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As monkeypox cases spiral, U.S. will stretch supply of vaccine by giving smaller doses

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As monkeypox cases continue to increase among high-risk people, federal officials on Tuesday announced they will stretch limited vaccine supplies by giving just one-fifth the current dosage.

The move would quintuple the existing supply of monkeypox vaccine doses, a priority in hard-hit communities such as Los Angeles County and San Francisco, where the virus has been rapidly increasing in communities where men have sex with men and vaccines remain in short supply.

The U.S. Food and Drug Administration issued an emergency-use authorization allowing healthcare providers to use the new vaccination technique for high-risk adults.

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“In recent weeks, the monkeypox virus has continued to spread at a rate that has made it clear our current vaccine supply will not meet the current demand,” FDA Commissioner Dr. Robert Califf said in a statement. “The FDA quickly explored other scientifically appropriate options to facilitate access to the vaccine for all impacted individuals. By increasing the number of available doses, more individuals who want to be vaccinated against monkeypox will now have the opportunity to do so.”

Los Angeles County health officials said they’re awaiting instructions from federal officials and hope to implement the strategy once clinicians have been trained.

“With this new alternate regimen that we have just gotten notice about, we will now have five times the number of doses,” said Dr. Rita Singhal, chief medical officer for the L.A. County Department of Public Health. “And so, with this, it would expand our capacity a good amount.”

Health experts say one of the only ways to get a handle on the growing outbreak is to dramatically increase vaccinations among higher-risk people, adding that the more cases climb, the harder the spread will be to contain. Doctors fear an increased spread could result in the virus becoming endemic in the wild animal population, meaning it would be virtually impossible to remove as a new disease of concern in the U.S.

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In an interview earlier this week, UC San Francisco infectious disease expert Dr. Peter Chin-Hong said expanding the availability of the vaccine would be a critical part in responding to the outbreak. Currently, the monkeypox vaccine is administered subcutaneously, or under the skin. The newer technique would administer a shot intradermally, or injecting it in a way that’s more shallow.

The expectation earlier this week was that federal officials wouldn’t act until more data came in on the effectiveness of the shallower injection method, and that wouldn’t be until the end of November or early December. But some scientists pointed out the intradermal technique has been used in other vaccines, such as for yellow fever, when vaccines are in short supply, according to Chin-Hong.

If the shallower injection can result in a boost in antibodies, “I think it will potentially be a good thing,” Chin-Hong said Monday.

In a town hall meeting with his colleagues last week, Chin-Hong expressed concerns about the rate of increase in monkeypox cases.

“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.

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 skin symptoms can appear as innocuous as a pimple. That makes it possible to pass on the virus to other people during intimate sexual encounters without infected people knowing that they are contagious with the virus.

Cases are rising steeply among men who have sex with men and transgender people who have sex with men, Chin-Hong said. About 98% to 99% of cases are among people in these groups.

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The spread of monkeypox cases has also been amplified by Pride events, specifically in gay saunas and at pool parties where there is intimate skin-to-skin contact, Chin-Hong said. The virus is not transmitted through pool water and generally not transmitted through surfaces. It can, however, be transmitted through infected bedsheets.

As the number of reported monkeypox cases has continued to climb, officials have been racing to get as many vaccine shots administered as possible as well as stretch the limited supply of doses.

Gov. Gavin Newsom declared a state of emergency over the spread of the virus earlier this month to “bolster the state’s vaccination efforts.” And the White House has declared the disease a public health emergency.

The Jynneos vaccine is a two-dose series with the shots administered four weeks apart. It also can be used preventatively and within two weeks of an exposure.

However, supplies are constrained, prompting health officials to recommend prioritizing first doses rather than stockpiling second-shot supplies in many cases.

“While supplies remain scarce, vaccinators in California may offer first doses of Jynneos to additional persons at risk rather than retain inventory as second doses for immunocompetent persons, even if second doses are consequently administered at an interval greater than 28 days,” guidance from the California Department of Public Health states.

The same is true in Los Angeles County, where the local Department of Public Health “asks that all providers prioritize administering first doses of Jynneos vaccine to eligible immunocompetent persons to protect as many at-risk people as possible.”

Singhal on Tuesday said L.A. County is continuing to prioritize first doses, but noted the decision by federal regulators could make it possible for administrators to provide second shots sooner.

Immunocompromised individuals should receive their second dose within the 28-day interval whenever possible, officials say.

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When asked about the FDA’s potential action last week, Los Angeles County Public Health Director Barbara Ferrer said that “we fully support any effort that can be made to safely increase the number of people that are going to be able to get vaccinated with the doses at hand.”

“We would be absolutely working hard to make sure we could do that very quickly here in L.A. County,” she said during a recent briefing.

She noted such a step “would require more training from vaccine administrators, so we have to take a look at the network that’s vaccinating now to make sure we can maintain that capacity,” but said, “most vaccinators would be able to go ahead with subcutaneous injection.”

Singhal said 647 monkeypox cases have been identified by the L.A. County Department of Public Health — “double the number of cases we had 10 days ago.”

As of last Thursday, 1,310 monkeypox cases had been reported statewide, most of them in L.A. County and San Francisco.

Of the 885 cases for which data are available, state officials said the vast majority — about 97% — did not require hospitalization. No deaths from the disease have been reported.

The number of cases has swelled more rapidly, however.

“Our pace of new cases has increased over the last few days and so, certainly, that’s of concern,” Orange County Deputy Health Officer Dr. Matthew Zahn said during a briefing Thursday. “If you compare us to surrounding counties, certainly L.A. County, our numbers are not as high. But we’re certainly seeing our numbers go up in Orange County.”

As of Monday, Orange County health officials were reporting 37 confirmed and probable cases of monkeypox.

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