Heinrich Wilhelm Gottfried von Waldeyer-Hartz, eponym of Waldeyer's tonsillar ring in the pharynx, considered “the first line of defense against exogenous aggressors”. Photograph: Wikipedia
Heinrich Wilhelm Gottfried von Waldeyer-Hartz, eponym of Waldeyer’s tonsillar ring in the pharynx, considered “the first line of defense against exogenous aggressors”. Photograph: Wikipedia

Additional thoughts regarding the benefit of throat disinfection during COVID-19-like epidemics

Discussing our sug­ges­tion for pre­ven­tive throat dis­in­fec­tion to counter the Coronavirus pan­dem­ic1 with col­leagues in the med­ical com­mu­ni­ty as well as in acad­e­mia has yield­ed pos­i­tive feed­back as well as objec­tions, and has led to addi­tion­al thoughts. And while in recent weeks we have been, and still are, focused on estab­lish­ing and com­pre­hend­ing as deeply as pos­si­ble the immuno­log­i­cal “big pic­ture” in viral epi­demics and beyond from so far only part­ly inter­con­nect­ed evi­dence in the spe­cial­ist lit­er­a­ture, in order to derive action­able rec­om­men­da­tions, we briefly sum­ma­rize below what has emerged with regard to our first arti­cle since it appeared.

Viral load and disease severity

There are strong indi­ca­tions that viral load in the throat cor­re­lates with dis­ease sever­i­ty in COVID-19.2 In addi­tion, it has been hypoth­e­sized for influen­za3 that dis­ease sever­i­ty cor­re­lates pos­i­tive­ly with the num­ber of con­tacts an infect­ed per­son has with oth­er infect­ed per­sons, put the oth­er way around, that sep­a­ra­tion from virus spread­ers helps in heal­ing. This seems to indi­cate that min­i­miz­ing viral load in gen­er­al should help in safe­ly con­quer­ing viral infec­tions of the res­pi­ra­to­ry tract. Viral load specif­i­cal­ly in the throat is set to mean virus that is still or again (after secre­tion from, or death and sub­se­quent dis­in­te­gra­tion of, infect­ed cells) out­side of body cells in which it can repli­cate and adverse­ly reg­u­late body func­tions.

Yet, as hypoth­e­sized by Professor Drosten of Charité Berlin, the ini­tial mas­sive repli­ca­tion of the nov­el Coronavirus in the throat, ensur­ing ear­ly sig­nif­i­cant expo­sure of the virus to Waldeyer’s4 ton­sil­lar ring – con­sid­ered “the first line of defense against exoge­nous aggres­sors”5 -, primes the immune sys­tem ear­ly in the course of the infec­tion such that it is bet­ter pre­pared should the infec­tion affect the lungs in a mean­ing­ful way. This may explain why, on a rel­a­tive basis, COVID-19 is far less dead­ly than was SARS 2003, where the virus was detectable in the throat only in about 30 % of cas­es dur­ing the first few days and in about 60 % of cas­es by the time the lungs were already mean­ing­ful­ly affect­ed,6 the lat­ter most pre­sum­ably because virus was trans­port­ed up to the throat with­in lung spu­tum.

These two points, tak­en togeth­er, should suf­fi­cient­ly explain why an objec­tion we have encoun­tered, also among col­leagues in the med­ical com­mu­ni­ty, along the lines that “once the virus has struck, and entered body cells, the dam­age is done, and employ­ing antivi­ral dis­in­fec­tants in the throat won’t help any­more,” appears mis­placed. If an infec­tion can­not be pre­vent­ed alto­geth­er, it can be ben­e­fi­cial that the virus is present to some extent in cells of a body area that is par­tic­u­lar­ly immuno­com­pe­tent, in order to intro­duce the immune sys­tem to the ene­my in a sig­nif­i­cant way as ear­ly as pos­si­ble and thus expe­dite devel­op­ment of the immune response, while at the same time destroy­ing most virus copies out­side of cells so that those copies can­not infect addi­tion­al cells in the throat and – most­ly via night­ly aspi­ra­tion of infect­ed mucus from the throat dur­ing sleep – even­tu­al­ly the lung.

We would again like to empha­size that evi­dence shows that the deep­er the sleep, the big­ger the risk of aspi­ra­tion of pha­ryn­geal mucus to the lungs.7 Since sleep in the first part of the night, the slow wave (“deep”) sleep phase, is deep­est, this is the most “dan­ger­ous” part of the night, so that much should be helped if the viral pop­u­la­tion present in the throat is destroyed imme­di­ate­ly before going to sleep.

And may we allow our­selves the com­ment that if a viral infec­tion is con­sid­ered, in response to our sug­ges­tion, as sim­ply an “intra­cel­lu­lar” prob­lem, then why try to devel­op vac­cines against COVID-19, when the result­ing anti­bod­ies bind to the virus (if, of course, not only in the throat) just as much exclu­sive­ly out­side of cells as the dis­in­fec­tant destroys it?

One for­mer fel­low stu­dent and now depart­ment head at Charité Berlin told us our sug­ges­tion would not work because the destroyed viral load would “be recre­at­ed with­in 20 min­utes”. Sifting through the lit­er­a­ture, we found no evi­dence sup­port­ing this claim yet sev­er­al indi­ca­tions from indus­tri­al virus pro­duc­tion set­tings that it should def­i­nite­ly take more than the time the slow wave sleep phase lasts to rebuild what the dis­in­fec­tant destroyed. The dis­tinct after­taste of gar­gling with hydro­gen per­ox­ide, even after rins­ing, may even sug­gest that some poten­tial­ly effec­tive rest of the gar­gling solu­tion will be present in the throat for some time dur­ing the ini­tial phase of the night.

While watch­ing the press con­fer­ence pre­sent­ing the Gangelt study by Professor Streeck and oth­ers8 we could not help but notice the log­i­cal incon­sis­ten­cy in the stance of pub­lic health offi­cials stat­ing that their pri­ma­ry aim was “to min­i­mize viral load” in order to reduce dis­ease sever­i­ty and addi­tion­al dead­ly out­comes from COVID-19, but then focus­ing entire­ly on advo­cat­ing sur­face dis­in­fec­tion, all the while Professor Streeck had already clear­ly stat­ed pub­licly9 (essen­tial­ly affirmed by essen­tial­ly every virol­o­gist we have read or heard) that even in very heav­i­ly infect­ed house­holds his team had nev­er been able to iso­late “liv­ing”, infec­tious virus from any sur­face they had tak­en swabs from. While at the same time the virus is clear­ly “liv­ing” in the throat as its ini­tial pri­ma­ry “dis­tri­b­u­tion cen­ter” from which it should be removed as much as fea­si­ble, in our view.

Countering pneumonia progression

Possibly the most impor­tant expan­sion to our thoughts (for which we thank Bruce L. Davidson MD, MPH, Seattle) regards the scope of the like­ly ben­e­fit from reg­u­lar throat dis­in­fec­tion dur­ing a viral epi­dem­ic. We sug­gest­ed doing this to min­i­mize lung involve­ment from an infec­tion, by pre­vent­ing that the virus enter the lungs in large quan­ti­ties via even­tu­al aspi­ra­tion of pha­ryn­geal mucus from the throat to the lungs.10

If one con­tem­plates the high­ly branched macro- (see the sketch above) as well as the micro-anato­my of the lungs, geared towards trans­port­ing every­thing for­eign back up towards the throat to then be either spit out or swal­lowed, and the radi­o­log­i­cal evi­dence of how pneu­mo­nia devel­ops in SARS-COV-like dis­ease, one can­not help but con­sid­er it high­ly like­ly that the ini­tial lung foci mul­ti­ply, at least in part and in ear­li­er stages, when virus present in those foci is trans­port­ed back up to the throat in lung spu­tum and then re-aspi­rat­ed to oth­er, pre­vi­ous­ly unaf­fect­ed parts of the lungs, poten­tial­ly depen­dent on sleep­ing posi­tion dur­ing the time of aspi­ra­tion.

Normally aspi­ra­tion of small amounts of infect­ed mucus dur­ing pneu­mo­nia does not mat­ter much because the patient is receiv­ing sys­temic antimi­cro­bial ther­a­py. But a pathogen spe­cif­ic for alve­o­lar cells (alve­o­lar type II11) and some low­er air­way cells with no effec­tive antimi­cro­bial ther­a­py (such as the nov­el Coronavirus) can, in the way described above, infect new areas and thus reduce the lungs’ oxy­gena­tion capac­i­ty in pre­vi­ous­ly unaf­fect­ed lung regions.

Disinfecting the throat dai­ly and pre­ven­tive­ly (because in rare cas­es lung involve­ment may occur even before the onset of rec­og­niz­able symp­toms) dur­ing viral epi­demics in the way we have sug­gest­ed may thus help not only in pneu­mo­nia pre­ven­tion, but also in coun­ter­ing its pro­gres­sion should one have devel­oped already.

Implication of other organs as an argument against the usefulness of throat disinfection

Finally, we encoun­tered the argu­ment that phe­nom­e­na such as loss of taste and smell, affec­tion of the gas­tro-intesti­nal tract, of the kid­neys and the heart have been report­ed, so that dis­in­fect­ing the throat would be essen­tial­ly use­less.

Loss of taste and smell hap­pen in the mouth and nose where the virus ini­tial­ly resides, and where our sug­ges­tion seeks to counter viral spread. The phe­nom­e­non is report­ed to be tran­sient, and no one dies of it.

The gas­tro-intesti­nal tract is affect­ed through swal­low­ing mucus, and low­er­ing the viral load this mucus car­ries is what our sug­ges­tion is about. In addi­tion, no one has been report­ed to have died of COVID-19-induced nau­sea or diar­rhea, and avoid­ing death from the infec­tion is all that is need­ed to con­quer COVID-19.

The kid­neys and the heart are affect­ed as a con­se­quence of sys­temic inflam­ma­tion result­ing from pneu­mo­nia, exact­ly the con­di­tion we want to pre­vent or at least ren­der less severe and non-lethal.

In sum­ma­ry, we believe it would be a good idea, also with a view to poten­tial future viral epi- and pan­demics, if the CDC and the WHO endorsed our sug­ges­tion so as to make it effec­tive on a glob­al scale.

The one objec­tion we could imag­ine is that the CDC and the WHO only dare endorse mea­sures that have been suc­cess­ful­ly test­ed in a clin­i­cal set­ting, even if com­mon sense and decades of expe­ri­ence in the den­tal are­na say that no risk worth men­tion­ing is asso­ci­at­ed with throat dis­in­fec­tion in the way we have described. Surprisingly, a clin­i­cal tri­al as to the effec­tive­ness of our sug­ges­tion has nev­er been con­duct­ed,12 despite a num­ber of cur­rent and espe­cial­ly retired med­ical prac­ti­tion­ers call­ing it “a good idea” and an “old-fash­ioned method”, imply­ing it has been prac­ticed before. We there­fore sug­gest it be clin­i­cal­ly test­ed in a large-scale clin­i­cal tri­al in dif­fer­ent age cohorts as soon as pos­si­ble.

_____
  1. https://loico.com/the-logic-of-surviving-the-coronavirus-pandemic/[]
  2. https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30232-2/fulltext[]
  3. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0011655[]
  4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5723023/[]
  5. https://www.ncbi.nlm.nih.gov/pubmed/11082757[]
  6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3322905/[]
  7. https://www.amjmed.com/article/0002-9343(78)90574-0/pdf[]
  8. https://www.youtube.com/watch?v=VnrHamW8OXQ[]
  9. https://www.youtube.com/watch?v=VP7La2bkOMo[]
  10. Some addi­tion­al evi­dence as to the extent such aspi­ra­tion hap­pens dur­ing sleep: https://pubmed.ncbi.nlm.nih.gov/9149581/; https://pubmed.ncbi.nlm.nih.gov/15179196/[]
  11. https://www.britannica.com/science/type-II-pneumocyte[]
  12. The study in Guangdong, PRC, that we have pre­vi­ous­ly referred to appears to have a dif­fer­ent objec­tive and to not even be active­ly recruit­ing at this time: http://www.chictr.org.cn/showprojen.aspx?proj=50660[]
Share on facebook
Share on twitter
Share on whatsapp
Share on pinterest
Share on vk
Share on linkedin
Share on xing
Share on google
Share on email
Share on print
After it has come to light that “Black Lives Matter” is a marxist – and blatantly racist – organization that could not care less about equal opportunity but that, according to rally signs exhibited by “activists”, simply wants to “kill” or “eat the rich”, now the climate change scare appears to be crumbling to pieces as well: It appears we now have the Edward Snowden of climate change alarmism.

This Post Has 4 Comments

  1. Elaine Camilleri

    AMEN . All that you have so intel­li­gent­ly and thought­ful­ly writ­ten makes so much sense. I can see the con­nec­tion very well because I am a speech pathol­o­gist and work with dys­pha­gia patients who are aspi­rat­ing espe­cial­ly post extu­ba­tion and we so reg­u­lar­ly stress oral care and hygiene with these patients. In fact we have a pro­gram called Frazier Water pro­to­col which requires thor­ough oral care every 2 hours for NPO patients before pt can have water or water and ice only in order to pre­vent aspi­ra­tion of oral micro organ­isms. So I can see how the high viral load of COVID in the oral cav­i­ty which is aspi­rat­ed when we sleep would be dis­as­trous. Since noth­ing is real­ly proven any­way at this time with this nov­el virus, why can­not you (as a doc­tor and sci­en­tist) reach out to pub­lic com­men­ta­tors in Europe and/or in the US? Tucker Carlson and Steve Hilton (Fox News) are two such good exam­ples here in the US. They are try­ing to help the coun­try but are offer­ing con­flict­ing and con­fused info about social dis­tanc­ing which is not fea­si­ble and incom­pat­i­ble with get­ting back to work and com­mu­ni­ty; sad­ly they offer no tan­gi­ble pre­ven­ta­tives except hand wash­ing and more test­ing. The only way to tack­le this is to reduce the sever­i­ty of it and reduce the trag­ic deaths it caus­es as you said. What can we do to get your valu­able info out there?

    1. loico

      Thank you very much for shar­ing your insight and your expe­ri­ence from an impor­tant front­line! As regards “get­ting the word out”, most of our enlarged per­son­al envi­ron­ment, and beyond that – judg­ing by the inter­est we see show­ing up in our pageview sta­tis­tics – pre­sum­ably at least sev­er­al thou­sand peo­ple world­wide are doing what we have sug­gest­ed. Family and friends are also pre­ven­tive­ly tak­ing a potent immune mod­u­la­tor, FDA approved for anoth­er indi­ca­tion, which we will very like­ly include in the planned arti­cle on the immuno­log­i­cal side of COVID-19-like crises. That said, it seems the WHO with its appar­ent­ly pop­u­lar and pow­er­ful yet part­ly mis­lead­ing “myth busters” has unnec­es­sar­i­ly cre­at­ed an envi­ron­ment of fear ver­sus non-WHO endorsed rec­om­men­da­tions. No one wants to “get caught” spread­ing “myths”, of course. As per your request, we have retweet­ed our arti­cle announce­ment to the two news anchors you named with the fol­low­ing text: “As request­ed by a read­er form­ing part of the med­ical com­mu­ni­ty, we com­mend this arti­cle and the one it expands upon to your val­ued atten­tion; what we have sug­gest­ed may help to save lung func­tions, lives and liveli­hoods. Thanks for shar­ing as you see fit.” We pro­mote our arti­cles to the lim­it­ed extent time cur­rent­ly per­mits, and we must at this point most­ly rely on our read­ers to spread the word via social media or oth­er con­tacts they may have. We can tell you that a promi­nent entre­pre­neur and reg­u­lar author with a well-known online pub­li­ca­tion, who him­self does, togeth­er with his fam­i­ly, what we have sug­gest­ed, has not been able to con­vince the med­ical doc­tor respon­si­ble for med­ical con­tent at said pub­li­ca­tion to pick up our sug­ges­tion, sim­ply because this col­league would not trust his own log­i­cal judge­ment over WHO “author­i­ty”. All the while he express­ly acknowl­edged that what we say was “plau­si­ble”. – What loico is fun­da­men­tal­ly about is a new (and at the same time actu­al­ly very old) par­a­digm in sci­ence, for­mu­lat­ed, among oth­ers, by Albert Einstein: “It is your the­o­ry that deter­mines what you can observe, not the oth­er way around.” People are con­di­tioned to rely on “facts”, not log­ic. It will take time for minds to open up to log­ic being a legit­i­mate extrac­tor of knowl­edge from dis­persed pieces of infor­ma­tion once again. So again, in case you have a minute left of your day, shar­ing your views as a med­ical pro­fes­sion­al – and poten­tial­ly our arti­cles – might help.

  2. Steffen

    It sounds plau­si­ble — would be great to test this in ani­mal mod­els…!?
    I am not sure if you can make ani­mals gar­gle for a minute how­ev­er.

    This could bridge the gap between in-vit­ro tests and humans. There might be reser­va­tions to test it in humans (argu­ment could be, e.g. by gar­gling you active­ly pro­mote virus pro­gres­sion to oth­er body areas – not that it would make too much sense, but, you know, test it but then you might have for­got­ten some­thing, and make things worse)

    I guess this would be anoth­er ani­mal test­ing set, mean­ing pro­fes­sion­al set­ting + fund­ings need­ed

    1. loico

      We agree: ” … not that it would make too much sense … ” 😉

      Since what we have pro­posed is known to be essen­tial­ly harm­less, there appears to be lit­tle need for ani­mal mod­els, and indeed a clin­i­cal tri­al test­ing it in humans is now under­way (see today’s “Update”).

Leave a comment / join the discussion