• Diana Bolton

The national demand for monkeypox vaccines has been so great this summer that some states have been turning people away. Vermont, however, has faced a different problem. In the six weeks shots have been available, the state has doled out only about 50 doses — a fraction of what the federal government has sent its way.

It's a curious situation for a state that was a national leader in COVID-19 vaccine rollout, both in terms of managing finite supplies and convincing people to seek a shot. The limited uptake has surprised health officials and could undermine attempts to prevent monkeypox from establishing a foothold in Vermont, particularly as the arrival of college students threatens to hasten the spread of the virus. 

Now the state is trying to make up ground. Last month, the Vermont Department of Health expanded eligibility for the vaccine to include all sexually active gay and bisexual men and has started offering the shots at some of its local offices. It's using press releases and social media announcements to drum up interest. 

"We're turning the spigot as far as we can," said Monica Ogelby, the state's immunization program manager. 

Monkeypox, a virus that can cause flu-like symptoms and excruciating skin lesions, had historically been confined to Africa. But an outbreak that began in Europe this year has since spread around the globe. In the U.S., some 20,000 people have been infected.

The virus spreads primarily through close physical contact, though people can also catch it by touching items such as clothing or bedsheets previously used by someone who is infectious. While anyone can contract it, the virus has overwhelmingly affected men who have sex with men; thus far, vaccination efforts have targeted that specific group. 

The virus' prevalence in the U.S. has been uneven. Cities such as New York and Washington, D.C., have reported many cases, while some entire states have reported barely any. In Vermont, only three people have tested positive.

Cases appear to be slowing down in most major cities as people get vaccinated and start changing their sexual behaviors. But it's not clear how long those behavioral changes will continue, which is why most experts stress that a robust vaccination strategy remains the best way to combat the virus.

The meager progress of Vermont's vaccination campaign is in some ways a symptom of the federal government's slow response to the outbreak. The primary vaccine approved for monkeypox — a two-dose regimen called JYNNEOS given four weeks apart — was originally developed for use against one of its viral cousins, smallpox.

The virus was circulating for weeks before the U.S. placed an order for doses it already had purchased with the Danish company that manufactures them. And when the feds began shipping doses to states in May, deliveries were sporadic, leaving state officials unsure how much they might have from week to week. 

States with outbreaks were prioritized in the first round of shipments. Vermont, which did not report its first case until late July, missed out, according to Ogelby. What arrived over the next few weeks wasn't much: 59 doses in mid-July, 27 a week later, 180 in August.

"It's really been a trickle," the immunization program manager said.

The limited supply forced public health officials to make decisions about how to offer the shots — and how aggressively to market them.

States were encouraged to first focus on people who were exposed to the virus. Some decided to widen the criteria early to include at-risk people, generally sexually active gay and bisexual men who hadn't been exposed; those states found that the demand was far greater than their supply.

Vermont, on the other hand, vaccinated only those who said they had been exposed to the virus — even as vaccination rates remained low. "We didn't really know what to expect," Ogelby said. "We were surprised that we didn't have more Vermonters seeking vaccines."

Among Vermont's first vaccine recipients was Marcus Weinman, a 29-year-old University of Vermont grad student. Weinman became eligible after he was deemed to be a close contact of a friend visiting Vermont from out-of-state; he said he was incredibly relieved to get jabbed.

But he had numerous friends in Vermont who also wanted the vaccine and weren't able to get it because they hadn't been exposed to the virus. Rather than wait to become eligible in Vermont, some people he knew decided to get their first shot in Québec, he said, where virtually anyone who wanted could get vaccinated for free.

On August 9, the U.S. Food and Drug Administration issued an emergency order that allows providers to change how they administer the vaccine so that each shot requires a smaller dose. States were suddenly able to stretch their supplies much further.

Still, it wasn't until two weeks later, on August 22, that Vermont expanded its eligibility, from post-exposure to sexually active gay and bisexual men at risk of exposure. Even then, the change wasn't widely publicized.

The health department has been consulting with Pride Center of Vermont on the rollout. Richard Elliott, the Burlington-based center's health and wellness coordinator, recalled some frustrations among the gay community about how long it took the state to expand eligibility. Since then, he said, "things have been going pretty smoothly." He suspected the vaccination rate will begin to climb in the weeks ahead.

In addition to the new state-run clinics, three private organizations are now offering vaccines: Planned Parenthood, Community Health Centers of Burlington, and the UVM Medical Center's infectious disease program, which works with many at-risk patients through its HIV and AIDS care. The latter two clinics are only scheduling existing patients, while Planned Parenthood is vaccinating anyone who qualifies.

Weinman, the grad student, wants the state to take a more proactive approach. "Find all the queer spaces and set up pop-up clinics," he said.

One such opportunity will come later this month at Burlington's Pride Festival. Pride Center is working with the state on hosting a vaccination clinic at the event. It's also pushing information about the vaccine on its social media pages and is encouraging more people to seek out shots.

The federal government has allocated about 1,750 more vials of the vaccine for Vermont, but the state can only request another shipment once it uses 85 percent of what it's already received. With the dose-saving strategy now in effect, the state needs to administer at least 500 more shots before it clears that threshold — far more than the 50 given out to date.

But the low number doesn't mean that Vermonters aren't interested in protecting themselves against the virus, according to Dr. Devika Singh, a physician at UVM's infectious disease program. Her clinic began offering vaccines to existing patients about two weeks ago.

The clinic has only given out a handful of shots so far, but Singh said she's expecting an uptick as word of the increased access gets around. Those who have gotten the shot at her clinic, she said, were visibly relieved. She recalled a scene in the waiting room with several people all waiting for shots.

"Everyone knew why they were there and what was happening," she said. "There was a euphoria."