The global reemergence of human Monkeypox; is mass vaccination essential?

Namdar, Ali Beheshti; Keikha, Masoud
doi:10.1016/j.vacun.2022.06.007
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    "titulo" => "The global reemergence of human Monkeypox&#59; is mass vaccination essential&#63;"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="p0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Monkeypox virus</span> &#40;MPXV&#41; is a double-stranded DNA virus that belongs to the genus <span class="elsevierStyleItalic">Orthopoxvirus</span>&#44; family <span class="elsevierStyleItalic">Poxviridae</span>&#59; this virus was identified for the first time following an outbreak of pustular disease in a macaque colony in Denmark in 1959&#46;<a class="elsevierStyleCrossRef" href="#bb0005"><span class="elsevierStyleSup">1</span></a> Monkeypox is considered as causative agent of the zoonotic disease monkeypox which was recognized as a human pathogen in the Democratic Republic of the Congo &#40;DRC&#44; formerly Zaire&#41; during early 1970s&#46; Outside of Africa&#44; in 2003 an outbreak in the United States was associated with rodents imported from Ghana&#44; and human-to-human transmission did not occur&#46;<a class="elsevierStyleCrossRef" href="#bb0010"><span class="elsevierStyleSup">2</span></a> This virus is genetically classified in 2 distinct clades&#44; the Congo Basin clade which is associated to higher virulence and mortality rate &#40;10&#37;&#41;&#44; and the West African clade with a lower mortality rate &#40;&#60;<span class="elsevierStyleHsp" style=""></span>3&#37;&#41; that was responsible for recent outbreaks in Nigeria&#46;<a class="elsevierStyleCrossRef" href="#bb0015"><span class="elsevierStyleSup">3</span></a> After 39&#8239;years without recognition of human monkeypox cases in Nigeria&#44; an outbreak was reported with 118 confirmed MPXV cases in September 2017&#46;<a class="elsevierStyleCrossRef" href="#bb0020"><span class="elsevierStyleSup">4</span></a> Moreover&#44; there were 183 confirmed cases throughout 18 states in Nigeria during November 2019&#46;<a class="elsevierStyleCrossRef" href="#bb0025"><span class="elsevierStyleSup">5</span></a> In recent years&#44; the number of cases and geographic spread of monkeypox have been increasing&#44; possibly because of waning immunity to smallpox and the recent monkeypox outbreak has gone global&#46;<a class="elsevierStyleCrossRefs" href="#bb0030"><span class="elsevierStyleSup">6&#8211;8</span></a> There have been 920 confirmed and 70 suspected cases in at least 30 non-African countries as to June 5&#44; 2022&#46;<a class="elsevierStyleCrossRef" href="#bb0020"><span class="elsevierStyleSup">4</span></a> The current epidemiological investigations showed recent MPXV outbreaks&#44; mainly caused by the West Africa clade&#44; occurred following travel and&#47;or international exportations of animal carriers&#46;<a class="elsevierStyleCrossRef" href="#bb0020"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bb0025"><span class="elsevierStyleSup">5</span></a></p><p id="p0010" class="elsevierStylePara elsevierViewall">However&#44; there is shifting in demographics of this outbreak that might shed light into reasons behind the reemergence of monkeypox in West Africa&#46; Mauldin et al&#46;&#44; 2022 suggested new MPXV cases with new variations in the Bayelsa&#44; Delta&#44; and Rivers states with unidentified source pool&#46;<a class="elsevierStyleCrossRef" href="#bb0045"><span class="elsevierStyleSup">9</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bb0050"><span class="elsevierStyleSup">10</span></a> Bunge et al&#46; &#40;2022&#41; recently revealed changing epidemiology of human monkeypox&#59; they found median age of MPXV increased from 4 to 21&#8239;years&#46; In addition&#44; the number of cases has increased 10-fold especially in DRC&#46;<a class="elsevierStyleCrossRef" href="#bb0055"><span class="elsevierStyleSup">11</span></a> The World Health Organization Research and Development Blueprint categorized monkeypox as an emerging zoonotic disease demanding high priority for further research&#44; and public health action in 2018&#46;<a class="elsevierStyleCrossRef" href="#bb0060"><span class="elsevierStyleSup">12</span></a></p><p id="p0015" class="elsevierStylePara elsevierViewall">There are 3 main reasons for the resurgence of monkeypox including&#58; &#40;1&#41; the African residents have experienced increased exposure with rodents as well as forest animals&#59; &#40;2&#41; waning immunity following discontinued global smallpox vaccination&#59; &#40;3&#41; genetic evolution of the monkeypox virus during time&#46;<a class="elsevierStyleCrossRef" href="#bb0025"><span class="elsevierStyleSup">5</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bb0045"><span class="elsevierStyleSup">9</span></a> The previous documents showed that smallpox vaccination was approximately 85&#37; protective against monkeypox&#46;<a class="elsevierStyleCrossRef" href="#bb0065"><span class="elsevierStyleSup">13</span></a> Bunge et al&#46; &#40;2022&#41; revealed that unvaccinated individuals accounted for approximately 80&#8211;96&#37; of monkeypox cases&#46;<a class="elsevierStyleCrossRef" href="#bb0055"><span class="elsevierStyleSup">11</span></a> Nguyen et al&#46; &#40;2022&#41; found that previous smallpox vaccination provides protection against MPXV by stimulation of IgG and memory B cells&#59; they have declared decline in immunity among vaccinated individuals as well as population growth cause increase of MPXV outbreaks in the central Africa states&#46;<a class="elsevierStyleCrossRef" href="#bb0025"><span class="elsevierStyleSup">5</span></a> According to CDC reports&#44; smallpox vaccination is recommended for prevention of secondary disease transmission from monkeypox-infected cases&#46; Currently&#44; there are 2 FDA approved vaccine for prophylaxis of monkeypox&#44; i&#46;e&#46; JYNNEOS &#40;pre exposure&#41;&#44; and ACAM2000 &#40;post exposure&#41;&#46; In addition&#44; Tecovirimat and Brincidofovir have been confirmed in clinical use as therapeutic regimen for monkeypox cases&#46;<a class="elsevierStyleCrossRef" href="#bb0070"><span class="elsevierStyleSup">14</span></a> The smallpox vaccination could benefit for induction of strong response against monkeypox&#46; Unlike SARS-CoV-2&#44; monkeypox can be spread from close contact via saliva or cough&#46;<a class="elsevierStyleCrossRef" href="#bb0045"><span class="elsevierStyleSup">9</span></a> However&#44; Beer et al&#46; &#40;2019&#41; proposed that risk of monkeypox transmission among household contacts who were unvaccinated was approximately 80&#37;&#46;<a class="elsevierStyleCrossRef" href="#bb0075"><span class="elsevierStyleSup">15</span></a> Unfortunately&#44; Adler et al&#46;&#44; recently discovered that prolonged upper respiratory tract MPXV DNA shedding even after skin lesion&#46;<a class="elsevierStyleCrossRef" href="#bb0080"><span class="elsevierStyleSup">16</span></a> Several European countries as well as the United Sates have initiated pre-exposure vaccination of individuals with high risk of exposure to monkeypox&#44; particularly healthcare workers&#46;<a class="elsevierStyleCrossRef" href="#bb0085"><span class="elsevierStyleSup">17</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bb0090"><span class="elsevierStyleSup">18</span></a> According to the interim guidelines provided by WHO regarding vaccination and immunization against monkeypox&#58; &#40;1&#41; Currently&#44; global vaccination is not required nor recommended against monkeypox&#44; &#40;2&#41; post-exposure prophylaxis is recommended using the second or third generation vaccine in case of contacts with monkeypox infected-cases&#44; &#40;3&#41; pre-exposure prophylaxis is recommended for health workers at risk&#44; &#40;4&#41; vaccination programmes must be applied using accurate surveillance system under the evaluation and supervision of professional experts with standardized protocols and appropriate data collection tools&#44; and &#40;5&#41; the necessity of vaccination should be decided by a full assessment of risks and benefits on a case-by-case basis&#46;<a class="elsevierStyleCrossRef" href="#bb0095"><span class="elsevierStyleSup">19</span></a></p><p id="p0020" class="elsevierStylePara elsevierViewall">In summary&#44; monkeypox&#44; which was previously considered as a rare zoonotic infection with low mortality rate&#44; has resurged with a higher contagious form causing higher death rates during recent decades&#46; It seems that genetic variation&#44; continuous evolution of monkeypox virus&#44; and waned immunity causes rapid dissemination of this disease in non-African territories&#46; The implementation of protective appropriate strategies&#44; e&#46;g&#46; screening and fast identification&#44; quarantine of individuals contacting monkeypox cases&#44; application of personal protective equipment&#44; face masking&#44; travel bans&#44; post-exposure prophylaxis as well as vaccination of individuals who may be at high risk of contamination could be tools to abate monkeypox outbreaks&#46;</p><span id="s0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0005">Conflict of interest</span><p id="p0025" class="elsevierStylePara elsevierViewall">Nil&#46;</p></span></span>"
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