May 14, 2020

TRUTH 

COVID-19 is actively spreading in communities across America. In the absence of treatment and a vaccine, the only things we have to manage the pandemic crisis are public health measures, such as good hygiene, physical distancing and face coverings. Looking to past pandemics, from the 1918-19 influenza pandemic to the Great Plague of the 18th century (when “quarantine” was first used), the central question has always been: how long is physical distancing required? The answer today is clear: 4 to 6 weeks is not enough to suppress the infection. Closer to 12 weeks are essential to approach elimination of the virus in the community and stop the spread.

Difficulties in contact tracing

A recent example in South Korea illustrates the problems that emerge with shorter periods of quarantine or physical distancing. On May 1, a 29-year-old man visited several nightclubs in Seoul. On May 7, he tested positive for COVID-19. More than 10,000 people were in the vicinity of the clubs between April 24 and May 6—a huge challenge for contact tracing! Officials immediately learned that two individuals who tested positive on May 2 were additional sources of early spread. The authorities began offering anonymous testing to encourage tracing of almost 2,000 club-goers (who were reluctant to be traced to the club district). With aggressive tracing and testing, it is hoped that the new cluster can be rapidly contained. This is the challenge. Unless the numbers are either zero or very low BEFORE a new cluster pops up, there is little chance of containment. 

How one COVID-19-positive person creates clusters

This diagram illustrates how just one infected individual entering the local population can lead to multiple new clusters if that person participates in a large group setting, like parties, weddings, nightclubs, or attends face-to-face business meetings. Studies show that most clusters then evolve within family groups, with an average of 3 to 5 people getting infected. An infected individual brings the infection home and may infect a family member in a vulnerable group. The second most common source of infection is that passed along on public transportation, such as subways and buses, where contact tracing would be extremely challenging.

TESTING 

Testing for COVID-19 infection itself (not the antibodies) is essential to trace or track COVID-19 in the community. The U.S. has not come close to the adequate testing we need to understand where infection is occurring in our communities or track any new episode. And the tests we do have are not well standardized. An unfortunate example is at The White House, where, according to reports this week, the Abbott rapid test in use has a 48% false negative rate. This means the result is almost like flipping a coin. New at-home testing may prove to be convenient, accurate, and fast enough to make tracing feasible.

Antibody testing is even more unreliable and is not broadly recommended for individual use. However, antibody testing is important to assess community spread (positive patients who have been infected) and identify individuals in the recovery phase who have high antibody levels and can donate plasma to help very sick COVID-19 patients. Although results with plasma infusions are encouraging, the extent to which the antibodies indicate true immunity and can help others remains to be seen. Clinical trials are moving forward.

The status of COVID-19 and antibody testing means that for myeloma patients—or any person returning to work—the re-entry into the community is a dangerous proposition. One must assume that anyone new encountered may have active COVID-19 infection that could be asymptomatic at that moment. 

Myeloma clinics are requiring COVID-19 testing before allowing patients back into the myeloma clinic, and this will also be a priority for all businesses as workers return. Hygiene, physical distancing and face coverings will be an ongoing recommendation to stay safe in any group setting. It is important to emphasize that thorough and frequent hand-washing, physical distancing and wearing masks are very effective in limiting the spread of infection in the hospital setting and will undoubtedly be effective in  broader use. 

So, creating a culture of infection-control measures, quite familiar to myeloma patients, is extremely important and can be very effective for the coming future.

THE FUTURE: CHALLENGES AND FUN

Elimination of COVID-19 in the community must be the goal. Without elimination, everyone, including the vulnerable, is at risk from community contacts. What does this mean for future activities?  Because there are so many challenges that will come with reopening society and work, it is important to identify where fun might be possible if we are to retain our sanity!
 
I will discuss the challenges first, but if you want to skip straight to the fun, please do.

Challenges

1. Face-to-face contacts or meetings: These are problematic, depending on the number in the group, the length of the contact or meeting, and whether any COVID-19 infected individuals have been present. Obviously, any coughing or sneezing is a higher-risk situation. The only way to stay safe is to follow the protective measures of hygiene, distancing, and masks.

   These precautions apply to returning to the myeloma clinic. Ideally, clinics will be set up so that there is NO waiting — you will go straight into a carefully cleaned consultation room. The consultations will be spaced out to prevent encounters with other patients or personnel. This will probably require appointments into the evenings and weekends to accommodate all patients. Rooms will be well-ventilated, and consultations will be kept shorter to avoid prolonged presence in a closed space. Longer discussions might be held in outside patio spaces, if feasible.

   Important considerations in evaluating the safety of a situation include: 

   Ventilation: to have good air circulation.

   Low volume: to minimize potential exposure to any infected individual.

   Limited contact with any unknown individuals: any exposure longer than 15 minutes is considered sufficient to allow cross infection.

   Physical distancing: especially important when talking, singing or shouting is occurring, which increases virus spread.

2.  Travel: This will remain problematic for some time, especially prolonged plane, train or bus trips. Even with many innovative protections, such as plastic shields and thorough cleaning, uncertainty will remain. Thus, individual travel in your own vehicle (or that of a trusted friend) is the safest choice, if possible.
3. Group celebrations and events: These should be avoided as much as possible. Events such as parties, weddings and choir practices have been major sources of infection spread.
4. Restaurants: The indoor spaces in restaurants will create a challenge and already have been sources of COVID-19 cluster-spreading events. Even with innovative changes, such as lower volumes, plexiglass shields and disposable items, challenges will remain. Outdoor patio spaces are preferable when possible. 
5. Sports: Unfortunately, attendance at indoor sports events will be the most severely affected for now. Creative solutions may be on the horizon.

Safe fun 

1. Outdoors: Several studies have shown that very few (0.3 % in one study) infections have come from outside exposures. So, many outdoor activities can be safe and enjoyable, from walking to jogging to trekking or a whole range of other activities.
2. Theater and the arts: Although for now, much of these activities will be difficult to reopen safely, many innovative solutions are being proposed.  Sadly, for example, the Hollywood Bowl concert season in Los Angeles has been cancelled for 2020. But impromptu concerts in many neighborhoods have popped up with small groups, pianists, and singers. The way forward is going to be innovation and resilience in seeking continued engagement with the artistic community. Drive-in movie theaters are reopening and artists in New York recently organized a drive-by art show. 
3. Sports: These appear on both the Challenges and Fun list because there are many ways to enjoy sports beyond merely sitting in an audience. Outdoor sports like golf, sailing, climbing, and many others offer much-needed exercise and fresh air. But when others are involved, testing for COVID-19 will be essential, and travel to these locations will require very careful consideration.  
4. Optimism in the face of a crisis: There are many other areas to seek enjoyment that will undoubtedly entail creative solutions to safety challenges. We can get through this crisis together. Resilience is needed to maintain our optimism and mental health. There are definite challenges now, and they will continue in the coming months. A concerted effort to seek out what can keep us sane is essential, whether it be creative ways to eat out safely, walk along the beach, going to a drive-in movie, or getting together with friends (a few only) who have been in sustained physical distancing mode for many weeks. 

History reveals that we do indeed get through crises. After the influenza pandemic of 1918-1919, came the Roaring Twenties, an amazing and productive period.

My bottom line for the week is: Establish your own strategies for infection safety, and in parallel work to actively maintain your sanity. We are innovative and definitely capable of getting through this together.

Translations:

Arabic  Dutch  German  Italian  Spanish  Russian  Turkish