The impact of vaccination against monkeypox on risk of mpox reinfection

Dadgar, Farhad; Rouhani, Jalil; Dehghani, Fatemeh; Keikha, Masoud

doi:10.1016/j.vacune.2023.10.014

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At the time of the writing of this letter, there were 87,545 laboratory confirmed mpox (formerly known as monkeypox) cases (85,962 outside the African continent) including 141 deaths from May 2022 to June 2023. Initial investigations suggested that about 85% of the individuals fully-vaccinated against small pox were less likely to develop severe mpox outcomes.<a class="elsevierStyleCrossRef" href="#bb0005">1</a> According to available literature, 9–18% of mpox infected-individuals in the 2022 multicounty outbreak had a history of vaccination against mpox.<a class="elsevierStyleCrossRef" href="#bb0010">2</a>,<a class="elsevierStyleCrossRef" href="#bb0015">3</a> In this scenario, it has been suggested that smallpox vaccination cessation is responsible for the reduction of cross-reactive immunity against mpox infection particularly in individuals with immunosuppression.<a class="elsevierStyleCrossRef" href="#bb0020">4</a> There are limitations regarding the impact mucosal immunity can have against mpox. During this outbreak, there were, so far, seven cases of mpox reinfection until June 2023. We aimed to discuss the clinical relevance of mpox vaccination on the prevention of mpox reinfection.Golden et al. recently reported an mpox reinfection case in the United Kingdom. The patient presented first clinical manifestations on July 2022, He reported inguinal lymphadenopathy, rectal pain, as well as rectal discharge at first attendance. Laboratory results rendered a positive RT-PCR to mpox from rectal swab sample and a negative Human Immnodeficiency virus (HIV) serology. The case had received two doses of Jynneos® smallpox vaccination 1week after the first attendance and 10 weeks after that. On November 2022, a second manifestation of infection revealed aphthous ulcers and inflammation of cervical lymph nodes. The patient described several condomless sexual intercourse with multiple male partners. He also had clinical history of previous, neuro-syphilis C. trachomatis, as well as Neisseria gonorrhoeae infections in the past<a class="elsevierStyleCrossRef" href="#bb0025">5</a>. The patient fully-recovered from mpox infection without severe complication.In another report, Lopez et al reported another mpox reinfection in a 51-year-old man with positive history of childhood smallpox vaccination. On July 2022, he presented typical mpox clinical symptoms e.g., pseudopustules on his anogenital regions as well as groin lymphadenopathy. He also complained of having a genital lesion and painful lymphadenopathy similar to the first episode on November 2022. The case reported having had unprotected multiple sexual-intercourse with men prior to this second clinical manifestatios. Nevertheless, he was discharged with healing cutaneous lesion without further serious complications.<a class="elsevierStyleCrossRef" href="#bb0030">6</a>Both cases reviewed in these articles on mpox reinfection in individuals that received complete smallpox vaccination, were neither HIV positive nor had any other immunosuppressive condition. Previous evidences suggested smallpox vaccination or natural infections lead to complete protection against mpox.<a class="elsevierStyleCrossRef" href="#bb0025">5</a>,<a class="elsevierStyleCrossRef" href="#bb0030">6</a> However, there is evidence of at least two cases of mpox reinfection in healthy individuals without comorbidities that had received full smallpox vaccination.Raccagni et al. suggested mpox reinfection with high RT-PCR cycle threshold (Tc) value following virus clearance after the first attendance.<a class="elsevierStyleCrossRef" href="#bb0035">7</a> In this relation, it has been postulated that persistent virus shedding or relapse from tissue reservoirs. In this report, both individuals informed of unprotected sexual-intercourse with multiple partners. However, genomic sequencing analysis was not performed to determined reinfection or relapse. A recent investigation showed that 83% and 71% of both vaccinated and mpox-infected individuals produce MPXV-neutralizing antibodies in serum.<a class="elsevierStyleCrossRef" href="#bb0040">8</a> However, sterilizing immunity may not be established without systemic infection. In this scenario, the virus adaptation such as a mutation-driven immune escape should not be ruled out regarding reinfection after smallpox vaccination. Overall, mpox-reinfection cases were fully-recovered without serious outcomes. Therefore, the broad awareness regarding possibility of mpox reinfection even in individuals who have received full mpox vaccination should be noted. In addition, further investigations are need to highlight the impact of smallpox vaccination regarding protection from mpox reinfections." 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ISSN: 2445-1460

Official journal of the Asociación Española de Vacunología (AEV) Vacunas is a peer-reviewed journal supported by an advisory board of experts in the field of vaccinology. The aim of the journal is to contribute to the dissemination of the scientific advances made in the area of basic and applied research in the field of vaccine-preventable diseases in humans. It places special emphasis on aspects associated with planning and evaluation (epidemiology of vaccine-preventable diseases, development of vaccination programs, evaluation of the efficacy, effectiveness and efficiency of vaccinations). Vacunas publishes, in Spanish and in English, Editorials, Original Articles, Special Articles, Reviews, Strategies and Vaccination Programs. There are also sections on Literature Reviews, News and on Congresses associated with vaccinations. The peer review process is done anonymously by reviewers with expertise in the area of knowledge of each manuscript as well as experts in methodology or statistics, as determined by the Editorial board, which works towards maintaining an efficient editorial process in order for the manuscripts to be published as soon as possible.

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Vol. 24. Issue 4.

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