Monoclonal antibodies, Nova Scotia's 'Unspent Ammunition'

Part 1: Why I registered for my first COVID briefing

A fixture of the pandemic in most jurisdictions in Canada has been the “COVID briefing”—taking place, almost without fail, weekly but sometimes twice or even three times within a five-day period. Here in Nova Scotia, the briefings have been live streamed, with the Chief Medical Officer of Health, Dr. Robert Strang, appearing along-side the province’s Premier. Earlier on it was Liberal Iain Rankin, and now it’s Conservative Tim Houston. We had an election.

Dr. Robert Strang (on screen) and Premier Tim Houston at January 12th COVID- briefing in Nova Scotia. As Omicron makes its way around the province at a swift pace the briefings are now video conference only and no reporters are allowed in the room. Image provided.

For the most part, I stayed away from the briefings, even though I had a keen interest in writing about the pandemic, and our government’s reaction to it. I just figured the other journalists in the province would be asking the same questions that were coming up for me, so why bother. I penned a few pieces, and over time I noticed that my questions and concerns were different, and that even the act of questioning the messaging coming from Public Health felt verboten.[i]

Back in May of last year, I published this piece in The Halifax Examiner about monoclonal antibody treatments, which were found to work by neutralizing the virus that causes COVID-19 by binding to the spike protein, blocking its attachment and entry into human cells, thereby reducing the severity of symptoms. At the time the article was published, Nova Scotia had 150 doses of bamlanivimab. Health Canada purchased 26,000 doses of the treatment and sent a portion to all the provinces and territories.

In a nutshell, if the IV infusion was provided early enough to the right people—that is to those at high risk of serious outcomes—bamlanivimab could prevent hospitalization and death.

But it wasn’t being used.

In order for you to understand the level of cognitive dissonance I was experiencing at that time, which is partly what fuelled my bull-doggish pursuit of this story, some context is necessary.

The exercise of revisiting, for the purpose of this article, the series of progressively restrictive measures that took place in the province last spring has been enough to produce a negative physical reaction in me, that I can only describe as the manifestation of fear and anxiety: a racing heart, pressure building up in my head, and an internal constriction. Even if you’re one who believes the benefits of lock downs and restrictions on slowing the transmission of the virus outweighs the myriad of collateral harms to society, it is worth remembering the sacrifices Nova Scotians (and Canadians) were asked to make (and continue to be asked to make) to prevent the hospitals from being overwhelmed.

That is the key point here: To prevent the hospitals from being overwhelmed.

By April 13th 2021, the daily case count in Nova Scotia had been in the single digits, no one was in hospital or ICU with COVID, but according to former premier Iain Rankin, there was a need for caution because of the “presence of variants” in New Brunswick. As a result the border restrictions were reinstated. By April 20th, with growing concern about the presence of the more transmissible UK/ ALPHA variant, additional travel restrictions were placed at the border. By April 25th gathering limits were lowered, fines increased, and people were being told not to travel outside of their communities unless it was essential.

In a media release, Rankin said, “We are at a very serious crossroads, the virus is spreading and we need to stop it now.”

As previously mentioned, the rationale that has always been provided in support of the lock downs and restrictions has been to prevent the overwhelming of a health care system, one, incidentally, that had been overwhelmed for years. We were told that keeping people out of the hospitals was paramount.  

On April 27, when more restrictions were announced, Rankin said, “This is not a time for half measures, we need strong, quick action to drive this virus out of our province.”

We were in lockdown again. Retail businesses deemed non-essential were forced to close, we were back to household bubbles, and public and private schools closed across the province. Then a few days later, more restrictions were announced: extended school closures, the border got even tighter, and exemptions that had been in place for funerals and for allowing immediate family members to be with their loved ones at the end of life—something I will never accept as necessary— were removed. Demonstrations protesting the lockdown were also prohibited during this time. The restrictions were extended to second week of June.

At the time, Dr. Robert Strang was quoted saying, “With almost 100 people in hospital, we all have a responsibility to our fellow Nova Scotians to keep them safe and stop that number from getting higher.”

Meanwhile, 150 doses, enough to treat 150 high risk patients were languishing in some fridge somewhere.

‘Unspent ammunition’

Before I continue, I need to provide some background, including the reason why I decided to file Freedom of Information requests with the Nova Scotia Health Authority and the Department of Health and Wellness in the first place. All the details are provided in a lengthy piece posted on my Web site, but here’s what wasn’t making any sense to me.

For my first piece on the subject of monoclonal antibodies I interviewed Dr. Lisa Barrett, an infectious diseases expert and assistant professor at Dalhousie University. Barrett co-chairs the Therapeutics and Prophylactics Advisory Group along with Clinical Infectious Diseases Pharmacist Dr. Tasha Ramsey. This group looks at various drugs and makes recommendations about whether they should be provided in “routine care” or for “pragmatic research” (ie. clinical trials) in the province. At the time of my interview it was my understanding that the province had 50 doses of bamlanivimab, but later, as a result of the FOI, I would find out the province ordered more doses, and had 150 stockpiled. They ended up only using 1 dose in the third wave.

But I’m getting ahead of myself.

In that May interview with Barrett she told me she was initially a “huge advocate” of the treatment, but that as a result of both complex issues related to timing and logistics, the Advisory Group decided that bamlanivimab would not be offered routinely as an early treatment to high-risk patients in the province. With regards to logistics, she explained that one of the main drawbacks of the therapy was that it’s administered by IV outside the hospital.

But even though setting up infusion clinics outside of hospitals might have been a logistical challenge, if the treatment could reduce the risk of hospitalizations and death by up to 85%—a statistic provided by Barrett’s own mentor, Dr. Anthony Fauci—it still seemed like a worthwhile challenge to take up.  

Barrett’s second main reason for not recommending the treatment—one having to do with timing—eventually became the bone that this dog has not been able to let go of.

In addition to the infusion clinic challenges, Barrett also told me in that May interview that during the third wave when the UK/ALPHA variant was dominant in the province, bamlanivimab would not have been effective.

“There’s a difference between the early UK variant and the late UK variants, and the late UK variants are the February/ March ones and those are the ones that we seem to have in Nova Scotia,” she said.

That’s how my first piece on the monoclonals ended. I gave Barrett the last word, and my editor at the time titled the piece:

But here is where it starts to get murky. In an email sent to me after the May article was published, the drug’s manufacturer, Eli Lilly, wrote and called into question Barrett’s assertion that the “late UK variant” was here in the province during the third wave. A spokesperson for the company wrote:

There are reports of some pockets, in some parts of the world, where additional mutations (such as the E484K mutation) which have the potential to alter their neutralization-sensitivity profile, have been seen in the UK variants. However, these reports are very rare, and there is no strong evidence of a significant presence of these “new UK variants” in North America. Based on data publicly available on Canadian and provincial databases, there are no reports of such variants in circulation here at this time.

Upon receiving this email I did three things: I filed a number of FOI requests to obtain the minutes of the Advisory Group and the COVID Network meetings, to see if there was any mention of this “late” UK variant rendering bamlanivimab ineffective.

I also turned to the federal government’s Health Infobase data (for April 5th) on variants of concern (VOC)—which I found out later was also circulated among the Advisory Group members—and it revealed that the B.1.1.7/ UK variant was the most prevalent variant of concern (VOC) in Canada, comprising more than 92% of all VOCs publicly reported. No mention of a “late” UK variant.

I also tried to talk to Barrett. I made numerous attempts to reach out to her, to provide her with the opportunity to respond to Eli Lilly’s statement and help shed light on how she or the Advisory Group made the determination that the treatment was essentially useless. Did she just make a mistake? Possible, we all make them. Or was there some other explanation? I didn’t know because a response was never received.

A few months later I received a package of the minutes, and discovered that nowhere in the un-redacted sections of the minutes was there any mention of a “late” UK variant circulating in the province during the third wave. In fact, in an April 29 email, Ramsey (who co-chairs the Advisory Group with Barrett) states that bamlanivimab “maintains activity against the B.1.1.7 [UK] variant and that is our predominant variant at the moment.”

Having to register for a COVID briefing was looking more and more likely.

[Stay tuned for Part 2 in the series]

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[i] During the pandemic I wrote a number of pieces including this one about how the pandemic pushed back the curtain on decades of austerity, which left Canadians and the health care system more vulnerable. It’s still very relevant, given how the health care system seems to be on the verge of implosion now. I also wrote two pieces – here and here – focusing on civil liberties, COVID restrictions, mobility rights, and the Charter Rights and Freedoms – as well as this Q&A with Ed Mills, principal investigator with the Together Trial, which looked at using re-purposed drugs including ivermectin and fluvoxamine as an early treatment for COVID. The three pieces written on monoclonal antibodies can be found here, here, and here.