COVID 19 Winter Update: What Transplant Recipients Need to Know

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COVID 19 Winter Update: What Transplant Recipients Need to Know

November 10, 2020

Presenters:

Alyssa Letourneau MD, MPH, Medical Director, Antimicrobial Stewardship Program, Massachusetts General Hospital

Areej El-Jawahri MD, Director of the Bone Marrow Transplant Survivorship Program, Massachusetts General Hospital

Presentation is 35 minutes with 38 minutes of Q&A.

Speaker 1 (00:00:00):

It is now my pleasure to introduce your host, Susan Stewart.

Susan Stewart (00:00:05): Introductions

Thank you very much, and welcome to the COVID-19 Winter Update: What Transplant Recipients Need to Know. My name is Sue Stewart, and I'm the executive director and the founder of BMT InfoNet, Blood and Marrow Transplant Information Network. I will be your host today. If you're not family with BMT InfoNet, we're a nonprofit organization that provides patients and their loved ones with high quality, easy to understand information about blood stem cell transplantation, as well as CAR T-cell therapy. I encourage you to check out our website at www.BMTInfonet.org, or feel free to phone us at (888) 597-7674, and we'll be happy to answer any questions you have.

So now, it's my pleasure to introduce to you our guest speakers for today, Dr. Areej El-Jawahri and Alyssa Letourneau. Dr. Areej El-Jawahri is the director of the Bone Marrow Transplant Survivorship Program, and the Associate Director of the Cancer Survivorship Program at Massachusetts General Hospital. She's also an Assistant Professor of Medicine at Harvard Medical School.

Dr. Alyssa Letourneau is the Medical Director of the Antimicrobial Stewardship Program at Massachusetts General Hospital. She's also an Instructor of Medicine at Harvard Medical School. I look forward to hearing from both of them about COVID-19 and how we can all protect ourselves and our loved ones. Please join me in welcoming Dr. El-Jawahri and Dr. Letourneau. Dr. Letourneau?

Alyssa Letourneau (00:01:52): Topics to be Discussed

Hi, thank you for having us. Okay, there we go. We're on the first slide. We're happy to be back. COVID-19 is still among us, and will be probably for some time, so I think these updates will probably be ongoing. And I'm happy to be joined by Dr. El-Jawahri to talk about this. She and I work closely together. I see a lot of the cancer center patients and bone marrow transplant patients at our facility.

For our outline today we're going to be discussing, "what is COVID-19?' A little review, although most of you probably already know. "What are the basic mechanisms by which COVID-19 spreads?' 'How can you protect yourself against acquiring COVID-19 and what are some strategies for doing that?'

Dr. El-Jawahri will talk about the safety of undergoing transplant during the COVID-19 pandemic; how to maintain contact with people who have had COVID-19; and how to avoid contact with people who have had COVID-19, and thinking about what steps you need to do should you get called about those types of situations. And then she will review, and I will assist her as well, in terms of thinking about treatments and vaccines.

Since we submitted our slides last week, there have been already multiple developments in terms of what is going on. And I am currently in the midst of working on some state initiatives here in Massachusetts for some of those entities that are now under emergency use authorization, which I will be happy to chat about.

Alyssa Letourneau (00:03:25): What is COVID-19? So, what is COVID-19? So many of you already know, it's a novel virus. It's a member of the coronaviruses. There are several coronaviruses that already infect humans. The first documented outbreak was in Wuhan, China, and has since affected every continent, essentially, in the world.

New Speaker (00:03:43): When do COVID-19 symptoms occur? The average time to showing symptoms is typically about four to five days after being exposed, although the range can be up to two weeks after exposure, and as soon as one day after exposure as well.

Alyssa Letourneau (00:03:56): Actual number of COVID-19 cases are probably under-reported. As of last week, there were about nine million cases, although I believe it's hitting 10 million cases already in the United States, and 229,000 deaths, unfortunately. Across the world, there are about 46 million cases, and as you can see there, about 1.2 million deaths due to coronavirus. These numbers are actually probably under-estimates, due to the testing that was limited initially when the pandemic started, especially in the United States, and the fact that many people may have died not having been tested for this disease.

Alyssa Letourneau (00:04:33): Most cases of COVID-19 are mild. In adults, most cases actually are pretty mild, and about 14% can be severe, and about 5% are critical. Children tend to have more mild symptoms and can be asymptomatic in up to about 40% of kids. Children can present with the post-infectious syndromes that we sometimes see, and we saw that in New York as well as in Boston, several weeks, about six weeks after we had surges in those respective cities. But those tend to present, not active COVID, but with other symptoms when they come in.

Severe disease in children makes up about less than 3% of the cases, and it usually is due to other underlying medical conditions, immunosuppression, chronic lung disease in children, and then infants are at higher risk as well. Up to a quarter of patients require hospitalization, and some potentially require ICU level care.

Alyssa Letourneau (00:05:30): People with  COVID-19 can spread the virus even if they have no symptoms.

People can spread the virus if they are asymptomatic. This is part of one of the reasons we have seen such a surge, although it's not necessarily the main cause of spread.

 (00:05:43): How does COVID-19 spread?

So how does COVID-19 spread? It's mainly, obviously, from person to person who are in close contact with one another. And this is typically defined as within six feet, for 15 minutes or greater, within a 24 hour period. It primarily spreads through respiratory droplets, which are small particles that can come out of your mouth when you're coughing, sneezing, and then singing, talking and breathing are other things that can cause spread.

The small droplets, we see this most often, at least what we're seeing now, especially with patients coming in currently, is that a lot of this is happening in households. Whereby there's a household contact that has COVID. People are getting together indoors to eat, and we have spread of the virus among the members that are in the household during that time. This is something we're all thinking about with the upcoming holidays, in terms of ways to try to minimize spread among households.

Droplets can also land on surfaces and objects, and be transferred by touch, but really, this is not the main way of spread. It can be stable up to 72 hours on plastic and stainless steel, as well as cardboard for less than 24 hours.

The last time we did this talk, which was, I believe, in March, when we had given an update there was a lot of concern about spread and this mechanism. People were wiping down their groceries and trying to be thoughtful about that. And now, we believe that that is less likely the main cause of spread for people, and that really, it's the person to person spread.

There is some evidence that some droplets, which are called aerosols -this is where some of the difficulty in understanding all of this - can stay suspended and can be a source of infection. But this is the sense ... The way that I think about this is, when somebody's talking or shouting or singing, that those droplets can become aerosols, which means they're slightly smaller. They can stay up in the air for a longer period of time.

But we don't think of them as staying in the air for an extended period of time, meaning they come out of the mouth and can hang there and drop down, as opposed to something like measles, which is considered the most infectious virus, whereby if somebody has active measles and they cough in your local grocery store, the virus will stay in the air for two hours. We know that for measles. That is not what we think that COVID-19 does. It can stay in the air for a small period of time, but not hours upon hours the way measles can. This is part of the reason masks are so important.

Alyssa Letourneau (00:08:16): Wear a mask around other people.

So how do we protect ourselves and others? Wearing a mask in public settings. And regular masks are fine, so regular cloth masks. The biggest thing is making sure it covers your nose and mouth, and that those are in place. And part of this is that it's preventing spread from the person who may have COVID, who doesn't know it yet, if they cough or sneeze or talk, that those droplets are staying within their masks as opposed to being spread into the air, or across the air into your face.

Alyssa Letourneau (00:08:47): Handwashing is important.

Washing your hands when you come home. This is a tenet in our home, whenever the children come in from outside. Wash your hands with soap and water for at least 20 seconds, that way you're coming in and cleaning off anything that might be on your hands. This is, in general, good for all viruses and all sort of infections that we think of being transmitted from surfaces such as doorknobs. So it's good for preventing flu, for preventing RSV, and a variety of other viruses that we are at risk for getting.

And if you can't use soap and water for some reason, using an alcohol-based hand sanitizer that has at least 60% alcohol is helpful for doing that as well. And the importance is that you're getting about a dime-sized amount on your hand, and you're rubbing it in completely and not shaking the rest of it off of your hands. So getting it on there, letting it air-dry as you rub it into your hands.

Alyssa Letourneau (00:09:41): Avoid touching your eyes, nose and mouth.

Other things that you can do is avoid touching your eyes, nose and mouth, again, because the virus, if it's on your fingers, can get into your mouth and nose and your eyes if you're touching them.

New Speaker (00:09:52): Stay six feet away from people in public.

Avoiding close contact, so maintaining six feet away from other people. That is key, because we believe the droplets don't really travel further than six feet.

Alyssa Letourneau (00:10:02): Cove your mouth and nose when you cough or sneeze.

Always cover your mouth and nose with a tissue if you're coughing or sneezing, or use your elbow as you can see in that picture. And then, wash your hands.

New Speaker (00:10:11): Disinfect frequently touched surfaces daily.

And then cleaning and disinfecting frequently touched surfaces daily is a good idea, so any doorknobs in the house that might be used by multiple people, cleaning that off to be sure we're keeping those clean and protecting yourself from this and other viruses. Again, it's thought that COVID-19 doesn't transmit as much in these surfaces, but it doesn't hurt to keep them clean to help protect you from a variety of viruses.

Alyssa Letourneau (00:10:39): Stay at home.

This has been difficult, and I can imagine all of us need some moral support in seeing family and others. But trying to protect yourself and staying at home is definitely a way to help protect yourself from acquiring COVID-19. If you go for a walk outside, I recommend putting on a mask, trying to stay six feet away from others. If you're going in an area where there really is nobody else and you're not going to run into anyone, then keeping that mask off during that time, but making sure you're bringing it with you in order to do that.

Alyssa Letourneau (00:11:12): Avoid travel.

I would still advise against traveling. The rates of COVID-19, especially in the United States, are pretty high across the board, and trying to stay safe while traveling is just a little bit more difficult.

New Speaker (00:11:24): Sitting indoors and eating with others can spread COVID-19.

And then, being careful around the holidays. We're coming up on Thanksgiving which, as you celebrate here in the United States, usually involves large family gatherings, indoors, with lots of eating. And these are the things that we do know, that sitting together, in close quarters indoors eating, is a high risk activity when it comes to transmitting COVID-19.

And we have seen this not only in household transmission that we have studied, but also in outbreaks that occur in healthcare facilities. These have frequently been related to the time that healthcare workers are sitting and having lunch together, and somebody was not symptomatic yet with their COVID-19 and ended up spreading it to other colleagues in that setting.

Alyssa Letourneau (00:12:16):

This is a public health problem, as you all know. We take a lot of social responsibility in terms of thinking about what we're doing, keeping our masks on when we go out, trying to stay safe. Staying home if we're symptomatic, obviously, but I feel like we always need to state that.

Alyssa Letourneau (00:12:35): Social distancing can save lives.

The importance of social distancing, even if you are low risk, because all of this can save lives. And in the spring, a lot of this was focused on trying to make sure we don't overwhelm our healthcare systems, because we weren't sure what the numbers were going to look like. Now it continues to be not wanting to overwhelm our healthcare systems, but we know the things that we can do for this.

Alyssa Letourneau (00:13:01):

So one thing that I forgot to add in here, what I think of as the three Ws. So, wear a mask, watch your distance, and wash your hands are the thought process I go through when going out. And just making it a habit, that putting on a mask when you're heading out the door, and making sure others are masked as well if they are to be around you, is important. All right, I'm going to pass it on to Dr. El-Jawahri.

Areej El-Jawahri (00:13:27): Is it safe to have a stem cell transplant during the COVID-19 pandemic?

Thank you, Dr. Letourneau. So, I will start by talking about the implications of all of this for transplant recipients. And I think one of the big questions that we get in our clinical practice is, "Is it safe for me to have a transplant in the context of COVID-19? How do we think about these decisions?"

Areej El-Jawahri (00:13:46):

And we'll start by saying that most people who need a transplant cannot afford to wait. That for a lot of diseases, we are using transplant as potentially curative therapy for different types of blood cancers, or even benign hematological conditions that are severe enough that require a transplant. And so, for many people, we don't have, unfortunately, the luxury of waiting.

Areej El-Jawahri (00:14:10):

There are certain circumstances where we do have that luxury and we can wait, and in those circumstances, those are things that can be easily discussed with your oncologist, with your oncology clinician, with your transplant doctor. I will say that hospitals across the nation, really across the globe, are taking a lot of extra precautions to keep the transplant floors and floors where they take care of patients who are immunocompromised very safe.

Areej El-Jawahri (00:14:37):

This has been a huge emphasis. You may have heard me say this in the first webinar, in some ways being in the hospital for me as a clinician on the transplant floor feels like the safest place to be. So just know that we are cognizant of these risks that patients face, obviously, and that in many, many, many institutions this is a top priority from an infection control perspective.

Areej El-Jawahri (00:15:07):

So the bottom line is, talk to your doctor if you think your transplant can be delayed. There has been a process for that, for example, in New York and Boston, during the peak months of the COVID surge. Earlier, there were some transplants, autologous stem cell transplants for multiple myeloma that were delayed, where delaying a couple of months was actually something that we can easily accomplish.

Areej El-Jawahri (00:15:33):

And in some ways, I have to say, there's been a couple of nice things about wearing masks in public for transplant recipients. We are, in general, seeing less colds and infection in our transplant recipients, because everyone is wearing a mask. My patients often comment about not feeling weird anymore about not wearing a mask, because everybody else is wearing a mask and there's this extra protection, and feeling like you're not standing out.

Areej El-Jawahri (00:15:58):

And so I do think in some ways, even in the post-recovery period, because a lot of the population is cognizant of the risk of infection, are using protective measures, we may actually be protecting our transplant recipients. Not just from COVID-19, but from other infections as well during that vulnerable period.

Areej El-Jawahri (00:16:20):

So to summarize, I think the general answer is yes, it is safe to have a transplant during COVID-19, but definitely talk to your doctor about balancing the risks and benefits. Especially if you do think that your transplant is a type of transplant where there may be some flexibility about timing. Again, that's not true for many diseases, but it can be true for certain diseases like multiple myeloma sometimes, as well as some benign hematological conditions that can be managed for a period of time without requiring a transplant immediately.

Areej El-Jawahri (00:16:52): How risky is COVID-19 for transplant recipients?

But how risky, actually, is COVID-19 to transplant recipients? I will say we still have limited data. We have more data than our last webinar, where we talked about this. The largest study to date has come out of Spain, including, actually, solid organ transplant recipients as well as stem cell transplant recipients, or bone marrow transplant recipients.

Areej El-Jawahri (00:17:17):

And focusing on the data on the 113 patients who've had stem cell or bone marrow transplants, the majority of these patients were hospitalized with COVID-19, so it is worth noting that. Of course, you have to keep in mind that we're also probably very protective and cautious, so a lot of these patients were hospitalized as a precaution given the concern for COVID-19 in a transplant recipient.

Areej El-Jawahri (00:17:44):

About 20% of them had severe illness, and 6% required ICU level of care. And 20%, unfortunately, died as a result of COVID-19. I know this is a very anxiety-provoking topic, but I do think, as I talk to my patients all the time, I do highlight that obviously, yes, 20% mortality rate in a virus post-transplant is problematic. But I think people also have this feeling or fear that there's 100% chance you're going to die if you get COVID-19 when you have a transplant, and that's simply not true.

Areej El-Jawahri (00:18:20):

So we shouldn't be getting COVID, we should all be trying to play it safe, obviously. But just know that we do have effective therapies and the mortality rate is lower than that. I will say that in the Spain cohort that I'm talking about, most of these patients were actually on immunosuppression, and just to be clear, when I'm speaking about immunosuppression I'm talking about corticosteroids, so prednisone or prednisone-like medications. Medications like tacrolimus, sirolimus. There are new medications for graft-versus-host disease, like ibrutinib and Jakafi, ruxolitinib, and those also kind of count in that category.

Areej El-Jawahri (00:19:00):

So most of these patients were actually being treated on immunosuppression. We should note that there have been other studies in the United States that have showed higher risk of COVID-19 in patients with blood cancers, so we know that there may be a slightly higher risk in our population.

Areej El-Jawahri (00:19:17): Does the risk of COVID-19 for transplant recipients decrease over time?

For those of you who are a year out from an autologous stem cell transplant, or more than two years out from an allotransplant, and off all immunosuppression, your risk is probably very similar to the general population. If you have no graft-versus-host disease, if you're far out from an allotransplant, if you're far out from an autotransplant, your risk is probably similar to anyone in your age group. And remember, as we talked about last time, age is a big risk factor. So it is something to keep in mind.

Areej El-Jawahri (00:19:49): When is it safe to come in contact with someone who had a mild case COVID-19?

So when it comes to contact with people who have COVID-19, these are the CDC guidelines. It is safe for people who've had mild to moderate COVID-19 to be around others after 10 days since symptoms first appeared. So 10 days after being symptomatic, and 24 hours with no fever, and without needing Tylenol or other fever reducing medication, with the caveat that symptoms must also be improving. So you must meet all these three criteria before you can be in contact with a patient, essentially, with COVID-19.

Areej El-Jawahri (00:20:27):

We have data to suggest that loss of taste and smell that you probably have heard about in the news may persist for weeks or months after recovery, so that is not, by itself, a reason not to be in contact with people. And this is new since our last update, but most people do not require testing to be around others. So let's say you had mild COVID-19, you had your course, about two weeks of having symptoms. You are now essentially asymptomatic, or symptoms are going away, and no fever. You do not need a negative test to be around others.

Areej El-Jawahri (00:21:04):

In fact, testing can still be positive for a little while even though you're not infectious. So that is a change from our last update. We have more data on this to support this information.

New Speaker (00:21:16): When is it safe to be in contact with someone who had a severe case of COVID-19?

This timeline for when to be able to be in contact with somebody who's been COVID-10 positive is different for people who became severely ill with COVID-19, those who required an ICU level of stay, or those who are very immunocompromised who got COVID-19, and I would put transplant recipients in that bucket.

Areej El-Jawahri (00:21:38):

In those circumstances, we may need to avoid contact up to 24 days from symptoms. And for those who are immunocompromised, we may need testing to ensure that it's actually safe to be around others, and really need to have a conversation your doctors about these scenarios. These are specific scenarios it's worth having the conversation, it's worth knowing what the options are in terms of testing.

Areej El-Jawahri (00:22:05): What should I do if I came in contact with someone who had COVID-19?

If you did have contact with someone who had COVID within that risky, symptomatic period, staying home for 14 days and quarantining after your last exposure is the safest thing from a public health perspective. Again, lots of tests are available now. A lot of people are going for testing. But remember, early, early testing can sometimes be negative, so it's better and safer to just quarantine in those circumstances, and make sure you don't have any symptoms before having contact with others.

Areej El-Jawahri (00:22:42): Current treatments for COVID-19.

So switching gears, we're going to talk about available treatments for COVID-10. The good news is, we have learned a lot in the past six months or so about this virus, and we have a lot of really great, effective treatments for this disease, which is fantastic. It's a testament to, really, the efforts of researchers and scientists across our community.

Areej El-Jawahri (00:23:04): Supportive care is the treatment for most patients.

For the majority of patients with COVID-19, it's the basic bread and butter supportive care to help relieve symptoms. People often recover at home with mild symptoms, so for majority of people who are mildly symptomatic, they're taking Tylenol, they're keeping an eye on their fluid and oral intake and don't require any more treatments and medications.

Areej El-Jawahri (00:23:31): New drugs approved to treat COVID-19

We should note that remdesivir did receive approval for those with COVID-19 who require hospitalization. We have heard about dexamethasone in the news relatively recently. Dexamethasone has been shown to decrease the risk of dying in those hospitalized with COVID-19, who are also on oxygen. So that's one of the new medications that, also, we have in the context of treatment.

The most recent news is we also know there is a monoclonal antibody that has been shown ... This is an antibody that targets a protein that is on the virus, so it's an antibody that seems to decrease hospitalizations, and I believe it has received emergency approval through the FDA.

We've heard about plasma, which is really a collection of antibodies, or pooled antibodies from people who recovered from COVID-19. That's still early. This may reduce the risk of dying from the virus, but we need more robust data to really fully understand the effect.

We should note that we really don't have any data to support hydroxychloroquine or azithromycin for prevention or treatment of this virus.

Let me turn it over to Dr. Letourneau about treatments, and just making sure, are there any things that you want to add about the monoclonal antibody or other treatment options for patients with COVID-19?

Alyssa Letourneau (00:24:58):

Yes. Thank you, yeah. I'll go back just one slide. I'd like to re-emphasize that just like for many other viruses, supportive care really is the key to getting patients feeling better.

(00:25:14) Remdesivir may reduce the length of time patients are hospitalized for COVID-19.

Remdesivir, which just had emergency use approval from the FDA at the beginning of May, and then was just approved officially by the FDA on October 22nd. This is an antiviral. It's only allowed to be used in the hospital for patients who are being admitted for COVID-19, or presumed COVID-19.

The data for remdesivir show that for those patients who were on oxygen, that it potentially shortens their duration of illness by about four to five days. So going from 15 days of feeling ill to about 11 days. And really, it was that small population ... Well, large population, but just patients on oxygen. There are some data to suggest it doesn't really work once patients are sicker, and who are in an intensive care unit on a breathing machine.

Alyssa Letourneau (00:26:10): Dexamethasone reduces the risk of death in hospitalized patients who are on oxygen.

Dexamethasone is the only drug, and it's an old drug that some of you probably have taken before, that has been shown to improve ... And remdesivir has not been shown, at least statistically with the number of patients they have done, to show that it decreases the risk of death. Dexamethasone actually showed it's the only drug we know of that does decrease the risk of death in hospitalized patients, and really, these are patients who are on oxygen. Patients who are not on oxygen, are outpatients, it actually may be harmful. And so really, it's a reserved agent for when people are in the hospital and ill. And patients in the intensive care unit may benefit the most.

New Speaker (00:26:51):

And part of that is the thought process that initially, when people are having symptoms, from day 10 and shorter, so within the first 10 days of symptoms, that it's really the virus that's causing the problem. And then once you're beyond the seven to 10 days of symptoms, that it's the immune system that's over-responding and potentially being the cause of some of the symptoms.

Alyssa Letourneau (00:27:14): Monoclonal antibodies may help reduce the number of people who need to be hospitalized for COVID-19, but supply is small.

The monoclonal antibodies, which some may be familiar with ... So, there's a product made by the pharmaceutical company Lilly, and then there's a product made by Regeneron. The Lilly product just received emergency use authorization last night, at about 8:00 PM or so it was announced. And so, again, very small trials. Small patient populations, but the thought process is that the monoclonal antibodies, and specifically the Lilly product currently with this emergency use authorization, will be for outpatients who have COVID-19, are symptomatic, and can receive it within a few days.

Alyssa Letourneau (00:27:57):

This is going to be ... There's, again, very little data for this. And the thought is that it will decrease hospitalizations and ED [emergency department] visits, which is great.

New Speaker (00:28:07):

The issue right now is, with this emergency use authorization, is that there's supply, but there is not much supply for the number of cases that we have in the United States. And so for a state like Massachusetts, we expect that we will probably get about, potentially, 300 doses per week to treat out 2200 patients who are positive per day, essentially. So the numbers are not there, and so it's going to be interesting to see how this rolls out. So, institutions, I have a meeting right after this to discuss with state health officials how to think about this.

Alyssa Letourneau (00:28:46):

It's believed to be a very safe product, and there are discussions among groups, obviously, that patients who are immunocompromised may be patients that could get this. But this is not going to be readily available and will have to be administered in the outpatient setting, and there's a lot to go into that. So more to come on the monoclonal antibodies.

New Speaker (00:29:08):

And the Regeneron product is still ... The only data we have is a press release, and we are unsure if that will be made available by this emergency use authorization. That's probably more than you needed to know, but I'm in the thick of all of this right now for our healthcare system here.

Alyssa Letourneau (00:29:26): The  use of convalescent plasma to treat COVID-19 patients is still being investigated.

The convalescent plasma, as Dr. El-Jawahri mentioned, these are still under investigation. They are under emergency use authorization. We do not use them in our facility. We have a full-on trial to try to see if it actually helps, because there haven't been any rigorous trials to show that. And there are numerous trials showing that hydroxychloroquine and azithromycin are not useful.

Alyssa Letourneau (00:29:50): Vaccines to protect again COVID-19

Do you want me to do the ... I'll do the vaccines as well. So the other announcement was by Pfizer yesterday morning, I think it was, I've lost track of my days, announcing in a press release again that they have some promising findings in terms of their COVID-19 vaccine. There are multiple ... Actually there might be more than four clinical trials, for vaccines in the United States. Vaccine clinical trials in general require thousands and thousands of patients. Most of these trials are about 60,000 patients each. They're all under investigation. They have a variety of mechanisms by which they work, and so we really need to await more data.

New Speaker (00:30:31): Pfizer vaccine potentially 90% effective in preventing COVID-19.

The Pfizer data that has been released by this press release is that there was potentially 90% effectiveness in the patients who received the vaccine. It is unclear where these patients live. It is unclear what these patients were doing, meaning, were these people who were wearing masks? Were they in areas where there was a lot of COVID-19? And so, having a little bit more of that information to really get a sense of how well this works is critical. And then, having the rest of the safety data to be sure that this is safe to use, although it appears to be that that is the case.

Dr. El-Jawahri, I'll let you handle the last two bullet points in terms of the transplant.

Areej El-Jawahri (00:31:12): Will it be safe for transplant recipients to get a COVID-19 vaccine?

Yeah, absolutely. Thank you, Dr. Letourneau. So, I do think a lot of probably the questions we'll be getting about, "Is it safe to take the vaccine for transplant recipients?" For the vaccine that you've been hearing about in the news from Pfizer, it is an RNA vaccine, so it is not a live vaccine. It's basically a vaccine that stimulates the immune system of the patient to essentially generate a response to a protein.

And so it is technically not a live virus, and therefore it is theoretically safe for transplant recipients. And I will say, most, most of the trials that we have across the globe are really inactivated vaccines. They're not live viruses, which are the ones that we worry about in transplants recipients who are immunocompromised.

Areej El-Jawahri (00:32:02): Vaccine guidelines for patients who had an allogeneic transplant (transplant using donor bone marrow or stem cells).

So, in general, I would say a couple of things. If you are greater than two years out from an allotransplant, and have no graft-versus-host disease, and off immunosuppression, vaccine will absolutely likely to be safe. And we'll probably have data on that safety very quickly. And a lot of us may actually, a lot of the transplant clinicians, may choose to vaccinate you if you fit in that category.

Areej El-Jawahri (00:32:30): Vaccine guidelines for patients who had an autologous stem cell transplant (transplant your own stem cells).

If you have autologous stem cell transplant and you are greater than a year out from an autotransplant, and again, you shouldn't be on any immunosuppression if you had an autologous stem cell transplant, the vaccine will also likely to be safe.

Areej El-Jawahri (00:32:45): Patients on immunosuppressants for graft-versus-host disease (GVHD) should talk to their doctors before getting the vaccine.

If you are on immunosuppressants, so again, to remind people, and what I mean by immunosuppression is corticosteroids, so prednisone and prednisone-like products, or tacrolimus, sirolimus, CellCept, ibrutinib, some of the newer agents that are used to treat graft-versus-host disease, talk to your doctor. Vaccine will likely still be safe. Again, this is not a live vaccine.

In a lot of vaccines that do have, generate, a big immune response, we do worry slightly about worsening graft-versus-host disease. So if you do have graft-versus-host disease, this is why you're on immunosuppression, that is something that you'll probably discuss with your doctor.

And in those circumstances, a lot of us will probably wait until we have some safety data in patients like you, who've had an allotransplant who have graft-versus-host disease. If you are early after an allotransplant, so within the first 100 days after an allogeneic, and actually within the first 100 days after an allogeneic or an autologous stem cell transplant, you should definitely talk to your doctor before receiving any vaccine. This is true for COVID-19, as well as others. So in that context, it's just better to talk to your transplant doctor and get a sense of the safety.

So the good news is, we think these vaccines will be safe for transplant recipients. We may need a little bit of time to have more information. We certainly don't want you, for example, to be the very first patient on immunosuppressant getting these medications. But we will have data. We will have data very quickly.

And patients who are immunocompromised are likely going to have access to the vaccine faster than others, because we obviously know that they're a higher risk population, that they may require a vaccine sooner. So stay tuned. Again, I kind of try to highlight all the different categories that you may fit in. And if in doubt, talk to your doctor about it.

Areej El-Jawahri (00:34:46): Centers for Disease Control has great information about COVID-19.

There are a lot of resources out there, the Centers for Disease Control has a really great website with a lot of up-to-date information on COVID-19. The CDC also has a lot of information about protecting yourself from COVID-19. At this point, I know there are a lot of questions, so we wanted to save a lot of time for questions at the end for everyone. Thank you so much for listening to us, and we're happy to take questions at this point.

Question and Answer Session:

Speaker 1 (00:35:23):

Ladies and gentlemen, if you have not already done so, you may type your questions into the Q&A pod. Type your questions into the box, and press enter on your keyboard to submit.

Susan Stewart (00:35:36):

There is a question from Michelle, "Will the vaccine be only allowed for family and others around transplant patients, and it's not safe for patients to get it? Should we buy an Aerus air scrubber or UV room cleaner?"

Areej El-Jawahri (00:35:53):

Great, so I might have answered some of Michelle's questions already. Again, early on, we will have some data, Michelle. I think it depends a little bit on the context for transplant recipients that are early after transplant, we're probably going to wait before recommending the vaccine right away. For people who are further out after transplant, it's definitely something that will likely be very, very safe.

Areej El-Jawahri (00:36:20):

Again, this is not a live vaccine, so there's only a theoretical risk for people who've had an allotransplant of aggravating graft-versus-host disease. So the population we still probably need more data on are patients with the graft-versus-host disease, to make sure it's safe. I don't think you need the UV light or the air scrubber, but I'll have Dr. Letourneau comment on that.

Alyssa Letourneau (00:36:43):

Yeah, that's a lot harder ... I'm not sure that there are data to support those two things in terms of protecting yourself, especially in your own home. I think one of the things ... I just want to reiterate, I'm happy people are excited about vaccines, as an infectious disease physician. And I also trained in pediatrics and adult medicine. Getting people vaccinated is very important, and I work with Dr. El-Jawahri and the whole oncology team here, to be sure we get people their vaccines as soon as they can, because that really is protective.

Alyssa Letourneau (00:37:18):

We try to cocoon families, so try to ... And we do this in pediatrics and in our immunocompromised patients, is trying to vaccinate everyone around those who may not be able to get vaccinated to help prevent infection. One thing I just want people to be aware of, we've made some huge strides. This is the fastest vaccine development we have ever seen, which is fantastic, and it's great that so many companies are jumping in and trying to do this.

Alyssa Letourneau (00:37:43):

There's still going to be very limited supply coming out, even with the initial doses coming out. And it's unclear to me as of this time who will be eligible to get those initial doses of vaccine, and so we will still have a lot of work to do.

Alyssa Letourneau (00:38:02):

There will still be a lot of mask-wearing and hopefully we will be immunizing those at highest risk, but just so people are aware, that if by tomorrow they say the vaccines are available, that really that's about five million doses, if that, for a population of 330 million in the United States. But I love the enthusiasm of people making sure they know it's safe for them and their families.

Susan Stewart (00:38:28):

Thank you. Next question is, "What is the state of nasal sprays that protect against COVID-19? Is povidone-iodine an alternative until a commercially available nasal spray or mouth rinse is on the market?"

Alyssa Letourneau (00:38:45):

I'm not aware of any of the nasal sprays that help prevent COVID-19. There were some data, although I'm not familiar with them, that perhaps some sort of mouthwash could potentially help prevent this. But I have not seen those data borne out, in the sense that that's what we're recommending to people, really. To help prevent COVID-19, it's really watch your distance, wear a mask, wash your hands, in terms of protecting yourself.

Susan Stewart (00:39:19):

Dr. El-Jawahri, do you have any concerns regarding COVID for patients who are on ACE inhibitors? Should they be stopped or switched?

Areej El-Jawahri (00:39:29):

That's a good question, Sue. So, again, there has been initial data that was ... The data has been, actually, fairly mixed about the use of ACE inhibitors and COVID-19, and whether they theoretically increase the risk of COVID-19 infection severity or even mortality. At this time, we are not recommending stopping ACE inhibitors for patients who are taking ACE inhibitors. I think that the data just simply does not support that approach at the present time.

Areej El-Jawahri (00:40:01):

Obviously, if you're concerned, certainly talk to your doctor about it. But for our population, and typically for our transplant recipients, we actually typically avoid ACE inhibitors because they do interact with tacrolimus and a lot of our immunosuppression. But if you're on an ACE inhibitor, you're welcome to talk to your doctor, although the data currently are not compelling for stopping ACE inhibitors in the context of COVID-19.

Alyssa Letourneau (00:40:27):

I agree.

Susan Stewart (00:40:29):

Okay. We have a question from a mother who says her son still required IVIg about every 10 weeks, and she wants to know whether you're seeing IVIg recipients receiving any protective immunity to COVID-19.

Alyssa Letourneau (00:40:45):

That's a great question. We do not know. We don't have those data. There are some suggestions that there are other things that come with IVIg, and that's the thought process with convalescent plasma as well, that may have protection, that we are unable to measure. So some of those studies are going right now.

Alyssa Letourneau (00:41:07):

I wouldn't suggest getting IVIg just routinely if you don't need it, obviously, which is difficult to do. There was a shortage recently, and it's highly regulated in terms of which patients we give it to. But I can't say definitively, we've seen any difference in patients who receive IVIg and their ris. Because presumably that IgG that is being infused at this point may have some COVID antibodies in it, depending on the timing in terms of when it was collected.

Susan Stewart (00:41:39):

All right, I've got a couple questions about masks. One person wants to know whether you can trust homemade cloth masks to protect you from COVID, and another would like you to talk about the difference N95 and KN95 masks for patients if they have to go to a doctor.

Alyssa Letourneau (00:42:01):

What I would say is that, for the cloth mask, the biggest thing about masks is actually that the person, you, yourself wearing a mask protects you a small amount from getting COVID-19. But the greatest protection is preventing ... The person wearing the mask, it helps prevent them from spreading COVID-19 to somebody else if they don't know that they have COVID-19.

Alyssa Letourneau (00:42:26):

So that's where, really, it requires everybody to wear masks, because you're protecting each other by doing that. Again, with the cloth masks, you have some protection if someone were in front of you and coughed, and had COVID-19. But that protection's not perfect. It's just a small amount of protection. But the protection is more if there's a person in front of you who as COVID-19, if they're wearing a cloth mask, and you're wearing a cloth mask, that the transmission risk there is very low. It's not zero, but it's very low.

New Speaker (00:42:58):

And we really know, some of that data comes out from an MMWR report [Morbidity and Mortality Weekly Report] from the CDC. I think it was published in May, where there were two hairdressers who had COVID-19. They wore cloth masks, and then their 140 clients who came through their salon also wore masks, and there were no known transmissions of COVID-19 among all of those people.

Alyssa Letourneau (00:43:23):

Mind you, a haircut is not very long. But I would say it's probably more than 15 minutes in general, and that's a reassuring study whereby the people who had COVID-19 were wearing a cloth mask and did not transmit to the other people, who were also wearing masks. And there are some great graphics online, and I don't know all the ... I can't name all the numbers off the top of my head, of showing what happens when you have a mismatch of who's wearing a mask and who's not.

New Speaker (00:43:51):

In terms of the N95, so I don't even remember the difference between an K95 ... I would have to look this up. I don't know if we want to ... Unless, Areej, you know off the top of your head, the KN95 versus the N95.

Areej El-Jawahri (00:44:01):

Yeah, I believe the N95 versus the KN95 is just where the masks are certified. They are essentially very similar. They block 95% of particles that we have. I think in the context of mask shortage, the KN95 mask became more widely available. So they're very, very, very similar, and I think of them very similarly. Again, there is, as you can imagine with increases in COVID numbers, a lot of these N95 and KN95 masks, we are trying to save up for our healthcare providers and frontline personnel who are caring for patients.

Areej El-Jawahri (00:44:43):

If you do have access to the N95 masks, unlike the cloth mask, as Alyssa mentioned, they are theoretically more protective of you rather than you giving an infection to somebody else. At the same time, they're also, obviously, hard to wear all the time. They are definitely more difficult to wear, and they're not recommended. If we all follow recommendations, if we all wear just basic cloth masks, we'll be protecting our entire population very well.

Areej El-Jawahri (00:45:13):

If you have access to them and you're going to a healthcare setting or going into an area that is crowded and you would feel more safe wearing them, I think it's reasonable to wear them. Just know that they are hard to come by, especially in areas where COVID-19 is increasing.

Alyssa Letourneau (00:45:32):

And I'd just like to say that there are varying discussions about the N95s versus surgical masks in healthcare settings. In places like Canada, they actually recommend healthcare providers wear surgical masks for all interactions, even with COVID-19 patients, unless there's some sort of aerosol-generating procedure, which is if somebody is getting intubated, where they're being put on a breathing machine, or they're having a nebulizer. And the WHO supports surgical masks as well. But the key is that people ... It's not just you that are masked, but that other people are masked as well. That is the key to protecting everyone.

Susan Stewart (00:46:18):

All right, so next question comes from someone who wants to know, "Can you get COVID again if you already had it?"

Alyssa Letourneau (00:46:28):

I can take that one. So there are reports of people who have acquired COVID-19 a second time. They're far and few between, but it's definitely something that we're keeping an eye on. There are debates about how much the coronavirus antibodies, our own immune response to COVID-19 after we've had it, how durable is it. Meaning, how long does that stay around, because sometimes that protection can go away. And this varies by virus to virus. And so, we are still exploring this. But the thought is there are some people that it's been shown that they can get re-infected. That is, it's a very small number, but that has been reported.

Susan Stewart (00:47:17): Is it safe to allow your child go to school if you recently had a transplant?

The next question is from a woman who had a stem cell transplant in July of this year. She's got a 16 year old son in school, and some of the parents and teachers have gotten the virus. She's worried about sending him to school and getting the virus, and then giving it to her, however at 16 he wants to go to school rather than do remote learning. Do you have any recommendations?

Areej El-Jawahri (00:47:41):

Yeah, what a tough question. It highlights the difficulties and the challenges that we're all facing. I know this is really hard. These are the questions that I get every day in my practice, and the reality is, every decision we make, we are balancing risks and benefits. And for a woman who has had a transplant relatively recently, with the recent infections in a school, again, it's all about balancing the risk and benefit.

Areej El-Jawahri (00:48:14):

If you ask me personally, I'd say try to avoid school until things calm down. Try to avoid going in person, for her 16 year old teenager, until things calm down. Again, know that there are limitations. I can't quote you a study to tell you how safe that is. But being smart and being safe, especially there was a recent outbreak in that school with a new transplant, is what I would recommend.

Areej El-Jawahri (00:48:41):

I know it's hard. It's hard to recommend that. It's hard to tell that to your 16 year old teenager, and we are facing those difficulties every day and making those choices every day. The reality is we are hopeful that this is not going to be the state of our world forever, and while it's going to take us a long time to, one, have an effective vaccine but also a vaccine that gets ramped up production-wise, most of us do believe that we need to get through this fall and winter, and by the spring of next year, and the fall of next year, we will be much better positioned to really live our lives in a much more full way than we are doing now. So I hear you. My recommendation, probably, would be to say try to avoid having your teenager go to school at this point in time, until things calm down at the school.

Susan Stewart (00:49:38): If you have had a bad reaction to the flu vaccine, is it safe to get a COVID vaccine?

All right, we have another person who says that she had a post-transplant reaction when she got a flu shot. It was an autoimmune reaction, and wants to know if that would affect whether or not it's safe for her to get a vaccine now that she's seven years post-transplant, for COVID.

Areej El-Jawahri (00:49:59):

Yeah, so vaccines are different, and so no, not necessarily. There are people who have allergic reactions to certain components of the flu vaccine that will not be the same with the COVID-19 vaccine. It depends a little bit upon the severity of her reaction, as well. But generally speaking, I wouldn't extrapolate that data.

Areej El-Jawahri (00:50:20):

I will say that at least what we know about the vaccines currently in the clinical trials is that the patients can get a reaction to the vaccine, in the sense they could have malaise, they could have low grade fevers - the things that we expect with some of these vaccines. So those in themselves are not ... They're kind of part of what we expect sometimes with vaccinations, so it depends a little bit on the severity of the reaction.

Areej El-Jawahri (00:50:45):

But at the same time, I would not generalize the experience with the flu vaccine with whatever COVID-19 vaccine will be available, and my guess is that when that vaccine is available, especially if she's that far out from transplant, that she'd be able to get that vaccine safely.

Susan Stewart (00:51:05): Can COVID-19 trigger GVHD to become active or worse?

All right. Excuse me. We have a question about whether COVID-19 can trigger GvHD to become active.

Areej El-Jawahri (00:51:15):

Yeah, what a great question. So we don't know, but that's our fear. That's exactly our fear, and that's why, for transplant recipients, for allogeneic stem cell transplant recipients, the entire field will be focused on starting with patients who don't have graft-versus-host disease who are little bit further out, to make sure that the vaccine is safe.

Areej El-Jawahri (00:51:40):

We know from our experience with our vaccines that, unless there is recurring, very difficult to control graft-versus-host disease, other vaccines, including the flu vaccine and the vaccines that we give post-transplant are safe. They do not trigger graft-versus-host disease reactions. So the expectation is that we will have the same idea with the COVID-19 virus. Nonetheless, we will need that data.

Areej El-Jawahri (00:52:07):

So we will start with the lower risk population among transplant recipients, people who don't have their reactive GvHD, and people who are not on immunosuppression. And then, we will have safety data that can make us feel more reassured, and again, we will likely have data in patients who have chronic or acute graft-versus-host disease as well. Because again, these are also populations that are high risk for COVID-19 if you're immunosuppressed, we worry about you, from a COVID-19 perspective.

Areej El-Jawahri (00:52:38):

And so, I do think we will have more data. Again, if we learn from our experience from other vaccines, especially in the active, obviously, not live vaccines, we haven't had problems. We haven't had these GvHD flares, generally speaking. So the expectation is that we'll see the same thing with the COVID-19 vaccine, as well.

Susan Stewart (00:53:01): How do you handle the return home of college students when there is a transplant recipient in the household?

All right. This is from a parent of an older patient, "How should an autologous stem cell transplant survivor, she's three years out and still on immunosuppression, welcome a college student back home who is coming from a school where the virus is rampant? Any testing or isolation procedures you recommend?"

Areej El-Jawahri (00:53:27):

Yeah, great question. So I do think colleges have been really great about having a lot of available testing, so I would say the first thing to note is to know what the actual testing practice at the particular college is. A lot of colleges are testing people, students regularly, and that is helpful.

Areej El-Jawahri (00:53:51):

Probably the safest approach is to have your college student isolate for a period of time, ideally 14 days, but if unable, 10 days before coming. That would probably be the most helpful, the safest way to go. At the same time, if they're asymptomatic, relatively recently negative test, a few days with no symptoms, I think is probably also reasonable. And all of us are going to be facing these scenarios, so to tell your college kid to be in isolation for 14 days may be hard. A shorter period of time with testing may be more doable. But Dr. Letourneau, what are your thoughts on that?

Alyssa Letourneau (00:54:34):

Yeah. I mean, you could go from the ... The way to do it the most safely and restrictively would be the 14 days of isolation, which is just hard to do. I know some folks can't do that before coming home, to wherever home is. But trying to do that at home, trying to stay in their own room or in a different part of the house, and wearing a mask if coming into other areas, is sometimes a way to do it. Testing can be helpful. Again, the testing characteristics are pretty good. They're not 100%, so just because it's negative doesn't always mean that it's actually negative.

Alyssa Letourneau (00:55:16):

Sometimes I've advocated getting a test two weeks before coming home, and then a couple days before coming home, and if they're both negative then that's pretty good. The reason I say both is that because some of these tests can say positive, depending which type of test you're using, how it's processed, how good the swab is, sometimes these tests can say positive for weeks on end.

Alyssa Letourneau (00:55:37):

Meaning if somebody had an asymptomatic infection at the beginning of September, and didn't test then because they were asymptomatic, and then got tested now and are asymptomatic and were positive, we wouldn't know based on that one test that, "Are they actually, actively shedding virus that is dangerous now? Or is that they were infected much earlier?"

Alyssa Letourneau (00:55:59):

And so, the two test points is another way to do this. Testing, but also, it can be limited in some areas depending which part of the country you're in and what access you have. So really, the safest, most conservative thing is to do the 14 days of isolation before coming home, although I recognize that that's difficult to do.

Susan Stewart (00:56:22): Why would a person test positive for COVID-19 after taking all the precautions?

All right. So next question is a little bit more complicated, it's from a woman who has rarely been outside her home without an N95 mask, and uses a lot of sanitizer, and she doesn't socialize in person. And a couple weeks ago, she, her children and her husband all came down with symptoms of a cold, head cold, et cetera. They all got tested afterwards, and everybody texted negative except for her. She almost never goes out except for short trips for groceries, and is obsessively careful. How is it that she would have a positive test while the others would not?

Alyssa Letourneau (00:57:04):

I mean, it could be a false positive. These tests are not perfect, given how careful she has been. But unfortunately, because we can't necessarily tell based on that, then we would do all of the precautions that we would normally do in terms of isolating for the 10 days that we would normally recommend that. Sort of staying away from others.

Alyssa Letourneau (00:57:32):

I'm not sure how careful all the other people are. It sounds like she's very careful, but sometimes, again, what I'm seeing right now ... So, I review all of the admissions coming into our facility here, and I'm seeing a lot of grandmothers had, quote, unquote, "just the family over", which is three different generations living in four different households, and then three days later everyone's sick with COVID.

Alyssa Letourneau (00:58:00):

And she thought she was being careful because she was just having the family over, and everyone has been careful. But when you start looking, and I'm doing quotes in the air, no one can see me. And when you start looking in terms of who's been actually doing things, you start seeing that the network gets really large very quickly if there's one person who's seeing one person outside their bubble or pod, and that person is seeing seven other people. And those seven other people are seeing lots of other people, as well. And so the risk increases as you increase your numbers.

Alyssa Letourneau (00:58:33):

But there are false positive tests. It's just really hard to piece those out, given how common COVID-19 is right now. And that's something we didn't talk about. I know we're at the hour now, is having a bubble or a pod. And I know having the group of people that you potentially spend more time with, and potentially time with without masks, and making sure that those people are very careful about what they're doing.

Alyssa Letourneau (00:59:02):

And typically, that would be your household, but for some people who potentially live alone or only live with one other person, trying to have other family, it's just being very thoughtful about what the other people are doing in terms of their time. Because it can, again, as you start thinking about these networks of spread, it can very quickly become that you're being exposed to actually very many people, when you think about it.

Alyssa Letourneau (00:59:26):

Depending where you live in the country, trying to see folks, if you want to have meals with people, I would advocate outdoors at different tables if you're from different households. And the tables being at least six feet apart. This will be harder in the colder regions. I think there's a run on outdoor space heaters right now, on the propane tanks, because of all of this. But in terms of staying safe, that's one of the things I would advocate for, is that the outdoors is much safer than indoors.

Susan Stewart (00:59:59): Are face masks effective if they are wet?

Okay. Another question from another mother. Her six year old tends to suck on his mask, or lick his mask, and it gets wet. Is it still effective when it's wet? And do you have any ideas about how to help him not suck on his mask?

Areej El-Jawahri (01:00:15):

Dr. Letourneau, I'm going to turn that one over to you.

Alyssa Letourneau (01:00:20):

So, the mask is, again, the goal of the mask is more to protect the child from spreading to somebody else. So I think it probably remains effective in that sense. It probably remains less effective, and again, these are not what the masks, the person wearing the mask is for, but getting infected. So if a droplet falls on a wet surface, then it's more likely to cross through, potentially.

Alyssa Letourneau (01:00:45):

I actually had a colleague who was supposed to send it to me, but there are plastic inserts, or plastic ... And I think you can find these online, basically like little frames that you can put inside the mask for people who are ... He's recommended this for patients or people who like to exercise a lot, so that the plastic gets ... It's not Plexiglass, but it's a piece of plastic that could get wet, and it prevents the mask from getting wet and having that uncomfortable feeling. So that might be something to help, in terms of the poor six year old who's trying to wear their mask appropriately.

Alyssa Letourneau (01:01:23):

And I have a three year old, as well, and frequently after we've gone for a walk, the mask is pretty wet. And it's just that they're breathing and that's what happens. They're drooling as well, probably, in the midst of that. But that plastic thing might be appropriate. And then trying to change masks frequently, if the child is going to school, then trying to switch the mask halfway through school or halfway through wherever they are to try to decrease that wetness. More that it might be uncomfortable for the six year old, as well.

Susan Stewart (01:01:53): How will a vaccine be distributed?  Will transplant recipients be given priority?

All right. Somebody wants to know whether the government has decided yet how a vaccine will be administered once it becomes available, and do you expect that transplant recipients will be given some priority?

Alyssa Letourneau (01:02:06):

Yeah, I think that they're ... I have not looked at the latest playbook. They call these playbooks, in terms of how they're talking about distribution and how they will weight distribution in terms of patients. So I don't know what the final say will be on that. I think it would also depend on ... It may change, when the administration changes, in terms of who gets priority. And then, there are discussions among healthcare systems about prioritizing certain patient groups, for example, there are debates whether healthcare providers should be prioritized for these vaccines.

Alyssa Letourneau (01:02:42):

Although, as Dr. El-Jawahri said earlier, in the hospital, actually, we have all our protective units. There are some shortages of personal protective equipment, but most people have that while they're in the hospital and feel protected and taking care of patients who have COVID. If we could decrease the number of patients coming in with COVID, that would be ideal. So potentially, vaccinating the high risk groups of patients that are coming in might be the better way to think about mobilizing this. So more to come. Unfortunately, I don't have an answer. But I know they're thinking about how to think about prioritizing groups for vaccination.

Areej El-Jawahri (01:03:19):

I just would like to add, I will just say that the American Society of Transplant and Cellular Therapy is definitely going to be an advocate for transplant recipients getting this early, as well. So I do think there will be a lot of advocacy, as well, on our end, to make sure that our higher risk population is receiving this. I know ASCO, the American Society of Clinical Oncology, is also advocating for patients with cancer in general in terms of getting on this list. So we got your back. We'll take it one step at a time and hopefully we will have a vaccine that's effective, that will be protective of our most vulnerable populations.

Susan Stewart (01:03:58): If you are immunocompromised, will the vaccine still be effective?

We have a number of questions from people who want to know variations here, but if you're taking a drug that makes you immunocompromised, will the vaccine still be effective?

Areej El-Jawahri (01:04:10):

That's a great question. We know from a case other vaccines that we've given to transplant recipients, it depends, in part, about how far you are from transplant and how much immunosuppression you're on. So generally speaking, patients on higher doses prednisone, greater than 0.5 milligrams per kilo, roughly, tend to have less robust response to vaccines. I will say that we do see an increase in titers after vaccination. This is not COVID-19, this is other vaccinations, even when you're on 20, 30 milligrams of prednisone.

Areej El-Jawahri (01:04:51):

This is, for example, the reason why we still recommend getting the flu shot every year for our patients while on immunosuppression, because we do see some increase in immunity. So it may not be 100% effective, but it may certainly be helpful, and we won't have that level of data, that granular data about the COVID-19 vaccine until probably two to three years out, to be honest with you, from having it available. But we can learn from experiences with other vaccines, in the transplant population.

Susan Stewart (01:05:24): If children have a predisposition to autoimmune diseases, are they at higher risk for post-COVID complications?

Another mother wants to know, is there any data that autoimmune predispositions like previous severe aplastic anemia, ulcerative colitis, skin diseases, et cetera, place children at a higher risk for longer term post-COVID complications?

Alyssa Letourneau (01:05:44):

I don't think we know that yet. Yeah, I don't think we have that data, as of now. The autoimmune, the the MICS, so the post-inflammatory syndrome that we've seen in kids and adults which comes, which, the numbers we saw here came in about four to six weeks after our big surge, it doesn't appear that certain patient populations have a higher risk for that, other than the fact that they were children and we see these autoimmune phenomenon in a variety of people.

Alyssa Letourneau (01:06:30):

And we saw it in ... There was just a few cases published in adults, as well. We had a case here, and it's something that we see. It's similar to what we think of in children as Kawasaki disease, which is typically in the younger patient population. It's an autoimmune phenomenon, but I'm not familiar with the fact that it's related in particular to any of the other autoimmune diseases that we see.

Alyssa Letourneau (01:06:55):

And then, there's the post effect - so, there's the autoimmune part that's been described, and there are certain markers in the blood that we can look for and a whole syndrome that presents with that.

There's also the separate entity that we're really only just getting to know, which I believe they're calling long-haulers, which are patients who have been infected, I think there was a piece in the New York Times recently about this, just have chronic symptoms, in some respect, and chronic fatigue that has stemmed potentially from one of these autoimmune processes. But again, we still don't know much. But people are obviously studying this to try to get a better sense of what's going on.

Alyssa Letourneau (01:07:38):

And part of this is, just for people to understand, is when you have a novel virus, a new virus that nobody has ever seen before, it's not unusual to see in such large numbers that people are being infected, it's not unusual to see the complete spectrum of what viruses can do.

Alyssa Letourneau (01:07:55):

A lot of viruses can cause a wide variety of these types of syndromes that you find once in a while, as an infectious disease physician. But when you have millions and millions of people getting infected, all in the same time frame, you see larger numbers of people coming in with these entities. And really, this will be just more to come, more to study, in this area.

Susan Stewart (01:08:19): If you need to be revaccinated after transplant, can the COVID vaccine be given at the same time as other vaccines?

All right. We only have time for a few more questions, unfortunately. We have one from a fellow, excuse me, who wants to know if you need to be re-vaccinated after stem cell transplant, what priority would you assign to COVID vaccines versus vaccines for other common diseases? Can the COVID vaccine be administered in tandem with the other vaccines?

Areej El-Jawahri (01:08:44):

Yeah, it's a great question. I mean, we should say we have professional societies, including the Infectious Disease Society of America, working in tandem with the Transplant and Cellular Therapy Society, that will likely incorporate the COVID-19 once we have one that's approved into the array of vaccines that people do get, post-transplant. Just, again, we don't know where that's going to fit in the context of the other vaccines. I think part of the issue is going to be, in terms of sequences, when is it most effective to give?

Areej El-Jawahri (01:09:19):

If we learn from the influenza vaccine, influenza vaccine is one of the earliest vaccines we give in transplant recipients. So the question that was asked earlier, how early is too early for the COVID-19 vaccine? Is there a period of time when you're just not going to have as much of a response to it? And that, we don't know yet. That is information that we will gain over time.

Areej El-Jawahri (01:09:43):

This applies more to people who are early post-transplant. There should be no reason to think or suspect that the COVID-19 vaccine will be unsafe to give with other vaccines, if it will fit with other vaccines that we give post-transplant. But the other and the sequence, and that information, will be more readily available over time. We just don't have the answers to these great questions.

Susan Stewart (01:10:10): Should you go to your local physician or your transplant center to get the  COVID-19 vaccine?

All right, this is probably going to need to be our last question. Should we access the vaccine with our local primary physician, or do we need to access the vaccine with our transplant center?

Areej El-Jawahri (01:10:24):

Yeah, it's a great question, and a really good one to end on. If you are greater than two years out from transplant, and off all immunosuppression, autos and allos, it is probably safe to access the vaccine with your primary care physician. If you are an allogeneic stem cell transplant recipient who's still on immunosuppression or less than two years from transplant, I would highly recommend contacting your transplant clinician team before getting the vaccine.

Areej El-Jawahri (01:10:57):

For those patients who have gone autologous stem cell transplant a year to two years out, that's a population where you probably are okay with the primary care doctor, but it's nice to confirm with your oncology team as well. So, again, if you're two years out and you are doing okay, and you're off immunosuppression, have no graft-versus-host disease, it's very likely that this is going to be very, very safe. Again, it'll all depend a little bit on the vaccine itself. And your primary care, if they feel unsure, they will probably direct you to your transplant team. But if you're early, in the first two years, I highly recommend talking to your transplant team.

Susan Stewart (01:11:34): Is it safe for patients recovering from CAR T-cell therapy to get the COVID vaccine?

And I think we'll squeeze in one more, because this is a little bit different twist. For CAR T-cell therapy recipients about eight months out, is it safe for them to take the vaccine?

Areej El-Jawahri (01:11:47):

Yeah, it's a great question. We still don't know a lot about vaccinations in the context of CAR T-cell therapy. We also, I should say, don't know to what extent CAR T-cell therapy impairs prior vaccinations, and prior immunity. So we have a lot of unanswered questions. If you are eight months out from a CAR T-cell therapy and your disease is in remission, and you're not getting any more treatment, it's likely that the COVID-19 is going to be very, very safe, in that population. Again, I'm talking about the most recent vaccine we're hearing about.

Areej El-Jawahri (01:12:23):

But most of the vaccines and trials are not live, they're inactivated vaccines. So they will likely be safe. We don't expect the vaccine to have any effect on the efficacy of CAR T-cell therapy, so we think you'll probably fit in that category of patients where it's really safe to give. If you are still receiving chemotherapy or treatment, that's when I would say, definitely talk to your oncologist or oncology team.

Susan Stewart (01:12:53):

All right, and with that, unfortunately, I think we'll have to close. I think we have enough questions here, we could probably go on for two hours, but unfortunately our time has come to an end. I want to thank Dr. El-Jawahri and Dr. Letourneau for a wonderful presentation, and I want to thank everybody who listened and posed very interesting questions, for participating in this event.