Reduce initial dose of the virus and optimize your immune system

Erik Peper and Richard Harvey

COVID-19 can sometimes overwhelm young and old immune systems and in some cases can result in ‘Severe Acute Respiratory Syndrome’ pneumonia and death (CDC, 2020). The risk is greater for older people who may simultaneously be dealing with cancers, cardiovascular heart disease, obesity, diabetes, emphysema, immune suppression or other health issues.  As we age the immune system deteriorates  (immunosenescence) which reduces the response of the adaptive immune system that needs to respond to the virus infection (Aw, Silva & Palmer, 2007; Osttan, Monti, Gueresi, et al., 2016).

Severity of disease may depend upon initial dose of the virus

In a brilliant article, How does the coronavirus behave inside a patient? We’ve counted the viral spread across peoples; now we need to count it within people, assistant professor of medicine at Columbia University and cancer physician Siddhartha Mukherjee points out that severity of the disease may be related to the initial dose of the virus.  Namely, if you receive a very small dose (not too many virus particles), they will infect you; however, the body can activate its immune response to cope with the infection.  The low dose exposure act similar to vaccination.  If on the other hand you are exposed to a very high dose then your body is overwhelmed with the infection and is unable to respond effectively.  Think of a forest fire. A small fire can easily be suppressed since there is enough time to upgrade the fire-fighting resources; however, during a fire-storm with multiple fires occurring at the same time, the fire-fighting resources are overwhelmed and there is not enough time to recruit outside fire-fighting resources.

As Mukherjee points out this dose exposure relationship with illness severity has a long history. For example, before vaccinations for childhood illnesses were available, a child who became infected at the playground usually experienced a mild form of the disease.  However, the child’s siblings who were infected at home develop a much more severe form of the disease.

The child infected in the playground most likely received a relatively small dose of the virus over a short time period (viral concentration in the air is low).  On the other hand, the siblings who were infected at home by their infected brother or sister received a high concentration of the virus over an extended period which initially overwhelmed their immune system. Higher virus concentration is more likely during the winter and in well insulated/sealed houses where the air is recirculated without going through HEPA or UV filters to sterilize the air. When there is no fresh air to decrease or remove the virus concentration, the risk of severity of illness may be higher (Heid, 2020).

The risk of becoming sick with COVID-19 can only occur if you are exposed to the coronavirus and the competency of your immune system. This can be expressed in the following equation.Risk ratioThis equation suggests two strategies to reduce risk:  reduce coronavirus load/exposure and strengthen the immune system.

What can you do to reduce the dose of virus exposure

Assume that everyone is contagious even though they may appear healthy.  Research suggests that people are already contagious before developing symptoms or are asymptomatic carriers who do not get sick and thereby unknowingly spread the virus. Dutch researchers have reported that, “The proportion of pre-symptomatic transmission was 48% for Singapore and 62% for Tianjin, China (Ganyani et al, 2020). Thus, the intervention to isolate people who have symptoms of COVID-19 (fever, dry cough, etc.) most likely will miss the asymptomatic carriers who may infect the community without awareness.  Only if you have been tested, do you know if you been exposed or recovered from the virus. To reduce exposure the dose of virus exposure, do the following.

  1. Follow the public health guidelines:
    • Social distancing (physical distancing while continuing to offer social support)
    • Washing your hands with soap for at least 20 seconds.
    • Not touching your face to prevent microorganisms and viruses to enter the body through mucosal surfaces of the nose mouth and eyes.
    • Cleaning surfaces which could have been touched by other such as door bell, door knobs, packages.
    • Wearing a mask and gloves to reduce spreading the virus to others.
  1. Avoid the person’s slipstream that may contain the droplets in the exhaled air. The purpose of social distancing is to have enough distance between you and another person so that the exhaled air of the other person would not reach you. The distance between people depends upon their activities and the direction of airflow.

In a simulation study, Professor Bert Blocken and his colleagues at KU Leuven and Eindhoven University of Technology reported that the plume of the exhaled air that potentially could contain the virus  droplets could extend much more than 5 feet. It  would depends upon the direction of the wind and whether the person is walking or jogging as show in Figure 1 (Blocken, 2020).

Slipstream

Figure 1. The plume of exhaled droplets that could contain the virus extends behind the person in their slipstream (photo from KU Leuven en TU Eindhoven).

The plume of exhaled droplets in the person’s slipstream  may extend more than 15 feet while walking and more than 60 feet while jogging or bicycling.  Thus social distancing under these conditions is much more than 6 feet and it means avoiding their slipstream and staying much further away  from the person. 

  1. Increase fresh air to reduce virus concentration. By increasing the fresh outside air circulation, you dilute the virus concentration that may be shed by an infected asymptomatic or sick person  (Qian & Zheng, 2018).. Thus, if you are exposed to the virus, you may receive a lower dose and increase the probability that you experience a milder version of the disease. To increase fresh air (this assumes that outside air is not polluted), explore the following:
    • Open the windows to allow cross ventilation through your house or work setting. One of the major reasons that the flu season spikes in the winter is that people congregate indoors to escape weather extremes. People keep their windows closed to conserve heat and reduce heating bill costs. Lack of fresh air circulation increases the viral density and risk of illness severity (Foster, 2014).
    • Use an exhaust fans to ventilate a building. By continuously replacing the inside “stale” air  with fresh outside air, the concentration of the virus in the air is reduced.
    • Use High-efficiency particulate air (HEPA) air purifiers to filter the air within a room. These devices will filter out particles whose diameter is equal to 0.3 µ m. They will not totally filter out the virus; however, they will reduce it.
    • Avoid buildings with recycled air unless the heating and air conditioning system (HAC) uses HEPA filters.
    • Wear a mask to protect other people and your community. The mask will reduce the shedding of the virus to others by people with COVID-19 or those who are asymptomatic carriers.
  1. Avoid long-term exposure to air pollution. People exposed to high levels of air pollution and fine particulate matter (PM2.5)  are more at risk to develop chronic respiratory conditions and COVID-19 death rates. In the 2003 study of SARS, ecologic analysis conducted among 5 regions in China with 100 or more SARS cases showed that case fatality rate increased with the increment of air pollution index (Cui, Zhang, Froines, et al. , 2003). The higher  the concentration of fine particulate matter (PM2.5), the higher the death rate (Conticini, Frediani, & Caro, 2020).  As researchers, Xiao Wu, Rachel C. Nethery and colleagues (2020) from the Harvard T.H. Chan School of Public Health point out,  “A small increase in long-term exposure to PM2.5 leads to a large increase in COVID-19 death rate, with the magnitude of increase 20 times that observed for PM2.5 and all cause mortality. The study results underscore the importance of continuing to enforce existing air pollution regulations to protect human health both during and after the COVID-19 crisis.

How to strengthen your immune system to fight the virus

The immune system is dynamic and many factors as well as individual differences affect its ability to fight the virus.  It is possible that a 40 year-old person may have an immune systems that functions as a 70 year old, while some 70 year-olds have an immune system that function as a 40 year-old. Factors that contribute to immune competence include genetics, aging, previous virus exposure, and lifestyle (Lawton, 2020).

It is estimated that 70-80% mortality caused by Covid-19 occurred in people with comorbidity who are: 1) over 65,  2) male,  3) lower socioeconomic status (SES),  4) non white, 5) overweight/obesity, 6) cardiovascular heart disease, and 7) immune suppressed. The majority of these risk factors are the result of economic inequality and life style patterns.  

By taking charge of your lifestyle habits through an integrated approach, you may be able to strengthen your immune system (Alschuler et al, 2020; Lawton, 2020). The following tables, adapted from the published articles by Lawton (2020) and Alschuler et al, (2020), list some of the factors that may strengthen or weaken the immune system.

Factors that strengthen the immune competence

increase immune competence rev1

Phytochemicals and vitamins that may support the immune competence

increase immune competence rev2

Factors that may weaken the immune competence

decrease immune competence rev

These factors have been superbly summarized by the World Health Organization Director General Dr. Tedros Adhanom in his presentation, Practical tips how to keep yourself safe.

REFERENCES

Abhanon, T. (2020 March 26). Practical tips how to keep yourself safe.

Alschuler, L., Weil, A., Horwitz, R. Stamets, P., Chiasso, A.M., Crocker, R., & Maizes, V. (2020 March 26). Integrative considerations during the CPVID-19 pandemic. Explore, 26.

Aranow C. (2011). Vitamin D and the immune system. Journal of investigative medicine : the official publication of the American Federation for Clinical Research59(6), 881–886. 

Aw, D., Silva, A. B., & Palmer, D. B. (2007). Immunosenescence: emerging challenges for an ageing population. Immunology120(4), 435–446.

Blocken, B. (2020-04-08). Cited in, Belgishch onderzoek: fietsen, joggen of wandelen do je best niet achtr elkaar in tijden van corona. DeMorgen. 

Casas R, Sacanella E, Estruch R. The immune protective effect of the Mediterranean diet against chronic low-grade inflammatory diseases. Endocr Metab Immune Disord Drug Targets. 2014;14(4):245‐254. 

CDC (2020, March 26). Severe Outcomes Among Patients with Coronavirus Disease 2019 (COVID-19) — United States, February 12–March 16, 2020. Morbidity and Mortality Weekly Report. CDC. March 26, 2020.

Conticini, D., Frediani, F., & Caro, D. (2020). Can atmospheric pollution be considred a co-factdor in the extremely high level of SARS-CoV-2 lethality in Northern Italy.  Environmental Pollution, available online, 4 April 2020, 114465.

Foster, H. (2014 December 1). The reason for the season: why flu strikes in winter. SITN Science in the News

Ganyani, T., Kremer, C., Chen, D., Torneri, A, Faes, C., Wallinga, J., & Hensm N. (2020).    Estimating the generation interval for COVID-19 based on symptom onset data     doi:https://doi.org/10.1101/2020.03.05.20031815

Heid, M. (2020-04-09).  The Germ-Cleaning Power of an Open Window. Elemental by Medium. 

Jagetia GC, Aggarwal BB. “Spicing up” of the immune system by curcumin. J Clin Immunol. 2007;27(1):19‐35. 

Lawton, G. (2020). You’re only as young as your immune system. New Scientist, 245(3275), 44-48.

Lee, G. Y., & Han, S. N. (2018). The Role of Vitamin E in Immunity. Nutrients10(11), 1614. 

Lewis ED, Meydani SN, Wu D. Regulatory role of vitamin E in the immune system and inflammation. IUBMB Life. 2019;71(4):487‐494.

Li, Y., Yao, J., Han, C., Yang, J., Chaudhry, M. T., Wang, S., Liu, H., & Yin, Y. (2016). Quercetin, Inflammation and Immunity. Nutrients8(3), 167. 

Malaguarnera L. (2019). Influence of Resveratrol on the Immune Response. Nutrients11(5), 946. 

Mukherjee, S. (2020). How does the coronavirus behave inside a patient? We’ve counted the viral spread across peoples; now we need to count it within people. The New Yorker, April 6, 2020.

Mukherjee, S., Dudley, J. I., & Das, D. K. (2010). Dose-dependency of resveratrol in providing health benefits. Dose-response : a publication of International Hormesis Society8(4), 478–500. 

Ostan, R., Monti, D., Gueresi, P., Bussolotto, M., Franceschi, C., & Baggio, G. (2016). Gender, aging and longevity in humans: An update of an intriguing/neglected scenario paving the way to a gender-specific medicine. Clinical Science, 130(19), 1711-1725.

Qian, H., & Zheng, X. (2018). Ventilation control for airborne transmission of human exhaled bio-aerosols in buildings. Journal of thoracic disease10(Suppl 19), S2295–S2304. https://doi.org/10.21037/jtd.2018.01.24

Prasad A. S. (2008). Zinc in human health: effect of zinc on immune cells. Molecular medicine (Cambridge, Mass.)14(5-6), 353–357. 

Wu, X., Nethery, R.c., Sabath, B., Braun, D., & Dominici, R. (2020). Exposure to air polution and COVID-19 mortality in the United States. Submitted to New England Journal of Medicine. April 5, 2020. 

 


Can changing your breathing pattern reduce coronavirus exposure?

sneeze

This blog is based upon our breathing  research that began in the 1990s, This  research helped identify dysfunctional breathing patterns that could contribute to illness. We developed coaching/teaching strategies with biofeedback to optimize breathing patterns, improve health and performance (Peper and Tibbetts, 1994; Peper, Martinez Aranda and Moss, 2015; Peper, Mason, and Huey, 2017).

For example, people with asthma were taught to reduce their reactivity to cigarette smoke and other airborne irritants (Peper and Tibbitts, 1992Peper and Tibbetts, 2003).  The smoke of cigarettes or vaping spreads out as the person exhales. If the person was infected, the smoke could represent the cloud of viruses that the other people would inhale as is shown in Figure 1.vaping

Figure 1. Vaping by young people in Riga, Latvia (photo by Erik Peper).

To learn how to breathe differently, the participants  first learned effortless slow diaphragmatic breathing. Then were taught that the moment they would become aware of an airborne irritant such as cigarette smoke, they would hold their breath and relax their body and move away from the source of the polluted air while exhaling very slowly through their nose. When the air was clearer they would inhale and continue effortless diaphragmatically breathing (Peper and Tibbetts, 1994).  From this research we propose that people may reduce exposure to the coronavirus by changing their breathing pattern; however, the first step is prevention by following the recommended public health guidelines.

  • Social distancing (physical distancing while continuing to offer social support)
  • Washing your hands with soap for at least 20 seconds
  • Not touching your face
  • Cleaning surfaces which could have been touched by other such as door bell, door knobs, packages.
  • Wear a mask to protect other people and your community. The mask will reduce the shedding of the virus to others by people with COVID-19 or those who are asymptomatic carriers.

Reduce your exposure to the virus when near other people by changing your breathing pattern 

Normally when startled or surprised, we tend to gasp and inhale air rapidly. When someone sneezes, coughs or exhales near you, we often respond with a slight gasp and inhale their droplets. To reduce inhaling their droplets (which may contain the coronavirus virus), implement the following:

  • When a person is getting too close
    • Hold your breath with your mouth closed and relax your shoulders (just pause your breathing) as you move away from the person.
    • Gently exhale through your nose (do not inhale before exhaling)-just exhale how little or much air you have
    • When far enough away, gently inhale through your nose.
    • Remember to relax and feel your shoulders drop when holding your breath.  It will last for only a few seconds as you move away from the person.  Exhale before inhaling through your nose.
  • When a person coughs or sneezes
    • Hold your breath, rotate you head away  from the person and move away from them while exhaling though your nose.
    • If you think the droplets of the sneeze or cough have landed on you or your clothing, go home, disrobe outside your house, and put your clothing into the washing machine. Take a shower and wash yourself with soap.
  • When passing a person ahead of you or who is approaching you
    • Inhale before they are too close and exhale through your nose as you are passing them.
    • After you are more than 6 feet away gently inhale through your nose.
  • When talking to people outside
    • Stand so that the breeze/wind hits both people from the same side so that the exhaled droplets are blown away from both of you (down wind).

These  breathing skills seem so simple; however, in our experience with people with asthma and other symptoms, it took practice, practice, and practice to change their automatic breathing patterns. The new pattern is pause (stop) the breath and then exhale through your nose. Remember, this breathing pattern is not forced and with practice it will occur effortlessly.

The following blogs offer instructions for mastering effortless diaphragmatic breathing.

https://peperperspective.com/2017/06/23/healing-irritable-bowel-syndrome-with-diaphragmatic-breathing/

https://peperperspective.com/2018/10/04/breathing-reduces-acid-reflux-and-dysmenorrhea-discomfort/

https://peperperspective.com/2019/03/24/anxiety-lightheadedness-palpitations-prodromal-migraine-symptoms-breathing-to-the-rescue/

https://peperperspective.com/2017/03/19/enjoy-sex-breathe-away-the-pain/

https://peperperspective.com/2015/02/18/reduce-hot-flashes-and-premenstrual-symptoms-with-breathing/

https://peperperspective.com/2015/09/25/resolving-pelvic-floor-pain-a-case-report/

References

Peper, E., Martinez Aranda, P., & Moss, E. (2015). Vulvodynia treated successfully with breathing biofeedback and integrated stress reduction: A case report. Biofeedback. 43(2), 103-109.

Peper, E., Mason, L., Huey, C. (2017).  Healing irritable bowel syndrome with diaphragmatic breathing. Biofeedback. (45-4). /

Peper, E., and Tibbetts, V. (1992).  Fifteen-Month follow up with asthmatics utilizing EMG/Incentive inspirometer feedback. Bio­feedback and Self-Regulation. 17 (2), 143-151. 

Peper, E. & Tibbetts, V. (1994). Effortless diaphragmatic breathing. Physical Therapy Products. 6(2), 67-71.  Also in:  Electromyography:  Applications in Physical Therapy. Montreal: Thought Technology Ltd. 

Peper, E.  and Tibbitts, V.  (2003). Protocol for the treatment of asthma.  In:  Zheng, Y. (ed).  Clinical Practice of Biofeedback. Beijing:  High Education Press (HEP). 163-176. ISBN 7-04-011420-8

 


Coronavirus risk in context: How worried should you be?

The coronavirus which causes coronavirus disease 2019 (COVID-19) appears to be a highly contagious disease. Some older people and those who are immune compromised are more at risk.  The highest risk are for older people who already have cardiovascular, diabetes, respiratory disease, and hypertension. In addition, older men over 65 years are much more at risk; however, the majority are smokers who have a compromised pulmonary system. Previous meta analysis showed that smoking was consistently associated with higher risk of hospital admissions after influenza infection. Nevertheless, it is reasonable to assume that over time all most all of us will become exposed to the virus, a few will get very sick, and even fewer will die.

The preliminary data suggests that most people who become infected may not even know they are infectious. Make the assumption that everyone could be contagious unless tested for the virus or antibodies to the virus since people appear to be infectious for the first four days before experiencing symptoms.

corona virus infection

The absolute risk that one would die of this disease is low although if you do become very sick it is more dangerous than the normal flu; however, the fear of this disease may be out of proportion compared to other health risks. For detailed analysis and graphic summaries see the updated research reports on the Coronavirus disease (COVID-19) by Our World in Data and Information is beautiful. These reports make data and research on the world’s largest problems understandable and accessible.

It is worthwhile to look at the absolute risk of COVID-19.  To read that more than 332,000 people world wide have died in the last five months is terrifying especially with the increasing death rate in Europe and New York; however, it needs to be understood in context of the size of the population.  The epicenter of this disease was Wuhan and Hubei Provence, China with a total population of about 60 million people.  Each year about 427,200 people die in the Wuhan and Hubei Province (the annual death rate in China is 7.12 deaths per 1000 people). Without this new viral disease, about 71,200 people would have died during the same two month period.  The question that has not been discussed is how much did the total death rate increase.  Would it be possible that some of the people who died would have died of other natural causes such as the flu?

The World Health Organization (WHO) and governments around the world should be lauded for their attempt to reduce the spread of the virus. On March 6, 2020, the United States Congress allocated $8. billion dollars to fight and prevent the spread of COVID-19. 

This funding will only partially prevent the spread of the virus because some people have no choice but to go to work when they are sick–they do not receive paid sick leave! This is true for about 30 percent of the American workers who have no coverage at work or the millions of self-employed workers (e.g. gig/freelance workers, waiters, cashiers, drivers, nannies, house cleaners).

To reduce the risk of the spreading COVID-19, anyone who feels sick or thinks they have been exposed, should receive paid sick leave so that they can stay home and self-isolate. The paid sick leave should be Federally funded and provide basic income for those whose income would be lost if they did not work.  Although it is possible that a few people will cheat and take the paid sick leave when they are well, this is worth the risk to keep the rest of population healthy. To provide possible relief, at the moment the House and Senate are working on a greater than $2 trillion dollar stimulus package. 

Personal and government responses to health risks are not always rational. 

Funding for health and illness prevention is driven by politics. For example, gun violence results in more than 100,000 people being injured each year and more than 36,000 killed—an average of 100 per day. Gun violence is a much more virulent disease than COVID-19 and more than 1.7 million Americans have died from firearms since 1968.

The Federal Government response to this gun violence epidemic has been minimal. For the first time since 1996 did the 2020 federal budget include $25 million funding for the CDC and NIH to research reducing gun-related deaths and injuries.

It is clear that the government response does not always focuses its resources on what would reduce injury and death rates the most.  Look at the difference in the national response to COVID-19 virus that has killed more than 82,000 people in the USA ($8.5 billion for the initial response and then $2 trillion stimulus package) as compared gun violence that kills 36,000 people a year in the USA ($25 million funding to study the causes of gun violence).

Be realistic about the actual risk of COVID-19 without succumbing to fear.

COVID-19 is a pandemic and I expect that 30% to 70% of us will be infected this year.  Hopefully, in the next 18 months an effective vaccine will be developed.  In the mean time, there is no known treatment, thus optimize health and reduce the exposure to the coronavirus.

To make sense of the danger of COVID-19, look at it in context to the flu. Depending upon the severity the  flu, 9,000,000 to 45,000,000 people get sick from flu and between 12,000 to 61,000 die from its complications. as shown below in Figure 1.  

influenza-burden-chart2-960pxFigure 1. The estimated U.S. influenza burden by year (from: https://www.cdc.gov/flu/about/burden/index.html)

This year the CDC estimates that there have been 20,000 to 40,000 deaths in the United States so far this year.  For comparison that is a thousand times  more deaths in the United States than have been blamed on the coronavirus so far.