A Pragmatic Approach to Immunity & Respiratory Viral Infections

Published in: Integrative Medicine Vol. 19, No. 5. October 2020

My paternal grandmother was notorious in our family for having succinct and poignant pearls of wisdom. One that was used a lot under stressful times was, “You play the cards in your dealt in life to the best of your abilities.” During these unprecedented, turbulent times in our modern world, these sagacious words ring even more true.

We are unfortunately living in a time when SARS-CoV-2, more colloquially known as COVID-19 (corona virus disease 2019) is as pervasive on everyone’s mind and in the media, as the necessity it is to drink water in order to survive. Our stressful times are now exacerbated by riots, civil unrest, political and economic uncertainties.

What we’re experiencing as a nation and as a world has not been seen in generations. It seems to affect everyone differently, physical, emotionally, and spiritually. I have family, friends, colleagues, and patients, for whom it’s just another day, and I have ones that are on the complete other side of the spectrum, feeling so distraught, they will descend into madness; and everything in between.

In just the past few months since the pandemic really seemed to grip the world, the research literature has exploded into thousands of articles. I won’t even go into everything else: blogs, tweets, posts, videos, etc., as it’s mindboggling and many times nauseating. Everyone seems to have an opinion, whether based on sound logic and science or not.

At first, I was going to write an article on the history of SARS-CoV-2, as well as pathophysiology, pathogenesis, testing, clinical symptoms, and naturopathic therapeutic interventions.

I have decided not to approach this article via this manner, given that there are so many sources out there that have done an outstanding job. For example, I cannot emphasis enough how readers should read IMCJ’s Focus on COVI-19, Vol 19, No. S1. It is exceptionally thorough and very well done.

So, why should I write what already has been written, albeit some of the following may be a bit redundant of other outstanding articles? Instead, I will write about the most common viruses that cause respiratory disorders, and what naturopathic treatment interventions have been proven in the scientific literature (evidence-based) to be effective in both prevention and treatment of many viruses, regardless of type. There are too many interventions to list, so I will focus on the ones I have utilized in my private practice for the past ten years (clinical-based medicine). I will provide a brief overview of SARS-CoV-2 virology, along with epidemiology. I will also discuss interventions to mitigate cytokine storm and attenuate inflammation, outside the use of acetaminophen and NSAIDS. Lastly, there is a fact that I feel has been significantly neglected the past few months since the pandemic really gained so much momentum, and that is the emotional impact. I will discuss some “natural” therapies that have
proven efficacy in what many are seeing in not only our patients, but friends, families, colleagues and maybe even
ourselves—anxiety, depression and even despair.

Coronavirus Context

According to Nature Reviews Microbiology, there are more than 1 × 10 31 (10 quintillion, or in the US, nonillion) viruses on Earth, 1 but only a bit more than 200 are capable of causing human illness. 2 The human microbiome contains approximately 38 trillion bacteria. 3 Compare this to the human virome, which contains approximately 380 trillion viruses! 4 Viruses are some of the smallest creatures on Earth, between 20-400 nanometers (nm) in diameter. They are essentially packets of nucleic acids (either RNA or DNA), surround by a protein shell and sometimes lipids. They are dormant outside a living cell and they need to hijack a host’s metabolic machinery in order to survive and produce copies of itself. 5,6

According to the Centers for Disease Control (CDC), colds and flus occur all year, but the “season” for them is typically December through February. 7,8 Viral infections most commonly cause upper respiratory tract infections (URTI’s), of which the most common are caused by influenza A and B, H5N1 and H7N9 avian influenza A, parainfluenza 1 through 4, adenoviruses, respiratory syncytial virus A and B and human metapneumovirus, rhinoviruses and yes, coronaviruses. 9

Given the current times, I would like to focus on coronaviruses. These are zoonotic pathogens of enveloped RNA viruses that cause respiratory illnesses of varying severity from the common cold to fatal pneumonia and only seven are known to cause disease in humans. Four out of the seven most frequently cause symptoms of the common cold; coronaviruses 229E and OC43 are known to cause the common cold. Serotypes NL63 and HUK1 have also been associated with the common cold. Rarely, severe lower respiratory tract infections, including pneumonia, can occur, primarily in infants, older people, and the immunocompromised. 10

Epidemiology, Pathogenesis and Testing

As of August 21, 2020, there have been 22,773,308 confirmed global cases of COVID-19, with 795,196 deaths. In the United States, there have been 5,600,107 cases and 174,647 deaths (case fatality rate of 3.12%). 11 I emphasize confirmed because many countries may be underreporting cases and/or deaths. 12 Some countries, like North Korea, refuse to even report data to the World Health Organization (WHO). 13

Viral shedding and the period of greatest infectiousness seems to be earlier in the stages of illness, when viral RNA levels in respiratory droplets are highest. 14 Is this person asymptomatic (does not have symptoms but is infected and will never develop symptoms), or pre-symptomatic (the phase when an individual is infected and may be shedding virus but hasn’t yet developed symptoms), and can one tell the difference? No, since symptoms may show up between 2 to 14 days after exposure, with infectiousness starting about 2 days prior to symptom onset, peaking about 0.7 days before symptom onset, then declines within seven days, but can occur up to 21 days after exposure This is where nucleic acid amplification (NAAT), most commonly with reverse-transcription polymerase chain reaction (RT-PCR) tests can be valuable, since they can detect the viruses about a week before any symptoms even show up. 15,16,17

Serological testing (IgA, IgM and IgG) seem to be a more precise diagnostic tool after day 14 of symptom onset, with IgA and IgM titers tending to dissipate after 3 weeks, while IgG confers long-term immunity, approaching 100% seropositivity by 16 to 20 days. 18,19 Recently, The Infectious Diseases Society of America (IDSA) released a statement stating that 3 to 4 weeks after exposure, is optimal.20

It should be noted that these are “general” statistics, in that antibody produced with SARS-CoV-2 are predicated upon how seriously ill the individual (i.e., less severe disease has been shown to lead to smaller antibody production 21) became and underlying immune competence. Given this novel virus, we also don’t know how long a person will have protective antibodies. One study showed IgG levels
declining by a median of approximately 75 percent from the acute to early convalescent phase of illness, and at eight weeks following infection, 40 percent of asymptomatic patients and 13 percent of symptomatic patients did not have detectable IgG. 22

According to a recent CDC report of over 370 000 confirmed COVID-19 cases in the US, the most common symptoms are cough in 50 percent, fever (subjective or >100.4°F/38°C) in 43 percent, myalgia in 36 percent, headache in 34 percent, and dyspnea in 29 percent. Anosmia, ageusia, abdominal pain, and rhinorrhea occur in less than 10% of cases. 23 Those infected with SARS-CoV-2 can have absolutely no symptoms, to mild, to severe and even death. Complications can be seen in the form of respiratory failure, arrhythmias, and thromboembolisms. 24 Certain lab values have now been associated with worse outcomes: elevations in D-dimer, ferritin, CRP, lactate dehydrogenase (LDH), creatine phosphokinase (CPK), troponin, as well as lymphopenia and thrombocytopenia.25,26,27

Convalescence appears to be around two weeks for mild infections and three to six weeks for severe disease. 28 The most common persistent symptoms were fatigue (53 percent), dyspnea (43 percent), joint pain (27 percent), and chest pain (22 percent). 29 Recovery course is variable and depends on age and pre-existing comorbidities in addition to illness severity.

The immense details of the various common viral infections are beyond the scope of this article, but in this author’s view, four main points should be considered: infection prevention, specific antiviral interventions, inflammation modulation, and immune balance and
enhancement.

CONTINUE READING: A Pragmatic Approach to Immunity and Viral Infections

Additional Sections include:

  • Prevention
  • Immune Support Nutrients
  • Treatment with Antiviral Compounds
  • Caveats

References

1. None Listed. Microbiology by numbers. Nat Rev Microbiol. 2011 Sep;9(9):628. doi: 10.1038/nrmicro2644.

2. ViralZone. Human viruses and associated pathologies. SIB Swiss Institute of Bioinformatics. https://viralzone.expasy.org/678. Accessed Aug 14, 2020.

3. Sender R, Fuchs S, and Milo R. Revised Estimates for the Number of Human and Bacteria Cells in the Body. PLoS Biol. 2016 Aug 19;14(8):e1002533.

4. Mokili JL, Rohwer F, and Dutilh BE. Metagenomics and future perspectives in virus discovery. Curr Opin Virol. 2012 Feb;2(1):63-77.

5. Drexler, M. How Infection Works. “What You Need to Know About Infectious Diseases.” National Academies Press (US); 2010. https://www.ncbi.nlm.nih.gov/books/NBK209710/. Accessed Aug 14, 2020.

6. Viruses. National Geographic Resource Library. https://www.nationalgeographic.org/encyclopedia/viruses/. Accessed Aug 14, 2020.

7. CDC. Influenza (Flu). The Flu Season. Last reviewed: July 12, 2018. https://www.cdc.gov/flu/about/season/flu-season.htm. Accessed Aug 14, 2020.

8. CDC. Common Cold. Last reviewed: March 18, 2019. https://www.cdc.gov/dotw/common-cold/index.html. Accessed Aug 14, 2020.

9. Kramer LD. Types of Viral Disorders. Merck Manual Professional Version. Last review March 2020. https://www.merckmanuals.com/professional/infectious-diseases/viruses/types-of-viral-disorders#v1017659. Accessed Aug 17, 2020.

10. Tesini BL. Coronaviruses and Acute Respiratory Syndromes (COVID-19, MERS, and SARS). Merck Manual Professional Version. Last review July 2020. https://www.merckmanuals.com/professional/infectious-diseases/respiratory-viruses/coronaviruses-and-acute-respiratory-syndromes-covid-19,-mers,-and-sars?query=coronavirus. Accessed Aug 17, 2020.

11. Johns Hopkins Corona Virus Resource Center. https://coronavirus.jhu.edu/map.html.

12. Lau H, T. Khosrawipour, P. Kocbach, et al. Evaluating the massive underreporting and undertesting of COVID-19 cases in multiple global epicenters. Pulmonology. 2020 Jun 6.

13. CDC Traveler’s Health. COVID-19 in North Korea. Last reviewed August 6, 2020. https://wwwnc.cdc.gov/travel/notices/warning/coronavirus-northkorea. Accessed Aug 17, 2020.

14. Zou L, Ruan F, Huang M, et al. SARS-CoV-2 Viral Load in Upper Respiratory Specimens of Infected Patients. N Engl J Med. 2020;382(12):1177. Epub 2020 Feb 19.

15. He X, Lau EHY, Wu P, et al. Temporal dynamics in viral shedding and transmissibility of COVID-19. Nat Med. 2020;26(5):672. Epub 2020 Apr 15. 16. CDC Coronavirus Disease 2019 (COVID-19). Symptoms of Coronavirus. Updated May 13, 2020. https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html. Accessed Aug 17, 2020.

17. Gillespe C. What’s the Difference Between Asymptomatic and Presymptomatic Spread of COVID-19? Explore Health. June 11, 2020. https://www.health.com/condition/infectious-diseases/coronavirus/vaping-and-covid-19-risk. Accessed Aug 17, 2020.

18. Long QX, Liu BZ, Deng HJ, et al. Antibody responses to SARS-CoV-2 in patients with COVID-19. Nat Med. 2020;26(6):845. Epub 2020 Apr 29.

19. Deeks JJ, Dinnes J, Takwoingi, et al. Antibody tests for identification of current and past infection with SARS-CoV-2. Cochrane Database Syst Rev. 2020;6:CD013652. Epub 2020 Jun 25. 20. Frellick M. ‘Sweet Spot’ for Antibody Tests is 3 to 4 Weeks Postexposure. Medscape Medical News. Aug 20, 2020. https://www.medscape.com/viewarticle/936084. Accessed Aug 21, 2020.

21. Ibarrondo FJ, Fulcher JA, Goodman-Meza D, et al. Rapid Decay of Anti-SARS-CoV-2 Antibodies in Persons with Mild Covid-19. N Engl J Med. 2020 Jul 21;NEJMc2025179.

22. Long QX, Tang XJ, Shi Q, et al. Clinical and immunological assessment of asymptomatic SARS-CoV-2 infections. Nat Med. 2020;26(8):1200. Epub 2020 Jun 18.

23. Stokes EK, Zambrano LD, Anderson KN, et al. Coronavirus Disease 2019 Case Surveillance – United States, January 22-May 30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(24):759. Epub 2020 Jun 19.

24. Mayo Clinic. Coronavirus Disease 2019 (COVID-19). Last updated Aug 7, 2020. https://www.mayoclinic.org/diseases-conditions/coronavirus/ symptoms-causes/syc-20479963. Accessed Aug 14, 2020.

25. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395(10229):1054. Epub 2020 Mar 11.

26. Guan WY, Ni ZY, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med 2020.

27. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: Summary of a report of 72,314 cases from the Chinese Center for Disease Control and Prevention. JAMA 2020.

28. WHO. WHO Director-General’s opening remarks at the media briefing on COVID-19 – 24 February 2020. https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19—24-february-2020. Accessed Aug 17, 2020.

29. Helleberg M, Niemann CU, Moestrup K, et al. Persistent COVID-19 in an Immunocompromised Patient Temporarily Responsive to Two Courses of Remdesivir Therapy. J Infect Dis. 2020 Jul 23;jiaa446.

Leave a Reply