At the start of the coronavirus pandemic in 2020, scarce ventilators and protective gear were subject to strict rationing. Today, as the pandemic rages on in its third year, another valuable category of products is subject to strict controls: treatments to ward off severe Covid-19.
There is a bigger menu of Covid pills and infusions now than at any time during the pandemic. The problem is, the supplies for those working against the Omicron variant are extremely limited.
This has forced state health officials and doctors across the country to find themselves in a difficult position to decide which patients receive potentially life-saving treatments and which do not. Some people at high risk of severe Covid are turned away because they are vaccinated.
Some hospitals are running out of certain drugs; others say they only have a few dozen treatments on hand. Staff distribute vitamins instead of authorized drugs. Others are trying to develop algorithms to decide who gets treatment.
âThere is simply not enough to meet the needs of all those who are going to have Covid in the coming weeks and are at risk of serious complications,â said Dr. Natasha Bagdasarian, Michigan medical director. “I don’t think there’s a way to make sure it’s reaching all the right people right now.”
At Family Health Centers in San Diego, a network of clinics for low-income patients, staff have had to turn away about 90% of the hundreds of people who call daily and are eligible for Covid treatments.
“It makes me nauseous to come home at night because I feel like I decide, with this limited resource, who should get it,” said Dr Christian Ramers, an infectious disease specialist there. .
A plentiful supply of effective treatments would be a powerful weapon as the virus reappears in the United States. Fueled by the highly contagious variant of Omicron, Covid cases have reached record highs, and the number of hospital patients has also risen sharply, although Omicron tends to cause milder illness than the other variants.
During most of the pandemic, monoclonal antibodies – a treatment typically given intravenously in hospitals or clinics – have been the primary option for newly infected patients. But the two most common types of antibodies don’t seem to work against the Omicron variant, which is quickly becoming the dominant version of the coronavirus around the world.
There is a third antibody treatment, manufactured by GlaxoSmithKline and Vir Biotechnology, which is potent against Omicron. But the federal government has only ordered about 450,000 courses of treatment, many of which have either already been used or have not yet been delivered to the states.
Two weeks ago, the Food and Drug Administration cleared the use of a new antiviral pill, developed by Pfizer, which shows great promise in tackling Covid in general and Omicron cases in particular.
The federal government supplies the pill, known as Paxlovid, to states, whose health officials decide where to send the pills and how to advise doctors to use them.
Supplies are already exhausted. New York City, for example, received about 1,300 courses of Paxlovid in late December, which it used in a week, according to a spokesperson for Alto Pharmacy, which distributes the city’s supply. New York City currently has no Paxlovid in stock.
The U.S. government doubled its order of Paxlovid on Tuesday, although supplies were not plentiful until April.
National and local authorities say the aim is to get Paxlovid to as many of the most vulnerable as possible, with particular emphasis on those with weakened immune systems or who are not vaccinated.
Unvaccinated people are at a much higher risk of hospitalization or death from Covid. But by giving them priority access to treatment, people feel “you’re rewarding intransigence,” said Dr. Matthew K. Wynia, director of the Center for Bioethics and Humanities at the University of Colorado, who has advised the state on how to ration. Covid treatments.
Only some states, like Ohio and Nevada, have sent Paxlovid to pharmacies that serve nursing homes, whose residents are particularly vulnerable to Covid. Many states, including Virginia, Pennsylvania, and Arizona, have sent most or all of their initial supplies of Paxlovid to drugstore chains like Walgreens and Rite Aid.
This was aimed at making the pills as widely available as possible. But the system rewards patients who have the time, energy, and common sense to seek treatment.
Patrick Creighton, 48, a sports radio host in Katy, Texas, woke up on New Years Eve with a burning throat. He was vaccinated but tested positive later that day. Fearing that his diabetes would increase his risk of becoming seriously ill, he decided to research Paxlovid, which he was reading about.
A telemedicine doctor wrote her a prescription the next day. Now he needed to find a pharmacy with Paxlovid in stock. He said he called 18 drugstores within driving distance: one Brookshire Brothers, four Krogers, four HE-B, three Walgreens, three CVS stores and three Walmarts. None had the pills.
His 19th appeal was a winner: a nearby Walmart had Paxlovid in stock. The ordeal was still not over. He was falsely told he might have to pay $ 500 for the free treatment. Then he had to see a second telemedicine doctor because of an issue with the way his prescription was sent. Then his wife had to make a second trip to Walmart to collect the pills. But on the evening of January 2, he finally took the first three pills of the 30 pills regimen.
Mr Creighton said he was worried about patients who were not able to overcome obstacles as best he could. âIt should be easily accessible to everyone. “
Treatment with GlaxoSmithKline antibodies is also difficult to find.
At the University of Pittsburgh Medical Center, staff now give 400 to 800 antibody treatments each week, up from 2,000 to 3,000 before Omicron made two of the products unnecessary. Demand has skyrocketed, but the hospital is running out of supplies.
“It is devastating to say to these patients, ‘Sorry, there is nothing we can do for you, we have to keep this drug only for our most severely immunocompromised immunosuppressed,” said Erin McCreary, infectious disease pharmacist at the hospital.
Louis Shantzek, a retiree from Miami, tried unsuccessfully to get an antibody infusion last week after testing positive for the virus. He is 72 years old and suffers from diabetes and heart disease, all factors that would normally make him eligible for antibody treatment.
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Mr. Shantzek’s symptoms included pain, fatigue and a bad cough. When his adult daughter called two nearby hospitals, he was told he could not receive an antibody infusion because he had received three doses of a vaccine and was therefore considered to be at relatively low risk.
“It’s like being told, ‘You are doing everything that you are supposed to do, but yet we are not going to help you,'” said Mr Shantzek, whose symptoms have since abated.
This isn’t the first time in the pandemic that scarcity of supplies has forced hospitals and doctors to make painful treatment decisions. At first, an intravenous treatment, remdesivir, became so popular that hospitals had to restrict its use. Reserves of remdesivir have since become more abundant, but the treatment is mainly used for patients already hospitalized with severe Covid.
Drugmakers say they are working as fast as possible to produce more treatments.
The federal government did not immediately order supplies of GlaxoSmithKline antibodies when the FDA cleared the treatment for use last May. At the time, the country had an adequate supply of other antibody treatments.
In the fall, the Biden administration ordered around 450,000 doses – the maximum quantity Glaxo could supply since the British company had already committed to fulfill orders from other buyers. (The U.S. government has announced plans to purchase an additional 600,000 treatments.)
Pfizer, meanwhile, developed Paxlovid in less than two years. But it takes up to eight months to produce the pills. Although Pfizer started manufacturing them before a major clinical trial of the drug began last summer, large quantities are only starting to become available now.
A growing number of hospitals are placing restrictions on treatment.
In western Indiana, officials at the Sullivan County Community Hospital determined last month they needed to restrict eligibility for antibody infusions, after weeks of receiving far fewer doses than those that they had ordered. They have chosen to exclude those who have been vaccinated almost entirely.
“It makes it difficult for some of these restrictions to put in place, when maybe it is a member of your family who does not meet the requirements, or it is your neighbor, or your child’s teacher at the school. ‘school,’ said Lori Resler, the hospital’s head nurse. officer.
In Texas, doctors and their staff called a long list of pharmacies to see who has Paxlovid in stock before prescribing treatment, said Dr. Luis Ostrosky, chief infectious disease officer at the University of Texas Health System. The idea is to avoid sending patients on a wild goose hunt, as many pharmacies have only received 20 courses of Paxlovid.
On Monday, Brooks Rizzo, a family nurse practitioner and director of the Sunflower Rural Health Clinic in Ruleville, Mississippi, arrived to find a line of patients waiting in the freezing cold as they sought out Covid tests and treatments.
Ms Rizzo said her clinic had not received any antibody treatment since December 24, and he not part of hospitals who were originally selected to receive supplies from Paxlovid. She said clinic workers resorted to the provision of vitamins and over-the-counter medications.
Dr Shireesha Dhanireddy, an infectious disease specialist at the University of Washington, said she spent the past weekend looking at Covid patient charts to determine who should receive rare treatments. The three-hospital system has tens of thousands of patients but only 60 courses of Paxlovid. Those who receive the pills include patients on certain types of chemotherapy and those who have recently received organ transplants.
At Johns Hopkins University, employees are rushing to develop algorithms to help allocate rare treatments, said infectious disease and epidemiology specialist Dr Kelly Gebo. Compounding the problem of shortage, workers get sick, making it more difficult to provide resource-intensive treatments like monoclonal antibodies.
âIt’s demoralizing as healthcare workers not being able to provide optimal care when we have limited resources,â she said.
Sharon LaFraniere contributed reports.