COVID-19 & HemOnc: an interview with David Marks

COVID-19 & HemOnc: an interview with Prof. David Marks

The Video Journal of Hematological Oncology (VJHemOnc) interviewed Professor David Marks, the Lead Clinician of the Bristol BMT Unit, University Hospitals Bristol, Bristol, UK on the 16th of March. Prof. Marks discussed the ongoing COVID-19 pandemic currently affecting countries worldwide and gave us an overview of how, in his personal opinion, this serious issue is likely to impact the UK health system and hematology cancer patients.

With the Coronavirus outbreak now impacting the NHS, which transplant and hematology patients are most at risk?

“All cancer patients appear to have a high-risk of getting severe COVID-19; this means pneumonia and a higher chance of mortality. Probably, the patients with the very highest risk are allograft patients who are close to transplant or are on immune suppression for graft-versus-host disease. These patients have multiple immune defects including lymphopenia and hypogammaglobulinemia.

For non-transplant hematology patients, high-risk patients include those on fludarabine or steroids. Many of our patients will have the known co-morbidities which include lung disease, particularly chronic obstructive pulmonary disease, cardiac disease, patients over the age of 60 and patients with hypertension. There may be a higher risk with diabetes and obesity, but this is less clear.”

“The goal of these patients must be to avoid getting the virus. That may be difficult to achieve. These patients should avoid crowded areas and consideration should be given to them reducing their contact with younger family members, realizing this may be difficult or impossible.

Reducing the number of visits to hospital is a goal and many will have telephone consultations or have less essential therapy postponed. I am advising my patients to wash their hands 10 times a day, especially before they eat. These patients can go for a walk in the fresh air; that is safe. The issue is that these measures may be necessary for several months and we all have uncertainty about how successful they will be if they are prolonged.”

What is your advice to transplant patients?

“There is of course more than one category of transplant patient, and a high stress are allogeneic transplant patients close to transplant. Autograft patients have an increased risk, but probably a lower risk than allogeneic transplant patients. The basic information is being conveyed by telephone consultation by clinical nurse specialists. We are yet to write this information, but this is work in progress.”

“There is a shortage of the most rigorous PPE worldwide. A recent change in the national recommendations was that for patients being assessed for possible COVID-19 do not require staff to wear full PPE and that a plastic apron, a surgical mask and gloves were sufficient. This is a concern to many of us as increasingly a high percentage of patients who are being assessed will have COVID-19 and could infect staff.

There is of course an overwhelming need to protect staff both looking at it from the staff point of view but also retaining those staff so they can continue to work and look after patients with the virus. The workforce is expected to be depleted significantly over the next few weeks.”

What progress is being made in COVID-19 research to help understand the disease?

“In 11 weeks there has been remarkable progress with the virus sequenced from the 1st cases in Wuhan and the virus cultured from the 1st cases in the United States, with this being made available to research centers. Several centers in the world are quite close to human testing of putative vaccines.

However, these need to undergo testing over several months to make certain they are safe followed by efficacy trials. If the vaccines being trialled are shown to be effective and safe then production will need to be dramatically expanded and realistically there will be no usable vaccine for 12 to 18 months. It is also not 100% certain that the vaccine will work.

The results of the randomized trial of remdesivir should be available in April. Other drugs being trialled include HIV agents in combination and chloroquine. Convalescent immunoglobulin from patients who have recovered from the virus is also a possible option.

In fact, many aspects of the virus that cause severe infection are potential targets for therapies and the effort being made worldwide it is unprecedented.”

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“If the epidemic progresses as we expect there will be insufficient ICU beds and ventilators to meet the needs of the UK population. All efforts are being made to expand the number of ventilators, but it is clear some difficult decisions will need to be made.

Using the available data and the known risk factors, it will be logical to select the patient’s with the highest chance of survival. Every decision of course should be individual, and it needs to be remembered that there is a degree of uncertainty in the risk factors and incomplete knowledge about the likely outcomes.”

What do you think of the response from the goverment and Public Health England so far?

“More recently the UK government has communicated quite well. The approach of the UK is very different to every other country and that is a concern to many of us. Only time will tell if these decisions, including those about social distancing, are correct. Some of the decisions are based on mathematical models and it is important that readers realize that these models are only as accurate as the assumptions behind them. One of the issues is that we do not actually know the number of cases and that denominator is clearly important for many calculations.

I (and many others) do have one area of definite disagreement with national policy and that is the unavailability of testing for healthcare workers who are self-isolating. This is not efficient, it makes it difficult to decide when they should return to work, some of them may have other viral problems, but I would also argue this need for testing on humane grounds.”

“Doctors and nurses who look after these patients and put themselves at risk are to be admired and supported. When you start your medical career you realize there may be risks, but you do not really anticipate this sort of situation. I think all doctors and nurses understand that they have a very important duty to perform but we need to minimize the risks to these people by giving clear guidance and giving them access to high quality PPE

My message is to stay in touch with what is going on, talk to colleagues, especially if you are worried, and do your best. Nobody should feel guilty if they have done their best. The work we do will make a huge difference.”

Professor David Marks, Professor of Hematology and Stem Cell Transplantation Bristol BMT Unit. Professor David Marks received his medical education at the University of Melbourne, Melbourne, Australia, and his clinical training largely at the Royal Melbourne Hospital. He was awarded his FRACP in 1988 and his PhD in ‘Mechanisms of cytotoxic drug action’ in 1990. He then moved to London to receive further training in stem cell transplantation with Professor Goldman at the Hammersmith Hospital as MRC/LRF fellow and senior registrar. A 3-year stint in Philadelphia as Assistant Professor in Hematology/Oncology enabled him to set up a new unrelated donor transplant program and work in p53 research in acute lymphoblastic leukemia (ALL). He returned to the UK in 1996 and was appointed to a consultant position in the Bristol BMT Unit (which he directs) and Honorary Senior Lectureship at the University of Bristol, Bristol, UK. Professor Marks’ research and scientific papers focus on clinical aspects of stem cell transplantation (particularly the use of alternative donors), ALL and infection. In 1999 he worked to initiate the Clinical Trials Committee of the British Society of BMT, the first national transplant trial group and chaired that group for 5 years. In 2004 he was promoted to Reader and in 2007 to Professor at the university and was Lead Clinician of the Bristol BMT Unit from 2003-9 and 2014 till now. He received FRCPath in 2006. He is Transplant Coordinator and Deputy Chair of the NCRI ALL working group and from 2007-2009 was President of the BSBMT. He also chairs the Adjudication Committee of BSBMT and is a current member of the ASBMT Practice Guidelines Committee. He is currently Vice Chair (Europe) of the Advisory Committee of the CIBMTR and recently was Scientific Secretary for EBMT London 2013.

Please be advised that the content found on this page is not comprised of the current clinical or governmental advice on the COVID-19 outbreak.

Edited by Thomas Southgate

With the Coronavirus outbreak now impacting the NHS, which transplant and hematology patients are most at risk?

“The goal of these patients must be to avoid getting the virus. That may be difficult to achieve. These patients should avoid crowded areas and consideration should be given to them reducing their contact with younger family members, realizing this may be difficult or impossible.

What is your advice to transplant patients?

There is of course an overwhelming need to protect staff both looking at it from the staff point of view but also retaining those staff so they can continue to work and look after patients with the virus. The workforce is expected to be depleted significantly over the next few weeks.”

What progress is being made in COVID-19 research to help understand the disease?

What do you think of the response from the goverment and Public Health England so far?

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