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Hospitals use a lottery to allocate scarce COVID drugs for the immunocompromised

Evusheld is treatment authorized to prevent COVID-19 in people who are seriously immunocompromised or have had serious adverse reactions to the vaccines.
Peter Bostrom/AstraZeneca
Evusheld is treatment authorized to prevent COVID-19 in people who are seriously immunocompromised or have had serious adverse reactions to the vaccines.

Dr. Vivian Cheung takes steroids to manage a rare genetic disease. The drugs suppress her immune system, which puts her at high risk of getting very sick from COVID-19. It also means that her body didn't really make antibodies in response to two shots she got of the Moderna COVID-19 vaccine.

Cheung is a pediatrician and research scientist. Before the coronavirus pandemic, she flew weekly from her clinic at the National Institutes of Health in Maryland to her lab at the University of Michigan. Now she hasn't been to her lab in two years. "Except for work, I don't go out at all," she says. "I haven't been inside of a grocery store for over a year."

In December, the Food and Drug Administration authorized Evusheld, a monoclonal antibody combination from the drug company AstraZeneca that's designed to give patients like Cheung protection. For those who don't respond well to vaccines, Evusheld shots put COVID-fighting proteins directly into their bodies.

Analysis by AstraZeneca — completed last year — showed that the drug reduced the risk of getting COVID-19 by 77% and that the protection from a single two-shot treatment lasted for at least six months. Early data suggests it may work less well against the omicron variant of the coronavirus, but it is still expected to offer some protection.

That gave Cheung hope, at a time when doctors say they're seeing the omicron wave cause a surge of serious breakthrough infections among immune-suppressed people. "Like many people, I thought: 'Wonderful. Finally, I'll have coverage against COVID-19,' " Cheung says.

But the drug is in short supply. The federal government controls distribution. It has shipped nearly 400,000 doses to health care providers and has ordered 1.2 million doses to date. Around 7 million people in the U.S. could benefit from the drug.

The Department of Health and Human Services, which manages the process, did not respond to questions about supply and distribution.

The scarcity has forced some doctors to run a lottery to decide who gets it.

At Massachusetts General Hospital in Boston, the initial deliveries of Evusheld covered fewer than 1% of its immune-suppressed patients — and came with little guidance on how to make fair use of a limited supply, says Dr. Camille Kotton, clinical director of transplant and immunocompromised-host infectious diseases. So the hospital devised a three-tier system to rank patients by medical need — and to give patients in the top tier an equal chance.

"We put everybody's name into a lottery," she explains. "If people literally get their name pulled in the lottery, we bring them in for an injection."

The Mayo Clinic, in Rochester, Minn., has a similar system — with five tiers and randomized selections within them — says Dr. Raymund Razonable, who runs its monoclonal antibody treatment program. "It's basically by luck," he says. "They happen to be randomly picked by the computer system." Razonable says it will likely take months for the Mayo Clinic to get through the list of several thousand people in its tier for most vulnerable patients.

Jackson Memorial Hospital in Miami — one of the largest transplant centers in the southeastern U.S. — waited weeks to get its first Evusheld shipments. Florida initially bypassed large hospitals and sent its first doses to a small private clinic, Stat and the Miami Herald reported.

"Unfortunately, the initial allocations in my state did not go to the largest transplant or cancer center ... despite the fact that Miami-Dade County is the center of a large transplant population," says Michele Morris, an infectious disease physician who cares for organ and stem cell transplant patients at Jackson Memorial Hospital and the Sylvester Comprehensive Cancer Center. The hospital received its first Evusheld shipment mid-January. "We do not have nearly enough to protect all of the patients at risk, but we have some," Morris says. The hospital is distributing its limited supply by notifying clinicians with the most immunocompromised patients first.

The government provides Evusheld to states based on their total adult populations. The approach doesn't prioritize where the need is greatest.

"Colorado, Washington, Massachusetts — those places are really struggling with having enough supply," says Dr. Anne Zink, state medical officer for Alaska and president-elect of the Association of State and Territorial Health Officials. Demand may be high in these areas because populations that require complex medical care often concentrate near specialized care centers that provide it.

Alaska, however, is having "the opposite experience," Zink says. "We have not had the same demand. We have not had to go to a lottery system. In fact, we are trying to reach out to oncologists to say, 'Do you know this is out there?' Because we have supplies and we think more people need to be reached."

Zink says the country's fractured health care system leads to inequities. People who know where to go and what to ask for are most likely to survive.

Back in Maryland, Dr. Vivian Cheung did a lot of sleuthing to get her Evusheld shots. She called the state's health department and got a list of all the places that received doses. She faxed doctor's notes to various hospitals and zeroed in on the University of Maryland hospital, which had the most doses. "I started literally calling colleagues who worked there, having friends to call colleagues who worked there and finally got a dose," she says.

Getting a dose — in the midst of the omicron surge — hasn't changed her daily life. She still doesn't go to the grocery store. It has provided her some peace of mind, along with some guilt: "I know the system. I know people who can pull strings for me — it's just wrong, right? Everything about this is wrong," Cheung says.

Cheung now advocates online for Evusheld doses for others. It's helping her feel like she has earned hers.

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