Recently, adjuvants have received increasing attention as essential vaccine components. Nearly 100 years have passed since Gaston Roman introduced the concept of adjuvants in 1925, during which numerous preclinical and clinical studies related to vaccine adjuvants have been conducted. However, to date, only a few adjuvants have been successfully used in marketed vaccines. This low clinical translational efficiency is mainly owing to the lack of comprehensive and in-depth understanding of the mechanisms of action of adjuvants in complex biological systems. In fact, MF59 is the first non‑aluminum adjuvant applied in approved human vaccines and is still used today
however, many unknowns regarding its mechanism of action remain. Therefore, in this review, the current status of the mechanism of action of MF59 and MF59-like adjuvants is discussed based on evidence-based temporal and spatial processes of immune-regulatory events. Moreover, the key factors of MF59 and MF59-like adjuvants that regulate humoral and cellular immune responses have been summarized. In addition, studies on the distribution and elimination of both antigens and adjuvants were analyzed based on published studies to gain mechanistic insights into the safety of MF59-adjuvanted vaccines. This review will not only benefit future prospects for the development of novel squalene-based adjuvants and their use in clinical applications but will also be valuable for future mechanistic investigations on other vaccine adjuvants.