Los Angeles Times
New vaccine strategy for monkeypox
Federal officials will stretch the supply by approving one-fifth the current dosage.
As monkeypox cases continue to climb among highrisk people, federal officials announced Tuesday that they would stretch limited vaccine supplies by approving one-fifth of the current dosage.
The move effectively quintuples the supply of vaccine, a priority in hard-hit areas such as Los Angeles County and San Francisco, where the virus has been rapidly spreading among men who have sex with men.
“In San Francisco, honestly, it’s a little bit like ‘The Hunger Games’ when it comes to accessing vaccination,” said state Sen. Scott Wiener (D-San Francisco). “It is heartbreaking.”
The new strategy is a “game changer of increased supply of vaccine,” said Dr.
Demetre Daskalakis, deputy coordinator of the White House’s national monkeypox response. Still, it is unlikely the approach will eliminate availability constraints, given robust demand among those considered to be at high risk.
“We will likely still run out of vaccines before we run out of arms,” Daskalakis said.
The U.S. Food and Drug Administration issued the emergency-use authorization on Tuesday, allowing healthcare providers to use a different vaccination technique for high-risk adults. Currently, the Jynneos vaccine is administered subcutaneously, under the skin and into the underlying fat. Moving forward, administrators will have the option to give the shots intradermally — shallower, between layers of skin — in a way that uses a smaller dose.
The Jynneos vaccine is a two-dose series, with shots administered four weeks apart. It can be used preventively or within two weeks of an exposure.
This is not the first time vaccines have been rationed
when doses are in short supply; the same strategy has been used with polio and yellow fever vaccines, according to Dr. Peter Chin-Hong, an infectious diseases expert at UC San Francisco.
The new method can be tricky and will require further training for clinicians. But if they administer the dose correctly, it will put the vaccine where there is a high concentration of immune cells, “so you don’t need that much to stimulate the immune system,” Chin-Hong said.
The FDA’s action also allows people younger than 18 who are at high risk of infection to get the vaccine. But they will need a full dose given subcutaneously, rather than the smaller intradermal dose.
Dr. Grant Colfax, director of health for the city and county of San Francisco, noted that the dosing change will not instantaneously boost supplies.
“I don’t think this is something that we could do overnight because of the training that will be required, but I do think it is a step in the right direction,” he said.
Roughly 9,500 monkeypox cases have been reported nationwide, according to the U.S. Centers for Disease Control and Prevention. Over 1,600 of those have been in California, according to a Times tally of data from L.A. and San Francisco counties and the state Department of Public Health.
“We have seen our first few pediatric cases and the first few female cases,” state epidemiologist Dr. Erica Pan said at a legislative hearing Tuesday.
Of the 885 California cases for which data are available, about 97% did not require the patient’s hospitalization, state officials said. No deaths have been reported.
Most of California’s monkeypox infections have occurred in L.A. County and San Francisco. L.A. County has recorded 683 cases — a figure that has doubled in the last 10 days. San Francisco has been hit harder on a per capita basis, with 501 cases, despite its population being just 9% of L.A. County’s.
Health experts say one of the only ways to get a handle on the outbreak is to dramatically increase vaccinations, adding that the more cases climb, the harder the spread will be to contain. Doctors fear that an increased spread could result in the virus becoming endemic in the wild animal population, meaning it would be virtually impossible to eliminate as a new disease of concern in the U.S.
Gov. Gavin Newsom this month declared a state of emergency over the spread of the virus to “bolster the state’s vaccination efforts.” The White House has likewise declared the disease a public health emergency.
At a town hall last week in San Francisco, Chin-Hong expressed concerns about the rate at which monkeypox was spreading.
“When you look at the rates of increase, you can see that it’s really approaching an exponential curve. And unfortunately, it’s going to become harder and harder to control, the ... higher these numbers get,” he said.
According to the U.S. Department of Health and Human Services, about 618,000 vaccine doses have been shipped nationwide. More than 109,000 have been sent to California, and 43,000 to L.A. County.
That total is far short of the needed supply. There are 300,000 to 400,000 Californians at the highest risk for monkeypox, each needing two doses under traditional methods.
San Francisco has administered 12,000 doses but would need 150,000 to fully vaccinate its highest-risk residents, Colfax said.
“We have consistently run out of vaccine early in the week when we get our shipments,” he said.
There are an estimated 1.7 million U.S. residents considered at highest risk for monkeypox.
Wiener said the country’s response has been a public health failure, adding that the federal government must do more to expand vaccine supplies. When clinics offer monkeypox vaccines, he said, supplies quickly run out.
“There’ll be a line three, four or five blocks long,” the state senator said. “People will show up at 2 or 3 in the morning, desperate to get a vaccine .... The San Francisco AIDS Foundation has a wait list that is so massive that at some point people question, ‘Should I even put myself on that wait list?’ It’s just not an acceptable way to do public health.”
Chin-Hong said data on the efficacy of the new dosing approach are limited, but public health officials had to act.
“As a public health practitioner, there’s no choice,” he said. “This is spiraling out of control, and the alternative ... was that we’d be seeing a lot of suffering in the next few months and a lot of disease. This is probably going to be as good an effort as any to really try to quell this continued outbreak on a steep curve.”
Anyone can get monkeypox. However, it has spread rapidly in LGBTQ communities in part because contagious lesions can appear first in the rectum, urethra and mouth before appearing on the skin, and because the first symptoms can appear as innocuous as a pimple. That makes it possible for infected people who don’t know they’re contagious to pass on the virus during sexual encounters.
Cases are rising steeply among gay and bisexual men and transgender people who have sex with men, Chin-Hong said. About 98% to 99% of cases are among people in these groups.
The spread of monkeypox has been amplified during Pride events, specifically in saunas and pool parties where there is intimate skinto-skin contact, Chin-Hong said.
The virus is not transmitted through pool water and is generally not transmitted through surfaces in public. It can, however, be transmitted through infected bedsheets and other surfaces in a household when there is continued exposure over hours.
Given the constrained supply of vaccine, California health officials have recommended that administrators prioritize first doses rather than stockpiling supplies for second doses — though immunocompromised individuals should receive a second dose within the 28-day interval whenever possible.
L.A. County health officials also ask that “providers prioritize giving first doses of Jynneos vaccine to eligible immunocompetent persons to protect as many at-risk people as possible,” but that second doses be deferred for those whose immunity is not compromised.
But completing the series is vital, officials say. In a statement, the FDA said there are no data indicating that one dose provides longlasting protection, “which will be needed to control the ... outbreak.”
Vaccine protection is the highest two weeks after the second dose. The CDC is urging high-risk people to reduce their chance of infection through limiting their number of sex partners and refraining from sexual contact in saunas or at clubs, parties and other venues.