Why do some resist COVID vaccines but embrace monoclonal antibodies?

NASHVILLE, Tenn. — As the delta surge struck all corners of Tennessee, briefly lifting the state’s coronavirus outbreak to the worst in the nation, millions of Tennesseans continued to spurn vaccines that are proven safe, effective, free and easy to get.

But many of these same residents have flocked to a different virus defense that is inferior by just about every important measurement, even according to its own advocates.

Monoclonal antibody treatment, while also safe and effective against COVID-19, provides protection that is temporary, less adaptable, harder to access and far more costly for taxpayers, and sometimes, patients themselves. The treatment only works in a narrow window after symptoms arise, and may in time become less effective if overused.

And yet Tennessee used so many monoclonal antibody drugs in recent months it contributed to federal officials capping shipments to states to preserve supplies. This prompted state officials to recommend the drugs be largely reserved for unvaccinated residents at most risk.

The duality between coronavirus vaccination and monoclonal antibody treatment is the latest puzzle of a politicized pandemic and a powerful illustration of the damage done by a relentless misinformation campaign against vaccination. Many vaccine-hesitant Americans, most of whom lean conservative, remain distrusting of the best defense against the virus but embrace a treatment developed by the same pharmaceutical industry, subjected to the same scientific scrutiny and authorized by the same federal agencies under the same political administration.

Related: Tennessee recommends vaccinated residents lose access to monoclonal antibody treatment for COVID-19

To the ears of a layperson, both technologies sound like the dizzying machinations of science fiction. But many are only afraid of one.

“For the people who are wary of the vaccine, if there was any rationality to their approach, they’d be wary of the monoclonals too,” said Dr. James Hildreth, president of Meharry Medical College and an expert on monoclonal antibodies. “People tell me over and over again that ‘I don’t want the vaccine because I don’t know what’s in it.’ Well, you don’t know what’s in the monoclonal antibody vial either.”

Hildreth is one of the people who truly understand what’s in that vial. He studied medicine at the University of Oxford under Sir Andrew McMichael, a renowned immunologist knighted for his research on viruses, who in turn studied under César Milstein, a biochemist who won the Nobel Prize for his role in developing monoclonal antibodies in the ‘80s. Hildreth’s research at Oxford helped develop monoclonal antibodies in the drug Raptiva, which was once used to treat psoriasis.

Monoclonal antibody technology has improved by “light years” since then, Hildreth said, and laboratories can now synthesize antibodies to fight COVID-19 on a scale that was once impossible.

But the tech remains prohibitively expensive, inaccessible to much of the globe and is ultimately incapable of stopping the pandemic, he said.

“There is no way in the world that we can imagine treating hundreds of millions of people with monoclonal antibodies,” Hildreth said. “The reality is we either let people get infected, and then many die to achieve herd immunity, or we vaccinate the planet. Monoclonal antibodies can not possibly be viewed as a substitute to that.”

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Monoclonal antibodies give a man a fish. Vaccines teach.

Monoclonal antibody technology is used to mass produce specifically selected human antibodies in a laboratory, then give those antibodies to patients either by injection or infusion. Unlike a vaccine, the drugs do not teach the body to develop its own antibodies. Instead, they provide a temporary defense that can minimize an infection.

To lean on a cliché, antibody drugs will give a man a fish.

Vaccines will teach him to fish.

The Food and Drug Administration last year granted two pharmaceutical companies, Regeneron and Eli Lilly, emergency use authorization to produce monoclonal antibody cocktails for use against the coronavirus. The drugs are bought by the federal government for about $2,100 per dose (vaccines cost about $20) then are distributed to states for use at hospitals and clinics.

The scientific review procedure that authorized these antibody drugs is the same process that was subjected to the vaccines, which were also granted emergency use authorization. Since the Pfizer vaccine was granted full approval in August, the antibody drugs now have a lesser stamp of approval than one of the vaccine options.

Dr. Karen Bloch, medical director of the antibody clinic at Vanderbilt University Medical Center, which was recently infusing as many as 80 patients a day, said she believed there is a false perception among many that the technology behind the vaccines is newer and therefore less trustworthy.

Both the vaccines and the antibody drugs are the result of decades of research adapted for use against the pandemic.

“And on a molecular basis in terms of antibodies, and in their level of approval, I would say they’re both fairly similar,” Bloch said. “The Pfizer vaccine has, in some ways, been vetted and approved just a bit more. Right now, the status of the monoclonal antibodies is identical to the J&J or Moderna vaccines.”

So the difference, it seems, is misplaced fear. Public polling, conducted across the country, shows many Americans are afraid of vaccines they believe were rushed and are more dangerous than the virus itself. In reality, serious complications from the vaccines are rare and treatable, while the virus has killed 4.7 million people worldwide.

Others eschew the vaccine because it uses messenger RNA to teach the human body how to develop COVID-19 antibodies, which has been widely – but falsely – likened to genetic manipulation or mad science.

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But there is far less outcry over how monoclonal antibody treatment was developed with some use of cell lines derived from an aborted human fetus or lab-grown proteins extracted from genetically engineered mice.

“If you are trying to weigh the pure (complexity,) the gist is monoclonal antibodies are far more on the cutting edge than the vaccine,” said Dr. Alex Jahangir, leader of Nashville’s coronavirus task force. “But it all comes down to the misinformation campaign, which has been so effective, typically from the right.”

Jahangir, a Vanderbilt trauma surgeon, said Tennesseans who reject vaccines and welcome antibody treatment are not unlike trauma patients who refuse to wear a seat belt and require invasive surgery after a car crash.

But neither seat belts, nor monoclonal antibodies, are the subject of targeted disinformation. There are no influential voices arguing that either are ineffective, toxic, sterilizing, or part of a grand plot for population control.

Vaccines face all these false claims. And, if left unchallenged, people believe them, Jahangir said.

“Five years ago, we were all kind of laughing that Jenny McCarthy was hyping anti-vax stuff,” Jahangir said. “We can’t let that pass now anymore. We’ve got to call out Tucker Carlson. We’ve got to help people get information from sources that are valid. There is not a ‘two-sides-to-the-story’ on a lot of these issues anymore.”

Trump: Antibody drugs 'more important' than the vaccine

To understand the divergence between COVID-19 vaccines and monoclonal antibody treatment, it helps to start with the origin of so many other divisions in this country – former President Donald Trump.

Both the vaccines and antibody treatment were authorized by the Trump Administration. But Trump only championed one of them.

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Last October, when Trump contracted COVID-19 and was hospitalized with severe illness, he was given Regeneron’s antibody cocktail, which at the time was experimental and almost entirely unavailable to the general public.

Then Trump promoted the drug as something it is not – “a cure.”

“They call them therapeutic, but to me it wasn’t therapeutic, it just made me better. I call that a cure,” Trump said in a video message on Oct. 7. "So I want to get these things done. We have to get them approved. And I want to get them to the hospitals where people are feeling badly. That’s much more important to me than the vaccine.”

Trump also got the COVID-19 vaccine but did not tout it with any of the same enthusiasm. He was quietly vaccinated at the White House in January and did not confirm his vaccination status until after he left office. Trump did not encourage his supporters to get vaccinated until February – squeezing a brief recommendation between jabs at his successor – and since then has only occasionally urged vaccination.

And Trump was booed by his own supporters when he recommended vaccination at a rally in August. One week later, he put out a statement he “probably won’t” get a vaccine booster shot in a move that many believe will only worsen vaccine hesitancy.

Once Trump set the tone, it was amplified by powerful voices on the right. Fox News hosts Carlson and Laura Ingraham, influential figures in conservative media, have dedicated hours of their shows to commentary that discourages vaccination. Similar messages swirl down through the echo chambers of conservative radio and far-right media outlets.

Viewers get a slew of arguments against vaccination: They are too new, or imperfect, or unnecessary for younger people. Some programs cherry-pick unverified or unverifiable accounts of vaccine complications. Some describe the White House efforts to vaccinate Americans as government overreach or outright tyranny.

“The advice they are giving you is not designed to help,” Carlson said on his show in July. “It is designed to make you comply.”

Monoclonal antibody treatment has received none of this pushback. Instead, it has been widely promoted by conservative leaders.

Hildreth, the Meharry president, said monoclonal antibodies have become strategically advantageous for politicians because it allows them to advocate for a defense against the virus without telling vaccine-hesitant supporters they should get vaccinated.

But this strategy will ultimately fail, if not politically, then at least from a public health standpoint, Hildreth said. Monoclonal antibody treatments are effective as a short-term stopgap but don’t produce any long-lasting defense to the virus, so they will never bring an end to the pandemic.

And overuse of monoclonal antibodies may create new strains of the virus more resistant to the treatment, much like how overuse of antibiotics has sparked the rise of antibiotic resistant bacteria, Hildreth said.

Vaccination prompts the human body to produce a range of natural antibodies to fend off the virus even as it mutates. However, monoclonal antibodies rely on one dominant antibody – hence the “mono” in the name – so it is easier for the virus to evolve around this defense, Hildreth said.

“That’s the danger of giving monoclonal antibodies to hundreds of thousands of people,” Hildreth said. “Because you’re going to drive selection towards a variant that is not recognized.”

Contributing: Associated Press 

Follow Brett Kelman on Twitter: @brettkelman.