(CNN) There is growing concern that the United States may have missed the chance to contain the monkey virus, as the nation has been slow to vaccinate those most at risk on a wider scale.
“I think we’re going to have to live with it until everyone at high risk is vaccinated,” Dr. Robert Murphy, executive director of the Havey Institute for Global Health at Northwestern University Feinberg School of Medicine, said this week.
The monkeypox vaccine has been part of the Biden administration’s response to the global outbreak since the nation identified its first case of the disease in May, but supplies have been limited even as demand for protection against the virus has surged.
Initially, US Centers for Disease Control and Prevention officials announced that monkeypox vaccines were being released from the National Strategic Stockpile and offered to “high-risk” contacts of monkeypox patients, as well as health care workers who treat them. .
Vaccinating someone already exposed to monkeypox to prevent disease is called post-exposure prophylaxis or a ring vaccination strategy. Embedding a patient’s immediate circle of contacts is like embedding a “ring” around them.
This approach has been used in response to sexually transmitted infections and prior monkey outbreaks.
“We can have a really effective containment and elimination strategy by identifying all cases and then treating those cases and close contacts of those cases with post-exposure prophylaxis,” said a federal health adviser who requested anonymity. not a government employee and not speaking for any federal agency.
“We know this works,” the consultant said. “We have data from other outbreaks to say that it’s effective. And so at the beginning, when the cases were low — in the tens, dozens of cases — we were able to work effectively with jurisdictions to identify those cases and, through consultation, figure out how many doses of vaccine we think they would need. to insert as many contacts as possible.”
But towards the end of June, the monkey outbreak became widespread.
The CDC’s initial strategy was “doomed to fail,” Murphy said, noting that a “ring” strategy requires rapid and robust dissemination to all known contacts of a monkey patient — which became increasingly difficult as cases grew, and in more places.
“The ring insertion 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 of the U.S. cases of mumps.
“We recognized that the traditional post-exposure prophylaxis strategy was not the best strategy for that time of the outbreak — and so we changed along with the nation,” said the federal health adviser.
After initial orders of 72,000 vaccines, 300,000 additional doses were made available. Another nearly 800,000 doses were approved this week, and will be available in the coming weeks. But the CDC estimates that 1.5 million people are eligible for two doses of the vaccine.
The CDC’s strategy targets the shots at people who may still have exposure to the monkey, not preventing cases among those who may be exposed in the future.
As of Friday, the U.S. has counted nearly 5,200 confirmed or probable monkeypox cases. With limited supplies and growing awareness of the virus and its painful consequences, vaccine appointments are still going fast.
Limitations of the ring strategy
Although the response to the U.S. monkeypox outbreak has evolved, there are clear reasons why federal health officials will consider a ring vaccination strategy early on.
“This is how we wiped smallpox off the planet, and it was how previous monkey outbreaks were controlled,” said Dr. This may interest you : Michigan’s major health system restores abortion status. Amesh Adalja, principal investigator at the Johns Hopkins Center for Health Security at the Johns Hopkins Bloomberg School of Public Health. Health.
But Adalja and many other public health experts say a broader vaccination response against the monkey should be implemented from the start, because the ring strategy comes with a limitation: It relies on robust contact tracing.
“Due to the unique nature of this outbreak — that it is spreading mostly among men who have sex with men and that it has exploited anonymous sex parties, raves, and the like — it quickly became clear that contact tracing was going to happen. Many contacts were lost, especially if the patients of the individual case do not know the names of their contacts,” Adalja said.
“It’s not that we don’t have traces of contacts. It’s just that individuals don’t know their contacts,” he said. “The contact tracing data was not complete enough to rely solely on the ring vaccine.”
For ring vaccination to work, “there has to be enough vaccine, those in the ring have to be identified and vaccinated, and that has to be done quickly,” said Dr. Tom Frieden, former CDC director and president and CEO of Resolve to Save. Life, he wrote in an email to CNN.
“Since many of the case contacts come from anonymous encounters, this makes ring vaccination much more difficult,” he wrote. “And since the monkey spreads through intimate contact, identifying those who were close to the patients is much more difficult than for smallpox, both because of the sensitivity of this information, and because some contacts can be anonymous.”
CDC spokeswoman Kristen Nordlund told CNN that “ring vaccination can only be effective if all contacts of a case are identified and vaccinated.”
“As the outbreak progressed, it became clear that some of the cases were having anonymous close encounters, which encouraged transmission. CDC then expanded our vaccination strategy,” he wrote in an email.
The federal health adviser said this is not the only case of monkeypox.
“The ring vaccine requires case identification and contact identification, and that’s a challenge for any disease. It’s a challenge for Covid; it’s a challenge for HIV; it’s a challenge for syphilis,” the consultant said. “And so being challenged doesn’t mean we didn’t want to pursue this strategy.”
‘We went against CDC’
Some local health authorities saw the writing on the wall at the start of the outbreak and never implemented ring vaccination for close contacts. To see also : Bitcoin can provide high quality, fair, health care for all. Instead, vaccines have been offered to a wider group of people at higher risk from the start.
In the nation’s capital, the DC Department of Health has been closely monitoring the spread of the monkeypox virus since the spring, and has watched with concern as cases emerge in regions of the world where the virus is not normally seen.
When the first US case was reported in Massachusetts, DC health officials organized a team trained to identify monkeypox and how it spreads. At that time, the municipality also ordered vaccinations.
“I was one of the first to request vaccines from the CDC, before there was a case,” said Anil Mangla, a state epidemiologist at the D.C. Department of Health. A potential case of monkeypox in DC was reported in early June.
After DC’s vaccine mandate arrived, shots were offered in both rings in late June. A ring included close contacts of cases identified by the epidemiology team. Both rings A transgender or non-binary transgender woman who has had multiple anonymous partners in the previous two weeks who is gay or bisexual or who has had sex with sex workers in establishments that engage in sexual activity or with sex workers in establishments that engage in sexual activity any resident who was bisexual came up.
Among the close ties, “we actually inserted 246 people into that first ring,” Mangla said Wednesday. “When I expand that network, we have vaccinated 6,628 — since last night –.”
He added that if DC focused on vaccinating close contacts in the first ring, those thousands of people who were voluntarily immunized in the second ring would receive the vaccine much later in the outbreak.
“We went against the CDC,” Mangla said of the district’s two-ring vaccine-wide approach, adding that the CDC is working on projects with the D.C. Department of Health to better understand this outbreak response pattern.
However, the supply of monkeypox vaccines has not met the growing demand in DC, or in most regions of the country.
“With this expansion, it’s very clear now that there needs to be a balance between vaccines for those who are clearly exposed, as well as those who are at risk,” Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases. Illness, he said this week on CNN. “What you want to do is strike a balance between vaccinating those who have clearly had exposure, but go beyond that.”
The public health community is “recognizing the tension between our desires and the limited supply,” the federal health adviser said.
With limited supply, cities prioritize first doses
On Monday, the D.C. Department of Health announced that due to “extremely limited” vaccine supplies, only the first doses will be given to high-risk residents, even though Jynneos is a two-dose vaccine. Read also : More women work in health and care, but earn 24 percent less than men: UN report. Second doses will be given later.
“This decision is based on the available scientific evidence, the acceleration of the outbreak, the demand for the vaccine from the large number of eligible people and the extreme shortage of JYNNEOS Monkeypox vaccine at the national level,” 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 for adults in a high-risk group, the first doses have been prioritized.
“New York City is the epicenter of the U.S. monkeypox outbreak and yet has insufficient vaccine supplies,” the city announced in mid-July. “Given the rapid increase in cases, the Department of Health has decided that the first dose is the best strategy to protect New Yorkers at higher risk until an adequate supply of vaccine is available. This single-dose strategy is consistent with the monkey vaccine distribution strategy adopted in the UK and Canada.”
Chicago also prioritizes the first doses of the first vaccine.
The city announced that it is prioritizing doses for all close contacts of monkey cases as part of a ring strategy, offering the vaccine to gay, bisexual or transsexuals who have sex with men and those who have had sexual contact with multiple partners. a social or sexual site or giving or receiving money in exchange for sex.
These vaccines are being offered through doctors’ offices and clinics, as well as venues such as spas and Pride events, pop-up events, according to the city’s announcement.
“The goal is to focus on equity while maximizing the doses administered,” Chicago Public Health Deputy Commissioner for Disease Control Massimo Pacilli wrote in an email.
Meanwhile, in a state without many monkey cases or vaccinations, the Connecticut Department of Public Health announced Thursday that it will begin a program starting Monday to administer vaccine doses to anyone who is gay, bisexual, or male. sex with men, transgender, gender non-conforming or gender non-binary and had multiple or anonymous sexual partners in the past 14 days. Connecticut has 28 possible or confirmed cases of monkeypox.
“This is a national model developed by the Centers for Disease Control and Prevention and is consistent with our neighboring jurisdictions,” said Public Health Commissioner Dr. Manisha Juthani. “DPH is partnering with 15 community-based clinics to expand vaccine availability and effective delivery to those most in need.”
A ‘rapidly closing’ window
Still, questions remain about where the nation’s fight against the monkey is headed.
“It’s not clear that the monkey can be contained at this point, but it’s certainly worth trying,” said Frieden, the former CDC director.
Federal health officials remain optimistic that the nation can end the outbreak.
“The question is, not only was this virus preceded, but ended with this outbreak? Absolutely,” Becerra said Thursday.
“We believe we’ve done everything we can at the federal level to work with our state and local partners and affected communities so we can get ahead of this and end this outbreak, but everyone has to pick up the paddle and paddle. They have to do their part.”
Lawrence Gostin, faculty director of Georgetown University’s O’Neill Institute for National and Global Health Law, said, “The window to have monkeypox is closing fast.”
“I think it’s still possible for it to hold, but it’s also possible for it to become endemic in the United States,” he said.
Endemic means that a disease has a constant presence in a population, but does not affect an incredibly large number of people, as is often seen in a pandemic. As part of the current outbreak, the United States now has the highest number of monkey cases among endemic countries.
To contain the monkeypox virus, Gostin has called on the United States to declare a national public health emergency, to raise awareness about the virus in a non-stigmatizing way and, of course, to make more vaccine doses available.
The World Health Organization declared the monkey outbreak a public health emergency of international concern last week. At the national level, HHS has not yet made such a decision.
“We continue to monitor the monkeypox response across the country,” Becerra said Thursday. “We will weigh the decision to declare a public health emergency based on the response we’re seeing across the country.”
