Monkeypox Virus Clade IIb Isolate Exhibits Reduced Virulence Relative to Clade IIa Isolates in Multiple Murine Models

Abstract

Monkeypox virus (MPXV) is the causative agent of mpox disease in humans. The virus is comprised of two clades, Central African clade I and West African clade II with case fatality rates of [~]11 and [~]4%, respectively. Since the discovery of mpox disease in 1970, the virus has been restricted to Africa. However, in 2022, a previously unrecognized subclade IIb caused the largest global outbreak of mpox disease with a case fatality rate of [~]0.2%. The difference in virulence of MPXV subclades in human infection warrants further investigation, however, one critical limitation is the lack of susceptible small animal models. In this study, we investigated the susceptibility of four murine models, including CAST-EiJ and three immunocompromised models (C57BL/6 Ifnar-/-, C57BL/6 Ifngr-/-, and C57BL/6 Ifnar-/-/Ifngr-/-) to MPXV clade IIa (WR 7-61 and US-2003) and IIb (MA-2022) isolates. All four mouse models were susceptible to clade IIa infection, leading to severe disease marked by decreased body temperature, weight loss, and lethality. In contrast, clade IIb infection produced minimal to mild disease at similar doses in all four murine models. The clade IIb isolate produced severe disease (40% lethality) at only the highest dose (8.0 log10 PFU) in the most susceptible immunocompromised mouse model, C57BL/6 Ifnar-/-/Ifngr-/-. This is the first demonstration of lethal disease with clade IIb in a murine model. In addition, these data demonstrate that clade IIa is [~]100- to 100,000-fold more virulent than clade IIb and provide three additional murine models for investigating MPXV infection and pathogenesis. IMPORTANCEMpox is an emerging human disease caused by four distinct MPXV subclades (Ia, Ib, IIa, and IIb). Despite genetic similarities, the case fatality rate varies considerably between the subclades: Ia ([~]11%), Ib and IIa ([~]4%), and IIb ([~]0.2%). Since 2022, multiple mpox outbreaks have occurred due to previously unrecognized subclades, leading to the declaration of two public health emergencies by the World Health Organization. This unprecedented global spread, coupled with the variation in severity of human disease, underscores the importance of research into the pathogenesis of emerging MPXV subclades. However, a critical limitation is the lack of suitable small animal models. This study identifies three additional murine models susceptible to MPXV clade II infection and demonstrates significant virulence differences between clade IIa and IIb. These models will enable rapid characterization of previously unrecognized subclades and will facilitate countermeasure development.