Skip to main content
PMC home page
Vaccines logoLink to Vaccines
. 2022 Aug 18;10(8):1342. doi: 10.3390/vaccines10081342

Vaccination for Monkeypox Virus Infection in Humans: A Review of Key Considerations

Kay Choong See 1
Editor: Martin F Bachmann1
PMCID: PMC9413102  PMID: 36016230

Abstract

Monkeypox virus infection in humans (MVIH) is currently an evolving public health concern given that >3000 MVIH cases have been reported in >50 countries globally, and the World Health Organization declared monkeypox a global health emergency on 23 July 2022. Adults (≥16 years old) usually have mild disease in contemporary studies, with a pooled case fatality rate of 0.03% (1/2941 cases). In comparison, poorer outcomes have been reported in children <16 years old (pooled case fatality rate 19% (4/21 cases)), immunocompromised patients, and pregnant women, with high rates of fetal demise in this group. Monkeypox-specific treatments include oral or intravenous tecovirimat, intravenous or topical cidofovir, oral brincidofovir, and vaccinia immunoglobulin, but the overall risk–benefit balance of monkeypox-specific treatment is unclear. Two effective vaccines exist for the prevention of MVIH: modified vaccinia Ankara and ACAM2000. Most probably, vaccination will be a key strategy for mitigating MVIH given the current rapid global spread of monkeypox, the existence of efficacious vaccines, and the uncertain risk–benefit profile of current antivirals. Priority groups for vaccination should include healthcare workers at high risk for occupational exposure, immunocompromised patients, and children. Vaccination strategies include pre-exposure vaccination, post-exposure prophylaxis, and ring vaccination of close contacts.

Keywords: epidemiology, infection control, post-exposure prophylaxis, pre-exposure prophylaxis, smallpox, vaccinia virus

1. Introduction

Monkeypox is a zoonotic orthopox DNA virus that is in the same genus as the variola virus (which causes smallpox) and the vaccinia virus (which is used in smallpox vaccines). Following the first reported case in a 9-month-old boy [1], monkeypox had previously caused only sporadic outbreaks of human disease within Africa, with limited secondary spread of travel-associated cases outside Africa [2,3]. However, monkeypox virus infection in humans (MVIH) is currently an evolving public health concern given that >3000 MVIH cases have been reported in >50 countries globally [4]. Increased reporting of MVIH is expected due to the cessation of smallpox vaccination since the eradication of smallpox in 1980 (smallpox vaccination has cross-protection for MVIH [5]), waning immunity in previously vaccinated adults [6], and cross-border international travel. Owing to the significant and rapid global spread of monkeypox, the World Health Organization declared monkeypox a global health emergency on 23 July 2022.

Containment of the current monkeypox global health emergency will not be easy. Four decades after the cessation of smallpox vaccination, global orthopox virus immunity is low, allowing monkeypox to spread relatively unchecked. Eradication of monkeypox may also be challenging since monkeypox, unlike smallpox, has non-human reservoirs of disease. Meanwhile, the virulence of monkeypox should not be underestimated. Next to smallpox, monkeypox is the second most pathogenic orthopox virus in humans [1]. Genetic variation among monkeypox strains may lead to immune-modulating genes that inhibit host defenses. For instance, the monkeypox inhibitor of complement enzymes (MOPICE) gene is present in Clade 1 but not in Clade 2, contributing to more severe disease and mortality in patients infected by Clade 1 [7]. Whatever the clade, smallpox-naïve and unvaccinated individuals will be disproportionately affected by MVIH. For instance, among 282 patients evaluated in Zaire between 1980 and 1985, the case fatality rate was higher in unvaccinated individuals compared to individuals vaccinated against smallpox (11% versus 0%) [8].

In general, vaccination is an important strategy for mitigating both the spread and severity of transmissible viral infections, particularly for immunocompromised individuals [9]. For MVIH, whether vaccination is warranted requires an understanding of the severity of the infection (pathology), risk of acquiring infection (epidemiology), treatment options, and prevention options. This paper therefore aims to review the contemporary literature about the pathology, epidemiology, treatment, and prevention of human monkeypox infection. A narrative synthesis of these key considerations will be undertaken.

2. Materials and Methods

The PubMed database (pubmed.ncbi.nlm.nih.gov) was searched for contemporary articles from 1 January 2017 to 22 July 2022 using the keyword “monkeypox”, resulting in 391 articles, with 238 (60.9%) articles published in 2022 alone. Original clinical and outcome data were extracted from published reports and organized according to World Health Organization administrative regions (Table 1).

Table 1.

List of WHO regions.

Region Countries
African Region (AFR) Algeria, Angola, Benin, Botswana, Burkina Faso, Burundi, Cameroon, Cape Verde, Central African Republic, Chad, Comoros, Ivory Coast, Democratic Republic of the Congo, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mauritius, Mozambique, Namibia, Niger, Nigeria, Republic of the Congo, Rwanda, São Tomé and Príncipe, Senegal, Seychelles, Sierra Leone, South Africa, South Sudan, Eswatini, Togo, Uganda, Tanzania, Zambia, Zimbabwe
Region of the Americas (AMR) Antigua and Barbuda, Argentina, Bahamas, Barbados, Belize, Bolivia, Brazil, Canada, Chile, Colombia, Costa Rica, Cuba, Dominica, Dominican Republic, Ecuador, El Salvador, Grenada, Guatemala, Guyana, Haiti, Honduras, Jamaica, Mexico, Nicaragua, Panama, Paraguay, Peru, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Suriname, Trinidad and Tobago, United States, Uruguay, Venezuela
Eastern Mediterranean Region (EMR) Afghanistan, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, United Arab Emirates, Yemen
European Region (EUR) Albania, Andorra, Armenia, Austria, Azerbaijan, Belarus, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Georgia, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Luxembourg, Malta, Moldova, Monaco, Montenegro, Netherlands, North Macedonia, Norway, Poland, Portugal, Romania, Russia, San Marino, Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland, Tajikistan, Turkey, Turkmenistan, Ukraine, United Kingdom, Uzbekistan
South-East Asian Region (SEAR) Bangladesh, Bhutan, North Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, Timor-Leste
Western Pacific Region (WPR) Australia, Brunei, Cambodia, China, Cook Islands, Fiji, Japan, Kiribati, Laos, Malaysia, Marshall Islands, Micronesia, Mongolia, Nauru, New Zealand, Niue, Palau, Papua New Guinea, Philippines, Samoa, Singapore, Solomon Islands, South Korea, Tonga, Tuvalu, Vanuatu, Vietnam
Open in a new tab

3. Results

3.1. Pathology

MVIH is defined by a positive result on a monkeypox virus polymerase chain reaction (PCR) assay in a specimen from any anatomical site [4,10]. Clinical samples that have demonstrated positivity include skin/anogenital lesions, blood, saliva, nose/throat/nasopharyngeal swab, semen, urine, rectal swab, feces, and deep tissue abscesses [4,11,12]. At least two clades of monkeypox exist: Clade 1 (associated with the Congo Basin) and Clade 2 (associated with West Africa). A new clade, Clade 3, has been suggested after phylogenomic analysis of the current 2022 European outbreak [13].

After a median incubation period of 7 days (range 3–20 days), MVIH presents clinically with a vesiculopustular illness, fever, and lymphadenopathy that may persist for another 3–4 weeks [4,10]. Skin lesions can be particularly extensive in immunocompromised patients, such as persons living with the human immunodeficiency virus [14]. Complications of MVIH include encephalitis, myocarditis, pneumonitis, acute kidney injury, keratitis, and secondary bacterial infections [4,11], which are again seen more in immunocompromised patients [15,16].

Adults (≥16 years old) usually have mild disease in contemporary studies [4,11], with a pooled case fatality rate of 0.03% (1/2941 cases) (Table 2), excluding the three studies with mixed adult–pediatric populations [15,16,17]. In comparison, serious consequences have been reported in children <16 years old [18] (case fatality rate of 17% in an older study [19] and 19% (4/21 cases) from the pooled results in Table 3), and in immunocompromised patients (case fatality rates up to 11% [20]). Prolonged PCR positivity of the skin lesions beyond 2 weeks has been reported in children, which may indicate a persistent presence of a replication-competent virus and increased propensity for transmission (Table 3). Separately, pregnancy outcomes appear to be poor, with high rates of fetal demise [6] (Table 4).

Table 2.

Adult cases of monkeypox virus infection in humans.

WHO Region N Patient Characteristics Source of Infection Clinical Features Treatment and Outcomes Ref/Year
AFR 7 24–41 years old, 2 (29%) males Transport industry and healthcare contact Vesiculo-papular rash (100%), fever (86%), cervical and inguinal lymphadenopathy (86%) Supportive treatment, recovery without sequelae [21]
2017
AFR 26 Median age 24 years, 14 (53.8%) males a Hunting, bushmeat, family contact Fever (100%), rash (100%), pruritus (46%), cervical and inguinal lymphadenopathy (35%) 61% hospitalized, 2 (7.7%) deaths [17]
2018
AFR 8 24–40 years old, 3 (38%) males Hunting, bushmeat, family contact Fever, rash Supportive treatment, 1 death [22]
2019
AFR 122 Median age 29 years, 84 (69%) males a Zoonotic, human-to-human, 2 healthcare-associated Vesiculopustular rash (100%), fever (88%), headache (79%), pruritus (73%), lymphadenopathy (69%), myalgia (63%), sore throat (58%) 1 spontaneous 2nd-trimester abortion in pregnant woman, supportive care for monkeypox, 7/118 (6%) deaths b [16]
2019
AFR 40 Median age 32 years, 31 (78%) males, 9 with HIV a Unclear Rash (100%), fever (90%), lymphadenopathy (88%), genital ulcer (63%), body ache (63%), headache (48%), sore throat (45%), pruritus (38%), conjunctivitis and photophobia (23%), nasal congestion (13%), cough (13%), skin ulcers (13%), nausea/vomiting (8%), hepatomegaly (8%), scrotal edema (5%) 21 (53%) developed complications (19 bacterial skin infection, 5 gastro-enteritis, 4 sepsis, 3 pneumonia, 3 encephalitis, 3 keratitis, 1 premature rupture of membrane at 2nd trimester with intrauterine fetal death), 11 (28%) developed anxiety and depression requiring counselling, supportive care for monkeypox, 5 (13%) deaths c [15]
2020
AFR 2 20-year-old brothers Family contact Fever, headache, odynophagia, dysuria, generalized skin lesions Supportive treatment, recovered [23]
2021
AMR, EUR, WPR 528 Median age 38 years old, 75% White, 98% gay/bisexual men Sexual close contact (95%) Rash (95%), anogenital lesions (73%), fever (62%), lymphadenopathy (56%), mucosal lesions (41%), lethargy (41%), myalgia (31%), headache (27%) Hospitalized for severe pain, soft-tissue superinfection, severe pharyngitis, eye lesions, acute kidney injury, myocarditis, infection control (13%), 5% received monkeypox-specific treatment (12 cidofovir, 8 tecovirimat, 1 vaccinia IVIG), no deaths [4]
2022
AMR 17 28–61 years old Unclear Rash (100%), fatigue or malaise (76%), chills (71%), lymphadenopathy (53%), headache (47%), fever (41%), body ache (35%), sore throat or cough (29%), sweat (24%) 1 patient treated with tecovirimat, 100% recovered [10]
2022
AMR 1 Middle-aged man Unclear Rash, fever, cough, fatigue, diarrhea, vomiting Treated with tecovirimat, recovered [24]
2022
AMR 1 33-year-old man Sexual contact Rectal pain, generalized umbilicated and pustular rash, tender cervical and inguinal lymphadenopathy Supportive treatment, recovered [25]
2022
AMR 1 28-year-old man Unclear Diffuse vesicular rash, umbilicated pustules, cervical lymphadenopathy Supportive treatment, self-resolving [26]
2022
EUR 2 Adult men Unclear Fever, rash, lymphadenopathy Supportive treatment, self-resolving [27]
2018
EUR 1 38-year-old man Unclear Fever, chills, rash, itchy penile ulcers, tender inguinal lymphadenopathy Supportive treatment, self-resolving [28]
2019
EUR 6 30–50 years old, 4 men, 2 women Household contact; nosocomial Rash (100%), lymphadenopathy (67%), reactive low mood (50%), deep thigh abscess (17%) 3 patients treated with brincidofovir, 1 with tecovirimat, prolonged PCR positivity 26–39 days, no deaths [11]
2022
EUR 2 1 adult male patient, 1 healthcare worker taking care of the patient 1 travel-related, 1 work-related contact Rash, fever, lymphadenopathy, malaise, headache, sore throat, earache, eye pain Supportive treatment, recovered [29]
2020
EUR 2 1 adult man and 1 adult woman Family contact Vesicular lesion Supportive treatment, recovered [2]
2021
EUR 12 32–52 years old, all men 2 contact, 10 unclear Rash (100%), non-specific syndrome of fever/myalgia/ malaise (92%) Supportive treatment, no deaths [12]
2022
EUR 1 71-year-old woman Sexual contact Extensive maculopapular rash, fever, fatigue, drowsiness, umbilicated skin lesions, inguinal lymphadenopathy Supportive treatment, discharged in good condition after 3 days of hospitalization [30]
2022
EUR 48 Median 35 years old (IQR 29–44), all men Sexual contact Vesicular-umbilicated skin lesions (94%), asthenia (67%), painful inguinal lymphadenopathy (52%), fever (52%), myalgia (52%), headache (52%), proctitis (27%), cough (17%), urethritis (15%) Supportive treatment, 1 patient required hospitalization for 32h, all recovered without sequelae [31]
2022
EUR 1 24-year-old man with HIV Sexual contact Painful skin umbilicated papules and pustules, painful tongue ulcer, inguinal and cervical lymphadenopathy, fatigue, anal pain, fever Supportive treatment, discharged after 5 days in hospital [14]
2022
EUR 1 44-year-old man with HIV Sexual contact Painless multiple vesiculopustular skin lesions with umbilication and central crusting Supportive treatment with recovery after 1 week [32]
2022
EUR 1255 Median age 37 years old, 98.9% male Intimate and prolonged contact during sex (86%) Anogenital rash (67%), fever (57%), disseminated rash (55%), lymphadenopathy (50%), asthenia (42%), oral/buccal rash (17%), myalgia (32%), throat pain (26%), headache (26%) 30 (6%) of the 530 cases were hospitalized (median admission 2 days), 33 reported complications (15 secondary bacterial infections, 11 oral ulcers, 2 proctitis, 2 pharyngotonsillitis), no deaths [33]
2022
EUR 2 26 and 32 years old, both men Sexual contact Skin papules and pustules, malaise, body ache, inguinal lymphadenopathy, dysphagia, fatigue, cough Supportive treatment, recovered [34]
2022
EUR 508 18–67 years old, 503 (99%) men, 225 (44%) had HIV Sexual contact (84%) Exanthema (98%), anogenital and perineal rash (72%), lymphadenopathy (61%), asthenia (47%), myalgia (36%), headache (32%), odynophagia (28%), proctitis (16%) Supportive treatment, 19 (3.7%) required hospitalization, with 7 having parapharyngeal abscesses, mouth ulcers, and bacterial superinfection, no deaths [35]
2022
EUR 521 20–67 years old, all men Sexual or intimate contact Symptoms not specified 38 (8%) of 455 cases hospitalized, no deaths [36]
2022
EUR 1 42-year-old man Sexual contact Cutaneous and perianal lesions, rectal ulcers Concurrent infection with Campylobacter spp., supportive treatment, recovered [37]
2022
EUR 1 32-year-old man with HIV Sexual contact Umbilicated pustules over genitals and hands, painful inguinal lymphadenopathy Supportive treatment, recovered [38]
2022
EUR 1 Adult man Sexual contact Fever, intense fatigue, chills, myalgia, sore throat, severe anal pain, no rash Supportive treatment, recovered [39]
2022
EUR 1 26-year-old man with HIV Sexual contact Fever, chills, rectal pain, umbilicated vesiculopustular rash, dysphagia, lymphadenopathy Supportive treatment, recovered [40]
2022
EUR 2 Both 37-year-old men Sexual contact Genital lesions (papules, vesicles), fever Supportive treatment, recovered [41]
2022
EUR 1 33-year-old man with HIV Sexual contact Asthenia, malaise, anorexia, fever, papules on elbows, ulcerated perianal lesion, inguinal lymphadenopathy Supportive treatment, recovered [42]
2022
EUR 4 All males in their 30s, 2 with HIV Sexual contact Umbilicated skin lesions in genital areas and limbs, inguinal lymphadenopathy, fever Supportive treatment, recovered [43]
2022
WPR 1 39-year-old man Unclear Fever, chills, myalgia, vesicular and pustular rash, cervical and inguinal lymphadenopathy Supportive treatment, recovered [44]
2020
WPR 1 34-year-old man Unclear Painless genital lesion, tender inguinal lymphadenopathy, fever, sore throat, skin rash Supportive treatment, no death [45]
2022
WPR 1 Man in his 30s with HIV Sexual contact Painless white pustules on the penis that became painful and pruritic, truncal rash, fever, malaise Supportive treatment, recovering after 2 days in hospital [46]
2022
Open in a new tab

a Combination of adults and children. b One neonatal death, four patients who died also had HIV with acquired immunodeficiency syndrome, and two other deaths were from secondary bacterial infection of skin lesions. c One neonatal pneumonia with encephalitis, one adult encephalitis, two adult sepsis, one adult suicide. HIV: human immunodeficiency virus. IQR: interquartile range. IVIG: intravenous immunoglobulin. PCR: polymerase chain reaction. Ref: reference. World Health Organization regions: African Region (AFR), Region of the Americas (AMR), South-East Asian Region (SEAR), European Region (EUR), Eastern Mediterranean Region (EMR), Western Pacific Region (WPR).

Table 3.

Pediatric cases of monkeypox virus infection in humans.

WHO Region N Patient Characteristics Source of Infection Clinical Features Outcomes Ref/
Year
AFR 3 15 months–9 years old, all males Family contact Fever, vesiculo-papular rash, cervical adenitis Supportive treatment, 2 (67%) deaths (signs of pulmonary edema, agitation, hypotonia) [21]
2017
AFR 14 1–15 years old, 5 males Family contact Fever, rash Supportive treatment, 2 (1.5%) deaths [22]
2019
AFR 1 11-month-old boy Unclear Fever, chills, diaphoresis, vomiting, cough, pruritus, generalized umbilicated pustules Supportive treatment, spontaneous recovery [47]
2019
EUR 1 18-month-old child Family contact Vesicular lesion Supportive treatment, recovered [2]
2021
EUR 1 <2 years old, female Unclear Rash, lymphadenopathy Supportive treatment, prolonged PCR positivity 22 days, no death [11]
2022
EUR 1 <10 years old, male Unclear Rash, sore throat, incidental IgA deficiency Supportive treatment, prolonged PCR positivity and partial resolution 3 weeks from symptom onset [48]
2022
Open in a new tab

Ref: reference. World Health Organization regions: African Region (AFR), Region of the Americas (AMR), South-East Asian Region (SEAR), European Region (EUR), Eastern Mediterranean Region (EMR), Western Pacific Region (WPR).

Table 4.

Pregnancy-related monkeypox virus infection in humans.

WHO Region N Patient Characteristics Source of Infection Clinical Features Outcomes Ref/
Year
AFR 4 20–29 years old Unclear Vesiculopustular lesions 2 first-trimester miscarriages, 1 stillborn, 1 birth of healthy infant [6]
2017
Open in a new tab

Ref: reference. World Health Organization regions: African Region (AFR), Region of the Americas (AMR), South-East Asian Region (SEAR), European Region (EUR), Eastern Mediterranean Region (EMR), Western Pacific Region (WPR).

3.2. Epidemiology

Although monkeypox was first found in monkeys, monkeys are incidental hosts, and the animal reservoir remains unknown. Animal-to-human transmission, human-to-human transmission, and asymptomatic circulation of monkeypox in human communities can occur [49,50]. Spread of monkeypox virus from forest animals (e.g., monkeys, rodents, squirrels) to exposed humans has been reported [19], which may be via contact with bodily fluids, bites, or preparation of bushmeat. Spread of monkeypox virus among humans occurs via close contact (including sexual contact), fomites, environmental contamination [51], respiratory droplets, or vertical (maternal–fetal) transmission [4,6].

Both travel-related [27,28,44] and autochthonous community transmission [36,52] have been reported. Secondary attack rates in contacts unvaccinated against smallpox are estimated to be about 10% [20]. Prior childhood vaccination is not completely protective, as 9% of cases reported prior vaccination in the largest observational study of the 2022 outbreak to date [4].

3.3. Treatment Options

Monkeypox-specific treatments include oral or intravenous tecovirimat (a small molecule virus inhibitor), intravenous or topical cidofovir (a viral DNA polymerase inhibitor), oral brincidofovir (a prodrug of cidofovir), and vaccinia immunoglobulin [4,11,53] (Table 5). Tecovirimat can be used for adults and children weighing at least 3 kg [54]. For pregnant women with severe disease, tecovirimat and vaccinia immunoglobulin are preferred over cidofovir/brincidofovir as cidofovir is a teratogen.

Table 5.

Treatment and prevention of monkeypox virus infection.

Treatment Prevention
Oral/intravenous tecovirimat, suitable for adults and children weighing >3 kg Respiratory droplet protection with surgical masks, use respirators for aerosol-generating procedures
Intravenous/topical cidofovir or oral brincidofovir, avoid in pregnancy (teratogenic) Hand hygiene, appropriate contact precautions including use of long-sleeved gowns and gloves during patient contact
Vaccinia immunoglobulin Modified vaccinia Ankara or ACAM2000 vaccine
Open in a new tab

In one case report, one adult patient received tecovirimat and recovered after one month in hospital [24]. In a case series, three adult patients treated with oral brincidofovir (200 mg once a week) all developed elevated liver enzymes, resulting in therapy cessation, and one patient treated with oral tecovirimat (200 mg twice daily for 2 weeks) experienced no adverse effects [11]. Nonetheless, the overall risk–benefit balance of monkeypox-specific treatment is unclear.

3.4. Prevention Options

Smallpox (vaccinia) vaccination is cross-protective for both smallpox and monkeypox [55], preventing about 85% of MVIH [56], though vaccine supply and production capacity are currently limited. Two vaccines exist: modified vaccinia Ankara (Jynneos/Imamune/Imvanex, Bavarian Nordic, Hørsholm, Denmark) and ACAM2000 (Emergent BioSolutions, Gaithersburg, MD, USA) (Table 6). The modified vaccinia Ankara vaccine is made from a highly attenuated and nonreplicating vaccinia virus and can be used in immunocompromised patients. It is administered as two subcutaneous injections separated by 4 weeks, with the peak antibody response 2 weeks after completion of the two-dose series. On the other hand, ACAM2000 contains replication-competent smallpox (vaccinia) and is contraindicated in immunocompromised and pregnant patients. It is administered once by a multiple-puncture technique using a bifurcated needle, with the peak antibody response after 28 days. After vaccination, local side effects (pain, erythema, induration) and systemic side effects (fever, chills, fatigue, myalgia, headache, nausea) are generally mild and transient. Nevertheless, severe adverse events (post-vaccination encephalitis and myopericarditis) may rarely occur, particularly for ACAM2000 [55]. Regular booster doses are recommended for persons with ongoing occupational risk for exposure to monkeypox (every 2 years for Jynneos and every 3 years for ACAM2000) [57].

Table 6.

Monkeypox virus vaccines and their uses.

Modified Vaccinia Ankara
(Jynneos/Imamune/Imvanex, Bavarian Nordic, Hørsholm, Denmark)		 ACAM2000
(Emergent BioSolutions, Gaithersburg, MD, USA)
Replication-competent No Yes
Administration Subcutaneous Multiple-puncture technique with a bifurcated needle
Number of doses 2, spaced 28 days apart 1
Peak vaccine response 2 weeks after 2nd dose 28 days after vaccination
Booster doses for ongoing high-risk (e.g., occupational) exposure Every 2 years Every 3 years
Pre-exposure vaccination Yes Yes
Post-exposure prophylaxis Yes Yes
Ring vaccination of close contacts for epidemic containment Yes Yes
Use in children Yes Yes
Use in pregnant women Yes No
Use in immunocompromised persons Yes No
Side effects Usually mild, local, rarely severe (e.g., post-vaccination encephalitis and myopericarditis) Usually mild, local, rarely severe (e.g., post-vaccination encephalitis and myopericarditis)
Open in a new tab

Given the limited vaccine supplies, prioritization of the following groups for pre-exposure vaccination may be reasonable: healthcare workers at high risk for occupational exposure [29,57], immunocompromised patients, and children (given the increased risk of severe disease and death). Despite the increased risk of pregnancy loss and stillbirth with MVIH, live vaccines should be used with caution in pregnancy, with the replication-incompetent modified vaccinia Ankara being preferred [54]. While vaccination is best administered before infection, vaccination as a post-exposure prophylaxis may also be useful if given within 4 days of exposure. This is especially important for high-risk exposures, such as physical contact with an infected person’s broken skin/mucous membrane or being near an infected person during an aerosol-generating procedure while not wearing a surgical mask/respirator [24]. Additionally, for epidemic containment, besides rapid diagnostic testing [58] and prompt identification and isolation of cases, vaccination of close contacts (ring vaccination) can help [59].

To limit the spread of monkeypox to both vaccinated and non-vaccinated persons, non-pharmaceutical shielding methods should address the known transmission routes. These methods include isolation of infected persons, hand hygiene, wearing of appropriate personal protection (long-sleeved gowns, gloves), proper cleaning of contaminated surfaces (for instance, with 70% ethanol [60]), and disposal of fomites. These methods can limit direct and indirect contact transmission. In addition, the wearing of face masks by infected persons and their close contacts can limit droplet transmission. When aerosol-generating procedures are performed for MVIH cases, healthcare staff may consider a higher level of protection, with N95/filtering facepiece 3 (FFP3) respirator masks for respiratory protection and face shields/goggles for eye protection [29].

4. Discussion

Contemporary data on MVIH suggest that the disease is mild in adults and more severe in children. Outcomes for immunocompromised patients and pregnant women may also be poor, with a high risk of fetal loss in the latter. Transmission risk is substantial from close contact and droplet spread, exacerbated by international travel. While specific treatment is limited, two current vaccinia virus-based vaccines are known to prevent MVIH effectively.

Although MVIH is not a novel disease, several knowledge gaps exist. Firstly, the current global outbreak is larger and more extensive than before, and the full impact of disease on the wider population of older persons, children, immunocompromised patients, pregnant mothers, and patients from resource-limited settings remains uncertain. Secondly, virulence factors contributing to the variable severity and outcomes of monkeypox infection have not been fully elucidated [7]. Thirdly, monitoring for post-MVIH sequelae would be needed, especially for serious complications such as sight-threatening corneal opacities and physically debilitating scars [8,61].

In addition, transmission routes are not completely clear, and more work is required to uncover sources and methods of transmission, including the extent to which airborne transmission contributes to the current monkeypox outbreak. Given that monkeypox can infect animals and animal reservoirs are not fully known [58,61], disease prevalence among animals in general—including domestic pets—should be studied. On a related note, measures to mitigate viral spread among animals should be considered for zoonotic transmission.

As case numbers increase, public health resources will be stretched. Increasing patient numbers may also reveal more cases with serious manifestations and complications, further burdening healthcare systems. Additional studies are needed to elucidate the efficacy and safety of current antiviral treatments and vaccines. More research is also needed to develop novel diagnostics (e.g., lateral flow assay for the detection of orthopoxviruses [62]) and therapeutics. In the meantime, frontline healthcare staff around the world should be trained to rapidly identify, isolate, and manage patients with MVIH [5].

5. Conclusions

Most probably, vaccination will be a key strategy for mitigating MVIH given the current rapid global spread of monkeypox, the existence of efficacious vaccines, and the uncertain risk–benefit profile of current antivirals. Priority groups for vaccination should include healthcare workers at high risk for occupational exposure, immunocompromised patients, and children. In addition, vaccination as post-exposure prophylaxis, ring vaccination of close contacts, and non-pharmaceutical shielding methods may also be used to limit human-to-human spread [10].

Author Contributions

Conceptualization, K.C.S.; methodology, K.C.S.; formal analysis, K.C.S.; investigation, K.C.S.; writing—original draft preparation, K.C.S.; writing—review and editing, K.C.S. All author has read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

The data presented in this study are contained within the article.

Conflicts of Interest

The author declares no conflict of interest.

Funding Statement

This research received no external funding.

Footnotes

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

  • 1.Sklenovska N., Van Ranst M. Emergence of Monkeypox as the Most Important Orthopoxvirus Infection in Humans. Front. Public Health. 2018;6:241. doi: 10.3389/fpubh.2018.00241. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Hobson G., Adamson J., Adler H., Firth R., Gould S., Houlihan C., Johnson C., Porter D., Rampling T., Ratcliffe L., et al. Family cluster of three cases of monkeypox imported from Nigeria to the United Kingdom, May 2021. Eurosurveillance. 2021;26:2100745. doi: 10.2807/1560-7917.ES.2021.26.32.2100745. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Ježek Z., Fenner F. Human Monkeypox. Volume 17 S. Karger Ag; Basel, Switzerland: 1988. [Google Scholar]
  • 4.Thornhill J.P., Barkati S., Walmsley S., Rockstroh J., Antinori A., Harrison L.B., Palich R., Nori A., Reeves I., Habibi M.S., et al. Monkeypox Virus Infection in Humans across 16 Countries—April–June 2022. N. Engl. J. Med. 2022 doi: 10.1056/NEJMoa2207323. [DOI] [PubMed] [Google Scholar]
  • 5.Brown K., Leggat P.A. Human Monkeypox: Current State of Knowledge and Implications for the Future. Trop. Med. Infect. Dis. 2016;1:8. doi: 10.3390/tropicalmed1010008. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Mbala P.K., Huggins J.W., Riu-Rovira T., Ahuka S.M., Mulembakani P., Rimoin A.W., Martin J.W., Muyembe J.T. Maternal and Fetal Outcomes Among Pregnant Women with Human Monkeypox Infection in the Democratic Republic of Congo. J. Infect. Dis. 2017;216:824–828. doi: 10.1093/infdis/jix260. [DOI] [PubMed] [Google Scholar]
  • 7.Weaver J.R., Isaacs S.N. Monkeypox virus and insights into its immunomodulatory proteins. Immunol. Rev. 2008;225:96–113. doi: 10.1111/j.1600-065X.2008.00691.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Jezek Z., Szczeniowski M., Paluku K.M., Mutombo M. Human monkeypox: Clinical features of 282 patients. J. Infect. Dis. 1987;156:293–298. doi: 10.1093/infdis/156.2.293. [DOI] [PubMed] [Google Scholar]
  • 9.See K.C. Vaccination for the Prevention of Infection among Immunocompromised Patients: A Concise Review of Recent Systematic Reviews. Vaccines. 2022;10:800. doi: 10.3390/vaccines10050800. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Minhaj F.S., Ogale Y.P., Whitehill F., Schultz J., Foote M., Davidson W., Hughes C.M., Wilkins K., Bachmann L., Chatelain R., et al. Monkeypox Outbreak—Nine States, May 2022. MMWR Morb. Mortal. Wkly. Rep. 2022;71:764–769. doi: 10.15585/mmwr.mm7123e1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Adler H., Gould S., Hine P., Snell L.B., Wong W., Houlihan C.F., Osborne J.C., Rampling T., Beadsworth M.B., Duncan C.J., et al. Clinical features and management of human monkeypox: A retrospective observational study in the UK. Lancet Infect. Dis. 2022;22:1153–1162. doi: 10.1016/S1473-3099(22)00228-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Peiro-Mestres A., Fuertes I., Camprubi-Ferrer D., Marcos M.A., Vilella A., Navarro M., Rodriguez-Elena L., Riera J., Catala A., Martinez M.J., et al. Frequent detection of monkeypox virus DNA in saliva, semen, and other clinical samples from 12 patients, Barcelona, Spain, May to June 2022. Eurosurveillance. 2022;27:2200503. doi: 10.2807/1560-7917.ES.2022.27.28.2200503. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Luna N., Ramirez A.L., Munoz M., Ballesteros N., Patino L.H., Castaneda S.A., Bonilla-Aldana D.K., Paniz-Mondolfi A., Ramirez J.D. Phylogenomic analysis of the monkeypox virus (MPXV) 2022 outbreak: Emergence of a novel viral lineage? Travel Med. Infect. Dis. 2022;49:102402. doi: 10.1016/j.tmaid.2022.102402. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.de Sousa D., Patrocinio J., Frade J., Correia C., Borges-Costa J., Filipe P. Human monkeypox coinfection with acute HIV: An exuberant presentation. Int. J. STD AIDS. 2022:9564624221114998. doi: 10.1177/09564624221114998. [DOI] [PubMed] [Google Scholar]
  • 15.Ogoina D., Iroezindu M., James H.I., Oladokun R., Yinka-Ogunleye A., Wakama P., Otike-Odibi B., Usman L.M., Obazee E., Aruna O., et al. Clinical Course and Outcome of Human Monkeypox in Nigeria. Clin. Infect. Dis. 2020;71:e210–e214. doi: 10.1093/cid/ciaa143. [DOI] [PubMed] [Google Scholar]
  • 16.Yinka-Ogunleye A., Aruna O., Dalhat M., Ogoina D., McCollum A., Disu Y., Mamadu I., Akinpelu A., Ahmad A., Burga J., et al. Outbreak of human monkeypox in Nigeria in 2017-18: A clinical and epidemiological report. Lancet Infect. Dis. 2019;19:872–879. doi: 10.1016/S1473-3099(19)30294-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Kalthan E., Tenguere J., Ndjapou S.G., Koyazengbe T.A., Mbomba J., Marada R.M., Rombebe P., Yangueme P., Babamingui M., Sambella A., et al. Investigation of an outbreak of monkeypox in an area occupied by armed groups, Central African Republic. Med. Mal. Infect. 2018;48:263–268. doi: 10.1016/j.medmal.2018.02.010. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Bunge E.M., Hoet B., Chen L., Lienert F., Weidenthaler H., Baer L.R., Steffen R. The changing epidemiology of human monkeypox-A potential threat? A systematic review. PLoS Negl. Trop. Dis. 2022;16:e0010141. doi: 10.1371/journal.pntd.0010141. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Breman J.G., Kalisa R., Steniowski M.V., Zanotto E., Gromyko A.I., Arita I. Human monkeypox, 1970–1979. Bull. World Health Organ. 1980;58:165–182. [PMC free article] [PubMed] [Google Scholar]
  • 20.Beer E.M., Rao V.B. A systematic review of the epidemiology of human monkeypox outbreaks and implications for outbreak strategy. PLoS Negl. Trop. Dis. 2019;13:e0007791. doi: 10.1371/journal.pntd.0007791. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Nakoune E., Lampaert E., Ndjapou S.G., Janssens C., Zuniga I., Van Herp M., Fongbia J.P., Koyazegbe T.D., Selekon B., Komoyo G.F., et al. A Nosocomial Outbreak of Human Monkeypox in the Central African Republic. Open Forum Infect. Dis. 2017;4:ofx168. doi: 10.1093/ofid/ofx168. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Doshi R.H., Guagliardo S.A.J., Doty J.B., Babeaux A.D., Matheny A., Burgado J., Townsend M.B., Morgan C.N., Satheshkumar P.S., Ndakala N., et al. Epidemiologic and Ecologic Investigations of Monkeypox, Likouala Department, Republic of the Congo, 2017. Emerg. Infect. Dis. 2019;25:281–289. doi: 10.3201/eid2502.181222. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23.Eseigbe E.E., Akude C., Osagie I.A., Eseigbe P. Human Monkey Pox Virus Infection in Plateau State, North Central Nigeria: A Report of Two Cases. West Afr. J. Med. 2021;38:1242–1246. doi: 10.55891/wajm.v38i12.55. [DOI] [PubMed] [Google Scholar]
  • 24.Rao A.K., Schulte J., Chen T.H., Hughes C.M., Davidson W., Neff J.M., Markarian M., Delea K.C., Wada S., Liddell A., et al. Monkeypox in a Traveler Returning from Nigeria—Dallas, Texas, July 2021. MMWR Morb. Mortal. Wkly. Rep. 2022;71:509–516. doi: 10.15585/mmwr.mm7114a1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25.Sukhdeo S.S., Aldhaheri K., Lam P.W., Walmsley S. A case of human monkeypox in Canada. CMAJ. 2022;194:E1031–E1035. doi: 10.1503/cmaj.220886. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.Costello V., Sowash M., Gaur A., Cardis M., Pasieka H., Wortmann G., Ramdeen S. Imported Monkeypox from International Traveler, Maryland, USA, 2021. Emerg. Infect. Dis. 2022;28:1002–1005. doi: 10.3201/eid2805.220292. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Vaughan A., Aarons E., Astbury J., Balasegaram S., Beadsworth M., Beck C.R., Chand M., O’Connor C., Dunning J., Ghebrehewet S., et al. Two cases of monkeypox imported to the United Kingdom, September 2018. Eurosurveillance. 2018;23:1800509. doi: 10.2807/1560-7917.ES.2018.23.38.1800509. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Erez N., Achdout H., Milrot E., Schwartz Y., Wiener-Well Y., Paran N., Politi B., Tamir H., Israely T., Weiss S., et al. Diagnosis of Imported Monkeypox, Israel, 2018. Emerg. Infect. Dis. 2019;25:980–983. doi: 10.3201/eid2505.190076. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.Vaughan A., Aarons E., Astbury J., Brooks T., Chand M., Flegg P., Hardman A., Harper N., Jarvis R., Mawdsley S., et al. Human-to-Human Transmission of Monkeypox Virus, United Kingdom, October 2018. Emerg. Infect. Dis. 2020;26:782–785. doi: 10.3201/eid2604.191164. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30.Bruno G., Fabrizio C., Rodano L., Buccoliero G.B. Monkeypox in a 71-year-old woman. J. Med Virol. 2022 doi: 10.1002/jmv.27993. [DOI] [PubMed] [Google Scholar]
  • 31.Orviz E., Negredo A., Ayerdi O., Vazquez A., Munoz-Gomez A., Monzon S., Clavo P., Zaballos A., Vera M., Sanchez P., et al. Monkeypox outbreak in Madrid (Spain): Clinical and virological aspects. J. Infect. 2022 doi: 10.1016/j.jinf.2022.07.005. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32.Maronese C.A., Beretta A., Avallone G., Boggio F.L., Marletta D.A., Murgia G., Cusini M., Gori A., Carrera C.G., Di Benedetto A., et al. Clinical, dermoscopic and histopathological findings in localized human monkeypox: A case from northern Italy. Br. J. Dermatol. 2022 doi: 10.1111/bjd.21773. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33.Rodriguez B.S., Herrador B.R.G., Franco A.D., Farinas M.P.S., Del Amo Valero J., Llorente A.H.A., de Agreda J., Malonda R.C., Castrillejo D., Chirlaque Lopez M.D., et al. Epidemiologic Features and Control Measures during Monkeypox Outbreak, Spain, June 2022. Emerg. Infect. Dis. 2022;28 doi: 10.3201/eid2809.221051. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.Noe S., Zange S., Seilmaier M., Antwerpen M.H., Fenzl T., Schneider J., Spinner C.D., Bugert J.J., Wendtner C.M., Wolfel R. Clinical and virological features of first human monkeypox cases in Germany. Infection. 2022 doi: 10.1007/s15010-022-01874-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35.Martinez J.I., Montalban E.G., Bueno S.J., Martinez F.M., Julia A.N., Diaz J.S., Marin N.G., Deorador E.C., Forte A.N., Garcia M.A., et al. Monkeypox outbreak predominantly affecting men who have sex with men, Madrid, Spain, 26 April to 16 June 2022. Eurosurveillance. 2022;27:2200471. doi: 10.2807/1560-7917.ES.2022.27.27.2200471. [DOI] [Google Scholar]
  • 36.Selb R., Werber D., Falkenhorst G., Steffen G., Lachmann R., Ruscher C., McFarland S., Bartel A., Hemmers L., Koppe U., et al. A shift from travel-associated cases to autochthonous transmission with Berlin as epicentre of the monkeypox outbreak in Germany, May to June 2022. Eurosurveillance. 2022;27:2200499. doi: 10.2807/1560-7917.ES.2022.27.27.2200499. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Raccagni A.R., Mileto D., Canetti D., Tamburini A.M., Rizzo A., Bruzzesi E., Castagna A., Nozza S. Monkeypox and pan-resistant Campylobacter spp infection in Entamoeba histolytica and Chlamydia trachomatis re-infection in a man who have sex with men. J. Infect. 2022 doi: 10.1016/j.jinf.2022.06.028. [DOI] [PubMed] [Google Scholar]
  • 38.Moreno D.M., Escribano P.C. Monkeypox Virus Infection: A Case Report. Actas Dermosifiliogr. 2022 doi: 10.1016/j.ad.2022.06.014. [DOI] [Google Scholar]
  • 39.Vallee A., Farfour E., Zucman D. Monkeypox virus: A novel sexually transmitted disease? A case report from France. Travel Med. Infect. Dis. 2022;49:102394. doi: 10.1016/j.tmaid.2022.102394. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 40.Oprea C., Ianache I., Piscu S., Tardei G., Nica M., Ceausu E., Popescu C.P., Florescu S.A. First report of monkeypox in a patient living with HIV from Romania. Travel Med. Infect. Dis. 2022;49:102395. doi: 10.1016/j.tmaid.2022.102395. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 41.Davido B., D’Anglejan E., Jourdan J., Robinault A., Davido G. Monkeypox 2022 outbreak: Cases with exclusive genital lesions. J. Travel Med. 2022:taac077. doi: 10.1093/jtm/taac077. [DOI] [PubMed] [Google Scholar]
  • 42.Mileto D., Riva A., Cutrera M., Moschese D., Mancon A., Meroni L., Giacomelli A., Bestetti G., Rizzardini G., Gismondo M.R., et al. New challenges in human monkeypox outside Africa: A review and case report from Italy. Travel Med. Infect. Dis. 2022;49:102386. doi: 10.1016/j.tmaid.2022.102386. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 43.Antinori A., Mazzotta V., Vita S., Carletti F., Tacconi D., Lapini L.E., D’Abramo A., Cicalini S., Lapa D., Pittalis S., et al. Epidemiological, clinical and virological characteristics of four cases of monkeypox support transmission through sexual contact, Italy, May 2022. Eurosurveillance. 2022;27:2200421. doi: 10.2807/1560-7917.ES.2022.27.22.2200421. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 44.Yong S.E.F., Ng O.T., Ho Z.J.M., Mak T.M., Marimuthu K., Vasoo S., Yeo T.W., Ng Y.K., Cui L., Ferdous Z., et al. Imported Monkeypox, Singapore. Emerg. Infect. Dis. 2020;26:1826–1830. doi: 10.3201/eid2608.191387. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 45.Jang Y.R., Lee M., Shin H., Kim J.W., Choi M.M., Kim Y.M., Lee M.J., Kim J., Na H.K., Kim J.Y. The First Case of Monkeypox in the Republic of Korea. J. Korean Med. Sci. 2022;37:e224. doi: 10.3346/jkms.2022.37.e224. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.Hammerschlag Y., MacLeod G., Papadakis G., Adan Sanchez A., Druce J., Taiaroa G., Savic I., Mumford J., Roberts J., Caly L., et al. Monkeypox infection presenting as genital rash, Australia, May 2022. Eurosurveillance. 2022;27:2200411. doi: 10.2807/1560-7917.ES.2022.27.22.2200411. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 47.Reynolds M.G., Wauquier N., Li Y., Satheshkumar P.S., Kanneh L.D., Monroe B., Maikere J., Saffa G., Gonzalez J.P., Fair J., et al. Human Monkeypox in Sierra Leone after 44-Year Absence of Reported Cases. Emerg. Infect. Dis. 2019;25:1023–1025. doi: 10.3201/eid2505.180832. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 48.Tutu van Furth A.M., van der Kuip M., van Els A.L., Fievez L.C., van Rijckevorsel G.G., van den Ouden A., Jonges M., Welkers M.R. Paediatric monkeypox patient with unknown source of infection, the Netherlands, June 2022. Eurosurveillance. 2022;27:2200552. doi: 10.2807/1560-7917.ES.2022.27.29.2200552. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 49.Guagliardo S.A.J., Monroe B., Moundjoa C., Athanase A., Okpu G., Burgado J., Townsend M.B., Satheshkumar P.S., Epperson S., Doty J.B., et al. Asymptomatic Orthopoxvirus Circulation in Humans in the Wake of a Monkeypox Outbreak among Chimpanzees in Cameroon. Am. J. Trop. Med. Hyg. 2020;102:206–212. doi: 10.4269/ajtmh.19-0467. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 50.Besombes C., Gonofio E., Konamna X., Selekon B., Grant R., Gessain A., Berthet N., Manuguerra J.C., Fontanet A., Nakoune E. Intrafamily Transmission of Monkeypox Virus, Central African Republic, 2018. Emerg. Infect. Dis. 2019;25:1602–1604. doi: 10.3201/eid2508.190112. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 51.Atkinson B., Burton C., Pottage T., Thompson K.A., Ngabo D., Crook A., Pitman J., Summers S., Lewandowski K., Furneaux J., et al. Infection-competent monkeypox virus contamination identified in domestic settings following an imported case of monkeypox into the UK. Environ. Microbiol. 2022 doi: 10.1111/1462-2920.16129. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 52.Vivancos R., Anderson C., Blomquist P., Balasegaram S., Bell A., Bishop L., Brown C.S., Chow Y., Edeghere O., Florence I., et al. Community transmission of monkeypox in the United Kingdom, April to May 2022. Eurosurveillance. 2022;27:2200422. doi: 10.2807/1560-7917.ES.2022.27.22.2200422. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 53.Semba R.D. The ocular complications of smallpox and smallpox immunization. Arch. Ophthalmol. 2003;121:715–719. doi: 10.1001/archopht.121.5.715. [DOI] [PubMed] [Google Scholar]
  • 54.Khalil A., Samara A., O’Brien P., Morris E., Draycott T., Lees C., Ladhani S. Monkeypox and pregnancy: What do obstetricians need to know? Ultrasound Obstet. Gynecol. 2022;60:22–27. doi: 10.1002/uog.24968. [DOI] [PubMed] [Google Scholar]
  • 55.Petersen B.W., Kabamba J., McCollum A.M., Lushima R.S., Wemakoy E.O., Muyembe Tamfum J.J., Nguete B., Hughes C.M., Monroe B.P., Reynolds M.G. Vaccinating against monkeypox in the Democratic Republic of the Congo. Antivir. Res. 2019;162:171–177. doi: 10.1016/j.antiviral.2018.11.004. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 56.Fine P.E., Jezek Z., Grab B., Dixon H. The transmission potential of monkeypox virus in human populations. Int. J. Epidemiol. 1988;17:643–650. doi: 10.1093/ije/17.3.643. [DOI] [PubMed] [Google Scholar]
  • 57.Rao A.K., Petersen B.W., Whitehill F., Razeq J.H., Isaacs S.N., Merchlinsky M.J., Campos-Outcalt D., Morgan R.L., Damon I., Sanchez P.J., et al. Use of JYNNEOS (Smallpox and Monkeypox Vaccine, Live, Nonreplicating) for Preexposure Vaccination of Persons at Risk for Occupational Exposure to Orthopoxviruses: Recommendations of the Advisory Committee on Immunization Practices—United States, 2022. MMWR Morb. Mortal. Wkly. Rep. 2022;71:734–742. doi: 10.15585/mmwr.mm7122e1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 58.Aden T.A., Blevins P., York S.W., Rager S., Balachandran D., Hutson C.L., Lowe D., Mangal C.N., Wolford T., Matheny A., et al. Rapid Diagnostic Testing for Response to the Monkeypox Outbreak—Laboratory Response Network, United States, May 17–June 30, 2022. MMWR Morb. Mortal. Wkly. Rep. 2022;71:904–907. doi: 10.15585/mmwr.mm7128e1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 59.Mohanty B., Costantino V., Narain J., Chughtai A.A., Das A., MacIntyre C.R. Modelling the impact of a smallpox attack in India and influence of disease control measures. BMJ Open. 2020;10:e038480. doi: 10.1136/bmjopen-2020-038480. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 60.Kampf G. Efficacy of biocidal agents and disinfectants against the monkeypox virus and other orthopoxviruses. J. Hosp. Infect. 2022;127:101–110. doi: 10.1016/j.jhin.2022.06.012. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 61.Damon I.K. Status of human monkeypox: Clinical disease, epidemiology and research. Vaccine. 2011;29((Suppl. 4)):D54–D59. doi: 10.1016/j.vaccine.2011.04.014. [DOI] [PubMed] [Google Scholar]
  • 62.Ulaeto D.O., Lonsdale S.G., Laidlaw S.M., Clark G.C., Horby P., Carroll M.W. A prototype lateral flow assay for detection of orthopoxviruses. Lancet Infect. Dis. 2022 doi: 10.1016/S1473-3099(22)00440-6. [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data presented in this study are contained within the article.

Articles from Vaccines are provided here courtesy of Multidisciplinary Digital Publishing Institute (MDPI)

RESOURCES