WHY WON'T THERE BE A NEW NORMAL, JUST NORMAL? . WHY IS THE OUTBREAK UNLIKELY AND EVEN IF THERE IS ONE,IT WON'T BE AS HARMFUL AS BEFORE?

Gestalt! That's what came to my mind before I wrote this article a few days ago. What is Gestalt? Gestalt psychology was born in Germany at the beginning of the 20th century. It was focused on the investigation of perception phenomena (mainly visual). In certain moments humans stop perceiving things in an individual way and begin to perceive “the whole”, everything is interrelated! This term is also used to define visual phenomena that can be perceived in 2 ways (ambiguous image, like the one below).

Today we are going to talk about “the whole “or the puzzle pieces that fit together:

The key to the puzzle is in several recently published studies related to cross immunity. The responsible for the current pandemic is a coronavirus; as we know we have the common cold (Coronavirus Alpha) and other coronaviruses (Beta) that caused epidemics in the past (SARS 2002 and MERS 2012). Well, scientists have found in people not exposed to SARS Cov- 2 or Covid 19 some immunity not only humoral (antibodies like S309(1)) but also cellular (T lymphocytes(2,3)) due to exposure to other coronaviruses. This could explain why we have so many mild or asymptomatic cases: there is an important part of the population with a certain degree of immunity to COVID 19.

We have already talked about the Spanish seroprevalence study(4) and how group immunity may not be achieved when 70% of the population is infected, but when 20% or 40% of the population is infected. The reason may be cross-immunity developed against other coronaviruses. It would also provide a response to the very low SARS Cov-2 k (dispersion factor) level. If you remember we said that the k-factor is 0.1(5) in other words: a very low number of people infected many people (10% have infected 80%). This fact could explain why many people do not have to develop antibodies or specific T cells, because they have previous immune defenses generated for other coronaviruses.

Cross-immunity could also explain why the elderly are more likely to have a severe disease than children. In the elderly there is a phenomenon called immunosenescence, our defenses are exhausted and despite having antibodies or T lymphocytes, these are less effective. That′s why, cancer is more frequent, but autoimmune diseases are less frequent at the end of life. Other theories claim that the COVID 19 impact on the elderly is due to the ACE2 receptor (the virus' gateway to the cells), which changes with age favoring the entry of the virus in those over 70 years old. It′s probably a combination of ACE2 plus immunosenescence that make our elderly vulnerable.

I hope that after the similarities with other coronaviruses, and not with the virus that caused the 1918 pandemic, we will stop comparing them not only from an immunological point of view but also in their potential consequences.

If we agree that they are not comparable after looking at the chart, I assume that you won't try to draw conclusions of the future evolution of COVID 19 from the 1918 Flu. Therefore, following all these facts, we can conclude that a new outbreak is unlikely. However, I am sure that there are still people who are skeptical about this possibility. For those who are driven only by experience (pure empiricists) and nothing else than experience, let see what is happening in Asia (where the pandemic began).

Countries like China have removed the need to wear masks in areas like Beijing (there are only small outbreaks due to cases imported from Russia). In South Korea they managed to control the disease without the need of mass confinement by controlling infected people, and despite an alarm in a Seoul bar area there is no outbreak. The number of new cases of COVID 19 in Japan was 39 on May 20 (compared to 743 on April 11).

If we look at the study of the University of Toronto(6) that does not see great differences in the influence of temperature, we should not think that when winter comes there won′t be an outbreak. Temperature does not seem to be a critical factor since we have cases in tropical, equatorial countries (although it′s true that not many) and in the Arabian Peninsula (where MERS is endemic)

Despite the overwhelming evidence, you remain skeptical...so let's look at how it all began.

1.- The virus had been among us for months without being detected because we were not looking for it and because we had no way of detecting it

2- When it arrived, we underestimated the virus and did not take any action (mass gathering events, border control...)

3- When we realized the size of the problem, there was no reliable tests so we could not control or track the cases. Now we have PCR and serologies (blood tests).

4.- Doctors treated patients without knowing anything about the disease. When the outbreak burst, treatment protocols are not like the current ones (non-invasive ventilation, anticoagulants, IL 6 inhibitor, steroids)

This pandemic has not been the result of a single mistake but of an error chain, a perfect storm that has brought us to this point. Therefore, even if there is an outbreak with the current disease knowledge, the detection methods available, virus contact tracking, prohibition of mass gathering events and an important part of the susceptible/vulnerable population that has already suffered the disease (it has been demonstrated that antibodies give immunity to those who overcome the disease) it′s very difficult or almost impossible to repeat the same situation. A second outbreak of the same proportions would not be due to the virulence of SARS Cov 2, but to our incompetence.

We must keep the prohibition of large events and the systems of early detection as South Korea has done, because they have been shown to be the key to control the disease. We know that few cases infect many (k factor), being able to control them is the key.

What does not make any sense from an economic or health point of view is to maintain unnecessary restrictions that damage our economy, and only give a false sense of security.

It′s true that there is uncertainty, but decisions need to be made. Possible is not the same as probable, let's make decisions based on the most probable and on the information we have. It would be as harmful not to act as to overreact and apply an excess of prudence. We have enough examples to return to total normality and not to the "new normal".

As Albert Einstein said, " two things are infinite: human stupidity and the universe, and I′m not sure about the universe".

References:

1.- Pinto, D., Park, Y., Beltramello, M. et al. Cross-neutralization of SARS-CoV-2 by a human monoclonal SARS-CoV antibody. Nature (2020). https://doi.org/10.1038/s41586-020-2349-y

2.- Grifoni A, Sette A, et al. Targets of T cell responses to SARS-CoV-2 coronavirus in humans with COVID-19 disease and unexposed individuals. Cell (2020) https://doi.org/10.1016/j.cell.2020.05.015

3.- Braun J. Presence of SARS-CoV-2 reactive T cells in COVID-19 patients and healthy donors. medRxiv (2020) https://doi.org/10.1101/2020.04.17.20061440

4.- https://www.mscbs.gob.es/gabinetePrensa/notaPrensa/pdf/ENE-C140520115618104.pdf

5.- Endo A. Estimating the overdispersion in COVID-19 transmission using outbreak sizes outside China. Wellcome Open Res 2020, 5:67 (https://doi.org/10.12688/wellcomeopenres.15842.1)

6.- Gesink D. Impact of climate and public health interventions on the COVID-19 pandemic: A prospective cohort study. CMAJ May 08, 2020 cmaj.200920; DOI: https://doi.org/10.1503/cmaj.200920