As Louisiana gears up to reopen in phases, new studies in other states would suggest that Louisianians, particularly those in the battlefield of New Orleans, have probably been infected much more so than our own diagnostic testing numbers would suggest. Recent studies in other cities like Miami, Los Angeles, and New York indicate that a far larger segment of the population than previously recorded has antibodies to the virus, meaning they’ve had the infection, but may have been unaware because of a lack of symptoms.
Louisiana’s reopening plan has been delayed by a few weeks. On Monday, Gov. John Bel Edwards announced that his stay at home order — previously set to expire at the end of this week — would be extended through at least May 15. While new cases and hospitalizations in the New Orleans area have declined sharply, some other parts of Louisiana are just beginning to plateau or are still seeing growth, meaning the state has yet to meet White House criteria to enter “phase one” of reopening.
Still, state officials continue to plan for reopening, and Edwards has previously emphasized the importance of expanded, accurate antibody testing.
“Let’s face it, at this point we have only been measuring symptomatic people, and we in the infectious disease community have often surmised that perhaps a much higher percentage of people are asymptomatic and therefore aren’t showing up in current data,” explained Dr. Fred Lopez, infectious disease specialist at LSU Health New Orleans. “But now that we see sero-surveillance with results from antibody tests in L.A. County, and Santa Clara County in California [where we now think the first U.S. death actually appeared based on an autopsy], and in New York City [where 21% had antibodies] these studies and others may indicate that 25% of people or even more may be asymptomatic, but have been exposed.”
Though some antibody tests now on the market have proved inaccurate, showing large numbers of false positives, scientists at LSU Health Sciences Shreveport told The Advocate last week that they have developed a test that’s 99.75 percent accurate.
But it’s still unclear if exposure, and the presence of antibodies, means people are immune, let alone how long any immunity may last. When the World Health Organization announced recently that having antibodies doesn’t mean a patient has acquired immunity, it faced pushback from scientists. The WHO walked the statement back slightly, saying on Twitter that they expected that being infected and developing antibodies would “provide some level of protection.”
“What we don’t yet know is the level of protection or how long it will last,” read a follow-up Tweet from the WHO.
And so, it seems that very little is actually known about cause and effect, vis-à-vis antibodies and immunity.
“If you have an antibody response from one of the new tests, assuming the test is accurate, we know you’ve been exposed,” said Dr. John Schieffelin, associate professor of pediatric infectious disease at Tulane University School of Medicine. “But just what’s required for immunity, we don’t know. How much of an antibody response is needed to protect you from the virus, and for how long? We need much more sophisticated tests to determine whether one has a cellular immunity, the sort of response in which your white cells are gobbling up and killing the virus, because that response is not necessarily because of any antibody component.”
If seroconversion for SARS-CoV-2, the particular coronavirus which causes COVID-19, does not confer complete immunity, how much immunity does anyone who has been exposed to the virus actually have? For states in the process of debating how quickly to reopen, it poses many questions.
One of the reasons which scientists theorize makes COVID-19 so dangerous is that our immune systems are totally unfamiliar with this coronaviral strain, and aren’t sure how to respond.
“Let’s look at children who don’t seem to develop as severe an immune response to COVID-19, in general,” Lopez said. “Many adults who become the sickest develop a very strong immune response, and therefore develop many more complications. This may sound counter-intuitive, but robust immune responses can easily get out of control, causing much more severe complications.”
‘We’ve become aware of just how much we don’t know’
Even in children, severe complications have happened. A 5-year girl old died a week ago in Detroit after contracting COVID-19, spending weeks on a ventilator, and developing a rare form of meningitis. It demonstrates to many in the scientific community that there’s still much we don’t understand about this virus and its ramifications.
“Meningitis isn’t usually prevalent as a complication of this virus, but we have seen some neurological symptoms in adult patients like headaches and confusion, and an absence of taste and smell,” Lopez said. “Now, we’re even seeing Guillain-Barré syndrome [a disorder of the immune system where the nerves are attacked by one’s own immune cells]. We don’t have a complete picture of important facts associated with COVID-19 because we haven’t had time for data collection.”
Children now account for just a sliver of the COVID-19 patients being tested, and it may well be that more children are asymptomatic, and therefore aren’t tested. Children’s Hospital of New Orleans is testing every child who’s admitted, whether they have particular symptoms of this novel coronavirus, or not. But Schieffelin said a better database needs to be compiled. Children are a critical component of the overall equation when it comes to getting back to our pre-COVID-19 lives because even if they experience far fewer critical cases, they can easily pass the disease to adults, who are more vulnerable. When schools reopen in August, we need real numbers about the infectious capability of our children who are in close proximity to one another both in classrooms and on playgrounds.
“A nationwide study of kids is needed,” Schieffelin said. “We’re missing lots of data on kids because we think they tend to be asymptomatic. At Children’s Hospital, at the beginning of the outbreak and even now, if they don’t need to be admitted and don’t have other problems, we send them home and we don’t test them, because we don’t have an abundance of tests and we need to save those for people who have symptoms and are sick. As schools in Denmark are opening, for instance, it may turn out they opened too early and will see a spike in cases. But, just as likely, we may not see a spike in the children if they’re asymptomatic, but we may very well see the adults around them getting sick.”
And, therein lies the conundrum of how fast to open up and with what degree of protection. As Atlanta restaurants reopened Monday on the heels of their hair salons, tattoo parlors, bowling alleys, massage parlors and gyms this past Friday, there is a great valley of unknown factors with respect to reinfection. It is part of the framework of this virus which Edwards must contemplate when he considers which parts of Louisiana’s restrictions to loosen.
“We’ve become aware of just how much we don’t know pertaining to this particular virus,” Shieffelin said. “We know that people are shedding virus after their symptoms go away, but for how long? To be safe, 21 days might be a good barometer. But, the larger question might be when we might see the ramifications of a lack of social distancing going forward. We may start to see new cases in as little as two to four weeks.”
Reopening could lead to second wave
Despite CDC social distancing guidelines still being in place, some people continue to congregate in large numbers, as weekend photographs from California illustrated. Once states begin to reopen — even if they do it slowly and cautiously — it seems likely that social distancing will become more difficult.
Dr. Deborah Birx told CNN and NBC News on Sunday that we should be employing social distancing throughout the summer, and that we need to keep our eyes on some of the unexpected consequences of this virus. Although we’re still talking about President Trump’s rather unconventional remarks last Thursday pertaining to ultraviolet light experimentation and injecting disinfectant to kill the coronavirus in our bodies, she urged everyone to move on and start looking at real data we are now compiling. Of particular concern, she noted, was the fact that we are seeing blood clotting in some younger people with the virus, and that’s causing strokes. Every day, she said, can be a new revelation into what this virus brings with it.
“So, what happens when we reopen,” mused Dr. Susan Hassig, associate professor of epidemiology at the Tulane School of Public Health and Tropical Medicine. “It’s probably going to explode with a second wave. The virus is still active, as we still see new cases, if even to a lesser degree.”
To mitigate the potential harm from reopening, every scientist The Lens spoke with re-emphasized that now more than ever is the time to take this virus seriously. Both infectious disease specialists and epidemiologists alike said that washing one’s hands, wearing a mask and social distancing will go a long way to curb whatever second wave may just be around the corner.
“With a reopening comes a lack of social distancing, and it’s still not mandatory in Louisiana to wear a mask,” Hassig said. “Maybe 40% of people in New Orleans have already been infected. But, who knows? Until we have the ability to rapidly test people and find out whether they’ve been exposed, it’s a guessing game. I tell people to be cautious. People want to take their chances, but it may be foolhardy. Just because we’re currently not running out of hospital beds doesn’t mean it’s time to let down our guard.”
There are still many people who believe this won’t be truly over until and if we can produce a vaccine that generates universal immunity.
“Let’s look at measles,” said Schieffelin. “It’s one of those viruses where we know a lot about the immune response because it’s been around for so long. We know that having a certain level of antibodies translates to a certain level of immunity, which is very similar to Hepatitis-B. But, at this point, we still don’t even know how many have been infected with COVID-19, nor how many people would need to be immune before we have herd immunity [when enough people are resistant, so the virus has nowhere to go]. Usually the standard definition is 80 percent. Measles is well over 95%, because it’s so contagious … and of course we have a measles vaccine. This virus is probably somewhere in between, making it very important that we get a vaccine. But 12 to 18 months is a very aggressive timeline for that vaccine. If the first trial vaccines hold up, then we can get it done. But, if there are any hiccups along the way, it just prolongs the time frame.”