By Janet von Konsky Miller, MPH
In recent years, my husband and I have often sought out community firework displays on the 4th of July. Whether we find a lookout spot to view the glittering sky show from afar or seek the crowds to experience the soundwaves as each explosive blast bursts a spray of colorful shapes overhead, we have enjoyed contributing to the “oohs” and “ahs” that invariably accompany the annual pyrotechnic shows. Last year we even ventured outside of our local festivities to experience renowned firework displays surrounded by Tahoe’s scenic grandeur. Amidst pandemic conditions, however, the 4th of July festivities this year will look much different. This year’s local firework shows are cancelled to discourage transmission-prone crowds from gathering.
News reports of COVID-19 spikes in cases throughout the US have been reported the week before the Independence Day holiday. As of July 2, the US has 2,732,531 cases1 and those numbers are increasing by an average of over 40,000 cases daily.2 Nine percent of all COVID-19 tests are currently positive in the US.3 California along with Arizona, Texas, and Florida comprise half of the nation’s new COVID 19 cases.2 As of July 2, 6.4% of California COVID-19 tests are positive, which has increased from 4.5% positivity on June 4.4 While Santa Clara County fares better than the state-wide positivity rates, these county rates are increasing as well (2.62% positive tests on July 2 up from 1.39% on June 4 in Santa Clara Couny).5
This July 4th marks 244 years since the Declaration of Independence was signed, a document declaring colonial independence from Great Britain. This document symbolizes the values of freedom and independence deeply rooted in American culture. This year’s anniversary calls Americans to conceptualize their freedom and independence from a pandemic perspective.
To explore freedom and independence within a pandemic, we must first understand the virus behind the pandemic. The SARS coV 2 virus causing COVID-19 is a new virus in humans. Over the past 6 months, scientists have examined past viruses that are similar to SARS coV 2 and have studied how this new virus affects human physiology. If we as community members better understand its effects, we might be better able to embrace the importance of following recommendations meant to slow transmission.
When exposed to the SARS coV 2 virus, the virus binds ACE2 receptors.6 These receptors are found in many places throughout the body, including the lungs. While over 40% of those exposed may not experience symptoms,7 symptoms will occur 4 to 5 days after exposure on average in symptomatic individuals.8 In more moderate forms of the disease, local inflammation will resolve as healthy immune systems attack and kill the virus. In severe disease, however, an inflammatory response called a “cytokine storm” ensues.8, 9, 10 A dysfunctional immune system that is unable to conquer the virus coupled with inflammation may lead to lung tissue damage, low oxygen levels, risk of opportunistic infection such as pneumonia, organ failure, and possible death.6, 8 Those who suffer severe disease and recover may be inflicted with post recovery health issues from lung damage.23, 25
An immune dysfunction associated with the severe COVID-19 cases is characterized by low levels of an immune cell called “T cells.”10, 11, 12, 13, 14 T cell levels decline with age and may contribute to the increased risk of severe COVID-19 with advancing age.8, 14 In Santa Clara County, only 12.5% of the COVID-19 cases but 68% of the deaths have occurred in individuals who are 70 years of age or older.15 In the same county, 34.5% of cases and 2.5% of deaths occur in individuals who are between 20 and 39 years of age.15
T cell levels also decline with malnutrition.16,17 Therefore, it may be possible that those who do not have access to adequate nutrition could be at risk of severe COVID 19 disease. National food insecurity rates are estimated to be twice the pre-pandemic rates.18 California food bank demands have soared 73% in 1 year.18
Obesity may promote T cell dysfunction and this may not be reversible with weight loss.19 The Centers for Disease Control and Prevention (CDC) report that over 42 out of every 100 US adults are obese.20 Factors influencing obesity include diet, exercise, and sedentary lifestyles, and obesity risk may increase with chemical exposures and gut dysbiosis.21 Obesity is a risk factor for severe COVID-19 disease.22
Personal freedom and community responsibility are not mutually exclusive. It is estimated that masks may cut SARS coV 2 transmission in half.24 It may save someone from severe disease, post recovery health issues, and death. If we all cooperate with transmission mitigation efforts, businesses will open sooner, lasting health effects will be reduced, the pandemic health care impact will be eased, and loved ones will be able to hug again. It only takes properly wearing a mask when in public. It only takes a 6-foot distance when in contact with others. It only takes regular hand washing and cleaning of frequently touched surfaces. By embracing these behavior choices, we help each other and we commit to end this global pandemic. This is freedom. This is community. Through interdependence we may experience independence.
1CDC. (2020). Cases in the US. July 3. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html
2NBC News. (2020). Fauci: COVID-19 cases could swell to 100,000 a day if U.S. doesn’t control virus. June 30. Retrieved from https://www.nbcnews.com/health/health-news/fauci-covid-19-cases-could-swell-100-000-day-if-n1232526
3CDC. (2020). Testing Data in the US. July 2. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/testing-in-us.html
4California State Government. (2020). COVID-19 State-wide Update: How are COVID-19 cases progressing? July 3. Retrieved from https://update.covid19.ca.gov/
5Santa Clara County Public Health Department. (2020). Novel Coronavirus (COVID-19): COVID-19 Testing Dashboard. July 2. Retrieved from https://www.sccgov.org/sites/covid19/Pages/dashboard-testing.aspx
6 Zabetakis, I., Lordan, R., Norton, C., Tsoupras, A. (2020). COVID-19: The inflammation link and the role of nutrition in potential mitigation. Nutrients. 12(5): 1466. doi: 10.3390/nu12051466
7 Lavezzo, E., Franchin, E., Ciavarella, C., Cuomo-Dannenberg, G., Barzon, L, Del Vecchio, C., Rossi, L., Manganelli, R., Loregian, A., Navarin, N., Abate, D., Sciro, M., Merigliano, S., De Canale, E., Vanuzzo, M.C., Besutti, V., Saluzzo, F., Onelia, F., Pacenti, M., Parisi, S., Carretta, G., Donato, D., Flor, L., Cocchio, S., Masi, G., Sperduti, A., Cattarino, L., Salvador, R., Nicoletti, M., Caldart, F., Castelli, G., Nieddu E., Labella, B., Fava, L., Drigo, M., Gaythorpe, K.A.M., Imperial College COVID-19 Response Team, Brazzale, A.R., Toppo, S., Trevisan, M., Baldo, V., Donnelly, C.A., Ferguson, N.M., Dorigatti, I., & Crisant, A. (2020). Suppression of a SARS-CoV-2 outbreak in the Italian municipality of Vo’. Nature. Jun 30. doi: 10.1038/s41586-020-2488-1
8 Tay, M.Z., Poh, Z.M., Renia, L., MacAry, P.A., & Ng, L.F.P. (2020). The trinity of COVID-19: immunity, inflammation and intervention. Nature Reviews Immunology. 20: 363–374. doi: 10.1038/s41577-020-0311-8
9 Ye, Q., Wang, B., & Mao, J. (2020). The pathogenesis and treatment of the ‘Cytokine Storm’ in COVID-19. Journal of Infection. 80: 607-613. doi: 10.1016/j.jinf.2020.03.037
10Diao, B., Wang, C., Tan, Y., Chen, X., Liu, Y., Ning, L., Chen, L., Li, M., Liu, Y., Wang, G., Yuan, Z., Feng, Z., Wu, Y., & Chen, Y. (2020). Reduction and functional exhaustion of T cells in patients with coronavirus disease 2019 (COVID-19). Front. Immunol. May 1. https://doi.org/10.3389/fimmu.2020.00827
11Ganjia, A., Farahania, I., Khansarinejada, B., Ghazavib, A., Mosayebia, G. (2020). Increased expression of CD8 marker on T-cells in COVID-19 patients. Blood, Cells, Molecules and Diseases. 83: 102437. doi: 10.1016/j.bcmd.2020.102437
12Qin, C., Zhou, L., Hu, Z., Zhang, S., Yang, S., Tao, Y., Xie, C., Ma, K., Shang, K., Wang, W., & Tian, D.S. (2020). Dysregulation of immune response in patients with COVID-19 in Wuhan, China. Clin Infect Dis. ciaa248. doi: 10.1093/cid/ciaa248
13Wang, F., Hou, H., Lui, Y., Tank, G., Wu, S., Huang, M., Liu, W., Zhu, Y., Lin, Q., Mao, L, Fang, M., Zhang, H., Sun, Z. (2020). The laboratory tests and host immunity of COVID-19 patients with different severity of illness. JCI Insight. 5(10):e137799. Doi:10.1172/jck.insight.137799
14Liu, Y., Pang, Y., Hu, Z., Wu, M., Wang, C., Feng, Z., Mao, C., Tan, Y., Liu, Y., Chen, L., Wang, G., Yuan, Z., Diao, B., Wu, Y., & Chen, Y. (2020). Thymosin alpha 1 (Tα1) reduces the mortality of severe COVID-19 by restoration of lymphocytopenia and reversion of exhausted T cells. Clin Infect Dis. ciaa630. doi: 10.1093/cid/ciaa630
15Santa Clara County Public Health Department. (2020). Novel Coronavirus (COVID-19): Demographics of Cases and Deaths. July 3. Retrieved from https://www.sccgov.org/sites/covid19/Pages/dashboard-demographics-of-cases-and-deaths.aspx
16Alwarawrah, Y., Kiernan, K., MacIver, N.J. (2018). Changes in nutritional status impact immune cell metabolism and function. Front Immunol. 9:1055. doi: 10.3389/fimmu.2018.01055
17Cohen, S., Danzaki, K., & MacIver N.J. (2017). Nutritional effects on T-cell immunometabolism. Eur J Immunol. 47(2): 225–235. doi:10.1002/eji.201646423
18 NY Times. (2020). As Hunger Spreads with Pandemic, Government Takes Timid Steps. May 13. Retrieved from https://www.nytimes.com/2020/05/13/us/politics/coronavirus-hunger-food-banks.html?
19Rebeles, J., Green, W.D., Alwarawrah, Y., Nichols, A.G., Eisner, W., Danzaki, K., MacIver, N.J., Beck, M.A. (2019). Obesity-induced changes in T-cell metabolism are associated with impaired memory T-cell response to influenza and are not reversed with weight loss. J Infect Dis. 219(10): 1652–1661. doi: 10.1093/infdis/jiy700
20CDC. (2020). Adult Obesity Facts. June 29. Retrieved from https://www.cdc.gov/obesity/data/adult.html
21CDC. (2020). Adult Obesity Causes and Consequences. June 11. Retrieved from https://www.cdc.gov/obesity/adult/causes.html
22CDC. (2020). CDC Updates, Expands List of People at Risk of Severe COVID-19 Illness . June 25. Retrieved from https://www.cdc.gov/media/releases/2020/p0625-update-expands-covid-19.html
23Science News. (2020). Some Patients Who Survive COVID-19 May Suffer Lasting Lung Damage. April 27. Retrieved from https://www.sciencenews.org/article/coronavirus-covid-19-some-patients-may-suffer-lasting-lung-damage
24CNN. (2020). Pelosi Says Federal Mandate on Masks Is ‘Long Overdue.’ June 28. Retrieved from https://www.cnn.com/2020/06/28/politics/pelosi-masks-federal-mandate/index.html
25Spagnolo, P., Balestro, E., Aliberti, S., Cocconcelli, E., Biondini, D., Della Casa, G., Sverzellati, N., Maher, T.M. (2020). Pulmonary fibrosis secondary to COVID-19: a call to arms? The Lancet. May 15. doi: 10.1016/ S2213-2600(20)30222-8