Orientações sobre o uso de vacinas contra a varíola símia. Edição corrigida

A erradicação da varíola humana (mpox em inglês) foi certificada em 1980. A varíola símia (mpox em inglês) é endêmica nos países da África Central e Ocidental desde a sua primeira detecção, em 1958. Trata-se de uma zoonose cujos casos geralmente ocorrem perto de florestas tropicais, onde diversos animais são portadores do ortopoxvírus causador da doença. A maioria das infecções em seres humanos pelo vírus da varíola símia em países onde a doença é endêmica é resultado de transmissão primária de animais para humanos. A transmissão de pessoa a pessoa pode ocorrer por meio de contato próximo com secreções respiratórias ou lesões cutâneas de uma pessoa infectada ou com objetos recém-contaminados. A transmissão também pode ocorrer através da placenta da mãe para o feto ou por contato direto durante ou após o parto. Até 21 de maio de 2022, 12 países onde não há varíola símia endêmica, em 2 regiões da Organização Mundial da Saúde (OMS), haviam notificado 92 casos confirmados da doença. Até 26 de agosto de 2022, 96 países sem endemicidade, de todas as 6 regiões da OMS, haviam notificado 45.198 casos confirmados de varíola símia, incluindo 6 óbitos. No mesmo período, os países onde a doença é endêmica notificaram 350 casos confirmados e 6 óbitos. Na Região das Américas, 29 países e territórios notificaram 23.479 (48%) casos confirmados e 3 óbitos. Diversos estudos observacionais sobre as vacinas de primeira geração demonstraram que a eficácia da vacinação contra a varíola humana na prevenção da varíola símia é de aproximadamente 85%. Atualmente, as vacinas originais (de primeira geração) contra a varíola humana não estão mais disponíveis.

Synergistic effect of two human-like monoclonal antibodies confers protection against orthopoxvirus infection.

The eradication of smallpox was officially declared by the WHO in 1980, leading to discontinuation of the vaccination campaign against the virus. Consequently, immunity against smallpox and related orthopoxviruses like Monkeypox virus gradually declines, highlighting the need for efficient countermeasures not only for the prevention, but also for the treatment of already exposed individuals. We have recently developed human-like monoclonal antibodies (mAbs) from vaccinia virus-immunized non-human primates. Two mAbs, MV33 and EV42, targeting the two infectious forms of the virus, were selected for in vivo evaluation, based on their in vitro neutralization potency. A single dose of either MV33 or EV42 administered three days post-infection (dpi) to BALB/c female mice provides full protection against lethal ectromelia virus challenge. Importantly, a combination of both mAbs confers full protection even when provided five dpi. Whole-body bioimaging and viral load analysis reveal that combination of the two mAbs allows for faster and more efficient clearance of the virus from target organs compared to either MV33 or EV42 separately. The combined mAbs treatment further confers post-exposure protection against the currently circulating Monkeypox virus in Cast/EiJ female mice, highlighting their therapeutic potential against other orthopoxviruses.

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.

Evaluation of the public policy impacts on Monkeypox in Brazil.

Brazil ranked third in the number of Monkeypox infected worldwide in early September 2022 and eighth in multiple deaths. Brazilian Ministry of Health prepared a public policy to face the smallpox outbreak. This paper aims to analyze the governmental public policy' impacts on Monkeypox using survival analysis. The information in the database was collected from epidemiological bulletins on the official websites of the Brazilian Ministry of Health and the World Health Organization (WHO). The survival analysis with parametric statistical analysis, semiparametric with Cox regression, and nonparametric analysis were used. The inference of causality was perceived by the impact caused by the national public policy with the proportional reduction in the number of cases in the treatment group (Chi-sq = 117.783, p < 0.001), contrary to what was perceived in the control group, as well as survival about the time of the states that elaborated their plans based on what was made available by the government. The need to evaluate government projects should be within the scope of project management in Brazilian states and provide for more assertive decision-making in the fight against smallpox.

Smallpox Geographies: vaccination, borders and Indigenous peoples in Australia's coastal north.

Australia's approach to its biosecurity and borders has always been two-pronged - quarantine first, vaccination second. This article asks what this combination looked like in practice by exploring two neglected smallpox vaccination campaigns directed towards Indigenous peoples in the early twentieth century. We argue these were important campaigns because they were the first two pre-emptive, rather than reactionary, vaccination programs directed towards First Nations people. Second, both episodes occurred in Australia's northern coastline, where the porous maritime geography and proximity to Southeast Asia posed a point of vulnerability for Australian health officials. While smallpox was never endemic, (though epidemic), in Australia, it was endemic at various times and places across Southeast Asia. This shifting spectre of smallpox along the northern coastline was made even more acute for state and federal health officials because of the existing polyethnic relationships, communities, and economies. By vaccinating Indigenous peoples in this smallpox geography, they were envisioned and embedded into a 'hygienic' border for the protection of white Australia, entwining the two-prongs as one approach. In this article, we place public health into a recent scholarship that has 'turned the map upside down' to re-spatialise Australia's history and geography to the north and its global connections, while demonstrating how particular coastlines and their connections were drawn into a national imaginary through a health lens.

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.

Navigating resistance in global health governance: Certification of smallpox eradication in China.

Certification is an essential stage in disease eradication efforts, encompassing epidemiological, managerial, and political complexities. The certification of smallpox eradication in the People's Republic of China (PRC, or China) exemplifies the multifaceted nature of the certification. Despite eradicating smallpox in the early 1960s, before the Global Smallpox Eradication Programme (SEP) intensified in 1967, China was one of the last countries certified as smallpox-free by the World Health Organization (WHO) in 1979. The WHO encountered notable resistance during the certification of smallpox eradication in China. This article examines the underlying motivations propelling China's resistance, the factors that contributed to the shifts in its stance, the challenges navigated by the WHO, and the ultimate achievement of certification despite controversies surrounding its transparency and credibility. Through the case of the certification of smallpox eradication, the article provides a historical context of China's selective engagement in global health governance, emphasising the critical importance of building a trusting relationship between the WHO and its member states. It offers insights for fostering effective collaboration among diverse stakeholders driven by varied political agendas in addressing shared global health challenges such as the coronavirus disease (COVID-19) pandemic.

Adverse drug reaction profile of third-generation smallpox vaccines used in France during the 2022 monkeypox epidemic.

Due to the start of the monkeypox epidemic in 2022, we retrospectively analyzed the adverse drug reactions (ADRs) reported in France after monkeypox vaccinations with the third-generation smallpox vaccine. Ninety-eight cases, representing 172 ADRs, were reported. ADRs were mostly expected reactogenicity reactions occurring within days after the first dose of vaccine and having a quick favorable outcome. Unexpected facial palsy and vaccination failure are discussed.

Smallpox lesion characterization in placebo-treated and tecovirimat-treated macaques using traditional and novel methods.

Smallpox was the most rampant infectious disease killer of the 20th century, yet much remains unknown about the pathogenesis of the variola virus. Using archived tissue from a study conducted at the Centers for Disease Control and Prevention we characterized pathology in 18 cynomolgus macaques intravenously infected with the Harper strain of variola virus. Six macaques were placebo-treated controls, six were tecovirimat-treated beginning at 2 days post-infection, and six were tecovirimat-treated beginning at 4 days post-infection. All macaques were treated daily until day 17. Archived tissues were interrogated using immunohistochemistry, in situ hybridization, immunofluorescence, and electron microscopy. Gross lesions in three placebo-treated animals that succumbed to infection primarily consisted of cutaneous vesicles, pustules, or crusts with lymphadenopathy. The only gross lesions noted at the conclusion of the study in the three surviving placebo-treated and the Day 4 treated animals consisted of resolving cutaneous pox lesions. No gross lesions attributable to poxviral infection were present in the Day 2 treated macaques. Histologic lesions in three placebo-treated macaques that succumbed to infection consisted of proliferative and necrotizing dermatitis with intracytoplasmic inclusion bodies and lymphoid depletion. The only notable histologic lesion in the Day 4 treated macaques was resolving dermatitis; no notable lesions were seen in the Day 2 treated macaques. Variola virus was detected in all three placebo-treated animals that succumbed to infection prior to the study's conclusion by all utilized methods (IHC, ISH, IFA, EM). None of the three placebo-treated animals that survived to the end of the study nor the animals in the two tecovirimat treatment groups showed evidence of variola virus by these methods. Our findings further characterize variola lesions in the macaque model and describe new molecular methods for variola detection.

Genomic and transcriptomic analysis of the recent Mpox outbreak.

The Mpox (formerly named Monkeypox) virus is the etiological cause of a recent multi-country outbreak, with thousands of distinct cases detected outside the endemic areas of Africa as of December 2023. In this article, we analyze the sequences of full genomes of Mpox virus from Europe and compare them with all available Mpox sequences of historical relevance, annotated by year and geographic origin, as well as related Cowpox and Variola (smallpox) virus sequences. Our results show that the recent outbreak is most likely originating from the West African clade of Mpox, with >99 % sequence identity with sequences derived from historical and recent cases, dating from 1971 to 2017. We analyze specific mutations occurring in viral proteins between the current outbreak, previous Mpox and Cowpox sequences, and the historical Variola virus. Genome-wide sequence analysis of the recent outbreak and other Mpox/Cowpox/Variola viruses shows a very high conservation, with 97.9 % (protein-based) and 97.8 % (nucleotide-based) sequence identity. We identified significant correlation in human transcriptional responses as well, with a conserved immune pathway response induced in human cell cultures by the three families of Pox virus. The similarities identified between the major strains of Pox viruses, as well as within the Mpox clades, both at the genomic and transcriptomic levels, provide a molecular basis for the observed efficacy of Variola vaccines in other Poxviruses.

Live attenuated smallpox vaccine candidate (KVAC103) efficiently induces protective immune responses in mice.

Smallpox, caused by the variola virus belonging to the genus Orthopoxvirus, is an acute contagious disease that killed 300 million people in the 20th century. Since it was declared to be eradicated and the national immunization program against it was stopped, the variola virus has become a prospective bio-weapon. It is necessary to develop a safe vaccine that protects people from terrorism using this biological weapon and that can be administered to immunocompromised people. Our previous study reported on the development of an attenuated smallpox vaccine (KVAC103). This study evaluated cellular and humoral immune responses to various doses, frequencies, and routes of administration of the KVAC103 strain, compared to CJ-50300 vaccine, and its protective ability against the wild-type vaccinia virus Western Reserve (VACV-WR) strain was evaluated. The binding and neutralizing-antibody titers increased in a concentration-dependent manner in the second inoculation, which increased the neutralizing-antibody titer compared to those after the single injection. In contrast, the T-cell immune response (interferon-gamma positive cells) increased after the second inoculation compared to that of CJ-50300 after the first inoculation. Neutralizing-antibody titers and antigen-specific IgG levels were comparable in all groups administered KVAC103 intramuscularly, subcutaneously, and intradermally. In a protective immunity test using the VACV-WR strain, all mice vaccinated with CJ-50300 or KVAC103 showed 100% survival. KVAC103 could be a potent smallpox vaccine that efficiently induces humoral and cellular immune responses to protect mice against the VACV-WR strain.

Never Let a Good Outbreak Go to Waste.

The multinational outbreak of mpox (formerly known as monkeypox) that began in 2022 resulted in more than 90,000 reported cases, over 150 deaths, and - importantly - a coordinated international response to a rapidly spreading infectious disease.1 Because of decades of global preparedness efforts, vaccines and therapeutics for a related orthopox virus (smallpox) were available in many global stockpiles. Few of these medical countermeasures were specifically designed, evaluated, or approved for use against mpox disease, requiring the global scientific community to identify how best to quickly translate what was known into what was needed.

Vaccines for Mpox - An Unmet Global Need.

In 1970, the first case of mpox (formerly known as monkeypox) was documented in an infant in Equateur Province, Democratic Republic of Congo (DRC).1 Infections with clade I monkeypox virus (MPXV) are endemic in the rainforest regions of central Africa and result from both zoonotic and human-to-human transmission. The cessation of smallpox vaccination in 1980 because of the eradication of smallpox has led to an increase in the number of individuals who are orthopox immune naïve and is felt to be responsible for a recent increase in mpox cases in the DRC. Comparisons of active surveillance in Sankuru Province from 2005 through 2007 revealed a 20-fold increase in the incidence of mpox compared with the 1980s, with a 5-fold-lower incidence among those with a smallpox vaccination scar.2.

Bisbenzimide compounds inhibit the replication of prototype and pandemic potential poxviruses.

We previously identified the bisbenzimide Hoechst 33342 (H42) as a potent multi-stage inhibitor of the prototypic poxvirus, the vaccinia virus (VACV), and several parapoxviruses. A recent report showed that novel bisbenzimide compounds similar in structure to H42 could prevent human cytomegalovirus replication. Here, we assessed whether these compounds could also serve as poxvirus inhibitors. Using virological assays, we show that these bisbenzimide compounds inhibit VACV spread, plaque formation, and the production of infectious progeny VACV with relatively low cell toxicity. Further analysis of the VACV lifecycle indicated that the effective bisbenzimide compounds had little impact on VACV early gene expression but inhibited VACV late gene expression and truncated the formation of VACV replication sites. Additionally, we found that bisbenzimide compounds, including H42, can inhibit both monkeypox and a VACV mutant resistant to the widely used anti-poxvirus drug TPOXX (Tecovirimat). Therefore, the tested bisbenzimide compounds were inhibitors of both prototypic and pandemic potential poxviruses and could be developed for use in situations where anti-poxvirus drug resistance may occur. Additionally, these data suggest that bisbenzimide compounds may serve as broad-activity antiviral compounds, targeting diverse DNA viruses such as poxviruses and betaherpesviruses.IMPORTANCEThe 2022 mpox (monkeypox) outbreak served as a stark reminder that due to the cessation of smallpox vaccination over 40 years ago, most of the human population remains susceptible to poxvirus infection. With only two antivirals approved for the treatment of smallpox infection in humans, the need for additional anti-poxvirus compounds is evident. Having shown that the bisbenzimide H33342 is a potent inhibitor of poxvirus gene expression and DNA replication, here we extend these findings to include a set of novel bisbenzimide compounds that show anti-viral activity against mpox and a drug-resistant prototype poxvirus mutant. These results suggest that further development of bisbenzimides for the treatment of pandemic potential poxviruses is warranted.

Orally available nucleoside analog UMM-766 provides protection in a murine model of orthopox disease.

Although smallpox has been eradicated, other orthopoxviruses continue to be a public health concern as exemplified by the ongoing Mpox (formerly monkeypox) global outbreak. While medical countermeasures (MCMs) previously approved by the Food and Drug Administration for the treatment of smallpox have been adopted for Mpox, previously described vulnerabilities coupled with the questionable benefit of at least one of the therapeutics during the 2022 Mpox outbreak reinforce the need for identifying and developing other MCMs against orthopoxviruses. Here, we screened a panel of Merck proprietary small molecules and identified a novel nucleoside inhibitor with potent broad-spectrum antiviral activity against multiple orthopoxviruses. Efficacy testing of a 7-day dosing regimen of the orally administered nucleoside in a murine model of severe orthopoxvirus infection yielded a dose-dependent increase in survival. Treated animals had greatly reduced lesions in the lung and nasal cavity, particularly in the 10 µg/mL dosing group. Viral levels were also markedly lower in the UMM-766-treated animals. This work demonstrates that this nucleoside analog has anti-orthopoxvirus efficacy and can protect against severe disease in a murine orthopox model.IMPORTANCEThe recent monkeypox virus pandemic demonstrates that members of the orthopoxvirus, which also includes variola virus, which causes smallpox, remain a public health issue. While currently FDA-approved treatment options exist, risks that resistant strains of orthopoxviruses may arise are a great concern. Thus, continued exploration of anti-poxvirus treatments is warranted. Here, we developed a template for a high-throughput screening assay to identify anti-poxvirus small-molecule drugs. By screening available drug libraries, we identified a compound that inhibited orthopoxvirus replication in cell culture. We then showed that this drug can protect animals against severe disease. Our findings here support the use of existing drug libraries to identify orthopoxvirus-targeting drugs that may serve as human-safe products to thwart future outbreaks.

Utility of Cytochrome P450 4F2 Genotyping to Assess Drug Interaction Risk for Brincidovovir, a Cytochrome P450 4F2 Substrate.

Smallpox was eradicated in 1980 but remains a biothreat due to the potential release of variola virus into the general population. Brincidofovir, the second medicine approved by the US Food and Drug Administration to treat smallpox, is metabolized by oxidative and hydrolytic pathways. The oxidative pathway is initiated by cytochrome P450 4F2 (CYP4F2), an enzyme lacking clinical probes for drug interaction studies. The aim of this work was to assess the impact of reduced activity CYP4F2 variants (rs2108622, C/T and T/T) on brincidofovir pharmacokinetics as a surrogate for drug inhibition. Genotyping was performed on blood from healthy participants receiving oral (n = 261) and intravenous (IV, n = 49) brincidofovir across 6 phase 1 trials. Plasma concentrations were measured by validated liquid chromatography tandem mass spectrometry methods. After oral administration, subjects with the lowest activity CYP4F2 genotype (T/T) had up to 36% higher AUCinf and 29% higher Cmax while subjects with the moderate activity CYP4F2 genotype (C/T) had similar Cmax and AUCinf compared to those with the wild-type genotype. Little to no increase in brincidofovir exposure parameters was observed following IV administration. Based on the lack of significant increases in brincidofovir plasma concentrations in subjects with low activity CYP4F2, a clinically meaningful drug-drug interaction is not expected with CYP4F2 inhibitor and brincidofovir coadministration.