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How accessible are Covid-19 antivirals? – Expert Q&A

Covid-19 reinfections are ramping up, but how accessible are antiviral medicines?

Earlier this spring, a Pfizer-funded survey reported that 54% of New Zealanders knew little about antiviral treatments for Covid-19.

The SMC asked experts about access to Covid-19 antiviral medicines and what we know about the risks of reinfection.

Dr Jin Russell, Developmental Paediatrician, Starship Children’s Hospital and PhD Student, School of Population Health, University of Auckland, comments:

How accessible are Covid-19 antivirals in NZ?

“There seem to be multiple barriers to accessing antiviral medications for Covid-19, and I’m concerned that we may have inequities in health outcomes as a result.

“The first issue is a lack of awareness – many members of the public don’t seem to be aware of their eligibility for antivirals should they have an infection, as found in an online survey of New Zealanders.

“The second issue is access to antivirals. Many people have reached out to me to tell me how they struggled to access antivirals, despite feeling they met eligibility criteria. Some have said they contacted several pharmacies that were listed on Healthpoint as dispensing pharmacies, only to find that these pharmacies were not dispensing antivirals. For instance, my own local pharmacy is listed as a dispensing pharmacy on Healthpoint, yet the pharmacists there recently told me they aren’t dispensing – they stopped after calculating that it would take them 45 minutes to dispense a single course of antivirals. Getting a GP appointment can be challenging due to shortages, leading to delays outside of the five-day window for antiviral treatment. A GP has told me that her patients have received conflicting information on their eligibility for antivirals from Healthline.

“Some previously fit and well people have told me that they experienced prolonged fatigue for several months – long Covid symptoms – after their first infection, and they wish that there was consideration of previous long Covid in the eligibility criteria. This is an emerging area of research.

“I’m concerned that we have several hundred people in hospital with Covid-19 and that a significant number of Covid-19 related deaths are being reported each week during the current wave. I wonder what proportion of these cases were eligible for antivirals and did not receive them.”

How important is access to Covid-19 antivirals in NZ?

“It’s important for the public to know that anyone 65 years of age or over, and Māori and Pacific and unvaccinated persons 50 years of age or over, and people with three or more high-risk medical conditions are eligible for antivirals.

“Antivirals have been found to be highly effective in reducing the risk of hospitalisation and death due to Covid-19 according to a recent paper published in The New England Journal of Medicine, so it is vital that we reduce barriers to accessing these.”

No conflicts of interest.

Dr Rawiri Keenan (Te Atiawa/Taranaki), Adjunct Senior Fellow, Medical Research Centre, Te Huataki, University of Waikato; Senior Research Fellow, Dept of Primary Care and General Practice, University of Otago Wellington, comments:

How important is access to Covid-19 antivirals in NZ?

“Increasing access to antivirals was important, but avoiding infection and reinfection in the first place is still the key thing that we can be doing right now. The Pfizer survey results need to be taken with a grain of salt because access has widened since then, and also it is a little self-serving for them to push more uptake of their medication. A medication that helps reduce the severe effects of the illness is helpful for keeping people alive and our hospitalisation rate down. But so far, evidence seems to suggest mild-to-moderate cases of COVID-19 are still at risk of Long Covid – and we aren’t sure if antivirals help with this.

“From a public health perspective, increasing the use of masks – even now as we climb towards 10,000 cases a day – would help. I’m not a modeller but I’m sure in many settings, stringent mask use would be more effective at reducing hospitalisations than antivirals once already infected. Sadly, the only certainty of this Christmas/New Year is that many, many people will be in hospital with COVID-19, many more at home isolating and unwell, and a number will die. As has been the case this entire pandemic, this will affect Māori and Pacifica people more.”

How accessible are Covid-19 antivirals in NZ?

“A concern with the rising number of Covid cases as we approach Christmas is that the ability to get these antivirals, where clinically appropriate, will reduce. While many pharmacies usually stay open over weekends, during these summer holidays on statutory holiday days they will join general practice teams in largely being closed.

“We were sold a ‘summer of certainty’ but unfortunately, GP teams – as with most other parts of the health system – are needing to pause usual care to meet the demands of COVID-19. There is, as far as I am aware, no plan for widening GP or pharmacy access to antivirals than usual over the prolonged statutory holiday periods, which will leave many people who could be eligible with limited access (they need to be started within five days of illness onset).

“While primary care teams (GP, nurses, pharmacy etc) are funded for assessments and prescription, etc. of antivirals, there has been no let up or catch up from previous waves, leaving the majority planning on closing over the Christmas period as usual to give staff a well-earned break. Though I’m sure for many, especially in rural areas, the on-call work will be more than the usual summer holiday-goers due to COVID-19. Sadly, with the state of the workforce, even if funding was made available to remain open/available, I’m not sure many GP teams would have the staff.

“Antivirals are great, the widened access to include more Māori and Pacifica in antivirals and boosters is great too – but with our out-of-date vaccines (not bivalent and many, many people are more than one-year since their booster) and the lack of basic public health measures for an airborne virus, we are relying too much on a treatment for an illness, when we know for everything from infection to diabetes – prevention is better than cure.”

Conflict of interest statement: “I am a team member for projects with Victoria University of Wellington and University of Otago funded by the Ministry of Health evaluating the Covid vaccine roll-out. I am a Locum GP; Member of Te Rōpū Whakakaupapa Uruta; Member of Te Aho o te Kahu Clinical Assembly and Member of Health Quality and Safety Commission Patient Experience of Care Governance Group.”

Dr Anna Brooks, Cellular immunologist, Senior Lecturer, and Senior Research Fellow, Maurice Wilkins Centre, University of Auckland, comments:

What’s the latest evidence on the health risks of reinfection?

“Emerging evidence is indicating that the risk of long-term health harms, not just Long Covid, increase with each subsequent reinfection. Our vaccine- and/or infection-induced immune system protection is not enough to prevent infection or protect against all health risks. This is especially important given the Omicron variants and subvariants that continue to evolve to evade our immune defences.

“First and foremost, prevention is always better than requiring treatment. No infection is safe, and given our vaccine- and/or infection-induced immunity only provides limited protection against illness and lasting health harms, each exposure event comes with a risk. Clear messaging about reducing harms needs to continue, including the importance of high quality masks and ventilation, encouraging testing before high risk events, and isolating when unwell with any symptoms.

“Therefore, it is important that we have both clear messaging surrounding the ongoing risks to our health from infection, as well as better access to antivirals when appropriate. A study currently under review conducted by a highly reputable group, revealed a 26% reduction in Long Covid symptoms for people who took Paxlovid, which is encouraging.”

What do these risks imply for NZ’s pandemic response?

“As data is showing that each infection increases health harms and antivirals can reduce the risk of these harms, it would be good to see access to antivirals extended, especially to those already living with Long Covid.

“People living with post-viral illnesses (Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and Long Covid) are calling for better access to antivirals, given all health protections have been dropped, and access to a second booster doesn’t extend to this ‘at risk’ group. Research efforts are underway to develop tests to clinically define immune dysfunction more conclusively in these groups. But can we really afford to keep ‘waiting for more data’ when there are tools available to reduce health harms?”

No conflicts of interest declared.

Dr Amanda Kvalsvig, epidemiologist, Department of Public Health, University of Otago Wellington, comments:

What does the latest evidence suggest about the risks of reinfection?

“The research literature continues to show substantial and growing evidence about the health risks from ongoing waves of Covid-19 infection, with further impacts in turn on the safe functioning of health, education, and other systems. So the big question is why the New Zealand public isn’t being advised every day that it’s in their best interests to avoid getting infected and reinfected.”

Recent research: The impact of Covid-19 reinfections is challenging to study because reinfections are undercounted in population data. But a recent study of the US Veterans Affairs cohort published in Nature Medicine has provided some very high-quality evidence. This study showed that people with a higher number of infections had a significantly higher risk of new and serious health conditions, compared with those who had experienced only one infection. The authors were careful to address important sources of confounding in their analysis, so this is a high-quality paper. The study appropriately didn’t test whether subsequent infections had milder or more serious early symptoms than the first – the amount of data collection needed to answer that question would have been huge and it would have added no practical, actionable information: we already know that serious health effects can follow a mild early infection.”

What do these risks imply for NZ’s pandemic response?

The need for action: The refrain we’ve heard so many times during the pandemic is that ‘more research is needed’ before the Government can act. But as our case numbers rise again, we need to question exactly what information is being awaited before the decision is made to step up and protect the public. The US Veterans Study referred to above had more participants than the entire population of Aotearoa New Zealand. That is a lot of data points. Even if the results were only applied to New Zealanders from a similar demographic, the population health consequences here would be highly concerning. The combined evidence from this study and thousands of others indicates that every day spent waiting to act is knowingly exposing more people to risk from these serious and life-altering outcomes.”

“The only sensible way to deal with this level of credible risk is to take a precautionary approach. We have plenty of protections that can keep people safe while going about their daily lives. Highly effective ways to keep us connected and safe include providing clean indoor air in all public settings including schools, requiring and providing high-quality masks on public transport, requiring rapid antigen testing for large events and when exiting isolation; providing protected sick leave for all workers, and many more. It’s frustrating to see that New Zealand is currently under-using all of these well-established and cost-effective protections in the face of very clear evidence of risk.”

No conflicts of interest declared.

Dr Emily Harvey, Co-lead of the Contagion Network modelling programme, COVID-19 Modelling Aotearoa, comments:

What is the outlook from here, with reinfections on the rise?

“Right now in Aotearoa NZ, our gradual waning of immunity from past infection and vaccination is being helped along by new variants that are better at evading our immunity and are causing a new wave of infections. From the modelling, we expect to see cases and infections rising over the next couple of weeks, and peaking late in December. Whilst the size of this variant-driven wave in terms of infections and cases is uncertain, we do know that it will produce a wave of hospitalisations and deaths as well.”

What part can antiviral treatments play?

“One thing to remember is that the current variants of COVID-19 are similar in severity to the original variant that was circulating in 2020, the key difference is that we now have vaccinations that substantially reduce the likelihood of hospitalisation and death, and we have improved therapeutics including antivirals. Antivirals have been associated with a significant decrease in the risks of hospitalisation or death, especially in higher risk groups, of around 80%. Another way of saying that is that they can make it 5 times less likely that you will be hospitalised or die.

“Effective use of antivirals has the potential to reduce the load on hospitals and the number of hospitalisations and deaths substantially. The biggest issue is that in order for them to work, they need to be used early on in the infections. This means that people need to be detecting that they have COVID-19 as early as possible in their infection, and then be able to get a prescription, and get it filled, promptly.

“Although Rapid Antigen Tests are an incredible technology, giving people the ability to test themselves at home and to get a result back quickly, we know there is a lag at the beginning of the infection before they will detect a case. Data from NZ shows that this lag means the majority of people will not test positive until day 2 or 3 of symptoms, and some will take 5 or 6 days.

“This can be a problem as antivirals need to be started within 5-7 days of symptom onset, and it can take some time to get a prescription especially over weekends or public holidays. Because of this, it would be good to see more availability of PCR testing for those people at high risk (those eligible for antivirals) who have COVID-19 symptoms but have tested negative on RATs. This would have the added benefit that it would also improve our variant surveillance in the community – right now, we do not have enough PCR testing going on to get a good picture of the variant landscape.

“Additionally, with the expected wave of infections lining up with the Christmas period, it will be difficult to find a GP or pharmacy that can prescribe antivirals, and to find a pharmacy that is open and can fill the prescription. For those at high risk (those eligible for antivirals) more availability of advance prescriptions would ease the load during the Christmas break.”

Conflict of interest statement:  “Dr Harvey’s employer receives funding from the DPMC for her to provide modelling and analysis to government officials on Aotearoa’s COVID response, and from the NZ Health Research Council for a project on modelling and equity for COVID-19 in Aotearoa.”

Associate Professor Dianne Sika-Paotonu, Immunologist, Associate Dean (Pacific), Head of University of Otago Wellington Pacific Office, and Associate Professor, Dean’s Department, University of Otago Wellington, comments:

What are antiviral treatments?

“Antiviral medicines are used to treat people who’ve already been infected with a virus, such as the SARS-CoV-2 virus, which causes Covid-19. Steps to widen the eligibility criteria and broaden availability for antiviral medications to treat Covid-19 have been announced previously in Aotearoa New Zealand. There had been significant global demand for antiviral medications, and countries had been challenged in trying to get access to some medications.”

What do antivirals do, and who needs them?

“In general, antivirals reduce and limit the severity of symptoms that someone might experience with a viral infection, lessen the duration of the viral illness and shorten the length of time that someone stays unwell for, and reduces viral transmission.

“Antivirals need to reach those who require them, at the time they need them, in order to prevent severe illness and hospitalisation – and try to help our hospitals and support systems, primary and community care right now.”

How available are Covid-19 antivirals in NZ?

“For antivirals to be effective, people with Covid-19 need to get access to them quickly and the sooner the better – within five days of symptoms showing. Accessibility and availability issues will limit and hamper the usefulness of antivirals to treat Covid-19.”

What is the outlook from here, with reinfections on the rise?

“The newer variants and subvariants of the SARS-CoV-2 virus have caused problems with higher transmissibility, with Covid-19 reinfections remaining problematic.

“The Covid-19 pandemic has continued to exacerbate pre-existing inequities in health for vulnerable communities, with inequitable impact recently demonstrated through the disproportionate representation of Covid-19 associated deaths for Māori and Pacific peoples – sympathies and condolences are respectfully extended to all family, whānau, kāinga, aiga and friends impacted and affected.

“It is important to remember, however, that antivirals are not a substitute for Covid-19 vaccines and boosters – these are still much needed at this time to work alongside simple public health measures that include vaccines and boosters, masks, isolating when sick, proper ventilation and other public health measures, remain important steps to help protect against the severe impact of Covid-19, against reinfection, and also other illnesses still circulating at this time.

“Vigilance is still needed – especially for our vulnerable communities.”

No conflicts of interest declared.