After the turmoil of 2020 and 2021, what we all desperately need for 2022 is some clarity about the future. With omicron spreading like wildfire, how safe are we even after our boosters? Do we need to upgrade our masks (to KN95 or the like) and pay better attention to cloth masks others are wearing? Do we need to get a COVID -19 test and which one(s) should we consider? Can we set plans for later in the year in hopes things will be better? These questions and many more spring to mind and create this anxiety and uncertainty experienced by so many.

Omicron is indeed a new variant

The omicron variant is definitely different. Omicron is very highly infectious / transmissible, but the pattern in patients is quite different versus the delta variant:

• Transmission of infection occurs even when individuals are without symptoms and a nose PCR and/ or a rapid antigen test is negative. Spending time with someone who may have had exposure poses a risk. Unfortunately, masks must be worn to protect from transmission of infection. This is the traditional behavior in Asia: wear a mask when there is a known increased level of community infection.
• The pattern of symptoms is different. Sore throat (typically the first symptom) and general “flu-like symptoms” are most common. There is no loss of smell or taste. A nose PCR test can be negative because the initial infection is in the throat. It takes a day or two for the antigen response to kick in. The rapid antigen tests can be negative early on (first 24-48 hours) even when the patient is already infectious.
• The very good news is that the omicron variant targets the throat and bronchial tubes versus the lungs. This means that severe pneumonia is rare and ventilators are not as needed. High flow oxygen through the nose is sufficient. Unfortunately, for children the bronchial infections can be more dangerous because their bronchial tubes are so small and can be easily blocked if inflamed.
• The critical news is that high-quality masks are THE best tool for early protection against the spread of infection when levels of community COVID-19 are high. Masks should be used indoors or outdoors especially in crowded spaces and if the exposure status of contacts or potential contacts is uncertain or unknown.

Value of vaccination and boosters

Every day the data become clearer. Vaccination and boosters protect against hospitalization and severe disease. Those who end up in the ICU are almost exclusively the unvaccinated.

For myeloma patients, there is a lingering concern for patients on active therapy especially anti-BCMA and anti-CD38 antibody therapies. With those therapies in particular, antibody responses can remain low despite boosters.

Key points:

1. Stay ON needed therapy to sustain a good response.
2. It is not clear how much treatment adjustments improve antibody responses, but can be considered with your doctor's guidance.
3. Good new options are the antibody treatments, which provide the needed anti-COVID-19 antibodies to patients with low levels. The new Evusheld product (given via intramuscular injection) is most encouraging and can be considered as quickly as available to achieve ~ 6 months protection (see last week’s blog). The intravenous Regeneron product is also an option.

The very encouraging feedback so far, during this omicron surge, is that although mild COVID-19 infections have occurred in myeloma patients severe infections appear to be extremely rare (I am personally aware of none at this point.) In Los Angeles, some say it’s time to learn to live with COVID-19.

Practical solutions to key question

With this background it is most helpful to propose solutions to the commonest concerns from myeloma patients:

1. Should I get a booster shot?

YES!

You can get a booster shot 5 months after you received the 2nd dose of the Pfizer or Moderna vaccine primary series. Because of mix and match approval, Pfizer and Moderna boosters can also be given to those who received the J&J vaccine 2 months after getting the single-shot primary vaccine.

An additional (or 2nd) booster shot can also be considered for those who qualify, based on timing. 

2. Should I get tested for COVID-19?

Most patients would have been tested to get into myeloma clinics or hospital settings. Periodic monitoring will occur. As noted above, none of the testing is 100% accurate. Serial testing is required to be more certain of a positive or negative result.

For the Abbott rapid antigen (home) test, a recent study showed false positives with some lots of test kits. Early in the infection, antigen tests can be negative.

For the very sensitive PCR test (typically from the nose), two issues have emerged:

1. Negative because tested too early or with omicron the infection is in the throat.
2. Persistent positive because small fragments of COVID-19 remain even when active infection has resolved, and the patient is no longer infectious.

Bottom line about testing

DO get a test if a critical question emerges such as the development of symptoms and the need to know if there is COVID-19 infection. Early intervention is important for myeloma patients.

DO use testing for any planned gatherings / meetings or work situations to be clear about the status of guests or other employees. The additional use of an attestation protocol is also helpful to be informed about the exposures / travel, etc. of potential contacts.

• BE AWARE of possible false results and keep using masks in all situations of concern.
• BE AWARE of the community level of infection. If the level is high, then obviously greater cautions are needed.
• BE AWARE of wastewater testing in many cities or regions.

On Tuesday, the Massachusetts Water Resource Authority (contracted with the company Biobot) for the Boston region announced that omicron levels were dramatically dropping from 10,000 RNA (virus) copies to 6,000 RNA copies/ml. Experts are starting to rely on this information to track infection trends— in this case a reversal of the recent omicron surge which is very good news. At the beginning of the omicron surge, wastewater data in California showed how widespread the infection was even early in December. Follow up data are awaited.

Expect to see more of wastewater information discussed to evaluate trends and how safe it is in your community which can guide mask wearing and the need for more careful testing or not.

BE AWARE of this fun fact: dogs can sniff out COVID-19 Test programs are underway to evaluate if a practical dog sniffing program can be developed.

3. Should I adjust my treatment to get a better vaccine response?

• Right now, this is a difficult question since we don’t have answers to the key question: do adjustments improve the antibody responses after vaccination or boosters?
• However, we do know that boosters help ALL patients.
• Timing of vaccination to avoid a recent treatment dose is a good idea when feasible. Always keep in mind that the top priority is to achieve or maintain a treatment response.
• The recent availability of Evusheld is a really helpful new option. This intramuscular antibody shot treatment provides the needed anti-COVID-19 antibodies which are critically important to those with low levels on active treatment. Another option is the Regeneron antibody cocktail, which is administered intravenously. This is also very helpful but seems to be less effective against the omicron variant.
• Please talk to your doctor about the best options for your particular situation.

4. Should I delay ASCT (or harvesting) right now?

During this current massive omicron surge, hospitals are being overwhelmed. This is NOT a good time for myeloma patients to be in the hospital. Discuss the pros and cons of delaying your stem cell planning to a better time with your doctor.

• Get vaccinated and boosted!
• Wear a mask in all situations of concern.

Wear the best mask possible such as an N95 or KN95 mask. A recent study showed that these masks provide really lasting protection during meetings or gatherings versus cloth masks, bandanas or even surgical masks. N95 and KN95 masks are now strongly recommended and there is a plan in the works to make such mask broadly available free!

• Pay attention to the type of mask others are wearing. Low quality masking puts YOU at risk.
• Use a simple attestation type approach to assess all your contacts (where have they been / who are their contacts, etc.) Simple put: could they be carrying an asymptomatic infection and putting you at risk? Be assertive about this: your health is important!

5. Can a myeloma patient truly stay safe these days?

YES, with a few simple precautions.

• Get vaccinated and boosted!
• Wear a mask in all situations of concern.
• Pay attention to the type of mask others are wearing. Low-quality masking puts YOU at risk.
• Use a simple attestation type approach to assess all your contacts (where have they been /who are their contacts, etc). Simply put, could they be carrying an asymptomatic infection and putting you at risk? Be assertive about this: your health is important!

Overall bottom line

These questions and answers are just the tip of the iceberg in terms of questions that come up in day-to-day situations. I am planning to create a video to cover as many additional questions a possible (and this will be available within the coming weeks). In the meantime, work hard to be safe in the hopes that the current omicron surge will recede as quickly as it spread and that by spring, we can return with more comfort to our daily lives.

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