Myeloma patients have a greater risk of developing complications from the COVID-19 infection. A recent heartfelt article by Jon Gluck in The Washington Post, “This is a dangerous time in the pandemic for people like me. Don’t forget us.,” notes that vulnerable people (such as myeloma patients) need to chart their own course to safety. More casual rules for the less vulnerable just do not apply.
In addition, as highlighted in the new book, The Eye Test by Chris Jones, all the numbers and reports we hear every day must be viewed (or eyed) with appropriate caution. Although we need to be guided by science, common sense should still apply in developing a sensible plan.
With these in mind, I will first summarize the current situation with the omicron variant, then offer a step-by-step guide for myeloma patients.
Summary of the omicron variant surge: Is a new variant lurking?
There is a degree of optimism, as the surge of new omicron cases is now starting to decrease across the U.S. — especially in the Northeast and in California. Is it too soon to expect the pandemic to end? Is a new variant lurking? The opinions of several experts are summarized in a recent article in the L.A. Times: “Will another devastating variant follow omicron? Experts debate COVID-19 future, ‘endgame.’”
Overnight, a new report indicated the detection of a “stealth variant” of omicron. This new variant is low-level and not classified as a variant of concern. However, this sub-variant is being detected globally — especially in Denmark and the UK at this time. Researchers will be monitoring this variant, and any other potential variants very closely.
Good news from South Africa
For perspective, being aware of what happened in South Africa in the 8 weeks since the omicron variant first emerged can be helpful. On January 18, 2022, CBS News covered the story that South Africa is over omicron.
As what is happening now in the U.S., the level of omicron infections dropped very rapidly from a high peak. At the 8-week point, life in Johannesburg returned to a bustling normal in restaurants and even the traffic jam resumed. There is definitely hope of a turning point happening.
This is where caution from the experts come in, as noted in the L.A. Times. There is a strong consensus that another variant is, indeed, lurking because of the very high level of global infections, both now and in the coming months. Better preparedness is required, including more aggressive sequence analyses of even minor surges and focus on the increasingly referenced wastewater analyses, which can indicate early trends in a community.
Much work needs to be done to allow potential transition from a pandemic to endemic infection — meaning that COVID-19 is at a low-level of 1% with a positivity rate of 10 or fewer cases/100,000 residents. The reality check here is that, for example in California, the positivity rate is in the 13.8% (Los Angeles County) - 26.6% (San Diego County) range, obviously still far from the 1% goal. We desperately need vaccines that will cover all potential variants plus vaccines which reduce susceptibility to infection in the nose and mouth/throat areas. Creative approaches such as oral and nasal vaccines are being discussed.
The experts also strongly emphasize the value of anti-viral therapies including monoclonal antibodies and oral anti-viral capsules from Pfizer and Merck. They also pointed out the current lack of availability for these therapies.
Another heartfelt article from New York Times reporter, Rebecca Robbins: “When My Mom Got Covid, I Went Searching for Pfizer’s Pills,” draws attention to the lack of access to crucial medicines for the vulnerable. Even with all her insights and connections, getting the pills (Pfizer’s antiviral pills, known as Paxlovid™ almost did not happen, mostly because of the pushback to having an in-person consultation in this virtual world before authorizing a prescription, which severely delays the process.
With this state-of-the-art summary, let me offer four practical steps for myeloma patients:
Step 1: Avoid infection, if possible!
As pointed out by Jon Gluck in his Washington Post article, a COVID-19 infection should not be taken lightly by a myeloma patient. Beyond the immediate risks from infection, there is also the possibility of chronic problems, such as the so-called long-haul COVID-19. The likelihood of long-haul symptoms linked to omicron occurring is still not fully known, although it is already happening.
So, I would advise to do the following for better prevention:
1. Get vaccinated (the 2-dose Pfizer or Moderna primary vaccine series are preferred) and a booster shot (an additional shot after the 2-dose primary vaccine series for Pfizer and Moderna; you can also get a Pfizer or Moderna booster shot if you previously received a single-shot J&J vaccine.) This gives protection against severe disease.
For those who have received their booster shot but still have low anti-COVID antibody levels or have concerns that this might be the case, there are two choices:
- Consider getting a second booster shot or;
- Attempt to get the Evusheld antibody treatment to increase antibody levels by receiving antibodies through an intramuscular shot. This can increase antibody levels (as noted below) for 6 months or so.
2. For an unfortunate percentage of patients, antibody levels may remain low. In that situation, consider monoclonal antibody treatment if antibody levels are low and/or if there is concern that that might be the case.
3. Evusheld was recently approved, which I discussed in my previous blog. This monoclonal antibody combination (as an intramuscular shot) is effective, with an 83% reduction in the risk of COVID-19 infection at 6 months. However, accessibility is a problem; the IMF is now looking at ways to assist patients and to improve Evusheld’s availability.
Step 2: Early intervention
If you were exposed to someone infected with COVID-19, if your COVID-19 test result comes back positive (whether through a PCR or rapid antigen test) or if you are experiencing or exhibiting symptoms of concern, contact your doctor as soon as possible.
Be aware that early intervention antiviral treatments are available to, hopefully, nip the infection in the bud.
- Remdesivir continues to be available. A three-day infusion (inpatient or outpatient), this was the treatment former President Trump received when he tested positive for COVID-19 and subsequently recovered. The FDA recently re-issued Emergency Use Authorization (EUA) for Remdesivir.
- Paxlovid is the oral capsule treatment which Rebecca Robbins searched with great difficulty for her mother! This treatment (a 5-day course by mouth) produced an 88% reduction in hospitalizations and death in the pivotal trial — rather impressive results, for sure. There is clearly a major push to improve Paxlovid’s availability.
- Molnupiravir is the second oral capsule available to treat early disease — in this case, a 52% reduction in the related hospitalizations and death. Less impressive, but still significant.
- Sotrovimab is another monoclonal antibody product against COVID-19, approved for the treatment of mild to moderate COVID-19. Interim trial data indicated an 85% reduction in hospitalizations and death at 29 days.
Step 3: Do not throw away your masks!
Because omicron (and potentially future variants) can spread rapidly, the old-style test and track techniques do not work. The omicron infection spreads BEFORE symptoms emerge and frequently, BEFORE PCR (the most reliable sensitive test) results are obtained. Obviously, over time, we will come up with more sensitive and reliable rapid testing. But for now, and in the foreseeable future, myeloma patients are best protected by masks.
Masks work very well and now, N95 and KN95 masks are broadly available and are even being given away for FREE from the government stockpile. Wearing a mask can keep you safe, particularly if the level of community infection is high and/ or if a new surge is suspected (for example, from wastewater analyses). Despite all the controversies around masks, myeloma patients are advised to wear their masks in all situations of concern!
Step 4 Maintain your focus on the myeloma.
The top priority is to achieve or sustain remission for the myeloma.
In a sense, Step 4 can also be considered as Step 1 because having myeloma in remission has such a positive impact in achieving best outcomes. Unfortunately, myeloma patients can’t tell when a random bad luck of contracting COVID-19 may occur. The striking point is that many testing positive for omicron have no idea how or where they were exposed. Thus, exercising extreme caution is the rule when infection levels are high.
In the case of active myeloma, pushing hard for options outlined in Step 3 is key, when a COVID-19 test turns out positive.
The IMF is available to help and will continue to explore solutions to short-term access issues. As discussed in the past, please speak with your doctor about any changes in treatment to improve antibody responses to the vaccines or boosters. Sustaining the best myeloma therapy possible remains the top priority.
The bottom line: Stay optimistic
Despite all cautions and concerns, there is tangible optimism that we are truly turning the corner when it comes to the COVID-19 pandemic, and that a lower-level endemic situation will emerge. Clearly, much ongoing work is required to make sure that what is around the corner is, indeed, a degree of normality that will be less stressful and less challenging because of our vaccinated-and-boosted status and because we have been working on our positive resilience! Let’s all think positively.
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