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Review 1: "Monkeypox Outbreak in the Netherlands in 2022: Public Health Response, Epidemiological and Clinical Characteristics of the First 1000 Cases and Protection of the First-Generation Smallpox Vaccine"

Published onDec 29, 2022
Review 1: "Monkeypox Outbreak in the Netherlands in 2022: Public Health Response, Epidemiological and Clinical Characteristics of the First 1000 Cases and Protection of the First-Generation Smallpox Vaccine"
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key-enterThis Pub is a Review of
Monkeypox outbreak in the Netherlands in 2022: public health response, epidemiological and clinical characteristics of the first 1000 cases and protection of the first-generation smallpox vaccine
Description

AbstractIn early May 2022 a global outbreak of monkeypox (MPX) started among persons without a travel history to regions known to be enzootic for monkeypox-virus. On August 8 2022, the Netherlands reported its 1000thmonkeypox case representing a cumulative incidence of 55 per million population, one of the highest cumulative incidences worldwide. Here we describe the epidemiological characteristics and clinical presentation of the first 1000 monkeypox cases in the Netherlands, within the context of the public health response. Additionally, we explored risk factors for and estimated the protective effect of first-generation smallpox vaccine against more severe MPX.The first 1000 MPX cases, reported between May 20 and August 8 2022, were predominantly MSM aged 31-45 years. The vast majority of infections were acquired through sexual contact with casual partners in private or recreational settings including LGBTQIA+ venues in the Netherlands. This indicates that, although some larger upsurges occurred from point-source and/or travel related events, the outbreak is mainly characterised by sustained transmission within the Netherlands. More severe MPX was associated with having one or more comorbidities as well as having participated in more (3+) different sexual activities 21 days before symptom onset. We found a vaccine effectiveness of the prior first-generation smallpox vaccine against more severe MPX of 58% (95% CI 17-78%), suggesting moderate protection against more severe MPX symptoms on top of any possible protection by this vaccine against MPXV infection and disease.

RR:C19 Evidence Scale rating by reviewer:

  • Reliable. The main study claims are generally justified by its methods and data. The results and conclusions are likely to be similar to the hypothetical ideal study. There are some minor caveats or limitations, but they would/do not change the major claims of the study. The study provides sufficient strength of evidence on its own that its main claims should be considered actionable, with some room for future revision.

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Review: The claims in this preprint are generally supported by the data and methods used. Decision-makers should consider the claim in this study actionable with limitations.

Summary and Strengths: The present work describes the public health response, epidemiological and clinical characteristics of the first 1000 cases of monkeypox (MPX) in the Netherlands and the vaccine effectiveness of the firstgeneration smallpox vaccine against severe MPX. Overall, the method and analysis procedures are appropriate. The findings suggest sustained local transmission through sexual contact, having comorbidities and participating in ≥3 different sexual activities in the 21 days prior to symptom onset were associated with severe MPX. The first-generation smallpox vaccine provided moderate level of protection against severe MPX. The findings from this study are valuable in terms of better understanding the MPX outbreak and the factors associated with severe MPX. The estimated vaccine effectiveness of the first-generation smallpox vaccine in real-life settings adds to the limited knowledge we currently have in this regard, and are valuable. The manuscript cites current literature and discusses the limitations. It is well-structured and well-written.

Limitations: The vaccine effectiveness analysis was conducted with self-reported vaccination status, and has the potential for misclassification. This study did not evaluate the vaccine effectiveness of the third-generation smallpox vaccine Imvanex®, which would be very useful in to inform public health vaccination strategies not only in the Netherlands but also in other jurisdictions that have administered Imvanex®.

Comments
1
Bryce Wo:

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