The recent monkeypox outbreak continues to surge in the U.S., as it does in many countries across the globe. Confirmed cases have climbed from just 40 on June 8, 2022 to 4,639 on July 27, 2022, distributed across almost all states. There is a significant risk that the current outbreak could become endemic in the U.S., if not further contained. One of the best tools available to help mitigate the outbreak is vaccination. However, there is a limited supply of vaccines and widespread reports that demand is outstripping supply, particularly in some jurisdictions.

Among the many factors that may be influencing supply at the local level is whether jurisdictions are requesting the vaccines allocated to them. Here, we explore jurisdictional request rates for JYNNEOS, the preferred monkeypox vaccine, based on publicly available data in all 50 states, Washington D.C., and 5 cities (allocations are also made to territories and tribal entities not described in this analysis) as of July 22, 2022. Overall, we find that while most jurisdictions have requested their full supply, some are well below that mark, raising questions about how quickly their at-risk populations can get protected.

There are currently two vaccines that can be used in the U.S. to prevent monkeypox: JYNNEOS and ACAM2000. JYNNEOS is FDA-approved for both monkeypox and smallpox, while ACAM2000 is approved for smallpox but has been granted an expanded access Investigational New Drug (EA-IND) protocol to allow its use for monkeypox. While both vaccines are effective, JYNNEOS is preferred because it has a lower risk profile for both the patient and provider, is less invasive to administer, and is not contraindicated for people with conditions associated with being immunocompromised, including people with HIV, who are pregnant, or have other select conditions, as is the case with ACAM2000. As such, JYNNEOS is being prioritized in the U.S. roll-out.

The federal government uses an evolving algorithm to determine allocation levels to jurisdictions based on current and projected monkeypox case burden in a jurisdiction and the size of the jurisdiction’s at-risk population, defined as men who have sex with men with HIV or who have an indication for HIV pre-exposure prophylaxis (PrEP). Jurisdictions must then request vaccine supply from the Centers for Disease Control and Prevention (CDC).

As of July 22, 2022, almost all (97%) of the allocated JYNNEOS vaccine supply has been requested by jurisdictions across the country. However, this varies significantly, and while most jurisdictions have requested their full allocation, a subset have requested well below:

• The request rate – the number of vaccine doses requested as a share of the jurisdiction’s allocation — ranges from a low of just 3% in Arkansas to a high of 115% in Maine.
• The majority of jurisdictions (37) have requested their full allocation of vaccine. This includes 11 that have requested 100% and 26 that have requested even more than their allocated amount (See Figure 1).
• The remaining 19 jurisdictions have requested less than their share, including 10 that have requested 50% or less (WA, MO, KS, GA, NV, MT, SD, OK, KY, and AR).
• Of the 10 that have requested 50% or less, some have relatively small numbers of confirmed cases, or no confirmed cases at all, and smaller at-risk populations. However, this is not the case for all. For example, Washington state has 103 cases and Georgia has 312 (both as of  July 27, 2022) and they have large or moderate size populations of men who have sex with men with HIV (with Georgia ranking 5^th among all states and Washington ranking 18^th), but they have requested 50% and 43% of their allocated doses, respectively. This may be temporary or an issue of timing – a recent media report notes that Georgia plans to request their full allocation soon.

Overall, there are not enough vaccine doses to meet demand right now and most jurisdictions are maxing out or exceeding their allocation and, in some cases, still unable to meet demand. However, this is not the case everywhere and jurisdictions likely have different reasons for not requesting the full allocation. In some cases, states with no or low reported cases may see an immediate need for the full vaccine allocation. In others there may be separate challenges at play. In the case of Georgia for example, the state indicated that its initially low request rate was due to concerns around storage and wanting more time to prepare and connect with community partners. While in some cases this may reflect an initial timing and/or preparedness issue, it is important to note that speed still plays a key role in curbing a growing outbreak.

Jurisdictions were notified of their 3rd round of vaccine allocation on July 28, 2022, which means more supply but also that they will likely now be grappling again with how much to request to respond to local need. Beyond the number of doses each jurisdiction accesses, there are other factors that could enhance or complicate vaccine uptake, including where vaccine access points are located, which community partners are included, how public officials educate those at risk about vaccination, the impact of stigma, and vaccine communication strategies, among others. Ultimately, and as we have written elsewhere, variation in jurisdictional decisions about how to address the monkeypox outbreak, including their vaccination strategy, will likely have an impact on local and national success in curbing it.