March 2020 - For many people with CML, the reporting on the current public health emergency with the COVID-19 virus, also known as coronavirus, may be a source of anxiety. In light of this, the iCMLf is sharing an expert statement specifically for chronic phase CML patients on the novel coronavirus and the COVID-19 disease.

Please read the full statement below.

We will be keeping you updated as more information becomes available. If you have specific questions please email info@cml-foundation.org. Physicians can post specific patient cases for advice and discussion on the iCMLf clinical case discussion forum.

Find more information on COVID-19 and CML on the iCMLf COVID-19 Hub

The novel Coronavirus and the COVID-19 Disease

Information for Chronic Phase Chronic Myeloid Leukemia Patients

State of the Art as of 08 March 2020

Dr Michael Deininger (USA), Dr François Guilhot (France), Dr Jeroen Janssen (Netherlands), Dr Tim Hughes (Australia), Dr Jeffrey Lipton (Canada), Dr Franck Nicolini (France), Dr Jerry Radich (USA), Dr Delphine Rea (France), Dr Giuseppe Saglio (Italy), Dr Susanne Saussele (Germany), Dr Rick Silver (USA), Dr Juan-Luis Steegmann (Spain)

Introduction

SARS-Cov 2 is a novel coronavirus that belongs to the large Coronaviruses (CoV) family. It emerged in December 2019 in Wuhan, China. This new virus is responsible for an illness called COVID-19 ranging from a simple cold to a more severe respiratory infection. The virus is spreading across the globe, representing a pandemic alert.

Transmission

Conventional routes of transmission of the new coronavirus consist of contact with respiratory droplets from infected persons. People may also possibly be infected by SARS-CoV-2 when touching a surface or object that has the live virus on it then touching their mouth, eyes or nose although it may not be the main route of infection. Finally, the new coronavirus can be detected in the gastrointestinal tract, saliva and urine, so these routes of potential transmission are currently under investigation.

Symptoms diagnosis and treatment of COVID-19

Symptoms

Symptoms of COVID-19 may occur around 2 to 14 days after coronavirus exposure. Main symptoms of are non-specific (and common to other viral infections such as seasonal Flu) and include fever, cough, chest pain or shortness of breath.

COVID-19 is in about 80% of cases asymptomatic or mild, severe in about 15% of cases (like pneumonia requiring oxygen) and critical in around 5% of cases (like acute respiratory distress syndrome, kidney failure, multiple organ failure or even death). On March 5, 2020, WHO estimates the global mortality rate around 3.4%. Recovery in mild forms of infection is around 2 weeks.

Diagnosis of COVID-19

Positive diagnosis of COVID-19 requires detection of the virus by nasopharyngeal swab in symptomatic patients. In most countries, tests are restricted to persons highly suspected of COVID-19 or who had been in close contact (directly or less than 2 meters from) with infected individuals.

Treatment of COVID-19

Treatment is essentially supportive, either at home or in hospital. There are currently no specific anti-viral medications to treat COVID-19. Severe forms of infection require transfer in hospital and eventually in an intensive care unit.

Risk factors for severe or fatal COVID-19

Older adults, people with some coexisting chronic illnesses (like chronic lung diseases as an example) and those contracting secondary infections seem to be at higher risk of severe COVID-19 but more precise risks factors are not clear yet. As a general rule, immunosuppressed individuals should be considered at high risk. Children are rarely affected.

Are CML patients at higher risk for severe or fatal COVID-19?

There are no available specific data on the new coronavirus infection or COVID-19 in CML patients treated with tyrosine kinase inhibitors (TKI).

At the moment in a normal situation, neither chronic phase CML per se, nor tyrosine kinase inhibitors against CML appear to induce a state of clinically significant immune suppression. However, we really do not know if protection from COVID-19 requires a level of immune control that CML or TKI therapy may in part impair. Therefore, we recommend CML patients under TKI therapy to be extremely cautious and to strictly follow the most restrictive measures suggested by health authorities of their respective countries, in order to avoid the risk of contamination and to prevent the spread of infection.

Don’t forget that you may be at higher risk of severe infection due to non CML-related causes (like older age, other diseases, immune suppressive treatment for another disease).

What to do in case symptoms compatible with COVID-19?

Everyone should follow its own country- or region- specific procedures/recommendations for what to do in case of symptoms compatible with COVID-19 and for coronavirus testing, as these procedures may slightly vary, depending on local situations, health system organization and government decisions. Importantly, these recommendations may evolve overtime thus staying updated with the goings on using only reliable sources of information is a key issue.

Most countries currently recommend isolation of COVID-19-affected patients either in the hospital or at home until they no longer represent a risk of infecting others. People who have been in close contact with COVID-19 patients who are tested positive for the virus may be asked in many countries, a quarantine of around 2 weeks (at home or in hospital) to avoid viral dissemination in the general population.

What to do if you have CML and you contract coronavirus or COVID-19

1. If you have symptoms compatible with COVID-19 or have been in close contact with a coronavirus infected person, follow your country-specific procedure (usually a dedicated call center).
2. Inform your hematologist/oncologist by phone or email or fax (don’t come to hospital on your own as you may contaminate health care providers or other fragile patients).
3. Don’t stop your treatment with TKIs unless your hematologist or oncologist asks you to do so, but ask your hematologist to contact the team taking care of you in case of confirmed COVID-19 as adjustment may be needed.

Prevention of coronavirus infection and COVID-19 for CML patients

Prevention is a key issue. Please follow the most restrictive measures suggested by health authorities of your country. Here are some commonly admitted rules:

1. Avoid close contact (<1 or 2 meters) with people having symptoms of respiratory infection
2. Avoid touching your face (eyes, nose, or mouth) with unwashed hands
3. Wash hands often with soap and water for at least 20 seconds especially after going to the bathroom; after using public transportations; before eating; after blowing nose, coughing, or sneezing. An alcohol-based hand sanitizer with at least 60% alcohol may also be used.
4. If cases have been detected in your area, limit social contacts
5. In case of blowing nose, cough or sneezing, use a tissue and immediately trash the tissue
6. Do not systematically wear facemask if you are not sick, unless your doctor asks you to do so or due to specific hospital/clinic/country policy.
7. Avoid nonessential travel especially in areas at high risk of contamination (WHO website).
8. Avoid travelling if you suffer from a cold or do it if necessary, using a facemask.
9. If you experience benign symptoms of respiratory infection and you have an appointment with your hematologist, call your hematologist first as there may be recommendations to postpone the visit in order to protect healthcare providers and other fragile hospitalized patients or outpatients.
10. If you feel well, don’t postpone your visit with your hematologist unless your doctor asks you to do so.

Updated information will be provided until the end of the epidemy or in case of breaking news

Sources of information

1. WHO website: https://www.who.int/health-topics/coronavirus
2. CDC website: https://www.cdc.gov/coronavirus
3. Eurosurveillance Editorial Team. Latest assessment on COVID-19 from the European Centre for Disease Prevention and Control (ECDC). Euro Surveill. 2020 Feb;25(8). doi: 10.2807/1560-7917.ES.2020.25.8.2002271.
4. Ruan Q, Yang K, Wang W, Jiang L, Song J. Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China. Intensive Care Med. 2020 Mar 3. doi: 10.1007/s00134-020-05991-x.
5. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, Liu L, Shan H, Lei CL, Hui DSC, Du B, Li LJ, Zeng G, Yuen KY, Chen RC, Tang CL, Wang T, Chen PY, Xiang J, Li SY, Wang JL, Liang ZJ, Peng YX, Wei L, Liu Y, Hu YH, Peng P, Wang JM, Liu JY, Chen Z, Li G, Zheng ZJ, Qiu SQ, Luo J, Ye CJ, Zhu SY, Zhong NS; China Medical Treatment Expert Group for Covid-19. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med. 2020 Feb 28. doi: 10.1056/NEJMoa2002032.
6. Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, Zhao X, Huang B, Shi W, Lu R, Niu P, Zhan F, Ma X, Wang D, Xu W, Wu G, Gao GF, Tan W; China Novel Coronavirus Investigating and Research Team. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N Engl J Med. 2020 Feb 20;382(8):727-733.