When New York City’s department of health announced on July 12 that monkeypox vaccine appointments were available in several sites around the city, demand was so high that the scheduling website crashed. Many people were unable to receive shots because of the time it took for appointments to be booked.
Vaccine rollout wasn’t supposed to go like this. Experts felt reassured when monkeypox cases first became known in the U.S. during May. They stressed that—unlike COVID-19 when it first emerged—monkeypox is a known threat, with existing vaccines that could be deployed as necessary.
The reality is more complicated. There is a limited supply of vaccines and distribution issues. Additionally, it’s been difficult to determine who should be given shots. The end result? At least in some areas, the demand for vaccines is exceeding available supply.
“Everybody would like to get the vaccine, and there’s just not enough vaccine,” says Dr. Carlos del Rio, a distinguished professor in Emory University School of Medicine’s division of infectious diseases. “You have a little bit of a Hunger Games approach.”
This may seem surprising considering that officials had previously claimed the country was stocked with enough vaccines from the Strategic National Stockpile. However, many stockpiled vaccines are the ACAM2000 older vaccine. This is approved to be used against smallpox but can also be used in cases of monkeypox. It’s a live virus vaccine containing a virus that’s related to smallpox but milder. The shot causes a temporary sore at the injection site, which—if not properly cared for—can potentially spread the virus to unvaccinated people in close contact. ACAM200 causes swelling of the heart, surrounding tissue and around 1 out 175 people. ACAM2000 is not available to some people with immunocompromised.
Jynneos is a new vaccine that consists of four doses spread over 4 weeks. It is suitable for widespread distribution. The U.S. had only about 2,000 doses of that product in the SNS when the outbreak began—so authorities have been rushing to obtain more.
By the end July, nearly 800,000.000 Jynneos Shots could be made available to purchase. The U.S. Food and Drug Administration is likely to approve a Danish manufacturing facility owned by Bavarian Nordic. Some Jynneos shots have been made in an approved third-party facility. The U.S. can place immediate orders. According to the U.S. Department of Health and Human Services, more than 300,000. doses were available for states and localities as of July 15. According to officials, nearly 7 million doses should be available in the United States by 2023.
During a July 15 press briefing, U.S. Centers for Disease Control and Prevention (CDC) Director Dr. Rochelle Walensky acknowledged that vaccine shortages are “frustrating” but said the administration is actively working to increase supply. According to her, federal officials will continue sending more vaccines to states with high case numbers. New York City, California, Illinois Florida Georgia Georgia and Washington D.C. are early hotspots. They account for over half of 1,814 confirmed cases nationwide as of July 15.
Mark Levine, Manhattan borough president in New York City, says he doesn’t feel enough doses have been sent to hard-hit areas. “We’re really not getting our fair share here,” he says, noting that New York accounts for almost a third of cases nationwide. “Most people are getting turned away.”
New York City officials announced recently that they would prioritize giving first doses of the drug to as many people at risk as possible to increase supply. This could mean some people will have to wait for their second dose for longer than the four-week time limit. CDC and FDA representatives warned against the move during the press conference, noting that patients are not sufficiently protected even after a single dose.
Ideally, public-health officials would use what’s known as a “ring vaccination” strategy against monkeypox, prioritizing inoculation for those who are known to have had close contact with an infected person to both protect those at greatest risk and maximize available vaccine supply, says Dr. Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security at the Bloomberg School of Public Health.
Andrew Kilianski is an adjunct professor at George Mason University and emerging infectious disease specialist. However, inadequate testing and contact tracing has made it difficult to determine who was infected. Federal health officials say that the nation’s testing capability has grown from 6,000 to 70,000 tests per week during the initial outbreak to now that there are 70,000. However, Kilianski believes screening remains inadequate.
“If you’re going to distribute your vaccine smartly and deliberately, you need to know who’s positive,” Kilianski says. “There’s not a lot of testing capacity, [even] for a pathogen we are ‘prepared’ for.”
New York City’s health department and Washington, D.C. have opened up vaccines to all men who have been in close contact with women and had several sexual partners recently. While anyone can get monkeypox—which spreads primarily through close contact and can result in a blister-like rash as well as flu-like symptoms—men who have sex with men have accounted for the majority of U.S. cases so far.
“When you’re thinking about just vaccinating contacts, that’s not going to be as much of a demand on the supply,” Adalja says. But if anyone who meets a few wide criteria and thinks they’re at risk can get vaccinated, “the demand is much higher than the supply.”
Levine adds that in New York City, the monkeypox vaccine rollout has run into some of the same equity issues that arose during COVID-19 vaccine distribution—namely problems with online appointment scheduling.
“When you have a [scheduling] system that requires you to sit hitting refresh on a website at a given hour of the afternoon, that’s going to [benefit] younger, technologically capable people who aren’t at the kind of job that precludes them from sitting in front of a computer,” he says. “Marginalized communities and people of color are underrepresented in who’s getting vaccinated.” (Since its system crashed, New York City has switched scheduling systems and made more appointments available.)
If COVID-19 showed us anything, it’s that the “last mile” of distribution—actually getting available vaccine doses to the people who need them—must be done carefully, Kilianski says. He’d like to see more widespread testing of monkeypox, which would make it easier to tell who may have been exposed. He believes that vaccines should be made available without appointment to those at high risk.
Kilianski also believes that messaging is important. While targeted communication to men who have sex with men has worked well, as evidenced by the high demand for vaccines, he says it’s also important to emphasize that anyone who has close contact with an infected person could catch monkeypox.
Like COVID-19 before it, monkeypox’s vaccine rollout has also shown the importance of global equity, Kilianski says. Monkeypox is endemic to certain parts of Africa—and if vaccines had been more accessible there, the global outbreak may never have happened.
“It takes a few hundred to a few thousand cases in the U.S. for us to start moving on this,” he says. “It really doesn’t have to be that way.”
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