With Michigan hitting just over 100 confirmed and probable monkeypox cases as of Wednesday, health care providers say they’re starting to split doses of the vaccine per the FDA’s advisory last week.
But given the limited vaccine supply and how overwhelmed health departments and clinics are right now, doctors say the focus still needs to be on the community that’s been hit hardest by the virus. That’s primarily men who have sex with men and have multiple sex partners. But in Michigan, vaccine eligibility has also expanded to include anyone who has multiple sex partners, especially if they engage in “high risk” activity (more on that below.)
Here’s what you need to know.
1. Phones are ringing off the hook as people try to get vaccinated
Michigan (and the rest of the U.S.) has seen a pretty significant uptick in cases the last couple of weeks. But Michigan’s case numbers are still, thankfully, only a fraction of what states like New York and California are experiencing. And even though monkeypox transmission is picking up, this isn’t COVID: there are still just about 13,000 confirmed cases nationwide right now, and deaths from monkeypox are extremely rare.
But Dr. Shira Heisler’s phones won’t stop ringing. She’s the medical director for the Detroit Public Health STD Clinic, and so many people were calling to get the vaccine, she had to set up a dedicated monkeypox hotline. Like so many in the public health world, the clinic is critically understaffed right now, so she recruited and trained medical students to answer the flood of patient voicemails stacking up.
“They are returning, in a day, over 50 voicemails,” Heisler said. “People are worried. I have people driving two hours to get this vaccine. I have people crossing state lines to get this vaccine.”
The state’s public health system is straining to respond to yet another viral outbreak. Underfunded even before COVID, local health departments and clinics like Heisler’s are trying to scrape solutions together on the fly. Like when one of the Dr. Heisler’s patients desperately needed TPOXX, the hard-to-get medication used to treat monkeypox. The patient was HIV-positive and had a compromised immune system.
“He had lesions in the mouth, really painful, and they were everywhere. I think I spent, I don't even know how many hours on the phone to get him TPOXX. And the ultimate thing was Oakland County and Washtenaw County [Health Departments] had the medication. Well, okay, my patient doesn't have transportation, and so I'm like, ‘Can you drop it off there?’ They’re like, ‘We don't have staff.’ I'm like, ‘We don't have staff!’”
Heisler couldn’t leave her patients in order to go pick up the medication. Eventually, a health department staffer dropped it off at the clinic the next day, but that’s not a sustainable system, she said.
2. The FDA is advising providers to split doses of the vaccine now
So far, Michigan’s only been allotted some 7,600 doses of the monkeypox vaccine, and roughly 2,500 of those have already been administered. And the U.S. isn’t expected to get a big boost in supply until next year. In response to the shortage, the FDA announced last week it was giving an emergency use authorization for a new type of vaccine administration: injecting it between upper layers of the skin (called “intradermal” injection) rather than subcutaneously, aka below the skin.
The FDA’s pointing to a study showing both types of administration produced similar immune responses. But the big upside is intradermal injection requires only a fifth of the usual dose — meaning, at least in theory, Michigan’s monkeypox vaccine supply could stretch to thousands more patients.
Not everyone’s convinced that’s a good idea. The pharmaceutical company that makes the monkeypox vaccine told the FDA it has some “reservations … due to the very limited safety data available” about splitting the dose, The Washington Post reported. But after the FDA held a call with medical providers about the research behind the decision, Dr. Heisler feels optimistic.
“One vial now can spread to five doses, so [that’s] five times the amount of people we can give it to,” Heisler said. “Which is quite incredible.”
3. Keep limited resources focused on the communities with the highest risk
While vaccine eligibility has expanded in Michigan to include all people with multiple sexual partners, resources are still limited, and experts say they should be focused on the communities with highest risk. As of July 25, 99% of cases with sex information available were men, the CDC said. “Among the male patients with information on sexual activity, 99%....reported male to male sexual contact.”
That doesn’t mean every man who has sex with men is at high risk, said Dr. Paul Benson, medical director of the Be Well Medical Center in Berkley, which focuses on the LGBTQ community.
“I don’t want people to think that every gay person is going around to bath houses, and that every gay individual should be vaccinated because they’re high risk,” he said. “There are an awful lot of individuals that are in monogamous, happy, gay, same sex relationships, who are not really high risk because they're not having the multiple sexual partners.”
And that’s true regardless of someone’s sexuality, since monkeypox is spread through “direct contact with the infectious rash, scabs, or body fluids” or “respiratory secretions during prolonged, face-to-face contact, or during intimate physical contact,” according to the CDC.
The risk to kids from monkeypox is low, according to the American Academy of Pediatrics. And so far, cases among children are very rare: as of August 17, kids account for fewer than 10 confirmed cases in the U.S. But college students should be cautious, Benson said.
“They may not identify as being high risk…[but] I think the issue needs to be dealt with that young, sexually active, heterosexual, multi-sexual-partnered individuals, they need to be vaccinated,” he said. “And moved closer to the front of the line compared to elementary school people or people that are in monogamous…relationships.”
But practical, “common sense” precautions can be effective at preventing transmission, Benson said. “Avoid intimacy with multiple people, and if you are going to have sexual relations or intimacy, do a health check on yourself,” he said. “Make sure there are no sores. Make sure you're not running any fevers and that you're feeling well. And ask those same questions of your partner.”
Don’t just trust that your partner will tell you if they’re experiencing symptoms either, he said.
“When we’re dealing with human behavior, it all goes out the window. I can tell you some very disappointing stories of patients that have monkeypox, and I told them, ‘You need to isolate.’ And they’ve gone on airplanes and went to sexual festivals and parties and spread it to other people. And these people end up calling me, wanting to go on the medication from Florida or other states. Not everybody does that…but there's a percentage of people, hopefully a very, very small percentage, that just don't follow sound medical advice.”
