Monkeypox vaccine strategy shift yields more supply for some, hurdles for others

Most places in the United States with heavy monkeypox caseloads have shifted their vaccination strategies to the Biden administration's low-dose, intradermal approach -- and they are reporting varying results so far.

Some say the shift has stretched their vaccine supply, helping them meet a growing demand for the Jynneos monkeypox vaccine. Others report a hurdle -- while the new method should allow for five small doses of vaccine to be extracted from a single vial, they have only been able to extract about four.

The situation "does vary geographically," Claire Hannan, executive director of the Association of Immunization Managers, wrote in an email to CNN.

"As of today, 75% of jurisdictions are already applying intradermal administration of vaccine, and another 20% are working to move in that direction," Fenton said.

Hannan shared similar results in her email to CNN based on a recent survey of immunization managers. When asked "Has your jurisdiction implemented the intradermal vaccination strategy?," 74% of survey respondents reported yes, 3% no, and 24% reported "partially."

So far, the US Department of Health and Human Services' Administration for Strategic Preparedness and Response has made a total of 1.1 million vials of Bavarian Nordic's Jynneos monkeypox vaccine available for free to jurisdictions to support monkeypox response efforts.

In early August, the US Food and Drug Administration issued an emergency use authorization allowing for health care providers to have the option of administering the Jynneos monkeypox vaccine intradermally, meaning between the layers of the skin, rather than subcutaneously, or in the fatty layer below the skin, which had been the typical way the vaccine was injected.

Administering the vaccine intradermally requires a fifth of the dose needed for a subcutaneous injection, allowing providers to get as many as five doses out of a standard one-dose vial.
"It's a little too early to tell how it's going to help with the supply meeting demand, but I think logically, you use less vaccine for one person," Dr. Emily Volk, president of the College of American Pathologists, told CNN.
"This is a dose-sparing approach, so it's going to allow for the doses that we do have to be usable for many more people. So, to me that is very positive and I am actually heartened that the public health community is thinking outside the box," she said. "It also buys time to make more vaccine."
More people eligible for vaccine

The City and County of San Francisco, New York City, Fairfax County in Virginia, Cook County in Illinois and Dallas County in Texas are just some of the places with a high number of monkeypox cases that have switched to administering vaccine intradermally

The San Francisco Department of Public Health wrote in an emailed statement to CNN that the US Centers for Disease Control and Prevention and the California Department of Health have provided guidance on how to switch to the intradermal technique "as a safe and effective way to vaccinate more people, as well as a requirement to receive additional vaccine allotments."

The statement added that switching to a new technique "takes time."
After New York City adopted the new intradermal vaccination strategy last week, it announced that it would make more than 12,000 new appointments available to the public for people eligible for vaccination who haven't yet received a first dose.

"As we continue to see a scarcity of federal supply of monkeypox vaccines, we must adapt to provide a range of options to those who are vaccine-eligible, and to do so in an equitable way," Health Commissioner Dr. Ashwin Vasan said in part in a news release last week.

In most places, the monkeypox vaccine is available for those who are considered to be at an increased risk of being exposed to the virus, including men who have sex with men. But in the state of Virginia, vaccine eligibility was expanded last week and now includes all people, of any sexual orientation or gender, who have had anonymous or multiple sexual partners in the last two weeks as being eligible to receive the monkeypox vaccine. The intradermal or ID method of administering vaccine is expected to help provide monkeypox vaccinations to this broader group of eligible people, Lucy Caldwell, a spokesperson for the Fairfax County Health Department, wrote in an email to CNN.

The Virginia Department of Health "expanded eligibility so we do anticipate that there may be additional demands; the ID method will help us to meet the demand," Caldwell wrote.
The expanded eligibility was announced last Monday and the shift to vaccinating people with an intradermal injection started Wednesday.

'We have more vaccine available now'
In Dallas County, monkeypox vaccination eligibility was expanded to include adults who had been diagnosed with HIV, chlamydia, gonorrhea or early syphilis within the past 12 months or are on HIV pre-exposure prophylaxis.

The county also had switched to the intradermal injection strategy -- and in a county where supply previously couldn't meet demand, now there appears to be a dwindle in vaccination demand and some improvement in supply.

"We have more vaccine available now. We expanded the criteria, and the calls are slowing down a little bit. So, we have more appointments available now," Dr. Philip Huang, director of the Dallas County Health and Human Services Department, told CNN.
"They're not all getting filled in," he said about the vaccination appointments. "We're having more no-shows."

Huang added that he was not surprised by the small drop in demand, as with most vaccination campaigns, there is an immediate high demand among the public to receive the vaccine and then that demand drops off over time.

"We've seen it before, even with Covid vaccines, certainly," Huang said.
"Early on, you get the ones who really want it and then after that there are people who aren't so anxious perhaps to get it that might still be at higher risk. So, it is sort of this fluctuation in supply and demand," he said. "Now that we've had more of the doses available -- and again, with the five doses per vial -- it stretches out how many people can be served with each vial."
But some local health officials have reported not being able to extract five doses per vial.