COVID-19 and Autoimmune Disease

At this point you have likely read numerous reports about the COVID-19 Coronavirus and hopefully have started implementing changes to minimize your risk of exposure or transmission of this new strain of virus. I will start off by saying I am not an infectious disease expert, but what I will seek to share with you below is a general summary of what we know about the current virus, guidance to easily consumable information from experts and expert organizations, and reminders about the fundamentals of supporting your immune system through optimal lifestyle habits.

General Information About COVID-19

From what we know currently, COVID-19 is a specific strain of a Coronavirus, which is a RNA virus. As a RNA virus it contains its genetic material as a single strand of RNA as compared to our double-stranded DNA. A virus is most simply an obligate organism that contains genetic material – the script for replicating itself and an interestingly complex capsid or covering. In the case of Coronavirus it is what we call an enveloped virus, acquiring aspects of its outer coating upon budding from an infected human cell. In order to replicate it must enter into a human cell and utilize our own enzymes and organelles to replicate and assemble all viral components before budding from the infected cell. When this subclass of viruses was first discovered, it was given the name coronavirus because of the specific orientation/appearance of the proteins on its envelope that appeared like a crown.

In general the subclass of Coronaviruses causes illnesses such as the common cold and upper respiratory tract infections, but there have been previous strains such as the SARS and MERS viruses that caused more severe respiratory compromise and patient deaths. From early indications with its origin in China, the COVID-19 virus appears to be a more virulent type of Coronavirus such as the SARS and MERS viruses, and has been causing respiratory failure and death in approximately 1 to 2% of infected individuals. The virus is transmitted from person to person in close contact (less than 6 feet) by droplets created when someone coughs or sneezes or spreads these secretions by touching surfaces. Simply coming into contact with such particles from an infected person, however, does not guarantee you will become infected depending on the nature of your immune response, but appears as the critical event for viral transmission and subsequent infection. It is still unclear if the virus can be transmitted from other bodily fluids and healthcare workers have been encouraged to take extra precautions with measures to prevent contact and droplet exposures.

Risk Factors and What We Are Learning About COVID-19

At this point in time it appears that the main risk factors for having a more severe course of illness are age greater than 60 years old, high blood pressure, diabetes, underlying lung disease, and relative immunodeficiency, which can be present in individuals with the primary immunodeficiency or secondary immunodeficiency from drug treatments or other immune related diseases.

For many with autoimmune disease, immune modulating or immune suppressing medications are used to help balance an overactive or dysregulated immune system. These medications such as TNF inhibitors like Etanercept, Infliximab or Adalimumab and even steroids such as Prednisone can make individuals more susceptible to infectious diseases caused by bacteria and viruses. Besides being more susceptible to infections, individuals on immunosuppressant medications who become infected may have a more serious illness course than someone not on such a medication.

All of this being said, it is very important to weigh the risk and benefits of a medication and in most cases individuals should continue such medications as there is likely a greater risk for complications by acutely stopping the medication than being infected with Coronavirus. For those on such medications please contact your prescribing physician to ensure your optimal treatment and if you develop symptoms such as cough, fever or difficulty breathing. These individuals should also take additional precautions to prevent exposure in larger public and social gatherings. Like nearly everything related to our current understanding of COVID-19, the increased precautions we are taking for those with diabetes including Type 1 diabetes and on immunosuppressant medications are based mostly on our theoretical understanding of how these medications and conditions affect the immune system and not from large amounts of data from the current COVID-19 pandemic.

Mortality in infected younger and healthy individuals appears to be between 0.1 to 0.2% with many having very mild disease courses. The primary symptoms typically appear in the first week after transmission and include fever, cough, shortness of breath or difficulty breathing. It is unclear at this point if someone can be an asymptomatic carrier or transmit the virus, but be clinically unaffected/not infected.

The current goals and strategies for preventing further spread of the virus specifically to higher risk individuals involves social distancing and self quarantine. By social distancing we hope to minimize contact between individuals thus preventing transmission from infected or nearly asymptomatic individuals with the ultimate goal of allowing our current healthcare force with its ceiling for providing care in hospital or intensive care settings to be able to handle those who become severely ill.

While it is recommended for infected individuals to wear certain types of masks in an attempt to prevent transmission of infected droplets, sadly much of the personal protective equipment needed by healthcare personnel is in shortage because it is being stored by individuals who do not necessarily need such equipment. The most important strategies for you to prevent transmission or to prevent infection are to continue with rigorous handwashing and current social distancing recommendations and do not necessarily include wearing a mask in every public setting in which you find yourself.

Remembering Our Foundations in this Stressful Time

It is important to realize that the strategies for prevention will be different than the strategies for active treatment. As a foundation we should ensure we maintain as optimal of lifestyle habits as possible including optimal nutrient density, movement, adequate rest, and most importantly adequate stress management in this extremely anxiety and fear provoking time. Being in a heightened state of stress or a sleep-deprived state will impair immune function and this is exactly what we do not want in this current environment. There have been many people talking about fancy diets, fasting, or restricting certain macronutrients as ways to prevent infection, but there is not tremendous evidence supporting you radically changing any optimal lifestyle habits to prevent becoming infected with the virus.

My recommendations and those of my clinic created by team nutritionist Ryan Hall, CNS are essentially identical to the nutrient dense eating templates and diets we recommend our patients currently, and if you are already following a certain dietary template including fasting, by all means please continue with what makes you feel most robust and well. If you have not been as optimal with your dietary pattern recently, perhaps you can use this as an opportunity within the limits of available food and resources to optimize your diet as it relates to nutrient density focusing on adequate vitamins and mineral intake.

If You Are Infected with COVID-19

As I stated before, some of the decisions one will make if infected with the virus will be different than the decisions one would make if not infected. For infected individuals self quarantine and masks as well as continued optimal hygiene and the disinfection/cleaning of affected surfaces are the most critical aspects of treatment. Outside of these recommendations, many individuals have suggested numerous types of antiviral herbs and other treatments including drug therapy. What I currently see as a reasonable treatment to initiate as soon as one detects any symptoms such as fever, cough, or difficulty breathing is the use of zinc lozenges, preferably zinc acetate lozenges approximately every 3 to 4 hours to try and prevent replication of the virus in oropharyngeal or respiratory tissue. In addition one may want to consider taking 1 teaspoon of Cod Liver Oil every 8 to 12 hours to provide supplemental omega 3’s and fat soluble vitamins, including vitamin A. While there have been numerous other recommended treatments including elderberry, vitamin C and specific herbs recommended by herbalists such as Stephen Buhner, it may be even more stressful and challenging for individuals to acquire these herbs at this time. The number of available zinc lozenges is already in very minimal supply and zinc obtained outside of a lozenge does not appear to provide the same effect as lozenges dissolved in the oropharyngeal mucosa.

I want to reiterate again that the most critical steps of treatment are the initial prevention of infection followed by continued optimal lifestyle habits most notably nutrition, adequate rest, hydration and stress management. Individuals with symptoms that may possibly be related to the virus should, even in mild cases, contact a healthcare provider or local health department to obtain testing if available. We still do not know the false positive rate or the number of people who test positive for the virus, but are not actually infected, so it will remain critical to ensure initial testing for individuals displaying consistent symptoms and minimize testing for those that are asymptomatic who may be wrongly diagnosed or even test negative when they are an asymptomatic or minimally symptomatic infected individual.

It has been very easy for the very young to look at the statistics and not be afraid of becoming infected, but the greater concern to our society is for minimally symptomatic healthy adults to transmit the virus to older individuals with risk factors for more severe disease.

Should you or a loved one become very sick with severe symptoms such as respiratory compromise requiring hospitalization in an intensive care unit, you may want to consider asking the intensive care team and hospital for the use of IV vitamin C typically given every four hours for a total of 6 to 12 grams of IV Vitamin C over a 24 hour period. There has been some limited but successful use of this treatment for individuals with severe sepsis in the ICU as documented by Dr. Marik at EVMS in Norfolk, Virginia (1) and there have been three studies of which I am aware that have been initiated in China with the use of IV Vitamin C for individuals with severe infections of COVID-19 given the limited treatment options for severe disease, but this does not mean that individuals taking smaller oral doses will receive any benefit in prevention or even treatment at home.

Conclusions

This is currently one of the most unsettling and fear provoking times our country has faced in recent memory, and while it seems we have a little control of what is going on, there is much we can do to support each other in our small communities, ensuring adequate nutrition and emotional care through acts of gratitude and love. We will only continue to learn more about the evolving virus and its threats to our country, and it will be critical to maintain behaviors in support of our own well being and those of our individual communities.

References and Links

1. https://www.ncbi.nlm.nih.gov/pubmed/27940189

CDC

Johns Hopkins Resource Center

Aviva Romm, M.D.: COVID-19 and Autoimmune Disease