Optimism for an Uncertain 2021
As we start off the new year, we are optimistic that things will be better. However, this optimism is tinged with a range of emotions that are hard to describe. There is fatigue—more mental, but also physical—that is difficult to shake after almost a year of isolation and only Zoom-type connections. For healthcare providers the fatigue is to a point of exhaustion. There is also a deep sadness about the tragedies of 2020: the lost lives, the loss of livelihoods, plus the suffering and personal crises of so many, including those suffering “long-haul symptoms” after being infected with COVID-19 or mental health issues lasting for six months or more.
Setting expectations for 2021
On top of that there is real uncertainty about the future. Yes, the vaccines will start to provide broad immunity in the community, but what about those new COVID-19 mutations? Will the vaccines still work well? Is there a time in 2021 we can expect to get together in person in a more normal fashion? What about travel and vacations? It will be great to set some realistic expectations for the months ahead.
Ashish Jha, Dean of Brown University School of Public Health, told The Atlantic he wants to aim for a Fourth of July barbecue at his house in Newton, Massachusetts. The guests would be outside, where any risks of virus spread are much lower, and masks would be worn for any needed time indoors. “It won’t be normal,” said Jha, “but…I think that’s when it’ll start to feel like we’re no longer in a pandemic.”
Needed changes to accelerate return to normality
Clearly, accelerating the roll-out of vaccinations is essential to establish immunity across the U.S. and globally as quickly as possible. Since it remains unclear if vaccines eliminate transmission of COVID-19, continued use of masks will be required for the foreseeable future. To keep any COVID-19 outbreaks small, rapid testing, contact tracing and quarantine will become a central part of the planning. This is what has kept COVID-19 infection levels so low in places like Taiwan, Vietnam, New Zealand and Iceland, as well as a number of African countries with a fraction of the GDP of the U.S. Guidance and funding for public health measures are crucial.
Better ventilation plus protective measures, such as plastic barriers, will become commonplace to reduce indoor spread of the virus. Maintaining separate, small social bubbles, I believe, will also be a standard approach to lower virus transmission. It is hard to know what will happen with major sporting and entertainment events until a high level of community immunity is achieved.
Will COVID-19 be like the measles or influenza?
For measles, vaccination provides lifelong immunity, whereas for influenza, a new vaccine is required annually. The development of the new COVID-19 mutations will require new vaccines in the future. The question is, how soon? Although there is a hope that the current vaccines will work for a few years, new vaccines may be needed quite soon.
The good news is that the Pfizer-type mRNA approach provides a customizable strategy: a new mRNA can be developed against any mutated spike protein target very quickly. So, we have the capability of staying ahead and sustaining community immunization on an ongoing basis.
Pandemic preparedness is also a key for the future. We do NOT want yet another virus crisis challenging the healthcare system and economies. Public health funding is essential. Fatigue or a desire to forget and move forward must not prevent investment in the future of global health.
Implications for myeloma patients
Avoiding COVID-19 infection continues to be the top priority, especially for patients with active myeloma requiring new therapy. For patients with MGUS or SMM, avoiding COVID-19 infection is also key but it is really important to emphasize that:
MGUS and SMM patients do NOT appear to be more likely to develop COVID-19 infection.
MGUS and SMM patients have expectations and outcomes similar to a matched non-myeloma population based upon age and/or risk factors such as high blood pressure, diabetes, obesity or underlying lung, heart or kidney conditions.
COVID-19 infection occurs almost exclusively in the community, rarely in a hospital or clinic setting. Therefore, the key staying safe in the community is to: wear a mask; socially distance; avoid crowds; be cautious about all indoor spaces and their ventilation; and, of course, be conscientious about hand washing and personal hygiene.
COVID-19 infection really does cause havoc with the immune system, as detailed in Scientific American. The longer-term implications of that for myeloma patients remains to be seen. COVID-19 can produce an exaggerated inflammatory response, damage white blood cells’ (Neutrophils Extracellular Tangle or NET response) ability to trap viruses and reduce the numbers and ability of T cells to kill viruses. This is a complex disruption of immune-functioning and could have longer term consequences already reflected by symptoms in long-haul patients. The number one recommendation continues to be to avoid infection at all costs!
It is very important for myeloma patients undergoing treatment to maintain the recommended therapy to keep you in (or achieve) remission. This is a top priority and arranging safe visits to the hospital or clinic must continue as best feasible to sustain ideal control of the myeloma. Obviously, telemedicine can be used for interim consultations, but some in-person follow-up can be essential to keep care on the best track forward.
Best diet for 2021
In these difficult times, staying healthy with the best diet is an important goal. For the fourth year in a row, U.S. News World Report has deemed the Mediterranean diet “Best Diet” of the year. I have discussed the benefits of this type of diet numerous times. It recommends:
Eliminating processed foods
Focusing on meals with plenty of vegetables, fruits beans, lentils, whole grains, nuts and seeds.
Using olive oil and reducing the use of butter
Avoiding sugars and refined flour as much as possible
Including plenty of fish and eggs. Meat should be included sparingly.
The big picture in 2021
Already, four major books have been written about the consequences of the COVID-19 pandemic and are reviewed in The Economist. The best, which I have referenced before, is “Apollo’s Arrow” by Nicholas Christakis. The author emphasizes the lessons from history—this is NOT the first pandemic the global community has faced! Let’s learn and plan for the future.
In the New Year, I recommend continuing to stay as safe as possible and hope, as Ashish Jha proposes, that the Fourth of July will be a time we start to feel more normal and can move forward strongly together.
Let’s be compassionate toward those less fortunate and work as best possible to stay resilient!
Dr. Brian G.M. Durie serves as Chairman of the International Myeloma Foundation and serves on its Scientific Advisory Board. Additionally, he is Chairman of the IMF's International Myeloma Working Group, a consortium of nearly 200 myeloma experts from around the world. Dr. Durie also leads the IMF’s Black Swan Research Initiative®.