Everyone is anxious to get back to some type of normal after weeks of staying home. However, we need to track closely what is happening in our part of the country and recognize the numbers and procedures the experts will rely on to guide the reopening of day-to-day life.
Returning to this new normal will include an emphasis on three things:
- TESTING, both for COVID-19 and, especially, antibody tests to assess immunity
- TRACING of contacts of those who are COVID-19-positive, followed by quarantine of those contacts, and
- TREATMENTS for COVID-19 while we await vaccine development. These treatments include both drugs and plasma treatments from recovered patients.
In addition, it is likely that in public settings, temperature-testing will occur (upon entering a restaurant, or other activities), a mask will be required, and some degree of physical distancing implemented. We will probably continue to wash our hands a lot and be aware of keeping surfaces in our personal space disinfected.
The Numbers That Can Guide Decisions
- Numbers of cases
- The most important number is how many people have been infected with COVID-19 and have recovered or continue to be infected. For the U.S. this number is most likely between 2% and 5% of the population. We desperately need much more population-based testing to know what the true numbers are in the U.S.
- Numbers as low as 0.9% have been reported from population-based testing in Iceland. South Korea reports that approximately 5% of the country’s population has been infected. For special sub-populations, the numbers can be much higher, including approximately 14% of pregnant women in New York City entering labor and delivery and as high as 40% to 50% in some nursing home or hospice settings.
- The bottom line:
- A substantial majority of people have NOT yet been exposed to COVID-19 and are susceptible to infection if exposed.
- Large-scale testing is urgently required to assess the true rate of COVID-19 positivity and recovery in the population. It is especially important to identify individuals who have safely recovered and those who have not.
- Numbers of people who can become infected if a new case emerges
- This is where tracing comes into play. When any new case emerges, it is urgent to trace contacts to limit spread. Obviously, contacts need to be quarantined or self-isolate. This will require a substantial U.S. work force, estimated at 100,000 people.
- Sophisticated electronic tracing, such as that proposed by Google and Apple, can be used, but this has raised legitimate privacy concerns.
- Super spreaders and high-risk public settings
- Physical distancing is central to reducing the spread of COVID-19. If physical distancing is relaxed, then contact tracing becomes crucial. The recognition of so-called super spreaders is really valuable. These types of carriers, who spread disease to an unusually large number of people, have been noted in prior epidemics. Mary Mallon, who came to be known as Typhoid Mary, spread typhoid to over 50 people while she felt absolutely fine. The same is true for COVID-19: individuals without symptoms can unknowingly shed high levels of virus and spread the disease.
- Such infected individuals, even without symptoms, who participate in meetings and parties have infected many individuals, creating large clusters of 50 or more. In the case of the Connecticut party, the cases produced 65% of the cases in the entire region. Recent data support the notion of regional spread from clusters in the Connecticut region.
- In the absence of physical distancing, rapid identification of such super spreaders is critical. Conversely, most infected individuals produce much more limited spread, perhaps just to family members or close friends. These low spreaders are also important to identify, so that we can assign resources where they are most needed.
- Several work settings require very special attention. As we all know, healthcare workers are not only at high risk for personal exposure but are also in an environment of super spreading. Equally, many jobs with public contacts are at higher risk, such as first responders, transit personnel, grocery employees, and workers at other high-volume essential businesses.
- The impact of delay in the introduction of physical distancing in New York has been the source of considerable controversy. Although we cannot redo the past, we can take careful heed for the future. Early indications of new cases need to be taken very seriously.
The Bottom Line: Tracing
- Rapid tracing is essential to limit spread as physical distancing is relaxed.
- Primary and regular ongoing testing of all who serve on the front lines will be essential.
- Basic PPE (personal protective equipment) must be broadly available. Front line personnel with documented antibody immunity can be both safe in themselves and help limit spread. High-volume testing capability is essential for both antibodies and the COVID-19 virus .
- Rapid testing of contacts linked to all new cases is essential to reduce spread, particularly in the case of a super spreader and / or high-risk settings.
- The length of required quarantine or isolation is still controversial. Recent data from Italy suggest that a longer time span is required since it can take several weeks for the COVID-19 infection to clear, with patients still testing positive long after symptoms have gone. Many patients in the U.S. already note the long road to recovery.
Guidelines are required to reinstitute physical distancing if a certain number or pattern of new cases emerges:
- Church group meetings, for example, have been a source of concern and could be limited. Very large gatherings will not be feasible in the short term.
- Guidelines for travel will be essential to limit local, regional, interstate, and international spread. Global travel will certainly be impacted by the many difficulties and tragedies emerging in so many countries. Resources are just not available to handle this COVID-19 crisis, as this New York Times editorial points out.
- Since global trade is part of the old normal, the new normal will be very different. Providing help to the less fortunate will be key.
- Myeloma treatment
- During the current crisis, decisions are being driven by a need to avoid exposure to COVID-19. The goal is to make fewer visits to high-risk medical clinics and hospital settings. Telemedicine is a good option. Delays in intense therapies, such as ASCT, plus reductions (if safe) of IV or SQ therapies can be discussed and considered.
- The new normal here can hopefully be like the old normal. However, there will be more telemedicine for day-to-day issues. We strongly hoped that the full range of therapies can be reinstituted in the coming months, as resources become available and full protections are in place in medical settings. It is key to have an open, ongoing discussion with your doctor as conditions improve in your city.
- COVID-19 treatments and vaccines
- Vaccines: It is unanimous that a vaccine is central to ending the COVID-19 pandemic. The excellent news is that many, many efforts are underway to develop an effective vaccine. The not so good news is that it will take time. Extreme optimists say 6 to 9 months. The majority, realistic opinion predicts a vaccine will be available in 12 to 18 months.
- Treatments: Encouraging treatment approaches include the management of the shock or crash syndrome for very ill patients. It was heartwarming to read the story of an emergency room doctor (a previously healthy former football star), who recovered from a dire situation using a cytokine-storm treatment of Actemra (tocilizumab).
As we marvel at the heroism of the healthcare workers, it is great to know that there is not only this strategy but the use of plasma from patients who have recovered from COVID-19 to accelerate recovery. There continues to be uncertainty about the value of hydroxychloroquine (Plaquenil). A recent trial was discontinued due to serious cardiac issues with the use of higher doses of the drug. It is exciting that a myeloma therapy, Selinexor, can have value as an antiviral agent.
How to Get Through the New Normal
There is little doubt that the coming months will be challenging. We will need as much resilience as possible and continue to be aware of the world around. And, as artist David Hockney said: “Do remember they can’t cancel the spring.” The many flowers bursting forth each day remind us that life goes on and will emerge and adapt together.
As we look to all our scientists to come up with treatments and a vaccine, it is extremely interesting for me to note that the original coronavirus was discovered by June Almeida, a Scottish woman scientist from humble beginnings not fully recognized for her achievement. So, in closing, let’s honor all of the individuals like June Almeida, who serve on the frontlines of healthcare crises, both past and present. We need collaboration and compassion as never before to get through this together.
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®.