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En español: Lo que debes saber sobre la viruela del simio

Los estadounidenses tienen bajo riesgo de contraer la viruela del mono: se está propagando entre los hombres que tienen sexo con hombres

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Crédito de la foto: Centros para el Control y la Prevención de Enfermedades de EE. UU.

By Céline R. Gounder, MD | NUEVA YORK – La Organización Mundial de la Salud dijo el 25 de junio que la viruela del simio aún no es una emergencia de salud pública que preocupe a nivel internacional. Se han informado más de 4,500 casos en todo el mundo, y ya superan los 300 en los Estados Unidos. Aunque es probable que haya un subregistro porque no se hace rastreo de contactos.

Todos deberían saber sobre los símtomas, cómo se disemina y los riesgos.

¿Debería preocuparme por la viruela del simio?

Actualmente, los estadounidenses tienen un bajo riesgo de contraer la viruela del simio. Se está extendiendo entre hombres que tienen sexo con hombres, pero es solo cuestión de tiempo antes de que pase a otros. Al 27 de junio, el Centro Europeo para la Prevención y el Control de Enfermedades había informado 10 casos en mujeres.

Generalmente es una enfermedad leve, pero puede ser grave o incluso mortal para las personas inmunodeprimidasembarazadasfetos o recién nacidosmujeres lactantesniños pequeños y personas con enfermedades de la piel, como eccema.

Podría volverse endémica en los Estados Unidos, y en todo el mundo, si continúa propagándose sin control.

¿Cómo se propaga?

La viruela del simio es una infección viral, prima cercana de la viruela. Pero causa una enfermedad mucho más leve.

Se transmite a través del contacto cercano, incluido el sexo, besos y masajes: cualquier tipo de contacto del pene, la vagina, el ano, la boca, la garganta o incluso la piel. En este brote, se ha transmitido principalmente por vía sexual.

Los condones y los protectores dentales reducirán, pero no evitarán, toda la transmisión porque solo protegen contra el contagio por piel, y por las mucosas cubiertas por estos dispositivos. Es importante saber que el virus puede entrar por una abertura en la piel, y penetrar las membranas mucosas de la nariz, la boca, los genitales y el ano.

Los científicos no saben si la viruela del simio se puede transmitir a través del semen o del fluido vaginal.

La viruela del simio se puede transmitir a través de gotitas respiratorias a unos pocos pies, pero no es un modo de transmisión particularmente eficiente. Todavía no se ha documentado transmission aérea, como covid-19.

No se sabe si la infección se puede transmitir cuando la persona no presenta síntomas.

¿Cuáles son los síntomas comunes?

Los síntomas pueden desarrollarse hasta 21 días después de la exposición y pueden incluir fiebre y escalofríos, ganglios linfáticos inflamados, sarpullido y dolores de cabeza.

No se sabe si siempre muestra alguno o todos esos síntomas.

Actualmente, los expertos creen que la viruela del simio, como la viruela, siempre causará al menos algunos de estos síntomas, pero esa creencia se basa en la ciencia anterior a 1980, antes de que existieran pruebas de diagnóstico más sofisticadas.

¿Cómo se ve la erupción de la viruela del simio?

La erupción generalmente comienza con manchas rojas. Luego se convierten en protuberancias llenas de líquido y después pus que pueden parecer ampollas o granos. Estas protuberancias luego se abren en llagas y forman costras. Las personas con viruela del simio se deben considerar infecciosas hasta que aparecen las costras y se caen.

Estas llagas son dolorosas. Antes, la erupción se observaba más en las palmas de las manos y las plantas de los pies, pero muchas personas en este brote presentan lesiones externas e internas en la boca, los genitales y el ano.

También dolor rectal o la sensación de necesitar defecar cuando sus intestinos están vacíos.

¿Cómo hacerse la prueba?

Si la persona tiene síntomas de viruela del simio, hay que hacerse una prueba en una clínica de salud sexual. Un profesional médico debe tomar una muestra de cualquier lesión sospechosa para su análisis. También hay evidencia emergente de que los frotis de garganta pueden detectar la viruela del simio, pero hasta ahora los funcionarios de salud no los recomiendan.

¿Hay una vacuna para la viruela del simio?

Sí. Dos vacunas son eficaces para prevenir la viruela del simio: la vacuna Jynneos y la vacuna ACAM2000. La FDA aprobó la vacuna Jynneos para prevenir la viruela del simio y la viruela en personas mayores de 18 años. ACAM2000 está aprobada por la FDA para prevenir la viruela. Actualmente, en el país se usa solo la vacuna Jynneos porque es más segura y tiene menos efectos secundarios.

La vacuna Jynneos es segura. Se ha probado en miles de personas, incluidas aquéllas inmunocomprometidas o con enfermedades de la piel. Los efectos secundarios comunes de la vacuna Jynneos son similares a los de otras vacunas: fiebre, fatiga, glándulas inflamadas e irritación en el lugar de la inyección.

La vacuna Jynneos es eficaz para prevenir la viruela del simio hasta cuatro días después de la exposición y puede reducir la gravedad de los síntomas si se administra hasta 14 días después de la exposición.

¿Puedo vacunarme contra la viruela del simio?

Actualmente, los Centros para el Control y la Prevención de Enfermedades (CDC) recomiendan la vacunación contra la viruela del simio solo para aquellos en mayor riesgo: personas que han tenido contacto cercano con alguien infectado; hombres que tienen relaciones sexuales con hombres y mujeres trans que recientemente han tenido múltiples parejas sexuales en un lugar donde la infección se está propagando; y algunos trabajadores de la salud, socorristas y militares que podrían entrar en contacto con los afectados.

Actualmente, los suministros de la vacuna Jynneos son limitados. El Departamento de Salud y Servicios Humanos liberará 56,000 dosis de la reserva nacional estratégica de inmediato. En las próximas semanas estarán disponibles 240,000 dosis adicionales, 750,000 a finales del Verano, y 500,000 este otoño. Un total de 1.5 millones de dosis.

¿Cuáles son otras formas de reducir el riesgo de transmisión de la viruela del simio?

La mejor manera es informarse. Si la persona está preocupada, el enlace de los CDC es el mejor recurso para encontrar una clínica de salud sexual: https://gettested.cdc.gov/. Muchas salas de emergencia o centros de urgencia, y otros centros de salud, todavía pueden no estar actualizados con lo ultimo sobre la viruela del simio.

Hay que abstenerse de tener relaciones sexuales si un miembro de la pareja está infectado. Los CDC también advierten sobre el riesgo de ir a raves u otras fiestas o lugares en donde la gente usa poca ropa. Y ofrece otros consejos de prevención, como el lavado de sábanas o juguetes sexuales.

¿Existe un tratamiento para la viruela del simio?

No existe un tratamiento seguro y probado específicamente para la viruela del simio. La mayoría de los casos son leves y mejoran sin tratamiento en un par de semanas. Medicamentos como el paracetamol y el ibuprofeno se pueden usar para reducir la fiebre y los dolores musculares. En casos raros, algunos pacientes desarrollarán una enfermedad más grave y pueden requerir un tratamiento más específico. Los médicos están probando terapias experimentales como cidofovirbrincidofovirtecovirimat e inmunoglobulina vaccinia. Si se administran temprano en el curso de la infección, las vacunas Jynneos y ACAM2000 también pueden ayudar a reducir la gravedad de la enfermedad.

¿Qué información errónea circula sobre la viruela del simio?

Abundan las teorías conspirativas. Pero no es un engaño. Es real. Esta infección no fue inventada por Bill Gates ni por las farmacéuticas. El virus no salió de un laboratorio de China o Ucrania. Los migrantes que cruzan la frontera con México no traen la viruela del simio a los Estados Unidos. No hay mandato de vacunación ni cuarentenas establecidas para la viruela del simio.

*********************

Celine Gounder, MD, ScM, FIDSA, es miembro sénior y editora general de Public Health, y creadora y presentadora de American Diagnosis, un podcast sobre salud y justicia social.

Es profesora asistente clínica de medicina y enfermedades infecciosas en la Escuela de Medicina Grossman de la NYU. Ella atiende a pacientes en las salas de NYC Health + Hospitals/Bellevue y en Indian Health Service y centros de salud tribales en todo el país.

***********************

El artículo anterior fue publicado previamente por Kaiser Health News y se vuelve a publicar con autorización.

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Monkeypox

Monkeypox vax outages & bureaucracy impedes healthcare providers

CDC on Friday reported that the number of confirmed cases of the monkeypox virus has doubled in the past two weeks escalating to 11,177

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Photo Credit: State of California

LOS ANGELES – Frustrations are mounting as the campaign to vaccinate people against infection of the monkeypox virus is derailed by a critical supply shortage of vaccine doses with added bureaucratic obstacles in getting financial reimbursement to the healthcare providers and clinics dispensing the vaccine.

The Los Angeles County Department of Public Health has nearly exhausted its limited supplies of the JYNNEOS and is anticipating resupply, but has paused its County-wide pre-registration link on its website, putting off scheduling new vaccine appointments.

In one notable example, Public Health’s Monkeypox Vaccination Pop-Up Clinic at the West Hollywood Library exhausted its supply of the vaccine on Friday and ceased operations. According to a press release from West Hollywood city officials, more doses of vaccine are anticipated to be delivered by the federal government in the coming days, on a date to be determined. Once supply is reestablished, then operations will resume for the Pop-Up Clinic.

Exacerbating the crisis, the Centers for Disease Control and Prevention on Friday reported that the number of confirmed cases of the monkeypox virus has doubled in the past two weeks escalating to 11,177.

In Los Angeles County, the County Health Department said that the county’s monkeypox profile is similar to the national case load increase as the disease spreads.

Complicating the issue, in an action taken earlier this week, Michelle Baass, the Director
of the California Department of Health Care Services, (DHCS) announced that Medi-Cal will only reimburse Federally Qualified Health Centers (FQHCs) for monkeypox vaccine administration when provided during a face-to-face visit with a provider.

Reacting to Baass’ decision, a group of 17 healthcare providers for the LGBTQ community in California sent a letter to Director Baass expressing deep concerns by the seemingly arbitrary move, which ran counter to the history of state efforts during the coronavirus pandemic.

In the letter [embedded below] the signatories representing the 17 organizations stated:

This decision will significantly hamper the ability of FQHCs to respond to the monkeypox outbreak with the speed and urgency it requires and flies in the face of Governor Newsom’s declared State of Emergency.

As health care providers who serve a significant percentage of low-income LGBTQ+ Californians, we believe this decision is a flagrant example of institutionalized homophobia and we urge the department to reverse course immediately. Monkeypox vaccine administration by FQHCs should be reimbursed in the same way as COVID-19 vaccines.”

The letter also stated:

Regrettably, DHCS’ announcement this week will only make it harder for many of our most
vulnerable LGBTQ+ Medi-Cal patients to be vaccinated. In the FQHC setting, monkeypox
vaccines are generally administered outside of a primary care visit by a non-billable provider.
This allows us to vaccinate a significantly greater number of patients on a daily basis
.

Forcing Medi-Cal patients to have a face-to-face visit with a primary care provider will dramatically slow our current vaccination effort and make it even harder to control the current outbreak. In the time it takes for one individual to have their vitals taken and engage in a face-to-face visit with a primary care provider, FQHCs have the ability to vaccinate 15-20 people. DHCS’ policy makes absolutely no sense from a public health perspective and it screams of discrimination.

Anthony Cava, a spokesman for the California Department of Health Care Services, responded to the Blade’s inquiry over the facts of the letter laid out by the Healthcare provider signatories. However Cava ignored the implications of homophobia and discrimination specified in the letter:

“In response to the monkeypox public health emergency, the Department of Health Care Services (DHCS) appreciates the tremendous effort, focus, and compassion that our clinic partners are bringing to the important work of combatting this virus in their communities. Their hard work and dedication make them critical partners in our response.

DHCS is committed to working with the Centers for Medicare & Medicaid Services (CMS) to respond to monkeypox. DHCS will broadly seek federal approval to reimburse vaccine administration and applicable laboratory testing at 100 percent of the Medicare rate, once established. As part of this request, DHCS will seek federal approval to reimburse Federally Qualified Health Centers (FQHC), and similarly situated clinics that are paid an all-inclusive rate, the vaccine administration fee for vaccine-only visits, consistent with how we are reimbursing for COVID-19 vaccine-only visits. The requested federal approvals will also include reimbursement for vaccine administration performed by non-clinic providers.

At this time, DHCS has not yet received federal guidance regarding reimbursement policies for the administration of the monkeypox vaccine. However, DHCS has communicated with CMS about the urgent need for clarity. Pending the release of such guidance, we informed FQHC providers that we will reimburse them for care provided, which may include the administration of the vaccine if it is done as part of a clinic visit that includes addressing this virus.”

Aaron Fox, the Director of Government Relations for the Los Angeles LGBT Center responded to the DHCS statement:

“Our community cannot wait for DHCS and CMS to continue talking. We must have action on this yesterday and we are in a Public Health crisis and government bureaucracy and inaction is unacceptable and will only result in increased suffering in our community,” Fox told the Blade in a phone call late Friday.

Fox added that his perception of the government response is that while the Biden-Administration and California have declared a Public Health Emergency, in terms of immediate action taken thus far it is little more than saying, “oh look there’s a house on fire,” but neglecting to dial 911 and get the fire dept rolling.

The Blade also had a conversation by phone late Friday with Jim Mangia, President and CEO of St. John’s Community Health, a network of community clinics in the greater Los Angeles region:

“While I applaud the spirit of the DHCS response, however, spirit alone will not stop this outbreak. DHCS has the power to make decisions about reimbursement rates and services allowable under Medi-Cal so they can set an interim rate for monkey-pox administration at the same rate it was set under COVID-19. I’ll note though that it took DHCS over a year to reimburse clinics for the COVID-19 community clinic programs. We urge them to do the right thing now before its too late.”

At a federal level, this last week on Tuesday, as part of a decision by Secretary of Health & Human Services Xavier Becerra to issue a determination under Section 564 of the Federal Food, Drug and Cosmetic Act to justify emergency use authorization of vaccines, the FDA also ordered a new vaccine approach.

This would change injections of the JYNNEOS vaccine from the subcutaneous route (delivery of the vaccine under the fat layer underneath the skin) to the intradermal route (delivery of the vaccine into the layer of skin just underneath the top layer).

This would allow for healthcare providers to squeeze five doses out of what used to be just one dose, which the FDA said should increase the number of vaccine doses in the national stockpile from 441,000 to more than 2.2 million.

In a letter first obtained by the Washington Post and later by the Blade, [embedded below] Paul Chaplin the President & CEO of Bavarian Nordic A/S, the sole manufacturer of the JYNNEOS Monkeypox vaccine expressed grave misgivings over HHS Secretary Becerra’s plan to dilute the dosage.

“Bavarian Nordic (BN) is dedicated to assisting Governments around the globe to control the current monkeypox outbreak and is fully supportive of dose-sparing approaches, such as delaying the second vaccination. However, we do have some reservations on the ID approach, due to the very limited safety data available,” Chaplin wrote.

Addressing both the reimbursement issues raised by the community clinic networks as well as the supply chain issues, California State Senator Scott Wiener told the Blade in an email,

“The Administration has been a strong partner in our effort to fight monkeypox, and we’re working closely and collaboratively to ensure our response is as effective as possible. I’m confident we’ll be able to resolve this issue.”

Wiener (D-San Francisco) was appointed by California Senate President Pro Tem Toni Atkins (D-San Diego) to chair the newly-formed State Senate Select Committee on Monkeypox. Also appointed as members of the committee are Senators Susan Eggman (D-Stockton), John Laird (D-Santa Cruz), Rosilicie Ochoa Bogh (R-Yucaipa), Lena Gonzalez (D-Long Beach), and Richard Pan (D-Sacramento).

LADPH reported Friday that the total Monkeypox / Orthopox Confirmed Cases were 797 which
included Long Beach and Pasadena
which have separate independent health departments.

Los Angeles County (excl. Long Beach and Pasadena)753
Long Beach36
Pasadena8

Long Beach data as of August 11, 2022 at 12:00 AM.
Pasadena data as of August 10, 2022 at 5:30 PM.

CDC Monkeypox data table for August 12, 2022, 11,177 total cases:

LocationCases
Alabama30
Alaska2
Arizona170
Arkansas15
California1,945
Colorado111
Connecticut59
Delaware8
District Of Columbia328
Florida1,085
Georgia851
Hawaii12
Idaho9
Illinois771
Indiana78
Iowa15
Kansas3
Kentucky11
Louisiana103
Maine3
Maryland275
Massachusetts202
Michigan92
Minnesota66
Mississippi11
Missouri20
Montana2
Nebraska15
Nevada74
New Hampshire15
New Jersey293
New Mexico16
New York2,295
North Carolina138
North Dakota2
Ohio89
Oklahoma12
Oregon95
Pennsylvania298
Puerto Rico48
Rhode Island31
South Carolina60
South Dakota2
Tennessee67
Texas815
Utah69
Vermont2
Virginia175
Washington251
West Virginia4
Wisconsin31
Wyoming0

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Monkeypox

Monkeypox virus cases in U.S. double in two weeks: 10,768 confirmed

“To date, there have been 738 cases of monkeypox identified in L.A. County, which is double the number of cases we had 12 days ago”

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Screenshot/YouTube KABC 7 LA

LOS ANGELES – The Centers for Disease Control and Prevention on Wednesday reported that the number of confirmed cases of the monkeypox virus has doubled in the past two weeks escalating to 10,768, the largest caseloads in the states of New York with 2,187; California with 1,892; Florida with 1,053; Georgia with 824 and Illinois with 734 cases.

In Los Angeles County, the County Health Department said that the county’s monkeypox profile is similar to the national case load increase as the disease spreads.

“To date, there have been 738 cases of monkeypox identified in L.A. County, which is double the number of cases we had 12 days ago,” said Dr. Rita Singhall of the L.A. County Public Health Department. “Additionally, there have been 33 cases reported in Long Beach and eight cases reported in Pasadena.”

On Tuesday as part of a decision by Secretary of Health & Human Services Xavier Becerra to issue a determination under Section 564 of the Federal Food, Drug and Cosmetic Act to justify emergency use authorization of vaccines, the FDA also ordered a new vaccine approach.

This would change injections of the JYNNEOS vaccine from the subcutaneous route (delivery of the vaccine under the fat layer underneath the skin) to the intradermal route (delivery of the vaccine into the layer of skin just underneath the top layer).

This would allow for healthcare providers to squeeze five doses out of what used to be just one dose, which the FDA said should increase the number of vaccine doses in the national stockpile from 441,000 to more than 2.2 million.

KABC reported that LADPH officials say they have received about 43,000 doses of the monkeypox vaccine, three-quarters of which have already been administered.

But with more shipments expected and the FDA’s new dose splitting, county officials say they should be able to reach tens of thousands more people who are at risk of catching the virus.

“We will be able to fully vaccinate with two doses, as a two-dose series, 85,000 to 90,000 people in L.A. County,” Singhall said.

CDC Data as of Wednesday:

Alabama27
Alaska2
Arizona163
Arkansas14
California1,892
Colorado111
Connecticut57
Delaware8
District Of Columbia319
Florida1,053
Georgia824
Hawaii12
Idaho9
Illinois734
Indiana77
Iowa13
Kansas3
Kentucky11
Louisiana97
Maine3
Maryland259
Massachusetts202
Michigan82
Minnesota61
Mississippi11
Missouri19
Montana2
Nebraska14
Nevada59
New Hampshire15
New Jersey293
New Mexico16
New York2,187
North Carolina131
North Dakota2
Ohio78
Oklahoma12
Oregon95
Pennsylvania282
Puerto Rico43
Rhode Island31
South Carolina49
South Dakota2
Tennessee67
Texas815
Utah64
Vermont1
Virginia175
Washington234
West Virginia4
Wisconsin31
Wyoming0

From KABC ABC 7:

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Monkeypox

Monkeypox vax strategy shift by Biden Administration amid shortages

As the estimated number of monkeypox cases in the United States reaches 8,900, top health officials announced the new move on Tuesday

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Los Angeles Blade file photo

WASHINGTON – The Biden administration, amid criticism it was slow to act on the monkeypox outbreak and still not meeting the demand for vaccines as the number of cases continues to grow, has announced a shift in guidance for implementation of the shot in an effort to enhance availability.

As the estimated number of monkeypox cases in the United States reaches 8,900, top health officials announced the new move on Tuesday as part of a decision by Secretary of Health & Human Services Xavier Becerra to issue a determination under Section 564 of the Federal Food, Drug and Cosmetic Act to justify emergency use authorization of vaccines. The announcement follows up on the Biden administration’s announcement last week declaring the monkeypox outbreak a public health emergency.

Becerra said in a conference call with reporters the 564 determination and change in approach to vaccines would “boost and strengthen” the Biden administration’s response to monkeypox, which has overwhelmingly affected gay and bisexual men, and “safely accelerates and multiplies our supply of effective vaccines by up to fivefold.”

“Today’s action also reaffirms HHS and this administration’s commitment to using all available resources and capabilities to end the monkeypox outbreak and provide the best possible care to those suffering from the virus,” Becerra added.

The new vaccine approach, which may may be considered minor to non-medical observers, would change injections of the JYNNEOS vaccine from the subcutaneous route (delivery of the vaccine under the fat layer underneath the skin) to the intradermal route (delivery of the vaccine into the layer of skin just underneath the top layer). In theory, that would allow for greater accessibility of monkeypox vaccines as it increases the number of doses from each vial of vaccine.

The change was made amid criticism the Biden administration failed to meet the demand for vaccines during the outbreak and geographic inequity as certain metropolitan areas of the country have more access to vaccines than other places.

As The New York Times reported last week, the Biden administration has faced criticism for not moving quickly enough in acquiring and distributing vaccines, including bulk stocks already owned by the U.S. government manufactured in Denmark by Bavaria Nordic now being given to other clients.

“The government is now distributing about 1.1 million doses, less than a third of the 3.5 million that health officials now estimate are needed to fight the outbreak,” the Times reported. “It does not expect the next delivery, of half a million doses, until October. Most of the other 5.5 million doses the United States has ordered are not scheduled to be delivered until next year, according to the federal health agency.”

Biden officials, nonetheless, touted the numbers of vaccines and tests in response to monkeypox as a positive, acknowledging the 1.1 million vaccines being made available as well as delivery of more than 620,000 of those doses, deployment more than 15,000 courses of the monkeypox treatment and increasing the country’s capacity to administer tests on a weekly basis to around 80,000. Meanwhile, officials also promoted the change in approach in vaccines as means to allow greater accessibility to the shots.

Rochelle Walensky, director of the Centers for Disease Control & Prevention, promoted during the conference call the use of intradermal injections and said they’re “often used for TB skin tests and have been used for other types of vaccines.”

Although Walensky conceded some health care providers “may not be as familiar with intradermal administration” as they are with subcutaneous injection, she said CDC would make additional guidance materials available, including a clinician alert message to the Association of State & Territorial Health Officials, outreach to key clinician partners and an education resource video. The change in guidance, Walensky said, is for vaccine implementation in adults and children — where single digit monkeypox cases have been reported — would continue to receive vaccination in the traditional subcutaneous approach.

But health experts aren’t responding with overwhelming praise to the decision to change the guidance on vaccine implementation from subcutaneous injections to intradermal injections, expressing concerns the new approach may be insufficient.

Jennifer Kates, director of global health & HIV policy at the Kaiser Family Foundation, was among those saying the change in guidance on vaccine approach was a mixed bag and told the Blade more data is needed to emulate the effectiveness.

“As we saw with COVID, using these authorities in the context of public health emergencies is an important strategy,” Kates said. “In this case, this step will significantly expand access to vaccines for those most at risk. However, there remain questions about the effectiveness of this approach — real world studies are needed — and challenges to translating vaccines into vaccinations.”

Peter Marks, director of the Center for Biologics Evaluation & Research (CBER) at the Food & Drug Administration, was asked during the conference call with reporters to respond to concerns the change in guidance was insufficient and downplayed the novelty of implementing the vaccines through the intradermal route as “not at all new.”

“In fact, the reason why the Bavaria part of this equation comes from the fact that in Germany, this vaccine was given intradermally originally, in an effort to replicate the original version of the smallpox vaccine,” Marks said. “It’s been given to thousands of people intradermally, so this isn’t the first time it’s been done.”

Walkensky said the intradermal vaccine approach has been implemented amid policies among localities to implement a one-dose approach to the JYNNEOS vaccine through the subcutaneous route. (The D.C. government is one of the jurisdictions that had enacted a one-dose approach amid a vaccine shortage.) There is not data, Walkensky said, to support that approach and “in fact, if anything, there are data saying that that is not protective enough.”

“So by using this alternative strategy of intradermal dosing, not only do we have more doses, but we actually allow people to get two doses in a way that shows immunologic response that’s superimposable from the subcutaneous dosing,” Walkensky said. “So we have more doses, and in fact, we have the ability to doubly vaccinate people so that they get the protection that they need.”

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