A Proposed Lottery System to Allocate Scarce COVID-19 Medications: Promoting Fairness and Generating Knowledge | Clinical Pharmacy and Pharmacology | JAMA | JAMA Network
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June 24, 2020

A Proposed Lottery System to Allocate Scarce COVID-19 Medications: Promoting Fairness and Generating Knowledge

Author Affiliations
  • 1Program on Ethics and Decision Making in Critical Illness, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
  • 2University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
  • 3Associate Editor, JAMA
JAMA. 2020;324(4):329-330. doi:10.1001/jama.2020.11464

On May 1, 2020, the US Food and Drug Administration (FDA) issued an Emergency Use Authorization for the unapproved drug remdesivir to treat hospitalized patients with severe coronavirus disease 2019 (COVID-19). The authorization was based on a preliminary report from a randomized clinical trial in 1063 patients that found that remdesivir shortened the median time to recovery from 15 days to 11 days.1 Anticipating immediate worldwide demand, the maker of remdesivir, Gilead Sciences, donated 1.5 million doses of remdesivir to countries affected by the pandemic, including the US, which received 607 000 doses (enough to treat approximately 100 000 patients). However, the US and other countries have 2 major problems related to this drug. First, the supply of remdesivir is insufficient to treat all eligible patients, which has required hospitals to ration the drug.2 Second, there remain major gaps in knowledge about the efficacy of remdesivir, including whether it reduces mortality and what subgroups of patients may benefit the most.

These problems are not specific to remdesivir or to the current pandemic: governments and health systems will predictably encounter situations during pandemics in which novel therapeutics are in short supply and knowledge about their harms and benefits is limited. Promising results from clinical trials of convalescent plasma,3 monoclonal antibodies, or other experimental drugs will put pressure on the FDA to emergently authorize use in the face of incomplete knowledge about efficacy and insufficient supply. Without careful planning, the rollout of such emergency authorizations risks unfair drug allocation and missed opportunities to learn more fully about the effects of these medications.

When there is an insufficient supply of newly approved antiviral agents (including remdesivir), the drug should be allocated to patients using a lottery system overseen by state health departments. In this model, states would create a central registry into which hospitals report the demographics and clinical outcomes of all patients entered into the lottery, including those who are not allocated the drug. This approach could simultaneously accomplish fair allocation (via the lottery) and rapid learning, because the lottery creates a natural experiment4 that achieves random allocation in which some patients receive the drug while others do not; researchers can use the lottery’s registry to assess the effectiveness of the scarce drug.

Critique of the US Response to the Remdesivir Shortage

The initial federal and state allocation of remdesivir has 2 major problems: unfair allocation of the drug to patients and missed opportunities to generate new knowledge that could reduce morbidity and mortality. After a largely unsuccessful attempt by the US Department of Health and Human Services (DHHS) to distribute remdesivir to hospitals across the country, the DHHS delegated this responsibility to state health departments.5 Some states provided no guidance to hospitals about how to select among eligible patients when the supply was insufficient for all patients, whereas others provided guidance that is ethically problematic.

For example, the New Jersey Remdesivir Advisory Committee advised that “remdesivir [should] be used in eligible patients on a first-come, first-served basis.” Similarly, the Minnesota Department of Health created 2 tiers of priority based on the severity of patients’ respiratory failure, then instructed hospitals that “no courses…should be held in reserve for future use. All courses should be immediately allocated.” First-come, first-served approaches disadvantage patients with poor health care access, such as individuals with disabilities who require special travel arrangements to reach the hospital. These approaches also render states unable to accomplish important ethical goals of public health, such as prioritizing patients most likely to benefit, or mitigating the disproportionate effects of COVID-19 on disadvantaged groups and essential workers.

The second major problem with the US government’s response is the absence of a plan to use the government’s supply of remdesivir to gain additional knowledge about its effectiveness. The FDA’s Emergency Use Authorization for remdesivir requires hospitals to report only serious adverse events that are potentially attributable to remdesivir. This minimal reporting requirement misses an opportunity to collect outcome data that would shed light on several pressing questions, such as whether remdesivir has an overall mortality benefit and whether certain clinical subgroups are more likely to benefit than others (eg, patients with mild vs severe hypoxemia).

A Centralized Lottery System

The allocation of scarce COVID-19 drugs should occur via a lottery system overseen by individual state health departments. Oversight by states, rather than the federal government, is appropriate because medical practice is regulated by states and because states have local health officers who could coordinate such activities. As part of participating in the lottery, health systems would report information on all patients entered into the lottery, not just those who ultimately receive the drug.

In practical terms, implementing a central lottery system would be relatively straightforward. States would determine the lottery’s baseline treatment probability for individual patients based on the number of available courses of remdesivir and epidemiological projections of the number of cases expected in the state over the period the supply of drug is supposed to last. When treating clinicians in a hospital identify a patient who is eligible to receive remdesivir, rather than appealing to a hospital-based committee for allocation of the drug, they would instead make the request to the state health department via telephone or an online portal. The clinicians would provide demographic and clinical information about the patient, which would be entered into a registry covering the entire state. A state health officer or designee would verify that a patient meets eligibility requirements for remdesivir, conduct the lottery using a random number generator, and inform the treating clinicians whether the patient can receive remdesivir. If so, the state would authorize the release of the drug to the patient. To achieve rapid distribution, the drug could be held in numerous regional locations across the state. Hospitals would report patients’ clinical outcomes at death or hospital discharge to the registry, which could be made available to researchers for analysis after enough patients are included.

Although the purpose of the lottery is to fairly distribute a scarce public resource, a secondary benefit is that the lottery creates randomization, which balances known and unknown confounders across patients who receive or do not receive remdesivir. In essence, the lottery creates a natural experiment that could be leveraged by researchers to make causal inferences about the effect of a factor outside their control (eg, the medication lottery) on patient outcomes in a situation resembling an actual experiment.4 Research leveraging previous lotteries in society has yielded important scientific insights, such as the Vietnam Draft Lottery and the effect of military service on lifetime income.6

Conducting the lottery at the state level, rather than having many individual hospitals conduct hospital-level lotteries, could allow rapid accrual of a large number of patients, providing greater statistical power to assess the effectiveness of remdesivir among clinical subgroups. If needed, researchers could pool data from multiple states to enhance statistical power.

There is precedent for using the occurrence of drug scarcity to advance scientific knowledge. The first published randomized clinical trial occurred in similar circumstances in the late 1940s. Small nonrandomized studies of streptomycin for pulmonary tuberculosis had yielded encouraging but inconclusive results; manufacturing challenges limited the amount of streptomycin that the British government could procure such that not all patients in need could receive it.7 Therefore, a team led by Bradford Hill used randomization to fairly allocate the scarce streptomycin and to rigorously evaluate its efficacy, which ultimately proved effective in reducing mortality from pulmonary tuberculosis.8

A major advantage of lottery systems is that even though they introduce randomness, they need not provide the same chances to all patients. Instead, to achieve public health goals, states can use a weighted lottery to give increased priority to certain groups, such as those most likely to benefit and those who have been disproportionately harmed by the pandemic. For example, the Commonwealth of Pennsylvania recently endorsed a weighted lottery system developed at the University of Pittsburgh that gives increased chances to receive the scarce treatment to essential workers and individuals from economically disadvantaged areas.9 A strength of a central lottery, compared with hospital-level lotteries, is efficiency. State-level lotteries could significantly decrease the administrative burden for the thousands of hospitals in the US that would otherwise need to develop and administer a scarce drug allocation protocol.

Response to Potential Criticisms

Administering the centralized lottery would require additional effort by state agencies. However, the time and expense to do so is relatively small compared with the magnitude of potential benefit derived from a program that ensures fair allocation and allows greater knowledge about the drug’s effectiveness. The data obtained from the lottery are not immune to the weaknesses of natural experiments, such as lack of blinding, but there are accepted strategies to mitigate the weaknesses, such as relying on outcomes that are unlikely to be influenced by knowledge of treatment (eg, mortality).4 Some may assert that the proposed lottery would require patient-level consent for research. However, the lottery is not a research maneuver; it is a public health intervention to fairly allocate a scarce resource that creates a type of natural experiment.

Conclusions

If state health departments had instituted lotteries with registries to allocate the first shipments of remdesivir in May 2020, substantially more information about the effectiveness of remdesivir would likely be available now. Implementing central lotteries paired with registries of clinical outcomes could simultaneously allow fair allocation of scarce COVID-19 medications and facilitate knowledge generation that could reduce morbidity and mortality during the pandemic.

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Article Information

Corresponding Author: Douglas B. White, MD, MAS, Program on Ethics and Decision Making in Critical Illness, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace St, Scaife Hall, Room 608, HPU010604, Pittsburgh, PA 15261 (douglas.white@pitt.edu).

Published Online: June 24, 2020. doi:10.1001/jama.2020.11464

Conflict of Interest Disclosures: Dr White reported receipt of personal fees from the American Thoracic Society and UpToDate Inc. No other disclosures were reported.

Funding/Support: Dr White received funding for this work from National Institutes of Health grant K24 HL148314.

Role of the Funder/Sponsor: The National Institutes of Health had no role in the preparation, review, or approval of the manuscript or the decision to submit the manuscript for publication.

References
1.
NIH clinical trial shows remdesivir accelerates recovery from advanced COVID-19. National Institute of Allergy and Infectious Diseases website. Published April 29, 2020. Accessed June 1, 2020. https://www.niaid.nih.gov/news-events/nih-clinical-trial-shows-remdesivir-accelerates-recovery-advanced-covid-19
2.
Evans  M, Walker  J. Hospitals are rationing remdesivir. Wall Street Journal. Published May 22, 2020. Accessed June 16, 2020. https://www.wsj.com/articles/location-plays-big-role-in-patient-access-to-first-covid-19-drug-11590157424
3.
Li  L, Zhang  W, Hu  Y,  et al.  Effect of convalescent plasma therapy on time to clinical improvement in patients with severe and life-threatening COVID-19: a randomized clinical trial.   JAMA. Published online June 3, 2020. doi:10.1001/jama.2020.10044PubMedGoogle Scholar
4.
Dunning  T.  Natural Experiments in the Social Sciences: A Design-Based Approach. Cambridge University Press; 2012. doi:10.1017/CBO9781139084444
5.
Ison  MG, Wolfe  C, Boucher  HW.  Emergency Use Authorization of remdesivir: the need for a transparent distribution process.   JAMA. 2020. doi:10.1001/jama.2020.8863PubMedGoogle Scholar
6.
Angrist  JD.  Lifetime earnings and the Vietnam draft lottery: evidence from Social Security administrative records.   Am Econ Rev. 1990;80(3):313-336.Google Scholar
7.
Yoshioka  A.  Use of randomisation in the Medical Research Council’s clinical trial of streptomycin in pulmonary tuberculosis in the 1940s.   BMJ. 1998;317(7167):1220-1223. doi:10.1136/bmj.317.7167.1220PubMedGoogle ScholarCrossref
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 Streptomycin treatment of pulmonary tuberculosis.   Br Med J. 1948;2(4582):769-782. doi:10.1136/bmj.2.4582.769PubMedGoogle ScholarCrossref
9.
White  DB, Schmidhofer  M, McCreary  M,  et al. A Model Hospital Policy for Fair Allocation of Scarce Medications to Treat COVID-19. Published May 28, 2020. Accessed June 5, 2020. https://ccm.pitt.edu/node/1133
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    4 Comments for this article
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    Mischaracterization of Minnesota's Allocation Framework & the Structure of the Remdesivir Allocation Problem
    Susan Wolf, J.D. | University of Minnesota
    This article incorrectly characterizes Minnesota’s framework for ethical allocation of remdesivir, revealing a larger error in the article’s analysis. The authors assert that Minnesota has allocated the drug on a “first-come, first-served” basis. The Minnesota framework explicitly rejects that approach, stating, “Allocation decisions should not consider or be based upon:… First-come, first-served.…” (1) Instead, as our related article says, “Minnesota’s remdesivir guidance prioritized those at greatest risk of mortality and serious morbidity, as well as those who stood to benefit from access to the drug.” (2) Drug supply will eventually be exhausted for a given shipment (as it would under a lottery system), but that does not make Minnesota’s allocation by clinical criteria a “first-come, first-served” system. Moreover, withholding the drug from a current patient for a future one raises serious ethical issues.

    The JAMA article’s mischaracterization reveals a further problem. By assuming that Minnesota’s effort to fully allocate available remdesivir without holding any in reserve will deny drug to later-arriving patients, the article ignores the fact that remdesivir has been sent to states in successive shipments. The article mistakenly treats remdesivir allocation as a one-time allocation problem. In Minnesota, allocation of each shipment is based on prioritizing those at greatest risk and those who stand to benefit, under then-prevailing evidence. (1,2) Allocation is thus determined by clinical criteria, or randomization if the number of patients in a priority category exceeds supply. It makes no difference whether a patient presents at 9 a.m. or 11 p.m., as long as the shipment holds out or another shipment has arrived.

    In contrast to the lottery proposal, Minnesota’s approach strives to be responsive to evolving evidence. The JAMA article would lump together for a lottery all patients meeting the broad eligibility criteria in the FDA’s Emergency Use Authorization (EUA) for remdesivir issued May 1. Instead, Minnesota has considered the EUA plus the subsequently published evidence on which patients are likely to benefit, refining the allocation framework over time. (1,2) A fundamental ethical goal has been to “protect the population’s health by reducing mortality and serious morbidity.” (1)

    ● Susan M. Wolf, JD, Law School & Medical School, University of Minnesota, Minneapolis, MN.
    ● Sarah Lim, MBBCh, Minnesota Department of Health, St. Paul, MN.
    ● Debra A. DeBruin, PhD, Center for Bioethics & Department of Medicine, University of Minnesota, Minneapolis, MN.

    References:
    1. Minnesota Department of Health. Ethical Framework for Allocation of Remdesivir in the COVID-19 Pandemic. Updated June 17, 2020. https://www.health.state.mn.us/diseases/coronavirus/hcp/remdesivir.pdf. Accessed June 25, 2020.
    2. Lim S, DeBruin DA, Leider JP, et al. Developing an ethics framework for allocating remdesivir in the COVID-19 pandemic. Mayo Clin Proc. Published online June 10, 2020. doi: https://doi.org/10.1016/ j.mayocp.2020.06.016.
    CONFLICT OF INTEREST: The authors collaborated with others in writing and refining the Minnesota framework for remdesivir allocation. S.M.W. and family members own shares in Vanguard Health Care ETF; this fund included Gilead Sciences Inc. among its 430 stock holdings listed as of May 31.
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    We Should Not Use Lotteries For Pandemic Treatments
    Maurizio Balestrino, MD | University of Genoa, Italy - Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Mother and Child Sciences
    White and Angus propose to allocate possible future scarce drugs using a lottery to (1) guarantee fair allocation of the medicine and (2) set up a randomization system that could be exploited to learn about effectiveness of the drug by using excluded patients as controls. They quote the 1948 trial of streptomycin in tuberculosis as a precedent (1). Moreover, they warn that such lottery should be “weighted” in order not to provide the same chances to all patients. As an example, they quote a provision that a state actually made to give the drug preferentially to “individuals from economically disadvantaged areas”.

    While I agree with some of their statements, it seems to me that their viewpoint has important shortcomings.
    First, it unduly introduces the term “lottery”, which is misleading, inappropriate, and unnecessary. It is misleading because it makes people think of trivial and money-related issues, which is not really what the authors advocate nor what should be done in an emergency. It is inappropriate because a “lottery” does not provide blindness. As the authors themselves point out, a trial without blindness is insufficient to reach clearly the desired conclusions. It is unnecessary because there is already a scientifically accepted term for randomly allocating treatments, i.e. “randomization”. In fact, the 1948 investigation that the authors quote never speaks of any “lottery” (2). Instead, it uses the term “random” (“Determination of whether a patient would be treated by streptomycin and bed-rest (S case) or by bed-rest alone (C case) was made by reference to a statistical series based on random sampling numbers…” ).

    Moreover, the authors call for adjustments of the randomization in order not to give everybody the same chances. Surprisingly, the authors do not even mention that any provision to reduce randomness would also reduce the quality of the study. Not only that, they endorse a situation that really occurred where treatment was allocated preferentially to “individuals from economically disadvantaged areas”. Allocating a life-saving resource based on the economic status of the recipients is, to put it mildly, unjust.

    Summing up, I agree with the authors that scarce, off-label, possibly life-saving resources might be allocated randomly, and that such randomness should be exploited to learn about drug effectiveness by using excluded patients as controls. However, I find fault with the term “lottery” and take a stand against reducing randomness, especially if based on the economic status of the recipients. The accepted and time-honored scientific term “randomization” should be used instead, even in presentations to nonprofessionals.

    REFERENCE

    (1) Group BMJP. Streptomycin Treatment of Pulmonary Tuberculosis: A Medical Research Council Investigation. Br Med J. 1948;2(4582):769-782. doi:10.1136/bmj.2.4582.769
    CONFLICT OF INTEREST: None Reported
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    Health Lotteries in Conflict with Human Rights
    Daniel Campagne, Ph.D. | Universidad Nacional de Educación a Distancia, Madrid, Spain
    White and Angus propose a “Lottery System to Allocate Scarce COVID-19 Medications”. In their article's reference 7, Yoshioka et all noted that the 1948 “lottery” was a one-time setup for verifying the efficacy of recently discovered streptomycin in a national tuberculosis pandemic in Great Britain. However, that streptomycin trial took place in 1946 and 1947, well before the United Nations’ Universal Declaration of Human Rights (December 10, 1948).

    Any randomized allocation for medical treatment is in conflict with relevant human rights. “Randomization“ in pandemic situations retains a large relative component, and subjective criteria have possibly decisive roles in
    the classification of patient, condition, and available means.

    A moral problem is manifest in present direct or indirect “triage” instructions to medical professionals in most countries where COVID-19 patients over a certain age were not hospitalized but treated (and died) at home or in their geriatric residence, an aspect of global elder mistreatment. The question is: who decides, and on what authority?

    Rights to health and health care are universal human rights. A health lottery would constitute an infringement of fundamental rights. Importantly, physicians should not be the judge of what category of patients or what individual should receive an available but scarce treatment. Physicians and other medical professionals are speaking out against their unwanted role in triage, or lottery. The matter of who decides has become a political issue, although politicians do not admit this publicly and as yet no legislation explains a moral justification of triage. The argument that a lottery system would produce interesting study data is morally unconvincing.

    Still, scarce means or medications do need an allocation system. But that system has to be perceived as just. This depends on the randomization model used. However, any necessary qualifying stage(s) before admission (or not) to treatment has hidden biases, making the system not completely random. Accountability is a novel and promising angle to triage that should be considered. A person should be held responsible for the health consequences of an unhealthy lifestyle that is knowingly maintained notwithstanding available alternatives.

    The patient is personally responsible for health problems on account of lifestyle. Compare the rights to treatment of a 30 year old who blatantly ignored lockdown or social distancing and knowingly exposed themselves to contagion risk, with those of a 60 year old who took all the precautions but was infected anyhow? Health or security workers are an example of that last category, so are the elderly in general. A just system would triage in favor of the second.

    The WHO and UNESCO defined health risks of lifestyle and the necessary actions to curb the enormous drain on resources from self-caused health problems, manifest as Non Communicable Diseases (NCD). The four main risk categories are tobacco use, physical inactivity, the harmful use of alcohol and unhealthy diets, which translate into a disease burden per risk factor where lifestyle is decisive. In COVID-19 we see the impact of this very communicable disease substantially aggravated by NCD’s.

    Smoking, alcohol misuse, overweight and sedentary lifestyle are voluntary. If a person freely chooses such a lifestyle, then that should affect his or her status when requiring scarce medical treatments. Our first objective should lie in reducing unhealthy lifestyle .
    CONFLICT OF INTEREST: None Reported
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    Response to Professor Wolf and Colleagues
    Douglas White, MD, MAS (1,2); Derek Angus, MD, MPH (1) | (1) Department of Critical Care Medicine, University of Pittsburgh School of Medicine; (2) Center for Bioethics and Health Law, University of Pittsburgh
    We thank Professor Wolf and colleagues for their engagement with our JAMA Viewpoint. We would like to respond to their main points and also to highlight an implication of their comments: the critical need for improved coordination between drug manufacturers and governments when allocating scarce COVID-19 medications.

    Wolf and colleagues contend that we characterized the Minnesota allocation framework as a first-come, first-served approach. This was not our intention. We described the framework as one that assigns patients different priority based on clinical criteria, then directs that all courses of the drug should be used immediately, with none saved for
    eligible patients who present later. The concern we attempted to raise in our Viewpoint is that, when applied in situations of actual scarcity, this approach has a similar limitation to first-come, first-served strategies: patients who present to care sooner (i.e., in the days after a hospital receives a remdesivir shipment) will be more likely to receive the drug than patients who present on later days. 

    For example, consider a hospital in Minnesota that received shipments of remdesivir on May 20, June 2, and June 16, 2020, each containing 15 treatment courses.  If the hospital admitted 15 eligible patients over the first three days of drug availability (e.g., May 20-22), all 15 treatment courses would be allocated to these patients, leaving no drug available for patients who presented from May 23 to June 1, before another shipment of remdesivir arrives. 

    Why is this problematic? In addition to concerns that it may disadvantage patients with barriers in access to care, it hamstrings the state’s ability to achieve their stated public health goals. Specifically, Minnesota understandably sought to increase the number of lives saved by giving heightened priority to patients with less severe respiratory insufficiency over patients with acute respiratory failure requiring mechanical ventilation. However, the state’s directive to use all drug immediately means that allocation outcomes are at the mercy of the characteristics of the patients who happen to be in the hospital in the days immediately after the drug arrives. If the inpatients at the time the drug arrives are mostly intubated patients with severe respiratory failure, then those patients will receive the bulk of the drug, which runs counter to the state’s goal of prioritizing patients with less severe respiratory disease. In other words, patients in the lower priority group who are admitted on the day the remdesivir arrives will be more likely to receive the drug than patients in the high priority group admitted a few days later when the drug supply is exhausted. Wolf and colleagues also contend that we “mistakenly treat remdesivir allocation as a one-time allocation problem” and “ignore the fact that remdesivir has been sent to states in successive shipments”. However, we were fully aware of the serial nature of remdesivir shipments when we wrote the JAMA viewpoint. Serial shipments do not solve the problem inherent in an allocation strategy that require all treatment courses to be used immediately: immediately allocating all courses of the drug undercuts the state’s ability to direct treatment to high priority groups.

    Wolf and colleagues claim that our lottery proposal is flawed because it “lump[s] together for a lottery all patients meeting the broad eligibility criteria in the FDA’s Emergency Use Authorization (EUA) for remdesivir issued May 1.”  However, we made this choice based on the input of an expert group of physicians, trialists, and biostatistician, who felt there was inadequate evidence to conclude that one clinical subgroup benefitted from remdesivir more than another. The authors of the largest remdesivir trial to date expressed similar reservations about drawing conclusions of differential benefit across disease severity because of low rates of outcome adjudication in patients with severe disease at the time the results were published in the NEJM.

    This uncertainty about differential efficacy across subgroups was a main reason we proposed centralized lotteries at the state level: to generate randomized evidence to reduce the residual uncertainty about which patients will most benefit from the drug. 

    In practice, using a lottery allowed us to extend the time period of remdesivir availability and to reliably direct more treatment to high priority groups, which is crucial to achieving public health goals during a pandemic. For example, in mid-May, there were about 4.5 eligible COVID patients per day in our health system and we received 16 courses of remdesivir from the Pennsylvania Department of Health. If we had used an allocation strategy that required all courses to be distributed immediately, the time period of remdesivir availability would have been about 3.5 days, because we would have dispensed all 16 courses of the drug to the first 16 patients who met criteria, regardless of whether they were a high or low priority group. However, the lottery allowed us to extend the time period of remdesivir availability to 14 days and preferentially provide the drug to patients in the state’s high priority groups.2 

    A diverse group of community representatives in Pittsburgh endorsed the lottery allocation framework we developed, which was incorporated into the statewide allocation recommendations from the Pennsylvania Department of Health.

    Wolf and colleagues’ comments highlight a critical area for improved coordination between governments and drug manufacturers: providing clarity to hospitals about the timing of shipments of scarce COVID-19 medications. Uncertainty around the timing of shipments of remdesivir made it more challenging to implement a lottery because of the need to estimate how long the supply of the drug needed to last.  Consequently, some planners may have felt that the lack of definitive dates of future shipments was an insurmountable barrier to using a lottery. However, we concluded that we had adequate clarity about the soonest date that the next remdesivir shipment would arrive, and we based our lottery parameters off that information. Nonetheless, official announcements from Gilead or the U.S. government providing a schedule for the remdesivir shipments would have added clarity and certainty. To maximize public health outcomes, it is critical that states and hospitals receive clear information about the timing of shipments of scarce COVID-19 medications.

    Douglas B. White, MD, MAS
    Department of Critical Care Medicine; University of Pittsburgh School of Medicine
    Center for Bioethics and Health Law; University of Pittsburgh

    Derek Angus, MD, MPH
    Department of Critical Care Medicine; University of Pittsburgh School of Medicine REFERENCES

    1. Beigel JH, Tomashek KM, Dodd LE, et al. Remdesivir for the Treatment of Covid-19 - Preliminary Report. N Engl J Med. 2020.

    2. https://www.health.pa.gov/topics/disease/coronavirus/Pages/Guidance/Ethical-Allocation-Framework.aspx Accessed July 10, 2020.



    CONFLICT OF INTEREST: None Reported
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