Initial US monkeypox vaccination strategy was ‘doomed to failure,’ experts say

“I think we’re going to have to live with it until they vaccinate every high-risk person,” Dr. Robert Murphy, executive director of the Havey Institute for Global Health at the Northwestern University Feinberg School of Medicine, said this week.

Vaccinating someone already exposed to monkeypox to help prevent illness is called post-exposure prophylaxis or a ring vaccination strategy. Vaccinating a patient’s close circle of contacts is like vaccinating a “ring” around them.

This approach has been used in response to sexually transmitted infections and prior monkeypox outbreaks.

“We can have a really effective strategy of containment and elimination by identifying all the cases and then providing the cases with treatment and the close contacts of those cases with post-exposure prophylaxis,” said a federal health adviser who requested anonymity because they’re not a government employee and don’t speak for any federal agency.

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“We know that this works,” the adviser said. “We have data from other outbreaks to say that it is effective. And so in the beginning, when cases were low — in the tens, the dozens of cases — we were able to effectively work with jurisdictions to identify those cases and, through consultation, figure out how many doses of vaccines would they need to vaccinate as many contacts as they think existed.”

But toward late June, the monkeypox outbreak had spread.

The CDC’s initial strategy “was just doomed to failure,” Murphy said, referencing how a “ring” strategy requires swift and robust outreach to all known contacts of a monkeypox patient — which was becoming increasingly difficult to do as cases were growing, and in more places.

“A ring vaccination strategy was never going to work, frankly,” Murphy said. “I mean, look how fast this virus has spread.”

Federal health officials expanded vaccination efforts to focus on the broader community of men who have sex with men, the demographic that makes up most US monkeypox cases.

“We recognized that a traditional post-exposure prophylaxis strategy was no longer the best strategy for that current moment of the outbreak — and so we shifted, along with the nation,” the federal health adviser said.

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After initial orders for 72,000 vaccines, 300,000 additional doses were made available. Another nearly 800,000 doses were OK’d this week, and will be available in the coming weeks. But the CDC estimates 1.5 million people are eligible for the two-dose vaccine.
The CDC’s strategy still directs shots toward people who might have had a monkeypox exposure — not preventing cases among those who might be exposed in the future.

As of Friday, the US has tallied nearly 5,200 confirmed or probable monkeypox cases. With limited supply and growing awareness of the virus and its painful effects, vaccination appointments are still going fast.

Limitations of the ring strategy

Even though the US response to the monkeypox outbreak has evolved, there are clear reasons why federal health officials would immediately consider a ring vaccination strategy early on.

“That’s the way that we eradicated smallpox from the planet, and it was the way that prior monkeypox outbreaks have been controlled,” said Dr. Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security at Johns Hopkins Bloomberg School of Public Health.
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But Adalja and many other public health experts argue that a broader vaccination response against monkeypox should have been implemented from the beginning, as the ring strategy comes with a limitation: It hinges on robust contact tracing.

“Because of the unique characteristics of this outbreak — the fact that it’s spreading mostly amongst men who have sex with men and has been kind of exploiting anonymous sex parties, raves and the like — it became quickly clear that contact tracing was going to miss a lot of contacts, especially if individual case patients didn’t even know the names of their contacts,” Adalja said.

“It’s not that we don’t have the contact tracers. It’s that the individuals don’t know their contacts,” he said. “The contact trace data was not complete enough to be able to rely solely on ring vaccination.”

For ring vaccination to work, “there has to be enough vaccine, those in the ring need to be identified and vaccinated, and this has to be done quickly,” Dr. Tom Frieden, former CDC director and president and CEO of Resolve to Save Lives, wrote in an email to CNN.

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“Because many contacts of cases were from anonymous encounters, this makes ring vaccination much more challenging,” he wrote. “And because monkeypox is spread by intimate contact, identifying those who were close to the patients is much harder than for smallpox, both because of the sensitivity of this information, and because some of the contacts may have been anonymous.”

CDC spokesperson Kristen Nordlund told CNN that “ring vaccination can only be effective if all contacts of a case are identified and vaccinated.”

“As the outbreak went on, it became clear that some of the cases were having anonymous close encounters, which fueled transmission. CDC then expanded our vaccination strategy,” she wrote in an email.

The federal health adviser said this is not unique to monkeypox.

“Ring vaccination requires identification of cases and identification of contacts, and that is challenging no matter what disease it is. It’s challenging for Covid; it’s challenging for HIV; it’s challenging for syphilis,” the adviser said. “And so just because it’s challenging doesn’t mean we didn’t want to pursue this strategy.”

‘We went against CDC’

Some local health officials saw the writing on the wall early in the outbreak and never implemented a ring vaccination of just close contacts. Instead, vaccines have been offered to a broader group of higher-risk people from the beginning.

In the nation’s capital, the DC Department of Health has been closely tracking the spread of monkeypox virus since the spring, watching anxiously as cases emerged in regions of the world where the virus typically is not seen.

When the first US case was reported in Massachusetts, DC health officials organized a team that was trained in identifying monkeypox and how it spreads. Around that time, the city also ordered vaccines.

“I was one of the first to order vaccines from CDC, before we had a case,” said Anil Mangla, state epidemiologist for the DC Department of Health. The first potential monkeypox case in DC was reported in early June.
After DC’s vaccine order arrived, shots were offered in late June in two rings. Ring one included the close contacts of cases identified by the epidemiology team. Ring two included any adult resident who was gay or bisexual with multiple anonymous partners in the previous two weeks or who was a transgender woman or nonbinary who has sex with men or sex workers or staff at establishments where sexual activity occurs.

Among the close contacts, “we actually have vaccinated 246 people in that first ring,” Mangla said Wednesday. “When I broaden that net, we have vaccinated — as of last night — 6,628.”

He added that if DC just focused on vaccinating the close contacts in ring one, those thousands of people who voluntarily got immunized in ring two would have received the vaccine much later during the outbreak.

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“We went against CDC,” Mangla said of the district’s broad two-ring vaccination approach, adding that the CDC is now working on projects with the DC Department of Health to better understand this outbreak response model.

However, the monkeypox vaccine supply has not met the growing demand in DC — or in most regions across the country.

“It’s very clear with the spread of this that there now has to be a balance between vaccines available for those who clearly have been exposed, as well as those at risk,” Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, said on CNN this week. “What you want to do is a balance between vaccinating those who clearly have had an exposure, but go well beyond that.”

The public health community “is recognizing the tension between our desires and limited supply,” the federal health adviser said.

With limited supply, cities prioritize first doses

On Monday, the DC Department of Health announced that due to the “very limited” supply of vaccines, only first doses will be provided to high-risk residents, even though Jynneos is a two-dose vaccine. Second doses will be provided at a later time.
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“This decision is based on the available scientific evidence, the acceleration of the outbreak, the demand for vaccine from the high number of eligible people, and extreme shortages of the JYNNEOS Monkeypox vaccine nationally,” the announcement said. “DC Health is confident that additional vaccine doses will be available when needed for those who have received their first dose.”

In New York City, which also expanded eligibility for the monkeypox vaccine to any adult in a high-risk group, first doses have been prioritized.

“New York City is the epicenter of the monkeypox outbreak in the U.S. and yet does not have sufficient vaccine supply,” the city announced in mid-July. “Given the rapid increase in cases, the Health Department has decided that providing first doses to offer protection to more at-risk New Yorkers is the best strategy until we receive adequate vaccine supply. This single dose strategy is consistent with the monkeypox vaccine distribution strategy taken in the UK and Canada.”

Chicago also is prioritizing first doses of vaccine.

The city announced that it is prioritizing doses for all known close contacts of monkeypox cases as part of a ring strategy, while offering vaccine to those who are gay, bisexual or trans men who have sex men and have had sexual contact with multiple partners, in a social or sexual venue or by giving or receiving money in exchange for sex.

These vaccines are being offered through doctors’ offices and clinics as well as pop-up events at venues, such as bathhouses and Pride events, according to the city’s announcement.

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“The goal is address equity along with maximizing doses administered,” Massimo Pacilli, the Chicago Public Health Department’s deputy commissioner of disease control, wrote in an email.

Meanwhile, in a state that does not have many monkeypox cases or vaccines, the Connecticut Department of Public Health announced Thursday that it will launch a program to administer doses of vaccine starting Monday to any adult resident who is gay, bisexual, a man who has sex with men, transgender, gender nonconforming, or gender nonbinary and has had multiple or anonymous sex partners in the past 14 days. Connecticut has 28 probable or confirmed monkeypox cases.

“This is a national model that has been developed by the Centers for Disease Control and Prevention and it is consistent with our neighboring jurisdictions,” Department of Public Health Commissioner Dr. Manisha Juthani said. “DPH is partnering with 15 community-based clinics to expand the availability and efficient delivery of the vaccine to those who need it the most.”

A ‘rapidly closing’ window

Still, questions remain around where the nation’s fight against monkeypox is heading.

“It’s not clear that monkeypox can be contained at this point, but it’s certainly worth trying,” said Frieden, the former CDC director.

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Federal health officials remain optimistic that the nation can end the outbreak.

“To the question, can we not only stay ahead of this virus but end this outbreak? Absolutely,” Becerra said Thursday.

“We believe that we have done everything we can at the federal level to work with our state and local partners and communities affected to make sure we can stay ahead of this and end this outbreak, but everybody’s got to take the oar and row. Everybody’s got to do their part.”

Lawrence Gostin, faculty director of the O’Neill Institute for National and Global Health Law at Georgetown University, said “the window for containing monkeypox is rapidly closing.”

“I do think it’s still possible to contain, but it’s also equally possible that this may become endemic in the United States,” he said.

Endemic means a disease has a constant presence in a population but is not affecting an alarmingly large number of people, as typically seen in a pandemic. As part of the current outbreak, the United States now has the highest case count of monkeypox among nonendemic countries.

To contain the monkeypox virus, Gostin called for the United States to declare a national public health emergency, raise awareness about the virus in non-stigmatizing ways and, of course, make more vaccine doses available.

The World Health Organization declared the monkeypox outbreak a public health emergency of international concern last week. On the national level, HHS has yet to make such a determination.

“We continue to monitor the response throughout the country on monkeypox,” Becerra said Thursday. “We will weigh the decision on declaring a public health emergency based on the response we’re seeing throughout the country.”

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