As Cheshire Medical Center continues to deal with the Monadnock Region’s ongoing surge in COVID-19 cases, some have wondered why the Keene hospital doesn’t offer monoclonal antibody treatment for outpatients, which has helped halt progress of the disease.
Dr. Aalok Khole, an infectious-disease physician at the Dartmouth-Hitchcock Health affiliate, said the decision made in the fall was based on the capabilities of the hospitals within the health system, as well as ongoing staffing constraints.
Cheshire Medical and Dartmouth-Hitchcock Medical Center in Lebanon are the only two hospitals within the 10-hospital Dartmouth-Hitchcock system with ICUs able to take care of the increasing numbers of seriously ill COVID-19 inpatients seen statewide, according to Khole.
Because of this, he said the system decided to send its COVID-19 inpatients primarily to one of those two hospitals, while Alice Peck Day Hospital in Lebanon agreed to serve as the system’s site for outpatients to receive the labor-intensive monoclonal antibody treatment.
Khole said Cheshire Medical had the treatment available for a short time in Keene last year.
“We had a clinic up and running in the summer of 2021 but delta had not come to the fore yet and hence we never ended up using it ...,” Khole said. “D-HH as a system began to discuss operationalizing this in September 2021 and [Alice Peck Day] went live with the clinic in the first week of October.”
Monadnock Community Hospital in Peterborough, which is not part of the Dartmouth-Hitchcock system, is the only local hospital to offer the treatment.
Monoclonal antibodies (mAb), used on outpatients, are laboratory-produced molecules that act as substitute antibodies that can restore, enhance or mimic the immune system’s attack on cells.
This means mAb treatment — which has received emergency-use authorization from the Food and Drug Administration — can block the virus from entering cells in the body and limit the amount of virus within the body, leading to milder symptoms and a decreased risk of hospitalization.
The goal of this treatment is to prevent people with COVID who are at high risk of getting very sick from needing hospitalization, such as those with underlying medical conditions. Adults and children at risk with mild-to-moderate COVID-19 are able to receive this treatment following a positive test result.
Khole said offering mAb — which is typically administered intravenously — involves a lot of logistics.
When someone tests positive for COVID-19, staff needs to determine whether they can be treated as an outpatient or if their illness is severe enough to require hospitalization. Once it’s determined someone can be an outpatient, they then need to be assessed to see if they have an increased risk for developing a severe illness, and, if so, to see if they meet other criteria for mAb.
“Then comes the piece about operationalizing a clinic, which needs to have a space, dedicated staff and necessary infection prevention-related input to administer these drugs, coupled with the monitoring time ... ,” Khole said. “So trying to do all of this at a time when things were surging, it was more of a logistical decision.”
Monadnock Community Hospital in Peterborough — which does not have an ICU — offers the treatment to a limited number of its patients, according to Chief Medical Officer Dr. Daniel Perli.
“Situations are reviewed by the primary care provider on a case-by-case basis. Availability of monoclonal infusions are limited, based on supplies that come from the state ... ,” he said in an email. “We highly recommend that all eligible patients be vaccinated and boosted to prevent serious illness from Covid-19.”
The hospital did not clarify after multiple requests from The Sentinel why they are able to offer the treatment.
However, the N.H. Hospital Association said there are a variety of reasons why a hospital may or may not provide mAb treatment.
“[I]t could be related to bandwidth, clinical resources, pooling resources to provide monoclonal antibody treatments across a health system, or that some new monoclonal antibody treatments being considered [have] scarce resources and not widely available, making the hospitals’ ability to provide the monoclonal antibody treatments unsustainable,” the association said in a statement to The Sentinel.
In the coming weeks, Khole said Cheshire Medical may be able to offer mAb after all, as well as COVID-19 treatment pills — another option for outpatients — recently given emergency authorization by federal officials, but nothing is set in stone yet.
He explained that, given the rising demand for treatment as COVID-19 community transmission continues to climb, the hospital felt offering mAb would best serve the community.
“The logistics and operations of the whole process are extremely complex but we have an extremely dedicated and driven workgroup trying to figure this out,” Khole said.
“A lot of work is going on on those fronts,” he said, “but no real final decisions or directions yet.”