For San Franciscans, the post-Omicron lull in the pandemic has meant the lifting of mask and vaccine mandates and the revival of public spring events like St. Patrick's Day celebrations.
But the celebratory atmosphere is taking place amid the looming threat of a new Covid variant.
Led by a more infectious subvariant of Omicron, rising case counts in countries like the U.K. and Germany have sparked concerns about a new wave of infection locally. While it's uncertain what a new surge would look like—how much cases could grow, and how severe they might be—health care facilities are gearing up for what comes next by building up their armories of Covid medications.
While health experts stress that vaccination is the best protection against serious illness or death from Covid, an array of treatments developed over the past two years are now a key part of the clinical toolbox for treating infected patients. And San Francisco hospitals are stocking up on these treatments in the hopes of averting a severe increase in hospitalizations and deaths.
These Covid therapies can be grouped into two major categories. Paxlovid and molnupiravir are oral antiviral pills meant to prevent the disease’s progression into a serious illness for mild and moderate cases of infection. Monoclonal antibody treatments, which include sotrovimab and bebtelovimab, are delivered through an IV and attach to the virus’ spike protein to reduce the risk of hospitalization or death from the virus.
During the peak of the Omicron wave in January, however, these tools were in short supply.
“They were extremely limited. I would say there were under 10 doses of monoclonal antibodies for the entire hospital, maybe 10 doses of Paxlovid and 50 doses of molnupiravir,” said Peter Chin-Hong, an infectious disease expert at UCSF. “Now, when things are good from a virus perspective we have a ton more, which we’re going to need for the future.”
In comparison to the situation earlier this year, Chin-Hong said as of March 21, UCSF had around 250 doses of Paxlovid, 300 doses of molnupiravir and 110 doses of sotrovimab.
Chin-Hong drew a line between UCSF’s approach and California’s SMARTER Covid response plan. The state’s plan relies, in part, on a network of warehouses to store masks, tests, ventilators and other high-need medical items in preparation of a future surge.
On the other hand, Covid treatments are allocated to local health facilities through a complex system that starts with the federal government allocating manufacturers’ supply to states. California then distributes treatments to counties like San Francisco, where a council of the city’s chief medical officers advises the city on allocation to eligible health care systems and pharmacies.
“As more supply of therapeutics become available and more dispensing organizations become eligible, we are working to disseminate information on accessibility to providers. The goal is always fair, equitable and efficient allocation,” said the city’s Department of Public Health in a statement.
The health department said that San Francisco has distributed 1,000 doses of Paxlovid, 1,200 doses of molnupiravir, 552 doses of sotrovamib and 105 doses of bebtelovimab to date.
San Francisco’s allocation currently goes to health care systems including UCSF, Dignity Health (St. Francis, St. Mary), Zuckerberg San Francisco General Hospital, Kaiser Permanente, Chinese Hospital and select CVS and Walgreens locations, according to the Department of Public Health.
Covid Treatments
Paxlovid - The oral antiviral pill treatment from Pfizer consists of co-packaged nirmatrelvir tablets and ritonavir tablets. The treatment is meant for treatment of mild-to-moderate Covid in adults and pediatric patients at risk of developing more severe disease. According to a clinical study, the drug reduced the proportion of people with Covid related hospitalization or death from any cause by 88% compared to placebo.
Sotrovimab - Developed by GlaxoSmithKline and Vir Biotechnology, Inc., the monoclonal antibody treatment is via an IV and works by attaching to the spoke protein of the coronavirus and is meant to reduce risk of hospitalization and death for patients with mild-to-moderate Covid.
Molnupiravir - An oral antiviral therapy developed by Merck which works by making it more difficult for the Covid virus to replicate. In a clinical study, the drug showed a 30% cut in the risk of hospitalization and death for patients with mild-to-moderate Covid.
Evusheld - A monoclonal antibody treatment that combines two human monoclonal antibodies, tixagevimab and cilgavimab meant for use as a preventative measure—or prophylaxis—for patients who are immunocompromised or who are not vaccinated. Studies have shown that protection against Covid infection from the medication could last six months or longer.
Remdesivir - An antiviral from Gilead Sciences, it’s the only Covid treatment that has full approval by the FDA. While Remdesivir is typically prescribed for use by patients hospitalized with Covid, the medication recently received an expanded indication for use in non-hospitalized patients as well.
Bebtelovimab - From Eli Lilly & Co., the monoclonal antibody treatment is meant for the treatment of mild-to-moderate Covid in adults and pediatric patients who are at risk of developing more severe disease. The medication delivered via an IV has been shown to work against the main Omicron variant and the Omicron BA.2 subvariant.
In a statement, Kaiser Permanente said it “currently has adequate supplies of Paxlovid, molnupiravir, sotrovimab and bebtelovimab to treat COVID-19 patients in alignment with the clinical recommendations of the National Institutes of Health.”
While this may help San Franciscans manage a new Covid wave in the short term, one longer-term threat remains: national politics.
The Biden Administration has warned it could run out of its supply of monoclonal antibody treatments as soon as May, and won’t be able to purchase additional oral antiviral pills if federal lawmakers don’t approve $22.5 billion in continuing Covid funding.
“Biden's plan is proactive and solid. If we do not fund it, it is worthless,” said Dr. John Swartzberg, a UC Berkeley infectious disease expert. “This will mean an inadequate supply of medications to treat Covid, the possibility of a shortage of vaccine and inadequate PPE supplies to deal with a surge.”
Osas Nosa-Idahosa, director of pharmacy at San Francisco’s St. Francis Memorial Hospital, attributed the treatment shortages seen during the peak of the Omicron wave to a few key factors that he doesn’t foresee happening again. The first was Omicron’s emergence soon after the Delta variant, which stretched clinical staff’s capacity to handle the skyrocketing case counts.
The second was the discovery that two prominent monoclonal antibody treatments used by clinicians were found to be ineffective against Omicron, leaving fewer options for patients.
Nosa-Idahosa says he’s confident in the current distribution strategy, in part because of the practice that the city and health care facilties have gotten in previous waves. He said he’s taking the approach of keeping limited doses on hand, with an eye towards ramping up if cases start to tick up.
Nosa-Idahosa said his hospital has 10 doses of sotrovamib, 3 doses of Paxlovid and 43 doses of Remdesivir currently on hand.
"We stockpile based on needs and demand,” Nosa-Idahosa said. “When I checked last week, the government had hundreds of thousands of these medications available, so all we have to do is just request and in a matter of days we have the medications. I think we’re more prepared now going forward than ever before.”
Chin-Hong said that UCSF has also worked on building its supply and distribution infrastructure for Evusheld, a monoclonal antibody treatment that functions as a preventative alternative to vaccines for immunocompromised patients or those who are unable to be vaccinated because of medical issues. As of March 21, the hospital system had 600 doses of the medication.
“All these things are going to be important in preparing for the future,” Chin-Hong said. “It's like repairing the roof of the house, even though the sun is currently shining.”