Coronavirus: What Transplant Recipients Need to Know

Presenters:  Areej El-Jawahri MD, Director of the Bone Marrow Transplant Survivorship Program, Massachusetts General Hospital; Alyssa Letourneau MD, MPH, Medical Director, Antimocrobial Stewardship Program, Massachusetts General Hospital

Summary:  The COVID-19 virus poses a significant health risk for certain transplant recipients. As treatment options are limited and there is currently no vaccine, protecting yourself against getting the virus is the best stratgey to reduce the risk of developing a severe or fatal case of the disease.

Highlights:

• COVID-19 is highly contagious. Each COVID-19 patient will spread the infection to 2-3 other people
• COVID-19 can be infectious up to 72 hours on plastic and stainless steel, and up to 24 hours on cardboard
• Certain transplant recipients are at a higher risk of developing a severe case of COVID-19
• The best strategy to protect you against coronavirus is not get infected in the first place

Thank you to Incyte Corporation for supporting this presentation.

Tips for Coping with Anxiety During the Coronavirus Crisis Click Here

See a story about a transplant survivor who battled COVID -19  Click Here

Transcript:

Sue Stewart (00:08): Welcome to today's webinar: Coronavirus: What Transplant Recipients Need to Know. This webinar is being sponsored by Blood and Marrow Transplant Information Network or BMT InfoNet, and I will be your host today. My name is Sue Stewart and I'm the Executive Director of BMT InfoNet. Before we begin, I'd like to thank the Incyte Corporation for supporting this event, and also to let you know that if you're unfamiliar with BMT InfoNet, we provide information and emotional support to transplant recipients before, during, and after transplant. I encourage you to visit our website, www.BMTInfoNet.org after this event to see the wide range of services we offer.

Today's webinar will feature presentations by our two experts, followed by a question and answer session addressing the questions you submitted when you registered. We will try to address as many of your concerns as possible. This webinar is being recorded and will be available for viewing on BMT InfoNet's website following the live event so you can go back and check it out or share it with others who may be interested.

Let me now introduce our speakers. Dr. Areej El-Jawahri Is a transplant physician and Director of the Bone Marrow Transplant Survivorship Program and Associate Director of the Cancer Survivorship Program at Massachusetts General Hospital. She's also an Instructor of Medicine at Harvard Medical School.

Dr. Alyssa Letourneau is an infectious disease specialist and Medical Director of the Antimicrobial Stewardship Program at Massachusetts General Hospital. She's also an Instructor of Medicine at Harvard Medical School. Please join me in welcoming Dr. El-Jawahri and Dr. Letourneau.

Alyssa Letourneau (02:08): Thank you. Thank you for having us. I would say that I'm not technically an expert in COVID-19, but I am an infectious disease physician and work with Dr. El-Jawahri in taking care of our transplant and hematologic malignancy population here at Massachusetts General Hospital. Everything we're sharing today is what we know, as of now, in terms of COVID-19 and I'll go through the outline and hopefully we can answer most of your questions.

So, we'll talk about, what is COVID-19? How is it that we differentiate this virus from the flu? Who are some of the folks that are at risk for this infection?

Dr. El-Jawahri Will talk about COVID-19 and transplant and things we were thinking about in that realm, how to avoid getting sick, which I think is probably one of the most important things we can talk about today and hopefully that you will take home with you or keep home with you, I should say, while you were at home hopefully watching this, listening to this and then COVID-19 and sort of the public health problem that we are seeing.

(03:07): ​So, COVID-19 is a novel virus. It's a member of the coronaviruses which we have seen previously. So, SARS and MERS viruses are both in the coronavirus family. There are coronaviruses that also cause just the regular runny nose that we see in lots of kids that don't tend to be as severe. But we know that this type of COVID-19, this SARS coronavirus two, as it is called or COVID-19 disease, which is the way we will call it since that's easier to say, is one of these in the member family where we see patients get very sick and unfortunately, it is more infectious than we typically are used to.

We do call it COVID-19. I'd like to just state here that people should not be calling it the Chinese virus. This is COVID-19 as discussed by the WHO and how the medical community is referring to it.

This virus originated in bats, we believe, and may have had another animal that it went into prior to coming to the human population. But essentially, we know that many viruses are infectious in animals and that they jump over into the human population and this is where we see a lot of novel viruses that cause pandemics. So the H1N1 flu virus back in 2009 and 2010 also jumped from the animal population.

This virus originated in Wuhan, China. We do expect it and what we're seeing is that it probably infects about two to three people when folks are exposed. So if someone has the infection, the rate at which it infects others is about two to three. That's called an R naught for those of you who have been watching the news recently.

And to just compare it, this is similar to the flu pandemic from the 1918 time-frame in terms of the all of the people who were infected around the world. This is a similar infectious rate as that.

After people are exposed, the average time to which patients come in with symptoms is about five days, but it can range from 24 hours to two weeks and that's where some of these two week quarantines are coming in when we think about that.

We do believe that some people may be infectious prior to presenting with symptoms, which is why this has probably infected many more people than expected. The other issue with infecting many more people than expected is that humans have not seen this virus before, this strain of virus and therefore none of us have immunity to it.

The cases as of the 18th are listed there on your screen. I looked this morning to see what they are reporting for today, and it's 256,000 cases worldwide of COVID-19. There are approximately 10,500 deaths from this disease. About 90,000 people who have recovered or known recovered for the United States for the same date for today, we have about 14,549 cases in the United States with about 218 deaths. So in terms of cases, we're seeing most of these cases in adults. There are fewer cases in kids. And again, we're not sure why that is. We're still trying to figure that out on a scientific level.

It's primarily transmitted from human to human via droplet and close bodily contact and bodily fluids. So basically, coughing, sneezing, and then having those droplets on your hands and then you're touching your nose and your eyes and your mouth, that is the typical way that it is transmitted. We're uncertain in terms of whether or not it lingers in the air after someone has coughed or sneezed.

We don't think it's like the measles virus. Measles is the most contagious virus that we are aware of where if somebody is sick with measles and coughs, the virus can remain airborne and remain in that air for two hours after somebody has been there, which is why measles outbreaks become a problem in terms of contact tracing when somebody has been ill with measles. So, we do not think that it's similar to that, but we do know that when people cough and sneeze and are within close range to you and that gets in your face, essentially you can become infected.

It can be stable we believe on plastic and stainless steel for about 72 hours and on cardboard for about 24 hours. These are data that were just released earlier this week, so hence the importance of washing your hands after touching things because the virus may be living on there.

About 81% of cases are mild is what we're seeing. About 14% are severe. And then, we have about 5% that are critical. And then looking at who is coming into the hospital, it's about 15 to 25% of patients require hospitalization and potentially ICU level care.

So, how does COVID-19 differ from the flu, which is the thing that we think about the most as most of us are aware of the flu? So, both of them can present with fevers. Both of them can present with sore throat. Oh, sorry. With myalgia, which are the muscle aches and pains that most people associate the flu with and feeling terrible and needing to stay in bed. The flu less commonly has sore throat, but we have been seeing that as a symptom that people are presenting with for COVID-19. Nasal and sinus congestion is much more common in the flu and less common in COVID-19, but doesn't mean that you wouldn't have that. The cough is different for the two as of now that we're seeing, is that it's productive or people are producing sputum. There's stuff coming up when people cough with the flu. And typically, with COVID-19, it's a dry cough with no sputum or phlegm coming up when people are coughing. With the flu, people don't typically get shortness of breath. In the beginning, they may get a pneumonia on top of the flu, but for the most part, people don't have shortness of breath, whereas with COVID-19, shortness of breath is a common presentation and typically can happen in the first several days to a week of their presentation after being symptomatic.

In terms of how people do if they're older or immunocompromised, what we know is both diseases that that is a risk factor for worsened disease. The risk of death we know from the flu is about 0.1% in this day and age, and from COVID-19, it ranges from one to three percent. That number is based on the numbers of people we've been able to test. And so perhaps at the end of this, it may be lower than that, but we still are very concerned with this number initially and we are taking this very seriously.

In terms of treatments, there are treatments for the flu. We have antivirals that help treat the flu that work very well and we have several types of antivirals that we can use to treat the flu. Unfortunately for COVID-19, right now there is no proven effective therapy for COVID-19. Again, there's no proven effective therapy for COVID-19. There are studies across the country that are working to see if something called Remdesivir is working. It's an antiviral medication that is not FDA-approved and there are clinical trials at academic centers across the country and the world that are studying this drug currently. There are other drugs that have been published and there are thoughts that perhaps they work, but it's unclear again whether they work and these are all experimental treatments.

There is a vaccine available for the flu, as you all know. You all probably get your flu vaccination every year and I would encourage that as long as your doctor agrees with you in terms of what you're on for immunosuppression, but we say almost everyone gets a flu shot every year. Unfortunately for COVID-19, the fact that it's such a new virus that we are seeing, there is no vaccine available currently. They have just opened up a clinical trial to test the safety of a vaccine for COVID-19, but the safety of it is the start and then it would take at least 12 to 18 months before we had something active on the market for that. And from my understanding, it would not be a live vaccine. This would be similar to the flu vaccination that we have now.

Who is at risk? So, the people that we have seen that have had more difficulty with this disease or been sicker with this disease are people who are over the age of 60, people who have any underlying medical conditions such as heart disease and or lung disease, so people who have asthma or COPD or something called bronchiectasis, and we see that they tend to be more sick with this infection. Patients on hemodialysis as well would be at higher risk. And then people who are receiving cancer treatment or who are on immunosuppressive medications would also be at higher risk of having severe disease from this infection. And as I said, the infection seems to be more severe and these high risk groups.

This is just a figure that was pulled on data for March 16th from the United States from February 12th sorry to March 16th and looking at people who are hospitalized for COVID-19 or presumed COVID-19 in terms of their age group. And so, this is just to show that just because you're young doesn't mean that you escape hospitalization. And then, you can see that the hospitalizations are in light blue, the intensive care unit admissions are in the medium blue and then the dark blue are the deaths. So, the ICU admissions increase with age as well and then the deaths also increase with age. And then, I'll turn it over to Dr. El-Jawahri to talk about this with transplants.

Areej El-Jawahri (12:39): So, a lot of the questions that we are seeing in the chat are all related to some of these issues relating to transplant risk. I would say that we should say that first of all, our data are very limited on transplant recipients with COVID-19, but we have a lot of experience with respiratory illnesses in general in the transplant population that can help guide us.

So, we know that any transplant recipient, allogeneic transplant recipient who's on active immunosuppression regardless of their age, are considered high risk for complications of any respiratory viruses and COVID-19 will not be an exception to that. So, I'll repeat that one more time: allogeneic transplant recipients who are active immunosuppression, whether it's tacrolimus, cyclosporins, steroids, regardless of their age are a higher risk of complications. People who have had an autologous stem cell transplant less than six months from their transplant are also at higher risk of complication, okay?

Transplant recipients who are off all immunosuppression who are greater than two years from transplant, this is for allogeneic transplant recipients more than two years out who are off all immunosuppression, your risk is similar to the normal population. So, this is no graft-versus-host disease, allogeneic [transplant] greater than two years ago]. We think your immune system is fully immune competent and your risk should be similar to the normal population. That being said, this is a disease that hits the normal population hard as you saw from Dr. Letourneau's talk, so that does not mean you're not at risk. It's just similar to the normal population.

For autologous transplant recipients, generally speaking, greater than six months from transplant, you are also similar risk to the normal population given your level of immunocompetence.

The other thing to talk about, transplant recipients with other medical conditions like heart disease, like lung disease are also at high risk, so these things add up, so just keep that in mind. So, if you are a transplant recipient who is not on a ton of immunosuppression, not on immunosuppression but have some underlying lung issue as a result of your transplant, you are considered a high risk patient.

A lot of people are asking about IVIG. We don't know that IVIG is protective against COVID-19. We know that it helps a little bit with some respiratory infections, although the data on that are also mixed. So IVIG, I would not consider that a protective agent against COVID-19.

And as Dr. Letourneau highlighted, we don't have available treatments or vaccine for COVID-19. Treatments right now are supportive and the best way is to really avoid getting sick. That is the key way to reduce your risk from COVID-19.

Just a little bit about COVID-19 and transplant and its impact on the transplant community as well. I would say that many, many transplant centers across the country and we've been in touch with many, are delaying less urgent transplant with COVID-19. So, elective transplants are essentially being delayed until we have a better sense of what's happening. It's hard to say myeloma autologous stem cell transplants are elective, but they are, meaning that we have the luxury of doing them at a later time. And so most transplant centers, for example, that's an example of an auto transplant that has been delayed.

Whether you should have a transplant or not is really a conversation you should have with your doctor. A lot of transplants are more urgent and unfortunately cannot be delayed, such as transplants for leukemia, for example. So, you need to talk to your doctor about whether you should have a transplant now or whether it's safe to delay it. But the majority of transplants we cannot delay because if we delay, we would not be treating the underlying disease.

I know some of you are concerned about transfusion transmissions and transmissions from donors. And unfortunately, given the paucity of tests, we don't have a ton of tests in the country right now. Stem cell donors are not being tested routinely by a COVID-19 test. However, the National Marrow Donor Program has really developed a very rigorous process that includes an extensive health screen or any travel to high risk areas, any symptoms. And as you guys know, a lot of these donors are watched for a period of time. So, we would have a sense if somebody's developing any symptoms and that information we will have before they donate. So again, currently donors are safe. We are checking their status. And so, even though we're not giving a COVID-19 test, particularly to every donor.

So, the biggest and most important thing is to talk about how to avoid getting sick. Washing hands with soap and water for at least 20 seconds frequently throughout the day, keeping your hands below the shoulder and avoiding your face.

I know one of the comments said that the CDC guidelines say that the virus lives in air up to three hours. Your biggest, biggest risk of getting COVID-19 is being in close contact with people who might be sick. It really is a virus that is transferred through droplets, meaning anybody who's sneezing or coughing on you, that is the major most common way to get infected. So, if somebody sneezes on a table and you walk by and you touch that table and then you touch your face, you can get infected that way. And so, this is why washing hands, social distancing, which I'm sure you guys are hearing a lot about in the news right now, and avoiding crowds is the key way to prevent getting sick.

For our transplant patients at risk, I really urge you to stay at home as much as possible, to have younger family members who are not at risk bring you groceries, things that you need and leaving them at the door to avoid extra exposures. Staying at home is the best way to protect yourself from getting sick. I should note that I know that that's hard to hear, but at the same time, walking outside in open air while staying away from other people is okay to do. So, walking outside, it's fine. Just try to avoid going to grocery stores, try to avoid going to pharmacies, try to stock up on the things that you need.

Cancel all travel. That is very, very important and I'm talking mostly about air travel. Obviously if you are traveling in your car and you're alone or with someone else, that's probably okay. The idea behind canceling air travel is really avoiding getting sick from a crowd of people.

We should note that as you guys have seen, the situation with COVID-19 is evolving over time and one of the concerns that our patients have when they come to us to clinic or through a virtual visit, they say to us, "If I go somewhere, if I need to go and help a family member or I travel somewhere, will I get stuck there?" And the answer is, it's possible. It's possible that you would go somewhere and be stuck there because obviously as you can see, the policies are changing very rapidly. As you guys know, California now, and it sounds like in New York as of today, have a shelter in place order. So, I do think this is going to be evolving. And so, if one of your concerns is, "Can I travel and will I be stuck?' And the answer is, you probably could be stuck somewhere. So, avoiding travel is key.

For other questions relating to going to physicians, doctors appointments, dental appointments, cancel all non-essential appointments and procedures. Your transplant team, your institutions are doing the same thing. We can tell you what's happening here at Mass General. We are essentially going through every single patient who's scheduled to see us in the transplant clinic and transitioning any of them that we can transition to a virtual visit and we're seeing them all virtually and avoiding them having to come to clinic.

Anybody who's a long-term followup, we're essentially postponing their visit here. We are only seeing people who absolutely need to be seen, people within the first 100 days post-transplant essentially are the only ones that are coming to our clinic. So any non-essential appointments: if you have your colonoscopy, if you have your mammogram scheduled, if you have a dental appointment, those should be canceled. Avoiding going to these offices, even if you have a routine appointment with your PCP, this is the time to cancel it and postpone it. Some places are going to be reaching out to you. Some institutions will be reaching out to you and asking you to cancel and postpone these appointments, but that may take some time. But from your perspective, I would say any non-essential appointments, please cancel.

Limit your visitors at home as well and keep a good distance. Six feet distance is relatively safe. I can highlight how important social distancing is. One of our colleagues is sick with COVID-19 and her partner is with her at home and he did not get sick primarily because they did social distancing. So, it's very possible to do social distancing even in your own home.

And again, I think we heard this all relatively recently, I think the average person touches their face about 200 times an hour or something like that. So, I think we need to avoid touching our face. We need to wash our hands; we need to just be cognizant of our environment.

Most of your household disinfectants work. We can talk a little bit more about, essentially anything with 70% and higher ethanol content will kill the virus. So, I know some of you are worried about having disinfectants at home. They are still available. They will be available. We expect disinfectants or household disinfectants to be available to buy. I do think the demand went up very acutely and it was hard for people to keep up and stores to keep up. But we do suspect the stocks will be available of these. So, don't panic. Those will be available to you.

And then, I do want us to spend a little bit of time talking about the big public health problem that we are facing as a nation and across the world. We, even if we are in the low risk group, even if we expect that we may not get as sick with COVID, although we've seen a lot of young people also get sick with COVID-19, we can help our healthcare system manage patients who get sick with COVID-19 by doing our social distancing, by staying at home. We can literally save lives. We are worried that we're going to have too many people sick in a very short period of time and we would not be able to manage them in our hospitals, provide adequate supportive care for them in the hospital, in the clinics, in the intensive care unit. And if we are able to flatten the curve and this curve you've seen on the news multiple times now, our healthcare system can actually save more patients than we would if the surge continues the way it is right now. So, we all have a responsibility for this. This is young, old, this is immunocompetent or immunocompromised. The more we do in terms of social distancing and staying at home will help our entire world, our entire globe deal with this virus.

There are resources on these slides deck that are available to you. The Center for Disease Control is a great resource to go to. They have up-to-date information. The World Health Organization also has a good website. There is a link on how to protect yourself from the CDC website that is also available here to think about.

And I think we are going to transition to questions. I know we got a lot of questions through the chat. We'll try to answer as many of them as we go. We'll go through several questions that we received from some of you prior to all of this and then we'll try to have our BMT InfoNet team walk us through additional questions.

Areej El-Jawahri (25:39): So the first question we have, if you have COVID-19 once, can you get it again?

Alyssa Letourneau (25:44): So, I'll take this one. From what we've seen, we do not think that you will necessarily get it again if you've had it once. Obviously, this is a new disease process. There were some reports out of China that a young woman had been infected twice, but it's unclear how robust her immune response was the first time around, meaning how infected was she? Did she just have a runny nose or did she have severe disease? So if you are runny nose and cough, perhaps your immune system has a more robust response. There are some preliminary primate data, so studies in monkeys that would suggest that you do not become reinfected once you've been infected with this virus, but more to come. And again, the vaccine studies will help us figure this out as well.

Areej El-Jawahri (26:28): The next question we have, should I stop taking my immunosuppressive medications? The answer is no, please don't stop taking your immunosuppressive medications. The reality is that those medicines are there for a reason and if you stop them abruptly, you may risk developing worst graft-versus-host disease and as a result, meaning much higher immunosuppression that you're on now. So you know, I think it's really important to talk to your doctor about your immunosuppressive regimen. But the answer for most of our transplant patients, if not all, that we should not be stopping immunosuppressive medications. We should be really working on social distancing and trying to stay safe.

Areej El-Jawahri (27:15): Are there things that I can do to boost my immune system?

Alyssa Letourneau (27:18): So I'll take that one as well. So the biggest things are the normal things that I think all our physicians tell us, which are eat well, get a good amount of sleep, which for most is seven to eight hours a night, and try to do some sort of exercise. And obviously exercise might be a difficult thing to do in this day and age, especially if you have to shelter in place. But even just moving around the house, walking back and forth, you know down your hallway, up and down the stairs, something to get your heart going. It is unclear whether any sort of immune boosters or certain vitamins would help prevent this or prevent infection that is unclear. And so it's the basics. It's eating well, sleeping well and trying to get some exercise in.

Areej El-Jawahri (28:04): If I feel sick home whom do I call? So this depends a little bit on your current care team. It is fine if you have concerns always to call your transplant physician. I think the question is really should I call my transplant doctor, should I call my primary care physician? If you are someone who is healthy, who has been years out from transplant, who's not on immunosuppression and you don't have any graft-versus-host disease and you've been following fairly routinely with either a local oncologist or a primary care physician, those are the people to call if you're sick. On the other hand, if you are following regularly with a transplant physician and or you're on immunosuppression and if you have graft-versus-host disease it's probably best to get in touch with your transplant team. When in doubt and when you don't know, you can always contact both. Clinicians are happy to answer questions during this difficult time.

Alyssa Letourneau (29:00): I just want to add one more thing that please call those physicians before you just show up, either in the clinic or in the emergency department. Obviously if you're having fevers and trouble breathing and need care immediately, going to the emergency department is the right thing. But if you're just feeling unwell, give them a call first because many institutions have a mechanism by which you will be seen because if this is COVID-19 there are special precautions that providers need to take to see you. And so we want to be sure that you're going to the correct clinic. So for example, here we do have a respiratory illness clinic where we are sending people who need to be physically seen where we're concerned that they may have COVID-19 but that is to help protect everybody, the people coming in to be seen and the providers who are providing care.

Areej El-Jawahri (29:48): Do I need to wear a mask in public? Does it help protect me from the virus? This is a complicated question and I will try to answer this one. Part of why this is complicated is that our healthcare system is already having a major shortage in protective wear, including masks. And so the reality is there is going to be, there is a national shortage in the United States and probably in other countries as well of masks and you may not be able to find mask even if you want them.

You know, I recently saw people who are walking down the streets who had masks on and were essentially touching their face every two seconds to adjust the mask. And that's probably more dangerous than having no mask at all. So our recommendation throughout the years for our transplant patients has been, for those of you who are high risk, again, those of you who are on immunosuppression, those of you who have graft-versus-host disease and those of you who are early post-transplant ,specifically within the first six months for autos within the first two years for allogeneic transplant. For those of you if you are going in public and you do have access to a mask, if you are going to a grocery store for example, it is probably safe to wear a mask as long as you're not adjusting your mask all the time and touching your face.

Areej El-Jawahri (31:14): Probably the biggest thing that protects you is actually social distance. It's being away from people and being cognizant of your environment. It is okay to wear a mask for protection if you are going for grocery store runs. That being said, if you don't have access to a mask I would not panic. And if you, you know, that is not been major way to protect yourself. Really masks are helpful when you are in close contact with someone who has COVID-19 who you're caring for. So for example, if one of your family members was sick and they think, or you think, or their doctors think they have COVID-19 we have asked all caregivers who are taking, family caregivers who're taking care of these patients to actually wear masks at home because of the close contact, potential close contact.

So I would say social distance, stay home as much as possible is number one, number two and number three. And then wear a mask if you have it if you're going in public, as long as you can promise not to touch your face. And then lastly, keep your mask for if your loved one or family member are sick because that is a very much needed time to have masks as well. Anything to add there? That's all turned out. Okay.

Areej El-Jawahri (32:37): Should myeloma patients stop maintenance therapy after transplant to increase immunity to coronavirus? This is a question that's going to be very individual and highly specific to your particular scenario. And I would encourage you talking to your doctor, your oncologist about that question. I would leave it as that because it's really different. Not every patient with myeloma is the same. And so this is a question you can ask your doctor. A lot of, I should say, a lot of patients on maintenance therapy are now having drugs shipped to them and not having to come to clinic. So there's a lot of ways, creative ways for us to provide care without having you guys come to clinic, which are also helpful.

Areej El-Jawahri (33:22): Why is it necessary for older people and people with underlying health issues to limit their exposure to children?

Alyssa Letourneau (33:28): So I'll take this one. So the reason for that is that we know that children can have the disease but have very few symptoms. So for all of you who have had children or been exposed to grandchildren or young children, they frequently have a runny nose and cough and are touching their face and touching everything else that's around you. And so they can be carriers of the COVID-19 and then they can transmit that to you and sometimes they can even transmit that without a lot of symptoms. And therefore the concern is that they are asymptomatic carriers and are exposing all of us to that. So trying to limit exposure to children, young children, many schools are now closed to help decrease the risk of spread of the disease. And so trying to limit that would be great. I think in this day and age of social media and everything you can do with smartphones and computers, doing virtual visits with your children and grandchildren may be the way to go for some of this.

Areej El-Jawahri (34:29): Should everyone avoid traveling or just those who are older and have weak immune systems? Everyone should avoid traveling right now. Everyone should, I know this is an inconvenience for a lot of us, but we all have a responsibility and like I said, just being young and healthy does not make you immune from getting COVID, from getting very sick from COVID, from being hospitalized with COVID. Everyone should avoid travel right now.

Areej El-Jawahri (34:59): Why does it take so long to develop a vaccine for the coronavirus?

Alyssa Letourneau (35:03): So I'll take this one, so because we've never had a vaccine for coronavirus in the past, so trying to develop something, although they had been working on a vaccine, I believe in Cambridge here, which is one of the ones that's going into clinical trial right now. But the problem is we need to test it. We need to show it, prove that it produces an immunity, so an immune response in healthy host. And then after that you need to test it in a large number of patients to see if it provides any immunity beyond it being safe. And so all vaccines take time to create. And therefore that's why we expect 12 to 18 months in terms of vaccine turnover.

Just so people are aware when we in the United States at least choose which flu virus types are going to be in the flu vaccination for the fall. So for September, 2020 we were choosing which, sort of September, 2020 in that winter we were choosing which strains basically in January because it takes that much time to produce all the influenza vaccines that we need. And so that is a production issue, that is because you have to grow the way that they're made. You need cell lines, et cetera to be able to produce the immunity to be able to put in the vaccine. So it takes time, unfortunately to be able to produce this.

Areej El-Jawahri (36:28): Do you have suggestions for managing anxiety during the coronavirus crisis? So, this is a really important question and it's important to all of us. I think we all are living through this difficult time. And I'd say a couple of things about that. I think one, the purpose of this presentation is to help empower you and not make you scared. Okay? That is the purpose of the presentation here. Knowledge can be empowering. Knowing what you can do under your control that can help the situation is helpful and important. And you know the things that you have under your control. And there are a lot of things unfortunately that are not under our control and that's what creates anxiety and fear. And I would say that for these situations, there are a few things that we can do.

One is be there for one another, and be there for one another from more than six feet apart, but be there for one another. The reality is you're not alone. We're all living through this. We are all scared. We're all worried about our loved ones and our family members. And so sharing in that burden together is helpful, and finding ways to creatively share in that burden because we are not seeing our loved ones on regular basis in a similar way that we did. So people are doing FaceTime, they're using Zoom chats, they're doing a lot of virtual ways of connecting with their loved ones.

The second thing is try to do the things that make you feel a little bit less stressed and relaxed. And that's different for different people. For some people it's exercise. For some people it's yoga. For some people it's prayer and spirituality, whatever it is that can help you cope with this. I should say there are a ton of these Headspace apps and you'll get apps that are offering free services right now for everyone giving this time. So those are good resources to think about because again, the things that we can control are the things that we can control and that is staying home, that's socially distancing, that's being cognizant of our environment, that's reducing the risk in our society. And the things that we can't control we can talk about, we can help support each other and we can also deal with the stress that we have and the anxiety that we have in doing things that help us manage that stress.

And the last thing that I say about that and this is, you know, we all oscillate in this you guys, yesterday I had a tough day and I went home and the way that helped me deal with it was listening to a lot of inspiring stories about how communities are coming together, how people are helping one another, how our people here in Boston are helping small businesses, helping families that may not have access to the financial resources to get food. There are a lot of these amazing stories that are incredibly inspiring and I just needed to hear and listen to positive stories for the day and that helped me cope in that particular day.

Alyssa Letourneau (39:32): I'd like to just add one other thing. I think it's important to, especially with how much news we're bombarded with, to make sure you take a little bit of time that is not feeding into that and trying to watch a funny show or listen to some music that you like.

I know that many of the museums that are closed, both in New York and Boston and elsewhere, have free online tours. There are operas and Broadway shows that are are streaming online for people to watch. So things that you would pay hundreds of dollars to try to go see are now being shown for free.

Areej El-Jawahri (40:07): For anyone who has kids, a lot of, as I said, the museums, the museums in DC as well as New York, the children's museums are doing tours. I believe that Epcot center and Walt Disney will also be doing free videos on the rides, et cetera. So there's a lot of things to try to give some normalcy to this in a very non-normal time. And I think trying to have a little bit of piece that is not coronavirus or COVID-19 time per day to try to breathe is very important in terms of coping with it.

Areej El-Jawahri (40:45): What can we do to show our doctors and our healthcare workers our gratitude for working so hard to save our lives? Well, thank you for that. I think you guys probably have seen this on social media as well. There are all these signs of we are staying at work for you, please stay home for us. That is the number one thing you can do to help us, is please stay home and socially distance. I can't emphasize that enough. That is the only way we can actually reduce the burden on the healthcare system.

Sue Stewart (41:17): So thank you Doctor El-Jawahri and Doctor Letourneau. That was an excellent presentation. I think it answered many of the questions that were posed by the people attending this webinar when they registered. I do want to mention with regard to anxiety, we do have a webpage on the BMT infoNet website that tells you where to go. It's bmtinfornet.org/tips-for-anxiety. You can go there and there are a lot of the suggestions that the doctors have already recommended, but there are also links to various wellness applications, links to those museum tours, links to live concerts, et cetera.

And if you have any ideas of other venues that are offering services that we should list on that website, we'd love to hear from you. Email help@bmtinfonet.org and we'll be happy to share those with other folks.

Areej El-Jawahri (42:33): We do have a few more questions and we do have a little bit more time, so I think I will ask some of the questions of the doctors. One person has asked when a vaccine is developed, will it be a live vaccine? As transplant patients, we can't have live vaccines, so how far out is expected that the virus will be active? Can we get that live vaccine if we're a transplant survivor?

Alyssa Letourneau (42:59): I'll try to answer the question, I don't believe it's going to be a live vaccine from what I've seen in terms of the clinical trial that has started.

Areej El-Jawahri (43:08): We should add to that a couple of things. So remember that vaccinations help reduce risks for everyone. So as Doctor Letourneau said, this is likely not to be a live vaccine, but the reality is vaccination across the community will reduce the risk for our transplant patients.

This is the case, for example, measles, again, our transplant patients can not get live vaccines until two years out from transplant and the reality is, because everybody else is vaccinated for the measles, it's not a big issue for our transplant population. Whether it's safe to get a live vaccine for transplant patients, that is something you should talk to your doctor about. Although essentially if you are on immunosuppression or if you are early post-transplant during the first two years, you should not be getting a live vaccine. Even if you are greater than two years and on immunosuppression or have any GVH, you should not be getting any live vaccines. That being said, we think regardless of whether it's a live or inactive vaccine, you will get the protection because of the community benefit across the community.

Sue Stewart (44:17): All right, next question. My husband's transplant was in May of 2019, I just got back from a trip on an airplane. It was a 10 hour trip. I am self quarantined in a hotel instead of going home. Do you think I could self quarantine at home safely?

Areej El-Jawahri (44:36): So a difficult question. I would say the answer to that is yes, you could probably self quarantine safely at home. You know, I don't know if your husband's still on immunosuppression or not. The reality is if you go home and you are practicing social distancing and you wait the period of time, generally speaking about 14 days to make sure that you're not infected and you're not having any issues, I think you would be fine. I think some of these difficult decisions are coming up for a lot of people and I understand the anxiety about it, but I think you can probably self quarantine safely at home.

Sue Stewart (45:22): Next question. With a shortage of disinfecting wipes, do you have a recipe to make your own?

Alyssa Letourneau (45:30): I do not have a recipe to make my own, but the CDC site that I put on there, I believe had a nice link. The one that was for prevention at home has a lot of information on that in terms of, and I think it actually may give the percentage of what you need to mix to be able to do that. So I would go there. I do not have a personal recipe. I apologize.

Sue Stewart (45:55): Okay, next question. I'm on antivirals, does this give me any protection against coronavirus?

Alyssa Letourneau (46:02): So unfortunately antivirals that we have in this day and age do not protect against coronavirus. So as I said, there are clinical trials that have opened up across the nation and across the world for our drug called Remdesivir. And so we are unsure if that works, but we are trying to study it and enroll patients in that study to see if it does work.

There's another antiviral, there's a article published this week in the New England Journal of Medicine. The New England Journal of Medicine has made all of their COVID-19 papers free to the public. So you do not need a subscription to see those. So if you are medically inclined and would like to read the jargon that we read in our papers, feel free to do so but they published a paper this week on Lopinavir-ritonavir which is a drug that was used, a combination drug that was used for HIV in the early ages of HIV. We don't use it as much anymore due to the newer agents that we have for HIV. There was thought that perhaps it had some activity against this, but in a small trial out of China it does not look like it helped much more than placebo than not giving the drug.

There are other medications which I know on the news have come out. The drug chloroquine which is an anti-malarial and its family member, hydroxychloroquine, which is brand name Plaquenil, which is used for a lot of arthritis and for immunosuppression for auto immune diseases. Those drugs have, it's been said that there may be some signal that they're helpful, but again we don't have clear data that that is the case and so we are not prescribing those in the public in terms of using those as treatment. Chloroquine is an old, old anti-malaria drug that is rarely used anymore and so even the supply of that is very limited in general and hydroxychloroquine is produced and is used as I said, for autoimmune diseases.

I would not suggest that you try to get these medications to take at home as prophylaxis, as we do not know if they work. And two, they have drug interactions and side effects that probably are, which could be harmful to you if you took them inappropriately. So we are not recommending those treatments to patients to be taking because we do not think that they're effective. And then your other antivirals, Atovaquone, which is not an antiviral, but it is something that many folks are on for prevention of pneumocystis pneumonia that is not active and all the antivirals for the herpes viruses. And cytomegalovirus are also not active against coronavirus.

Sue Stewart (48:37): Right. Next question. Is it safe to have a regular cleaning crew come over and clean our house? This is a four woman crew that's come to us for years.

Areej El-Jawahri (48:48): Yeah, so great question. This is actually a question that has come up a lot for our, some of our colleagues. The answer is no. I would not have people come to your house to clean your house at this point of time, whether it's one or four people. I would really try to limit the household to people who live there, immediate family members only.

Sue Stewart (49:14): Okay. Is there any cross protection from having had other strains of coronavirus?

Alyssa Letourneau (49:23): No. It doesn't look as though there are. So far, you know, we're questioning whether some of the coronaviruses that cause runny nose and such in kids is why they're not getting as sick. Although we think it has more to do with some receptor process that they have not developed yet. But it is not clear that having had other coronaviruses protects them, so this is a novel coronavirus that has never been seen in human transmission and that's why the risk of infection is so much greater. Similar to the SARS virus that emerged in the 2002 era and the MERS virus which was more in the, I'm not going to remember the years, but the mid-early 2000's or mid 2000's and so these are novel viruses that humans have not seen before that have frequently come from animal populations and therefore we have no protection.

Sue Stewart (50:22): Next question, how do I know the condition of my immune system? How do I know whether I'm immunocompromised or not?

Areej El-Jawahri (50:32): So just to be, again clear because a lot of the questions are about this. I'm going to say it one more time. In terms of high risk population and by that I mean, when I say that I mean anybody above the age of 60 regardless of your status of transplant. Okay. Whether you've gotten transplant or not above the age of 60 you're at risk. Anybody with underlying medical conditions, heart disease, lung disease, diabetes, are at higher risk. Okay? Regardless of whether you had a transplant or not, for those who had an allogeneic stem cell transplant, if you are still on immunosuppression, if you have graft-versus-host disease, or if you are within the first year of your transplant, you are at high risk of complication. You don't need to check your immunity. There's no perfect immunity test that we have a lot of, to be honest with you, the immunity test for T cells and how active they are, are available in labs and they're not available in clinic, but we know that immunosuppression and being that early post-transplant impairs your immunity. We know that information.

So anybody who had an allogeneic transplant who has GVH, who's on immunosuppression, or even if you are, if you don't have GVH and you're off immunosuppression, but you're in the first year, you're at higher risk of complications from this.

For autologous stem cell transplant recipients, for auto transplants, anybody who is within the first six months of their auto transplant is at higher risk. I hope that helps answer that question and also some of the other questions I'm seeing on the chat.

Sue Stewart (52:14): Next question is, "I'm due for booster shot. Will delaying those booster shots mean I have to restart at the beginning of the shots?"

Areej El-Jawahri (52:23): No. I think people are talking about their vaccine series. We are routinely ... Anybody who is due for visits because of vaccines, we are delaying them right now just because it's not worth the risk of exposure. You will not have to restart your shots again. You will get your booster shots later.

Sue Stewart (52:41): Okay. "Should we be wearing protective glasses to protect our eyes?"

Areej El-Jawahri (52:49): So again, the biggest protection, the biggest protection you can do is staying away from other people, staying at home, number one thing. Masks and goggles or glasses when you're leaving the house if they're available could potentially help, but really we have such a shortage of them from the healthcare system perspective.

Just to give you a sense, in the healthcare setting perspective, we are only using those in the context of close contact with somebody with suspected or proven COVID-19. So the reality is if you go to the grocery store without a mask, without goggles, without touching your face and you go quickly and you keep your distance from other people, you should be fine.

I should note that if you can avoid going to the grocery store and have other people, if your high risk and have other people bring you groceries, I think that's the safest way to go and wash your hands.

Sue Stewart (53:53): We have a couple of questions on this topic. "Is take-out food safe, and is it safe to receive packages of food at home or food delivery?"

Areej El-Jawahri (54:04): Yes it is. I would say it's safe to get the food delivery. Ideally they would drop it off and walk away, and you go outside and pick it up. Again, there are some data to suggest that the virus potentially can live on cardboard, and so paper products is the thing I'm thinking about.

So again, if you bring it into the house, you wash your hands. You get the food out, you wash your hands, you eat. So the big thing again is washing your hands and just being thoughtful about that.

Sue Stewart (54:32): Okay. So with that, I think that will be our last question. Again, I want to thank [Dr. El Jawahri and Dr. Letourneau for a very excellent presentation on a very important project and topic for all of us. As I said at the beginning, we have recorded this presentation and we will get it up on our website as soon as possible. We will send an email to everybody letting them know when it is available, so you can go and look at it again, in case you want to refresh your memory on what was said here.

Our website is www.bmtinfonet.org. Please do check there for our various services. And I again want to thank Incyte Corporation for their sponsorship of this event. And should you have any other questions that were not answered or concerns or suggestions, please feel free to email us at help@bmtinfonet. org. Thank you everyone for participating.

Areej El-Jawahri (55:31): Sue, I just want to make one comment because I saw one last question that I think is important to answer. Defining immunosuppression. If you are on any medication that you're taking by mouth, Tacrolimus, Sirolimus, Prednisone, any medicine systemically, I'm not talking about topical treatment of the skin or topical mouthwash for oral GVH, but any intravenous medication like Rituxan, any oral medication, systemic medication given through an intravenous line or orally are considered immunosuppressants, you are immunosuppressed. It doesn't matter what Prednisone dose you are on. If you're on 40, if you're on 20, if you're on 10, you're technically immunosuppressed and I'll end with that.

Sue Stewart (56:19): Thank you for that clarification. Any other questions you saw that you want to address?

Areej El-Jawahri (56:24): No. I think those were the big ones because we didn't really define it, but we are happy to take any other questions through the website. I'm happy to answer them.

Sue Stewart (56:34): Okay. So if you have questions you could email us and we'll try to get an answer for you. And once again, thank you for participating and be safe, be well, be sequestered. Practice social distancing and hopefully we will all get through this doing well. Thank you.