Attention-grabbing headlines suggest that our crucial COVID-19 pandemic tools—monoclonal antibodies and vaccines—are incompatible. Beyond the controversy rests an evidence-based reality: monoclonal antibodies and vaccines are complementary aspects of patient care. Both are powerful interventions that can prevent hospitalizations and deaths from this virus. After weeks of declining cases and hospitalizations, the United States is experiencing another surge of new infections likely due to multiple factors, including relaxed mask use in indoor spaces, possible waning immunity from one- or two-dose vaccine schedules, holiday gatherings, colder weather, etc. Therefore, it is time to put aside the ideological divide and embrace monoclonal antibodies and vaccines as complementary tools to confront and restrain COVID-19.
Our hospital in the Bronx, NY, was devastated by COVID-19 in the Spring of 2020, but subsequent waves have been smaller and less deadly due in part to the success of offering both interventions in parallel, monoclonal antibodies for the treatment of COVID-infected patients, and vaccinations for prevention.
In the 12 months since monoclonal antibody therapies received federal government emergency use authorization, health care systems nationwide have worked tirelessly to create an infrastructure to treat at-risk communities, some of whom also suffer a disproportionate toll from COVID-19 due to structural racism and poor social determinants of health. Along the way, monoclonal antibodies served as a bridge that enabled us to counsel patients about their health risks and the importance of vaccines. It is a successful approach that can be replicated anywhere.
A recent patient was a young, unvaccinated single mother suffering from high fevers, body aches, shortness of breath, and chest tightness from a COVID-induced asthma attack. She had not yet been vaccinated and stated that neither she nor her children would receive the vaccine. She told us she did not trust it and was afraid of its side effects. However, she was unaware of the potential ravages of COVID-19, including the possibility of dying and orphaning young children. Similarly, she was hesitant about monoclonal antibody therapy, but ultimately agreed to the treatment since it could alleviate her suffering. COVID-19 left her unable to care for her children for many days and sickened at least three other members of her household. She acknowledges that her family’s circumstance could have been different had she been vaccinated and is now amenable to getting her family vaccinated as soon as possible.
Successes like this are possible when clinicians and patients understand the facts about COVID-19 vaccines and monoclonal antibodies and patients are presented with accurate information. Both agents underwent an accelerated but scientifically rigorous evaluation from initial discovery to large clinical trials, to robust data review by FDA scientists. Both act via anti-spike protein antibodies that either passively (monoclonal antibodies) or actively (vaccines) prevent progression of SARS-CoV- 2 infection. Both can mitigate illness and decrease viral shedding, which benefits the individual and possibly, close contacts. Monoclonal antibodies, like vaccines, also play a role in prevention within specific populations, like severely immunocompromised individuals who have been exposed to the virus.
One important difference between monoclonals and vaccines is the duration and breadth of protection. Vaccines prime a variety of immune cells to quickly respond to future threats, while monoclonal antibodies provide immediate protection that may be therapeutic in vaccine naïve persons and when vaccine-mediated antibodies wane and breakthrough infections occur. Also, unlike COVID-19 vaccines, which are widely available and accessible, persons eligible for monoclonal antibodies must meet certain qualifications and receive treatment, often in a medical setting, shortly after diagnosis. Finally, unlike vaccines, monoclonal antibodies will not bring us closer to ending the pandemic, but can reduce pressure on overburdened emergency rooms, hospitals, and health care workers.
Facing a limited supply of monoclonal antibodies and increasing numbers of vaccine breakthrough infections (due to high rates of SARS-CoV-2 infections in the community and waning antibody levels from original vaccinations), monoclonal antibody programs may be tasked with deciding between treatment of unvaccinated persons and vulnerable, vaccinated individuals. This would heighten moral injury experienced by clinicians and exacerbate “compassion fatigue” toward the unvaccinated. Therefore, it is incumbent on health care systems to continue to offer these life-saving treatments while promoting vaccination and other proven public health interventions.
The approach of our program—monoclonals today, vaccines tomorrow—stresses a dual path that acknowledges the complementary nature of these tools and builds lasting relationships with our patients. Monoclonal antibody treatment encounters provide an opportunity to debunk social media and cultural misinformation, and become a trusted resource for vaccine facts, and ultimately vaccination, once patients are ready. This strategy is increasingly important as new SARS-CoV-2 variants take hold in our communities, emphasizing the need to urgently vaccinate as many eligible individuals as possible
Our patient decided that vaccination is part of her responsibility to her children—an example of what is possible with shared medical decision-making built on trust and respect. Each referral for antibody treatment presents a valuable opportunity to educate, develop relationships with patients and their families, build public confidence, and ensure the health of our communities through future vaccination.
Priya Nori and Liise-anne Pirofski are infectious disease physicians. This article originally appeared in The Doctor’s Tablet.
Image credit: Shutterstock.com
