Philly’s monkeypox vax supply must be stretched. The health commissioner is weighing how to do it.

Philadelphia’s health department is facing logistical challenges and cultural concerns as a decision looms on how best to stretch its monkeypox vaccine supply as the outbreak grows.

Last week the U.S. Food and Drug Administration permitted health providers to offer just a fifth of the standard dose of the monkeypox vaccine JYNNEOS.

But switching to smaller doses isn’t simple, said city Health Commissioner Cheryl Bettigole in an interview Friday. Different needles and injection techniques are needed, and record-keeping is another challenge, she said, explaining why her agency has held off on offering smaller doses so far.

“We’re trying to move very quickly,” Bettigole said. “We need both the providers and the community to be on board with whatever we decide.”

She expects to announce how the Philadelphia Department of Public Health will handle the new directive in the coming week.

Roughly 24,000 vaccine doses would be needed to provide the recommended two-shot series to each resident at higher risk, which includes men over 18 who have recently had multiple or anonymous sexual encounters with other men. Some transgender and nonbinary people as well as sex workers also may be at high risk. The city was allocated just over a third of that amount by the federal Department of Health and Human Services, Bettigole said, and a delivery expected this week will likely be the last in 2022.

» READ MORE: Philly sex workers finally have access to the monkeypox vaccine

So far the city has been prioritizing people already exposed to monkeypox, but to contain the virus health experts have said vaccine should be made available to everyone most likely to encounter it.

The FDA decision to allow smaller doses came as the United States reported more than 10,000 cases of the virus nationally. Philadelphia reported 128 cases Monday, the most recent data available, almost half of all the cases reported in Pennsylvania, and demand for the vaccine here far exceeds supply.

The smaller dose offers similar protection as a full dose if it is injected directly into the skin, the FDA has said, rather than the fatty layer of tissue beneath the skin.

“If we can take that number and multiply it by a factor of five that could completely change the landscape of this,” said Dusty Latimer, a nurse-practitioner at the Mazzoni Center, an LGBTQ-focused Philadelphia health clinic.

Bettigole noted that though the FDA has cited a small study as evidence that small doses will protect people, other studies done in Germany boosted her confidence in the approach.

“It is the best thing we have right now,” she said of the vaccine, approved in 2019. “It is at least safe.”

Not only does the city lack doses, it also doesn’t have the special needles used for the skin injections. Health department staff are determining how quickly they can get the needles. The city is hoping for federal funds for monkeypox response but doesn’t know how much it may get.

Intradermal injections also require more precision — and therefore training — than the kind of injections that have been used to administer a full dose of monkeypox or COVID-19 vaccine.

“It’s been a minute since most people in medicine have done intradermal injections,” Latimer said.

A telltale bubble on the skin at the injection site shows that the shot went in correctly. Among the unanswered questions, Bettigole said, is what to do if one of these shots is given incorrectly. If the smaller dose is injected too deeply, it won’t create the needed immune response, she said.

The intradermal injections are more likely to leave a permanent mark, particularly in people prone to develop thick keloid scars. If patients don’t have a choice of which kind of injection to get, she said, some may avoid the shots entirely rather than risk a scar that some might consider stigmatizing.

Some patients may have other skin conditions that would make the larger dose a better option, Latimer said.

Yet offering patients a choice of vaccines creates an additional complication for the providers, because it’s yet another layer of record-keeping.

Providers also will face questions from patients skeptical that the smaller dose can be just as effective as a larger one, Latimer said. It’s a discussion he’s “anticipating and am not terribly excited to have on a regular basis right now.”

Clear guidance from the city on who is or isn’t eligible for the deeper, higher-dose shots would help providers, he said.

A survey to providers and community leaders on how best to handle vaccine distribution is due Monday, the commissioner said, and an announcement is expected to follow within days.

“We need input from vaccine providers, input from community leaders, community members,” Bettigole said, “about how they feel about this.”