Shifting strategies for monkeypox vaccines

By Anne Blythe

Raynard Washington, the Mecklenburg County health director, takes umbrage when he hears people say the monkeypox vaccine clinic staged at the Charlotte Pride celebration last month fell short of expectations.

In mid-August, Mecklenburg Public Health worked with the state Department of Health and Human Services to administer the Jynneos vaccine at the Pride events through a pilot program offered by the White House and Centers for Disease Control and Prevention.

The pilot program had set aside 50,000 doses of the vaccine from the Strategic National Stockpile, vials that had been reserved to fight potential smallpox outbreaks. Monkeypox is related closely enough to smallpox that the vaccine can be used to prevent either disease, even though monkeypox is a much milder infection that rarely causes death.

Mecklenburg County received enough vaccine to inoculate 2,000 people from monkeypox that weekend. The county health department had more supply than takers at the two-day event.

Nonetheless, Washington chooses to put a different spin on the large-scale vaccine event than some in the national media.

“I definitely would not call vaccinating 540 people not a success,” Washington said during a phone interview with NC Health News. “That pilot that we did with the CDC and the feds was literally organized the week of.”

A little more than a week before, the Food and Drug Administration amended the emergency use authorization for Jynneos, changing how the vaccine could be administered. Before then, the vaccine was administered subcutaneously, in the layer of tissue between the skin and the muscle below, in two doses four weeks apart. 

The Mecklenburg County health department had not planned to do a large-scale event because supply was limited before the FDA decision on Aug. 9. That allowed administration of the vaccine intradermally, just under the skin, similar to how tuberculosis tests are given. Changing the administration method stretches the supply because only one-fifth of a five-milliliter vial is required per dose, meaning vaccine administrators could get five shots from a vial instead of one.

With a couple thousand vials en route, Mecklenburg, which had the highest number of cases at the time, did a lot of scrambling days before the Pride events.

“So in context, certainly we would consider it a success that we were able to mobilize so quickly, and to get so many people engaged,” Washington said. “We have been since the beginning of our response activities, sort of managing both a broader outreach campaign and a very targeted campaign, specifically at the Black and brown community to assure that access was available.

“We noticed very early on that there was a divergent in our case demographics and our vaccine demographics, where we were seeing more individuals of color with cases and fewer, a lower proportion that were getting the vaccine.”

The health department worked with party promoters, nightclubs and an inclusive church to get the word out and provide monkeypox vaccination opportunities during the Pride celebrations. 

In a trend that mirrors what has happened elsewhere across the South, the larger events have not drawn as many vaccine-takers as Jynneos vials allotted to the events. Some attribute it to people not wanting to interrupt the party. Others question whether people are vaccine weary because of the COVID-19 pandemic. Some say, such public settings turn people off. Public health advocates have shifted the vaccine strategy to smaller, more targeted events.

“We started working with the party promoters several weeks before Pride and actually and even participated in Black Pride — Charlotte has a separate Black Pride, which a lot of people don’t know about — and so we started working closely with them,” Washington said. ”Even in one weekend where at just a couple of parties, we were able to vaccinate 200 people, and you know the majority of them are Black, and so we had been working the ground prior to Pride, and Pride got a lot of national attention.

“Our campaign efforts have been going on before and after that, vaccinating individuals,” he said.

Engaging the community

Monkeypox cases in North Carolina and across the country have largely been confined to men who have sex with men, or MSM.

As of Sept. 15, 446 cases of monkeypox had been reported in North Carolina, according to DHHS. Ninety-eight percent of the cases were in men. Ten women have contracted the virus, according to the dashboard.

So far, North Carolina has vaccinated at least 16,042 people to protect them against monkeypox. The shots are available to anyone older than 18 who has had close contact with someone infected with the virus within two weeks.

The shots also are recommended for people who have had sexual contact within the past 90 days with gay, bisexual or other men who have sex with men or transgender individuals. People who were diagnosed with syphilis in the past 90 days or people with HIV or taking medications to prevent HIV also are encouraged to get a vaccine.

In North Carolina, where nearly 70 percent of the cases have been among the Black population, they represent only 27 percent of the people who have been vaccinated. Kody Kinsley, DHHS secretary, highlighted that a week and a half ago when he went to N.C. Central University, an HBCU in Durham, and got a vaccine to highlight partnerships that DHHS wants to continue to build with HBCUs.

At a White House briefing on Sept. 7, Demetre Daskalakis, deputy coordinator of the White House Monkeypox Response team, said building partnerships at the ground level with county health departments and community organizers would be key to virus containment efforts.

“It’s not about just the vaccine allocation,” Daskalakis told reporters, “It’s about that intense community engagement that happens on the ground because, ultimately, public health is a local event.  And so, giving the tools that people need to be able to sort of reach health goals is what we’ve been doing.  And the support of organizations that serve Black and brown people have been pivotal in really turning the tide in what I think you’re going to see, the new vaccine numbers emerging over the next few weeks.”

Erika Samoff, who heads up HIV/ STD surveillance for the state’s Division of Public Health, said the plan is to recruit and deploy more community health workers to help attack the spread of monkeypox. 

“Which I think is a really smart way to spend public health funds, to employ people who are coming from the populations that are sometimes most affected by disease,” she said. “I think that’s something new that we haven’t had before.”

Rebby Kern, director of education policy at Equality North Carolina, agrees that a successful campaign against monkeypox will require open lines of communication between state leaders and a collaboration of LGBT advocates. They have set up an educational site at poxvirusnc.org. They’ve had two virtual town halls since the first case was reported in North Carolina on June 23 and have plans for a listening session on Sept. 29.

The response thus far

David Wohl, an infectious disease specialist at UNC Health, spoke recently with NC Health News about the federal response to monkeypox compared to its response to COVID-19. Public health advocates complained in May, June and July that the demand for vaccine vials outpaced the supply.

“We’ve all become armchair epidemiologists and procurement specialists,” Wohl said. “I do think that there were problems with the monkeypox response but they are at a different level of magnitude compared to what happened with COVID-19 during the previous administration. 

“These are two very different outbreaks. These are two very different fumbles, if you will. So while the current administration was slow off the block in things like procuring vaccine and getting therapeutics out there, to their credit, testing was never a problem as far as capacity.”

There was no scramble to get reagents and stand up testing sites. Health care workers were not waiting for personal protective equipment.

“There was a cogent message,” Wohl said. “You might not have always agreed with the message, but one part of government wasn’t saying one thing, another part saying another thing, and there wasn’t denial, saying, ‘Oh this is nothing. It’s going to go away.’ It’s a completely different response and we’ve all become very cynical and jaded. 

Nonetheless, some things frustrated Wohl.