Monkeypox emerges on a global scale: A historical review and dermatologic primer

To the Editor: Thank you for your kind words and very important response. As an evolving public health emergency, new information is continuing to emerge, and recommendations should be frequently clarified and updated. You have highlighted a very important issue.¹ Given the increasingly apparent scarcity of JYNNEOS vaccines and related to our central message of urgency to contain, all pre- and post-exposure treatments including ACAM2000 must be considered where appropriate. Moreover, ACAM2000 is more abundant in the strategic national stockpile. We therefore fully agree with your response. Responses such as yours and Peebles² add invaluable support and further context to the case.

Your response also raises the opportunity for us to clarify an important point. Our paper, without specifically naming it, describes Dryvax which was the smallpox (vaccinia virus) vaccine in use from 1931 until ACAM2000 was approved in 2007. Both are live and replication-competent vaccinia vaccines which would pose similar risk profiles and considerations. They differ primarily in production media (calf lymph vs cell culture). Broadly speaking, our intent was to contrast “traditional” vaccines with the more contemporary (JYNNEOS), namely replication-competent versus replication-deficient. The former presents risks, as you and we cite, to those with serious allergy, immunocompromised status, pregnancy or breastfeeding, underlying heart disease, or a history of atopic dermatitis or another exfoliative skin condition. However, as you expound, ACAM2000 is the current vaccinia virus vaccine in use and well stocked. Altogether, we acknowledge that our paragraph regarding vaccination would benefit from clarity, which your response adds.

Recommendations will likely change, as with the dose sparring approaches of JYNNEOS, including splitting vials for intradermal administration, as recently approved by the Food and Drug Administration in another emergency use authorization.³ As more cases arise and vaccines are used both before and after exposure, it is important to carefully track patterns of disease and vaccine impact, including any potential cutaneous adverse events that may arise. We encourage providers to consider reporting monkeypox cases and vaccinations to the American Academy of Dermatology's registry⁴: https://www.aad.org/member/clinical-quality/clinical-care/monkeypox/registry.

Conflicts of interest

Drs Rosenbach and Freeman are members of the AAD's Monkeypox Ad Hoc Task Force and are speaking on behalf of themselves and not the Academy.