COVID-19: An evolving situation

The health and safety of those with primary immunodeficiencies and their families have always been IDF’s top priorities. The COVID-19 pandemic has changed how we live and our programming during this unprecedented time reflects our commitment to offer support to those impacted by COVID, both directly and indirectly. IDF’s Educational Forums are designed to empower the community with information to be prepared and stay safe. 

During the July 23 Online Educational Forum, COVID-19: An Evolving Situation, participants heard from Dr. Mark Ballow, a member of IDF’s Physician Advisory Committee, who provided both general COVID information and more community-specific concerns.

In order to illustrate the current trajectory of the virus in hotspots, Dr. Ballow presented several slides with graphs showing the trends in the number of COVID-19 cases in states like Florida, Georgia, and Texas. Cases stayed fairly low in the spring during lockdowns, but spiked in June and July when restrictions eased.

“All this is occurring because we were kind of successful initially in the policy of social distancing and other measures to dampen down the spread of the virus but as soon as we started to open up, clearly I think the consensus is that we opened up too soon. This is a virus that is very contagious, as you can see from the curves,” said Dr. Ballow, pointing out in his presentation that the U.S. had 4 million cases, with 145,000 deaths.

Dr. Ballow described how our understanding of transmission of the virus has changed. Contracting the virus from surfaces like countertops or door handles is less of a concern than catching it through face to face interaction with others, he explained.

“It is spreading primarily through respiratory droplets,” added Dr. Ballow.

Dr. Ballow also showed a Texas Medical Association risk chart ranking the overall risk to exposure to COVID-19 connected with certain activities. The lowest risk is opening the mail. The highest is frequenting a bar or attending a large social gathering in a closed environment like a stadium, indoor concert, movie theater, or church.

After sharing the status of the virus pandemic in the U.S., Dr. Ballow outlined how COVID-19 could be curtailed with specific antibodies. Convalescent plasma, or plasma taken from people who have recovered from the virus, can clear the virus and prevent respiratory failure. Of particular interest is monoclonal antibodies, made from the cells of those recovered from the virus. Monoclonal antibodies can act as a prophylactic therapy, and those receiving it may be immune to the virus for up to a month.

Vaccine development is on a fast track, said Dr. Ballow, and include the following types:

• Genetic vaccines – The genes of the coronavirus are injected directly into the host to provoke an immune response.
• Viral vector vaccines – A virus is used to deliver the coronavirus genes into a host to create an immune response.
• Protein-based vaccines – Part of the virus is used to make a vaccine, a process commonly used to make other vaccines.
• Whole-virus vaccines – Weakened or inactivated versions of the virus are used to provoke immune response.

Dr. Ballow also answered several questions from members of the PI community who tuned in for this interactive webinar. Below, are questions asked by the PI community and abbreviated versions of Dr. Ballow’s answers. To watch the full Online Educational Forum, COVID-19: An Evolving Situation, click here. For a current list of upcoming IDF Events, click here.

Dr. Ballow also recommended visiting the Johns Hopkins University and Medicine Coronavirus Resource Center and the Centers for Disease Control and Prevention for up-to-date information on COVID-19.

Q&A with Dr. Ballow

What about the status of COVID-19 and patients with PI?

I think that patients with PI are very cognizant of this virus and how it’s spread, so I’m sure they’ve been staying at home, social distancing, good handwashing, wearing masks, doing all the right things, and I think maybe that’s accounted for the fact that we haven’t see much COVID-19 in our patients with primary immune deficiency.

Or perhaps, as I mentioned before, maybe those that are getting replacement immunoglobulin, either subcutaneous or intravenous, maybe that’s partly protective. We don’t’ know.

Obviously, as we go forward, usually it takes about nine months for a batch of gamma globulin to be made by the manufacturers, so as we move forward, nine months from March, we’ll see more widespread antibodies in immunoglobulin products and maybe this will play a role in protecting our patients. We just don’t know at this point.

I think all of you are aware companies are collecting convalescent plasma, so called hyper immune gamma globulin, from individuals who have recovered from COVID-19. I don’t know when that will be available. I would think that by the time that is available, all of these specific monoclonals to the spike protein of the virus will be available.

In my own personal opinion, I think it’s these monoclonals, particularly these cocktails of monoclonals, are going to be a very exciting way of providing prophylaxis against the virus.

How long, knowing that we don’t have that many statistics, do you recommend that those with PI practice isolation, social distancing, and mask wearing?

I think that’s going to depend on your community, and what the prevalence or incidence of the virus is in your community. You can get on the Johns Hopkins website, which has the most detail, even by county.

So, answer to that question is right now I think maybe until next summer until we have an efficacious vaccine. We are not going to achieve herd immunity. Enough individuals who have had the virus and have antibodies or have had the vaccine and made antibodies, so therefore, when you’ve reached 70 to 75 percent of individuals in the community who have a specific immune response and therefore can’t get infected, that’s called herd immunity. We’re not going to achieve that because of the nature of the virus.

If an individual with PI comes across someone who has tested positive for COVID-19, do you have any recommendations about how they should proceed?

It depends on how they came across. There’s actually some interesting data. Close contacts, in other words, household family members, the transmission rate is 10 to 40 percent; close but less sustained, the transmission rate is about 7 percent; passing interactions like in a shopping center where you walk by somebody, it’s only 0.6 percent.

It depends on what the nature of the contact is. If it’s close contact, they should get tested. I wouldn’t get tested right away. I’d wait five days and get tested at that period of time since that’s enough time for virus to show up in the  saliva and nasal secretions.

Once a vaccine is approved, should a patient with PI rush to get that vaccine?

I don’t think they should rush. I think we have to be cognizant of safety.

I think the vaccine is going to first be administered to first responders and hospital personnel, and then to nursing homes, and then probably to the elderly. I would probably wait a couple of months. I think what the PI community is doing, its doing well with social distancing, and wearing masks and other sanitizing steps. I think is fine.

Don’t rush into the vaccine until we’re sure that it’s safe. Even though they’re going to test it in 30,000 people in the phase three trial, it doesn’t go into people who have co-morbidities or underlying issues, so that doesn’t happen until it goes into the general population and that’s where we have to make sure, particularly with PI patients who may have other underlying conditions, that they don’t get adverse effects.

What process should a person use when determining whether or not it’s safe to return back to work, if they are a patient of the PI community?

It depends on the place of work and what safety policies they’ve implemented. Have they separated their co-workers? Is everyone wearing masks in the environment? Is there enough use of hand sanitizers around, for example? I think it just depends on the environment and doing common sense things.

For those of our attendees who are teachers or who work in school settings, are there any recommendations in terms of whether or not it is safe for them to return back to school?

We don’t have the answer to that question. That is the hottest debated question of the week, I think. And certainly in areas like the Southeast, like in Florida, where the virus is so dominant, I think it’s unsafe. Kids can transmit the virus and they may be asymptomatic, that’s clear. We actually know that.

Are there any recommendations on what a person should do if he or she is diagnosed with COVID-19?

They have to social distance, right? I mean that’s clear. Again, the CDC outlines a lot of information on this, but we don’t necessarily want patients running to the emergency room. I think that may be a bad choice.

But certainly if you have symptoms you need to contact your physician, so that you can do telemedicine and work with your physician, and so they can keep a close eye on you. There may be protocols at your local hospital. But I think a lot of those protocols right now are on patients who have pneumonia or have severe respiratory compromise before those protocols kick in.

If patients with PI are considering traveling, flying for example, should they wear a face shield?

The airlines are saying that they have bent over backwards to try to provide a safe environment as possible with using good cleaning in between flights. Everyone now has to wear a mask on the flights.

I think that might be a good idea to not only wear a mask, but also a face shield as well. There is some concern that the virus can be transmitted through the mucosa of the eyes, and so that’s why you see in the hospitals that everyone not only wears a mask, but a face shield as well.

Is it safe for members of the PI community to hug others who they do not live with if they are both wearing masks?

It can be. It should be a small group. You need to ask the appropriate questions. Those individuals that you are visiting, do any of them have symptoms? Have any of them be in contact with anyone who has developed COVID-19? I think that’s an important question as well.

For parents of children with PI, what recommendations do you have in terms of who they should connect with regarding safety for their children?

That should be based on their previous experience. I would hope that the clinical immunologist would be providing the most up-to-date information with regard to the virus in patients with PI.

In regard to children being diagnosed with COVID-19, is there any special precaution parents should take with children with PI?

I think it’s all the same kind of precautions whether you an adult with PI or a child with PI. I think they’re really the same. And so should you let your child go back to school? I don’t know. I think that schools are going to have a hard time with providing the appropriate environment for safety.

Now, that may not be true for all particular school environments. Obviously, the private schools may have more of a luxury of smaller classes and better able to do social distancing, and other measure to keep an eye on the kids and have them wear masks etc.

I think the public school system is going to be very difficult. It remains to be seen how successful that is. I think a lot of the school systems are giving parents a choice of remote learning or a combination of remote learning and in-school learning. I think we just don’t have enough information and we have to be very cautious.

Are cloth masks effective enough for PI patients?

Depends on the type of cloth mask. It depends on how many layers. So there are cloth masks that are multi-layered. Two or three layers, in fact, one of my friends who has a co-morbid condition actually puts a coffee filter in as another layer. You can get N-95 masks almost everywhere now, so those are obviously better than a plain cloth mask or a regular surgical mask. The problem is once it gets very moist, and gets a little bit wet from wearing it all day, it’s obviously much less effective. So, you can make your own cloth masks, just make it multilayered.

When do you think there will be sufficient antibodies in IVIG?

I think nine months. But that remains to be seen because as I’ve said before, there will be some antibodies, but whether they will be high enough to act as prophylactic antibodies remains to be determined. We don’t know.

Is there any recommendation you have for the PI community in terms of what they really need to consider now that there are increased rates of transmission, and now that certain states are opening up?

Social distancing, good handwashing, and wearing a mask. If you socialize, know who you’re socializing with, ask all the appropriate questions. Confine your experience to small groups outside. You saw that one slide that ordering food out from a restaurant could be fine, that could be safe. Again, wearing a mask, and prepaying for it over the phone so you’re not handing them a credit card. That’s level 2 on that diagram. So, that’s fine. I think stay away from indoor gatherings of individuals. That clearly, clearly, is not good for anyone. Not only the PI community, but anyone.