The San Francisco Department of Public Health has expanded eligibility for monkeypox vaccines to include all gay, bisexual, and trans people. Starting next Tuesday, September 6, local providers will begin offering second doses to people who received their first dose at least a month ago.
"This expansion of eligibility, as well as second dose availability is aligned with the movement of the state and other Bay Area agencies," said San Francisco Public Health Officer Dr. Susan Philip. "Two doses provides longer lasting protection compared to a single dose, and is recommended by the FDA and CDC for this vaccine. We will continue to work to distribute the vaccines to those who need it as quickly and as equitably as possible."
A statement from the San Francisco Department of Public Health notes that this change is in alignment with other Bay Area counties, some of which started giving second doses this week.
Santa Clara County health officials issued a release August 31 stating that people can now make appointments for second doses if it has been 28 days or more since the person received their first dose. People can click here to make an appointment.
There is no need to restart the series if more than 28 days have passed since first dose administration, officials stated, adding that people who get their medical care through large healthcare systems, may also be able to get a second dose through their regular doctor. The vaccine offers the best protection when individuals get both doses.
On August 31, the San Francisco health department updated the criteria on its MPX website to state that "all gay, bisexual, trans people, and men or trans people who have sex with men or trans people" are now eligible for vaccination. This is broader than the previous criteria, which limited eligibility to gay and bi men and trans people who had more than one sex partner in the past two weeks.
In addition, people who have had close contact with a person with MPX, those who have attended venues or events where a case was identified, sex workers of any gender or orientation, and certain clinicians and laboratory workers will remain eligible.
DPH is encouraging people to seek second vaccine doses from their health care provider rather than mass vaccine clinics, regardless of where they received their initial shot. "Health care providers now have the infrastructure" to offer the vaccine, a DPH spokesperson told the Bay Area Reporter.
Split-dose vaccine strategy
The MPX virus is related to smallpox, though less severe, and smallpox vaccines can prevent MPX too. DPH is offering the Jynneos vaccine, a safer alternative to older live-virus smallpox vaccines. Because the virus has a long incubation period, vaccines may be used either as post-exposure prophylaxis within several days after exposure or as pre-exposure prophylaxis for those at risk.
The original Jynneos indication calls for two doses administered by subcutaneous injections four weeks apart. In an effort to stretch the limited vaccine supply, SF and other jurisdictions resorted to a one-dose strategy to give twice as many people partial protection as soon as possible. But experts say the vaccine does not provide full protection until two weeks after the second dose.
"This is a two-dose vaccine and it's important to receive the second dose in the series," Centers for Disease Control and Prevention director Dr. Rochelle Walensky told reporters during an August 26 briefing. "I encourage providers to continue to highlight the importance of the second dose so that all vaccinated people optimize their protection from the vaccine."
To stretch supplies even further, the Food and Drug Administration recently issued an emergency use authorization that allows Jynneos to be administered by intradermal injection, splitting a single vial into five doses. The skin contains plentiful immune cells that recognize viral antigens in the vaccine and trigger a strong immune response. Studies show that the subcutaneous and intradermal methods produce similar antibody responses. However, some experts caution that intradermal administration may not be appropriate for people living with HIV, and it should not be used for people with keloids, an overgrowth of scar tissue that is more common among Black people
The federal government is now reporting the number of distributed vaccine doses assuming providers will use fractional-dose administration. DPH received 8,000 doses last week and expects 13,000 more in the next allotment, according to the statement.
Vaccine availability
People who initially received a subcutaneous first dose of Jynneos can get an intradermal second dose, or they can get both doses using the intradermal method. According to the FDA protocol, the second dose should be given a month after the first, but experts say waiting up to several months will not compromise effectiveness.
The walk-in MPX vaccine clinic at Zuckerberg San Francisco General Hospital and Trauma Center will be open for first doses only without an appointment through Friday, September 2. Starting next week, the clinic will continue to serve first dose walk-ins and will begin administering second doses by appointment to San Francisco Health Network patients and to a limited number of walk-ins as supply allows.
If a person's primary health care provider does not offer the vaccine, they can receive a second dose by appointment at the San Francisco AIDS Foundation's Strut clinic in the Castro, Kaiser Permanente, UCSF, DPH's Adult Immunization and Travel Clinic, and SF Health Network providers.
San Francisco is among the first jurisdictions to expand eligibility to include all gay, bi, and trans people regardless of their recent sexual history. The new criteria do not take into account the fact that some cisgender women and straight-identified men are connected to gay men's sexual networks. Washington, D.C. recently took the opposite approach, expanding eligibility to include people of any sexual orientation or gender who recently had multiple sex partners.
San Francisco's approach has the advantage of not requiring people to divulge their sexual activity while DC's approach is independent of self-identification. Both could be important as health officials and providers try to expand their reach to vaccinate people beyond early adopters, who have disproportionately been white gay men. Latino people in the Bay Area and Black people nationwide have higher MPX rates but are less likely to have received the vaccine.
Updated, 8/31/22: This article has been updated to include information about Santa Clara County.
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