Ms. S, a primary care patient in one of our clinics (M.L.B.), recently called in with loss of taste and a terrible cough, worse than her regular breathing problems. She said she had gone out to play bingo the past weekend with friends, her first outing in weeks. Two days later, one of her friends called and told Ms. S she had tested positive for Covid-19.
Ms. S was frightened — as an older woman with heart and lung conditions, getting Covid-19 posed a serious threat to her life, especially since she hadn’t yet received her booster vaccine. But she didn’t have a home test to check for Covid-19.
“What do I do now?” she asked.
The answer should have been, “Let’s get you tested for Covid, and if you’re positive, we’ll get you an infusion of Covid-fighting antibodies as soon as possible.”
But Ms. S already felt too sick to wait in line at the testing site or take a bus to the infusion center. She had no family to bring her a test or transport her. She would have to ride Covid out on her own, without the treatment that could reduce her chance of hospitalization or death by 85%.
This scenario has been playing out across the U.S. since November 2020, when monoclonal antibodies were authorized as the most effective treatment to prevent individuals diagnosed with mild Covid-19 from becoming seriously ill. But the supply has been severely limited, and getting treatment requires a positive Covid-19 test result and traveling to an infusion center no later than 10 days after symptoms start. Those are not easy tasks for individuals experiencing with Covid symptoms in the first place.
Anticipating the shortages in supply, federal guidelines have prioritized people who are the most likely to benefit from treatment — those at the highest risk of getting severely ill, like Ms. S. But has the limited supply of this lifesaving therapy reached these patients?
Research that we and several colleagues published on Friday in the Journal of the American Medical Association confirms the worst: Through August last year, those who most needed monoclonal antibody therapy were the least likely to get it. We analyzed data from about nearly 2 million Medicare patients diagnosed with Covid-19 between November 2020 and August 2021 and identified all who received antibody therapy. Ideally, those at highest risk of hospitalization or death, such as individuals like Ms. S with multiple chronic illness, and those over 65 years old would be first in line to receive treatment. Instead, we found that individuals with no chronic illness were five times more likely to receive antibody therapy than those with six or more chronic conditions, who represented more than 1 in 3 Medicare enrollees.
We also found that the likelihood of getting treatment varied substantially by region of the country. In the western U.S., less than 3% of eligible patients with Covid-19 received monoclonal antibody therapy, compared to 11% in the South. This fits with reports that states with lower vaccination rates seem to be embracing monoclonal antibodies as a central part of their strategy to fight Covid-19. Yet the Food and Drug Administration and the Centers for Disease Control and Prevention have made it clear that antibody treatment is not a substitute for vaccination.
Monoclonal antibody distribution by state
The federal government has tried to fight this inequitable spread, taking over distribution from suppliers in September 2021 as demand started to grow. But inequities persisted in the winter of 2021 when federally coordinated distribution, based on Covid case counts and other factors, was in place. This system will collapse further as only one of three available monoclonal antibody products seems to be effective against the Omicron variant, further restricting an already limited supply. Emerging Covid therapeutics such as the oral antiviral Paxlovid, which the FDA has authorized for emergency use, and others on the horizon will likely face the same supply shortages as monoclonal antibodies.
How can these problems supply and distribution problems be fixed to ensure that new Covid-19 therapeutics don’t encounter the same serious pitfalls? A starting place is to educate both patients and physicians about who is eligible for these therapies (for example, those 65 and older or those with diabetes or heart disease) and the importance of rapid diagnosis. Speed is crucial in delivering antibody therapy, which should start as soon as possible after a positive test result and within 10 days of symptom onset. Monoclonal antibodies, as well as new antiviral treatments like Paxlovid, are effective only if taken as early as possible, underscoring the ongoing importance of improving access to testing — not only to limit the spread of Covid-19, but to improve access to treatment.
The mechanisms of distribution, on the federal and state levels, should ensure that supply is being distributed fairly at the local level ensuring that communities with the most vulnerable patients get an appropriate share of treatment. This is an example of a “last-mile” problem that requires close coordination between local health systems and state governments. There are both short- and long-term fixes to close the last mile of access, such as streamlining the process of getting infusion appointments in the short term and fostering the development of brick-and-mortar and mobile infusion sites for future waves.
More and better Covid therapeutics will continue to emerge and be in high demand. Without a concerted effort to ensure they are fairly distributed, those most in need of them will continue to be left behind.
Caroline Behr is a fourth-year medical student at Harvard Medical School. Michael Barnett is a primary care physician at Brigham and Women’s Hospital in Boston and an assistant professor of health policy and management at the Harvard T.H. Chan School of Public Health. The views expressed here are their own and do not necessarily reflect those of the institutions they are affiliated with.
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