COVID pills too scarce to fight surge
With thousands infected each day, new drugs won’t satisfy demand
Two newly authorized COVID antiviral pills started arriving at a small number of Bay Area medical centers and pharmacies last week. But supply is so meager that the medications probably won’t make a major impact in the current omicron surge.
The number of pills getting allocated to each county is far outmatched by the sheer quantity of new infections reported each day. And the supply is expected to be tight for the next several weeks or even months, health officials have signaled, such that by the time the pills are more widely available, the worst of the omicron wave — which modelers predict will peak around mid- to late January — will probably have subsided.
The pills were authorized in the United States only about two weeks ago, and, while the drugmakers began manufacturing them before that, months will be needed to ramp up complex production processes.
The limited availability of pills, Pfizer’s Paxlovid and Merck’s Molnupiravir — along with national shortages of sotrovimab, the one remaining monoclonal antibody infusion treatment that works against omicron — means that only a tiny proportion of people who could benefit from the treatments will be able to get them in the near term.
Both the pills and the infusions stave off severe disease and hospitalization by treating COVID patients early during infection. The pills block the virus’ ability to replicate, while the infusions block the virus from infecting human cells. Pills have been hailed as the real game changers because they will make treatment more accessible — cheaper than infusions and able to be taken at home.
“We’ve used all of our supply of Paxlovid at this point, even though we’re being quite restrictive as to who can get the medication,” said Dr. Sarah Doernberg, who oversees the rollout of COVID antiviral treatments at UCSF, which got 40 courses of the drug the last week of December and ran out within a week. “On a public health level ... we don’t have enough supply nationwide to really prevent the hospitalizations and spread of infection and other goals of giving some of these very rarely available treatments out.”
Most people who get COVID probably won’t need treatment, especially if they are vaccinated and don’t have underlying medical conditions. Plus, omicron appears to cause less severe symptoms than previous variants. Still, for the millions of Americans who are unvaccinated, have weakened immune systems, or who are vaccinated but at high risk because of age or co-morbidities, the drugs could be lifesaving.
Because of supply restrictions and soaring demand, providers are limiting Paxlovid and sotrovimab to people who are at the very highest end of the risk spectrum — those who are severely immunocompromised and unlikely to mount a response to vaccination, or those who are unvaccinated and at high risk for severe disease because of underlying conditions.
This is a change from as recently as a few months ago, when patients were able to access monoclonal antibodies if they were just moderately high risk — such as those who were vaccinated and have diabetes or cardiac conditions. But since then, two monoclonal antibody treatments have been halted because they are less effective against omicron. That has whittled the antibody options to just one, sotrovimab, for the growing number of people who need it now. Many providers are running low, or are out of sotrovimab, which is made by GlaxoSmithKline and Vir Biotechnology.
Both the pills and the monoclonal antibody treatments are allocated by the federal government to states, and then from the state to local health departments, based on new case rates and an equity measure.
Merck did not immediately respond to questions about why supply of the pills are so limited. Pfizer said producing Paxlovid “requires a significant amount of manufacturing capacity” that takes six to eight months, and the company is expanding to ramp up production. The federal government said last week it is doubling its order of Paxlovid, from 10 million to 20 million courses, though most of it will not be available right away because of the manufacturing lag.
On top of supply constraints, lack of predictability makes prescribing the drugs challenging. Some providers didn’t get their expected delivery of pills, or got them later than expected. Without knowing how much they’ll get in the near future, providers find it hard to tell patients when or whether they’ll be able to get treatment.
And then there’s the issue of timing. The pills must be taken within the first five days of symptoms, but given how hard it is to get a test right away, that can be difficult, Doernberg said. For that reason, she recommends that people who know they are severely immunocompromised contact their provider immediately at the first inkling of COVID symptoms so they can get tested quickly.
Of the two authorized pills, Paxlovid is more effective, reducing hospitalizations by 88%, compared with Molnupiravir’s 30% reduction rate. The supply of Molnupiravir is slightly better, providers say, but some consider it a less desirable option because of concerns it may lead to the virus mutating in an immunocompromised patient.
California Health Secretary Dr. Mark Ghaly said last week that the state is unlikely to see a huge increase in supply this month and looks forward to getting more in February and March.
Contra Costa County, for instance, has gotten just 120 courses of Paxlovid and Molnupiravir so far, while 1,300 new cases are getting reported each day. Similarly, Sonoma County has also gotten 120 courses, to be distributed by three pharmacies. San Francisco got 100 courses of Paxlovid and 500 of Molnupiravir, but at least 160 courses of the latter were delayed.
“At this point, there’s simply not enough of it for it to be game changer,” said Will Harper, a spokesperson for Contra Costa Health Services, adding that “120 courses is a drop in the bucket when we are seeing more than 1,300 new COVID cases each day.”
The pills will be allocated to more than 5,000 pharmacies and providers around the country, including nearly 400 in California, according to federal and state officials. But not all have received the pills yet. And those numbers represent a very small percentage of providers and pharmacies overall. Each Bay Area county, for instance, has nine or fewer locations receiving the pills, according to the state.
“It’s hard to battle this current surge with such a short amount of treatment options,” said Deepak Sisodiya, director of pharmacy at Stanford Health Care, which expects to receive and begin prescribing antiviral pills this week. “A glass-half-full approach looking forward, there will still be patients affected as that peak potentially subsides, there will still be a need for it as COVID will still be with us.”