May 21, 2020

As cities across America start to reopen, how should myeloma patients react? This week, two of the world’s top medical journals, The Lancet (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31140-5/fulltext) and The New England Journal of Medicine (https://www.nejm.org/doi/full/10.1056/NEJMp2014836), offered their assessment of the U.S. pandemic response. Unfortunately, America’s report card is not good when compared to countries such as Taiwan, South Korea, Germany and New Zealand, where testing and tracing were begun early and controlled infection spreading in the community.

The bottom line is that myeloma patients in the U.S. are largely responsible for their own safety on reentering community life and, hopefully, returning to the myeloma clinic, doctors’ office or the hospital, if needed.

What are some key points to guide decision-making in the weeks to come?

Consider the Status in Your Community

COVID-19 infection is still widespread in communities across America. As emphasized in a recent Los Angeles Times editorial (https://www.latimes.com/opinion/story/2020-05-21/coronavirus-high-risk-groups), individuals at a higher risk of a threat from COVID-19 are more common than you might think. These higher risk groups include people of color, those with diabetes, obesity, hypertension and chronic lung or kidney disease, to mention a few. This covers about half of Americans.

Avoid Contact with People Who Are COVID-19 Infected

Let’s start with the good news. COVID-19 infections in myeloma patients have been occurring at much lower rates than expected for individuals with compromised immune systems. It seems that a major factor keeping them safe has been the protections that all myeloma patients have learned. 

In general, infections have been acquired in the community, NOT following visits to a clinic or hospital. Except during the massive infection surges, when systems broke down, vulnerable patients were very protected and rarely, if ever, developed infection in the hospital setting. 

This is the good news about the efforts to return to the new normal (or abnormal). With these protections in place, it is hoped that in June or July myeloma doctors can reopen their offices for treatment and/or expand procedures, such as ASCT (and harvesting stem cells), and other more intensive treatments, as well as clinical trials. Some centers are already starting these activities.

How to Avoid Infection in the Community Setting

Since infections are likely not happening through doctor visits, what are the situations that carry the highest risk for myeloma patients?

Large events of any type

A recent study published by the National Academy of Sciences (https://www.wsj.com/articles/superspreader-events-offer-clue-on-curbing-coronavirus-11589977873?), along with a series of other reports, indicate that virus-laden aerosol spread can rapidly transmit COVID-19 infection in large group settings. These are called “super spreader events” and have been the source of most major regional outbreaks of COVID-19 at everything from Mardi Gras celebrations (https://www.nola.com/news/coronavirus/article_dedfb5e4-7c2a-11ea-901f-6720fa25be5a.html) to a large biotech corporate meeting (https://www.biospace.com/article/approximately-100-covid-19-cases-stem-from-biogen-meeting/)to churches and nightclubs in South Korea, a carnival in Germany, a ski resort in Austria, and the list goes on. It is not known if individuals who are super spreaders have a much higher load of virus or just more aggressive disease. Some scientists think that just banning mass gatherings may be enough to keep the COVID-19 pandemic in check. 

So, myeloma patients especially should avoid large events of any type where unknown individuals can spread infection. This will be difficult due to the pent-up desire to return to sporting events, concerts and the like, but can reduce excess sickness and deaths while preserving a huge component of the economy. For example, researchers at Columbia University estimate (https://www.nytimes.com/2020/05/20/us/coronavirus-distancing-deaths.html?) that if the U.S. had begun imposing social distancing measures one week earlier than it did in March, about 36,000 fewer people would have died in the coronavirus outbreak.

From a public health standpoint, large events are a serious risk. If an individual who is a super spreader is in a small group setting, early spread can be detected and contained, as has been achieved successfully in several countries, such as Germany. As a result, spread to the larger community is avoided. It will be great if this can occur in America.

Mass transit travel 

Many innovative changes, like using UV light to sterilize empty train cars (https://www.theverge.com/2020/5/20/21265221/nyc-mta-ultraviolet-light-uvc-coronavirus-disinfect-puro-pictures), are required to make trains, subway cars, planes and other forms of mass transit safe. Qatar Airways is now requiring onboard crew to wear hazmat suits (https://www.cnn.com/travel/article/qatar-airways-full-body-cover-protection/index.html)! But for now, myeloma patients should continue to avoid any type of mass transit.

Activities to Modify and Stay Safe 

Some activities carry risk, but we cannot completely avoid them. Good hygiene, masks and physical distancing must continue:

• Grocery shopping: The FDA offers guidelines (https://www.fda.gov/food/food-safety-during-emergencies/shopping-food-during-covid-19-pandemic-information-consumers) for keeping safe while shopping for food during the COVID-19 outbreak. Although there have been well-chronicled risks for grocery store employees, there have been very few instances of spread to customers, and certainly not from food directly.
• Restaurants: It is still best to avoid although there are some safer options with outside patios, plexiglass and the like. Please note: There HAS been important spread coming from restaurants and bars.
• Hair salons: These are opening in some states. Like mass transit, creative solutions are being explored here, including reducing numbers of patrons, spacing out appointments and even giving haircuts in the park. We need to monitor this development.
• Visiting with grandchildren: This is a very important matter for many myeloma patients. The New York Times published a guide to visits in an article titled “When Can I See My Grandkids? (https://www.nytimes.com/2020/05/20/well/family/coronavirus-grandchildren-grandparents-when-can-i-see-my-grandkids.html?)” The author suggests considering the number of contacts each family has had in the previous weeks when determining if it’s safe to visit. 

Vulnerable Communities

Many communities are not only vulnerable due to health issues, but also because of socioeconomic factors that make it impossible to physically distance or access food, avoid mass transit or communal settings. Just as there must be a social commitment to NOT infect others (by wearing masks and taking sensible precautions), it is important to help others get through this safely as well. We ARE in this together.

The Navajo Indian nation (https://www.cnn.com/2020/05/18/us/navajo-nation-infection-rate-trnd/index.html) is being ravaged by the COVID-19 pandemic. Self-isolation is not possible for families living in a single room without electricity or water. Tribal members go to communal sites for water pick-up and other activities. African Americans (https://www.theguardian.com/world/2020/may/20/black-americans-death-rate-covid-19-coronavirus)have been adversely affected across the country in disproportionate numbers. In Louisiana, not only did Mardi Gras function as a super-spreader event, but the communities were just not able to cope as more and more at-risk individuals became infected.

The Good News

• Physical distancing, masks, careful and frequent hand washing, and all the details we have emphasized DO work in protecting us from infection by this crazy COVID-19 virus. But please exercise caution as you venture back into our old-world activities. It would be great if we lived in New Zealand (https://www.nationalgeographic.com/travel/2020/04/what-new-zealand-did-right-in-battling-coronavirus/), and re-entry to the community setting was much less of a challenge and risk. But unless you are hiding on an island somewhere (as some are), we need to take great care as we continue to live in this new abnormal.
• There is promising, although very early, news on the vaccine front. A few of the over-100 efforts presented good safety (https://www.nytimes.com/2020/05/20/health/coronavirus-vaccine-harvard.html) and some efficacy benefit (https://www.statnews.com/2020/05/18/early-data-show-moderna-covid-19-vaccine-generates-immune-response/) in preliminary testing this week. Let’s hope that one or more will hit the jackpot and provide efficacy and protection with an excellent safety profile.
• I have mentioned changes in preferred food items grocers are reporting while their customers are on lockdown. We are eating more processed and “comfort” foods. Another item reportedly becoming popular (not my personal favorite) are canned cocktails (https://www.nytimes.com/2020/05/14/dining/drinks/canned-cocktails-coronavirus.html), which make mixing a one-step process. But then again, perhaps you prefer to stick with orange juice!

Until things get safer, please stay protected as much as possible.

Translations:

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