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Protecting against SARS-CoV-2. "Simplicity is the Ultimate Sophistication" - (Da Vinci). An essay

Writer's picture: dave shanahandave shanahan

Updated: Jul 2, 2020

Protecting against SARS-CoV-2. "Simplicity is the Ultimate Sophistication" - (Da Vinci).

An essay (if you will), from someone with dearly held relations working in healthcare.

Wearing face masks in close company, handwashing, physical distancing are logical behaviours we take to reduce transmission of SARS-CoV-2

As the incidence of SARS-CoV-2 reportedly falls and we return to “business near usual”, is it realistic to believe in healthcare, that high risk medical procedures are no longer inherently dangerous for adjacent healthcare workers?

With 30% of Covid19 infections affecting healthcare workers, are we wise to overlook solutions in plain sight, which potentially reduce infection with this virus and its potential long-term consequences, especially as we return to work?

Does anyone who reflects or thinks seriously for a moment, believe that healthcare professionals engaged in clinical procedures around the patient's mouth and nose, are not at risk of potential exposure to SARS-CoV-2, especially by asymptomatic virus carriers who are perfectly well?

While waiting for a vaccine, or curative treatments or clinical trials to report, does it make sense to forego, simple additional, cheap interventions hiding in plain sight, which could address the risk in any way that’s meaningful?

What if we could deploy treatments with compelling data to reduce the potential for transmission of this debilitating viral infection? Imagine if there were products which are commercially available with a proven use case, against viral infections of the mouth and nose with proven safety over decades across the world? Just ponder that for a moment……

As the link attached to this excellent article from the New York Times (1) makes clear, scientific publication and opinion often lags the experience and reality for those at the coalface. Delays and intransigence do cost lives.

With Covid19, silent spreading, asymptomatic transmission, pre-symptom spreading, all essentially mean the same thing. Patients infected with SARS-CoV-2 spreading and shedding virus unknowingly and thereby infecting others. This is community-based transmission. Infected individuals with asymptomatic illness creating clusters of infection. It can happen easily, via innocuous contact, such as sharing a table condiment, as documented in this NY Times article.

The primary route for transmission and infection with Covid19 is via the mouth and nose. These are viral reservoirs and the main portal for viral entry and exit. Transmission occurs from droplet infections, from the aerosols we generate when we breathe, by touching contaminated surfaces, then touching our own eyes, mouth or nose.

Here are some facts

· Healthcare workers make up 30% of infected patients.

· The occupational hazards to healthcare workers are immense.

· Infection with SARS-CoV-2, is a serious health risk. It could result in long term lung and neurological problems in some of us.

· SARS-CoV-2 is a serious infection without a cure or a vaccine.

· It can be fatal in a small minority of people.

Due to the facts outlined, any preventative measures likely to be useful should be deployed, especially practical, obvious and cheap interventions, if it’s likely they could lower the risk of transmission. This is not rocket science! Wearing PPE, practicing social distancing and hand hygiene is rooted in common sense. Its obvious such interventions by their very nature lower transmission potential.

So, to the crux of this article.

Iodine is amongst our oldest and most powerful killers of bacteria and viruses. It is an unstable element. Iodine containing solutions such as Povidone-iodine (PVP-I), harness the power of iodine, which is insoluble, using povidone to capture the iodine in solution. Thus, it is formulated in various presentations today, concentrated for surface disinfection in hospitals, diluted as pre-surgical skin disinfectant or modified to remove unsafe constituents for further dilution and safe use in the mouth and nose, to address viral infection.

PVP-I has been licensed and approved by European and US regulators and is approved and still widely used across Asia as a virucidal agent for the mouth and nose against viral infection. It was part of Wuhan’s response to protect healthcare workers during the pandemic.

PVP-I, as pre-procedural mouthwash and nasal treatment in ENT (ear, nose and throat) and dental patients prior to procedure, has the largest safety record available. It has proven virucidal activity against SARS-CoV-2 in vitro, with additional safety data supporting its use, for up to 5 months in the oral and nasal mucosa. No other agent available today including Hydrogen Peroxide, Chlorhexidine, Hypochlorous solution, etc can match this profile in dental or ENT care.

This point is elegantly made by Dr Avinash Bidra, (BDS, MS, FACP), in the Journal of the American College of Prostadontists 2. Dr Bidra who practices at the

University of Connecticut Health Centre, published June 20th -

SARS-CoV-2 Viral Inactivation Using Low Dose Povidone-Iodine Oral Rinse—Immediate Application for the Prosthodontic Practice - doi: 10.1111/jopr.13207”

Dr Avinash suggests in addition to patient pre-procedural rinsing, that dentists and dental staff could also use the solution for added protection during the day with regular rinsing.

Despite this data and proven safety, PVP-I is not being used or recommended by the dental and ENT professional bodies, who provide guidance on best practice. This lack of guidance, awaiting definitive randomised trials to commence and report, has left confusion and uncertainty for front line staff.

When it comes to adopting sensible PPE strategies against a pandemic, we don’t have the luxury of waiting for "definitive proof" before we act. Healthcare workers are infected daily by patients who present with little obvious risk. Once infected, the implications can be serious, an illness with potential lifelong impacts, even causing death.

PVP-I, as an additional layer of PPE, could be prescribed by dentists and ENT surgeons for their patients as a pre-treatment rinse and nasal treatment to protect other patients and themselves. Gargling PVP-I and employing the same treatment in the nose before surgery is just plain common sense – it’s not rocket science to quote a cliché.

Dentists and Surgeons are well qualified to develop the correct protocols supporting informed patient consent, excluding such approaches in patients considered unsuitable. In choosing an agent approved for use in the mouth and nose and with strong in-vitro data against SARS-CoV-2, they could lead by asserting the importance of occupational safety in their clinics, for themselves and their patients.

The reluctance of the professions to run ahead of proven science may be understandable. Perhaps in-vitro activity may not confer in-vivo effect. However,

Povidone iodine is cheap and available and the benefits it likely confers far outweigh the very modest risks arising. It might be the difference in stopping viral transmission from an asymptomatic patient to a frontline care worker. This decision ultimately comes down to dental specialists and clinical leaders who operate on large numbers of patients each day to educate themselves on the compelling evidence for PVP-I. Ultimately, the lives they protect, could be their own.

We are at war with a virus. In wartime, we accept and understand the need to make sacrifices and to take unknown risks. Using PVP-I liquid in the mouth and nose as pre-treatment in patients undergoing dental and ENT procedures hardly seems to constitute much of either.

1.

2. “ SARS-CoV-2 Viral Inactivation Using Low Dose Povidone-Iodine Oral Rinse—Immediate Application for the Prosthodontic Practice - doi: 10.1111/jopr.13207” Bidra et al, June 2020.

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