Mpox 03 Duffy 508

CDC ACIP — Vaccine Advisory Committee

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National  Center  for Emergin  g and  Zoonotic  Infectious  Diseases 
JYNNEOS Vaccine Safety Monitoring During the 2022 
Mpox Outbreak ─ United States 
Jonathan Duffy, MD, MPH 
Immunization Safety Office Centers for Disease Control and Prevention 
Advisory Committee on Immunization Practices 
February 22, 2023 
    
     
   
    
      CDC Mpox vaccine safety data sources 
 Vaccine Adverse Event Reporting System (VAERS) 
 Vaccine Safety Datalink (VSD) 
 V-safe after vaccination health checker 
 Single-patient emergency Investigational New Drug (EIND) procedures 

VAERS 
         VAERS is the nation’s early warning system for vaccine 
safety 

       
     
          
      
         
 
        
        
      
               
           
               
  JYNNEOS EUA* required reporting to VAERS for 
adverse events and vaccine administration errors 
 The vaccination provider is responsible for MANDATORY reporting of the 
following listed events following JYNNEOS to VAERS: 
– Vaccine administration errors whether or not associated with an adverse event 
– Serious adverse events (irrespective of attribution to vaccination) 
– Cases of cardiac events including myocarditis and pericarditis 
– Cases of thromboembolic events and neurovascular events 
*EUA indications: intradermal injection for individuals aged ≥18 and subcutaneous injection for individuals aged <18 years; Fact Sheet 
for Healthcare Providers Administering Vaccine: Emergency Use Authorization of Jynneos (Smallpox and Monkeypox 
Vaccine, Live, Non-Replicating) for Prevention of Monkeypox Disease in Individuals Determined to be at High Risk for Monkeypox Infection (fda.gov) 

   
        
           
           
          
    
  
  
  VAERS: JYNNEOS surveillance methods 
 VAERS reports received and processed by January 20, 2023 
 Adverse event reporting rates were calculated by dividing the number of 
VAERS reports by the number of vaccine doses administered in the U.S. 
– Vaccine doses administered during May 22–January 13 and reported to CDC by January 23, 2023 
• Dose 1: 698,188 
• Dose 2: 426,980 
• Total: 1,125,168 

    
 
 
 
  
 
 
 
  
   
 
  
  
 
 
  
  
 
 
 
  VAERS: JYNNEOS report characteristics, n = 1,817 
Characteristic n (%) 
Sex 
Male 1,415 (78) 
Female 238 (13) 
Not reported 164 (9) 
Age 
0-17 25 (1) 
18-64 1,501 (83) 
≥65 83 (5) 
Not reported 208 (11) 
Other vaccines on same day 
Yes 45 (2) 
No 1,772 (98) Characteristic n (%) 
Dose in series 
1 1,013 (56) 
2 471 (26) 
Not reported 333 (18) 
Route of administration 
Intradermal 1,001 (55) 
Subcutaneous 378 (21) 
Intramuscular 211 (12) 
Not reported 227 (12) 

    
      
         
  
    
    
      
       
     VAERS: vaccine administration error reports 
 Represent 50% of all JYNNEOS VAERS reports 
– Of these, 96% did not report an adverse health event 
 Error reporting rate 
– Intradermal: 937 per million doses administered 
– Subcutaneous: 306 per million doses administered 
 Errors frequently reported with attempted intradermal administration: 
– Absence of a wheal without vaccine leakage (42%) 
– Vaccine leakage from injection site (12%) 

rate 
  
 All adverse health events VAERS: adverse health event reporting rates per 
million doses administered by route of administration 
       
      
   
  
    
 Intradermal rate 
All adverse health events 685 
Injection site erythema 152 Dizziness 129 
Injection site swelling 112 
Urticaria 110 
Injection site pruritus 93 
Erythema 78 
Syncope 73 
Pruritus 72 
Hyperhidrosis 70 
Loss of consciousness 69 Injec  tion sit  e erythema 
  Injection site swelling 
  Injection site pain Pain 107 
107 
99 96 
Fatigue Erythema Headache 80 77 77 
Dizziness 74 
  Injection site pruritus Pyrexia 66 66 Subcutaneous 
639 
  
   
      
           
    
   
          
          
        Serious Adverse Event definition 
 Death 
 A life-threatening adverse event 
 Inpatient hospitalization or prolongation of existing hospitalization 
 A persistent or significant incapacity or substantial disruption of the ability 
to conduct normal life functions 
 A congenital anomaly/birth defect 
 An important medical event that based on appropriate medical judgement 
may jeopardize the individual and may require medical or surgical 
intervention to prevent one of the outcomes listed above 

      
  
  
 
   
  
  
 
 
        
                
     VAERS: serious adverse events reported after JYNNEOS*, 
n = 26 
SAE reporting rate: 22 reports per million doses administered 
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   Dehydration Myocarditis  (n =5) 
Death  (n=2)** Idiopathic thrombocytopenic 
pur
pura Pericarditi  s (n=2) 
In
jection site discoloration Urticari  a (n=2) 
In
jection site pain Appendicitis 
Injection site scar Asepti  c meningitis 
Met
hemoglobinemia Asthenia 
Retrograde amnesia Atrial  fibrillation 
Rha
bdomyolysis Cellulitis 
Sudden hearing loss Chest  pain 
*The report of an adverse event to VAERS is not documentation that a vaccine caused the event. 
**Reported causes of death: drowning, cocaine toxicity. 
Myocarditis and pericarditis 
  
        
        
          
        
  
    
          
   Myocarditis and pericarditis 
 Myocarditis and pericarditis have occurred following either primary 
vaccination or revaccination with live vaccinia virus smallpox vaccines 
– The mechanism is poorly understood, and it was unknown whether persons who receive JYNNEOS might experience myocarditis or pericarditis 
 Epidemiologic analysis groupings: 
– Myocarditis with or without pericarditis 
– Pericarditis 
 Surveillance risk interval: symptom onset within 30 days after vaccination 
Case definitions available at: DOI: 10.15585/mmwr.mm7027e2 

      
  
       
   
     
        
              
    
 
  
    
        
   Myocarditis rate per million persons during 30-day period 
Observed after JYNNEOS 
Data source Dose 1 
cases doses rate per million 
(95% CI) Dose 2 
cases doses rate per million 
(95% CI) 
VAERS 2 726,851 2.75 (0.33–9.94) 3 445,019 6.74 (1.39–19.70) 
Vaccine Safety 
Datalink 1 37,646 27 (0.67–148) 1 21,919 46 (1.15–254) 
Expected 
 Historical myocarditis population background rates per million persons: 
– U.S. military in 20021: 21.6 
– MarketScan database, males 18–64 yrs in 2017–20192: 2.7 – 7.5 
 Historical myocarditis rates after live, replicating smallpox vaccines (Dryvax or ACAM2000) ranged from 78 to 5,230 cases per million persons
1,3 
References: 
1) Halsell, et all. DOI: 10.1001/jama.289.24.3283; 2) Oster, et al. DOI: 10.1001/jama.2021.24110 ; 
3) Mandra, et al. DOI: 10.1017/dmp.2020.478 

      
  
      
 
     
        
                
    
 
  
  
          
   Pericarditis rate per million persons during 30-day period 
Observed after JYNNEOS 
Data source Dose 1 
cases doses rate per million 
(95% CI) Dose 2 
cases doses rate per million 
(95% CI) 
VAERS 4 726,851 5.50 (1.50–14) 2 445,019 4.49 (0.54–16.23) 
Vaccine Safety 
Datalink 0 37,646 0 0 21,919 0 
Expected 
 Historical pericarditis population background rates per million persons: 
– Italy, 2001–20051: 22.8 
– U.S. Nationwide Inpatient Sample database, 2003–20122: 4.7 
 Historical pericarditis rate after live, replicating smallpox vaccines (Dryvax 
or ACAM2000) was 925 cases per million persons in one U.S. military study3 
References: 
1) Imazio, et al. DOI: 10.1136/hrt.2006.104067; 2) Kumar, et al. DOI: 10.1159/000445206 ; 
3) Engler, et al. DOI:10.1371/journal.pone.0118283 

V-safe 
     
         
      
   
            
  
        
          
      
          
   V-safe Mpox: active vaccine safety monitoring 
 Smartphone-based system that uses text messaging to initiate web-based 
survey monitoring for adverse events following vaccination 
 V-safe is used to: 
– Characterize the basic safety profile of a vaccine when given outside a clinical trial setting 
– Provide information for public health communication around vaccine safety 
– Facilitate reporting to the Vaccine Adverse Event Reporting System (VAERS) 
for medically attended adverse events following vaccination 
 V-safe supplements CDC’s other vaccine safety monitoring systems, VAERS and 
Vaccine Safety Datalink (VSD) 

     
               
  
 
                     
 
 
 
 
  
   
         
      
       
        
V-safe Mpox: characteristics of active participants* 
Characteristic N=181 
n (%) 
Age in years 
18-49 112 (61.9) 
50-64 56 (30.9) 
≥65 13 (7.2) 
Gender identity 
Male 139 (76.8) 
Female 28 (15.5) 
Transgender 7 (3.9) 
None of the above or 
unknown 7 (3.9) 
Immunocompromised** 32 (17.1) Characteristic N=181 
n (%) 
Race/Ethnicity 
White, non-Hispanic 111 (61.3) 
Hispanic 28 (15.5) 
Asian, non-Hispanic 11 (6.1) 
Black, non-Hispanic 10 (5.5) 
Multiracial, non-Hispanic 10 (5.5) 
Other race, non-Hispanic 2 (1.1) 
Unknown race or ethnicity 9 (5.0) 
*active participants defined as having completed at least one 
survey, November 16, 2022 – January 29, 2023 **defined as self-report of immunocompromising condition or taking immunosuppressive medications at the time of vaccination 

        
        
          
        
  
                    
          V-safe Mpox: reactions and health impact events reported by v-safe
participants at least once in days 0-7 after vaccination, by dose
100 
90 
81 
62 
26 
19 
14 
5 80 
54 
16 14 
10 
0 
0 10 20 30 40 50 60 70 80 Percentage 
Any injection site reaction Any systemic reaction Any health impact Unable to perform normal Unable to work or attend Sought medical care (clinic 
daily activities school only) 
Dose 1 Dose 2 
Includes 42 participants who completed at least one survey after dose 1 and 50 participants who completed at least one survey 
after dose 2, data collected November 16, 2022 – January 29, 2023 

          
        
            
  
                    
          V-safe Mpox: top injection site and systemic reactions reported by v-safe
participants at least once in days 0-7 after Mpox vaccination, by dose
100 
90 
80 70 
6462 
60 50 
40 
30 20 10 
0 
Redness at site Itching at site Lump at site Swelling at site Fatigue Headache Pain at site Myalgia Rash at site Fever 55 52 50 
40 
24 24 24 
17 17 54 
46 
40 42 
28 26 
22 
16 
6 
Dose 1 Dose 2 
Includes 42 participants who completed at least one survey after dose 1 and 50 participants who completed at least one survey 
after dose 2, data collected November 16, 2022 – January 29, 2023 Percentage 

Adverse  Events  in  persons  <18 years  of age 
 
   
 
  
    
    
      
     
     Single-patient emergency  Investigational  New  Drug  
(EIND) procedures 
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 CDC facilitate  d JYNNEOS EIND  authorization  s fro  m FDA  fo r 65 person  s aged  <1 8 
year  s prior  to  the  EUA  being  issue  d o  n August  9,  2022 
– CDC  solicite  d informatio  n fro  m vaccine  provider  s about  adverse  event  s 
occurring  durin  g the  28 day  s afte  r each  dose 
 Ages: 4 months to 17 years 
 Sex: 58% male 
 Adverse events reported: 
– D
ose 1: 10 (18%) of 57 
– Dose 2: 5 (21%) of 24 
– Injection site reactions: pain, erythema, swelling, and induration 
– Systemic adverse events: fever, fatigue, and headache 
 No serious adverse events were reported 

      
            
    
        
     
      
      
       
    VAERS: reports for persons aged <18 years 
 JYNNEOS vaccine was administered to 1,245 persons aged <18 years in the 
U.S during this surveillance period 
 VAERS received 25 reports for persons aged <18 years 
– Ages from 12 through 17 years 
– Vaccine administration errors, n = 21 (84%) 
• e.g., administered intradermal dose instead of subcutaneous dose 
– Only 1 adverse health event reported: syncope 
– No serious adverse events reported 

Conclusions 
       
         
        
           
     
             
          
   Conclusions 
 JYNNEOS post-licensure and post-authorization vaccine safety surveillance 
findings to date are consistent with those observed in clinical trials 
 No new or unexpected safety concerns have been identified 
 Serious adverse events were rare among adults, and none have been identified among persons aged <18 years 
 VAERS and Vaccine Safety Datalink data do not suggest an increased risk for myocarditis or pericarditis following JYNNEOS, but the possibility of a small risk cannot be excluded 

    
 
      
                  
         For more information, contact CDC 
1-800-CDC-INFO (232-4636) TTY: 1-888-232-6348 www.cdc.gov 
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.