October 1, 2020

We had all hoped COVID-19 would be behind us by now. However, the increasing number of cases in many parts of the U.S. and many countries globally has prompted serious concerns about what is to come. We clearly need to stay vigilant and continue to adapt to the constraints of the new COVID-19 world.

Learning again from Iceland

Although it is perhaps a little unfair to compare outcomes and strategies in a small country like Iceland with many much larger nations, there are still important scientific lessons to be gleaned. In mid-September, there was a sudden spike in the number of COVID -19 cases in a country that had previously had close to zero cases. So, what happened?

• A breakdown in quarantine: Two French tourists violated quarantine upon arrival in Iceland. They tested positive at the airport and were confined to quarantine. However, they apparently slipped out and visited two downtown bars. After that, at least 100 cases were traced back to these super-spreader encounters! Some of the exact details are a little murky, but the reaction has been swift, with an immediate four-day closure of bars and discos. Chief epidemiologist Thorolfur Gudnason said it was important to have targeted measures to prevent “a generalized epidemic.” New cases have already dropped down, so it seems this cluster will be rapidly contained, as was a much smaller one in the town of Akranes in July.

• Double testing: Currently in Iceland, there is only one person in the hospital with COVID-19 and not in the intensive care unit. At the peak of the crisis in that country, only 44 patients were hospitalized, and there have been only 10 total deaths. The key strategy which is allowing Iceland to open up its economy and mostly limit any new COVID-19 cases is to test all new arrivals at the airport, as was done with the French tourists. Individuals who test positive are quarantined, but even those who test negative are quarantined for five days. After five days, they are tested again.
  
  A key observation is that approximately 20% of individuals who are initially negative, end up testing positive with the second test after 5 days. We already know that at least 40% of individuals (health care workers, for example) testing positive for COVID-19 are asymptomatic, as is the case with these individuals. This situation was illustrated recently when an asymptomatic myeloma patient was found to have severe lung involvement with COVID-19 on a routine whole-body FDG/PET scan performed to assess the status of the myeloma. Such asymptomatic individuals are not only at personal risk but are also potential sources of super-spreader events. In Iceland, these individuals are identified and quarantined—exactly the type of vigilance needed to stay safe.

• Dogs sniff out COVID-19 at the airport: Iceland has a plan in development use dogs to sniff out COVID-19 at the airport. This strategy has already been implemented at the Helsinki airport in Finland. Right now, four dogs are trained and used in two dog-screening shifts because they get tired after a lot of sniffing. Not sure if this approach will catch on, but it is certainly simple, cheap effective and people friendly.

New COVID-19 mutations identified in the U.S.

Scientists in Houston just released the results of a study in which they checked for mutations in over 5,000 COVID-19 cases. The main finding supports earlier studies indicating that a dominant mutation (D614G), which first emerged in Italy, was responsible (99.9%) for a second wave of infections in Houston this summer. This strain led to many more infections in younger individuals.

Researchers have found that this D614G-mutated COVID-19 virus strain spreads more easily and produces higher virus loads, potentially leading to more super-spreader events. The fact that many additional mutations were also found leads to a concern that new strains will repeatedly and sequentially emerge, evading the body’s immune control and potentially frustrating the ability to have an effective vaccine. It could be that, as with the flu, new vaccines will be required each year.

Mixed messages about vaccines

Operation Warp Speed, an initiative to accelerate development of a COVID-19 vaccine, is a huge, highly structured organization funded with $10 billion and involving both civilian and military personnel. One can only marvel at the potential and hope that there will indeed be success in developing, manufacturing and distributing an effective and safe vaccine in a greatly accelerated timeline.

A very comprehensive review of all SARS-CoV-2 (COVID-19) vaccines in development was recently published, but many questions have been raised. One issue is that not enough older individuals have been entered into vaccine trials. In a recent study, the median age of participants was 40. A small study of COVID-19 vaccination in older adults is encouraging, however, especially at a higher dose. In addition, concern has been raised that vaccines will not work well in obese individuals, one of the key higher risk groups. Obviously, there is an additional concern that vaccines will not work well in those with compromised immune systems, such myeloma patients.

Many questions remain to be answered as we await developments in the coming weeks and months.

Good news for sparrows in San Francisco

As I have noted in previous blogs, many animals, from goats to lions, have rapidly adapted to the quieter environment during the COVID-19 pandemic. In San Francisco, researchers have observed that noise in the city has dropped a lot (by seven decibels) due to less traffic and human activity. The male sparrows have reacted by lowering the volume of their songs by four decibels (softer, but still loud enough because of less background noise) and using a broader bandwidth, which is attractive to female sparrows.

This ability to rapidly react in the face of a massive environmental change is truly heartwarming as it reflects a true resilience in the natural world.

Building resilience

As we face an autumn of uncertainty, it is wonderful to have a new publication from Cigna and the Resilience Research Center. What is especially helpful in the report is the detailed discussion of how to build resilience, which I have discussed in several blogs and in a conversation with Sue Dunnett.

The approach developed by the Resilience Research Center team is divided into six steps:

• Step 1: Acknowledge the problem[s]
• Step 2: Break down issues so they are not overwhelming
• Step 3: Determine what you can do (versus what is out of your control)
• Step 4: Find helpful resources
• Step 5: Start implementing plans (take action)
• Step 6: Reflect, grow and repeat as needed

These steps illustrate that resilience is not a passive process, but a quality that can be strengthened with focused effort. If we in the myeloma community work together to strengthen our resilience, we can get through the next phase of the COVID-19 crisis with much more ease and confidence.

Stay safe and be well!

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