Covid Talk With Dr. Ayoub Abulkhir

COVID19, a type of Coronavirus, has been around since December 2019. The infections at this point are showing up in between 25-27 countries. Since then, there have been numerous conspiracies and rumors towards this virus; numbers of cases and new findings can go sideways everyday; or even causes shortages on both daily and medical supplies.  

Even so, the uncertainty irritates our anxiety and mental wellbeing.  Focusing on what we can do and how we can influence others, rather than placing our worrism on the unknown or hatred would be the key.

During this time, we’ve consulted with our Medical Collective Dr. Ayoub Abulkhir and have him share with us what this virus really is, how it impacts our daily lives, and what we can do to protect ourselves as well as our loved ones.  

Just a head up that this is Not-So-Noirstone-typical capsule read, it can be somewhat intense, however, this curated information seems to be able to help build the fundamental wellbeing.

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Up to date : Mar 24, 2020 (mortified on Apr 7, 2020)

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Q1 : What is Coronavirus?

A1 : Coronaviruses are named for their corona-like appearance with pointed structures (proteins). In Latin the word "corona" means "crown"(1).

Coronaviruses are commonly found in different animals, some have the capability of transmitting between animals and humans. Due to this ability, the coronaviruses are known as Zoonotic Viruses(1).

“Coronavirus” is just an umbrella term for different types of coronaviruses. Some of them can cause mild to moderate respiratory (nose, throat, lung) illnesses, while others can cause more critical diseases, including severe acute respiratory syndrome (SARS) back in 2002 - 2004 and Middle East respiratory syndrome (MERS) back in 2012(1).

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Q2 : This is not the first time for us to experience coronavirus, but what makes this string - COVID19 different from the previous virus?

A2 : To begin, Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is the novel coronavirus which means it’s a new type of coronavirus that was not previously known or understood by health experts, while the disease caused by this new virus is officially called Coronavirus disease (COVID-19)(2)

Scientists believe this type of coronavirus has jumped from a different animal to humans,which is rare. It has become transmissible from human to human, which is even more rare among coronaviruses. Up to date, there isn’t enough epidemiological information to determine how easily and sustainably this virus spreads between people, but it’s currently estimated that, on average, one infected person will infect between 2 and 3 more(2-4).

Another reason that this virus is different from other well known coronavirus is an infected person might not show symptoms for up to 14 days after exposure. That’s especially worrisome because this novel coronavirus has the ability to be transmitted while a person is not showing any symptoms(5).

The SARS-CoV-2 is a highly contagious virus spread primarily through droplets of saliva or discharge from the nose when an infected person coughs or sneezes. Transmission can happen when people are in close contact with one another, usually up to about six feet(6).  So it’s important that we practice respiratory etiquette (for example, by coughing into a flexed elbow and frequently hand washing).

If you’re tired of singing Happy Birthday for 20 seconds, try this with Brandon Flowers from The Killers and his tune of Mr. Brightside.

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Q3 : COVID19 binds to ACE-2 receptors and enters the cell wall membrane, how does this specific ACE-2 receptor influence our immune system and organ functions? Does age play a role in having more or less of ACE-2 receptors in the body?

A3 : SARS-CoV-2 is an enveloped positive-stranded RNA virus that consists of four structural proteins including spike (S) glycoprotein, envelope (E) protein, membrane (M) protein, and nucleocapsid (N) protein. Spike glycoprotein is the most important surface protein of coronavirus, which can mediate the entrance to human respiratory epithelial cells by interacting with cell surface receptor angiotensin-converting enzyme 2 (ACE2)(11).

ACE-2 is actually an enzyme with an important regulator of the immune response, especially inflammation. ACE2 is expressed by epithelial cells (cells that come from surfaces of your body) of the lung, intestine, kidney, and blood vessels(12).

The main function of the ACE 2 is naturally protected against lung injury. The expression of ACE2 is substantially increased in patients with type 1 or type 2 diabetes, who are treated with ACE inhibitors and angiotensin II type-I receptor blockers (ARBs)(12).

Hypertension is also treated with ACE inhibitors and ARBs, which results in an upregulation of ACE2. ACE2 can also be increased by thiazolidinediones and ibuprofen(12). These data suggest that ACE2 expression is increased in diabetes and treatment with ACE inhibitors and ARBs increases ACE2 expression. Consequently, the increased expression of ACE2 would facilitate infection with SARS-CoV-2.

When SARS-CoV-2 binds to ACE-2, the protein loses its enzyme activity. It is believed that ACE-2 exhaustion is responsible for the severity of pneumonia and catastrophic effects like heart failure and circulatory collapse.

The resilience of ACE-2 may explain the diversity of responses to coronavirus infection. ACE2 receptor abundance goes down in the elderly in all these tissues. Thus, the conditions associated with critical diseases and death from COVID-19 infection like (advanced age, diabetes, high blood pressure, heart disease, cigarette smoking) are all associated with diminished baseline ACE-2 activity(13). Not only that, but the second phase of COVID-19, the progression from a minor viral illness to severe respiratory distress, may reflect ACE-2 exhaustion, occurring several days after the initial symptoms.

‍Q4 : Does NrF2 Activator help modulate inflammatory response by protecting the cells or even mitochondria? And where can we find NrF2 Activator?

A4 : NrF2 (nuclear factor erythroid-2-related factor 2) is a transcription factor that activates over 500 genes via molecules called Sirtuins. NrF2 regulates the magnitude of innate immune responses in several disease models, including pneumonia. NrF2 activation showed a protective role against inflammatory lung injury(17). NrF2 activation can be achieved through exercise, calorie restriction (including fasting) and ingestion of natural nutrients that are NrF2 activators. Common NrF2 activators include curcumin (from turmeric spice – probably the best studied and most potent NrF2 activator), along with resveratrol (from grapes), quercetin (from onions) and sulforaphane (from broccoli) followed by antioxidants found in green tea and other sources(18).

Activation of NrF2 is believed to provide many health benefits including reducing systemic inflammation, pain protection against diabetes (reducing insulin resistance) and protection against a variety of degenerative and immune-based diseases(18).

In recent years, numerous investigations have focused on the protection against ARDS by Nrf2 activators, especially in hyperoxia, lung inflammation and ARDS(18); however, to date there is no evidence on the effect of NrF2 in the COVID-19.

NRF2 is a basic leucine zipper (bZIP) protein that regulates the expression of antioxidant proteins that protect against oxidative damage triggered by injury and inflammation.

Q5 : What makes some people more vulnerable to this pandemic?

A5 : The answer lies in their immune systems.

As we get older, we become more prone to develop health issues like diabetes, heart diseases, lung diseases, cancers. When coronavirus enters our upper airways, it is vital that our immune systems identify it as a harmful agent quickly before it has time to spread down into our lungs and cause breathing difficulties.

One of the reasons we might be seeing older people succumbing to the effects of the virus more readily is that their immune system does not recognise and act as quickly as younger people.

A major part of a person's immune system is the white blood cells. These are produced in bone marrow as immature cells and travel to different organs, including the spleen, to mature into the army we need to fight off infections. In older people, however, the production of white cells in the bone marrow slows down, and the rate of maturation is also much less robust than that of younger people, leaving them with fewer types of certain white blood cells needed to fight off an infection like COVID-19.

While we need our immune systems to respond aggressively to the virus, we also need it to attack only the infected cells within our body and not healthy cells. There is evidence that older people's immune systems become less able to distinguish "self" from "non-self" - that is, to identify foreign agents.

In addition, although older people at this stage in their illness may start producing antibodies to the virus, it has been shown that the antibodies become less able to attach to the virus itself and fight it off. This change may partly explain why pneumonia and influenza are more common among older people and result in death more often.

(Updated on Apr 6, 2020 : Besides older populations, more younger populations have tested positive.  Younger populations may not suffer from pneumonia as easily as the older folks, however, it is vital to be aware of our own immunity regardless of age.)

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Q6 : Where “Cytokine Storm” is being mentioned more often lately, what exactly is cytokine storm and who is prone to it easily?

A6 : Let’s first understand that Coronaviruses have many mechanisms for evading the innate immune system, so it isn’t clear that stimulating innate immunity will offer much protection, but weakened innate immunity is likely to contribute to severity of illness, so measures to optimize innate immunity are warranted.

Once pneumonia develops and disease severity increases, the role of the immune system changes. Much of the damage is due to over activity of immune responses, which is known as a “cytokine storm”.  

In this activity, the immune system goes into overdrive, not knowing when to shut itself off, thereby attacking healthy cells within the lungs and other parts of the body, making the effects of COVID-19 worse. It is thought that immune boosting therapies may be contra-indicated during phase two of COVID-19 infection(14, 15).

Innate immunity refers to nonspecific defense mechanisms that come into play immediately or within hours of an antigen's appearance in the body. These mechanisms include physical barriers such as skin, chemicals in the blood, and immune system cells that attack foreign cells in the body.

An overactive immune response can be deadly. All Covid-19 patients sick enough for hospitalization should be given an inexpensive, quick, and readily available serum ferritin blood test(15). Indeed, elevated serum ferritin values have recently been reported in Chinese hospitalized patients with Covid-19. This is a good first screening tool for the possibility of a cytokine storm syndrome in sick patients with high fevers.

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Q7 :General public has an expectation and image that vaccines are the magic bullet. From what I understand that it’s not difficult to make, but it does take time to test if it actually works.  How does a vaccine actually work in the human body and does it work if the recipient has autoimmune issues or is vulnerable to begin with?

A7 : Vaccination is a simple and effective way to protect people of all ages against harmful diseases before they come into contact with them. Vaccination is also safe, however, side effects from a vaccine are usually minor and temporary, such as a sore arm or mild fever.

To produce protection against a disease, vaccines activate biological reactions in the body. Those reactions vary depending on the type of vaccine and its mode of administration, any licensed vaccine is rigorously tested across multiple phases of trials before it is approved for use, and regularly reassessed once introduced, that is the reason behind the long time of producing a safe, effective, and efficient vaccine. Which it is anticipated in case of COVID-19.

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Q8 : Both WHO and CDC recommended the length for self-isolation is 14 days, however in some cases it might take 24 days before showing symptoms, some might take up to 37 days (according to a study published on Lanchet), or some don’t even have any symptoms. How do we know if we are positive since the testing isn’t widely available to the public?

A8 : The incubation period from the exposure to COVID-19 virus to illness is 2 to 14 days, with an average of 5 days in most of the cases. Unlike the flu, illness from COVID-19 virus appears to start gradually with fever, cough,  fatigue, aches and pains, and a sore throat. These symptoms typically last for 5 days and are followed by recovery. This is called Phase One of the infection and for 80% of people it is the only phase.

The resert 20%, however, Phase Two starts after 5 days, with more aggressive symptoms like shortness of breath, symptoms of pneumonia (chest pain when breathing or coughing, confusion or changes in mental awareness (in adults age 65 and older)). Both groups will continue to shed the virus in secretions for several weeks and may still be contagious after symptoms end.

Due to people who are infected but lack symptoms are able to infect others, widespread infection is likely to happen. It is difficult to identify these populations, unless screening has been done to all citizens, symptomatic or not. Unfortunately, this is a big challenge. For this reason, healthy young people need to take the same precautions as older people take, if the pandemic is to be controlled.  

Infants and young children, even when heavily infected, are relatively resistant to sickness from this virus, which is the opposite of the flu. Interestingly, young adults in the U.S., in contrast to China, are just as likely to require hospitalization as older adults, although mortality increases with age and is greater in people with high blood pressure, diabetes and heart disease.

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Q9 : Do region and climate play key roles in how this type of virus proliferates or mutates?

A9 : As SARS-CoV-2 is a novel virus, scientists aren't sure what kinds of patterns to expect as it spreads or how it might be affected by weather and climate. Research related to other illnesses, however, suggests that the risk of pandemics is growing as rising temperatures ignite animal migrations and other changes.

As we can see the COVID-19 virus continues to spread even as the first hints of spring begin to appear across the Northern Hemisphere. Answering these kinds of questions about the coronavirus will take time. But in general, links between climate and infectious disease are a growing subject of interest among scientists.

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Q10 : There always have been a good portion of people experiencing similar symptoms and taking a longer period of time to recover.  Is it possible this type of coronavirus already existed somewhere prior to this outbreak?  

A10 : Coronaviruses are known to jump from animals to humans, so it’s thought that the first people infected with the COVID-19 virus is a group primarily made up of stallholders from the seafood market – contracted from contact with animals. The hunt for the animal source of Covid-19 virus is still unknown, although there are some strong contenders.

The least thing that we know is a team of virologists at the Wuhan Institute for Virology published a detailed showing that the new coronaviruses' genetic makeup is 96% identical to that of a coronavirus found in bats, while another study published after argues that genetic sequences of coronavirus in pangolins are between 88.5 and 92.4 percent similar to the human virus(1, 16). Some early cases of Covid-19, however, appear to have inflicted people with no link to the Wuhan market at all, suggesting that the initial route of human infection may pre-date the market cases. More studies are needed to identify the source.

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Q11 : If a person recovers from COVID19, how long do the antibodies stay in the system and what is the chance of getting infected again?

A11 : The infected patient’s body develops antibodies that are very specific to the virus that infected them. After they’ve recovered these antibodies don’t disappear, they go into hibernation, and are ready to wake up as soon as the same pathogen tries to contaminate the body again.

For example during the SARS epidemic most people who became infected had long-term immunity lasting eight to 10 years. This characteristic of the immune system is the same against all known viruses there’s no sign at this stage that there might be re-infection. While it certainly seems scientifically unlikely, the notion of a single virus that infects the same person twice is instructive. It warns against blind confidence in screening tests and underlines the importance of monitoring patients who appear to be cured.

Enhanced understanding of the immune response could also help if the question of repeated infection returns through a mutation of the virus. If the pathogen changes in such a way that the body no longer recognises it, the virus can infect somebody twice.

We don’t get the same strain of the virus twice, but we can get it the following year after the virus has mutated slightly. Coronaviruses are known for their tendency to mutate although the COVID-19 virus has not undergone any such modification.

Until today it is unknown whether recovery from infection with COVID-19 produces immunity to the virus. There are cases reported of apparent re-infection, but they might represent flare-up of an infection that had been suppressed and not cured. Without individual immunity, vaccines will not work and there will be no herd immunity.

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Q12 : Other than social distancing and sanitizing, what can the general public do to protect themselves and modulate the immune system on a daily basis?

A12 : This new coronavirus is spreading so rapidly and having such a significant impact on people around the world is due to the fact that we lack immunity to it.  

If a person is self-isolating, and especially if having symptoms, it is important to maintain good nutrition and hydration. Thus, it is paramount to ensure adequate eating and drinking regularly, even if there is low appetite.

There are a few things that a person can do today that don’t cost anything. We recommend you prioritize these basic steps for protecting, improving health, and potentially the immune system.

• Proper handwashing: the coronavirus is killed by proper handwashing for 20 seconds with soap or using hand sanitizer that is greater than 60% alcohol.
• Don’t smoke: Smokers have an increased risk of catching infections and suffering severe complications from those infections. Cigarette smoke suppresses the immune system leaving smokers to heal more slowly than non-smokers.
  Moreover, smoking has an adverse effect on the antioxidants (such as vitamin C) that circulate through the human body.  Smoking of any sort is also a direct irritant to respiratory tissues.

• Get adequate sleep: Science says 7–9 hours per night is needed for optimal health. Sleep is important for health in general, and as a bonus it may also benefit our immune function. Human body produces and releases cytokines when you sleep. Cytokines are proteins that target inflammation.
  
• The right amount of exercise: regular, moderate exercise decreases the inflammatory response and increases immune regulation .
• Stress management: while acute stressors may temporarily enhance immune functions, chronic stressors likely diminish immune function.

• Get sunshine and fresh air where possible
  

While there is not yet robust scientific evidence specifically around the immune system and COVID-19 infection, taking some specific supplements may improve your overall health and are likely to not be harmful if taken as directed. Vitamin D, vitamin C, and zinc are essential for innate immunity but excess levels of these actually impair immune function.

• Maintaining adequate levels of vitamin D is particularly important. Vitamin D is normally produced in our skin when exposed to sunlight, and in the late winter and spring blood levels of vitamin D tend to be low because of reduced sun exposure. Staying indoors will further reduce blood levels. Thus, almost everyone should supplement with Vitamin D through the winter, but the dose needs to be individualized over a range of 1000 to 5000 IU/day. Vitamin D is best absorbed with a large meal. Low vitamin D results in poor regulation of your adaptive immune system.
  
• Vitamin C is a cofactor for many enzymes. It enhances the function of many enzymes all over the body by keeping their metal ions in the reduced form. It also acts as an antioxidant, limiting inflammation and tissue damage associated with immune responses. While it’s unclear whether taking a Vitamin C supplement is beneficial for COVID-19, for most people there’s no harm in taking up to 2,000 mg  per day.
  
• Zinc is a component of many enzymes and transcription factors in cells all over the body, and inadequate zinc levels limit the individual’s ability to mount an adequate immune response to infection. Zinc is present in a wide variety of foods. Oysters are known as the best source of zinc, but you can also get it from red meat, beans, nuts, whole grains, and dairy. However it is important to remember that phytates should only be supplemented if blood levels are low.

As a reminder, COVID-19 is a new disease, and we are still learning about it, so to date, there hasn’t been any specific studies of vitamin D, C, and zinc for COVID-19.

Q13: I guess the Mental Virus spreads faster than the physical virus itself.  The uncertainty brings up the anxiety. Does this whole atmosphere fighting toilet paper affect our immune system or inflammatory response?

A13 : During the COVID-19 pandemic many people have been panic buyers all over the globe like the world is ending. Many goods have been flying off shelves, especially toilet papers although they do not offer special protection against the virus. I believe this behaviour is a  result of the anxiety and the unprecedented stressful situation. This stress has a deleterious impact on the immune system. When we’re stressed, the immune system’s ability to fight off antigens is reduced. That is why we are more susceptible to infections.

It is known that the stress occurs when life events surpass our abilities to cope. It causes greater levels of the stress hormone known as cortisol. In short spurts, cortisol can boost the immunity by limiting inflammation. However over a long period, the human body can get used to having too much cortisol in your blood which opens the door for more inflammation. In addition, stress decreases the body’s lymphocytes, the white blood cells that help fight off infection. The lower the lymphocyte level, the more at risk for viruses, including the common cold and cold sores.

High stress levels also can cause depression and anxiety, again leading to higher levels of inflammation. In the long-term, sustained, high levels of inflammation point to an overworked, over-tired immune system that can’t properly protect you.

Stress can also have an indirect effect on the immune system as a person may use unhealthy behavioural coping strategies to reduce their stress, such as drinking and smoking.

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Q14 : Any advice you want to give to our urban families?

A14 : Fighting the COVID-19 virus is like a marathon that requires patience. My advice to all people is to respect public health guidelines which are:

1. Practice physical distancing by keeping a distance of at least 2 meters from other people when you go out. Because when someone coughs or sneezes they spray small liquid droplets from their nose or mouth which may contain viruses.
2. Regularly and thoroughly wash your hands with soap and water for at least 20 seconds. If water and soap are unavailable, use hand sanitizer that has 60% or more alcohol. It kills viruses that may be on your hands.
3. Practice respiratory hygiene by covering your cough or sneeze with a tissue, then immediately throw the tissue in the garbage and wash your hands if the tissues are not available. Aslo, sneezing or coughing into your sleeve or arm. By following good respiratory hygiene you protect the people around you from viruses.
   
   

Thank you Dr. Abulkir for your valuable time from your busy schedule and I’m sure this is one of the most difficult moments for medical providers.  Stay safe and wish you good health.

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C O N C L U S I O N

From Dr. Abulkir :
Boosting the immune system through diet and no specific food, supplement or natural health product will not prevent you from catching COVID-19 virus. Proper hygiene and physical distancing are the right procedures that can help reduce the risk of infection or spreading infection to others.

From Nicole Lui :
To date, there’s no 1 single thing to prevent being infected, however we can make conscious choices to help support our immune system through lifestyle micro-changes as Dr. Abulkir mentioned above.

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Reference & Resource :

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18. Liu Q, Gao Y, Ci X. Role of Nrf2 and its activators in respiratory diseases. Oxidative medicine and cellular longevity. 2019;2019.

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