The number of monkeypox vaccine doses distributed across the United States has more than tripled since last week, according to the US Department of Health and Human Services, but supply falls far short of demand – and short of the levels that experts say will be needed to control the outbreak.
Michael Austin Nicolo, a bartender in New York City, is one of more than a thousand people in the US who have been diagnosed with the virus this year. He’s also one of many more who have struggled to find an available vaccine.
“I just first heard about monkeypox like everybody else, through the news, social media, the grapevine, and how it was becoming something we need to be worried about and how it was predominantly affecting gay men or men who have sex with men,” Nicolo said.
It was enough to send him in search of more information on how to protect himself.
“At the time, there was little resources on finding the vaccine,” he said.
“I had two friends reach out with links, and we clicked on them, and they are already completely like – they were gone immediately. There was no access to anything,” he said.
“We just kind of kept an eye on the links and kept on living our lives. And then after Pride weekend is when I started to show symptoms of it – and that was too late.”
Where vaccines are going
The US Centers for Disease Control and Prevention estimates that more than 1.5 million men who have sex with men are eligible for the monkeypox vaccine. Although monkeypox is not a sexually transmitted disease, it spreads through skin-to-skin contact and in this outbreak, has mostly been spreading among men who have sex with men.
More than 132,000 doses of the Jynneos vaccine – a two-dose regimen manufactured by Bavarian Nordic – have been pulled from the national strategic stockpile and distributed nationwide, according to HHS data, but it hasn’t been enough to meet demand.
“We got an allotment of 200 vaccines, and the appointments for that went in about an hour and a half,” said Dr. David Holland, chief clinical officer of the Fulton County, Georgia, Board of Health.
The CDC says decisions about how to allocate the limited vaccine supply are based equally on the number of cases and the population at risk in a specific area.
The Jynneos vaccine is available now for people at high risk of exposure: those who have been identified as close contacts of someone who has been diagnosed with monkeypox, those who have had sex with a partner diagnosed with monkeypox within the past 14 days, and those who have had multiple sex partners in the past 14 days in an area with monkeypox spread, according to the CDC.
As more vaccines become available, the agency will continue to evaluate the distribution strategy, a spokesperson said.
The District of Columbia has received the most vaccines per capita, by far, and the city has many more confirmed cases per capita than any state.
But as of Wednesday, two states with confirmed cases – New Mexico and South Dakota – have yet to receive any doses.
After DC, New York has received the most vaccine doses per capita: more than three times the US average. About three-quarters of the state’s supply went to New York City.
In a letter on Tuesday, New York Mayor Eric Adams urged the Biden administration to increase the vaccine allocation, calling his city an “epicenter” of the virus in the US.
White House Covid-19 Response Coordinator Dr. Ashish Jha said Wednesday that additional monkeypox vaccine doses will be arriving within weeks from a plant in Denmark.
“The issue is, we need to get more vaccines out there,” he said.
“We are incredibly focused on making sure that vaccine doses get to the United States and get out to places like New York City. Do we wish we had more doses? Of course. We had a stockpile, and what we need is more. We are getting more.”
Dr. Carlos del Rio, executive associate dean at Emory University School of Medicine, says “the problem is, we simply don’t have enough vaccine. So we’re trying to play catch-up.”
There are also other issues to be considered, he said.
“I think the challenge is that we need to make sure that the vaccine doesn’t go just to the people that are savvy and can get it quickly. We don’t want the vaccine only to go to white wealthy individuals.”
Could a single-dose strategy be helpful?
A full course of the Jynneos vaccine, as approved by the US Food and Drug Administration, requires two doses given four weeks apart. But some experts say that one dose might be enough for now – and that delaying second doses might be a way to address the discrepancy between supply and demand.
In his letter, Adams called for the administration to “consider alternative vaccine schedules, utilizing a longer interval between the first and second dose, that would allow more of the immediately available vaccine to be used for first doses.”
Bavarian Nordic CEO Paul Chaplin told Science in early July that “There are a lot of data to support a single shot.”
Chaplin said the second dose could be given two years later and still achieve the same immune response as the standard schedule, so countries have a long time to provide second shots if they decide to use single shots for now.
Health experts say providers are not expected to hold back doses right now.
“From what we’ve been told, it’s: Give the doses you have, and in your later allocations, there’ll be additional doses that will cover second doses,” said Claire Hannan, executive director of the Association of Immunization Managers.
Not a sustainable strategy
If the virus isn’t contained as soon as possible, health officials fear, it could spread beyond the population groups that are now at high risk.
Janet Hamilton, executive director of the Council of State and Territorial Epidemiologists, says the US must get past a vaccine strategy focused on high-risk post-exposure because “there is no vaccine-preventable disease that exists that can be controlled solely post-exposure when there is no prior immunity.”
Monkeypox is endemic in parts of Africa, but it is essentially a new disease to the US, and there is no immunity built up in the population.
“Everyone is susceptible at this point in time,” Hamilton said. “There’s no way we will ever be able to control this disease in a completely susceptible population without a pre-exposure vaccine strategy.”
A need for more and easier testing
In the meantime, people affected by the virus say they need other resources, as well. The Biden administration has moved to expand testing, with the CDC announcing a collaboration with five private companies to double the nation’s testing capacity. Some of those companies have already begun offering testing. But that didn’t happen soon enough for some.
Nicolo said that when he first went to his doctor with monkeypox symptoms, they took a sample to test – but he learned days later that it had been discarded, untested.
Two days after that visit, his symptoms worsened, and he returned to the doctor. The second sample tested positive.
Christian Redondo, a graduate student in Atlanta, noticed a sore and called his local board of health, which said it wasn’t doing testing and referred him to his primary care doctor.
His primary care doctor told him to go to the emergency room to get tested, but Redondo was able to contact a friend at his county health department who said yes, in fact, he would need to go there for a test.
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“Then, I was in the waiting room for, I don’t know, something like four or five hours. It was a very long time. And when I was asking them about it, they said they had to wait for permission from the CDC to even test me for monkeypox,” he said.
Testing is necessary to prevent further cases and learn more about the full scope of the outbreak.
“I think one of the challenges that we have is that we’re simply not doing enough testing, so there probably are much more cases than we actually are currently registering,” Emory’s del Rio said.