Every six months, Ashley Fisher gets an infusion of medication that wipes out her B-cells, the immune system’s equivalent to a weapons producer.
In a typical immune system, B-cells build antibodies that fight off viruses. For Fisher, who has multiple sclerosis, B-cells play a key role in slowly degrading her brain and spinal cord. Killing some of them off has stopped the damage, and she's lived symptom-free for four years.
But it’s at a cost. Her body can’t drum up the antibodies for the COVID vaccine, so she’s been paused in a early-2020 era lockdown even though she's vaccinated. In December, after nearly two years of ordering takeout and declining invitations, she wondered if she should try another type of drug, one that might not work as well but would allow the vaccine to prod her immune system into making antibodies.
That’s when her doctor mentioned Evusheld, a new monoclonal antibody for immunocompromised people. Unlike other monoclonal antibodies patients have taken to treat COVID, the treatment directly injects coronavirus antibodies into a patient's system and provides protection for about six months.
But the drug is in short supply nationwide, with only 1.2 million doses ordered for a population about seven times that size. Fisher, a 38-year-old data health care analyst, pestered her doctors’ office for the next two months. Finally she got the call, and last Friday she got two shots of Evusheld and an immediate sense of freedom.
“I feel so much relief, feeling like I'm kind of more back on par with other people,” said Fisher, who lives in New Orleans. “I can barely even process it.”
It's a relief not many immunocompromised patients have felt in Louisiana. Fisher is one of the few people to receive the drug, which has been deemed a precious resource. But its scarcity, along with familiar pandemic challenges like staffing and communication, has left it sitting on shelves.
Louisiana has received about 6,144 doses of Evusheld from the federal government, according to the Louisiana Department of Health.
But hospitals and pharmacies have only requested about 2,000 doses. More than half of those have gone unused, according to federal data. Almost 40% of the nearly 40 hospitals and pharmacies who received the drug have not reported using a single dose. The remaining 4,656 courses that have gone unclaimed are being held by the state.
People with compromised immune systems are currently recommended to take four vaccine shots: three mRNA shots as the primary series, then a fourth booster five months later — a timeline the Centers for Disease Control and Prevention has indicated will soon be shortened to three months.
But even four shots might not muster a response for some people. It's not well understood how the vaccine works in people with weak immune systems, but one study found that only about 50% of immunocompromised patients have antibodies after two doses of the mRNA vaccines.
"The direction I've always been given, despite having gotten vaccines whenever I could, is that I should treat myself as though I am unvaccinated," said Fisher.
Data from last year showed that an injection of Evusheld, manufactured by AstraZeneca, could reduce the risk of getting COVID by 77%. While early data suggest it may not be as effective against the omicron variant, it is still thought to be effective against hospitalization and death.
Despite its benefits, many immunocompromised patients aren't aware they qualify. When Fisher posted on her social media that she got Evusheld, others with MS were thrown off. Even people who are aggressive about their own treatment didn’t know about it.
“I feel like this one really just kind of has really snuck under the radar,” said Fisher.
Like other stages of the pandemic, the distribution of this scarce resource has been a patchwork system, with hospitals and pharmacies left to decide how to divvy it up. Some hospitals, like Our Lady of the Lake Regional Medical Center in Baton Rouge, instructed doctors who treat immunocompromised patients to give it at their discretion. But they’ve run into roadblocks with that approach. The hospital's limited supply — 72 doses — made clinicians feel like they should save it for people who really need it. As a result, only four people have received it.
“We find that we have less people getting it because we’re trying to make so many difficult decisions about who is best to get it that we’re using it less often than we should,” said Dr. Catherine O’Neal, medical director of Our Lady of the Lake. “When resources become scarce, we have trouble figuring out how to use them.”
Other states have been criticized for not having enough prioritization policies in place. In Florida, for example, the majority of the first doses were given to a small concierge clinic rather than the state’s large transplant or cancer centers. Some patients in other regions have reported crossing state lines for easier access to the drug. And some hospitals have introduced complicated equity formulas, using factors such as how disadvantaged a patient’s zip code is to balance the scales of who should get priority access.
Getting patients and providers up to date on a constant whirl of changing information is difficult, said O’Neal, pointing out that complex schedules for things like the pneumococcal vaccine took years to drive home to patients and doctors.
“The messaging for this virus and prevention for small subgroups has become so complicated,” said O’Neal.
Some patients feel they're sufficiently protected from their vaccines or want more time to talk about it with their doctor, said O'Neal, and clinicians may be hesitant to push a new drug while the omicron variant is on the downslide if they don't know how many doses the next shipment might contain.
Ochsner Health is also running up against distribution issues. It has a tiered system and reaches out to patients based on how likely they are to benefit from added protection. The hospital system, Louisiana’s largest, has received about 900 doses of the drug and 2,000 offers have been made to patients as of last week, according to Dr. Jonathan Hand, section head of transplant infectious diseases. About 100 patients, Fisher included, have accepted.
Staffing and finding a place where immunocompromised patients can safely receive the injections has been a challenge.
“Similar to other pandemic strategies we have tried to rapidly expand for our patients in an environment in which health care workers are in high demand and are spread thin,” Hand said in an emailed statement.
Louisiana is not alone in its sluggish use of Evusheld. Many states have more than half their allotment available.
But the state does have a greater share of immunocompromised patients than the national average and one of the lowest vaccination rates in the U.S., making the likelihood a vulnerable person will be exposed to the virus higher.
For Fisher, Evusheld made all the difference. Her first dinner reservation on the books for Jewel of the South this week, where she’ll dine inside the cozy French Quarter restaurant without the creeping fear that she’s putting her life on the line. Arnaud’s for fried soufflé potatoes is next. She’ll stick to venturing out on weeknights at places she knows will check for vaccination, as required in Orleans Parish, but it feels like reclaiming a tiny piece of normal life.
"It's like the light at the end of the tunnel," said Fisher. "It's a huge deal. It's totally a huge deal."