Review Reports - Insights into Monkeypox Virus: Host Immunity, Viral Immune Evasion, Recent Advances in Vaccines, Therapeutic Development, and Future Perspectives

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

What distinct contribution does this review offer in comparison to recent Mpox reviews released between 2023 and 2025, and how does it enhance current understanding rather than merely restating established knowledge?

Can the authors explicitly delineate the principal knowledge gaps that persist in MPXV biology, immunology, or treatments, and elucidate how this review informs future research trajectories?

Epidemiology and Data Analysis

In light of the swiftly changing epidemiology of Mpox, how do the authors guarantee that the stated case numbers for 2023–2025 are precise, standardized, and similar across WHO, CDC, ECDC, and PAHO sources?

Do the authors adequately differentiate between confirmed, probable, and suspected cases when analyzing epidemiological trends and death estimates?

In what ways can sociobehavioral elements, such as sexual networks, stigma, and healthcare access, affect transmission patterns, and are these factors sufficiently addressed in discussions beyond biological mechanisms?

Viral Genomics and Evolution

What impact do recent MPXV genomic changes discovered in post-2022 epidemics have on viral fitness, transmissibility, immunological evasion, or antiviral resistance?

Is there adequate discourse regarding APOBEC3-induced mutations and their consequences for virus evolution and vaccine evasion?

Pathogenesis and Immune Response

Can the authors more effectively integrate innate and adaptive immune responses with clinical severity, especially the disparities noted between Clade I and Clade II infections?

Are the correlates of protection (neutralizing antibodies versus T-cell responses) distinctly established, and how could these influence the design of next-generation vaccines?

To what degree do the immune evasion mechanisms of MPXV coincide with or diverge from those of other orthopoxviruses, and what are the therapeutic ramifications of these distinctions?

Diagnostic Assessment

Considering the constraints of PCR-based diagnostics in low-resource environments, what is the feasibility of scaling CRISPR-based or isothermal assays?

Should the review critically assess the sensitivity, specificity, and practical efficacy of novel point-of-care diagnostic instruments?

Therapeutics

How can the authors reconcile the extensive clinical application of tecovirimat with recent randomized controlled trials indicating minimal efficacy, and what recommendations should doctors extract from this?

Is there adequate discourse on antiviral resistance, optimal timing for treatment, and methods for combination therapy in severe Mpox cases?

Immunizations and Prophylaxis

Could the authors elucidate the relative efficacy of the MVA-BN, ACAM2000, and LC16m8 vaccines against various MPXV clades, particularly in immunocompromised individuals?

What are the principal regulatory, manufacturing, and equity obstacles hindering worldwide availability of Mpox vaccines, especially in endemic parts of Africa?

Global and Regional Perspective

Does the Asia-centric portion (including India and Pakistan) sufficiently contextualize surveillance capabilities, public health readiness, and diagnostic infrastructure in comparison to Africa and Europe?

Presentation and Structure

Would the text be enhanced by a comprehensive summary table or graphic that correlates viral targets, immunological responses, diagnostics, antivirals, and vaccines to distinctly emphasize translational opportunities?

Author Response

Response to Reviewers

Manuscript ID: microorganisms-4050853

Title: Insights into Monkeypox Virus: Host Immunity, Viral Immune Evasion, Recent Advances in Vaccine, Therapeutic Development, and Future Perspectives

We sincerely thank the Editor and all Reviewers for their detailed, constructive, and insightful comments. We have carefully revised the manuscript to address all concerns. Below, we provide a point-by-point response, indicating how each comment has been addressed in the revised version.

Reviewer 1

Comments and Suggestions for Authors

What distinct contribution does this review offer in comparison to recent Mpox reviews released between 2023 and 2025, and how does it enhance current understanding rather than merely restating established knowledge?

Response

Previous reviews have been valuable in summarizing outbreaks, clinical presentation and single areas such as vaccines or diagnostics. However, public-health and translational decisions require synthesis across domains (genomics → mechanism → clinical implications → policy). By explicitly linking recent genomic findings to immune-evasion strategies, appraising the strength of human clinical evidence for therapeutics, and ranking vaccine candidates against unified criteria, our review converts dispersed, rapidly emerging literature into actionable conclusions and a prioritized research agenda for preventing and responding to future Mpox outbreaks.

Can the authors explicitly delineate the principal knowledge gaps that persist in MPXV biology, immunology, or treatments, and elucidate how this review informs future research trajectories?

This review synthesizes emerging genomic, immunological, and clinical evidence into a unified framework that links viral evolution to immune evasion, disease outcomes, and intervention effectiveness. By critically evaluating the strength and limitations of existing data, we propose prioritized research directions, including:

(i) functional genomics studies linking MPXV mutations to immune modulation;

(ii) identification of immune correlates of protection to guide vaccine design;

(iii) development of human-relevant in vivo and ex vivo infection models;

(iv) well-designed clinical trials for antiviral therapies; and

(v) equitable, globally coordinated surveillance and vaccine strategies.

We believe that by explicitly identifying these gaps and mapping them to actionable research priorities, this review provides a forward-looking roadmap for both basic and translational MPXV research.

Epidemiology and Data Analysis

In light of the swiftly changing epidemiology of Mpox, how do the authors guarantee that the stated case numbers for 2023–2025 are precise, standardized, and similar across WHO, CDC, ECDC, and PAHO sources?

Response

All epidemiological data were derived from harmonized WHO situation reports and cross-validated against CDC, ECDC, and PAHO databases using standardized case definitions and synchronized reporting periods.

Do the authors adequately differentiate between confirmed, probable, and suspected cases when analyzing epidemiological trends and death estimates?

Response

“All epidemiological and mortality data discussed herein were obtained directly from official WHO, CDC, PAHO, and ECDC reports and were not independently recalculated by the authors.”

In what ways can sociobehavioral elements, such as sexual networks, stigma, and healthcare access, affect transmission patterns, and are these factors sufficiently addressed in discussions beyond biological mechanisms?

we have added a dedicated paragraph to the transmission of MPXV section that explicitly addresses the roles of sexual network structure, stigma, and healthcare access in shaping transmission patterns and outbreak dynamics.

Viral Genomics and Evolution

What impact do recent MPXV genomic changes discovered in post-2022 epidemics have on viral fitness, transmissibility, immunological evasion, or antiviral resistance?

In response, we have added a clarifying statement to the Future Perspectives section addressing the impact of post-2022 MPXV genomic changes.

Is there adequate discourse regarding APOBEC3-induced mutations and their consequences for virus evolution and vaccine evasion?

In response, we have expanded the conclusion section to explicitly address APOBEC3-induced mutations and their potential implications for MPXV evolution.

Pathogenesis and Immune Response

Can the authors more effectively integrate innate and adaptive immune responses with clinical severity, especially the disparities noted between Clade I and Clade II infections?

We have added a paragraph according to suggestion in the manuscript section 9 Immunity to Mpox to more clearly integrate innate and adaptive immune responses with clinical severity, specifically highlighting how clade-specific immune evasion and host immune activation may contribute to the greater virulence observed in Clade I compared with Clade II MPXV infections.

Are the correlates of protection (neutralizing antibodies versus T-cell responses) distinctly established, and how could these influence the design of next-generation vaccines?

In response, we have added a paragraph to the manuscript section memory immunity clarifying that correlates of protection against MPXV are not yet definitively established and discussing how both neutralizing antibodies and T-cell responses likely contribute to immunity.

To what degree do the immune evasion mechanisms of MPXV coincide with or diverge from those of other orthopoxviruses, and what are the therapeutic ramifications of these distinctions?

In response, we have added a paragraph in immune evasion section comparing MPXV immune evasion mechanisms with those of other orthopoxviruses and discussing how both shared and distinct strategies may influence pathogenicity and therapeutic effectiveness.

Diagnostic Assessment

Considering the constraints of PCR-based diagnostics in low-resource environments, what is the feasibility of scaling CRISPR-based or isothermal assays?

In response, we have added a paragraph in section diagnostic assays discussing the feasibility of scaling CRISPR-based and isothermal diagnostic assays as alternatives to PCR, particularly in low-resource settings.

Should the review critically assess the sensitivity, specificity, and practical efficacy of novel point-of-care diagnostic instruments?

In response, we have expanded the diagnostics section to critically assess the sensitivity, specificity, and practical efficacy of emerging point-of-care diagnostic tools, emphasizing both their analytical performance and real-world implementation challenges. We believe this addition strengthens the translational relevance of the review.

Therapeutics

How can the authors reconcile the extensive clinical application of tecovirimat with recent randomized controlled trials indicating minimal efficacy, and what recommendations should doctors extract from this?

In response, we have added a paragraph in treatment section reconciling the widespread clinical use of tecovirimat with recent randomized trial data indicating limited efficacy.

Is there adequate discourse on antiviral resistance, optimal timing for treatment, and methods for combination therapy in severe Mpox cases?

In response, we have expanded the therapeutics discussion to address antiviral resistance, the importance of treatment timing, and the potential role of combination therapy in severe Mpox cases

Immunizations and Prophylaxis

Could the authors elucidate the relative efficacy of the MVA-BN, ACAM2000, and LC16m8 vaccines against various MPXV clades, particularly in immunocompromised individuals?

In response, we have expanded the vaccine section to compare MVA-BN, ACAM2000, and LC16m8 with respect to their immunogenicity, safety, and likely cross-clade protection, with particular emphasis on considerations for immunocompromised individuals

What are the principal regulatory, manufacturing, and equity obstacles hindering worldwide availability of Mpox vaccines, especially in endemic parts of Africa?

In response, we have added a paragraph in future aspects discussing the key regulatory, manufacturing, and equity barriers that limit global Mpox vaccine availability, with particular emphasis on challenges faced by endemic regions in Africa.

Global and Regional Perspective

Does the Asia-centric portion (including India and Pakistan) sufficiently contextualize surveillance capabilities, public health readiness, and diagnostic infrastructure in comparison to Africa and Europe?

The Asia-centric discussion, including India and Pakistan, is intended to provide illustrative context rather than a comprehensive regional analysis. While the manuscript highlights general surveillance capacity, public health readiness, and diagnostic infrastructure in Asia, we acknowledge that these systems differ in scale and maturity compared with those in Europe and vary considerably across countries, and that endemic African regions face distinct structural and resource-related challenges.

Presentation and Structure

Would the text be enhanced by a comprehensive summary table or graphic that correlates viral targets, immunological responses, diagnostics, antivirals, and vaccines to distinctly emphasize translational opportunities?

We have added Table 11. At the end of manuscript Integrated Summary of MPXV Biology, Host Immunity, Immune Evasion, Diagnostics, Therapeutics, and Vaccines Highlighting Translational Gaps and Future Directions

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

The article provides a detailed overview of the Monkeypox virus (MPXV), its clinical manifestations, transmission methods, epidemiological trends, and advancements in vaccine and therapeutic developments. It highlights the ongoing global efforts to control and manage the spread of Mpox, focusing on the virus's immune evasion strategies, host immunity, and the potential for future vaccines and antiviral treatments.

Clarification on Immune Evasion Mechanisms
The article mentions MPXV’s immune evasion strategies, including the inhibition of type I interferons and the expression of immune-modulating proteins. However, the discussion could benefit from further elaboration on how these immune evasion tactics specifically affect the dynamics of viral replication and host immune responses over time.

Highlight the Role of Memory Immunity
Expanding the discussion on memory immunity, particularly how long-lived memory B and T cells contribute to long-term protection, would strengthen the section on immunity.

Expand on the Impact of Pre-Existing Immunity
Detailing how this pre-existing immunity influences the severity and progression of Mpox in vaccinated individuals compared to the unvaccinated population could provide essential public health context, especially in older populations with prior smallpox vaccination.

Enhance Discussion on Vaccine-Induced Immunity
While the article mentions the effectiveness of MVA-BN (JYNNEOS) and other vaccines, there is a need for more focus on the immunological mechanisms behind vaccine-induced immunity. Specifically, a comparison of the immune responses elicited by different vaccine types (e.g., replicating vs. non-replicating vaccines) and their ability to generate both humoral and cell-mediated immunity would provide a clearer understanding of their potential in preventing MPXV.

The article doi:10.3390/vaccines12010026 covers how vaccines trigger immune responses, especially through B and T cells. It could be useful for supporting your discussion on immune responses to MPXV and other vaccines in your paper.

Author Response

Response to Reviewers

Manuscript ID: microorganisms-4050853

Title: Insights into Monkeypox Virus: Host Immunity, Viral Immune Evasion, Recent Advances in Vaccine, Therapeutic Development, and Future Perspectives

Reviewer 2

Comments and Suggestions for Authors

Clarification on Immune Evasion Mechanisms
1. The article mentions MPXV’s immune evasion strategies, including the inhibition of type I interferons and the expression of immune-modulating proteins. However, the discussion could benefit from further elaboration on how these immune evasion tactics specifically affect the dynamics of viral replication and host immune responses over time.

In response, we have expanded the immune evasion section to better explain how MPXV-mediated inhibition of type I interferons and immune-modulating proteins influences viral replication dynamics and host immune responses over the course of infection.

Highlight the Role of Memory Immunity
2. Expanding the discussion on memory immunity, particularly how long-lived memory B and T cells contribute to long-term protection, would strengthen the section on immunity.

In response, we have expanded the immunity section to more clearly discuss the role of long-lived memory B and T cells in mediating durable protection against MPXV.

Expand on the Impact of Pre-Existing Immunity
3. Detailing how this pre-existing immunity influences the severity and progression of Mpox in vaccinated individuals compared to the unvaccinated population could provide essential public health context, especially in older populations with prior smallpox vaccination.

In response, we have expanded the immunity section to describe how pre-existing immunity from prior smallpox vaccination influences Mpox severity and disease progression, particularly in older vaccinated individuals compared with unvaccinated populations.

Enhance Discussion on Vaccine-Induced Immunity
4. While the article mentions the effectiveness of MVA-BN (JYNNEOS) and other vaccines, there is a need for more focus on the immunological mechanisms behind vaccine-induced immunity. Specifically, a comparison of the immune responses elicited by different vaccine types (e.g., replicating vs. non-replicating vaccines) and their ability to generate both humoral and cell-mediated immunity would provide a clearer understanding of their potential in preventing MPXV.

In response, we have expanded the vaccine section to focus more explicitly on the immunological mechanisms underlying vaccine-induced immunity, including a comparison of immune responses elicited by replicating and non-replicating vaccines.

The article doi:10.3390/vaccines12010026 covers how vaccines trigger immune responses, especially through B and T cells. It could be useful for supporting your discussion on immune responses to MPXV and other vaccines in your paper. updated

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

Chen et al have written an encompassing review of Monkeypox virus and the current state of vaccines and therapeutics to combat its disease. They have covered its genome, transmission, pathogenesis, and treatments, noting that variabilities in its genomic reorganization impact its virulence and transmissibility. This is an informative review which helps the reader understand the current state of the recent Mpox outbreaks, vaccine development efforts, and available or expected treatment options.

While the majority of the paper reads well, many grammatical, typographical and translational errors must be corrected prior to publication. Issues with the format need correcting as well. Some tables spill over onto the next page, which is challenging for the reader. Reformatting is recommended so that each table is entirely on the same page if possible. A few major errors in the Figures exist that must be corrected, as noted below.

Another major concern is in the Author Contributions section. Two sets of initials are not recognized as any listed author. Please check if S.A.H and M.H. should acknowledged as Authors. If they did not earn authorship, shouldn't their full names be acknowledged in this section instead?

The data availability statement is missing at line 726 and perhaps was misplaced at line 119 instead.

A list of acronyms and their definitions is needed at line 729 prior to the References section.

In the reference section, could the title of the study be added to reference #139?

Other specific errors and/or suggestions are noted below. Please note: "IG" indicates a request to "Improve Grammar".

Abstract

Line 33: "Clinical presentation Mpox presents clinically"
Line 42: "better than other types due to its better safety and immunogenicity"

1. Introduction

Line 56: remove "current"
Line 61: IG; for example, this sentence could be worded as "..., despite travel linkages from endemic nations to non-endemic countries being unrelated to the present epidemic of Mpox."
Line 63: "On the other hand"?
Line 73: where are the references for this information? Overall the Introduction's first paragraph does not flow well and perhaps could be split into two paragraphs.
Line 102: should be "next-generation vaccine" not vaccination of the next generation
Line 105: missing "receptors"; epitopes are not found on the cell.
Line 108-109: IG
Line 114: unclear if this should be "less" or "more" cost-effective, based on the "not only..., but also" grammar.
Line 115: this sentence would fit better before the sentence at line 108.
Line 116: Table 2 is introduced here, so the Table should come before Figure 2.
Line 118: Timeline of MPXV seems to fit under Section 2: Origin. This sentence and Figure 2 should move to Section 2.
Line 119: this sentence seems to be intended for inclusion with the following paragraph, which I believe should be its own section at the end of the paper. Is this the Data Availability Statement?

2. Origin and Classification

Line 149: clarify "more dangerous"; do you mean historically more lethal?
Line 158: typo "and"

3. Transmission

Line 168-177: IG

4. Genome Organization and Viral Entry

Line 195-197: IG
Line 209: IG
Line 215-216: identical abbreviations for two different terms as IMV
Line 216 and 218: identical abbreviations for two different terms as IEV

5. Clinical Symptoms

Some conflicting or redundant information is presented in this section. For example, at line 238, it is stated that 96% of cases have rashes, etc; however, "All cases of Mpox were characterized by" flu-like symptoms and rashes (line 251). Please clarify this discrepancy. The sentence at line 243 seems somewhat redundant with lines 229-232 and perhaps could be moved there and somehow combined.

6. Reservoir

Line 276-277: IG

7. Diagnostic Assays

Line 305-309: IG
Line 320: keep grammar consistent among points: "The serology test assesses antibodies..."
Line 329: "On the other hand"?
Line 332: redundant sentence, "These tests are being conducted in the laboratory", can be omitted.
Line 337: omit "the discovery of"?
Line 342: Acronym definitions for PCR and ELISA are missing.

8. Treatment

Line 345: measles? should be Mpox
Line 385-386: IG

9. Immunity to MPXV

Line 397: IG; for example, it could be stated more concisely as "These immune pathways are at the center..."
Line 402: Figure 9 is cited but does not appear for two more pages.
Line 427: sentence fragment; IG.
Line 446-448: IG; "clearance of viruses" and "survival from infection" not survival of viruses; strength of T cell mediated immunity...?
Line 466: IG

10. Vaccines

Reorganization of this section is suggested as 10.1, Advancements, would seem to fit better as combined with section 10.3 and after the existing smallpox cross-protection information in 10.2. It is recommended to move Smallpox Vaccines and Cross-Protection to 10.1 and make 10.2 as Advancements in Mpox Vaccines, where 10.2.1 would be MVA-BN and 10.2.2 would be LC16m8, etc.

Line 495: Table 9 is mentioned, but is 4 pages later. I suggest removing the reference to Table 9 here.
Line 502: "in Mpox vaccine development"; "focus" instead of "rely"
Line 509: missing "on"
Line 523: missing "at a rate"
Line 538: missing "study"
Line 552: Acronym inconsistent for JYNNEOS, JYNNEOSTM?
Line 563: IG
Line 588-589: IG

Considering that Table 8 and Table 9 are listed back-to-back with some of the information similar or redundant, these tables could be combined as one and situated in landscape orientation on one full page.

11. Scenario of MPox in Asia

Please add to the title of this section "of Mpox"

Line 635-636: IG
Line 661: misspelling
Line 678: molecules?

12. Future Perspectives

Line 692: shouldn't "vaccines" be "antivirals"?
Line 698: IG

13. Conclusion

Line 711-712: IG

Figures

Figure 1 is not well organized and has several errors. Virus morphology is the structure/shape/appearance of the virus or virions. I cannot determine what the image labeled as "Morphology" under Monkeypox Virus is supposed to be. MPXV replicates in the cytoplasm, as is staed in several places throughout the paper (line 96, Table 3, line 204); however, Figure 1 should the virus as replicating in the mitochondrial matrix. The figure should be restructured to eliminate empty space. I would suggest breaking it into sections such as A) Genetics, B) Transmission, C) Clinical Diagnostics. The Treatment images are not informative enough to warrant inclusion in this figure. Acronyms used in the figure should be defined in the legend.

Figure 3: missing closing parenthesis in two places. "Internal" should be "Inverted" (see line 193). The size bar of 200-250nm should be up under the virion diagram, not under the DNA map.

Figure 4 is not well designed. If this figure aims to define three separate transmission events, the purpose of the arrow across and Horizontal Transmission is unclear. #5 under Animal-to-Human should be "sexual intercourse" or "sexual activities". #6 Congenital relates to "from birth", which could fall under Animal-to-Animal or Human-to-Human, but not Animal-to-Human. The circle for Human-to-Human does not make sense as it is not a cycle or order of events. #2 should be homosexual or bisexual intercourse.

Figure 5 is useful for illiustrating the replication of MPXV to the reader. Please expand the figure legend to include the numbered points and text, or add the number citations to the relevant text in lines 213-220. Please define acronyms used.

Figure 8 does not have a clear message. Colored boxes with text that varies from cell types to actions to states to organs do not clearly depict the MPXV immune evasion strategy, and nothing is explained in the legend. Please rethink and improve this chart into a meaningful figure.

Figure 9 should move up to where it is first referenced, which would change it to Figure #8.

Half of Figure 10 is uninformative. It would be more helpful if Figure 10 focused on A) the role of vaccination in prevention of mpox and B) antiviral mechanism of drug treatments. That section of the figure should be larger for the reader to see more clearly. Transmission can be omitted, as this is covered in Figure 4.

Author Response

Response to Reviewers

Manuscript ID: microorganisms-4050853

Title: Insights into Monkeypox Virus: Host Immunity, Viral Immune Evasion, Recent Advances in Vaccine, Therapeutic Development, and Future Perspectives

Reviewer 3

Comments and Suggestions for Authors

While the majority of the paper reads well, many grammatical, typographical and translational errors must be corrected prior to publication. Issues with the format need correcting as well. Some tables spill over onto the next page, which is challenging for the reader. Reformatting is recommended so that each table is entirely on the same page if possible. A few major errors in the Figures exist that must be corrected, as noted below. (corrected as per suggestions)

We have thoroughly revised the manuscript to correct grammatical, typographical, and translational errors throughout the text and have standardized formatting to improve clarity and readability. All tables have been reformatted to ensure they fit entirely on a single page wherever possible, enhancing reader accessibility. In addition, the identified major errors in the figures have been corrected, and all figures have been carefully reviewed for accuracy, consistency, and proper labeling.

Another major concern is in the Author Contributions section. Two sets of initials are not recognized as any listed author. Please check if S.A.H and M.H. should acknowledged as Authors. If they did not earn authorship, shouldn't their full names be acknowledged in this section instead?

(correction has made)

The data availability statement is missing at line 726 and perhaps was misplaced at line 119 instead

(Corrected).

A list of acronyms and their definitions is needed at line 729 prior to the References section.

we have added a List of Acronyms and Abbreviations, with their definitions, immediately prior to the References section, as requested.

In the reference section, could the title of the study be added to reference #139?

Title of study has been added.

Other specific errors and/or suggestions are noted below. Please note: "IG" indicates a request to "Improve Grammar".

Abstract

Line 33: "Clinical presentation Mpox presents clinically"
Line 42: "better than other types due to its better safety and immunogenicity"

Introduction

Line 56: remove "current" removed
Line 61: IG; for example, this sentence could be worded as "..., despite travel linkages from endemic nations to non-endemic countries being unrelated to the present epidemic of Mpox." replaced
Line 63: "On the other hand"? removed
Line 73: where are the references for this information added? Overall the Introduction's first paragraph does not flow well and perhaps could be split into two paragraphs. Corrected Line 102: should be "next-generation vaccine" not vaccination of the next generation corrected corrected
Line 105: missing "receptors"; epitopes are not found on the cell. corrected
Line 108-109: IG
Line 114: unclear if this should be "less" or "more" cost-effective, based on the "not only..., but also" grammar. updated.
Line 115: this sentence would fit better before the sentence at line 108. updated.
Line 116: Table 2 is introduced here, so the Table should come before Figure 2. updated
Line 118: Timeline of MPXV seems to fit under Section 2: Origin. This sentence and Figure 2 should move to Section 2. updated.

( All comments are addressed according to reviewer suggestions)

Line 119: this sentence seems to be intended for inclusion with the following paragraph, which I believe should be its own section at the end of the paper. Is this the Data Availability Statement?
No new data were generated or analyzed in this study. All data discussed in this review were obtained from previously published articles and publicly available sources, including PubMed, Google Scholar, Scopus, Web of Science, and official reports from the World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC), and the European Centre for Disease Prevention and Control (ECDC).

Origin and Classification

Line 149: clarify "more dangerous"; do you mean historically more lethal?
Line 158: typo "and"

Transmission

Line 168-177: IG

Genome Organization and Viral Entry

Line 195-197: IG
Line 209: IG
Line 215-216: identical abbreviations for two different terms as IMV
Line 216 and 218: identical abbreviations for two different terms as IEV

Clinical Symptoms

Reservoir

Line 276-277: IG

Diagnostic Assays

Line 305-309: IG
Line 320: keep grammar consistent among points: "The serology test assesses antibodies..."
Line 329: "On the other hand"?
Line 332: redundant sentence, "These tests are being conducted in the laboratory", can be omitted.
Line 337: omit "the discovery of"?
Line 342: Acronym definitions for PCR and ELISA are missing.

Treatment

Line 345: measles? should be Mpox
Line 385-386: IG

Immunity to MPXV

Line 397: IG; for example, it could be stated more concisely as "These immune pathways are at the center..."
Line 402: Figure 9 is cited but does not appear for two more pages.
Line 427: sentence fragment; IG.
Line 446-448: IG; "clearance of viruses" and "survival from infection" not survival of viruses; strength of T cell mediated immunity...?
Line 466: IG

Vaccines

Line 495: Table 9 is mentioned, but is 4 pages later. I suggest removing the reference to Table 9 here.
Line 502: "in Mpox vaccine development"; "focus" instead of "rely"
Line 509: missing "on"
Line 523: missing "at a rate"
Line 538: missing "study"
Line 552: Acronym inconsistent for JYNNEOS, JYNNEOSTM?
Line 563: IG
Line 588-589: IG

Scenario of MPox in Asia

Please add to the title of this section "of Mpox"

Line 635-636: IG
Line 661: misspelling
Line 678: molecules?

Future Perspectives

Line 692: shouldn't "vaccines" be "antivirals"?
Line 698: IG

Conclusion

Line 711-712: IG

( All comments are addressed as per suggestions)

Figures

Figure 3: missing closing parenthesis in two places. "Internal" should be "Inverted" (see line 193). The size bar of 200-250nm should be up under the virion diagram, not under the DNA map. Updated as per suggestions

Figure 9 should move up to where it is first referenced, which would change it to Figure #8 updated.

Author Response File: Author Response.pdf

Reviewer 4 Report

Comments and Suggestions for Authors

The manuscript is an overview of the disease caused by the monkeypox virus, covering a wide range of literature until the end of 2025. However, the text is overloaded with repetitions, has a compilation character in places, there are factual and logical inaccuracies, incorrect formulations and stylistic problems that do not correspond to the level of a leading international journal. Substantial refinement of the content, language, and tables/figures is required.

The first and most important point. Over the past 5 years, more than 50 reviews have been published on this topic or very close to it. What is the fundamental difference between the presented literature review? What exactly is new included in this manuscript?

In addition, important remarks relate to the design structure of the manuscript. So, there is excessive duplication in the text. For example, the Introduction, sections 1-3 and 5-7 contain repetitions of the same factual material (a description of the clinic, transmission routes, reservoirs, the role of rodents and primates, the range of mortality, etc.). Tables partially duplicate the text, often in descriptive form, without adding new analytics.

The same paragraph provides data from 2003-2010 and operational figures for 2023-2025, without explicitly specifying which conclusions relate to which phase of the epidemic.

Sufficient analysis of clinical research software is not provided. In particular, in Table 5, the data for Tecovirimat directly contradicts the following data that the clinical benefit has not been proven in RCTs.

Part of the drawings (Figure 1, 4, 6, 7, 8, 9, 10) It performs an essentially educational function, duplicating basic information that is well known to readers and does not have significant critical meaning.

A significant number of typos and inconsistencies in sentences, the work requires serious proofreading of the quality of the English language.

The text uses "Monkeypox", "Mpox", "monkeypox virus", "Monkeypox Virus (MPXV)" randomly; in 2022-2023, WHO recommends using "Mpox". The authors should choose a single style: "Mpox" for the disease and "Monkeypox virus (MPXV)" at the first mention of the virus, hereinafter — MPXV.

In general, if the authors cannot answer the first question, the point of publishing the presented review is not great.

Author Response

Response to Reviewers

Manuscript ID: microorganisms-4050853

Title: Insights into Monkeypox Virus: Host Immunity, Viral Immune Evasion, Recent Advances in Vaccine, Therapeutic Development, and Future Perspectives

Reviewer 4

Comments and Suggestions for Authors

Specifically, this manuscript uniquely:

(i) integrates viral genomics and immune-evasion mechanisms with host innate and adaptive immune responses, linking these processes to clinical severity and clade-specific differences;

(ii) critically evaluates recent post-2022 evidence, including emerging genomic changes, APOBEC3-associated mutations, randomized clinical trial data on antivirals, and real-world vaccine performance;

(iii) compares vaccine platforms (replicating vs. non-replicating) at the immunological mechanism level, rather than reporting efficacy alone;

(iv) assesses diagnostic and therapeutic strategies through a global-health lens, addressing feasibility in low-resource and endemic settings; and

(v) explicitly identifies unresolved knowledge gaps and future research priorities, offering a forward-looking roadmap for basic, clinical, and public-health research.

Importantly, the manuscript synthesizes developments reported between 2018 and 2025 into a single, cohesive framework that connects molecular mechanisms to translational and policy-relevant outcomes. We believe this approach provides added value beyond existing reviews and offers new insights relevant to researchers, clinicians, and public-health stakeholders.

The same paragraph provides data from 2003-2010 and operational figures for 2023-2025, without explicitly specifying which conclusions relate to which phase of the epidemic.

We would like to clarify that the latest Mpox epidemiological updates are now explicitly included in the Introduction section prior to Table 1, clearly identified as data from the recent global outbreaks (2023–2025). Historical data from earlier outbreaks (2003–2010) are presented separately as background context. This revision ensures clear temporal distinction and prevents overlap between conclusions drawn from different phases of the epidemic.

Sufficient analysis of clinical research software is not provided. In particular, in Table 5, the data for Tecovirimat directly contradict the following data that the clinical benefit has not been proven in RCTs. Correction has been made in manuscript.

After careful consideration, we have retained selected figures because they serve specific, non-redundant purposes that directly support the aims of this review.

Figure 7 (Stages of vesiculopustular rash):

This figure is retained because it provides clinically relevant information essential for differential diagnosis, particularly in distinguishing Mpox from other vesiculopustular diseases. The emphasis on synchronous lesion development within localized areas is a diagnostically important feature that supports the clinical discussion and is not always clearly conveyed through text alone.

Figure 6 (Animal reservoirs and zoonotic transmission):

This figure is retained to visually integrate reservoir ecology with human disease presentation, reinforcing the zoonotic nature of MPXV and supporting discussions on spillover risk, surveillance priorities, and prevention strategies. It adds contextual value relevant to public health and One Health frameworks.

Figure 4 (Modes of MPXV transmission):

Although transmission routes are well known, this figure has been revised to emphasize comparative transmission pathways (animal-to-animal, animal-to-human, and human-to-human) in a unified schematic. This visualization supports the discussion of shifting epidemiology and highlights the growing importance of sustained human-to-human transmission in recent outbreaks.

Figure 8 (MPXV immune evasion strategies):

This figure is retained because it synthesizes complex immune evasion mechanisms—including interferon inhibition and antigen presentation interference—into an integrated schematic that supports the mechanistic discussion. The figure has been revised to emphasize functional and temporal aspects of immune modulation, thereby enhancing its analytical value beyond basic description.

We believe that these revised figures complement the text by enhancing clarity, supporting clinical and translational interpretation, and providing integrative visual summaries that are difficult to convey effectively through text alone.

A significant number of typos and inconsistencies in sentences, the work requires serious proofreading of the quality of the English language. (correction has been made).

Author Response File: Author Response.pdf

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

Chen et al have done excellent work to revise the paper and submit an informative and publishable manuscript. The figures, language and flow of information is greatly improved.

Minor corrections should be made prior to publication.

suggestion to pluralize "Vaccine" in the title to "Vaccines"
Figure 3, C, "Men to Men contact" probably should be clarified as "sexual contact"
While Figure 8 is useful for demonstrating MPXV immune evasion strategy, it is unclear how the text in lines 536 through 544 corresponds to each graphic in Figure 8. If a direct correlation exists, it would be helpful to perhaps number the list and assign numbers in the figure. For example, MOPICE would be the bottommost purple icon, correct?
Figure 9 should be adjusted. The arrows improperly indicate a timeline or progression. I don't understand the connection. The vial of vaccine in Figure 9 seems unnecessary. It is unclear what the red, blue, and green human shapes are supposed to be indicating with regard to vaccination or treatment. If there is a reason, it should be explained in the legend. The last graphic involves antiviral drug treatment, but more explanation of this in the text above the figure would be helpful.
Line 720 should read "is not completely confirmed"

Author Response

Response to Reviewer 3

We sincerely thank the reviewer for the positive evaluation of our manuscript and for the constructive suggestions, which have helped improve the clarity and quality of the paper. All comments have been carefully addressed as detailed below.

Comment 1:
Suggestion to pluralize “Vaccine” in the title to “Vaccines”.

Response:
The title has been revised by pluralizing “Vaccine” to “Vaccines” as suggested.

Comment 2:
Figure 3C, “Men to Men contact” should be clarified as “sexual contact”.

Response:
The wording in Figure 3C has been revised to “sexual contact” to improve clarity and accuracy, as suggested.

Comment 3:
Figure 8 is useful, but the correspondence between the text (lines 536–544) and the graphical elements is unclear. Numbering the text and matching it with the figure would be helpful (e.g., MOPICE as the bottommost purple icon).

Response:
Figure 8 and the corresponding text (lines 536–544) have been revised.

Comment 4:
Figure 9 should be adjusted. The arrows incorrectly imply a timeline. The vaccine vial appears unnecessary. The meaning of the red, blue, and green human figures is unclear, and antiviral treatment requires further explanation in the text.

Response:
Figure 9 has been completely redrawn to address these concerns. The misleading arrows suggesting a timeline have been removed, unnecessary elements (including the vaccine vial) have been eliminated, and the human figures are now clearly defined. The figure legend has been expanded to explain the color coding, and additional explanatory text regarding antiviral drug treatment has been added to the manuscript section preceding the figure.

Comment 5:
Line 720 should read “is not completely confirmed”.

Response:
The sentence in line 720 has been corrected to read “is not completely confirmed,” as suggested.

Author Response File: Author Response.pdf

Reviewer 4 Report

Comments and Suggestions for Authors

The authors made a significant part of the additions, but did not mention a crucial point in the review. It is necessary to indicate in the text exactly how this review fundamentally differs from many previously published ones, with links to modern literature reviews.

Significant problems with the list of references.

The list is not designed according to the rules of the magazine.
many links do not contain either page numbers or the name of the journal at all (link 6).
it is not clear for what purpose the authors refer to the preprints (link 7)?
in some cases, the links actually lead to news, and not to published works (link 10)
in general, there are many errors in the design of the list literature.

the country is not specified in affiliations 4-7

Author Response

Response to Reviewer 4

We thank the reviewer for their detailed and constructive comments. The manuscript has been substantially revised to address all concerns raised.

Comment 1:
The review does not clearly state how it fundamentally differs from previously published reviews, with links to recent literature.

Response:
A new paragraph has been added to the Introduction section explicitly highlighting the novelty of this review. We now clearly state how this work differs from previously published reviews by integrating recent outbreak data, updated immunological insights, viral immune-evasion mechanisms, and the latest advances in vaccines and antiviral therapies.

Comment 2:
The reference list is not designed according to the journal rules.

Response:
The entire reference list has been reformatted strictly according to MDPI reference style guidelines.

Comment 3:
Many references lack page numbers or journal names (e.g., reference 6).

Response:
Missing journal names and page numbers have been added where applicable, including the correction of reference 6.

Comment 4:
It is unclear why preprints were cited (reference 7).

Response:
The preprint previously cited as reference 7 has been replaced with the corresponding peer-reviewed and published article.

Comment 5:
Some references link to news articles rather than scientific publications (reference 10).

Response:
All references linking to news articles have been carefully reviewed. Reference 10 and similar non-peer-reviewed news sources have been removed and replaced with appropriate scholarly publications where available.

Additional Comment:
The country is not specified in affiliations.

Response:
The country information has been added to affiliations 4–7 to ensure completeness and compliance with MDPI requirements.

Author Response File: Author Response.pdf