As infectious disease leaders at Boston-area hospitals gathered on a Zoom call the evening of May 5, Massachusetts General Hospital Chief of Infectious Disease Dr. Rochelle Walensky slowly realized her hospital was the only one on the call that had received a shipment of Gilead's promising coronavirus treatment remdesivir from the federal government.
"It was awful. I knew I wanted to give it to them, but I had no idea if I could and I didn't have the power to say that on the call," Walensky said. "The state of affairs was astonishing."
Mass General contacted the state government and offered to redistribute its share of the drug, and the handful of other hospitals that had received the drug followed. The state public health department ultimately coordinated redistribution of the drug to nearly 40 facilities based on hospitals' proportional share of hospitalized COVID-19 patients.
Massachusetts hospitals who were research competitors before the pandemic quickly collaborated to ensure equitable distribution of a limited supply of remdesivir across the state after the federal government initially sent out mysterious shipments of the drug to hospitals across the country. Massachusetts pioneered the approach of having state health departments distribute the drug, which HHS ultimately adopted nationwide.
Mass General initially received enough of the drug to treat roughly 170 patients, while other hospitals with some of the highest numbers of COVID-19 patients in the state were left empty-handed.
"I can't sleep at night knowing I had a drug in my pocket, and that hospitals across the city treating vulnerable populations needed it," Walensky said. "That's not how you act as a physician during a pandemic."
Southcoast Health operates three hospitals in Massachusetts, and on May 6 received enough remdesivir to treat around 120 coronavirus patients from the federal government through the distributor AmerisourceBergen. The system agreed to repackage its shipment to send to hospitals left out across the state.
"On one hand, it looked to be a very troubling issue that we were going to be leaving some patients untreated, and physically sending medications away from the region," said Southcoast Health Chief Clinical Officer Dr. Dani Hackner, who is a member the state health department's remdesivir distribution working group. "But it was just as troubling that in some regions, patients by luck of where they lived would not have access to a therapeutic medication."
Boston Medical Center was left out of the initial distribution, despite having one of the highest COVID-19 caseloads in the state. David Twitchell, vice president and chief pharmacy officer at Boston Medical Center Health System, said he was "very happy" to hear that the doses would be redistributed.
"It's one more tool in the tool belt," Twitchell said.
Boston Medical Center is closely monitoring its patients who receive remdesivir, Twitchell said, in hopes of learning more about treating coronavirus patients.
HHS' Office of the Assistant Secretary for Preparedness and Response has said it will send out later shipments of remdesivir to state health departments, though allocation details remain a mystery. ASPR did not respond to an inquiry about how initial distributions of remdesivir were determined or how subsequent shipments to states will be distributed. HHS said Gilead has donated enough doses to treat approximately 78,000 U.S. COVID-19 patients, and the department said on May 9 that it has given out less than 10% of its total expected supply.
"It's unclear if and when we might be getting more, or what the pipeline looks like, which makes it difficult to allocate if we have no idea if any more is coming," Walensky said.
The Massachusetts Department of Public Health has requested enough doses to treat 3,700 patients by the end of June, a spokesperson said.
In the meantime, hospitals are developing their own protocols for how to best target the drug based on limited data available from the federal government. Southcoast's distribution method prioritizes patients who are early in the course of the disease, those who don't have liver or kidney disease, and then further winnows eligibility using severity scores.
HHS sent shipments to a dozen states, which have taken varied approaches to distributing their shares of the drug. Illinois sent out doses based on data about hospitals' COVID-19 hospitalization and intensive care unit numbers. Virginia's health department is using a random selection model based on confirmed COVID-19 cases, a hospital's ability to handle the drug, and availability.
For Massachusetts, equity was a priority for every dose even when the medicine was spread among different hospitals and health systems.
"It gets us out of the unfortunate situation many health systems have been in, when they are competing for a scarce resource. The patient comes first," Hackner said.