Jay Varma Profile picture
Aug 9 14 tweets 4 min read
Having now read the one study on intra-dermal #monkeypox vax & spoken with a few folks more knowledgeable than me about immunology, some thoughts below on @FDAgov @CDCgov approach

/1
Level of neutralizing antibodies from intra-dermal should be equivalent to subcutaneous. This switch should both expand vax supply & increase protection in those most at risk - critical goals right now.

/2
We still do not know for sure:
-how much protection comes from antibody response vs. other forms of immunity
-whether the total immune response varies by subcutaneous or intra-dermal

/3
As with standard subq vax administration, we *really* need real-world effectiveness studies: how much does vax prevent infection &, in those infected, reduce severe disease?

These will take months, but need to be in place now for both for post-exposure & pre-exposure use.

/4
Ideally, these real-world studies would also involve use of ACAM (smallpox vaccine).

Is it possible for @CDCgov to evaluate SQ Jynneos vs. ID Jynneos vs. ACAM as both pre- and post-exposure prophylaxis?

/5
Given totality of evidence & acute vax shortage & urgency, I support the intra-dermal approach as long as we proceed with getting the best quality evidence we can as above.

Next big concern is implementation.

/6
Mass vax campaigns are like industrial manufacturing: every step in the process needs to go perfectly for it to work & even small error rates at one step can result in big problems.

/7
Staff in TB clinics give intra-dermal injections (PPD) all the time. Most other vaccinators do not. They need to build confidence so, when they do 50 in a day, they do it right every time, especially since not much room for error with lower dose vaccination.

/8
The syringes need to be in sufficient supply and able to withdraw vax from bottle accurately. From folks I’ve talked to, seems this should be easy with #Jynneos. (Was not so easy with #COVID19 vaccine).

/9
Itching & redness at site of injection will be a big issue. BUT with vax targeted to those at highest risk & other interventions for prevention possible, I’m not too concerned about vax acceptance. I’d be more concerned if we were encouraging entire US population to get it.

/10
Note that I support current intra-dermal approach based on assumptions:
-It’s not possible to increase Jynneos supply dramatically
-Other approaches (behavior change; testing & tracing) will not stem this outbreak alone

/11
Many others, such as @PrEP4AllNow, can speak more to increasing vax supply. Per their research, there is more administration can & should be doing.

/12
Mass screening & outreach could also drive incidence down, but depends on tests that use alternative specimen types (OP, saliva) or provide rapid results from skin. Until those available, mass testing not practical for outbreak control.

/13
In sum, I recommend those at risk get vaccinated with either intra-dermal or subcutaneous.

But really hope we get the data comparing effectiveness & develop tools to supplement vaccination.

/end

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More from @DrJayVarma

Aug 9
Concur with discussion below. Adds to weight of evidence that direct inoculation via receptive intercourse (anal, oral) likely primary route of infection for many patients

Important implications ⬇️

/1
Helps explain why >10K cases globally during 2022 outbreak remain tightly connected to gay men & their sexual networks: transmission via anal/oral receptive intercourse far more efficient than other routes.

/2
Short incubation period and likelihood of direct inoculation supports why pre-exposure #monkeypox vaccination for groups at highest risk likely much more effective at preventing disease than post-exposure vaccination.

/3
Read 5 tweets
Aug 9
I’m really surprised by this & don’t agree. Unlike a drug, vax are given to healthy people w/expectation they’ll be protected from future disease. We know little about efficacy of even standard dosing. Why not at least measure immune response in volunteers before using?

/1
Ethics of this seem weirdly out of synch with Tpoxx, which is used to treat sick people who have no other options. Yet @US_FDA insists animal model clinical trial insufficient. Yet animal model for vaccine is acceptable when given to healthy people?

/2
Yes, recognize you have a bio marker for vax that you don’t have with drug. But how strong js evidence base for that correlate of protection against this #monkeypox clade & this route of exposure (primarily through receptive & insertive intercourse)?

/3
Read 4 tweets
Aug 1
A lot of people do not understand how worrisome the #polio case in NY.

Based on what's been discussed publicly:

-the person with paralytic polio got infected in NY

-the source case in NY has not been found

/1
-for one person to get paralytic polio, it means that 100s were infected, b/c only ~1 in 200 develop paralysis

-since case was detected in early June & weeks have gone on before vax catch-up campaign, likely means 1000s of infections cumulatively to date

/2
-detection in wastewater further supports the fact that many have been infected & are shedding polio virus

-(injectable) polio vax works extremely well at preventing severe disease, but it does not block people from being infected & shedding virus in their feces

/3
Read 4 tweets
Apr 13
I get that public health folks (myself included) are getting their moment in the sun, but is it really necessary to ape political & sports pundits with hot takes?

1/4
We don't know what direction BA.2 is headed.

Preventing infections is beneficial to health.

Masks prevent infections.

There are no direct harms from wearing a mask.

Some perceive widespread mask use as unacceptable, particularly in children.

2/4
Local officials should make judgments based on what their population believes is feasible & acceptable, accounting for both real & perceived harms.

What one jurisdiction chooses to do may not be right for another.

3/4
Read 4 tweets
Apr 11
One (of many) limitations of @CDCgov & @nycHealthy #COVID19 levels is that they tell you where epidemic has been, not where it might be going.

As of today, there’s a 33% chance #NYC will move from low -> medium citywide in one week (by April 18, 2022)

🧵⬇️

/1
My colleagues @WashburneAlex @WCMPopHealthSci Nathaniel Hupert have developed a forecast based on observation that outbreaks of new #COVID19 variants have growth rate & duration that is similar regardless of where outbreak occurs worldwide. Methods at bit.ly/3vajeHH

/2
Our forecast for #NYC’s current BA.2 outbreak is based on the hypothesis that cases in #NYC’s BA.2 outbreak will follow a trajectory similar to the UK’s BA.2 outbreak. See this image that tracks growth rate over time for both UK and NYC.

/3
Read 8 tweets
Dec 22, 2021
In this OpEd (nytimes.com/2021/12/20/opi…), I argued that we should reduce the recommended isolation period for #COVID19 in vaccinated persons. This is how I think through a problem like this. 🧵⬇️
Call it #ThinkLikeAPublicHealthPractitioner, which is different than thinking like a virologist, epidemiologist, or clinician.

Virology helps us answer: how infectious are people with COVID-19 based on duration of infection, vaccination status, symptoms, and other factors?
Epidemiology helps us answer: what is the impact on community disease transmission for different isolation policies and different levels of adherence to those policies?
Read 15 tweets

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