Codon Usage in Monkeypox Viruses

The monkeypox virus (mpox virus, MPXV) epidemic in 2022 has posed a significant public health risk. Yet, the evolutionary principles of MPXV remain largely unknown. Here, we examined the evolutionary patterns of protein sequences and codon usage in MPXV. We first demonstrated the signal of positive selection in OPG027, specifically in the Clade I lineage of MPXV. Subsequently, we discovered accelerated protein sequence evolution over time in the variants responsible for the 2022 outbreak. Furthermore, we showed strong epistasis between amino acid substitutions located in different genes. The codon adaptation index (CAI) analysis revealed that MPXV genes tended to use more non-preferred codons compared to human genes, and the CAI decreased over time and diverged between clades, with Clade I > IIa and IIb-A > IIb-B. While the decrease in fatality rate among the three groups aligned with the CAI pattern, it remains unclear whether this correlation was coincidental or if the deoptimization of codon usage in MPXV led to a reduction in fatality rates. This study sheds new light on the mechanisms that govern the evolution of MPXV in human populations.

Antibodies Induced by Smallpox Vaccination after at Least 45 Years Cross-React with and In Vitro Neutralize Mpox Virus: A Role for Polyclonal B Cell Activation?

AIMS

To evaluate whether antibodies specific for the vaccinia virus (VV) are still detectable after at least 45 years from immunization. To confirm that VV-specific antibodies are endowed with the capacity to neutralize Mpox virus (MPXV) in vitro. To test a possible role of polyclonal non-specific activation in the maintenance of immunologic memory.

METHODS

Sera were collected from the following groups: smallpox-vaccinated individuals with or without latent tuberculosis infection (LTBI), unvaccinated donors, and convalescent individuals after MPXV infection. Supernatant of VV- or MPXV-infected Vero cells were inactivated and used as antigens in ELISA or in Western blot (WB) analyses. An MPXV plaque reduction neutralization test (PRNT) was optimized and performed on study samples. VV- and PPD-specific memory T cells were measured by flow cytometry.

RESULTS

None of the smallpox unvaccinated donors tested positive in ELISA or WB analysis and their sera were unable to neutralize MPXV in vitro. Sera from all the individuals convalescing from an MPXV infection tested positive for anti-VV or MPXV IgG with high titers and showed MPXV in vitro neutralization capacity. Sera from most of the vaccinated individuals showed IgG anti-VV and anti-MPXV at high titers. WB analyses showed that positive sera from vaccinated or convalescent individuals recognized both VV and MPXV antigens. Higher VV-specific IgG titer and specific T cells were observed in LTBI individuals.

CONCLUSIONS

ELISA and WB performed using supernatant of VV- or MPXV-infected cells are suitable to identify individuals vaccinated against smallpox at more than 45 years from immunization and individuals convalescing from a recent MPXV infection. ELISA and WB results show a good correlation with PRNT. Data confirm that a smallpox vaccination induces a long-lasting memory in terms of specific IgG and that antibodies raised against VV may neutralize MPXV in vitro. Finally, higher titers of VV-specific antibodies and higher frequency of VV-specific memory T cells in LTBI individuals suggest a role of polyclonal non-specific activation in the maintenance of immunologic memory.

The global patent landscape of emerging infectious disease monkeypox

BACKGROUND

Monkeypox is an emerging infectious disease with confirmed cases and deaths in several parts of the world. In light of this crisis, this study aims to analyze the global knowledge pattern of monkeypox-related patents and explore current trends and future technical directions in the medical development of monkeypox to inform research and policy.

METHODS

A comprehensive study of 1,791 monkeypox-related patents worldwide was conducted using the Derwent patent database by descriptive statistics, social network method and linear regression analysis.

RESULTS

Since the 21st century, the number of monkeypox-related patents has increased rapidly, accompanied by increases in collaboration between commercial and academic patentees. Enterprises contributed the most in patent quantity, whereas the initial milestone patent was filed by academia. The core developments of technology related to the monkeypox include biological and chemical medicine. The innovations of vaccines and virus testing lack sufficient patent support in portfolios.

CONCLUSIONS

Monkeypox-related therapeutic innovation is geographically limited with strong international intellectual property right barriers though it has increased rapidly in recent years. The transparent licensing of patent knowledge is driven by the merger and acquisition model, and the venture capital, intellectual property and contract research organization model. Currently, the patent thicket phenomenon in the monkeypox field may slow the progress of efforts to combat monkeypox. Enterprises should pay more attention to the sharing of technical knowledge, make full use of drug repurposing strategies, and promote innovation of monkeypox-related technology in hotspots of antivirals (such as tecovirimat, cidofovir, brincidofovir), vaccines (JYNNEOS, ACAM2000), herbal medicine and gene therapy.

Mpox vaccination and treatment: a systematic review

The Human monkeypox virus (mpox) belongs to the Poxviridae family, characterized by double-stranded DNA. A 2022 outbreak, notably prevalent among men who have sex with men, was confirmed by the World Health Organization. To understand shifting prevalence patterns and clinical manifestations, we conducted a systematic review of recent animal and human studies. We comprehensively searched PubMed, Scopus, Web of Science, Cochrane Library, and Clinicaltrials.gov, reviewing 69 relevant articles from 4,342 screened records. Our analysis highlights Modified Vaccinia Ankara - Bavarian Nordic (MVA-BN)'s potential, though efficacy concerns exist. Tecovirimat emerged as a prominent antiviral in the recent outbreak. However, limited evidence underscores the imperative for further clinical trials in understanding and managing monkeypox.

Potential use of cidofovir, brincidofovir, and tecovirimat drugs in fighting monkeypox infection: recent trends and advancements

Recent years have witnessed the rise of more recent pandemic outbreaks including COVID-19 and monkeypox. A multinational monkeypox outbreak creates a complex situation that necessitates countermeasures to the existing quo. The first incidence of monkeypox was documented in the 1970s, and further outbreaks led to a public health emergency of international concern. Yet as of right now, neither vaccines nor medicines are certain to treat monkeypox. Even the inability of conducting human clinical trials has prevented thousands of patients from receiving effective disease management. The current state of the disease's understanding, the treatment options available, financial resources, and lastly international policies to control an epidemic state are the major obstacles to controlling epidemics. The current review focuses on the epidemiology of monkeypox, scientific ideas, and available treatments, including potential monkeypox therapeutic methods. As a result, a thorough understanding of monkeypox literature will facilitate in the development of new therapeutic medications for the prevention and treatment of monkeypox.

Behavioral Intention of Receiving Monkeypox Vaccination and Undergoing Monkeypox Testing and the Associated Factors Among Young Men Who Have Sex With Men in China: Large Cross-Sectional Study

BACKGROUND

The worldwide human monkeypox (mpox) outbreak in 2022 mainly affected men who have sex with men (MSM). In China, young men who have sex with men (YMSM) were at a potential high risk of mpox infection due to their sexual activeness and the eased COVID-19 restrictions at the end of 2022.

OBJECTIVE

This study aimed to investigate the behavioral intention of receiving mpox vaccination and undergoing mpox testing in 4 different scenarios and explore their associations with background and behavioral theory-related factors among Chinese YMSM.

METHODS

An online cross-sectional survey was conducted among YMSM aged 18-29 years from 6 representative provinces of China in September 2022. Participants recruited (recruitment rate=2918/4342, 67.2%) were asked to self-administer an anonymous questionnaire designed based on prior knowledge about mpox and classic health behavior theories. Data on the participants' background, mpox knowledge and cognition, mpox vaccination and testing cognition, and the behavioral intention of receiving mpox vaccination and undergoing mpox testing were collected. Descriptive analysis and univariate and multivariate linear regressions were performed. Geodetector was used to measure the stratified heterogeneity of behavioral intention.

RESULTS

A total of 2493 YMSM with a mean age of 24.6 (SD 2.9) years were included. The prevalence of having a behavioral intention of receiving mpox vaccination ranged from 66.2% to 88.4% by scenario, varying in epidemic status and cost. The prevalence of having an mpox testing intention was above 90% in all scenarios regardless of the presence of symptoms and the cost. The positive factors related to vaccination intention included mpox knowledge (ba=0.060, 95% CI 0.016-0.103), perceived susceptibility of mpox (ba=0.091, 95% CI 0.035-0.146), perceived severity of mpox (ba=0.230, 95% CI 0.164-0.296), emotional distress caused by mpox (ba=0.270, 95% CI 0.160-0.380), perceived benefits of mpox vaccination (ba=0.455, 95% CI 0.411-0.498), self-efficacy of mpox vaccination (ba=0.586, 95% CI 0.504-0.668), and having 1 male sex partner (ba=0.452, 95% CI 0.098-0.806), while the negative factor was perceived barriers to vaccination (ba=-0.056, 95% CI -0.090 to -0.022). The positive factors related to testing intention were perceived severity of mpox (ba=0.283, 95% CI 0.241-0.325), perceived benefits of mpox testing (ba=0.679, 95% CI 0.636-0.721), self-efficacy of mpox testing (ba=0.195, 95% CI 0.146-0.245), having 1 male sex partner (ba=0.290, 95% CI 0.070-0.510), and having in-person gatherings with MSM (ba=0.219, 95% CI 0.072-0.366), while the negative factor was emotional distress caused by mpox (ba=-0.069, 95% CI -0.137 to -0.001).

CONCLUSIONS

Among Chinese YMSM, the intention of undergoing mpox testing is optimal, while the mpox vaccination intention has room for improvement. A future national response should raise YMSM's mpox knowledge, disseminate updated information about mpox and preventive measures, improve preventive service accessibility and privacy, and provide advice on positively coping with the associated emotional distress.

A comprehensive review of monkeypox virus and mpox characteristics

Monkeypox virus (MPXV) is the etiological agent of monkeypox (mpox), a zoonotic disease. MPXV is endemic in the forested regions of West and Central Africa, but the virus has recently spread globally, causing outbreaks in multiple non-endemic countries. In this paper, we review the characteristics of the virus, including its ecology, genomics, infection biology, and evolution. We estimate by phylogenomic molecular clock that the B.1 lineage responsible for the 2022 mpox outbreaks has been in circulation since 2016. We interrogate the host-virus interactions that modulate the virus infection biology, signal transduction, pathogenesis, and host immune responses. We highlight the changing pathophysiology and epidemiology of MPXV and summarize recent advances in the prevention and treatment of mpox. In addition, this review identifies knowledge gaps with respect to the virus and the disease, suggests future research directions to address the knowledge gaps, and proposes a One Health approach as an effective strategy to prevent current and future epidemics of mpox.

Role of vaccination in patients with human monkeypox virus and its cardiovascular manifestations

Human monkeypox, caused by the monkeypox virus (MPXV), is an emerging infectious disease with the potential for human-to-human transmission and diverse clinical presentations. While generally considered milder than smallpox, it can lead to severe cardiovascular complications. The virus primarily spreads through contact with infected animals or through human-to-human transmission. Cardiovascular involvement in human monkeypox is rare but has been associated with myocarditis, pericarditis, arrhythmias, and even fulminant myocardial infarction. Vaccination plays a crucial role in preventing and controlling monkeypox, but the eradication of smallpox has left global populations vulnerable. This review explores the cardiovascular manifestations of human monkeypox, the role of vaccination in disease prevention, and the importance of continued research and development of effective vaccines to protect against this emerging infectious threat. The global impact of monkeypox outbreaks, particularly on vulnerable populations, further highlights the importance of understanding and addressing this disease.

Mpox reinfection: A rapid systematic review of case reports

Background

Mpox re-emerged worldwide with the multi-country outbreaks that occurred in May 2022, threatening the public health of human beings.

Methods

This rapid systematic review summarized mpox reinfection cases documented. Electronic databases (PubMed, MedRxiv, and Social Science Research Network) were searched without time limitation, using the keywords "mpox," "monkeypox," & "reinfection," "reoccur," "reoccurrence," "episode," and "relapse". All laboratory-confirmed cases of mpox reinfection published in the literature were included in this study.

Results

A total of seven publications (nine cases) from Africa, Europe, and South America were included. All mpox reinfection cases were male, with a median age of 36; 88.89% of cases had unprotected sexual behaviors with other males before each illness episode. The average onset interval between the two episodes was about 4 months. Perianal lesions and lymphadenopathy were major symptoms in both episodes, and no differences in clinical severity were reported between the two episodes. The mean duration of the two episodes was approximately 22 days and 13 days, respectively; which the mean duration of the second episode was shorter than the first infection (t = 2.17, p = 0.0487). Sexually transmitted infections were commonly concurrent among most cases, accounting for 55.6% and 77.8% in the two episodes, respectively. Full vaccination against mpox was rare among reinfection cases.

Conclusion

A second infection is possible even in a short period. Reinforcing monitoring, reducing high-risk behaviors, and heightening health education regarding mpox for high-risk populations are crucial to limit mpox spread, including persons with a history of mpox infection.

An overview on mRNA-based vaccines to prevent monkeypox infection

The human monkeypox virus (Mpox) is classified as a member of the Poxviridae family and belongs to the Orthopoxvirus genus. Mpox possesses double-stranded DNA, and there are two known genetic clades: those originating in West Africa and the Congo Basin, commonly known as Central African clades. Mpox may be treated with either the vaccinia vaccination or the therapeutics. Modifying the smallpox vaccine for treating and preventing Mpox has shown to be beneficial because of the strong link between smallpox and Mpox viruses and their categorization in the same family. Cross-protection against Mpox is effective with two Food and Drug Administration (FDA)-approved smallpox vaccines (ACAM2000 and JYNNEOSTM). However, ACAM2000 has the potential for significant adverse effects, such as cardiac issues, whereas JYNNEOS has a lower risk profile. Moreover, Mpox has managed to resurface, although with modified characteristics, due to the discontinuation and cessation of the smallpox vaccine for 40 years. The safety and efficacy of the two leading mRNA vaccines against SARS-CoV-2 and its many variants have been shown in clinical trials and subsequent data analysis. This first mRNA treatment model involves injecting patients with messenger RNA to produce target proteins and elicit an immunological response. High potency, the possibility of safe administration, low-cost manufacture, and quick development is just a few of the benefits of RNA-based vaccines that pave the way for a viable alternative to conventional vaccines. When protecting against Mpox infection, mRNA vaccines are pretty efficient and may one day replace the present whole-virus vaccines. Therefore, the purpose of this article is to provide a synopsis of the ongoing research, development, and testing of an mRNA vaccine against Mpox.

Single-dose Effectiveness of Mpox Vaccine in Quebec, Canada: Test-negative Design With and Without Adjustment for Self-reported Exposure Risk

INTRODUCTION

During the 2022 mpox outbreak, the province of Quebec, Canada, prioritized first doses for pre-exposure vaccination of people at high mpox risk, delaying second doses due to limited supply. We estimated single-dose mpox vaccine effectiveness (VE) adjusting for virus exposure risk based only on surrogate indicators available within administrative databases (eg, clinical record of sexually transmitted infections) or supplemented by self-reported risk factor information (eg, sexual contacts).

METHODS

We conducted a test-negative case-control study between 19 June and 24 September 2022. Information from administrative databases was supplemented by questionnaire collection of self-reported risk factors specific to the 3-week period before testing. Two study populations were assessed: all within the administrative databases (All-Admin) and the subset completing the questionnaire (Sub-Quest). Logistic regression models adjusted for age, calendar-time and exposure-risk, the latter based on administrative indicators only (All-Admin and Sub-Quest) or with questionnaire supplementation (Sub-Quest).

RESULTS

There were 532 All-Admin participants, of which 199 (37%) belonged to Sub-Quest. With exposure-risk adjustment based only on administrative indicators, single-dose VE estimates were similar among All-Admin and Sub-Quest populations at 35% (95% confidence interval [CI]:-2 to 59) and 30% (95% CI:-38 to 64), respectively. With adjustment supplemented by questionnaire information, the Sub-Quest VE estimate increased to 65% (95% CI:1-87), with overlapping confidence intervals.

CONCLUSIONS

Using only administrative data, we estimate one vaccine dose reduced the mpox risk by about one-third; whereas, additionally adjusting for self-reported risk factor information revealed greater vaccine benefit, with one dose instead estimated to reduce the mpox risk by about two-thirds. Inadequate exposure-risk adjustment may substantially under-estimate mpox VE.

The Current State and Progress of Mpox Vaccine Research

On July 23, 2022, the World Health Organization (WHO) declared the monkeypox (mpox) outbreak a "Public Health Emergency of International Concern." Since 2022, outbreaks of mpox in many countries around the world have primarily resulted in fatalities among immunocompromised individuals, such as untreated HIV/AIDS patients. Since the eradication of smallpox was declared by the WHO in 1980, the global vaccination against smallpox has been gradually discontinued. China also stopped routine smallpox vaccination in 1981. The protective effect of the smallpox vaccine has decreased over time due to aging and declining immunity in those who were vaccinated. For individuals, timely vaccination against smallpox is an effective means of protection against mpox. However, due to safety concerns with the smallpox vaccine and the limitations of current mpox vaccines, there is no vaccine that is safe, effective, and has low side effects applied in clinical settings. This article provides a comprehensive review of the development of mpox virus (MPXV) vaccines, their application in special populations, and the current state of vaccine research, considering the etiology, transmission, and prevention of the MPXV. Vaccination, as an effective method of epidemic prevention, can provide long-term immune protection and effectively reduce the severity of infection. However, as there is no licensed specific MPXV vaccine available globally, the vaccines currently used for mpox prevention are mostly smallpox vaccines. These smallpox vaccines can offer some degree of protection against mpox by activating cross-protection in the body.

A field diagnostic method for rapid and sensitive detection of mpox virus

The mpox outbreak has subdued with fewer reported cases at the present in high-income countries. It is known that mpox virus (MPXV) infection has been epidemic for more than 50 years in African countries. The ancestral MPXV strain has changed into multiple clades, indicating the ongoing evolution of MPXV, which reflects the historical neglect of mpox in Africa, especially after smallpox eradication, and bestows the danger of more severe mpox epidemics in the future. It is thus imperative to continue the development of mpox diagnostics and treatments so we can be prepared in the event of a new mpox epidemic. In this study, we have developed an MPXV detection tool that leverages the recombinase-aid amplification assay by integrating lateral flow strips (RAA-LF) and one-step sample DNA preparation, with visible readout, no need of laboratory instrument, and ready for field deployment. The detection limit reaches 10 copies per reaction. The performance of our RAA-FL assay in diagnosing mpox clinical samples is on par with that of the quantitative polymerase chain reaction (PCR) assay. Taken together, we have developed a point-of-care RAA-LF method of high accuracy and sensitivity, readily deployable for field detection of MPXV. This diagnostic tool is expected to improve and accelerate field- and self-diagnosis, allow timely isolation and treatment, reduce the spread of MPXV, thus effectively mitigate MPXV outbreak in the future.

Human monkeypox: An updated appraisal on epidemiology, evolution, pathogenesis, clinical manifestations, and treatment strategies

Monkeypox (Mpox) is a zoonotic viral disease caused by the monkeypox virus (MPXV), a member of the Orthopoxvirus genus. The recent occurrence of Mpox infections has become a significant global issue in recent months. Despite being an old disease with a low mortality rate, the ongoing multicountry outbreak is atypical due to its occurrence in nonendemic countries. The current review encompasses a comprehensive analysis of the literature pertaining to MPXV, with the aim of consolidating the existing data on the virus's epidemiological, biological, and clinical characteristics, as well as vaccination and treatment regimens against the virus.

Bias in vaccine effectiveness studies of clinically severe outcomes that are measured with low specificity: the example of COVID-19-related hospitalisation

Many vaccine effectiveness (VE) analyses of severe disease outcomes such as hospitalisation and death include 'false' cases that are not actually caused by the infection or disease under study. While the inclusion of such false cases inflate outcome rates in both vaccinated and unvaccinated populations, it is less obvious how they affect estimates of VE. Illustrating the main points through simple examples, this article shows how VE is underestimated when false cases are included as outcomes. Depending how the outcome indicator is defined, estimates of VE against severe disease outcomes, whose definition allows for the inclusion of false cases, will be biased downwards and may in certain circumstances approximate the same level as the VE against infection. The bias is particularly pronounced for vaccines that offer high levels of protection against severe disease outcomes but poor protection against infection. Analysing outcomes that are measured with low sensitivity generally does not cause bias in VE studies; defining outcome indicators that minimise the number of false cases rather than the number of missed cases is preferable in VE studies.

Mpox: The Reemergence of an Old Disease and Inequities

Mpox, previously known as monkeypox, is caused by an Orthopoxvirus related to the variola virus that causes smallpox. Prior to 2022, mpox was considered a zoonotic disease endemic to central and west Africa. Since May 2022, more than 86,000 cases of mpox from 110 countries have been identified across the world, predominantly in men who have sex with men, most often acquired through close physical contact or during sexual activity. The classical clinical presentation of mpox is a prodrome including fever, lethargy, and lymphadenopathy followed by a characteristic vesiculopustular rash. The recent 2022 outbreak included novel presentations of mpox with a predominance of anogenital lesions, mucosal lesions, and other features such as anorectal pain, proctitis, oropharyngeal lesions, tonsillitis, and multiphasic skin lesions. We describe the demographics and clinical spectrum of classical and novel mpox, outlining the potential complications and management.

Prospective monitoring of adverse events following vaccination with Modified vaccinia Ankara - Bavarian Nordic (MVA-BN) administered to a Canadian population at risk of Mpox: A Canadian Immunization Research Network study

MVA-BN is an orthopoxvirus vaccine that provides protection against both smallpox and mpox. In June 2022, Canada launched a publicly-funded vaccination campaign to offer MVA-BN to at-risk populations including men who have sex with men (MSM) and sex workers. The safety of MVA-BN has not been assessed in this context. To address this, the Canadian National Vaccine Safety Network (CANVAS) conducted prospective safety surveillance during public health vaccination campaigns in Toronto, Ontario and in Vancouver, British Columbia. Vaccinated participants received a survey 7 and 30 days after each MVA-BN dose to elicit adverse health events. Unvaccinated individuals from a concurrent vaccine safety project evaluating COVID-19 vaccine safety were used as controls. Vaccinated and unvaccinated participants that reported a medically attended visit on their 7-day survey were interviewed. Vaccinated participants and unvaccinated controls were matched 1:1 based on age group, gender, sex and provincial study site. Overall, 1,173 vaccinated participants completed a 7-day survey, of whom 75 % (n = 878) also completed a 30-day survey. Mild to moderate injection site pain was reported by 60 % of vaccinated participants. Among vaccinated participants 8.4 % were HIV positive and when compared to HIV negative vaccinated individuals, local injection sites were less frequent in those with HIV (48 % vs 61 %, p = 0.021), but health events preventing work/school or requiring medical assessment were more frequent (7.1 % vs 3.1 %, p = 0.040). Health events interfering with work/school, or requiring medical assessment were less common in the vaccinated group than controls (3.3 % vs. 7.1 %, p < 0.010). No participants were hospitalized within 7 or 30 days of vaccination. No cases of severe neurological disease, skin disease, or myocarditis were identified. Our results demonstrate that the MVA-BN vaccine appears safe when used for mpox prevention, with a low frequency of severe adverse events and no hospitalizations observed.

Orthopoxvirus-Specific T-Cell Responses in Convalescent Mpox Patients

Orthopoxvirus-specific T-cell responses were analyzed in 10 patients who had recovered from Mpox including 7 people with human immunodeficiency virus (PWH). Eight participants had detectable virus-specific T-cell responses, including a PWH who was not on antiretroviral therapy and a PWH on immunosuppressive therapy. These 2 participants had robust polyfunctional CD4+ T-cell responses to peptides from the 121L vaccinia virus (VACV) protein. T-cells from 4 of 5 HLA-A2-positive participants targeted at least 1 previously described HLA-A2-restricted VACV epitope, including an epitope targeted in 2 participants. These results advance our understanding of immunity in convalescent Mpox patients.

Prevalence of intentions to receive monkeypox vaccine. A systematic review and meta-analysis

BACKGROUND

Immunization, as a preventive strategy against infectious diseases, has consolidated its position as a fundamental pillar in the field of public health. Therefore, the present study aimed to determine the prevalence of the intention to receive the monkeypox (Mpox) vaccine.

METHODS

A systematic review and meta-analysis of the available evidence was performed using five databases (PubMed, Scopus, Web of Science, Embase, and ScienceDirect) with a search strategy until July 24, 2023. Data analysis was performed in R software version 4.2.3. The quality of the included cross-sectional studies was assessed using the "JBI-MAStARI". In addition, a subgroup analysis by population and continent was developed.

RESULTS

Twenty-nine cross-sectional articles with a total sample of 52 658 participants were included. The pooled prevalence of intention to vaccinate against Mpox was 61% (95% CI: 53-69%; 52,658 participants; 29 studies; I2 = 100%). In the subgroup analysis, the intention to be vaccinated against Mpox according to continents was 64% (95% CI: 53-74%; 13,883 participants; 17 studies; I2 = 99%) in Asian countries, 43% (95% CI: 39-47%; 1538 participants; 3 studies; I2 = 53%) in African countries, 62% (95% CI: 45-78%; 35,811 participants; 6 studies; I2 = 99%) in European countries, and 63% (95% CI: 32-89%; 1426 participants; 3 studies; I2 = 99%) in American countries. In the subgroup analysis on the intention to be vaccinated against Mpox, according to study subjects, it was 54% (95% CI: 45-62%; 10,296 participants; 11 studies; I2 = 99%) in the general population, 57% (95% CI: 33-79%; 3333 participants; 10 studies; I2 = 99%) in health care workers, and 76% (95% CI: 70-82%; 39,029 participants; 8 studies; I2 = 98%) in the lesbian, gay, bisexual, transgender, and intersex (LGBTI) community. In addition, as a secondary outcome, a prevalence of refusal of Mpox vaccination was found to be 22% (95% CI: 16-30%; 45,577 participants; 21 studies; I2 = 99%).

CONCLUSION

The study highlights the importance of recognizing regional and subgroup disparities in Mpox vaccine willingness and refusal. It emphasizes the importance of employing strategies to achieve widespread vaccination coverage and safeguard public health worldwide.

TERMS USED

Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI), Prospective International Registry of Systematic Reviews (PROSPERO), and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

Challenges and Counteracting Strategies Including Optimum Health Service Practices for Frontline Nurses During the Mpox Outbreak and Futuristic Vision

Introduction

Monkeypox (mpox) is an evolving infectious disease caused by the monkeypox virus (MPXV). On July 23, 2022, the WHO declared the recent mpox outbreaks a public health emergency of international concern (PHEIC), which terminated on May 11, 2023. As of July 11, 2023, 88,288 confirmed cases and 149 deaths have been reported from 112 countries and territories. Currently, mpox is not a PHEIC, as the outbreak and its impacts are nearly over. Nurses played significant roles during the mpox 2022 outbreak as frontline workers.

Purpose

In light of the impending mpox global outbreak in 2022, this brief report provides an update on the enormous difficulties faced by frontline nurses while playing a crucial role in handling the mpox outbreak and some potential solutions to these difficulties. The methodological framework employed in this narrative brief report involves conducting a comprehensive analysis and synthesis of relevant literature and hypothetical scenarios. The aim is to put forth practical strategies that can effectively tackle the difficulties encountered by frontline nurses in the context of the mpox outbreak. Additionally, the report seeks to envision a healthcare system that is more resilient in the face of future challenges.

Conclusion

It is important to understand the challenges the nurses face from their perspective. As frontline health care workers, the various health issues of nurses and their concerns must be taken care of appropriately by adopting optimum health service practices, adequate safety measures, recommended precautionary measures, and boosting them mentally while handling mpox patients. Counseling and the arrangement of workshops are required. Appropriate care should be taken to address the various health issues concerning nurses by adopting health service practices at optimum levels. Side by side, recommended safety and precautionary measures should be followed.

Breaking Barriers: Current Advances and Future Directions in Mpox Therapy

BACKGROUND

Mpox, a newly discovered zoonotic infection, can be transmitted from animal to human and between humans. Serological and genomic studies are used to identify the virus.

OBJECTIVE

Currently, there are no proven effective treatments for Mpox. Also, the safety and efficacy of intravenous vaccinia immune globulin, oral Tecovirimat (an inhibitor of intracellular viral release), and oral Brincidofovir (a DNA polymerase inhibitor) against the Mpox virus are uncertain, highlighting the need for more effective and safe treatments. As a result, drug repurposing has emerged as a promising strategy to identify previously licensed drugs that can be repurposed to treat Mpox.

RESULTS

Various approaches have been employed to identify previously approved drugs that can target specific Mpox virus proteins, including thymidylate kinase, D9 decapping enzyme, E8 protein, Topoisomerase1, p37, envelope proteins (D13, A26, and H3), F13 protein, virus's main cysteine proteases, and DNA polymerase.

CONCLUSION

In this summary, we provide an overview of potential drugs that could be used to treat Mpox and discuss the underlying biological processes of their actions.

Poxviridae Pneumonia

Poxviridae family includes several viruses that infecting humans usually causes skin lesions only, but in some cases their clinical course is complicated by viral pneumonia (with or without bacterial superinfections). Historically variola virus has been the poxviridae most frequently associated with the development of pneumonia with many large outbreaks worldwide before its eradication in 1980. It is still considered a biological threat for its potential in biological warfare and bioterrorism. Smallpox pneumonia can be severe with the onset of acute respiratory distress syndrome (ARDS) and death. Vaccinia virus, used for vaccination against smallpox exceptionally, in immunocompromised patients, can induce generalized (with also lung involvement) severe disease after vaccination. MPXV virus occasionally can cause pneumonia particularly in immunocompromised patients. The pathophysiology of poxviridae pneumonia is still an area of active research; however, in animal models these viruses can cause both direct damage to the lower airways epithelium and a hyperinflammatory syndrome, like a cytokine storm. Multiple mechanisms of immune evasion have also been described. The treatment of poxviridae pneumonia is mainly based on careful supportive care. Despite the absence of randomized clinical trials in patients with poxviridae pneumonia there are antiviral drugs, such as tecovirimat, cidofovir and brincidofovir, FDA-approved for use in smallpox and also available under an expanded access protocol for treatment of MPXV. There are 2 (replication-deficient modified vaccinia Ankara and replication-competent vaccinia virus) smallpox vaccines FDA-approved with the first one also approved for prevention of MPXV in adults that are at high risk of infection.

Vaccines against mpox: MVA-BN and LC16m8

INTRODUCTION

Global outbreaks involving mpox clade IIb began in mid-2022. Today, clade IIb and clade I outbreaks continue. Reliable mpox vaccines can prevent serious mpox disease and death.

AREAS COVERED

Globally, two vaccines hold mpox indications, regardless of mpox viral clade: MVA-BN (Bavarian Nordic) and LC16m8 (KM Biologics). This review summarizes the human and pivotal animal data establishing safety and efficacy for MVA-BN and LC16m8, including real-world evidence gathered during mpox outbreaks from 2022 through 2024.

EXPERT OPINION

Some regulatory decisions for MVA-BN and LC16m8 followed pathways based on surrogate outcomes, including lethal-challenge studies in nonhuman primates, among other atypical aspects. Nonetheless, MVA-BN and LC16m8 hold unencumbered registration in multiple countries. Effectiveness of MVA-BN as primary preventive vaccination (PPV) in humans against clade IIb mpox is clear from real-world studies; effectiveness of LC16m8 against clade IIb is likely from surrogate endpoints. Effectiveness of MVA-BN and LC16m8 as PPV against more-lethal clade I is likely, based on animal-challenge studies with multiple orthopoxvirus species and other studies. Both vaccines have solid safety records. MVA-BN's replication incompetence favors adoption, whereas LC16m8 has more pediatric data. Additional real-world evidence, in additional geographic settings and special populations (e.g. pregnancy, immune suppression, atopic dermatitis), is needed.

[Human monkeypox (Mpox)]

Until recently, human monkeypox (Mpox) were rarely observed outside of Africa, where the Mpox virus (MPXV) is endemic in some regions. In early May 2022, a global Mpox outbreak occurred. Crucial to this outbreak was human-to-human transmission during sexual activity. In particular, young men who have sex with men (MSM) became ill. In July 2022, this Mpox epidemic was declared a public health emergency of international concern by the World Health Organization. As of 26 September 2023, 90,618 confirmed cases of Mpox have been reported worldwide, with Germany accounting for around 3700 cases. The strongest increase in incidence occurred from May to mid-August 2022; since then, the number of cases has declined significantly as a result of intensive prevention efforts (education, vaccination). Currently, there are only sporadic, smaller outbreaks-in Germany (Berlin) most recently in August 2023. Despite the current calm epidemiological situation worldwide, isolated cases must therefore still be expected in Germany. The clinical picture of the "new" clade IIb-associated Mpox variant, which is mostly transmitted sexually from person to person, differs markedly from that of the "classical" Mpox (clades I and IIa), which, apart from rapidly breaking human infection chains, essentially occur as a zoonosis.