There Are More Monkeypox Vaccines—But Immunocompromised People May Still Be at Risk

Questions emerge about vulnerability of immunocompromised individuals in places where only one dose of the two-dose monkeypox vaccine regimen is available. Concerns are heightened amid new FDA-approved dose splitting plan.

A man waits in line to recieve the Monkeypox vaccine before the opening of a new mass vaccination site at the Bushwick Education Campus in Brooklyn on July 17, 2022, in New York City. - New York, on the US East Coast, has already either administered or scheduled 21,500 vaccines and hopes to speed up the process, promising more than 30,000 jabs for the whole state. (Photo by Kena Betancur / AFP) (Photo by KENA BETANCUR/AFP via Getty Images)
Photo: KENA BETANCUR/AFP via Getty Images

Fast Facts

  • The FDA authorized splitting monkeypox vaccine doses to stretch supply.
  • Health experts are unsure if the lower dose is enough to fully protect immunocompromised people.
  • Prevention is still key to stopping the spread of monkeypox—and if someone begins to feel ill, they should contact a healthcare provider right away.

With vaccine demand far exceeding supply as the monkeypox virus continues to spread, it's not unusual for individuals to have difficulties securing the second dose in the FDA-approved two-dose regimen.

And while some research has shown that one dose of the monkeypox vaccine may be sufficient to keep serious illness at bay for many people, there's growing concern about how those who are immunocompromised—such as H.I.V. patients— may fare without the full two-dose vaccination.

Exacerbating these concerns further, the US Foods and Drug Administration (FDA) recently provided emergency use authorization for a low dose approach to monkeypox vaccination that involves splitting one vaccine dose into five smaller doses—in an attempt to make existing supply stretch further.

This latest development raises further questions about the level of protection being provided to those with compromised immune systems.

"When we talk about dose-sparing strategies or giving a single dose and delaying the second on immunocompromised patients, we actually have a lot of uncertainty around these‌ strategies," Michael Chang, MD, an infectious disease physician at the University of Texas Health Houston and Memorial Hermann Hospital, told Health. "If you ask me about protection against infection, the truthful answer is we don't necessarily know."

Here's a closer look at what the current monkeypox dosing strategy may mean for immunocompromised individuals.

Why Are Vaccine Doses in Short Supply?

Technically, the United States had a head start tackling the monkeypox outbreak. In 2014, the Strategic National Stockpile, a federal storehouse of supplies for public health emergencies, reported it had 20 million smallpox vaccines (which are effective for monkeypox as well). Fast forward to the present, and only 2,400 doses were left when the current monkeypox outbreak erupted.

"The primary issue is that no one anticipated the scope and scale of this monkeypox outbreak," explained Dr. Chang. "It was a surprise to many that we would have over 30,000 cases globally, especially since traditional monkeypox has not been that easily spread from person to person."

That lack of supply has been challenging at best. Most recently, the U.S. Department of Health and Human Services (HHS) announced plans in July to allocate an additional 786,000 doses of the JYNNEOS vaccine, thus substantially increasing the supply of monkeypox vaccine doses available throughout the country.

Still, even that amount is not enough to protect the 1.6 to 1.7 million men who have sex with men, a population that the Centers for Disease Control and Prevention (CDC) says represents nearly all the monkeypox cases in the country.

Why Are the Immunocompromised at Risk?

Immunocompromised states can range from cancer to Type 1 diabetes. Individuals with low immunity are at increased risk when exposed to pathogens or disease. With regard to monkeypox in particular, the World Health Organization (WHO) reports that such individuals develop severe cases and may even have their number of lesions expand from just a few to several thousand. What's more, in some rare but severe cases, there are reports of large areas of skin coming off.

Given that monkeypox cases predominantly involve the gay community, some health officials are particularly worried about individuals living with HIV or AIDS. About 1.2 million people in the United States have HIV, and more than half of the individuals living with HIV are gay and bisexual men, according to the CDC.

For this reason, some medical professionals recommend getting the vaccine in any amount you can to have some form of protection if you're immunocompromised.

"You would be privileged to receive that one-fifth dose and that second one-fifth dose as part of protecting yourself against monkeypox, because you're at high risk," Donald Alcendor, PhD, an associate professor at the Center for AIDS Health Disparities Research Division of Microbiology & Immunology at Meharry Medical College, told Health.

Protecting Yourself While Awaiting a Second Vaccine

While waiting for the second dose of the monkeypox vaccine, the most important step for immunocompromised individuals is to assess their risk. This means developing an understanding of how likely it is you may come into contact with the virus. While not a sexually transmitted disease, most cases have happened from physical contact during intercourse.

Talking with sexual partners about their recent sexual history may help you avoid viral exposure.

"It's really important to have open and transparent discussions with any sexual partners or intimate partners," explains Dr. Chang. He says questions you might want to ask are:

  • Do you have a new sexual partner?
  • Do you know the history of your sexual partners?
  • Are any of your sexual partners having symptoms, whether that's lymph node swelling, fever, sore throat, or rashes all over the body?

Another group of individuals you should have frank discussions with are people you come into daily close contact with, such as those in your household. It's important to understand how your risk is affected by the activities of other household members.

If you are exposed and can't get your hands on a vaccine, Alcendor recommends finding other available treatments such as TPOXX. TPOXX is an FDA-approved antiviral drug for adults and children that can help fight off the monkeypox virus. ‌

TPOXX may be helpful for monkeypox infections concentrated in the eyes, mouths, genitals, or anus. An alternative option recommended by Alcendor is using immunoglobulins from people that have recovered from the disease. Although the CDC says the use of immunoglobulins has no proven benefit against monkeypox, doctors may decide to prescribe it in severe monkeypox infections.

Another alternative to the Jynneos two-dose regimen, though somewhat risky, is the single-dose ACAM2000 vaccine. The ACAM200 vaccine takes four weeks to take effect and carries more side effects. Depending on your condition, a doctor may recommend you take ACAM2000 if the Jynneos vaccine is unavailable. Although this may not be the best option for people with severely weakened immune systems.

Finally, Alcendor says people who have the means to travel out of state may be able to find a vaccine in another area where monkeypox cases are low. Individuals can also try signing up for alerts from local health departments regarding monkeypox vaccine availability. Both New York and Los Angeles have established such alert systems.

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