April 30, 2020

This week, there was renewed concern in the myeloma community after a report appeared in the Washington Post about higher risks for cancer patients who become infected with the coronavirus. I would like to emphasize that this was based upon an extremely limited experience in China, which manages and treats myeloma very differently than we do in the U.S. 

The study included a total 105 patients, of whom only 9 had some type of blood cancer, including leukemia, lymphoma, and myeloma—so, not just myeloma. We do not have a lot of detail from this report, but 3 out of the 9 hematological cancer patients had poorer outcomes, meaning possibly one or two myeloma patients at most. But with no patient information provided, it is hard to say. 

Keep in mind that we do not yet have enough information to draw any conclusions about myeloma outcomes. However, considerable information from the U.S. and around the globe paints a different picture from the Chinese report.  With rare exceptions, COVID-19 infected myeloma patients (of which there have been VERY few) have done very well:

• Dr. Rafat Abonour (Indiana University) tweeted this week that a patient who is in remission on Revlimid maintenance and who became infected with COVID-19, is now doing fine. 
• In Cleveland Clinic’s myeloma program, just 2 out of 1,000 patients in follow-up have tested positive and are doing fine. 
• The busy University of California San Francisco (UCSF) myeloma center reported no COVID-19-positive patents. 
• In the Asia-Pacific region, few myeloma patients have tested positive for COVID-19, and again, are almost all doing well.

In the U.S., the main risk factors for infection and serious consequences continue to be non-cancer related. The main risk groups are those with hypertension, obesity, diabetes, and chronic lung or kidney diseases, all linked to the expression of the ACE2 receptor, which is what the COVID-19 virus binds to on cells. The process triggers a complex anti-virus response. This response causes severe lung and other organ damage, and cardiovascular complications such as strokes, which have been occurring in young individuals. 

The good news for myeloma patients is that myeloma therapies are mostly anti-inflammatory and can be helpful in suppressing this dangerous over-reaction process.

Global Guidance Heading into the New Abnormal

In searching for details of a new normal it is increasingly clear that it is going to be very abnormal—in fact, a new abnormal. For now, recommendations for myeloma patients remain the same: Please stay safe at home or with limited careful public activity as needed, wearing a mask. With the avalanche of daily information about COVID-19, which facts will guide future decision-making?

Lessons from Italy 

As someone who had an April vacation planned in Italy this year I have more than a casual interest in why things went so terribly wrong when COVID-19 infection struck the Lombardy region in Northern Italy. As the title of a recent article in the Los Angeles Times notes, the virus disaster in Italy is a “lesson for the world.” It turns out to have been a perfect storm.
 
When you think of Italy, you envisage beautiful rolling hillsides and ancient hilltop villages. However, the Lombardy region outside Milan, where the emerging pandemic struck, is the industrial heart of Italy. It accounts for 20% of the GDP of Italy and is densely populated. It has a high percentage of individuals over the age of 65 and over 20% of the nursing homes in Italy. Local designer leather goods and textile manufacturers employ Chinese workers who are in frequent contact with China. In January 2020, and most likely in December 2019, the virus is thought to have arrived in the region from China. (However, a team of scientists in Milan believes it could have come to Italy by way of Germany.) Flights from China were stopped on January 31, but by then it was too late. In early February, community spreading of the virus was documented and the hospitals filled quickly. 

Because of budget cutbacks, resources were limited: 8.6 ICU beds per 100,000 people (versus 33.9 beds per 100,000 people in Germany, for example). Care of increasingly sick COVID-19 patients fell to local physicians ill equipped to handle the situation. And things kept getting worse because stay-at-home orders were not implemented until March 7, with a full lockdown on March 26, because such orders were blocked by powerful manufacturing industry officials. Then, the impact on nursing homes started to be felt, escalating the problems.

• Takeaways: 
  • Heed early warning signs before it becomes impossible trace and quarantine based on all new infections.
  • Real-time testing is vital before the situation gets out of control, resulting in excess needs for urgent care. 
  • Special attention must be paid to the most vulnerable, and particularly to places where people live, work, or congregate in close settings.

Positive Lessons from New Zealand, Sweden, Iceland, Korea 

New Zealand, Sweden, and Iceland have taken different approaches to control COVID-19, and all are succeeding in balancing different priorities as they search for a best way forward for their countries.

• New Zealand, COVID-19 elimination: Epidemiologist Dr. Michael Baker has led a push to eliminate the virus by closing borders with a travel lockdown, which began on March 23, and conducting aggressive testing, contact tracing, and surveillance. In a country of 5 million, having only 17 deaths supports the validity of the strategy. While this is a fantastic achievement, New Zealand’s population has had limited exposure to COVID-19. When the country re-opens, its entire population will be at risk of COVID-19 infection. They are safe right now but will need a vaccine to protect their people for the future. 
• Sweden, herd immunity: Sweden is using the exact opposite approach. The country is allowing a considerable amount of normal social activities at places like restaurants and parks, while protecting the most vulnerable. This means that many people have been exposed to COVID-19. It is  currently estimated that up to 25% of people in Stockholm have been exposed to coronavirus and are possibly immune. The approach taken by the country’s public health officials is to rely on the common sense of Swedes to limit contacts with strangers, while building up a resilient population that will able to withstand the risks outside contacts as restrictions are relaxed globally. A level of so-called herd immunity is reached when over 50% of individuals are exposed, ideally even a bit higher. It is really quite brave (or foolhardy, say critics) to move immediately in that direction without waiting for a vaccine.
• Iceland—testing, tracing, and sequencing: The country’s Prime Minister, Katrín Jakobsdóttir, has followed the advice of scientists with aggressive testing—which has been performed on 12% of the population. Prof. Kári Stefánsson, CEO of deCode Genetics (the home of the IMF Black Swan-supported iStopMM project), led the effort to successfully sequence the COVID-19 virus, and all new clusters have been traced, followed by the quarantine of any contacts. In 93% of the cases, the government has learned how and where an infected patient was exposed to COVID-19. This has allowed Iceland to set plans for re-opening strategies, crucial for a country so dependent on tourism. All are wishing the country well in appreciation of these laudable efforts to combat COVID-19.
• Korea—high-density environments: A new report from Korea provides excellent guidance on dealing effectively with outbreaks in high-density environments, including nursing homes, high-rise complexes, factories, and ships. When a cluster of new cases emerged in a high-rise complex in Korea, authorities immediately shut it down. It turned out that 43% of cases came from one side of the 11th floor of the 19-floor mixed commercial/residential building, which was the busiest, most cramped area. By immediately tracking the positive individuals, the outbreak was contained. 

Strategies Moving Forward

• Success of the remdesivir trial: In early results reported this week, the experimental drug remdesivir slightly improved survival and reduced the time of intensive care needs by four days. Further results are anxiously awaited. Dr. Anthony Fauci expressed optimism that results can indicate benefit for patients, particularly if used early enough. However, it is uncertain if early virus shedding is reduced by treatment.
• Vaccine news: The announcement this week that AstraZeneca has agreed to manufacture and distribute a vaccine being developed by Oxford University, which could be ready by the end of the year, is very good news then, for New Zealanders and the rest of the world! 
• Quarantine fatigue: A dominant mood right now is quarantine fatigue. So many people are ready to return to whatever the new abnormal will be. This is time once again to take encouragement from the resilience shown by Mother Nature in recovering from the insults of pollution with renewed activity. As we saw from the IMF Wall of Resilience, illustrations of natural resilience inspired so many myeloma support group leaders. I am eagerly awaiting the publication of a new book about the remarkable abilities of birds to collaborate and problem-solve. 

Inspiration for the Future

In these difficult and emotional times, it is inspiring to have a source of wonderment. A book called “The Boy, the Mole, the Fox and the Horse,” by Charlie Mackesy, illustrates the power of love, friendship, and kindness as we look to the future. Each animal shares different advice. The horse ventures that the boy should “Always remember you matter, you’re important and you are loved, and you bring to this world things no one else can.” 

Amen. Who can say more?

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