Over the weekend I looked up at the sky in Los Angeles and saw a small plane skywriting the encouraging words, “We will get through this together (https://twitter.com/MayorOfLA/status/1246266118697652224/photo/1).” 

After weeks of staying at home, hand washing, and following the recommended safety recommendations to prevent COVID-19, it is important to be thankful for remaining healthy and to look ahead at the coming months as we adjust to our new normal—together.  

“Who will you choose to be during COVID-19?” Dr. Tamer Issa asks, in a discussion (https://www.issaptwellness.com/blog/Who-Will-You-Choose-to-Be-During-COVID-19-~7132.html) of our options. We can choose to be fearful, to learn, and to grow. The choice is ours. And it’s okay to experience each of those three options at various moments during this challenging time.

Encouraging New Information 

To think realistically about the future, it helps to know what we are learning and how we can all contribute to the safety and sanity of ourselves and others.

• Impact of COVID-19 on the myeloma community: Fortunately, few myeloma patients have been severely impacted by the COVID-19 infection. By strongly implementing physical distancing, hand washing, and other strict measures throughout Asia and in other areas around the globe, the number of infected and severely ill myeloma patients remains very low. In San Francisco, for example, the mayor implemented very strict guidelines early on, and so far, no patients in the very busy University of California, San Francisco (UCSF) myeloma program have been impacted by COVID-19. Likewise, at the very busy Myeloma Clinic in Heidelberg, Germany—which also implemented strict guidelines early on—there are no COVID-19-infected patients.

The bottom line: we have learned that staying at home works in protecting patients!

• Improved management of COVID-19-infected patients: 
  • One myeloma patient in China (https://www.hematology.org/newsroom/press-releases/2020/case-study-treating-covid-19) became infected and grew quite sick, but was successfully treated using the tocilizumab (an anti-IL 6 monoclonal antibody) to literally weather the storm of cytokines. This cytokine storm makes patients very sick and “crash,” doctors told NPR (https://www.npr.org/sections/health-shots/2020/04/07/828091467/why-some-covid-19-patients-crash-the-bodys-immune-system-might-be-to-blame). This treatment is very encouraging and is now being evaluated in clinical trials.
  • There is better understanding and management of patients who develop low blood-oxygen levels. The COVID-19 virus directly attacks hemoglobin (https://chemrxiv.org/articles/COVID-19_Disease_ORF8_and_Surface_Glycoprotein_Inhibit_Heme_Metabolism_by_Binding_to_Porphyrin/11938173), the oxygen-carrying molecule in red blood cells that carry oxygen from the lungs to organs and tissues. This means that blood oxygen levels can drop really, really  low. In addition, because of fluid build-up in the lungs, it turns out that even the high pressures produced by ventilators (https://www.statnews.com/2020/04/08/doctors-say-ventilators-overused-for-covid-19/) cannot get oxygen through the fluid-filled lung sacks into the bloodstream. Using a gentler approach, with just oxygen through the nose (cannula), plus simpler assist devices, can help patients get the oxygen they need. It would be extremely helpful if there were a lesser need for ventilators. A novel approach using nitric oxide, which increases blood flow, may also help and is being evaluated (https://www.latimes.com/science/story/2020-04-05/viagra-discovery-could-treat-coronavirus-patients) to also improve oxygen flow into the blood stream.
• Many anti-COVID-19 virus therapies are under evaluation: In addition to those I’ve mentioned in my last several blog posts (https://www.myeloma.org/week-review-dr-brian-gm-durie), an unexpected addition to the list is the formal assessment of Selinexor, a myeloma treatment. A low-dose Selinexor treatment protocol will be implemented (https://investors.karyopharm.com/news-releases/news-release-details/karyopharm-evaluate-low-dose-selinexor-potential-treatment). This is interesting and exciting news.

What to Expect in the Coming Weeks 

An important part of “getting through this” is having realistic expectations for the coming weeks and months. Some key milestones and datasets that can guide us:

• After 76 days of total lockdown, Wuhan, China, the epicenter of the COVID-19 pandemic, is this week relaxing its physical and social distancing restrictions, although masks are still required. Trains are running and flights have resumed. COVID-19 case numbers are extremely low, and it is hoped they will stay that way. But only time will tell. This trial of a return to normality, approximately three months after the start of the crisis period, is being watched closely around the world. The COVID-19 infection emerged in late December 2019 (although there was certainly spread a bit earlier), and the source of infection (the Wuhan live food market) was closed on January 1, 2020, when there was already noted to be spread in the community .

The bottom line: 

• We really need to watch and see how the relaxing of restrictions in Wuhan works out. It is a test for all of us to understand if there can be an early return to a new normal and what that new normal looks like. 
• For the U.S., the equivalent three-month period of community spread is March, April, and May, although, like China, earlier spread is quite likely to have occurred. Some states, such as California and Washington, have witnessed much lower caseloads linked to early restrictions, and may be among the earliest to have an opportunity for return to the new normal. Some states and communities will undoubtedly be later. The flattening of the curves of COVID-19 occurrence is great and saves lives, but also extends the curves for additional weeks. 
• The initial results from Iceland (https://www.medrxiv.org/content/10.1101/2020.03.26.20044446v2.full.pdf) have just been published. This elegant survey of COVID-19 infections in Iceland provides many details about the occurrence and spread of COVID-19 at the community level:
  • First, through molecular sequencing of the virus they have documented several mutations or strains (which they call clades) of the virus. It is possible to track strains coming from Italy, Austria, the UK, Denmark, and a strain linked to the U.S. West Coast. The identification of the different strains allows community tracking that can assess the origin from travelers entering Iceland from around the world. One patient was noted to have two strains of virus. This is important because as the virus grows, it can recombine, creating a new strain (https://www.nytimes.com/2020/03/20/opinion/coronavirus-facts.html) that is a combination of the original two.  So, any multiple exposures to different strains for an individual become a concern.
  • Second, the researchers have created a baseline for ongoing population analyses and studies of symptomatic patients and contacts.
  • Ongoing community spread is documented, alerting everyone to the challenges ahead in attempting to contain COVID-19 and develop a vaccine. (Here is a review of COVID-19 vaccine prospects (https://www.cell.com/immunity/pdf/S1074-7613(20)30120-5.pdf?_returnURL=https%253A%252F%252Flinkinghub.elsevier.com%252Fretrieve%252Fpii%252FS1074761320301205%253Fshowall%253Dtrue), shared today on Twitter by IMF Board of Directors Member Dr. S. Vincent Rajkumar of Mayo Clinic.)

Safety for the Future 

We are starting to learn about the recovery phases of COVID-19 infections: 

• When a patient recovers, antibodies against the virus appear in the blood. It is now possible to measure these antibodies, and such testing will become essential in assessing how safe it is for individuals to resume physical contact with others and travel. Initial results (https://www.medrxiv.org/content/10.1101/2020.03.30.20047365v1.full.pdf) indicate varying patterns of antibody response, suggesting that it will take some time to be secure about safe antibody levels or patterns. This suggests that wearing masks and taking your temperature may remain important to limit spread if a person’s infection status is uncertain. Personal devices, such as the Oura smart ring, which is currently being tested at UCSF (https://www.fiercehealthcare.com/tech/ucsf-launches-study-to-use-wearable-data-from-oura-ring-for-early-covid-19-detection), may prove useful, even essential. Researchers are studying whether data collected by the device, combined with responses to daily symptom surveys, can predict illness symptoms.
• The testing of wastewater for the presence of COVID-19 may provide another guide to the safety of the local region. A study in Massachusetts (https://www.statnews.com/2020/04/07/new-research-wastewater-community-spread-covid-19/?) showed high levels of COVID-19 in the wastewater, even before extensive community spread was known.

New Examples of Resilience 

Adapting to the new normal is a challenge. But we can gain encouragement from the world around us. In Wales, for example, a herd of goats (https://www.theguardian.com/news/2020/mar/31/llandudno-goats-herd-running-riot-coronavirus-lockdown), noticing that nobody was out and about (due to the coronavirus) decided that this was an excellent opportunity to explore the town for food! But the animal kingdom’s top award for innovation in the face of adversity goes to birds, who, a recent study (https://www.cnn.com/2020/04/07/world/birds-new-behaviors-study-scli-intl-scn/index.html) tells us, display extremely creative efforts in pursuit of food. They set bait for fish and track boats that stir fish in their wakes. 

We humans are pretty good at improvising, too. The Connecticut Multiple Myeloma Fighters Information group members, for example, held their first virtual support group meeting on April 8.  “We had the opportunity to see each other and catch up on life as well as myeloma patient safety and the coronavirus,” said Robin Tuohy, Vice President, IMF Support Groups.  “I think what we enjoyed most was just sharing and laughing together. Hearing about opening day and one of our member’s son catching his first fish! Another member shared about his granddaughter being born. Life goes on!”

Life does go on. And we will get through this together.

Translations:

Arabic (https://s3.us-west-1.wasabisys.com/imf-d8-prod/2020-04/Dr%20Durie%20hopeblog_0409_ARB.pdf)  Dutch (https://s3.us-west-1.wasabisys.com/imf-d8-prod/2020-04/Dr%20Durie%20hopeblog_0409_DUTCH.pdf)  French (https://s3.us-west-1.wasabisys.com/imf-d8-prod/2020-04/Dr%20Durie%20hopeblog_0409_FRA.pdf)  German (https://s3.us-west-1.wasabisys.com/imf-d8-prod/2020-04/Dr%20Durie%20hopeblog_0409_GER.pdf)  Italian (https://s3.us-west-1.wasabisys.com/imf-d8-prod/2020-04/Dr%20Durie%20hopeblog_0409_ITA.pdf)  Russian (https://s3.us-west-1.wasabisys.com/imf-d8-prod/2020-04/Dr.%20Durie%20hopeblog_0409_RUS.pdf)  Turkish (https://s3.us-west-1.wasabisys.com/imf-d8-prod/2020-04/Dr%20Durie%20hopeblog_0409_TUR.pdf)