It’s simple to really feel like we’re in a pandemic “Groundhog Day” loop because the U.S. faces yet one more Covid-19 surge with overwhelmed hospitals, closed faculties, and firms delaying return-to-office plans.
To make certain, the existence of vaccines, boosters, and a few essential new therapies make this January really feel completely different than the final one. However as one other yr of pandemic fatigue looms, the nation is as soon as once more within the place of getting to determine methods to allocate and distribute scarce well being care assets, from ICU beds to Covid-19 medication.
Necessary errors are nonetheless being made.
Within the penultimate week of 2021, the Meals and Drug Administration granted emergency use authorization to Paxlovid, a two-drug antiviral developed by Pfizer for treating people ages 12 and up who take a look at constructive for Covid-19 and are at excessive danger for development to the extreme type of the illness. When began inside 5 days of symptom onset, Paxlovid appears to be extremely efficient at decreasing hospitalization or loss of life.
That the drug could be taken at house is a serious profit over different therapeutic choices, together with one other tablet, molnupiravir, which can be much less efficient, in addition to remdesivir and sotrovimab, each of which should be administered intravenously at hospitals or clinics.
The issue is that there isn’t nearly enough Paxlovid to deal with the staggering quantity of people that may benefit from it. For instance, in Pennsylvania, the place we reside and work, there have been greater than 33,000 new cases of Covid-19 recognized on January 7, 2022, by far essentially the most for the reason that pandemic began, and greater than 60% of American adults are estimated to have at the very least one continual situation that places them at excessive danger for extreme Covid-19. Provide pales compared to this demand: Pennsylvania acquired solely 2,080 complete therapy programs of Paxlovid in its preliminary allocation from the federal authorities. Within the first week of distribution, Michigan acquired 1,600 programs of the drug; Wyoming acquired solely sufficient for 100 folks. Further shipments are anticipated to ramp up over the subsequent month, however nationwide shortages seem like they’ll last until April.
We’ve been right here earlier than, with vaccines and earlier Covid-19 remedies. The distinction, nonetheless, was that the federal authorities distributed different scarce therapies to state and territorial well being departments, which distributed them to hospitals and clinics, which in flip decided which sufferers would obtain them. Dealing with shortages, many hospitals developed allocation processes that recognized the very best danger sufferers who have been most certainly to learn from these therapies, based mostly on issues like vaccine standing, immune suppression, and sure circumstances that improve danger. They then tried to decide on pretty amongst these people utilizing approaches corresponding to weighted lottery techniques. These randomly choose amongst eligible sufferers, with some having higher odds based mostly on issues like residence in a deprived group, important employee standing, and being pregnant.
Though there could also be different honest methods to do that, the essential factor about these approaches is that they aimed to reduce giving benefits to essentially the most well-off, well-connected, and well-informed sufferers.
This isn’t how issues are working for Paxlovid. As a result of that is an at-home therapy, several states — together with Arizona, Georgia, Pennsylvania, and Virginia — have determined to distribute the drug to business retail pharmacies fairly than hospitals. On one hand, this is sensible as a result of pharmacies could also be simpler locations for sufferers to entry the drug and hospitals have their arms full proper now. However, pharmacies usually are not within the place to simply confirm affected person eligibility or choose these at highest danger for extreme Covid-19.
As a result of Paxlovid has thus far been allotted to only a tiny fraction of pharmacies, they’ll probably be inundated with lots of or hundreds of prescriptions, many for sufferers they’ve by no means served earlier than. This unfamiliarity might place sufferers in danger as a result of Paxlovid can have life-threatening interactions with different medicines sufferers could also be taking however the pharmacy might not learn about. Though that is additionally true of different medication, a novel problem with Paxlovid is that its emergency use authorization standing means it doesn’t come up within the drug interplay apps that physicians usually use, making one other layer of evaluation useful.
Pharmacies that do attempt to confirm eligibility and medical historical past will probably require clinicians to ship take a look at outcomes and medical information, creating burden on each ends in addition to delay. Hospitals and well being techniques, in distinction, have already got entry to this info for a lot of sufferers.
A decentralized, pharmacy-based strategy may even end in a “first come, first served” allocation, which can profit those that are already most lucky. The New York Instances tells the story of a 48-year-old Texan with diabetes who was in a position to entry Paxlovid after securing a prescription through a telemedicine appointment, calling 19 pharmacies, and making a number of journeys to get the drug after an issue together with his prescription. This story demonstrates exactly the type of effort that many individuals, together with these at larger danger, would by no means be capable of undertake on account of lack of time, assets, or know-how.
The one factor worse than anticipating sufferers to interact on this type of wild goose chase can be asking overburdened well being care suppliers to do it every time they write a prescription.
The Division of Well being and Human Providers has distributed roughly 15% of the Paxlovid supply to federally-funded well being facilities serving deprived communities, however states nonetheless have to equitably allocate their shares of the drug to folks prone to profit essentially the most. Distributing Paxlovid solely through retail pharmacies whereas the provision stays low will end in these with the loudest voices, the strongest advocates, and essentially the most time and assets getting entry — although these elements don’t have anything to do with whose want for the drugs is biggest.
As an alternative, states ought to allocate a big provide of Paxlovid to their hospitals and well being techniques, which might extra simply confirm affected person eligibility, verify essential drug interactions, and pretty distribute the treatment. Sure, this can add to their already heavy load within the midst of the present Omicron surge, however it may additionally assist extra successfully scale back hospital admissions by getting the drugs to sufferers most certainly to finish up there, reducing the pressure.
When the provision will increase, pharmacies can play an essential and expanded function, particularly in the event that they’re in a position to provide each testing and prescriptions onsite. Within the meantime, except hospitals and well being techniques are allowed to steer the allocation course of, will probably be left to medical doctors to fastidiously prescribe Paxlovid just for their sufferers on the very highest danger of extreme Covid-19 outcomes — as soon as once more problematically leaving public well being options in the hands of individuals and asking them to make ethically difficult selections on their very own.
Holly Fernandez Lynch is a senior fellow on the Leonard Davis Institute for Well being Economics and an assistant professor of medical ethics, well being coverage, and regulation on the College of Pennsylvania. Keith Hamilton is an infectious illnesses doctor and affiliate professor of scientific medication and infectious illnesses on the College of Pennsylvania.