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Polycythemia Vera and Clotting: Am I High Risk For COVID-19?

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Published on July 14, 2020

Polycythemia Vera and Clotting: Am I High Risk For COVID-19?

Are polycythemia vera (PV) patients at a higher risk during the coronavirus pandemic? Should they worry about clotting, strokes, or even hospital capacity to treat them? Should they avoid foods with vitamin K or take supplement IP6?

In this replay of our recent MPN Answers Now program, host Esther Schorr gets the answers to these questions from two MPN experts, Dr. Angela Fleischman from UC Irvine Health and Dr. Joseph Scandura from Weill Cornell Medicine. PV advocate, Nick Napolitano also shares his experience and concerns.

This program is sponsored by Incyte. This organization has no editorial control. It is produced by Patient Power and Patient Power is solely responsible for the content.

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Transcript | Polycythemia Vera and Clotting: Am I High Risk For COVID-19?

Esther Schorr:
Greetings from Southern California. I'm Esther Schorr with Patient Power and welcome to this MPN Answers Now program sponsored by Incyte. Today's program is specifically for polycythemia or PV patients, and we'll be discussing the risks and concerns that you may have during the COVID-19 pandemic. I am just thrilled to be joined today by three wonderful guests. The first is Dr. Angela Fleischman, who's an Assistant Professor, Department of Medicine, Division of Hematology/Oncology at UC Irvine Health. Boy, that's a mouthful. Nice to see you, Dr. Fleischman.

Dr. Fleischman:
Thank you, thank you. And I'm really excited about this event, so thanks for inviting me.

Esther Schorr:
Thank you. And we have Dr. Joseph Scandura, who is the Scientific Director of the Richard Silver Myeloproliferative Neoplasm Center at Weill Cornell Medicine.

Dr. Scandura:
Hi.

Esther Schorr:
And we're just so happy to have you here too, Dr. Scandura. Thank you for being here. And last but not least, we have Nick Napolitano, who is a PV patient, and an amazing advocate. So, Nick, thank you for being here and being willing to share your story.

Nick Napolitano:
Glad to be here, Esther. I need to get a long title. I feel left out.

Esther Schorr:
I know. Mine's pretty short compared to them too. It's like a mouthful. I practice a lot. So, I tell you what. Nick, let's get started with you. You were diagnosed with PV in your 30s and you have two young children, right?

Nick Napolitano:
Yes. So after a routine physical about five years ago, my numbers were elevated and they did some more digging and found that I had polycythemia vera. And yes, I have two kids, and living in this COVID time right now, it's a blessing and also a challenge. On the one hand, we're having tons of fun. The kids are in the house all the time. My wife is home. But it's also stressful. We both work. There's what's going on in the world today around COVID and how that impacts me with a rare blood cancer. So, it hits both ends of the spectrum right now.

Esther Schorr:
So what are your main concerns, Nick? I mean, you've got everybody at home, and you've been hunkered down. So what are you concerned about?

Nick Napolitano:
Primarily, the fact that my body is already fighting something. And if I have COVID, if I get COVID, how does that impact my body's ability to fight something else if I'm already fighting a rare blood cancer? And that is probably my main concern. The other concern is stress. Working with the kids home, and just kind of balancing all that, how does stress impact my symptoms possibly? I've seen an increase in symptoms since we've been home. I've seen new symptoms since I've been home that have come to the forefront. So those are probably two of my primary concerns.

Esther Schorr:
Okay. And I also know you either had an appointment recently or you're about to have an appointment for a checkup or at the hospital.

Nick Napolitano:
Yes. That's the one today.

Esther Schorr:
Do you have concerns about going, or have you gone?

Nick Napolitano:
I have less concern. I went today and the hospitals are doing a fantastic job at making sure that all the procedures are in place, making sure that we're comfortable. If I'm being honest, I'm still a little bit uncomfortable going to the hospital and just looking around and thinking I can get it any which way. But the hospital - I've been twice now during COVID - they're doing an outstanding job making sure that we feel comfortable and following procedures.

Esther Schorr:
No, that's great. And I know from the checkups that my partner and husband, Andrew, has had to have, actually, he is today having an IVIG infusion for myelofibrosis, to support him in that and CLL that he has just said that everybody's very buttoned-down and careful in dealing with all patients, so that's encouraging. But you mentioned that the pandemic brought up some anxiety for you. I mean, can you talk a little bit about that? I know when you're first diagnosed, that's pretty scary. Is it like that?

Nick Napolitano:
At times. I dealt with anxiety a lot when I was first diagnosed and I had to get medication to treat it. And it still pops up every now and again, but I would say over the past four months, it's been a little bit more often, a little bit more severe. I can't help but correlate the two, the what's going on at home, what's going on out in the world today, and then my symptoms. But as a PV patient, you also worry about progression. So all of a sudden my symptoms are heightened, so does that mean I'm progressing? So you know, it's been concerning, to say the least.

Esther Schorr:
So I'm hoping that through the conversation with our two experts today that maybe some of the issues that you're dealing with, and I would assume some of the concerns that people listening, maybe we can get some answers and hopefully some reassurance or guidance about those things. One other thing I wanted to touch base with you about is I know that you are now located in what is kind of a former hotspot. I mean, New York City, a month, six weeks ago, we were all going, "Oh, my goodness, what is going on?" And now successfully at least things have calmed a bit. Any words of wisdom for other people in the country who are now facing what you saw in New York weeks ago?

Nick Napolitano:
Very simple: follow the rules. Stay indoors. Don't go out. If you have to, wear a mask. My family did that pretty strictly. The community did it where I am, and I think we're better for it. We're not out of the woods yet, but follow the rules.

Esther Schorr:
Okay. Good advice. Good advice. Thank you, Nick. So let's chat a little bit with our clinical experts and start with questions just in general about COVID-19 and risks related to that. So, let's start with Dr. Scandura. Are PV patients at higher risk for getting COVID?

Dr. Scandura:
I would say as a general rule, and of course, every patient has their own history and medication history, and maybe comorbid conditions that contribute, but as a general rules I don't think PV patients are at any greater risk for getting the disease. This is an infectious disease that we get from other people. The exact mode of transmission, it's clearly droplet-transmitted. Maybe very fine droplets, aerosols can contribute as well, and that's where a lot of the guidelines for trying to prevent transmission have come to be. And the one thing we know is that transmission is preventable. You mentioned, Nick mentioned New York. In March, every other day we were doubling the number of cases, and that went on for over a month. And with a really heroic social experiment, if you will, the number of cases slowly slowed and then began to decline. And there's a lot of lagging things that happened.

First, the number of admissions dropped. Then the number of people in the hospital start dropping. Then the number of people in the ICU start dropping. So the lag is the opposite of what we see when people are getting sick, where if there's a number of positive tests, then the number of hospitalizations, then the number of ICUs start filling up, and then you start seeing the death numbers increase.

Esther Schorr:
Mm-hmm.

Dr. Scandura:
So there's a large lag, both on the lead-in and the lead-out. But what Nick's advice is, is exactly what my advice would be. Be careful. You're not treating yourself. You're treating the community. Wear a mask doesn't help you that much, but it does help the community. There are a fairly sizable number of people who are probably low symptomatic to asymptomatic who can spread.

Esther Schorr:
So Dr. Fleischman, do you see PV patients as immunocompromised because that term gets thrown around a lot as, "Oh, if you're immunocompromised, then you're at greater risk." But where do PV patients sit in all of that?

Dr. Fleischman:
So that's a very good question. Anybody with a hematologic malignancy, their immune system is not quite "normal," however in the scheme of hematologic malignancies, a PV person would have a much more intact immune system compared to, say, somebody with MDS or with a leukemia. So that's a difficult question. They're somewhat immunocompromised but should have a relatively intact immune system. Another issue and I'm not sure whether we'll address it in another question, maybe not necessarily think about immunocompromised, but it seems that part of the negative consequences of COVID come from an over-robust immune response to COVID. From my perspective, I think that's what I would be more concerned about in somebody with a myeloproliferative neoplasm, not that their immune system is compromised, but they may have an over-exuberant immune response to COVID.

Esther Schorr:
Is that the cytokine storm that people talk about?

Dr. Fleischman:
Correct.

Esther Schorr:
Okay. Just because I know some people hear that and don't know what it is. So that's your immune system in overdrive.

Dr. Fleischman:
Yeah, that's a good way to put it, yeah.

Esther Schorr:
Okay. All right, so that might be something that a patient with an MPN or PV is one of them might be of more concern.

Dr. Fleischman:
From my perspective, yes. But for everything that we're talking about, we really do have to take things with a grain of salt that there's so much that we do not know about this disease, and we can really only base our discussions on the known biology of the disease, and what little we know about COVID thus far.

Esther Schorr:
Okay. Oh, go ahead, please.

Dr. Scandura:
There are a number of large efforts to try to collect this information, and right now we don't have data to draw from to say, "Patients with PV have a worse or better outcome than those without." I would say apocryphally, it seems about the same. Patients with PV, where we've had patients who have tested positive, they do about the same as everybody else. But there are large efforts that allow us to move away from apocryphal stories. The American Society of Hematology is trying to collect some of this information, and the European Leukemia Network is trying to collect this information. And as frustrating as it is, it takes time to collect the information and to analyze it to see.

So far there's no signal that PV patients are at any increase in risk of getting the disease, and I think that's unlikely to change. But so far there's no sign that they're at any greater risk of complications from the disease.

Esther Schorr:
Okay, well that's good news. In the spectrum of good to bad news, that's good news. So I know that just in general there's been a lot of discussion about young people and COVID, and whether it seemed at the beginning that COVID was, "Oh, it's only older people who are getting affected," and now it's very clear that there aren't age barriers. Can you put in some perspective, either of you, about when we think about teenagers or young people with PV, is there something in particular that we should be thinking about or concerned about with these young people that's different from anybody else?

Dr. Scandura:
Well, I'll say I have three teenagers at home.

Esther Schorr:
But they don't all have PV.

Dr. Scandura:
None of them have PV, and none of them have COVID.

Esther Schorr:
Right.

Dr. Scandura:
But it's tough for a teenager to be at home. As wonderful as I am, and my wife are, apparently we're not as wonderful as most of their friends. So it's important, it's part of the social development for teenagers, right? There's two things that work against us in COVID. They like to interact with other teenagers, and they're risk-takers. So I think what we have to do as adults or parents or physicians treating teenagers is to counsel on what is good behavior, and what can be acceptable, and what maybe is there's too much risk that should be avoided. Large groups of teenagers and parties, probably not a good idea. But being locked up in your room for three months, probably not a good idea either. So it's threading that needle.

Esther Schorr:
Okay. So I know that in some of the hot spot areas right now of the country that hospital capacity is an issue in general, that if the curve isn't flattened, you get to a point where the hospitals can't handle everybody. I guess it would be good to maybe discuss for our audience about whether they as PV patients should be concerned about getting critical treatments like phlebotomy. I know that that's a common one in the context of hospital capacity. I don't know how that's being handled at major medical centers or even in clinics.

If a PV patient has checkups that they need to have, or they need to go in for a phlebotomy, I know that there's some concern that if COVID patients are taking overcapacity, will there still be room for them to get the checkups that they need as a PV patient, COVID aside?

Dr. Scandura:
I can say looking at what happen in New York and what we did, and Angela, I think you're kind of on the other end of things in that we're kind of in a low ebb, but when this started, my philosophy and that of many of my colleagues was if you don't need to come see us, let's talk on the phone, let's do a video visit. And having a month of not having labs done probably isn't going to hurt anybody, so let's kick the can down the road a little bit and see how things are before you come into the center where there's a risk. At one point our hospital was virtually 100% COVID. There was nothing else going on except for the rare other. And a lot of people stayed home and had their myocardial infarction at home. That's a hidden part of the pandemic is loss of care leading to adverse outcomes.

But as things have loosened up, now I'm telling our patients exactly the opposite. This is the best time to come. If you need elective procedure, if you need certainly to come to see your oncologist, this is the time to do it. We're in the best situation we've been in six months, and we have a lot of procedures in place to keep patients safe and to keep healthcare providers safe, and to make everybody confident in what's going on. So now's the time to do it. But it depends on what's going on in your local area.

Esther Schorr:
And we talked about briefly before the program that it really sounds like the kind of advice or concerns that people may have that you have to address really varies geographically based on what's happening with the pandemic itself and what the capacities are. I mean, is it a different situation where you are, Dr. Fleischman?

Dr. Fleischman:
Where we are in Southern California, the numbers seem to be rising now. At the beginning, we were obviously in panic mode, and so preparing for the worst, and had a period of time where we were really trying to prepare for the worst, and thankfully it didn't come at that time, but now numbers are really steadily coming up, and it's becoming more and more of an issue. It seems like there's less of a panic factor now, I think, because it's not something new for us anymore, so there's just not this crisis mode feeling that everybody has. But it's definitely getting worse.

Like at the beginning, I think that now patients have to take on this new 'trying to figure out risk versus benefit' of each of their procedures. You know, going in for a CBC or a phlebotomy, you always have to weigh... Obviously the chance of contracting COVID from going in for a lab draw or phlebotomy is pretty small, but it's not zero. So weighing that into the risk versus benefit factor is important for patients. And I think we've learned there's a lot of things that can be done via Zoom, via phone, and sort of trying to manage things a little bit differently.

Esther Schorr:
Okay.

Nick Napolitano:
Just to tack onto that.

Esther Schorr:
Yes, please.

Nick Napolitano:
I received a phlebotomy in May, early May, so relatively still very active with COVID. I did not have a problem with it. Dr. Fleischman and Dr. Scandura both made good points. So the conversation that I was having with my doctor three or four months ago was, "Let's take a look at how you're trending with your numbers. If you don't need to come in and do a CBC for a couple of months, let's not do it." At that point, I was trending up, and so I needed to come in, but there wasn't a problem getting a phlebotomy during that time.

Esther Schorr:
Okay. Great.

Nick Napolitano:
Yeah, so they're making it a priority depending on how your numbers are trending.

Esther Schorr:
Great, thank you, Nick. So, we actually got a number of questions directly from PV patients in our community about clotting. So the overall question is, "Should patients be worried about their clotting risk in the context of COVID and the virus? Is the situation different, and are there other things they should be looking for or be concerned about?" Open question to whoever wants to tackle that.

Dr. Fleischman:
Well, that's the very good question, and I'm not sure whether we have a definitive answer. A PV person, even before COVID, is at higher risk of blood clotting, and potentially the added insult of COVID and it's the known risks of blood clotting and COVID, those could potentially be exaggerated in a PV patient.

Esther Schorr:
So if let's say, a PV patient does contract COVID, what kind of treatment would they receive to make sure that they don't clot, that they don't have these other complications? Is that a whole different treatment regimen?

Dr. Fleischman:
I mean, I don't know whether there are any standard guidelines. Dr. Scandura, has there been a statement on standard guidelines for...

Dr. Scandura:
The American Society of Hematology is not recommending for patients with COVID routine with anticoagulants. And one of the issues with COVID is there is, particularly in severe COVID, so this is not, "I was tested positive. I'm at home. I may even have flu symptoms that are relatively severe, but I'm not requiring hospitalization. I'm not losing my ability to oxygenate myself." So those people definitely should not have... or there's no evidence that they benefit from anticoagulation or any particular change in their therapy.

Hospitalized patients is a grayer area, and the American Society of Hematology has come out saying that that institutional guidelines, but there's no recommendation really one way or the other. I think there are studies on both sides of it, meaning that there was a study looking retrospectively in New York actually of patients who were on anticoagulation already, and then contracted COVID. And whether or not they did any better or worse, and there was no detectable difference. So it didn't seem to hurt them, it didn't seem to help them that they were on antiplatelet therapy or anticoagulation. But that's retrospective, so it may be flawed.

There was a study from China from the early days where people with severe COVID who had dramatically increased evidence of hyper-activation of the coagulation system, that those people benefited from anticoagulation. I know at my own center that hospitalized patients because we were only admitting relatively sick people, so if there wasn't a pretty good chance you were going to end up on a ventilator, you weren't being admitted. So the people being admitted were very sick, and for those, we started using anticoagulation routinely because of the risks of clots and what we had seen in many patients of all these microvascular clots.

But this is across the board. It was unique to PV. And I would say right now there's no evidence that patients with PV should be treated any differently than the general population. The treatment should be directed by the severity of the illness.

Esther Schorr:
So let me take this in a little different direction because there were a number of questions from our community about actual medications that are being used for PV, and whether they would be beneficial or not beneficial. So one that came up is there any speculation that Pegasys might play a beneficial role for reducing clotting. Does Ruxolitinib (Jakafi), is that beneficial or not beneficial, or it just is what it is and we don't know yet about these medications and whether they're better or worse in the context of the virus? How's that for a mouthful?

Dr. Fleischman:
I think those are all good questions, and it's really interesting that it's been proposed that two of the treatments for MPN had been proposed as potential therapies for COVID. Interferon is sort of helping the immune system overcome the virus, and then Jakafi, there are actually a number of clinical trials looking at Ruxolitinib in COVID patients, and that from my understanding the rationale behind this is because it reduces inflammation, may be beneficial for some of the sequela of COVID.

Again, we don't really know. I don't think anybody should start these therapies for the sole purpose of hoping it's going to help them with COVID, but if they're on them already, they can be more confident that it would be helpful rather than harmful for them. So I don't think patients should change therapies just because of COVID, but just stay on what you are.

Dr. Scandura:
The short answer is there's not enough information to answer the question. It will come, but it's not available now. I think the rationale for interferons is strong, but it's not proven. The rationale for using Ruxolitinib in the setting of cytokine storm is strong, but it's not proven. So what we need to do is look at in the setting of controlled clinical trials and see if these are truly beneficial or not. I would say arguing in favor of interferons, these are what your body usually makes to help fight off a viral infections, so it might be beneficial.

COVID for strange reasons doesn't induce an interferon response very well, and so that may be. Viruses are tricky, and sometimes they find ways to subvert or escape the immune system. But that by no means indicates that giving Pegasys would be beneficial. It just is a rational. The same for Ruxolitinib. It's a wonderful drug at choking off cytokine production. That's one of the main benefits in patients with myelofibrosis, who have symptoms. It's very good at reducing symptoms, mainly because it reduces these excesses of cytokines. In a disease that's linked to the cytokine storm, hemophagocytic syndrome that Ruxolitinib has been beneficial in that similar setting. And there's a couple of small studies that show some minor benefit.

Esther Schorr:
It sounds like don't change horses in mid-stream right now. If you're on a medication, stick with it. Stick with what your physician and telling you because there's just not enough data to support changing one way or the other. So, before we move on, I want to talk a little bit about stroke, which is another common concern. I have one other question for you, Dr. Fleischman. There was some question about whether foods high in Vitamin K should be avoided because of K's enhancement of blood clotting. Is that right?

Dr. Fleischman:
So Vitamin K is important for blood clotting, so people who are on warfarin, that's why their INR can go up and down depending on what they're eating. But aside from that, I don't think that one should necessarily change their diet or avoid Vitamin K foods just simply because they're concerned about Vitamin K helping out their blood clotting. That's really not necessary to do here.

Esther Schorr:
Okay. So let's talk a little bit about stroke. So, Dr. Scandura, would PV patients necessarily have a worse outcome during their treatment for COVID? In that case, should they be worrying about stroke in that context, either during treatment or later on after treatment?

Dr. Scandura:
I would answer this with the best approach for patients with PV is to not get COVID. The best approach there is to follow guidelines, wash your hands, wear a mask outside, keep your social circles small and in some ways constrained. We let our kids, for instance, interact with their friends, a couple of friends who we know their parents are doing the same. So we're not increasing our circles geometrically beyond one level. So if people are doing that, they're really doing all they can to reduce their risk in a way that we know will affect outcomes because you don't want to get COVID. Even if you're okay, you can spread it to others.

If you have COVID and you have PV, then again, I don't think we have any signal whatsoever that patients with PV do any differently than patients without. And so until that changes, unless we get new information, I would say you follow the same guidance that everybody else should follow.

Esther Schorr:
One of our community asked, "Does being anemic put PV patients at greater risk of contracting COVID-19 or of having a worse outcome from it?"

Dr. Fleischman:
I mean, again, contracting, no, because it's...

Esther Schorr:
Right.

Dr. Fleischman:
Nothing increases or decreases your risk of contracting other than not being exposed to it. But does anemia itself... I mean, if you're severely anemic, maybe you're not getting as much oxygen to your organs as you would if you were not anemic, but beyond that, I don't know whether that's really a great impact in terms of the impact of COVID.

Esther Schorr:
Yeah, I guess the second part of that question has something to do with whether starting on hydroxyurea (Hydrea) to lower the patient's numbers would make any sense. I'm just reading into the question that came in.

Dr. Scandura:
It may be the other way around if their blood counts aren't under control.

Esther Schorr:
Mm-hmm.

Dr. Scandura:
I think this has come up a few times in patients who are maybe managed with phlebotomy and whether you should push the doses of drugs to cut down on the phlebotomy, to cut down on the number of healthcare visits, but I think that depends a little bit on what's going on in the community. In New York City right now, I would say that doesn't make sense. If you really... you're in the high-risk area, then it's a conversation to have with your physician, and you have to look at the risks and benefits of that and keep in communication. There isn't a single answer to that question, but certainly one worth discussing with your healthcare provider.

Esther Schorr:
Okay. The one other question that came up is about a supplement and I have to plead ignorance of IP-6. That's supposed to inhibit iron content in the blood. Is there any benefit to taking that to reduce the number of phlebotomies? I guess that's maybe to reduce the risk of having to go into the hospital or clinic, you know, taking it down to a lower number during this time.

Dr. Fleischman:
I mean, I don't think that people should go to extremes and try things that aren't proven simply to try to avoid phlebotomy. I think they should just keep on their medical care as if this was a regular time because the concern is if you try something extreme or something that we don't really have much data for, it might end up doing more harm than good.

Esther Schorr:
Okay. All right, well, we'll get toward the end here. Let's say, Dr. Scandura, you've treated some PV patients with COVID. Can you comment on how they've done in general, and maybe that's true with you too, Dr. Fleischman, just in general?

Dr. Scandura:
We kept close tabs on our patients across the center, but what we've found is the patients who are positive run a spectrum of disease. Most of the patients we've kept out of the hospital, and so they've done okay. Some people were shedding virus for a very long period of time. Some people did quite well and bounced back quickly. This isn't just PV patients, this is across all MPNs. We've had people on different therapies. For a while, we were pretty happy because we hadn't seen patients who had been treated with interferon get tested, but we did have a couple. Same with Ruxolitinib, same with Hydrea, so there was no obvious signal there. But it's kind of apocryphal stories in maybe 20 or so patients that we've had that we have good records on.

Esther Schorr:
Okay.

Dr. Scandura:
I would say there's nothing so far that we know that indicates there's a difference from the general population except for we had a few fairly frail patients with advanced myelofibrosis who did less well.

Esther Schorr:
Mm-hmm.

Dr. Scandura:
I think that they didn't have reserve, I think, is part of the problem.

Esther Schorr:
Is that a similar experience to what you've had, Dr. Fleischman, and you've seen?

Dr. Fleischman:
I mean, I have to say that no one from my personal patient panel has had COVID. Many patients have asked for COVID swabs or the antibodies, and no one has come up positive thus far. I know we did have one myelofibrosis patient with COVID who happened to be on Ruxolitinib and who did well. But beyond that, I really don't have any other personal experience with our patient panel and COVID.

Esther Schorr:
No, okay. No, that's fine. So in wrapping up here, I would just love each of you to kind of wrap up what you're saying to your patients, and Nick, maybe you think about what would you like to say to other PV patients in terms of what would your message be to someone who's concerned. So maybe, why don't we start with you, Nick? What would you say to the patients that are listening today?

Nick Napolitano:
Yeah, I would say I hope you got the same as I did out of this call, which was hope. Dr. Fleischman, Dr. Scandura answered a lot of really tough questions and dispelled a lot of myths, I think. So continue to stay cautious, but be hopeful that we're not at any greater risk as anyone else to get it. But stay cautious and stay hopeful.

Dr. Scandura:
I would say you have to listen to the environment that you're in and keep in close contact with your healthcare providers. Things change, we get new information all the time. The local situation changes, and communication's the way to make sure everybody's getting the most appropriate care at the time for them and their individual disease. I would just say one other thing is of all of my professional life, and life on this earth, this COVID situation has been the one that has taught me the most about humanity and medicine of anything. It's a very weird disease, but if you had told me in December that we were going to tell New York City to stay in your apartments for months at a time, and to wear masks in the street, and that people actually did it, I would tell you, you got to get off whatever it is you're using because it's not ever going to happen, and it did happen.

Esther Schorr:
And it did.

Dr. Scandura:
Very serious. And if you look at the curves, it worked. And so the reason why it wasn't a bigger catastrophe in New York is people did their job. They took care of each other. And this is what we need to do across the country. People need to do their job to not spread and to minimize their own risk.

Esther Schorr:
Yeah. No, very well said. So, Dr. Fleischman, on the other coast, on the coast that I'm on, what do you say, and how do we convince our compatriots and other community members to listen to what Dr. Scandura's saying?

Dr. Fleischman:
Yeah, I think really prevention is the key. And in Southern California, it depends on where you go. Some places you go, everybody's wearing masks, other places no one's wearing masks. So I think that being a good example and wearing a mask, and if you politely suggesting that other people wear a mask, and when, you know, "Please for me. I have a blood condition. I may be at higher risk. I'd really appreciate it if you wore a mask or stayed six feet away from me." I think showing by example how people should be considerate of each other is probably key. And maybe focusing not so much on changing your treatment for your PV, because I don't think there's any reason to change your current management, but focusing that energy on prevention and educating other people about how to be safe and how to protect each other.

Esther Schorr:
It's a very consistent message across all of you, and I want to thank you all so much for doing that and helping to, as Nick said, dispel some myths and reinforce some of the behaviors and things that you feel are important for PV patients. So thank you very much for watching. Thank you, Nick. Thank you, Dr. Fleischman. Thank you, Dr. Scandura. And I'm Esther Schorr. Please remember that knowledge can be the best medicine of all.

 

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