BPHED, BScH, MSc, BScPhm, RPh, CGP
Why is COVID-19 less severe in children than in adults? Why does the virus get exponentially worse in older adults? There are many unanswered questions that have been confounding health officials globally. Our scientists continue to work hard. We all need to unlock the seemingly “random” pieces of the COVID-19 puzzle, particularly the HOW and WHY different people are so badly affected. In my experience with science, I have found there is usually little randomness, but rather a lack of understanding. Thankfully, some recent studies could help shed some light on what might be happening.
What is generally understood now about COVID-19
Antibodies in our blood are essential to neutralize and kill viruses and bacteria. Both the immunocompromised and the elderly populations have been found to have lower levels of antibodies and they are more susceptible to COVID-19. It is also well documented that chronic conditions that cause a lot of inflammation (diabetes, heart disease, stroke, allergies, asthma, etc.) can make COVID-19 even deadlier. A few of the most severe symptoms of COVID-19 are mucus production and blood clotting, which can lead to suffocation and stroke, respectively. Weak immune systems and chronic inflammation can both increase your risk but they do not fully explain how COVID-19 is selecting some of its victims. There is still a missing piece to the puzzle that we do not understand yet. The answer may be walking around in young asymptomatic spreaders.
A new piece to the puzzle: antibody-dependent enhancement
New research suggests that COVID-19 is causing an antibody-dependent enhancement reaction (ADE). To summarize a lot of science talk, it generally means that the amount of neutralizing antibodies in your body from a previous infection can either help or hurt you. In order to ensure these antibodies remain protective, we need to maintain them at a high level in comparison to the virus, at a higher ratio, so that they are able to surround and neutralize the amount of virus in the body. On the other hand, if you dip below this ratio, your body can harm itself by overreacting with excessive inflammation that can damage your lungs, leading to potential suffocation or even stroke.
A good analogy for antibody-dependent enhancement is an over/under sports bet. In a basketball game there is a +13 point spread that the Raptors are going to beat the Warriors. If the Raptors win by 13 or more points you win (high antibody levels = you don’t get sick), but if the Raptors don’t beat the spread and win by less than 12 points, you in fact lose (low antibodies = you get sick). But how is there even an antibody spread to COVID-19 when we have never had it before? What could be priming our immune systems to have a bad reaction to COVID-19?
What about a common cold, another coronavirus?
The coronavirus family is the second leading cause of the common cold in humans, making up 15-20% of all cases, and has been suggested to have a 30-40% similar genetic sequence to SARS-CoV-2, the coronavirus that causes COVID-19. Common cold coronaviruses circulate the globe annually and generally only cause minor symptoms. It is quite possible that a cold (coronavirus) is priming our immune systems, acting as friend or foe, causing cross immunity to COVID-19 for youths, where antibody levels are high, while harming elderly when levels are low.
We have seen in the past how a virus from one species can provide cross immunity in another. In humans, the smallpox virus was deadly for centuries with a death rate of around 30%. It wasn’t until 1796 that Edward Jenner discovered that milk maids, who had acquired cowpox, did not show any symptoms of smallpox after they encountered the deadly virus. This discovery, that milk maids were immune to smallpox via exposure to cowpox, actually led to the concept and invention of the vaccine.
One or many of the common cold coronavirus strains could be our “cowpox” in this COVID-19 pandemic. Treatment may be complicated as it appears that it might be very concentration dependent. If true, simply giving a vaccine could become deadly if we do not perform follow up blood work to ensure everyone maintains neutralizing antibody levels above an acceptable threshold that is yet to be determined. Unfortunately, as mentioned before, this level may be a moving target as higher levels of inhaled virus should require even higher concentration of neutralizing antibodies. This could help to explain why we have seen healthy young healthcare workers getting seriously ill and even dying from COVID-19. They may have just been exposed to and inhaled too much virus.
If you take a tiny sip from a pint filled with virus you might have enough antibodies to neutralize it. On the other hand, if you chugged the whole pint, even individuals with strong immune systems and high amounts of neutralizing antibodies may succumb to the virus. In the sports bet example above, drinking “a pint of virus” could be like raising the point spread to +35 differential, it would be very tough to win that bet. As is usually true, it would be better if we never made a bet in the first place. The problem is since everyone has had the common cold before, we likely have all made a bet already, but we just don’t know what bet we placed!
We all need to wear masks in public
How do we rig the bet with COVID-19 and fix it so we win? The easiest and quickest answer is: MASKS SHOULD BE MANDATORY IN PUBLIC AT ALL TIMES. Sorry, the caps are to attract attention and not meant to appear that I am frustrated and yelling… much. The truth is masks help to reduce the amount of virus we breathe in, but more importantly the amount of virus that is exhaled from those symptomatic or asymptomatic spreaders out there. Think of a cold day… what do you notice comes out of your mouth when you exhale? Tiny water droplets that gently float away, drifting off, despite the fact that they are freezing and likely becoming heavier. Now imagine how many water particles, containing COVID-19 virus, are being exhaled in a busy grocery store, a department store or a local pharmacy frequented by the infected. Recent studies suggest that the virus can float around in these tiny water droplets in the air for up to 2-3 hours. The only way to help prevent the amount of virus being both exhaled and then inhaled by others is to WEAR A MASK IN PUBLIC AT ALL TIMES. Sorry, again not yelling just trying to drive home my point.
Still not convinced? Let’s look at the countries that immediately made masks mandatory in public at all times. One example is South Korea, which is situated right next to China and had some of the earliest cases reported. Yet, they have limited the spread of the virus and their death rate more effectively than pretty much anywhere else. In fact, according to June 2nd stats, as displayed on worldometers.info, Canada has 11 times more relative cases and 39 times more relative deaths than South Korea. The USA has even more grim stats as they have 25 times more relative cases and an astounding 65 times more deaths. Again the major difference is that South Korea has MANDATORY MASKS IN PUBLIC AT ALL TIMES. Masks reduce the spread of the virus, but more importantly they reduce the death rate of COVID-19.
This hilarious social media meme sums a great analogy to why we need to all wear masks, enjoy.
I was recently asked by friends on how to explain the importance of wearing masks to youth, particularly teenagers, so they understand as they generally are not directly affected by COVID-19 much. I thought of a loaded gun analogy for COVID-19 spread. Everyone starts off as an empty gun that has a very sensitive trigger and is prone to fire randomly. Unbeknownst to them, if they do not practice social distancing and wearing a mask in public, they could encounter COVID-19 and become loaded. By accident, now as a loaded weapon, they could inadvertently shoot others, their mom, dad, friends, grandparents and even pass along COVID-19 to load other’s guns. If not careful their bullets could harm or even kill those they love. The fact they didn’t know they were loaded doesn’t help the shooter’s sense of guilt. After all, hindsight is always 2020 (pardon the pun). Would haves, should haves, and could haves can become consuming thoughts as grief of a loved one passing and feelings of responsibility or remorse sinks in.
I know we are fatigued and tired of the social distancing. We are excited that businesses, our economy, are slowly starting to open again. The weather is nice, the sun is out, but if we do not follow the same social distance rules we might be in line for a large 2nd bubble of COVID-19. Just last Friday I went to the local grocery store and was shocked to discover that I was the only customer wearing a mask. On my drive home I saw a group of 8 teenagers hanging out in a circle on their lawn, no distancing, no masks. I saw 3 mothers with strollers walking shoulder to shoulder while 7-8 children bicycled in very close proximity around them, again no masks. It looks like we are already back to our pre-COVID-19 world, how exciting, did we beat the virus? What’s that you say, it isn’t over? Oh shoot, we all better start wearing masks and social distancing again soon as we might start to see cases spread in the next few weeks.
Hang in there. If the science is proven and this theory is true, we could soon start to develop blood tests to monitor antibody concentrations and determine a safe over/under threshold and ensure everyone is above it. If scientifically proven and ethically approved we could distribute a live strain of the common cold coronavirus to maintain our antibody levels well above any set threshold. This would be analogous to the smallpox situation that was eradicated with cowpox. Some might prefer a few weeks of the sniffles if it means we get protection against COVID-19. I cannot stress it enough that this needs to be confirmed first through science and not experimented by the public.
I will repeat again, everyone should wear a mask out in public at all times. Masks lower both the risk of transmission and the amount of virus we could get. If we all cooperate and work together we might soon be able to regain control over this pandemic. A semblance of normal life may not be so far off after all. I originally believed it would be years before we are able to open up our economies fully, now it might be much quicker. By far the most important benefit, however, would be to reduce the pain and suffering the world has had to endure, the loss of loved ones. Hopefully the time for healing is right around the corner.
In the meantime,
Stay Healthy, Stay Home.
And remember when in public
All the best,
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