A prospective national cohort evaluating ring MVA vaccination as post-exposure prophylaxis for monkeypox

Update on Mpox: What the Primary Care Clinician Should Know

Mpox is a viral infection, which primarily caused sporadic outbreaks in West and Central Africa until causing a global epidemic in 2022. The disease has disproportionately affected people with human immunodeficiency virus and men who have sex with men. Transmission is through close physical contact, including sexual contact. Infection presents with a characteristic rash, with frequent anogenital involvement-polymerase chain reaction of skin lesions is diagnostic. Vaccination is available for primary prevention and postexposure prophylaxis. Treatment consists of supportive care, with antiviral medications available via clinical trials and/or for patients with severe disease.

Pockenvirusinfektionen in der Dermatologie: Poxvirus infections in dermatology - the neglected, the notable, and the notorious

Die Familie Poxviridae umfasst derzeit 22 Gattungen, die Wirbeltiere infizieren können. Humanpathogene Pockenviren gehören den Gattungen Ortho‐, Para‐, Mollusci‐ und Yatapoxvirus an. Bis zur Eradikation der Variola vera im Jahr 1979 waren die Pocken, im Volksmund auch Blattern genannt, eine schwerwiegende Gesundheitsbedrohung für die Bevölkerung. Noch heute sind Dermatologen mit zahlreichen Pockenvirusinfektionen konfrontiert, wie den Bauernhofpocken, die als Zoonosen nach Tierkontakten in ländlichen Gebieten oder nach Massenversammlungen auftreten können. In den Tropen können Erkrankungen durch Tanapox‐ oder Vaccinia‐Viren zu den Differenzialdiagnosen gehören. Dellwarzen sind weltweit verbreitet und werden in bestimmten Fällen als sexuell übertragbare Pockenvirusinfektion angesehen. In jüngster Zeit hatten sich Mpox (Affenpocken) zu einer gesundheitlichen Notlage von internationaler Tragweite entwickelt, die eine rasche Identifizierung und angemessene Behandlung durch Dermatologen und Infektiologen erfordert. Fortschritte und neue Erkenntnisse über Epidemiologie, Diagnose, klinische Manifestationen und Komplikationen sowie Behandlung und Prävention von Pockenvirusinfektionen erfordern ein hohes Maß an Fachwissen und interdisziplinärer Zusammenarbeit in den Bereichen Virologie, Infektiologie und Dermatologie. Dieser CME‐Artikel bietet einen aktualisierten systematischen Überblick, um praktizierende Dermatologen bei der Identifizierung, Differenzialdiagnose und Behandlung klinisch relevanter Pockenvirusinfektionen zu unterstützen.

Poxvirus infections in dermatology - the neglected, the notable, and the notorious

The family Poxviridae currently comprises 22 genera that infect vertebrates. Of these, members of the Ortho-, Para-, Mollusci- and Yatapoxvirus genera have been associated with human diseases of high clinical relevance in dermatology. Historically, smallpox had been a notorious health threat until it was declared eradicated by the World Health Organization in 1979. Today, dermatologists are confronted with a variety of poxviral infections, such as farmyard pox, which occurs as a zoonotic infection after contact with animals. In the tropics, tanapox or vaccinia may be in the differential diagnosis as neglected tropical dermatoses. Molluscum contagiosum virus infection accounts for significant disease burden worldwide and is classified as a sexually transmitted infection in certain scenarios. Recently, mpox (monkeypox) has emerged as a public health emergency of international concern, requiring rapid recognition and appropriate management by dermatologists and infectious disease specialists. Advances and new insights into the epidemiology, diagnosis, clinical manifestations and complications, treatment, and prevention of poxviral infections require a high level of expertise and interdisciplinary skills from healthcare professionals linking virology, infectious diseases, and dermatology. This CME article provides a systematic overview and update to assist the practicing dermatologist in the identification, differential diagnosis, and management of poxviral infections.

Current Status of Vaccine Development for Monkeypox Virus

Monkeypox virus (MPXV) of poxviridae family causes a zoonotic disease called monkeypox (Mpox). MPXV cases have a fatality ratio ranging from 0 to 11% globally and have been more prevalent in children. There are three generations of smallpox vaccines that protect against MPXV. First and second generation of the vaccinia virus (VACV) vaccine protects MPXV. However, various adverse side effects were associated with the first and second generations of vaccines. In contrast, the Modified Vaccinia Ankara-Bavarian Nordic (MVA-BN) replication-incompetent vaccine shows fewer adverse effects and a significant amount of neutralizing antibodies in mammalian cells. A third-generation Modified Vaccinia Ankara-Bavarian Nordic (MVA-BN) was approved to prevent Mpox in 2019. Recently, MVA-BN-based Imvanex, Imvamune, and JYNNEOS vaccines have also been administered against MPXV. Globally, the World Health Organization (WHO) declared a global health emergency in May 2022 due to increased MPXV cases. Various computational studies have also designed a multi-epitope-based vaccine against the MPXV. In the multi-epitope-based vaccine, different epitopes like B-cell, Cytotoxic T Lymphocyte (CTL), CD8+, and CD4+ epitopes were derived from MPXV proteins. Further, these epitopes were linked with the help of various linkers to design a multi-epitope vaccine against MPXV. In summary, we have provided an overview of the current status of the vaccine against MPXV.

Mpox and HIV-Collision of Two Diseases

PURPOSE OF REVIEW

The global outbreak of mpox has brought renewed attention to a previously neglected disease which is particularly severe in people with underlying untreated HIV co-infection. For this population, the disease is progressive, severe, and often lethal. In this review, we examine the pathogenesis of mpox disease and its collision with co-existent HIV infection and discuss key considerations for management as well as emerging clinical dilemmas and areas for future research.

RECENT FINDINGS

Co-existent untreated HIV infection characterized by severe immunocompromise potentiates the nefarious effects of monkeypox virus infection leading to severe manifestations of mpox. Treating mpox in the context of HIV requires mpox-directed therapies, supportive care, and HIV-specific treatment to restore immune function. Preventative measures for PWH are like those in healthy individuals, but the effectiveness and durability of protection conferred by existing vaccines in PWH remain to be fully characterized. Mpox is an important opportunistic infection in PWH. Clinicians should be aware of the unique features of the disease in this population and approaches to care and management of mpox in PWH.

Clinical Strategies and Therapeutics for Human Monkeypox Virus: A Revised Perspective on Recent Outbreaks

An enveloped double-stranded DNA monkeypox virus (MPXV) is a causative agent of the zoonotic viral disease, human monkeypox (HMPX). MPXV belongs to the genus Orthopoxviridae, a family of notorious smallpox viruses, and so it shares similar clinical pathophysiological features. The recent multicountry HMPX outbreak (May 2022 onwards) is recognized as an emerging global public health emergency by the World Health Organization, shunting its endemic status as opined over the past few decades. Re-emergence of HMPX raises concern to reassess the present clinical strategy and therapeutics as its outbreak evolves further. Keeping a check on these developments, here we provide insights into the HMPX epidemiology, pathophysiology, and clinical representation. Weighing on its early prevention, we reviewed the strategies that are being enrolled for HMPX diagnosis. In the line of expanded MPXV prevalence, we further reviewed its clinical management and the diverse employed preventive/therapeutic strategies, including vaccines (JYNNEOS, ACAM2000, VIGIV) and antiviral drugs/inhibitors (Tecovirimat, Cidofovir, Brincidofovir). Taken together, with a revised perspective of HMPX re-emergence, the present report summarizes new knowledge on its prevalence, pathology, and prevention strategies.

Monkeypox: A comprehensive review of a multifaceted virus

In May 2022, the world witnessed the re-emergence of the zoonotic disease monkeypox. While this was not the first epidemic of this disease, what differentiated the outbreak was the rapid global spread and increase of cases, which led the WHO to declare monkeypox a global health emergency. Although the disease spreads mainly through inadequately cooked meat of various rodent species, this virus also shows droplet, respiratory, sexual, and even vertical transmission. Monkeypox further multiplies in lymphoproliferative organs and presents with a classical smallpox-like rash, fever, headache, and muscle aches. Diagnosis is confirmed with a polymerase-chain-reaction test and is managed largely supportively with possible usage of some antivirals and immunoglobulins. Moreover, some pre-exposure and postexposure prophylactic vaccines have been developed. This paper aims to conduct an in-depth review of the historical epidemics, transmission, pathophysiology, clinical presentation, and management of the monkeypox disease.

What does the anesthesiologist need to know about monkeypox?

PURPOSE

Monkeypox (or "mpox" as preferred by the World Health Organization) is an emerging infectious disease with sustained global transmission occurring outside of West Africa and the Democratic Republic of Congo. The recent 2022 mpox outbreak has involved widespread atypical presentations. Infected patients requiring surgery can increase the exposure of health care professionals and other patients to the virus. As it is a relatively new infectious disease internationally, there is less familiarity in managing this risk, especially in the surgical and anesthesia setting. This paper aims to provide information about mpox and how to manage suspected or confirmed cases.

SOURCE

Various authorities such as the World Health Organization, Infection Prevention and Control Canada, Public Health Agency of Canada, the Centers for Disease Control and Prevention (USA), and the National Centre for Infectious Diseases (Singapore) have recommended that public health and hospital systems prepare to recognize, isolate, and care for suspected and confirmed cases appropriately, as well as manage any possible exposure of staff and patients.

PRINCIPAL FINDINGS

Local authorities and hospitals should set up protocols for health care providers (HCPs) to minimize nosocomial transmission and risk to HCPs. Antivirals used in patients with more severe disease may cause renal or hepatic impairment and thus anesthetic drug pharmacology. Anesthesiologists and surgeons should be able to recognize mpox, and work with local infection control and epidemiologic programs to familiarize themselves with relevant infection prevention guidelines.

CONCLUSION

Essential measures include clear protocols for transferring and managing surgical patients who are suspected or confirmed to be infected with the virus. Care in use of personal protective equipment and handling contaminated material is necessary to prevent inadvertent exposure. Risk stratification after exposure should be done to determine need for post-exposure prophylaxis for staff.

Efficacy of the modified vaccinia Ankara virus vaccine and the replication-competent vaccine ACAM2000 in monkeypox prevention

BACKGROUND

Recently, there has been an uptick in reported cases of monkeypox (Mpox) in Africa and across the globe. This prompted us to investigate the efficacy of the two vaccines that can prevent Mpox, the modified vaccinia Ankara virus (MVA) vaccine and ACAM2000 vaccine. We analyzed them to determine their rates of humoral cell responses, adverse events, and rash reactions and used these factors as the primary indicators.

METHODS

This study adapted primary data obtained from the Medline, Google Scholar, and Cochrane Library databases. We included a total of eight studies, three of which explored the ACAM2000 vaccine and five of which explored the JYNNEOS MVA vaccine.

RESULTS

There were significant differences in the rates of humoral responses after inoculation by the two vaccines. JYNNEOS MVA vaccine immunization resulted in a statistically significant increased humoral immune response with an effect size of 81.00 (42.80, 119.21) at a 95% CI and a rash reaction with an effect size of 96.50 (42.09, 235.09.21) at a 95% CI. ACAM2000 resulted in a lesser increase in neutralizing antibodies than JYNNEOS MVA vaccine. Similar findings were identified for the rates of adverse reactions, but the difference was not statistically significant. The differences in rash reaction rates in the two vaccination groups were also not statistically significant.

CONCLUSION

ACAM2000 and JYNNEOS vaccines have proven to be efficient in preventing Mpox even though variations exist in their modes of action and associated significant effects. The nonreplicating nature of JYNNEOS prevents the occurrence of the adverse effects seen with other vaccines.

Hematopoietic stem cell donor vaccination with cytomegalovirus triplex augments frequencies of functional and durable cytomegalovirus-specific T cells in the recipient: A novel strategy to limit antiviral prophylaxis

To enhance protective cytomegalovirus (CMV)-specific T cells in immunosuppressed recipients of an allogeneic hematopoietic cell transplant (HCT), we evaluated post-HCT impact of vaccinating healthy HCT donors with Triplex. Triplex is a viral vectored recombinant vaccine expressing three immunodominant CMV antigens. The vector is modified vaccinia Ankara (MVA), an attenuated, non-replicating poxvirus derived from the vaccinia virus strain Ankara. It demonstrated tolerability and immunogenicity in healthy adults and HCT recipients, in whom it also reduced CMV reactivation. Here, we report feasibility, safety, and immunological outcomes of a pilot phase 1 trial (NCT03560752 at ClinicalTrials.gov) including 17 CMV-seropositive recipients who received an HCT from a matched related donor (MRD) vaccinated with 5.1 × 108 pfu/ml of Triplex before cell harvest (median 15, range 11-28 days). Donor and recipient pairs who committed to participation in the trial resulted in exceptional adherence to the protocol. Triplex was well-tolerated with limited adverse events in donors and recipients, who all engrafted with full donor chimerism. On day 28 post-HCT, levels of functional vaccinia- and CMV-specific CD137+ CD8+ T cells were significantly higher (p < .0001 and p = .0174, respectively) in recipients of Triplex vaccinated MRD than unvaccinated MRD (control cohort). Predominantly, central and effector memory CMV-specific T-cell responses continued to steadily expand through 1-year follow-up. CMV viremia requiring antivirals developed in three recipients (18%). In summary, this novel approach represents a promising strategy applicable to different HCT settings for limiting the use of antiviral prophylaxis, which can impair and delay CMV-specific immunity, leading to CMV reactivation requiring treatment.

Monkeypox: epidemiology, pathogenesis, treatment and prevention

Monkeypox is a zoonotic disease that was once endemic in west and central Africa caused by monkeypox virus. However, cases recently have been confirmed in many nonendemic countries outside of Africa. WHO declared the ongoing monkeypox outbreak to be a public health emergency of international concern on July 23, 2022, in the context of the COVID-19 pandemic. The rapidly increasing number of confirmed cases could pose a threat to the international community. Here, we review the epidemiology of monkeypox, monkeypox virus reservoirs, novel transmission patterns, mutations and mechanisms of viral infection, clinical characteristics, laboratory diagnosis and treatment measures. In addition, strategies for the prevention, such as vaccination of smallpox vaccine, is also included. Current epidemiological data indicate that high frequency of human-to-human transmission could lead to further outbreaks, especially among men who have sex with men. The development of antiviral drugs and vaccines against monkeypox virus is urgently needed, despite some therapeutic effects of currently used drugs in the clinic. We provide useful information to improve the understanding of monkeypox virus and give guidance for the government and relative agency to prevent and control the further spread of monkeypox virus.

Monkeypox: disease epidemiology, host immunity and clinical interventions

Monkeypox virus (MPXV), which causes disease in humans, has for many years been restricted to the African continent, with only a handful of sporadic cases in other parts of the world. However, unprecedented outbreaks of monkeypox in non-endemic regions have recently taken the world by surprise. In less than 4 months, the number of detected MPXV infections has soared to more than 48,000 cases, recording a total of 13 deaths. In this Review, we discuss the clinical, epidemiological and immunological features of MPXV infections. We also highlight important research questions and new opportunities to tackle the ongoing monkeypox outbreak.

In this Review, Ng and colleagues examine the clinical, epidemiological and immunological aspects of monkeypox virus (MPXV) infections, with a focus on mechanisms of host immunity to MPXV. The authors also consider the unique epidemiological and pathological characteristics of the current non-endemic outbreak of the virus and discuss vaccines, therapeutics and outstanding research questions.

Recent advances in the diagnosis monkeypox: implications for public health

Introduction

Monkeypox virus is a zoonotic double-stranded DNA poxvirus in the genus Orthopoxvirus, family Poxviridae. Until recently, monkeypox was found primarily in Central and West Africa, where the virus had split into Congo Basin and West African clades.

Areas Covered

On 6 May 2022, monkeypox was detected in the United Kingdom and the virus has now been detected in every continent except Antarctica. The current outbreak represents the first documentation of widespread community transmission outside of Africa.

Expert Opinion

On 23 July 2022, the World Health Organization declared monkeypox a public health emergency of international concern and issued a series of guidance and recommendations for governments, health professionals and the public. This manuscript reviews what is known about monkeypox virus, with a focus on recent diagnostics and epidemiologic advances, and explores how recent advances in our understanding of the virus will be used to combat the expanding outbreak.

Monkeypox and Its Possible Sexual Transmission: Where Are We Now with Its Evidence?

Monkeypox is a rare disease but is increasing in incidence in different countries since the first case was diagnosed in the UK by the United Kingdom (UK) Health Security Agency on 6 May 2022. As of 9 August, almost 32,000 cases have been identified in 89 countries. In endemic areas, the monkeypox virus (MPXV) is commonly transmitted through zoonosis, while in non-endemic regions, it is spread through human-to-human transmission. Symptoms can include flu-like symptoms, rash, or sores on the hands, feet, genitalia, or anus. In addition, people who did not take the smallpox vaccine were more likely to be infected than others. The exact pathogenesis and mechanisms are still unclear; however, most identified cases are reported in men who have sex with other men (MSM). According to the CDC, transmission can happen with any sexual or non-sexual contact with the infected person. However, a recent pooled meta-analysis reported that sexual contact is involved in more than 91% of cases. Moreover, it is the first time that semen analysis for many patients has shown positive monkeypox virus DNA. Therefore, in this review, we will describe transmission methods for MPXV while focusing mainly on potential sexual transmission and associated sexually transmitted infections. We will also highlight the preventive measures that can limit the spread of the diseases in this regard.

The current Monkeypox outbreak: Updates and concerns

Since 1958 witnessed the detection of Monkeypox virus in monkeys, no human infection was encountered until 1970. Afterwards, zoonotic transmission was the rule near African rainforests, mainly in DRC. Most cases occurred in children who weren’t immunized against smallpox. Since 2003 and the first human infection in the USA, research was accelerated. Two clades were identified with different virulence, demographic distribution and transmissibility. The mean age of infection increased with waning smallpox vaccine immunity. Mild febrile prodrome can precede lymphadenopathy, which doesn’t occur in smallpox. Homogenous crops of lesions appear in stages until scabs fall and contagiosity ends. However, since May outbreak, cases started to appear in non-endemic areas, human transmission increased and was linked to close sexual contact especially in MSM community. Lesions were found mainly perioral, at genitals and perianal. Newer system for nomenclature was suggested in which there are 3 viral clades and the responsible clade for the outbreak is clade 3 (lineage B.1). About 50 mutations were detected compared with the strains isolated 4 years ago. Gene loss and APOBEC3 may be related to accelerated mutation rate which may accelerate human transmission. Previous mistakes in failure to allocate available vaccines to control the disease in previously endemic areas should be avoided and rapid ring vaccination of potential contacts and those at risk should be a priority. Case isolation, contact isolation or tracing for an incubation period, standard measures for airborne infections and safe sex should be implanted in the light of the current uncertainty.