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Facing a monkeypox vaccines shortage, the U.S. is pursuing a new dosing strategy

MARY LOUISE KELLY, HOST:

It was about three months ago that the first case of monkeypox was discovered in the U.S. Now, there are well over 13,000 cases. That is more than any other country in the world. The U.S. government's plan to get the disease in check is largely based on a vaccine, but there are a lot of questions about how well that plan might work. So here to take on those questions are two of our NPR health correspondents, Pien Huang and Michaeleen Doucleff. Hey, you two.

MICHAELEEN DOUCLEFF, BYLINE: Hello.

PIEN HUANG, BYLINE: Hey, Mary Louise.

KELLY: Pien, you start. Just give us an update. There have been a lot of twists and turns in the vaccine rollout so far. How's it going?

HUANG: Well, it's not going great. I mean, from the beginning, the government was slow to order vaccines. There was a lot of confusion from states, cities. And there have been long lines of people waiting to get it. And many people haven't been able to get one yet. You know, months into the response, the government is still playing catch-up. They've recently set up a White House response team. They've shipped more than 700,000 vials of the vaccine out. And they are working to get a lot more. But it just has not been enough. Cases keep rising. The vast majority are still being detected in gay and queer people, primarily men who have sex with men. And states and public health officials are getting very frustrated. The added complication is that the White House is now pursuing a new dosing strategy which involves giving a smaller vaccine dose to more people. And that's been controversial for some.

KELLY: A smaller dose - OK, what is the controversy there?

HUANG: Well, previously, getting that vaccine meant getting a full vial injected into your arm. And now with this new strategy, a smaller dose is getting injected into the skin very close to the surface. And this allows providers to use one-fifth of the original dose, which stretches the supply. And that sounds great - right? - stretching the supply. But it isn't all that simple. I mean, from a messaging perspective, it's been very confusing trying to explain why the government thinks a smaller dose will work just as well.

KELLY: Yeah.

HUANG: From a perspective of giving it out, it also takes additional training, different needles. And Dr. Mark Del Beccaro, who is helping to lead the vaccine rollout in Seattle and King County, says it's just hard to get these small doses out of the vials.

MARK DEL BECCARO: That - the federal announcement of five doses per vial was, I think, incredibly optimistic. And what we're seeing in real life is three to four doses per vial.

HUANG: In reality, this dose-splitting strategy is not yielding as much as federal officials had hoped. And yet, Del Beccaro says it seems like the government is already using this new math when they count how many doses they're sending to health departments.

KELLY: Michaeleen, let me back us up a little bit. Pien's been telling us about vaccine availability or lack thereof. What about efficacy? If you can get the vaccine, does it work?

DOUCLEFF: Yeah. So here's another reason why cutting the dose, as Pien's been talking about, is a bit concerning. Right now, we don't know how well the vaccine works. It clearly offers some protection, but at what level, we don't know. And that's because there has never been a clinical trial to measure its efficacy. In fact, there has been very little testing of this vaccine against monkeypox in people. Most of the studies have been in animals. I was talking to Dr. Boghuma Titanji about this. She's an infectious disease specialist at Emory University, and she's been immunizing people at her clinic. And here's how she counsels people about the vaccine.

BOGHUMA TITANJI: I tell them, you know, we do know that you're going to get some protection from this. Some protection is better than no protection. We also do know that it can reduce the severity of the disease if you do develop the disease. But we don't know for a fact that you would be completely protected from getting monkeypox.

DOUCLEFF: And to be clear, she's talking about protection with the full vial. If we cut the dose, she says, it could lower that protection further.

KELLY: Can I pause on something you just said? There's been very little testing. You said there's never been a clinical trial for this vaccine. What is the evidence for giving it to people right now?

DOUCLEFF: Yeah. So there's never been a Phase 3 clinical trial to measure efficacy. But this vaccine, which is called JYNNEOS, was actually developed to stop smallpox. Versions of this vaccine were what were used to eradicate smallpox. And so versions of this vaccine have been around for decades and have been given to hundreds of millions of people. So it has a very long track record.

Back in the 1980s, researchers started to notice something really remarkable about the smallpox vaccine. During monkeypox outbreaks, people who had been immunized against smallpox were actually less likely to get monkeypox. They were protected. And that's because smallpox is closely related to monkeypox. They're a bit like cousins. And since then, researchers have shown that indeed, the vaccine does trigger the production of antibodies against monkeypox inside people's blood. And so it's that experiment and some animal studies that this vaccine has been approved on.

KELLY: Let me pose another question and put this one back to you, Pien. There's the question of, does the vaccine work? There's the question of, do we have enough of them? Then there's the question of, do people want this? Does it seem like people are open to getting the monkeypox vaccine?

HUANG: Actually, yes. I mean, there's a huge demand right now. And there's many more people that want the vaccine than can actually get it. And one of the biggest concerns at the moment is equity. You know, a disproportionately high number of Black, Latinx members of the gay and queer community are getting monkeypox. And the data suggests that they have had a harder time getting access to vaccines. In North Carolina, for instance, 70% of the monkeypox cases have been in Black men, but just a quarter of the vaccines have gone to them. Chicago is also seeing gaps in vaccines for Black and Latino men. And these are just the places that have shared their data. Kenyon Farrow with the advocacy organization PrEP4All says a sentiment that he's been seeing online, especially from gay men of color...

KENYON FARROW: OK, so they let white gay men take all the first, you know, full course of doses. And so we're now supposed to believe that, you know, a fifth of a dose is going to do us just as well.

HUANG: Farrow says that public health has a lot of work to do in terms of explaining why they believe that this new strategy is not inferior.

KELLY: Michaeleen, I'll give you last word. If we can get enough doses out there and get them to the people who need it and get the people who need it to take it, realistically, can we still slow down this outbreak?

DOUCLEFF: So there's some tantalizing new data right now that suggests that, yes, this vaccine can slow down monkeypox outbreaks. There are several countries that rolled out the vaccine much earlier than the U.S. did, and that includes the U.K. and Germany. And there are signs that their outbreaks are slowing down quite quickly. In the U.K., for example, the number of new cases has been steadily declining for several weeks now. So that's hopeful. But doctors and researchers I talked to say the vaccine alone isn't it enough to stop the outbreak here. People need to reduce their risk. And - this is key - doctors need to catch more of the monkeypox cases out there. Right now, many are still not getting detected.

KELLY: NPR health correspondents Michaeleen Doucleff and Pien Huang. Thanks to you both.

HUANG: You're welcome.

DOUCLEFF: You're welcome. Transcript provided by NPR, Copyright NPR.

Pien Huang is a health reporter on the Science desk. She was NPR's first Reflect America Fellow, working with shows, desks and podcasts to bring more diverse voices to air and online.
Michaeleen Doucleff, PhD, is a correspondent for NPR's Science Desk. For nearly a decade, she has been reporting for the radio and the web for NPR's global health outlet, Goats and Soda. Doucleff focuses on disease outbreaks, cross-cultural parenting, and women and children's health.