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Key Points
- On May 27, 2022, the Washington State Department of Health (DOH) reported the first case of confirmed orthopoxvirus presumed to be monkeypox virus (MPV) in a Washington resident. As of August 11, 2022, there were 31,800 MPV cases in 82 countries that have not historically reported cases. The U.S. has over 10,000 confirmed cases, and there are 254 confirmed and probable cases in Washington state. More information: 2022 U.S. Monkeypox Outbreak | Monkeypox | Poxvirus | CDC
- JYNNEOS vaccine is fully licensed for use in the U.S. for individuals 18 and older for the prevention of smallpox and monkeypox disease. Due to the increased number of cases in the U.S. and the limited vaccine supplies available, on August 9, 2022, the Food & Drug Administration (FDA) issued an Emergency Use Authorization (EUA) allowing a smaller intradermal dose for adults in lieu of subcutaneous injection. Individuals at risk of keloid scars should continue to receive the subcutaneous route. The EUA also authorized the full subcutaneous dose for children and adolescents under 18.
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To vaccinate more individuals with the limited vaccine supply, the Department of Health strongly encourages providers to utilize the smaller dose intradermal route for vaccinations of adults when possible. It’s important that we continue to vaccinate those who are at risk in the current outbreak to prevent further spread of the virus. Except for the intradermal route of administration, vaccine guidance and prioritization is unchanged.
Background
MPV cases in Washington state are doubling approximately every 7-8 days, indicating ongoing person-to-person community spread. MPV can cause a painful and scarring rash. The risk of severe illness is increased in children, pregnant women, and immunocompromised individuals; 12 deaths have been reported in other countries.
Any person, irrespective of gender identity or sexual orientation, can acquire and spread monkeypox. In this outbreak, most of the reported cases worldwide are among gay, bisexual, or other men who have sex with men (GBMSM). As of August 11, 254 Washington cases are in men and 3 in women.
Close contact or sustained skin-to-skin contact including sexual contact with a person with MPV or contact with contaminated fomites (e.g., shared linens) are the most significant risk factors associated with human-to-human transmission of MPV. There is also documented transmission for persons to animals.
Intradermal Vaccination Routes
Because the intradermal route uses a lower dose than the subcutaneous route, more individuals can be vaccinated with a given volume of vaccine. Clinical studies indicate the antibody response from the intradermal route is non-inferior to that obtained through subcutaneous injection. For more information about these studies, side effects, and other screening and contraindications on vaccinations, please review the FDA and CDC guidance linked in this document.
Those who are administering intradermal vaccinations can review refresher information here: https://www.youtube.com/watch?v=TLv1mR6mECQ.
Infection Control of Vaccine Vial
JYNNEOS vaccine is provided in preservative-free 0.5 mL vials. When utilizing for multiple doses, it is critical to follow aseptic technique, appropriate needle and syringe, and follow administration guidance to prevent contamination. Once the vaccine vial is accessed, it must be used within 8 hours to maintain effectiveness. More information can be found here: JYNNEOS Smallpox and Monkeypox Vaccine Subcutaneous Vaccine Preparation and Administration Summary: STANDARD REGIMEN (cdc.gov)
Vaccine Guidance
JYNNEOS is licensed for a 2-dose series given at an interval of 28 days. In the setting of limited vaccine supply, DOH recommends prioritizing the administration of first vaccine doses rather than retaining inventory for second doses. This means that some people may have their second dose of vaccine delayed beyond 28 days until vaccine supply increases. Exceptions include people with moderate to severe immunosuppression, for whom the second dose should be administered as close to 28 days after the first dose as possible.
Post Exposure Prophylaxis (PEP)
- CDC recommends that the vaccine be given within 4 days from the date of exposure in order to prevent onset of the disease. If given between 4–14 days after the date of exposure, vaccination may reduce the symptoms of disease, but may not prevent the disease.
- Those with previous smallpox vaccination who are exposed to MPV, and who have not received the smallpox vaccine in the last 3 years, should consider getting vaccinated.
- Due to the EUA, those under the age of 18 can receive post exposure vaccination in accordance with Washington state law.
- If the individual develops symptoms of disease after the first dose is administered, it is not recommended for the individual to receive the second dose.
Outbreak Response Post-Exposure Prophylaxis: Individual-directed PEP
For persons with risk factors that might have recently exposed them to MPV, even if they have not had a documented exposure to someone with a confirmed diagnosis.
Persons meeting both of the criteria below:
- Gay, bisexual, or other person born male who has had sexual contact with another person born male, or trans or non-cisgender people (regardless of sex at birth) who have sex with people who identify as gay, bi, or otherwise MSM in the past 3 months, and
- At least one of the following risk criteria**:
- Multiple or anonymous sex partners in the last 3 months
- History of early syphilis or gonorrhea in the prior year
- Methamphetamine use in the last 3 months
- Attendance at a bathhouse, public sex venue, or group sex (sex including >3 people at the same time) in the last 3 months
- Experiencing homelessness/unstable housing (including living in a shelter, car, or congregate setting; living with friends or relatives; couch surfing) in the last 3 months
- Being incarcerated currently or in the last 3 months
- Exchanging sex for money, drugs, or other purposes in the last 3 months
- Black, Hispanic/Latinx, Native Hawaiian and Other Pacific Islanders, Asian, Indigenous, or American Indian/Alaska Native
For individuals under the age of 18 meeting the identified criteria, obtain consent in accordance with Washington state law.
These criteria may be changed in the future as vaccine availability changes or as we learn more about populations at risk for monkeypox virus infection. Every attempt should be made to maximize vaccine usage in open vials by planning clinical events while ensuring to follow requirements to discard unused portions in open vials 8 hours after opening. This could include expanding recipients of vaccine to those outside the individual-directed PEP and ensuring second doses are administered to prevent wastage.
*Examples include (but not limited to) sexual intercourse, intimate skin-to-skin contact (such as club dancing, cuddling, hugging, etc.)
**Incubation period is 21 days; use of 3 months is to expand identification of individuals at risk.
Documentation in the Washington Immunization Information System (IIS)
It is important that the vaccine route is accurately documented to ensure appropriate dosage for transfer into the IIS. Please see this link for more information: Monkeypox Vaccine Management WAIIS.
We appreciate the help of Washington health care providers to help reduce the spread of MPV and assist Washingtonians to the best health.
Resources & Guidance
https://www.cdc.gov/poxvirus/monkeypox/considerations-for-monkeypox-vaccination.html
COCA call link: Webinar Thursday, August 11, 2022 - CDC and FDA Update: Interim Clinical Considerations for Monkeypox Vaccination
DOH webpage for health care providers: Monkeypox (MPV) Provider FAQs and Resources | Washington State Department of Health
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