September 3, 2020

As the COVID-19 pandemic wears on, it is more and more difficult to simply stay at home to stay safe. With some schools reopening, and interactions with people and in places outside your own safety bubble (https://www.myeloma.org/videos/covid-19-faq-20-bubble-should-myeloma-patients-exercise-practice) becoming all but inevitable, what types of guidelines should myeloma patients follow when they need to venture away from home?

A Personal Car Trip

First of all, one has to acknowledge that all ventures out into the community carry some risk of exposure and COVID-19 infection. The goal is to keep the risks as low as possible. A recent New York Times article (https://www.nytimes.com/2020/09/01/travel/road-trip-safety.html) offered many helpful tips for taking a safe car trip.

• Putting gas in the car 
  Definitely wear a mask, since others may be close by. Use hand sanitizer before and after refueling. Although the risk of transmission from so-called fomites or surfaces you touch is relatively low, it is good to be very cautious. All of this is very similar to the precautions taken when going to the grocery store (https://www.myeloma.org/videos/covid-19-faq-6-precautions-should-myeloma-patients-take-when-getting-their-groceries).


• Choosing quiet times for activities 
  The key source of COVID-19 infection is spread in the air from people with infection who may or may not be symptomatic. All outside activities are much safer than indoor activities because of the ventilation. A recent description of a COVID-19 super-spreader event during a bus ride (https://www.nytimes.com/2020/09/01/health/coronavirus-bus-china.html) illustrates the danger of prolonged exposure when ventilation is poor. But even a busy outside patio can pose increased risks. Food pick-up or delivery is an excellent option for reducing the number of contacts. “Ghost Kitchens” (https://thespoon.tech/can-ghost-kitchens-save-the-vanishing-restaurant-biz/) are springing up everywhere and provide excellent, high-quality food.


• Staying overnight at a hotel 
  This can be considered if rigorous precautions are taken. The key question is: “How long has the room been unoccupied?” If the answer is three days, then the room should be COVID-19 free. It is important to check in and out at quiet times, if at all possible. Avoid indoor restaurants and bars, as well as all confined spaces. 

So, going on a trip can be accomplished, but planning and thinking ahead are essential!

Understanding Your Immune System

• Interferon
  A recent Washington Post article (https://www.washingtonpost.com/science/2020/08/31/interferons-coronavirus-immune-boost/) highlights how COVID-19 infection hijacks the body’s immune system. The COVID-19 virus shuts down the production of interferon (type 1 interferon, a natural protein), which normally fights the virus. This means that the virus keeps building up and triggering other parts of the immune system, in some cases, seriously over-stimulating and leading to damaging inflammation in, for example, the lungs. Several research groups are now looking at treatment with interferon to break this dangerous cycle and control virus replication. As with so many things, timing is everything, and the best impact will probably be early in the infection. So, stay tuned. There promises to be exciting data coming relatively soon to illustrate the level of benefit that can be achieved. 


• COVID-19 and myeloma treatments
  For myeloma patients it has been amazing to note that many myeloma treatments, rather than reducing the immunity against COVID-19, might actually be helpful in shutting down the virus. A new analysis (https://jamanetwork.com/journals/jama/fullarticle/2770277) in JAMA shows that dexamethasone treatment does indeed improve outcomes with COVID-19.  Interferon treatment, noted above, was also used as treatment for myeloma for several years. When options for myeloma therapy were very limited, I had several patients who remained in remission for several years with interferon treatment. This worked best in patients with IgA myeloma. Selinexor, recently approved for relapsed/refractory myeloma (https://www.fda.gov/drugs/resources-information-approved-drugs/fda-grants-accelerated-approval-selinexor-multiple-myeloma), also has anti-virus properties, as do both IMiDs and proteasome inhibitors, to varying degrees. All of these findings lend credence to the notion that viruses can perhaps be triggering myeloma. 

COVID-19 Antibodies

• Naturally developing antibodies
  A major part of the body’s response to COVID-19 is the production of antibodies, so-called neutralizing antibodies, which can destroy the virus. A recent detailed study of naturally developing COVID-19 antibodies (https://www.nejm.org/doi/full/10.1056/NEJMoa2026116) was published in the NEJM. This study from the deCODE genetics facility in Iceland (the home of the IMF-supported iStopMM Black Swan projec (https://www.myeloma.org/black-swan-research-initiative/istopmm)t) was quite reassuring because it revealed that antiviral antibodies lasted for at least four months in individuals recovering from COVID-19 infection. Of interest, approximately 56% of positive antibody tests occurred in those with known COVID-19 infection, however the others were unknown and had not been directly tested. 


• Herd immunity
  There are many interesting and important aspects of this study. It was estimated that 0.9% of Icelanders were infected by COVID-19 and the risk of death from infection was 0.3% —both very low (versus other countries). This means that Icelanders are at risk of a second wave of infections. However, the low infection rate is much preferable to herd immunity. Herd immunity is achieved when a large part of the population is immune to a specific disease by becoming infected. Yes, with herd immunity additional infections will be lower moving forward. But the toll of infections and deaths is extraordinarily high and unacceptable. For this reason, most experts consider any push for herd immunity truly unethical. In addition, the occurrence of second COVID-19 infection (https://www.cnn.com/2020/08/24/health/covid-19-reinfection-hong-kong-study/index.html)suggests that the risk of ongoing infections persists. 


• Convalescent plasma 
  Convalescent plasma has been used as a way of giving antibodies from those previously infected to those struggling to fight the disease. Problems with this approach include the frequently low and quite variable levels of antibodies in the plasma of patients who have recovered from COVID-19. Results of studies so far were recently released. Although the FDA granted Emergency Approval (https://www.fda.gov/vaccines-blood-biologics/investigational-new-drug-ind-or-device-exemption-ide-process-cber/recommendations-investigational-covid-19-convalescent-plasma) for use of convalescent plasma, a follow-up NIH analysis (https://www.cnn.com/2020/09/01/health/coronavirus-plasma-nih-panel/index.html) concluded quite decisively that not enough positive information exists to recommend the use of convalescent plasma as treatment. There was only a 3% difference in outcomes, and more studies were strongly recommended.

Current Perspective on Staying Safe

Although every day we are learning more and about COVID-19, how to stay safe and how to manage or prevent infection, myeloma patients must remain careful and cautious to avoid exposure and infection. Wearing masks is a mainstay of prevention. Telemedicine (or emails and phone calls) continues to be very important to reduce the number of expeditions into the community, especially if the infection rate is greater than 5%.

This is the percentage being used as a safe cutoff for reopening of schools. Always remember that those without symptoms, including children, can be infected and infectious. In addition, a majority of new infections occur within households of families (and friends). If a family member or friend is out in the community, this can be the source of infection for the whole group.

As far as a possible vaccine, there is tremendous hype in the media right now. The key point is that it will definitely take some time, months perhaps, to know if a vaccine is both safe and effective, particularly for patients with myeloma. Think of it as something that will help in 2021, but not something to rely on sooner than that.

Staying Sane, As Well As Safe

Please also remember to continue to connect socially, if virtually. The IMF is now helping over 90 myeloma support groups to connect via Virtual Support Group Meetings (https://www.myeloma.org/support-groups), with guest speakers and other program items as needed. Please reach out to the IMF to get any help that you need, even if it’s to find a blow-up movie screen to watch movie in the backyard or organize a virtual barbecue or joint cooking class or celebration with friends before the summer ends. 

Please stay safe!

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