Prevention & Treatment of COVID-19

Availability, prioritization, effectiveness, and cost

They say —

“An ounce of prevention is worth a pound of cure.”

Meaning it is better to take precautions beforehand than to suffer the consequences afterward.

I recently learned that Benjamin Franklin coined this phrase. In 1733, he visited Boston and was most impressed with the city’s fire prevention methods (yes, I am talking about fire again). Upon returning to his hometown of Philadelphia, Franklin supposedly sent an unsigned letter to The Pennsylvania Gazette detailing how the city should prepare for a fire. He began that letter with the line “an ounce of prevention is worth a pound of cure.”

I begin this post about the forms of treatment for and prevention of COVID with Benjamin Franklin’s quote because is an important (maybe THE MOST important) message as went enter year 3 of the pandemic. Prevention of disease — through vaccination, masking, avoiding crowds, testing, and staying home when sick — must be prioritized. These forms of primary prevention, which prevent the disease from occurring in the first place, are the most important action we can take.

We each need to be healthy. We each need to be taking steps to slow the spread of disease. We each be part of the work that is needed to end the pandemic.

A couple of notes before we dive into the types of treatment for COVID that are available… first, each of the forms of treatment below has been approved with an Emergency Use Authorization (EUA). Aside from the Pfizer COVID vaccine, none of these treatments have been permanently authorized (aka licensed) for use. So if you are unwilling to get a vaccine because you believe that the vaccines have not received formal/non-emergency approval from FDA, please read this again — the treatments that are available are only available through Emergency Use Authorization. The most scrutinized and studied intervention for COVID is the vaccine. Not the treatments.

Second, (a personal disclaimer) the treatment of an individual who has been diagnosed with COVID is determined by a physician (usually a primary care or family physician). As an epidemiologist, I write about population-level health; so I am writing here about available treatments, who is eligible to receive those treatments, and what those treatments are designed to do. If you need treatment for a COVID diagnosis, you must seek treatment from a physician. And due to the severity of your illness, underlying health conditions, and supply/availability of treatments, how you are treated for a COVID infection may differ from the guidelines issued at the population level.

So… you are diagnosed with COVID and need to be hospitalized. What is the course of treatment? The National Institutes of Health recommends —

NIH website for more information.

Determining which treatment is best for you (if you are hospitalized) will be determined by the attending physician. Please respect this individual. Trust their training and judgment. You can ask questions, but remember if you are in the hospital, you are the patient. Let your doctor do their job.

Imagine you are diagnosed with COVID and do not need to be hospitalized. What treatment options are available to you?

Option 1: Monoclonal antibodies

Antibodies are proteins used by your body’s immune systems to fight infection (they block the virus’s ability to enter the cells; slowing down infection). Often these antibodies are made by your body. But the monoclonal antibodies used to treat COVID infections are actually manufactured in a lab. They are given to individuals (who is eligible is detailed below) through an IV or a series of 4 injections. This form of treatment requires the sick individual to come to a clinic/hospital for treatment. And it takes about 30 minutes to complete the treatment.

There are side effects associated with monoclonal antibody treatment, such as fever, difficulty breathing, nausea, vomiting, tiredness, and muscle fatigue (among others). Side effects from the treatment are more common and more severe than the side effects associated with the COVID vaccines (just saying).

Monoclonal antibodies are available to individuals regardless of vaccination status. In order to qualify to receive monoclonal antibodies, an individual —

1. Must test positive for COVID (by an antigen or PCR test, not a home test), AND

2. Have mild to moderate symptoms for less than seven days (so you must be symptomatic), AND

3. Has to be 65 years of age or older, OR

4. Has to be at least 12 years old (and weigh 40 kg/88 lbs) with an underlying health condition that puts that individual at risk for severe disease.
   Note: Included on this list of conditions is obesity (high BMI), pregnancy, and smoking status (current & former smokers are eligible), along with many other diseases.

There is a limited supply of monoclonal antibodies. And with COVID cases rising across the country, the supply is not keeping up with the demand. As a result, there are hospital systems across the country that are reserving monoclonal antibody treatment for individuals who are unvaccinated. There are two reasons for prioritizing the treatment of unvaccinated individuals over individuals who are vaccinated.

First, the vaccines are effective (by themselves) at preventing severe disease, hospitalizations, and death. Upwards of 86% of all COVID hospitalizations are among unvaccinated individuals (of all ages). And individuals who are unvaccinated are 13 times more likely to die from COVID compared to vaccinated individuals.

Second, monoclonal antibody treatment (which received EUA approval in November 2020) has not been studied in vaccinated individuals, so we do not know (for sure) if there are any additional benefits to the treatment among vaccinated individuals. It is unclear if the risk of severe disease, hospitalization, and death will decrease even more if a vaccinated individual (whose risk is already low) receives monoclonal antibodies.

If a healthcare system makes the decision to limit monoclonal antibody treatment to unvaccinated individuals it is because (1) the vaccines work, and (2) keeping unvaccinated individuals out of the hospital reduces the strain on the healthcare system and reduces that amount of money, time, and supplies spend on that patient.

AN IMPORTANT NOTE about monoclonal antibodies —

While monoclonal antibodies are a useful treatment for COVID, they are a “one and done” treatment. An individual who receives monoclonal antibodies has a one time infusion to fight their current infection. Monoclonal antibodies do NOT stimulate long lasting immunity in the body. An individual who receives this treatment, will be susceptible to a future infection if they are exposed to the SARS-CoV-2 virus.

Monoclonal antibodies are equivalent to a missile used by the military. The missile provides a targeted, immediate, and dramatic impact. It destroys the enemy and is destroyed upon impact. The missile can be used once to have an impact. Vaccines, on the other hand, are equivalent to training an army. They train the immune system to develop a sustained and impactful defense against disease.

Vaccines are designed to win the war; monoclonal antibodies can provide an assist to win a single battle.

While both monoclonal antibodies and vaccines help to prevent severe infection, hospitalization, and death from COVID, monoclonal antibody treatment is far more costly than getting vaccinated.

• Vaccines produce sustained protection; monoclonal antibodies fight the current infection, but have no long lasting benefits to the sick individual.

• Vaccines are available to everyone (over 5) and the supply of vaccines is ample. The supply of monoclonal antibodies is limited.

• Vaccines prevent infection — you are five times more likely to be diagnosed with COVID if you are unvaccinated compared to those who are vaccinated. By the time you need treatment, you are already sick. And you are more likely to be sick if you are unvaccinated.

• Vaccines are received before you are even exposed to the SARS-CoV-2 virus. There is a short window of time where monoclonal antibodies can be received. And you are required to get and pay for a COVID test before you can get monoclonal antibodies.

• Vaccine side effects are mild. The side effects of monoclonal antibodies are more frequent and can be more severe.

BOTTOMLINE — vaccines provide primary prevention (the type of protection that will prevent disease before you get sick). AND vaccines provide sustained protection against all of the (known) COVID variants.

Getting vaccinated is the healthiest decision.

Option #2: The other form of COVID treatment is the Merck pill, known as Molnupiravir. There is one huge benefit of this pill (4 capsules taken 2 times per day for 5 days) over monoclonal antibody treatment — you do not need to go to a hospital to receive treatment. A prescription can be sent to the pharmacy for you, and the pills can be taken at home. Unfortunately, this pill (which is designed to inhibit viral replication) has only been shown to reduce an individual’s risk of hospitalization by 30%. So if you get sick with COVID and take the pills, you will reduce your chances of needing to be hospitalized, but only by 30%. It a step in the right direction, but not a majorly breakthrough or pandemic-stopper.

Additionally, Molnupiravir can NOT be given to children or pregnant women. And you must be COVID positive (by PCR or antigen test) to receive the treatment.

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While treatments for COVID are necessary and are able to prevent hospitalizations and deaths, the best form of medicine is prevention.

I cannot stress the importance of vaccinations enough.

The treatment options available are required because people continue to get sick.

We cannot treat our way out of a pandemic - we do not have the supply to do so and these treatments do not prevent the next infection.

Treatment is needed to protect our healthcare system. Treatments are needed to prevent severe illness and death on a person-by-person basis.

This pandemic is a global problem. Global problems need global solutions.

And the best form of medicine is prevention.

Get vaccinated. Wear a mask.