Regeneron Versus Vaccines

National Institute of Allergy and Infectious Diseases (NIAID), NIH, Public domain, via Wikimedia Commons

The latest front in the political war over COVID-19 appears to be monoclonal antibodies. The NYT describes a man who refused vaccines but got COVID-19:

The answer turned out to be monoclonal antibodies, a year-old, laboratory-created drug no less experimental than the vaccine. In a glass-walled enclosure at Houston Methodist Hospital this month, Mr. Jones, 65, became one of more than a million patients, including Donald J. Trump and Joe Rogan, to receive an antibody infusion as the virus has battered the United States.

Vaccine-resistant Americans are turning to the treatment with a zeal that has, at times, mystified their doctors, chasing down lengthy infusions after rejecting vaccines that cost one-hundredth as much. Orders have exploded so quickly this summer — to 168,000 doses per week in late August, up from 27,000 in July — that the Biden administration warned states this week of a dwindling national supply.

…

Amid a din of antivaccine falsehoods, monoclonal antibodies have become the rare coronavirus medicine to achieve near-universal acceptance. Championed by mainstream doctors and conservative radio hosts alike, the infusions have kept the country’s death toll — 2,000 per day and climbing — from soaring even higher.

And after months of work by President Biden and Southern governors to promote the treatments, they have won the affection of vaccine refusers who said that the terrors and uncertainties of actually getting Covid had made them desperate for an antidote.

The federal government has ordered 1.8 million doses. That sounds like a lot but that’s barely enough to treat a week’s worth of COVID patients at our present infection rate. But monoclonal antibodies have becomes the one treatment for COVID-19 that no one is skeptical of. Which, oddly, has conservatives doing a victory lap:

Two months ago, Governor Ron DeSantis of Florida was being roundly castigated for promoting the use of Regeneron’s monoclonal-antibody treatment as part of his state’s efforts to fight COVID-19. Desperate to find something sinister in the push, DeSantis’s critics threw out every charge they could dream up. At first, the line was that Regeneron’s treatment didn’t work. Then, it was that Regeneron’s treatment worked fine, but represented a dangerous distraction from the vaccine. And, finally, it was that Regeneron’s treatment was part of a corrupt plot to enrich DeSantis’s donors.

Today, we learn from the Washington Post that, actually, none of that was the problem. Instead, DeSantis’s sin is that he has been relying upon monoclonal-antibody treatment too much, and that this is unfair to other states that now need it.

What a difference eight weeks make.

This is a bizarre paragraph and I’m surprised to see it under Cooke’s byline, since I usually find him reasonable even on rare points of disagreement. No one has ever said that monoclonal antibodies didn’t work. What we said eight weeks ago, what we said four weeks ago, what we are saying today and what we will say tomorrow is the same: monoclonal antibodies are not a substitute for the vaccine. And to hear them flogged by a governor who has mindlessly and cynically opposed cheap anti-COVID-19 interventions is infuriating. DeSantis has threatened the funding of schools that impose mask mandates, threatened to fine government agencies that require vaccines and threatened to fine businesses that require vaccine passports. All of this while his state became Ground Zero for the Delta Wave. To his credit, he has been overall positive on vaccines and Florida’s vaccination rate is decent. But watching him now tout monoclonal antibodies as the cure for what ails us is a bit like getting a stern lecture from Mrs. O’Leary’s cow on the virtues of sprinkler systems.¹

Putting the politics aside, what’s the deal with monoclonal antibodies? Antibodies are the proteins your body uses to identify and destroy infectious agents like viruses. They are very specific to specific diseases. When you are exposed to a disease, it takes time for your body to figure out what antibodies are needed to kill the disease. In that window, the disease may do so much damage that it’s too late for your body to recover.²

Vaccines work by exposing your body to a dead or attenuated virus (or a piece of one, in the case of the HPV and COVID vaccines).³ This lets your body learn how to fight the invader with minimal danger. Think of them as military exercises for your body, preparing it to fight an actual war should the need arise. After that, if the virus shows up, it finds a well-trained defense ready and waiting to annihilate it.

Monoclonal antibodies, by contrast, are copies of existing antibodies. Immune cells in a lab are exposed to the virus or a piece of the virus. The antibodies they make are then copied in large numbers for injection into sick patients. These antibodies can fight the disease immediately while your body ramps up its own defenses. To continue a military analogy, it’s like dealing with a surprise invasion by hiring mercenaries to hold the line while you organize your army.

Monoclonal antibodies are, in this sense, similar to the immunoglobulin injection given for rabies exposure. Rabies is so lethal that when someone is exposed to it, we give them three vaccine shots — to teach their bodies how to fight it — as well as an injection of antibodies to kill any actual virus in their bodies.⁴

The good thing is that, unlike the other COVID-19 “cures” pushed by the vaccine skeptics — ivermectin and hydroxychloroquine — monoclonal antibodies actually work. Preliminary results indicate they may reduce hospitalization and death by 30-70% if they are given within the first ten days of infection.⁵ Like mRNA vaccines, monoclonal antibodies also show promise beyond COVID-19, with research being done into wether they can treat cancer or autoimmmune diseases.

They are not, however, cheap. A single dose of Regeneron’s medicine costs about $2000. A full course can run about $10,000. And they can not be manufactured in the kind of massive numbers that vaccines can, certainly not in the quantities needed to keep up with the current Delta wave.

Moreover, monoclonal antibodies do not prevent transmission of the virus. New data on the vaccines shows that vaccinated people have lower viral loads and those loads reduce faster than the unvaccinated, which means they are significantly less infectious. Monoclonal antibodies are only given after someone is sick (or, in some cases, after exposure) and may be too late to prevent transmission.

What’s revealing, however, is how much the enthusiasm for monoclonal antibodies exposes every single anti-vaccination talking point as a lie. Consider:

• Anti-vaxxers have screamed that the vaccines are experimental and untested. It’s not true. But monoclonal antibodies are even more experimental. We don’t know what side effects they have yet. Moreover, monoclonal antibodies are given after infection or exposure. And we know that even mild cases of COVID-19 infection can have significant long-term health effects.
• Anti-vaxxers have made a huge deal of the vaccines not being 100% effective. No vaccine is. But monoclonal antibodies aren’t 100% effective either. They are less effective than vaccines at preventing death and hospitalization and there is no evidence that they are effective in preventing transmission.
• Anti-vaxxers have criticized the vaccines for targeting the spike protein rather than the entire virus. But the monoclonal antibodies target the spike protein too.
• “Follow the money!” anti-vaxxers shout. But monoclonal antibodies are literally a hundred times more expensive than vaccines. The federal government is spending $3.6 billion to acquire new doses that can treat a few hundred thousand people. For that money, you could vaccinate the entire adult population of Japan.
• Anti-vaxxers claim that the virus will mutate to evade vaccines. That’s a mis-statement. Viruses can’t change to evade vaccines because vaccines don’t treat infections. They can mutate to evade immunity but that’s true no matter how that immunity is acquired. But that mutation issue is more important for monoclonal antibodies. The virus is directly exposed to them and a short course could cause more resistant mutations to thrive — as happens with antibiotics. REGEN-COV, in fact, uses two different antibodies specifically to mitigate the danger of mutation.

In the end, anti-vax sentiment has never been about the science. It has always been about identity. It has always been about ignoring what They tell you and finding the hidden truths that They don’t want you to know. And in the case of COVID-19, it has been layered with a bizarre belief that vaccine mandates are the first stages of Communism.

Look, this isn’t either-or. Both of these ways of dealing with COVID-19 are medical miracles. But they attack the virus at different points in its life cycle: vaccines are given before exposure to prevent infection, prevent transmission and make breakthrough infections less severe. Monoclonal antibodies are given after exposure to reduce the severity of infections. The best way to approach COVID-19 is to use both. Vaccinate everyone and then use monoclonal antibodies to deal with the breakthrough infections. If COVID-19 is the enemy, vaccines and monoclonal antibodies are how you create a layered defense against it.

Vaccines don’t make monoclonal antibodies unnecessary — we will still get breakthrough infections and we still need medicines that can treat them. And monoclonal antibodies don’t make vaccines unnecessary — we still need a cheap frontline defense that also prevents transmission. In fact, given the extreme expense and shortage of monoclonal antibodies, the case for vaccination is strengthened. We need to save monoclonal antibodies for those who can’t get vaccinated or for whom it doesn’t work. Monoclonal antibodies are the defensive backs to the vaccines’ defensive line. Not getting vaccinated because you have faith in experimental monoclonal antibodies therapy is like defending against the Kansas City Chiefs with only a free safety. More concretely, it is selfishly demanding an expensive treatment that should be saved for those who desperately need it. All because some circus clown with a Twitter account and seltzer bottle told you vaccines weren’t safe.

It is a sign of how easily we default to culture war nonsense — and how intellectually bankrupt the Republican Party is — that some people want to set these two medicines against each other as if we have to chose between them. But we don’t. Get vaccinated. And do so knowing that either (a) the vaccine will keep you from getting sick, sparing tremendous expense and saving vital medicine for those who need it; or (b) if you’re unlucky enough to get a breakthrough infection, we have a therapy — albeit an expensive one in short supply — that has a good chance of saving your life. And also know that, by getting vaccinated, you significantly lower the chance that you will spread the disease to that 1% for whom neither the vaccine nor the antibodies work.

The one thing I will never forgive the GOP for is politicizing this.⁶ Running around proclaiming victory because monoclonal antibodies work is silly. No one ever said they didn’t. Scientists and doctors love monoclonal antibodies. But they are not, never were and never will be a substitute for a safe, readily available and effective $20 poke in the arm.

1. You would think NR would have learned from singing DeSantis’s praises back in February but apparently not. I get it: NR were the original Never Trumpers and want DeSantis to run for and win the Presidency. But at some point, you have to call the man out. He thought the vaccines would let him play footsie with the COVID lunatic fringe without consequence. And Floridians are paying the price for that.
2. Or, with some diseases, your body may overreact and destroy itself, which seems to be part of how COVID-19 kills.
3. Or, in the case of the mRNA vaccines, having your body manufacture a replica of a piece of the virus.
4. The IG shot is the big one that goes into your butt and hurts like a bastard. Ask me how I know.
5. There’s a lot of variance in the results because we’re still fairly early — these drugs only finished Phase III trials a few months ago.
6. Well, that and, by the end of the year, what is sure to be their open support for the January 6 insurrection.