Thread by @ASlavitt

COVID Update: The marvels of science are slowly but surely taming this virus.

Vaccines are helping mute the effects of Omicron. And now Paxlovid, approved by FDA under EUA, ushers in a new era of the pandemic. Patience & caution still required. 1/

For almost everyone, vaccines make dying from COVID extremely unlikely. Delta increased the need for a booster. Omicron increases it further if you want to avoid even a mild infection.

But the main point is vaccinate the globe & the country & fewer will lose their lives. 2/

Still, in the US at least, this leaves 130 million people who aren’t vaccinated, the majority of whom are eligible.

This isn’t a failure of science. The vaccine is very well tolerated & production scales nicely. But it is a vulnerability nonetheless. 3/

The refusal of many to get themselves vaccinated falls directly on the backs of nurses, doctors & medical staff. And it puts people who can’t get vaccinated at some risk.

But increasingly, thanks to science, it is the unvaccinated who are most at risk of serious illness. 4/

Enter Paxlovid, which can be given orally 3-5 after infection, and reduces serious illness by 88%— and believed effective against Omicron.

This drug, and a class of even better ones which are sure to follow, will soon render COVID even less dangerous. 5/

The drug inhibits viral replication and has been approved for those at serious risk 12 and older.

The US has purchased 10 million treatments, but will begin with only 200k in January, with the full order delivered by September. 6/

The ramping of supply & the choices it creates begs a number of interesting & even ethical questions and not all the questions about the drug are answered. 7/

Why the low supply to begin with?

Two reasons. First while many factories can produce, it takes a while to ramp this type of chemistry. I’m no expert in this type of pill production but others who know more will I’m sure opine. 8/

Second, unlike vaccines, the anti-virals are being distributed much more equitably globally from the outset.

One could argue that those countries with the least amount of vaccine should be given the highest priority for Paxlovid. 9/

If this means the US needs to wait, given the abundance of vaccines in the US, that would seem appropriate from a life saving standpoint & just. Wealthy nations benefit as reducing replication also reduces chance for mutations to form. 10/

It raises the question of how to think about the use of the treatment in the US while volume builds.

Should the treatment be used disproportionately to protect unvaccinated people? Or does this reduce the likelihood of more vaccinations? 11/

Consider the numbers. 200,000 in all@of January is the amount of total cases we are currently experiencing in a day.

While this will improve dramatically throughout the year, it means the anti-viral isn’t for everyone who tests positive. So who is it for? 12/

But with 40,000 dying each month, if the right people are targeted 200,000 & growing can cut that number down meaningfully. 13/

First priority would be people with organ transplants or who are immunocompromised & to whom the vaccine don’t help very well.

Older people in assisted living & people with co-morbidities are also a priority. 14/

But unvaccinated people are dying at a rate 13x vaccinated people. Undoubtedly to save the most lives, the therapy would go disproportionately to unvaccinated people. 15/

Paxlovid and the drugs which follow are likely to change the course of how we think about COVID & what feels safe to do when they’re widely available.

In the meantime, the drug should reduce suffering & death as much as possible. 16/

Paxlovid will be distributed through states and from there presumably to local health departments, hospitals & pharmacies.

There will also be a direct allocation to community health centers. 17/

Adapting to a world of oral anti-virals will take time and also bring with it unanticipated issues & unforeseen consequences.

Will it’s effectiveness wane over time as some are concerned? Will new variants alter the effectiveness? 18/

This is what progress feels like. Slow to happen. Requiring more patience than we have. Incomplete. Raising ethical questions. Still leaving uncertainty.

All of that. Big don’t let those things get in the way of seeing this breakthrough as a giant step towards normal./end