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Zain Chagla is an associate professor at McMaster University and infectious diseases physician who is leading a pilot program offering monoclonal antibodies at St. Joseph’s Healthcare Hamilton.

COVID-19 has led to significant societal disruption amid wave after wave of infectious variants, but one common theme has prevailed throughout the pandemic here in Canada: the need to preserve health care capacity so that our hospitals are not overrun. Throughout prior waves, and into this one, hospitalizations and the numbers of patients in critical care have served as the key metrics by which difficult decisions need to be made. Vaccinations have played an incredible role in significantly reducing risk, ensuring that most individuals, even with a breakthrough infection, do not end up in hospital.

But this is not enough. The reality, it seems, is that COVID-19 will be with us forever, and that certain groups, despite interventions put in place, will be disproportionately infected: The elderly, those with significant underlying medical conditions, and those with suppressed immune systems face risks from COVID-19 even with a full series of vaccines. Those who are unvaccinated, particularly those with risk factors, also pose a continuing risk to hospital capacities.

As a society, we know that endless cycles of lockdowns are not sustainable. And yet we also know that we need to reduce pressure on our health care system in the face of high community transmission and the emergence of variants. The way forward, then, must be a greater focus on therapeutics for COVID-19 to mitigate hospitalization among the most vulnerable and to allow us to get to the point where we can live with it. How we manage COVID-19 today compared with how we handled it the start of the pandemic is very different, and therapeutic options need to be a part of overall risk reduction.

Broadly, therapeutics fit into two categories. The first category of drugs directly target the virus, and include monoclonal antibodies and remdesivir, which have been approved by Health Canada, as well as Paxlovid and molnupiravir, which are awaiting approval here but have received emergency-use authorization from the U.S. Food and Drug Administration. These kinds of medications interfere with the virus entering and replicating within cells, and when given early may significantly reduce the risk of hospitalization among high-risk individuals by up to 80 per cent. The second category of drug may target the immune response, which can become overactivated and lead to hospitalization; these include fluvoxamine and inhaled steroids.

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When monoclonal antibodies came to the Canadian market last summer, many Canadian health care professionals recognized the potential for their use. We knew this therapy would make a difference with our then-significant unvaccinated population, as well as for many patients living with immune-compromising conditions; we recognized the potential of administering therapy, not only to reduce health care demand, but to improve the quality of life among those at highest risk of complications. But while people in the United States got to work setting up thousands of monoclonal clinics in repurposed spaces where patients could self-refer, we also knew that there would be barriers to delivering these antibodies, including where clinics would be located and staffed, how the therapy could be administered efficiently (since the antibodies are most effective within seven days of symptoms showing), and how patients would be recruited.

With our partners, we launched a clinic to work through the feasibility of providing the treatment here. It wasn’t straightforward, and we’ve had to overcome many obstacles, but over the past three months we have administered more than 150 doses of monoclonal antibody therapy with very successful patient outcomes, particularly among high-risk groups. Going through the process repeatedly made us improvise, pivot, and partner with community resources and health care providers, getting better with every dose administered. Our incredible nurses have really become local champions for therapeutics, and together we’ve created a non-judgmental space for everyone, regardless of vaccine status, to do what we are trained to do as medical professionals: treat patients.

We’ve learned lessons that could be useful for other health care providers. First, health care networks need a stable supply of these medications. While we recognize supply chains can be tight and that these therapies are in global demand, it is important to be open and transparent about supply. Since many of these drugs are acquired federally and distributed provincially, all levels of government should provide dashboards which include information about supply and expected future access. This not only allows for local innovation to support delivery of treatments, but also encourages appropriate stewardship of these therapeutics to use limited resources to support the highest-risk populations. With unstable or unclear supply deliveries, clinicians are forced to make difficult decisions about which patients should receive the scarce treatment.

Second, local innovative solutions are warranted. Health care partnerships across regions need to ensure access that high-risk patients are supported through their COVID-19 diagnosis. Accessing timely testing of high-risk patients, linking that testing to a clinician familiar with therapeutics, the administration of those therapeutics, and continuing monitoring of the patient’s condition are fundamental to any program’s success. However, solutions will look different for those in Thunder Bay or Timmins, Ont., than they would for Toronto, and creating local implementation plans will allow for equitable approaches.

Third, patients need to understand that therapeutic options are now, and must be, a part of the COVID-19 health care landscape. Many patients in our clinical experience did not realize that there were early-treatment options. Education in high-risk communities is paramount so that vulnerable patients realize they need to get tested if they have symptoms, are given resources to access this testing, and have people within health care networks to advocate for their ability to be treated appropriately to reduce the risk of hospitalization and death. This would represent a fundamental paradigm shift from how we’ve largely managed COVID-19 diagnoses over the past two years: telling patients to wait at home and hoping that things improve. Knowing that providers can intervene can allow patients to access therapy when it’s most effective.

Finally, support for laboratory and clinical research into therapeutic options, particularly ones delivered before hospitalization needs to happen, is paramount. As a local primary investigator in an early COVID-19 therapeutics trial in April, 2020, it was an incredibly difficult process to co-ordinate research nationally in this space, particularly for drugs that are being repurposed for therapy. Canada has a robust network of researchers, and breaking down barriers as well as financial support for early therapeutics is imperative so that we can support the growth of multiple treatment options for patients.

To be clear, therapeutics will not stop COVID-19 transmission. They will only modify the effects of the disease among those who are infected; they are not a solution to reducing COVID-19 in our communities. But they may be just as important to our holistic approach to COVID-19 because they are a viable solution for improving outcomes for those at risk, and ensuring our hospitals are not overrun.

This needs to be the year where COVID-19 treatment, using all the health care tools in our tool box, becomes mainstream. And Canada needs to be at the forefront of this thinking in order to protect its population.

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