Can the ring vaccine in the US contain monkeypox?

Ring vaccination has worked for smallpox because a person-to-person pattern of spread allows chains of transmission to be predicted and broken. The process is straightforward: find the people most at risk of infection and give them vaccinations. But to take those actions today to curb monkeypox, you need to find cases, you need to identify their likely contacts — and, crucially, you need to have vaccines to distribute. So far, none of these efforts are going well in the US, and epidemiologists, scientists and LGBTQ sexual health experts are skeptical that ring vaccination will be successful.

For one thing, the numbers are growing too fast. “If there were five people, we could do our best to do a ring shot,” says Gregg Gonsalves, an assistant professor of epidemiology at the Yale School of Public Health and a longtime HIV/AIDS activist. “But now that you’re dealing with potentially thousands of cases across the US, trying to trace them all and vaccinating all their contacts doesn’t seem like that’s going to happen.”

Any attempt to identify, warn and protect those most at risk will therefore have to rely on incomplete information. If ring vaccination is a fence around infection risk, “there are huge gaps in the fence,” says Steven Thrasher, an assistant professor of journalism at Northwestern University and author of a new book on the interplay of viral infections and inequality.

“As far as I can tell, contact tracing was random, to say the least, and testing was basically unavailable until last week,” agrees Angela Rasmussen, a virologist and associate professor at the International Vaccine Center of the Vaccine and Infectious Disease Research Organization the University of Saskatchewan. “The vaccine is being released in droplets and droplets and it seems like anyone who signs up fast enough can get one. But this is not a ring vaccination. That’s just offering doses to people who might be at risk.”

There’s a lot to unpack here and plenty of finger pointing. Start with the vaccines. Spreading from both wildlife and person-to-person to humans, monkeypox has been a constant presence in Africa for decades. (Whether the international community should have looked into this then, rather than just getting involved now, is debatable.) There are two potentially applicable monkeypox vaccines: the ancient smallpox vaccine that was stockpiled against potential bioterrorism, and a newer vaccine with fewer side effects. When the US government first became aware of the outbreak in late May, it had only 32,000 two-dose cycles of this safer vaccine available in the Strategic National Stockpile. Another million doses were hung – bottled and ready for shipment – at a plant in Denmark, but the Food and Drug Administration had not approved their distribution. Earlier this month, the Department of Health ordered 5 million doses of the newer vaccine, but most won’t arrive until next year.

The limited doses available were sent to state health officials using an HHS algorithm that calculated a ratio of cases already detected to the number of people believed to be at highest risk. That sent most of them to big cities: New York, Los Angeles, San Francisco, Chicago and others. In New York City, online registration for 9,200 vaccination appointments took 7 minutes.

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