Winter is Coming
I say this in the most literal sense, although many would use the phrase to evoke fear. Winter is, in fact, coming, and likely bringing with it the rise in COVID-19 cases. Will this winter be like last March and April all over again, but worse and longer? What will the impact be of a rise in cases? Should we be preparing to shut down society again? What strategies and knowledge has emerged to help mitigate the damages of a larger, longer second wave? These are all critical questions that need to be addressed. Fortunately, our knowledge of COVID-19 is moving faster, in regards to progression in our understanding of this virus and the science behind it, than we have moved at any other time in history. Unfortunately, many of our leaders, media figures, and, dare I say, even some top doctors in various jurisdictions are not evolving their positions with the changing understanding. Instead, they are holding in place and growing roots to protect their mantras, undoubtedly out of fear.
“The illiterate of the 21st century will not be those who cannot read and write, but those who cannot learn, unlearn, and relearn.” ― Alvin Toffler
What We Know and Don’t Know Regarding Infection and Reinfection
Transmission: Surface Contamination vs. Droplets vs. Aerosol For months, it has been drilled into us that the novel coronavirus, or SARS-CoV-2, is spread through droplets emitted when we breathe, sneeze, or cough, thereby pushing the narrative that we should be meticulous with our handwashing hygiene, surface sanitation, social distancing, and wearing masks. In fact, we have rearranged our society based on this narrative.
Hand Washing and Surface Areas
What does the evidence say regarding surface area and handwashing? For one, a rise in temperature dramatically reduces the lifespan of the virus.
“At room temperature (24°C), virus half-life ranged from 6.3 to 18.6 h depending on the relative humidity, but was reduced to 1.0 to 8.9 h when the temperature was increased to 35°C.”1 As for handwashing, some lazy journalists from major publications have cited a 16% reduction in transmission with hand sanitization, but that is misleading. A 2006 systematic review and a 2008 meta analysis published far before the emergence of SARS-CoV-2 have cited data showing 16%2 and 21%3 reductions in viral infections in general, respectively, with thorough hand sanitization. Of course, this data is based on viruses such as the large family that makes up the common cold and influenza. One of these were completely undetectable on most surfaces within 24 hours[4,5 While the novel coronavirus persists on surface areas for up to 72 hours.1 This would suggest that handwashing and sanitation are more important for the novel coronavirus, not less. Even with a 21% reduction in transmission, as the 2008 meta analyses on other viruses showed, sanitation is undoubtedly an important tool.
So why is the number of cases continuing to rise, even with the extra efforts to sanitize? Compliance may be the answer. On four occasions, I have loitered near the entrance to the grocery store, watching to see the frequency of individuals who use hand sanitizer, waiting for ten people to enter. Optimistically, it seems only about one in five people at my grocery store use the hand sanitizer left for use. What is more astounding is that roughly eight in ten people were wearing masks, and in six cases, I witnessed individuals sanitizing the carts that had already been sanitized by staff, while wearing a mask, but not bothering to sanitize their hands.
This brings me to an important question regarding many stores now refusing to accept cash. To be frank, this hasn’t affected me at all, since I put everything on my card to gain the points. That said, the logic surrounding it makes no sense. Has it been done simply to placate employee fear? When paying with cash, there is a limited number of hands that are touching said cash. However, when using cards, unless the purchase is small enough to allow for the “tap” feature, every customer must touch the keypad. This leads to a far greater risk of transmission. While it may temporarily mitigate the fears of cashiers, it could potentially lead to a higher chance of them contracting the virus through other forms of community spread. More transmission means more chance of becoming infected with the virus eventually.
On top of making little sense from the overall transmission perspective — and I have searched through numerous pages of Google results on the subject of trying to find any evidence for this, while only finding information regarding cashier fears — the notion you can sanitize your debit card (while ignoring the fact that hands touch the pads) and arguments for more online purchases stoke conspiracy fears. Many view this new cashless society as a further step towards total control from the government, banks, and large corporations, now able to monitor almost all of our moves. Personally, I feel this ship has already long sailed because of all the information we already divulge to the government and the banks to get credit and that our conversations are being monitored with microphones in our phones to use for marketing purposes.6 Even if this war has already been lost, forcing society to go cashless based on an irrational fear-based position that goes against better logic only reignites the fires and fears.
The overwhelming message we continue to hear is that the novel coronavirus is primarily spread through droplets,7,8 despite there being much contradictory evidence and unresolved dichotomy.9 Droplets, believed to be the primary source of transmission, are thought to be able to travel at most 3–6 feet;10 however, some research suggests that airborne droplets may travel as far as 20 or more feet.11,12
If the airborne droplets can travel farther than 6 feet, our social distancing policies need to be evaluated for effectiveness; however, in this case, the importance of masks would actually increase. Critics claim that masks cannot stop the virus from traveling, as the virus is so small. This is true for aerosol transmission, which may still well be at play. But this argument ignores the fact that the droplets, believed to be the primary source of transmission, are indeed stopped by masks. The odd controversy regarding the efficacy and safety of masks has become such an issue that the final part of this series will be devoted entirely to it.
It is astounding that with all of the evidence for its likelihood, aerosol transmission, meaning airborne droplets containing the virus small enough to stay airborne for extended periods of time, has been largely ignored by the media and many health authorities. As noted by an opinion piece published in the scientific journal Nature in July, health authorities were ignoring the mounting evidence for aerosol transmission.13 At the time of this writing in mid-September, the media and health authorities are overwhelmingly ignoring this evidence.
Perhaps, acknowledging this mode of transmission would put to question many of the social distancing practices in place. Since there are questions surrounding how much each mode of transmission is playing a role in the spread of COVID-19, focusing on the modes that we can address, namely larger droplets and surface contamination, is believed to be prudent. Unfortunately, withholding or ignoring information, particularly in the age of the Internet, is not a wise strategy to gain trust with the general population.
Aerosol transmission can explain the rapid transmission on cruise ships, such as the Diamond Princess,14 as well as the spread through long-term care homes,15 where ventilation systems are often inadequate and outdated.16 I, for one, would be interested in a cost analysis for various governments to fund large-scale upgrades to ventilation systems, including ventilation systems that can kill the virus through heat17 in high-risk facilities such as long-term care homes, in comparison to the shocking price tag of shutting down society. Additionally, large indoor facilities such as sporting stadiums and concert halls could look to ease in opening, with significant investments in disinfecting ventilation systems, on top of thorough protocols for surface decontamination and strategies to reduce droplet spread, such as mandatory masks. We’re all looking for a way to get “back to normal,” but normal is likely impossible for the foreseeable future. The best we can do is weigh the pros and cons and make the sacrifices we can to ensure the operations of what we desire.
Viral Shedding in Asymptomatic vs. Symptomatic
Infections One of the questions that has come out over time is how infectious asymptomatic patients are compared to those with serious illness. A recent study by Korean researchers suggested that asymptomatic patients had similar rates of viral shedding as those who were expressing symptoms,18 detailing the need for increased testing to identify as many carrying the virus as possible.
This is also showing to be true for children, who have been overwhelmingly asymptomatic, and originally believed to not be significant spreaders of the virus.19 This position came into question after numerous large outbreaks happened at summer camps20 and schools all across the world. New information published has shown that older children, defined as aged over 10 years old, are just as likely to spread the virus as adults.21 Another study suggests that even children younger than 5 years have relatively high viral loads.22
Keeping children out of school for the foreseeable future is too great of a blow to their education, advancement, and importantly, to their mental health. Further, keeping children, especially younger children, socially distanced and wearing masks all day long is altogether unfeasible. Despite this, there have been questions regarding liability if schools are the source of outbreaks,23,24 which is a discussion I find hysterical and asinine. Children need to be back at school, and being back at school will further the risk of outbreaks. There is no debating and no side stepping this. Further, if children are back at school and driving outbreaks, we need to think about the effectiveness of other interventions, such as shutting down the economy and businesses.
Our way out of this is through various treatments and interventions to ameliorate the damage the virus causes. Spread will be mitigated through a (hopefully) soon-to-be-developed safe and effective vaccine, not through futile attempts to stop it. Where we are with different interventions is discussed later in this series, which I will publish for the next several weeks.
To further my point on the inability to completely stop the virus is the resurgence we are seeing in Vietnam,25 Spain,26 and even New Zealand,27 which was previously virus free-for 100 days.28 We live in a global economy, and very few countries are self-sustainable. So long as the virus is alive and spreading elsewhere, it will work its way back into any country that manages to eradicate it through shutdowns. There is no way to extirpate the novel coronavirus from a single jurisdiction. Our route forward is in lessening the impact, mortality rate, and long-term health consequences through various treatments, while decreasing transmission through vaccination. It is here to stay, and we need to learn to live with it.
When it comes to reinfection and immunity, we still have a lot of questions to answer. It is without a doubt that we will gain some form of immunity after shaking off COVID-19, but the question is how much and for how long. So far, there have been only a handful of recorded cases of reinfection, with time differences between them being 4.5 months for one Hong Kong resident29 and only 48 days for one Reno resident (both males).30 Additionally, due to having so few data points and that they are completely opposed to each other, we cannot draw any conclusions on severity and rate of reinfection. The Hong Kong reinfection case being less severe and asymptomatic the second time around suggests a better immune response. However, the Nevada reinfection case was more severe the second time around.31 We likely won’t begin gathering trends on the average length of building up long-term immunity to lessen the impact of the virus for months, if not years.
We also don’t know how long COVID-19 antibodies remain in the body, with contradictory evidence presented so far. Researchers from the Medical University of Vienna's Center for Pathophysiology, Infectiology and Immunology reported that only 60% of individuals who had recovered from COVID-19 gained antibodies32 — a finding that was widely reported and caused fear in the population, despite having a sample of only 25 individuals.33 Another study published by researchers in Iceland, which examined over 30,000 people in order to develop the best antibody test and then conducted said test on 1215 people who had tested positive for COVID-19, found that 91% of the test subjects gained antibodies, with no drop in antibody levels after 4 months.34 The latter study is significantly more robust, and is also much more promising.
It is also becoming clear that some form of T-cell immunity35 is acquired following infection with COVID-19, with T-Cell activity perhaps taking the lead in our immune response36. Evidence is also emerging that individuals who had contracted SARS in 2003 already have some T-cell immunity.37 It is also possible that many of us already have some T-cell immunity from previous bouts with more common and innocuous coronaviruses.38 T-cell immunity, why it’s important, and how it can also contribute to the aging process are subjects of the first article I published related to coronavirus, written in an attempt to dispel ridiculous claims from many supplement peddlers about “strengthening the immune system.” Here are some excerpts from the article:
Your immune response, while fighting off a pathogen, is what leads to common “side effects,” such as congestion, coughing, and systemic acute inflammation (which can lead to longer-term damages), which are the body’s attempts to get rid of the bacteria or viral particles. A “stronger” immune response may mean you feel sicker as you fight off the same damage. This is assuming that the person is not immunocompromised or immunodeficient. By law companies selling such supplements can’t market to these groups of individuals and currently, there is no or limited evidence that these products would help them. This “benefit” is being marketed to otherwise healthy people who wouldn’t want to be “boosting” or “strengthening” their immune response.
T-cells are a type of white blood cell, which develops in the thymus and plays a central role in the immune response. Imagine these malleable T-cells, called “naïve” T-cells as the body’s army or national guard that protects us against invading threats. These immune cells originate as precursor cells, derived from bone marrow, and develop into several distinct types of T cells, each with specialized roles, once they have migrated to the thymus gland. For example, some T-cells are “trained” to broadly recognize and fight off pathogens (cytotoxic T-cells), while some become “specialized” and memorize a previous intrusion (memory T-cells), so that the immune response can occur rapidly if the same pathogen reappears. This is a very basic representation of how immunity works, and the basis for how and why vaccines are effective. We essentially “strengthen” our immune response with vaccines by preparing T cells using a low dose or a dead version of the pathogen so that the immune system can stop a threat faster when it appears again. You may be thinking, “Great, I want to shorten the amount I am sick,” and sure, that sounds good... for now.
T-cells are one of the major tools we have to fight off new threats, while viruses such as HIV (human immunodeficiency virus) attack these cells, shortening our lifespan. HIV specifically targets T-cells and other white blood cells, which over time causes AIDS (acquired immunodeficiency syndrome), where failure of the immune system allows life-threatening infections such as the common cold to thrive, leading to death. Even in the absence of a persistent and devastating virus, individuals with autoimmune diseases, as well as those taking immunosuppressant medication, newborns and the elderly are immunocompromised, meaning their immune systems are not quite as robust as those of the healthy population. This is why these individuals are at a much higher risk of dying from an illness than younger, healthier people who may not even notice they have it. This is also the main reason why the flu vaccine is highly recommended for the elderly.
From puberty onwards, a process called thymus involution occurs, which is the gradual shrinking of our thymus, leading to reduced production of naïve T-cells. With every pathogenic threat, naïve T- cells migrate to the lymph nodes and become trained to fight it. As we age, we produce fewer naïve T-cells and they can become more difficult to train against new threats. As such, a new threat can be catastrophic when we cannot mount an appropriate immune response and defeat the pathogen. Why would we want to recklessly deplete our “army reserve” of naïve T-cells? That would be, effectively, consciously deciding to shorten our health and lifespan to slightly shorten a short and slight inconvenience, all the while making that very slight inconvenience MORE inconvenient (remember, the stronger immune response leads to more symptoms). This is why “boosting immunity” sounds insane, and thankfully, the products making these claims don’t actually do what they imply.
Of course, regarding COVID-19, this process is a bit different. Hopefully, with each reinfection and each new year of effective vaccines, we need to train progressively fewer T-cells to fight and adapt to the evolving threat. This will effectively render the virus less harmful with passing time, meaning that with each season, it will (hopefully) become less deadly, and less debilitating to society. The antibody levels may reduce, but our T-cell immunity will grow. Of course, we want to mitigate how many T-cells we recruit over a lifetime for a single threat. Effective vaccines and decreased spread of the virus is one way to accomplish this.
Is Herd Immunity Possible Without a Vaccine?
Derided by their neighbours and many across the world, Sweden chose to run counter to most other nations by not imposing any meaningful lockdowns, instead aiming to isolate those at risk while allowing society to function as normal. Effectively, it was the rest of the world running the experiment, while Sweden chose to continue operating as it had the past. For months, Sweden was ridiculed as foolish, with experts and the media detailing their “failed plan.” It seems as if they are finally being vindicated.39 Sweden’s rates of new cases are now lower than those of their neighbors day after day, despite not imposing lockdowns. As more and more Swedes have become infected with COVID-19, gaining at least temporary immunity, the spread has slowed, even in the absence of a lockdown.
Early estimates indicating that Sweden’s plan would lead to 180,000 deaths in a country with a population of 10 million people have proven to be astronomically inflated, with just under 6000 actual deaths as of mid September, 2020.40 Of course, this number is much higher than that of their neighbors, but still relatively low in comparison to the untold death and destruction the worldwide lockdowns will lead to, which I wrote about in last week’s article. Now, the question for Sweden is, will a vaccine be available before the reinfections start spreading? That’s the million-dollar question. And if the vaccine will indeed be available, Sweden’s strategy may go down as the most prudent of the lot. It still may, even without any intervention to slow down a second wave of virus infections in the country, knowing the degree to which the infection fatality rate is lower than the case fatality rate, as I will discuss in more detail in future articles.
In the coming weeks I will further discuss what we know about the virus, its long-term health consequences, what we know regarding true death rates, and potential interventions that will help to reduce its severity.