October 28, 2021
Information about the COVID-19 pandemic continues to evolve. This week, there are data about a new, more infectious Delta variant (AY.4.2) in the U.K. and studies of antibody levels and immunity to COVID-19 in myeloma patients undergoing different therapies. Both raise some concerns for myeloma patients. There are also new cautions about the risks of flying.
But the continued rollout of booster shots and the likely approval of vaccinations for children (5-to-11-year-olds) by next Wednesday, plus the unexpected anti-COVID benefit of a cheap antidepressant all represent good news. It is important to stay alert to this fast-changing updates.
Emergence of new Delta plus COVID-19 variant
The new Delta-plus variant (AY.4.2) accounts for 10% of cases in the U.K. Some scientists estimate AY.4.2 has 10-to-15% higher transmission advantage over the original Delta variant, which is why it is circulating and increasing more slowly than the original variant. It appears to carry the same risk of hospitalizations and deaths. Fortunately, right now, the 4.2 variant accounts for only about 1% of U.S. cases. However, sequence analyses are much less rigorous in the U.S. than in the U.K., which is among the global leaders in identifying new COVID-19 mutations. It is too soon to know the global impact of the Delta-plus variant. However, its emergence is a clear warning of the potential for important new mutants and the need for vigilance.
Two new studies assess antibody levels and immunity in myeloma patients
The first is a study of the immune response to COVID-19 vaccination in myeloma patients, led by Dr. Samir Parekh of the Tisch Cancer Institute and Icahn School of Medicine at Mount Sinai in New York. Forty-four patients with myeloma were compared to twelve healthy individuals. A key observation was that 15% of patients had a complete absence of anti-spike protein COVID-19 antibodies. Detailed immunologic studies indicated that these same patients also lacked cellular (T cell) responses, making them particularly vulnerable to COVID-19 infections. This lack of immunity was particularly seen in myeloma patients receiving anti-CD38- (daratumumab or isatuximab) and anti-BCMA-antibody-based therapies (drug conjugate or bispecific).
These results emphasize the need for careful antibody testing and immune studies in myeloma patients to identify those patients who are most vulnerable and in need of additional vaccine doses and/or boosters, as well as enhanced safety protocols, plus possible potential protective therapies.
Key follow-up information is required. For example: How quickly does immune reactivity against COVID-19 recover or improve if therapies are delayed or stopped for a few weeks? Can an additional vaccine dose or a booster beyond that (a 4th dose) trigger more adequate anti-COVID-19 immunity?
The second study, a pre-print from the U.K., reports data on 214 patients with myeloma or smoldering multiple myeloma (SMM). Patients were studied at least three weeks after their second vaccine dose. Both the Astra Zeneca vaccine (available in the U.K.) and the Pfizer vaccines were studied. Findings were a little more encouraging: 92.7% of patients had positive anti-spike protein COVID-19 antibodies and only 6.3% had no antibodies nor other immune responses. Predictors of poorer immune responses included being male; having NOT achieved VGPR (very good partial response) or CR (complete response); therapy including anti-CD38 or anti-BCMA antibody therapies; and use of the Pfizer vaccine versus the Astra Zeneca vaccine, which performed better in this U.K. analysis. Of note, a recent study from Israel also emphasizes a more significant drop-off in immunity over time with the Pfizer vaccine.
Again, we need to study and monitor antibody levels in myeloma patients, be aware of poorer prognostic factors, and be ready with mitigation strategies.
What we know about COVID-19 transmission on planes
Although overall, the risks of flying remain relatively low, most studies were done before the emergence of the more infectious Delta variant, and certain activities really increase the risks of COVID-19 spread, the Wall Street Journal reports. Researchers highlight the meal service (particularly on international flights) as a very high-risk period, increasing risk by 59%. The concern occurs because all passengers take off their masks at the same time. At this moment, you only need one infected passenger (index case) to spread the infection to many others (secondary cases). Researchers in Hong Kong traced a cluster of 50 cases to a flight from New Delhi to Hong Kong. Only 20% were symptomatic and 8 were children exempt from masking requirements.
Other problem time periods include boarding and disembarking, when many passengers are active and in close contact. Studies of wastewater from planes has confirmed that infected passengers were likely on board. Mask-wearing does make a big difference. A new type of mask can also be considered, which is attached to a small device in which HEPA filters clean the air (such as the BROAD AirPro mask). This is very comfortable to wear for several hours at a stretch.
Some good news
Two new studies highlight potential treatment options for COVID-19 infection:
- A study from Brazil illustrates the potential value of an inexpensive anti-depressant called fluvoxamine to reduce hospitalizations and severe disease. A total of 741 patients were assigned to get fluvoxamine and 756 to receive a placebo (no drug). In a randomized comparison, a 10-day treatment of fluvoxamine reduced the need for hospitalization substantially in patients completing the full course of therapy as prescribed. Further studies are required but these encouraging results indicate the potential value of an already available cheap drug.
- In a study from Canada, researchers at the University of Toronto have created mirror image peptides that can neutralize COVID-19! These peptides are chemically stable (they do not break down in the body) and cheap to produce. Prof. Philip Kim, a senior author on the study, says: “You can imagine [the peptides] being formulated as a nasal spray to prevent infection from occurring.” This is obviously a very exciting possibility, and we await further developments.
Status of additional vaccine doses and boosters
It is very encouraging and important for myeloma patients that extra doses of vaccine have been approved for the Pfizer, Moderna and J&J vaccines. For the immune compromised, the additional dose can be a full dose, with the new idea that a further (4th dose or “booster”) can be considered to further enhance the antibody response. Stay tuned for further information about this potential 4th-dose booster.
The pending approval of vaccination for children (ages 5 to 11) is not only important for the children, but for potentially vulnerable family, friends, and contacts, including teachers and others in contact with children. This can have a big impact.
Covid headlines this week
So, quite a bit of news this week! It is really essential to stay alert to remain as safe as possible in these coming months. We will continue to get through this together.
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