The San Francisco Department of Public Health is starting to offer monkeypox vaccines to more at-risk gay and bisexual men and transgender people in an effort to stem the growing outbreak.
"The vaccine is going to be our most important tool for really getting this under control," San Francisco Health Officer Dr. Susan Philip told the Bay Area Reporter during a phone interview June 30. She said DPH is working with HIV prevention partners, sexual health clinics, community organizations and advocates to finalize details about eligibility and access.
The rollout is part of an enhanced vaccine strategy released by the White House and the Department of Health and Human Service on June 28. The Centers for Disease Control and Prevention activated its Emergency Operations Center the same day to facilitate the national monkeypox response.
"Now we have a comprehensive monkeypox response plan that's focused on a few key pillars," White House COVID-19 response coordinator Dr. Ashish Jha said at media briefing this week. These include scaling up and decentralizing testing, scaling up and delivering vaccines, supporting health care providers, and "deep engagement with communities that are most affected," including the LGBTQ community.
The monkeypox outbreak outside endemic countries in Africa was first reported in the United Kingdom in early May. As of July 1, the CDC has identified 460 confirmed cases in 30 states; Washington, D.C.; and Puerto Rico. California has reported the most cases, at 95, including 16 in San Francisco, five in Alameda County, and at least one each in Santa Clara, San Mateo, and Santa Cruz counties. Worldwide, the CDC has tallied more than 5,300 cases in non-endemic countries.
While anyone can get monkeypox through close personal contact, the virus is primarily spreading within networks of gay, bisexual, and other men who have sex with men. Many of these men reported multiple recent sex partners or attended venues and events where sex and other intimate contact takes place. Only a small number of cases have been identified among women and children.
DPH does not yet have a demographic breakdown for the San Francisco cases, but Philip said she expects the local epidemiology to follow the same pattern.
Because of limited testing and the challenges of contact tracing when people have sex with casual partners or attend large gatherings, many experts think the latest case counts do not reflect the full extent of the outbreak.
Currently, state laboratories test for orthopox (the virus family that includes smallpox and monkeypox), but confirmation of a monkeypox diagnosis must be done at the CDC. The White House recently announced that five large commercial labs will offer monkeypox testing, but this has not yet started in California, Philip said.
"We are dramatically scaling up and decentralizing testing," Dr. Raj Panjabi of the White House National Security Council told reporters. "We're trying to increase testing access and convenience in every community."
Monkeypox transmission
Monkeypox, which is related to smallpox but less severe, causes flu-like symptoms, swollen lymph nodes, and a rash that can appear anywhere on the body. In the current outbreak, many men have presented with lesions on the genitals or in the anal area that may resemble common sexually transmitted infections such as herpes or syphilis. Some cases are "a bit more subtle" and might be missed if people aren't looking for them, Dr. Andrea Tenner, DPH's director of public health emergency preparedness and response, previously told the B.A.R.
The monkeypox virus spreads through close personal contact, including skin-to-skin contact, kissing, and respiratory transmission at close range. But it does not spread through the air over longer distances like the coronavirus that causes COVID-19, according to the CDC. It can also spread via clothing, bedding, or surfaces that come in contact with fluid from the lesions. It is not yet known whether monkeypox is transmitted in semen or vaginal fluid, but it does spread via contact with sores during sex.
Monkeypox has an incubation period of up to three weeks before symptom onset, and the illness usually lasts two to four weeks. It is considered infectious until the sores heal completely and scabs fall off. Most people recover without treatment, and there have been no deaths in non-endemic countries so far. But the sores can leave scars, some patients have required hospitalization for pain management, and people with severe disease can develop complications. Pregnant people, children, and immunocompromised individuals — including those with poorly controlled HIV — are at greater risk for severe illness.
Vaccine rollout
Smallpox vaccination can prevent monkeypox too. Because the monkeypox virus has a long incubation period, vaccines can be used both as post-exposure prophylaxis for up to two weeks after exposure (but sooner is better) and as pre-exposure prophylaxis for people at high risk. People over the age of 50 or so who were vaccinated as children may have some protection against monkeypox, but immunity could have waned over time.
A safe nonreplicating smallpox and monkeypox vaccine called Jynneos was approved in 2019. It is administered as two doses, four weeks apart. An older live virus vaccine can cause adverse side effects, especially for immunocompromised people. The United States maintains a stockpile of the older vaccine in case of bioterrorism, but Jynneos is in short supply.
Monkeypox can be contained through ring vaccination, or targeted vaccination of close contacts of known cases. Because contact tracing can be difficult or incomplete, a broader strategy involves vaccinating people who are likely to have been exposed, such as gay and bi men with multiple recent sex partners and those who attended venues or events where the virus was known to be present. Broader still is vaccinating individuals at high risk in communities where the virus is circulating.
The local and national vaccination efforts will start with people at greatest risk and expand as the vaccine supply increases. "The administration's current vaccine strategy prioritizes making it available to those who need it most urgently," CDC director Dr. Rochelle Walensky told reporters. "As soon as we have more vaccines available, we will of course continue to expand from a post-exposure prophylaxis strategy ideally to a pre-exposure prophylaxis strategy."
So far, around 10,000 doses of Jynneos have already been deployed nationwide. HHS has allocated another 56,000 doses to affected communities, and an additional 240,000 doses are "on their way in the next few days," Panjabi said.
San Francisco received 60 vaccine doses in early June and another 300 since then, of which 150 have been administered so far, according to Philip. Another 200 doses are expected later this week. DPH is now prioritizing gay and bi men and trans people who have had close contact with a known monkeypox case or could have been exposed at a venue or gathering.
"We do anticipate that supplies will increase week over week and that we will be able to ramp up who we get the vaccine to," Philip said. "We really want people in these initial days to be patient ... allow the highest-risk people to go first."
New York City and Washington, D.C., briefly launched monkeypox vaccine clinics last week, offering the shots to gay and bi men with a high likelihood of exposure, but had to stop after their limited supply was snapped up within hours.
HHS expects more than 750,000 additional Jynneos doses to be made available over the summer, and 500,000 more doses will complete manufacturing and inspection throughout the fall, adding up to 1.6 million doses by the end of the year.
The number of gay and bi men and trans people eligible for monkeypox vaccination is unclear, but eligibility for HIV PrEP can serve as a rough proxy. Around 940,000 HIV-negative men are considered eligible for PrEP, and some proportion of the approximately 700,000 gay and bi men living with HIV are also at risk for monkeypox.
HIV activist James Krellenstein of PrEP4All told the B.A.R. that the expected 1.6 million doses is not enough to meet the demand. The advocacy group is urging the Biden administration to further expand testing and accelerate the vaccine procurement process.
According to Krellenstein, the U.S. has more than a million purchased vaccine doses ready to go at the Bavarian Nordic manufacturing facility in Denmark. The federal Food and Drug Administration failed to inspect the factory on schedule, but the European Medicines Agency has done a recent inspection that the U.S. could recognize. The U.S. owns an additional 15 million doses that just need to be put in vials for distribution, he said.
At this time, vaccination is not indicated for the population at large. While it is expected that monkeypox will reach beyond the currently affected social and sexual networks — for example, to household members and caregivers — most experts think it is unlikely to spread widely in the general population.
For this reason, and because it is not currently causing severe illness in the most affected groups, the World Health Organization last week declined to declare monkeypox a public health emergency of international concern. But the agency is watching the outbreak and will continue to reassess.
"This is clearly an evolving health threat that my colleagues and I in the WHO Secretariat are following extremely closely," WHO director-general Dr. Tedros Adhanom Ghebreyesus said in a statement.
As the vaccination effort ramps up, health officials urge anyone with a rash or other possible monkeypox symptoms to seek medical care, get tested, and avoid sex, other close contact, and social gatherings until the results are known. People who test positive for monkeypox are advised to isolate for three weeks. Those who think they might have been exposed should self-monitor for symptoms.
In San Francisco, people who do not have a regular health care provider can contact City Clinic on Seventh Street or the San Francisco AIDS Foundation's Magnet sexual health center in the Castro.
"In San Francisco, we have such a knowledgeable community. We have such expert community-based organizations and advocates and health care providers that we are in a good position to really deal with this outbreak," Philipp said. "We want to support everyone's sexual health in San Francisco by making sure that they're aware and preventing additional cases of monkeypox."
Click here for the latest updates on vaccine eligibility and locations.
To contact City Clinic, click here or call its new phone number, 628-217-6600. To contact SFAF's Magnet clinic at Strut, click here or call 415-581-1600.
Updated, 7/1/22: This article has been updated with the latest numbers from the CDC.
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