Almost two years after COVID-19 sent San Francisco into a citywide lockdown, promising therapeutics are finally making their way to local hospitals and health clinics. But demand is far outpacing supply as cases continue to climb well beyond previous surges.
“Everyone is getting less supply than they need,” said Dr. Sarah Doernberg, an infectious disease specialist at the University of California, San Francisco. “It’s a record number of patients and we just don’t have enough drug to give to everyone.”
The U.S. Department of Health and Human Services distributes available treatments across the country based on factors including population size, vaccination rate, case counts and other health indicators. In December, San Francisco medical facilities were initially allocated 100 doses of Paxlovid, an antiviral pill from Pfizer, and 500 doses of Merck’s antiviral pill, Molupiravir, officials at the San Francisco Department of Public Health (SFDPH) told the Examiner.
This week was the second allocation, and San Francisco received 180 Paxlovid and 460 Molupiravir.
San Francisco’s allocation currently goes to UCSF, Dignity Health, Zuckerberg San Francisco General, Kaiser, Chinese Hospital, and Alto Pharmacy. North East Medical Services also received pill-based therapeutics separate from the San Francisco allocation.
“Once treatment units are allocated to San Francisco, the Hospital Chief Medical Officer Council advises on the allocation to the eligible systems and pharmacies,” a spokesperson for SFDPH said in an email. “As more supply of therapeutics become available and more dispensing organizations become eligible, we are working to disseminate information on accessibility to providers.”
UCSF received 40 doses of Paxlovid in December, but those were used up within a week, Doernberg said. The small supply is typically refilled every week or two, but exact amounts depend on availability.
Molupiravir is still in stock at UCSF, she said. But its ability to prevent hospitalizations among extremely high-risk individuals, who are prioritized for drug access, is estimated to only reduce hospitalization and death by 30%, compared with 88% for Paxlovid.
Despite the record-high case counts, hospitalizations have remained far lower than with the delta and alpha variants, San Francisco Health Director Grant Colfax said during a press briefing Tuesday. That has in part been driven by San Francisco’s high vaccination rate of 81%.
But San Francisco’s relatively strong response to the COVID-19 pandemic and high vaccination rate has also meant it gets allocated fewer doses of some COVID-19 therapeutics such as monoclonal antibodies that work against the omicron variant.
For example, the entire state of California in December was allocated 2,658 doses of sotrovimab, the one monoclonal antibody that remains effective against omicron. States with smaller populations such as Illinois, Pennsylvania and Ohio — where vaccination rates are lower — received more doses.
Monoclonal antibodies are laboratory-made proteins injected into the bloodstream that mimic the immune system’s ability to fight off harmful pathogens, including the coronavirus, by blocking the virus from attaching to and entering human cells. The infusion process takes about two to three hours, followed by an observation period for any immediate effects.
Stanford Health Care is offering 10 to 15 monoclonal antibody treatments per day depending on availability. Stanford and other hospitals in San Francisco are also offering remdesivir, a treatment option approved in 2020 for severe cases of COVID-19. The therapy requires an infusion on three successive days at the hospital’s centers.
That has made for a dizzying situation for monoclonal antibody providers, who during the delta surge were trying to get more people in the door for treatments. As cases have skyrocketed with omicron, and antibody treatments remain scarce, facilities have had to readjust their prioritization to serve only those with the highest needs, such as cancer patients and or people who have received organ transplants.
“Prior to the omicron surge, things were slow here. We had plenty of product. We administered almost 400 doses and we could only confirm three people were hospitalized,” said Kee Conti, director of infusion therapy at Total Infusion in Oakland. “Then omicron happened. And now, it’s unbelievable.”
Antiviral drugs and effective monocolonal antibody supplies are expected to increase in the coming months — long after local public health experts project the worst of the omicron surge to be over.
“We are in the middle of the worst of this omicron surge,” Colfax said Tuesday. “Vaccines and boosters remain the bulwark of protections from the coronavirus.”
Colfax said based on data coming out from places such as South African and New York City, cases are expected to begin declining again in late January or February. And while hospitalizations have stayed low, those at the highest risk are still finding it difficult to secure the treatments they qualify for. And health care providers are overwhelmed in the meantime, with calls and questions from people across the risk spectrum about appointments.
“There are days where we have 200-300 patients looking for treatment and we have 20 doses,” said Conti, referring to the sotrovimab monoclonal antibody.
“It’s hard when we run out of medications and patients who should be getting treated and are eligible come in and we don’t have the medication to give them,” Doernberg echoed.
Most cases of COVID-19 in San Francisco now are the omicron variant, and symptoms, if any, are mild. People who are not high risk or are asymptomatic do not qualify for COVID-19 therapies.
“These anti-SARS-CoV-2 therapeutics are of greatest benefit for non-hospitalized patients who have risk factors for progression to severe COVID-19,” the National Institutes of Health guidelines read. “The risks for progression are substantially higher for those who are not vaccinated or who are vaccinated but not expected to mount an adequate immune response to the vaccine.”
Individuals who could qualify for antibody treatment but aren’t able to find an appointment often are referred to other therapies such as the Paxlovid pill. Although the U.S. Department of Health and Human Services keeps an updated list of where COVID-19 therapeutics can be found, another challenge playing out in real time now is figuring out which pharmacies have these antiviral drugs.
“Providers have to call pharmacies and there is this huge time pressure because patients really need to get on treatment within five days of symptoms,” said Doernberg. “If you are high risk, making a plan for getting tested and contacts for treatment is important. People who aren’t at such high risk, don’t overload the systems that are in place.”