New York City, San Francisco Buck Federal Bureaucrats on Monkeypox

Decision to prioritize first doses of monkeypox vaccine signals waning influence of CDC, FDA

Pro-monkeypox vaccine protest in New York City / Getty Images
July 22, 2022

New York City and San Francisco are delaying second doses of the monkeypox vaccine in order to get shots in as many arms as possible, thumbing their noses at federal bureaucrats who've insisted on a two-dose regimen as the outbreak spins out of control.

The monkeypox vaccine is supposed to be given in two doses spaced 28 days apart, per guidance from the Food and Drug Administration and the Centers for Disease Control and Prevention. But with supplies scarce—and with both agencies under fire for their sluggish response to the outbreak—some jurisdictions are taking matters into their own hands. New York City and San Francisco, which have the first and second-largest number of monkeypox cases in the United States, respectively, are now prioritizing first doses of the vaccine for high-risk individuals, even if it means some recipients need to wait longer for their second shot.

The one-dose strategy is a "much better" approach, Peter Chin-Hong, an infectious disease expert at the University of California, San Francisco, told Forbes on Wednesday. Though the FDA and CDC have warned that one dose offers insufficient protection from monkeypox—a disease three times as lethal as COVID—Chin-Hong stressed that some protection is better than none.

"There's nothing magical about spacing vaccines the way they're spaced on the label," Chin-Hong said. "You can catch people back up with their second doses later."

A similar debate unfolded in the early days of the coronavirus vaccine rollout, when federal regulators insisted the scarce mRNA vaccines be given in two doses three weeks apart, in keeping with the terms of the FDA's Emergency Use Authorization. That intransigence sparked criticism from some immunologists and health care experts, who warned that the bureaucratic caution was costing lives. A "first doses first" strategy, libertarian economist Alex Tabarrok argued in the Washington Post, would let the United States vaccinate its population more rapidly and hasten the end of the pandemic.

That argument proved correct: The British government accelerated its vaccination program by allowing a 12-week interval to elapse between shots, which turned out to provide stronger immune response in the long run.

The federal government's monkeypox response has so far ignored these lessons. Both Rochelle Walensky, the director of the CDC, and Peter Marks, the director of the FDA's Center for Biologics Evaluation and Research, are urging states to stick to the approved dosing schedule, even as the prospects of containing monkeypox continue to dim.

That some localities have shrugged off the agencies' advice may be a sign that the agencies' legitimacy is waning—including among the blue states typically friendly to federal regulators. From masks to vaccines to monoclonal antibodies, many liberal cities took their cues from the CDC throughout the coronavirus pandemic. Now, with cases of monkeypox overwhelmingly concentrated in those cities' gay populations, blue enclaves are embracing the federalism they scorned in 2020, experimenting with public health policies that don't have the government's seal of approval.

"New York City is the epicenter of the monkeypox outbreak in the U.S. and yet does not have sufficient vaccine supply to reach the number of people who need it protect themselves," New York City's public health department said in a statement. "Given the rapid increase in cases, the Health Department has decided that providing first doses to offer protection to more at-risk New Yorkers is the best strategy."