Introduction

Epidemics of infectious diseases have long been a major public health challenge globally. In May 2022, an outbreak of monkeypox (Mpox) suddenly appeared and rapidly spread to Europe, the Americas, and then to all six World Health Organization (WHO) regions [1]. Mpox is a disease caused by the mpox virus (a zoonotic virus) [2]. Human-to-human transmission of mpox can occur through direct contact with infectious skin, mouth, or other lesions on the genitals [1]. This global outbreak primarily (but not only) affects gay and bisexual individuals, but also affect other men who have sex with men (MSM) - thus establishing a steady chain of transmission from person to person among this group people [3].

Vaccination is an effective measure to reduce the spread of the mpox virus and protect the health of the community [4,5,6]. Given this, there has been a renewed interest globally in vaccination as a preventive measure for mpox. Currently, two mpox vaccines, ACAM 2000® (smallpox or cowpox live vaccine) and JYNNEOS™ (cowpox virus modified strain - Ankara-Bavarian Nordic non-replicating antigen), are available as pre-exposure prophylaxis against mpox [7, 8]. Reports from several case studies have confirmed the effectiveness of these vaccines in preventing mpox [9, 10]. The WHO [1] and the Centers for Disease Control (CDC) [11] in the United States recommend that people at risk (researchers with occupational exposures, gay bisexual and other MSM, people with multiple sex partners, and sex workers) should be actively vaccinated against mpox during epidemics.

However, as with COVID-19, the effectiveness of mpox vaccines depends not only on the scientific success of the vaccine development [12], but equally on the willingness of people at risk to receive these vaccines [13]. Vaccine uptake willingness is therefore an important aspect that should be considered for mpox prevention and control [14, 15]. Nonetheless, vaccine hesitancy (refusal or delay of vaccination despite available services) remains a major problem facing vaccination uptake worldwide. In 2019, the WHO listed vaccine hesitancy as one of the top ten health threats facing the world [16]. There is now cumulative evidence on the willingness of different populations to receive the mpox vaccine, and the results show wide variation [17, 18]. MSM are one of the main affected groups by the mpox epidemic and the target audience for mpox vaccination [1]. Exploring the willingness of MSM to receive mpox vaccination and the factors that influence it can contribute to the successful design and implementation of public health strategies to control the spread of the virus.

Currently, a few studies have assessed mpox vaccination willingness in different populations [19,20,21]. However, to the best of our knowledge, there are no systematic reviews that have explored the overall rates of the willingness and the factors that influence the willingness to vaccinate against mpox among MSM. The purpose of this systematic review, therefore, was to synthesize results from different studies of mpox vaccination intentions among MSM, and to assess the factors influencing mpox vaccination intentions. This work provides a data-driven approach to support public health departments in providing scientifically effective mpox prevention guidance to MSM, while contributing to effective responses to potentially preventable future outbreaks of mpox or other similarly serious epidemic outbreaks.

Methods

Study design

This was a systematic review that adhered to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The protocol for this systematic review is registered with PROSPERO (CRD42023452357).

Eligibility criteria

To be eligible for this review, a study had to be a descriptive or observational study, published in English, conducted on gay or bisexual individuals as well as other MSM, and report on participants willingness to be immunized with the mpox vaccine and factors influencing their willingness to take the vaccine.

Nonoriginal articles such as literature reviews, commentaries, conference abstracts, letters to the editor, case reports were excluded; Qualitative studies that did not assess participants willingness to take the mpox vaccine were also excluded from the review.

Search strategy

We conducted searches in five electronic databases (PubMed, EMBASE, Web of Science, Scopus, and CINAHL). Our search terms included mpox, mpox virus, sexual minorities, gay men and MSM, vaccination, vaccine, willingness, attitude, intention, and hesitation. We applied Boolean logic operators and truncation characters to combine subject terms and keywords in the search formula. After devising the search strategy, two reviewers (JL and RH) conducted a thorough search of each database for publicly available literature related to willingness to receive vaccines against mpox, covering the period from the database’s inception up to May 12, 2024. The search was not restricted by publication status. The detailed search algorithms used for each database are presented in Appendix A.

Study selection

We imported the search results into COVIDENCE TM [22] for literature screening. After automatically removing duplicates, literature screening was performed in two steps based on the eligibility criteria. First, three reviewers (JL, SL and SY) screened titles and abstracts of literature and eliminated those did not meet the inclusion criteria. Second, reviewers assessed eligibility separately by reading the full text of all potentially eligible studies. Any conflicts regarding the inclusion or exclusion of a particular article were resolved by consensus between the two senior researchers (JC, WC).

Quality assessment

For quality assessment and risk of bias evaluation, we used the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for analytical cross-sectional studies to assess included cross-sectional studies [23]. The checklist for cross-sectional studies of JBI analysis has eight items, including research inclusion criteria, definition of research subjects, research environment, validity of exposure measurements, objective evaluation criteria, confounder assessment and treatment strategies, reliability and validity of outcome measurements, and rational use of statistical analysis methods. “Yes”, “No”, “Unclear”, or “N/A” was applied to assess quality of each item in the checklist. Two researchers (SL, SY) assessed each study separately and determined the quality of the studies by summarizing the score of each item given by two researchers. Any disagreements were resolved by group consensus with the two senior researchers (WC, JC).

Data extraction

Data extraction was performed by two authors (XD and JH). The extracted data included study characteristics and outcome measures. Study characteristics included study author, year of publication, country, date of survey collection, participants group, sample size. The outcome measures included main survey questions and vaccine willingness response options, and main results. The extracted data was checked for completeness by another author (WC). Any disagreements were resolved by consensus.

Statistical analysis

We used Stata 17.0 software to analyze the data and calculate the pooled rates of vaccine willingness across all studies. Cochran’s Q test and I2 test were used to assess heterogeneity between studies. Statistical heterogeneity among studies was indicated by a p value < 0.1 and I2 > 50%. To explore the source of heterogeneity, we carried out subgroup analyses. Next, we combined the effect sizes while excluding significant clinical heterogeneity using a random effects model. The sensitivity analysis of the willingness rates of the included studies was performed by the one-by-one exclusion method to assess the stability and reliability of the results. We used Egger’s test at a P value < 0.01 to check for the presence of publication bias.

Results

Search resultsp

The study search and screening flowchart is displayed in Fig. 1. A total of 924 studies were imported into COVIDENCE for screening, 510 duplicates were removed. After title and abstract screening, 47 studies were eligible for full text screening. Finally, a total of 20 studies were included in the systematic review and meta-analysis. The main reasons for full-text screening articles being excluded were studies did not evaluated willingness of vaccination (n = 11, 41%), they were not empirical studies (n = 7, 26%) or did not targeted on MSM (n = 5, 19%).

Fig. 1
figure 1

Flow diagram of the study selection process

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Study characteristics

Researchers of all included studies conducted cross-sectional online survey in either 2022 or 2023. The Chinese population was most frequently studied, with six studies recruiting participants in China [18, 24,25,26,27,28], followed by three surveys in Netherlands [29,30,31]. Reyes-Uruena et al. conducted a survey in 59 countries or subregions in Europe [32]. Zheng et al. conducted two survey studies with different samples at two different time points [18, 24].

The sample size varied from 154 participants to 32,902 participants for each study. Four studies [26, 33,34,35] targeted MSM that living with HIV (MSMWH), with one study [27]included male sex workers (MSW), a subgroup of MSM. Of all studies, 11 used Likert scales as the outcome score classification standard, and seven studies rated with “yes/no”. In two studies [18, 34], participants were asked one question on vaccine hesitancy, instead of willingness. According to the JBI quality assessment tool, 11 studies were found to have a low risk of bias and 9 studies have a moderate risk of bias (Appendix B). An overview of the included studies and study characteristics is presented in Table 1.

Table 1 Characteristics of the included studies
Full size table

Mpox vaccine willingness rate

The lowest willingness rate to vaccinate reported was 29.2% (214/732) by Hori et al. [17]. The highest rate was 94.5% (1,033/1,093) as reported in Huang et al.’s study [28]. The pooled willingness rate among the 20 studies was 77.0% (95% CI: 73-81%) (Fig. 2). The I2 of the 20 studies was 99.4%, p < 0.001, which showed high heterogeneity. In addition, the pooled rate of mpox vaccine unwillingness among MSM was 16% (95% CI: 13-20%, I2 = 98.1%) among the included nine studies [24, 26,27,28, 31,32,33, 38, 39] (Fig. 3).

Subgroup analyses were performed using survey countries (P = 0.002) and continents (P = 0.05), survey date (P = 0.296), study sample size (P = 0.001), and whether participants were infected with HIV (P = 0.002) as different group variables (Appendix C). The results suggest that countries, study sample size, and whether participants were infected with HIV may be sources of heterogeneity. Subgroup analysis by participant groups showed that the general MSM (80%, 95%CI: 75-84%) had a higher overall willingness rate than MSMWH (64%, 95%CI: 55-73%) (Fig. 4).

The sensitivity analysis showed that the result was stable. The result of the Egger’s test was p = 0.106, indicated no publication bias (Appendix C).

Fig. 2
figure 2

Mpox vaccine willingness rates among MSM

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Fig. 3
figure 3

Mpox vaccine unwillingness rates among MSM

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Fig. 4
figure 4

Subgroup analysis of mpox vaccination willingness rates by participant groups

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Factors associated with mpox vaccine willingness among MSM

A total of 11 articles were included in the meta-analysis of factors associated with mpox vaccination willingness among MSM. Table 2 shows the factors associated with willingness, factor effect values on willingness to vaccinate, I2 values and H values. A total of nine factors were extracted from the meta-analysis, of which six factors (more sexual partners [26, 30, 34, 41], history of sexually transmitted diseases [35, 36, 41], use of PrEP [36, 41], worried about mpox epidemic [26, 29], Worried about mpox infection [24, 29, 30, 34], confidence in vaccine safety [26, 28]) were highly heterogeneous (I2 ≥ 50%), and therefore a random effects model was chosen. A fixed-effects model was applied to three factors (confidence in vaccine effectiveness [26, 29, 40], high level of mpox knowledge [24, 36], agreed that people at high-risk should be given priority for vaccination [27, 28]) that had low heterogeneity (I2 < 50%). All the 9 factors had statistical significance with MSM vaccination willingness, and all were facilitators of vaccination willingness.

Table 2 Meta-analysis of factors of mpox vaccine willingness among MSM
Full size table

Discussion

This systematic review and meta-analysis of 20 studies estimated that the willingness to vaccinate against mpox among MSM was 77.0% (95% CI: 73-81%). We found that willingness in MSM was higher than that of healthcare workers (willingness rate 58.5%, 95% CI: 40.5–67.4%) [21]. Both MSM and health care workers are at risk for mpox exposure. The majority of reported cases of mpox outbreaks are from MSM and those who are sexually active or have frequent intimate contacts [42, 43]. MSM are more likely to have a need for and priority to receive vaccination.

There are differences in willingness rates across countries. The large survey conducted by Reyes-Urueña et al. [32] revealed that people living in the subregions of South-Eastern and Central Europe as well as Eastern Europe reported lower vaccination rates than those in other regions. In addition, we found that willingness rates ranged from 56.85 to 94.5% in the six studies conducted in China [18, 24,25,26,27,28]. Geographic differences in vaccine willingness outcomes are plausible due to differences in government measures, social environments, or economic levels across countries. Besides, different vaccine willingness measurement tools also had an impact on the results [

Data availability

Data available within the article or its supplementary materials.

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Acknowledgements

We appreciate the valuable suggestions provided by Dr. Wang Nina during the manuscript revision process.

Funding

This work was supported by the Hunan Provincial Key Laboratory of Nursing (grant number 2017TP1004) and the Hunan Provincial Science and Technology Department, China.

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Authors and Affiliations

  1. **angya School of Nursing, Central South University, 172 Tongzipo Road, Yuelu District, Changsha, Hunan, China

    Jiajia Liu, **aoyu Du, Jiaqi Hao, Ruixue Hui, Wenjun Chen & Jia Chen

  2. Hunan Provincial Maternal and Child Health Care Hospital, Changsha, China

    Siying Liu

  3. Centre for Social Research in Health, University of New South Wales, Sydney, Australia

    Simin Yu

  4. Ottawa Hospital Research Institute, Ottawa, Canada

    Amos Buh

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  1. Jiajia Liu
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Contributions

Jiajia Liu: Investigation, Data collection, Data analysis, Writing– original draft and editing. Siying Liu: Investigation, Data collection, Data analysis. Jia Chen: Conceptualization, Supervision, Review, Project administration. Simin Yu: Investigation, Data collection. **aoyu Du: Writing–editing, Data collection. Jiaqi Hao: Data collection. Ruixue Hui: Investigation, Data collection. Wenjun Chen: Methodology, Writing–Editing, Formal analysis. Amos Buh: Writing–Editing, Review. All the authors have read and agreed to the published version of the manuscript.

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Correspondence to Wenjun Chen or Jia Chen.

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Liu, J., Liu, S., Yu, S. et al. Willingness to receive mpox vaccine among men who have sex with men: a systematic review and meta-analysis. BMC Public Health 24, 1878 (2024). https://doi.org/10.1186/s12889-024-19260-9

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