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In the United States, the circumstances around monkeypox vaccine are a good news, bad news kind of story.

The good news is that there is a licensed vaccine. At the start of many outbreaks of new or rare diseases, there are no vaccines. But the bad news quickly overtakes the good. Demand outstrips supply, both domestically and internationally. In the U.S., the federal government has decided to use fractional doses — one-fifth of a normal dose, per person — to try to stretch supplies.

Putting that seemingly sensible approach into action will be easier said than done, said Claire Hannan, executive director of the Association of Immunization Managers.

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Members of  the organization — leaders of state, territorial, and local immunization programs — work where the rubber meets the road, where vaccine doses in vials are positioned where they will turn into vaccinations in arms. These people are beyond exhausted, as they struggle to deal with a complicated monkeypox vaccine rollout that comes on top of multiple rounds of Covid vaccinations — primary series plus boosters — and prepare for a busy autumn where delivery of flu shots and updated Covid boosters will soon begin.

STAT spoke to Hannan about how the monkeypox vaccination campaign is functioning. The interview has been lightly edited for clarity and length.

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What are your members facing when it comes to the distribution of monkeypox vaccine?

Well, what aren’t we facing? I mean, it’s a case of trying to respond as quickly as possible with obviously limited supply. It’s a less-than-perfect situation. It’s extremely challenging for my members because Health and Human Services isn’t using the existing Covid vaccine delivery infrastructure. So they’re having to learn a new ordering system. It’s not connected to their inventory, tracking, and management. The vaccine is not getting shipped directly to the provider site, so they’re having to plan for transport.

Is it being shipped to health departments?

You can only have it shipped to five sites per state. And so, for example, a state like Pennsylvania has five sites that are receiving shipments. They are then transporting vaccine to 12 sites across the state and from there, transporting it from those 12 sites to direct provider administration sites. So the vaccine is traveling three times. It takes hours. It takes a lot of staff. The tracking is very difficult. The tracking is basically by email that your vaccine has been delivered. And then we try to track it down and it hasn’t been delivered. It’s inefficient. It’s a real struggle.

We don’t have a standardized or centralized distribution. We don’t have standardized provider enrollment. We don’t have standardized data sharing. All of that infrastructure that’s been built for Covid, we don’t have that. So I think it’s just exhausting and challenging. Trying to do the best we can and make the vaccine as accessible as possible for those communities that need it. But definitely it’s a challenge with resources too. We don’t have specific funding for it.

Will any of this change now that the monkeypox outbreak has been declared a public health emergency?

I’m very happy that they have declared an emergency. I think that helps with resources. I’m very happy that they have named a command structure, that you have a White House coordinator in place. I’m hoping that that will really improve things. But it’s very challenging.

And it’s really frustrating to try to do all of these things at the same time you’re trying to plan for a Covid booster campaign. I mean, you’re spending three hours trying to track a package that with Covid, you can track it online in two seconds. You just click on the box, find out where it is. You order something on Thursday. Eight days later, where is it?

Robert Fenton, the newly appointed White House monkeypox coordinator, is from FEMA. You’d expect that organizational expertise would be a strong suit of someone from FEMA, no?

I think so. But I think that they’re using channels that are not meant for vaccines. They’re distributing vaccine through the Strategic National Stockpile structure. They’re drop shipping at the sites at 3 a.m. There’s no one there to receive it and put in the freezer. I hope that things will get better. But I think that there’s just there’s a mentality of “We’ve got to do this. We’re doing it this way, let’s figure it out.”

We certainly want to do that. But if you’ve built an extensive system to respond to a fire and then there’s a fire, and someone tells you to respond to it a different way, it’s really challenging for you. Especially when you’re dealing with all these other things. When you go on the media and say, “We’re going to allow providers to get five doses out of a single dose vial,” and then the states are just left to figure out how that’s going to work.

You mean how to operationalize using fractional doses with intradermal administration?

Yeah. Implementation and operationalization are extremely challenging and just coming at a really difficult time on a staff that’s really exhausted.

So it’s not as easy as taking one can of soda and pouring a little bit into five glasses instead of giving the whole thing to one person?

Exactly. How do you take a fifth of a dose out of the vial? You need all new supplies. Ancillary supplies have to be ordered. Providers have to be trained. And people are exhausted.

We’ve got a whole system built around Covid. And we’re not using it. I don’t understand the complexities of why. Why do we have to order via email? Why can’t we just order in our ordering systems? You’ve built an entire calendar, you have an entire structure of contacts in your phone. And then there’s a new emergency and they hand you a brand new phone? What am I supposed to do with this?

So when you look to the fall and you look at millions of doses going out this way, at the same time, you’re trying to do Covid boosters the other way, I think some of my members, they’re on the ledge.

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