The Defense Health Agency and military services are working to make the mpox vaccine available for those at risk for contracting the virus after the Centers for Disease Control and Prevention recommended travelers to parts of Africa be immunized.

The federal agency issued an advisory last month recommending that travelers to central and east Africa who may be at risk -- largely those who have sexual contact with men -- get the two-dose vaccine.

During an outbreak in 2022, 146 military health system beneficiaries, including 118 active-duty personnel, had confirmed or suspected cases, according to the Defense Health Agency's September Medical Surveillance Monthly Report.

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The majority of active-duty members -- nearly 90% -- who contracted the virus got it in the U.S., with most stationed in California, Virginia or Maryland. The Army^[2] and Navy^[3] together accounted for nearly 80% of the cases, which largely affected enlisted personnel between the ages of 20 and 34, according to the Armed Forces Health Surveillance Division.

The virus, previously known as monkeypox, is related to smallpox and typically causes symptoms such as fever and headaches, but can result in painful blisters and life-threatening conditions.

To safeguard against additional cases, either at home or while deployed, the Defense Health Agency and the services have made the Ankara-Bavarian Nordic vaccine, a third-generation smallpox vaccine, available at military health facilities and through the Tricare^[4] health program.

According to the Navy and the Air Force^[5], the vaccine is not mandatory for troops deploying to Africa but has been made available to those who want it on demand.

The Army did not respond to a request for information by publication.

"When the U.S. declared mpox a national health emergency, the Air Force worked in coordination with DHA to ensure the vaccine was available for airmen and Guardians on demand," an Air Force official told Military.com in an email.

"Navy personnel traveling overseas are provided a health consultation to assess for risks associated with health threats in the area and can receive medication or a vaccine may be available to help prevent or reduce severity of mpox ... infections, particularly for those at high risk of severe infection," Navy Bureau of Medicine spokeswoman Cmdr. Jessica McNulty said in an email Oct. 24.

Those considered to be at high risk for contracting the virus include people in close contact with an infected individual, with close contact defined as skin-to-skin contact, including kissing. Most of those affected have been gay or bisexual men, and anyone who has sex with multiple partners is considered at high risk, according to the World Health Organization.

The 2022-2023 mpox outbreak in the U.S. sickened more than 34,000 individuals and killed 63, according to the CDC. Armed Forces Health Surveillance Division epidemiologists said the impact may have been lower in the U.S. military as a result of an effective vaccine campaign targeting at-risk service members.

"It has been posited that effective targeting of pre- and post-exposure vaccine prophylaxis campaigns toward the MSM population, along with decreased high-risk sexual activities due to awareness campaigns by Defense Health Agency personnel, may have contributed to the significant decline in military health system beneficiary cases," they wrote.

They added that they reviewed military health system cases to help military leadership and the medical community to anticipate the illness' effect on readiness as well as develop prevention and mitigation strategies.

The current surge in Africa and elsewhere has been caused largely by a new strain of the virus, which is bringing the illness to previously unaffected areas. According to the World Health Organization, there have been nearly 45,000 suspected or confirmed cases in 17 countries this year.

The CDC has issued its travel alert for the Democratic Republic of the Congo, where more than 21,000 cases have been reported, as well as Burundi, Central African Republic, Rwanda and Uganda, recommending that physicians discuss prevention and awareness with patients who have plans to travel to these countries.

McNulty noted that, although the vaccine is in short supply, stocks are increasing, and personnel who are at risk or deploying to affected countries should work with their military treatment facility or Navy Environmental Preventive Medicine Unit to assess whether they meet the criteria for getting the immunization.

"Given the evolving nature of monkeypox outbreaks, MTF providers should be reviewing the latest CDC information on monkeypox," she wrote.

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A nonprofit animal rights and medical ethics organization is suing the Defense Department for refusing to disclose details on its use of pigs and goats for medical training at four major military hospitals.

The Physicians Committee for Responsible Medicine, a group of roughly 17,000 doctors who promote plant-based diets and aim to protect animals from research and testing, filed a federal lawsuit Oct. 23 seeking documents on medical training at Naval Medical Center Portsmouth, Virginia; Madigan Army Medical Center, Washington; Darnall Army Medical Center, Texas; and Naval Medical Center San Diego.

The suit alleges that at least 80 invasive procedures, including stabbing and evisceration, have been conducted recently on the animals and the DoD has refused to release documents on the training despite a Freedom of Information Act request.

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According to the group, the DoD has ignored the FOIA and has not responded to subsequent emails and phone calls on the inquiry.

"The violation of federal law -- of not producing this information in a timely manner, ignoring requests or just continually delaying it -- this lack of full transparency is concerning," said retired Navy^[2] Cmdr. Erin Griffith, an emergency medicine physician and longtime PCRM member, in an interview with Military.com.

The DoD has had a policy in place since 2011 that limits the services' use of live animals for medical training if alternatives like advanced simulators, mannequins, cadavers or actors can provide the same level of proficiency.

Using dogs, cats, nonhuman primates and marine mammals for such military medical training is generally prohibited under the directive.

In 2014, the Pentagon clarified the policy with an intention to "fully transition to the use of simulations" for most training, but it did not apply to combat or survival skills.

"Medical simulation technology will be used to the maximum extent practicable, before the use of live tissue training to train medical professionals and combat medics of the DoD," a 2019 update to the directive states. "The use of live tissue training within DoD may be used as determined necessary by the medical chain of command."

The Defense Department and the Navy declined to comment, citing the ongoing litigation. The Army^[3] did not respond by publication.

Griffith said the PCRM suspects that the Pentagon violates its own policies, despite evidence showing that animal use is not as effective as state-of-the-art simulators.

Documentation obtained by PCRM noted that Naval Hospital Portsmouth uses 60 pigs a year in emergency medical training.

"Doing these trauma procedures requires you to know anatomy to do the procedures correctly. I don't have to tell you the differences of the anatomy of a pig and a human -- it's everything from how much pressure you need, how thick the skin is, to the shape," Griffith said. "It's definitely not human anatomy."

A 2022 Government Accountability Office report found that, while the DoD has taken steps to replace animals in trauma training, it has failed to show how well it is doing with this goal because it lacks measurable objectives for making assessments.

"DoD does not have performance measures upon which to rely when assessing DoD's programs in reducing its use of animals," GAO analysts wrote.

The GAO recommended that the DoD develop performance measures and clarify guidance to reduce and replace the use of animals in trauma training.

"By developing specific and measurable objectives and performance measures for monitoring progress, DoD could provide greater assurance that it could assess progress in increasing its use of alternatives to live animals during trauma training," they wrote.

In military journal articles and other publications, members of the U.S. defense community have said training with live animals is invaluable -- not just the medical treatment portion but the mental training needed to handle the emotional shock of violence.

"[Such] training also provides clinical and psychological 'conditioning for the horrors and chaos of war,'" a 2013 article in the Journal of Military and Veterans' Health states.

But Griffith, who has deployed to combat and trained on goats and pigs as a military emergency physician, said realistic, high-tech simulators cause equal levels of distress and the DoD "overestimates" the role a sedated animal plays in lieu of performing trauma treatment on a battle buddy.

"You can't in the moment be emotional about the tragedy of what has occurred. You have to tap into your training and the science and your education in order to best treat the patient," Griffith said. "I can tell you, having treated people in combat, that you rely on repetitive procedural training, which you can do over and over on a [human] simulator."

The group cites studies by the U.S. and Canadian militaries that show simulation training is as effective or even more so than practicing on animals. According to the group, 97% of emergency medicine residency programs -- 284 of the 292 programs -- surveyed in the U.S. and Canada train without animals, including emergency medicine programs affiliated with the Air Force^[4] at Wright State University and the Army at the Medical College of Georgia.

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