In this article, we suggest what we consider, in large part potentially instead of drastic quarantine for basically everyone, to be the most logical and most promising approach to surviving the Coronavirus pandemic, both on an individual and on a systemic level. We draw conclusions from information uncovered and discussed by the medical scientific community and by medical practitioners, and give practical instructions on what to do.
We will start with the core points and leave contextual elaboration of our views to the latter part of this as well as to subsequent articles.
The one question that really matters
It is widely estimated that around 70 % of the respective population will eventually be infected by the Coronavirus. While the majority of infections appears to result benign, a large number of those infected require hospitalization, close to 10 percent can currently be estimated to require intensive care, and between 1 and 3 percent to die. It has by now become apparent that not just older people with serious comorbidity are at risk of serious health problems or even death from a Coronavirus infection, and we personally are aware of the case of a 40 year old healthy man very quickly needing intensive care after catching the virus (he likely became infected in the hospital where he had work assignments as a craftsman, and continued to work there while already having fever; he has since died in the hospital’s ICU). Measures against the spread of the virus as drastic as those purportedly employed in the People’s Republic of China, though purportedly successful, can not be expected to be employed in the exact same way in the rest of the world. The one and only question that matters, therefore, for both the individual and the entire health care system which risks to become overwhelmed by a steady inflow of new patients, is not so much how to avoid an infection but how to radically minimize its diverse consequences. The one question that matters is how to avoid needing hospitalization and particularly intensive care, and ultimately how to avoid to die of Coronavirus-induced pneumonia.
The logical answer
Diverse hints helpful at attempting to craft a confident answer to this question have been mentioned, often in passing, in media appearances as well as in media and scientific publications by members of the medical scientific community, and we will seek to put them into their systematic context while elaborating more deeply on the core point.
The two crucial dots needing to be connected were provided by Professors Dr. Christian Drosten, Charité Berlin, and Dr. Clemens Martin Wendtner, Ludwig-Maximilians-Universität München, as well as by the pulmonologist Bruce L. Davidson MD, MPH, Seattle, respectively.
Professors Drosten and Wendtner, for their part, observed that for the first 5 days after the occurrence of symptoms the virus replicates massively in the throat, much unlike the SARS virus of 2003 was observed to be doing, and that this massive replication was already declining when measurements began (implying that from a certain point onwards, in line with Professor Drosten’s observations, pharyngeal swabs will often result in false negative testing results). They also found a newly mutated variant of the virus which was first only detected in the throat and a few days later also massively replicating in the lung. Symptom onset, in case an infected person does not remain asymptomatic, has since been estimated to occur around 5 days into the course of an infection, around the time the viral population in the throat peaks. Around this time, an infection often starts affecting the lungs. If lung involvement remains mild, it will start to reverse after a few days; if it results in pneumonia, the latter will either heal up within one to two weeks or progress rapidly to severe disease.
Combined, these findings signify that, in the case of a Coronavirus infection, people can be expected to eventually aspirate fluids with large viral loads from their throats into their lungs, eventually overwhelming the body’s protective mechanisms. Importantly, this can happen, according to the data provided by Professors Drosten and Wendtner, even before the infected experience significant recognizable symptoms.
Adding to this the immunological commonplace that a successful immune response to a pathogenic attack is in large part a question of quantity – simply put: how many pathogens collide with how many immune cells – the logical conclusion to be drawn is that in order to avoid falling seriously ill from a Coronavirus infection, if not to avoid what can be called an infection at all (pathogens are present in the throat at all times, but normally in manageable quantities), the (potential) viral population in the throat must be actively minimized by all suitable means at our disposal. This means preventing the virus from populating the throat in significant quantities in the first place, and radically suppressing any virus population that may have developed in the throat by regularly employing disinfectants with known significant antiviral capabilities against the novel Coronavirus, and which are safe to use in the throat. This should, in most cases, ensure that we can safely bridge the time span the immune system requires to ultimately gain the upper hand against the virus and provide us with long term immunity.
While this appears to primarily help the individual to win his personal battle against the Coronavirus, it at once helps winning the war in general. Since evidence at least indirectly suggests that infections predominantly occur via microscopic fluid drops transmitted from an infected person over the air, through speaking and coughing, a drastically suppressed viral load in the throats of infected people, whether they show symptoms or not, reduces the risk of virus transmission, slowing and eventually even halting its spread.
In this article, we will address the issue in these quantitative and practical aspects. In a follow-up article we plan to address the question of who is especially vulnerable and should therefore observe (in part potentially with help from others) the precautionary measures of contact avoidance as well as minimization of the viral load in the throat with extreme rigor, and who is rather unlikely to develop severe disease.
What to do
Of course: avoid exposure, especially via inhalation, and wash your hands. But, as mentioned, you can and should seriously consider to do more:
Gargle with hydrogen peroxide at a concentration of 1 % for 60 seconds (in case this seems long to do in one go, consider that you can do 4 times 15 seconds or 6 times 10 seconds). Do not swallow the solution, but spit it out after gargling.
One to a maximum of four times a day. The most important – and normally only – time to do it is before going to sleep to minimize the viral load that may be aspirated into the lungs during sleep.
When? In what circumstances?
- Once a day before going to bed as a preventive measure, even if you do not expect to have been infected yet.
- Since you may be infected even without experiencing symptoms, you should do it before an unavoidable interaction with vulnerable persons, before visiting a doctor’s office or possibly to prevent transmission generally if you have to go out, but not more than 4 times a day and not in case your mucosa in the mouth feels irritated or burning. DO NOT DISREGARD THE SOCIAL DISTANCING MEASURES WHILE THEY ARE STILL IN FORCE. What we suggest here is an additional safety measure in and after situations where you cannot avoid contact with others, primarily the especially vulnerable.
- Of course, in order to diminish the risk of getting infected yourself, you should equally do it as soon as possible after coming in contact with many different people or with people who are infected or show any signs of possibly being infected.
- If you have symptoms or are tested positively, do it to minimize viral load, but not more often than four times a day.
Generally everyone, but not children, even if you suppose they could be exceptionally vulnerable (which typically they are the least to be), and not if you cannot coordinate gargling without swallowing the mouthwash.
Be careful and always use the right concentration. Probably you will find the hydrogen peroxide in a 3 % or 6 % concentration. Dilute it with water to arrive at 1% (case 3% combine one part hydrogen peroxide with two parts water, case 6% combine one part with 5 parts water). If the mucosa does feel significantly irritated, you could further dilute it to 0.5 % (combine 1 part 1 % solution and 1 part water). In case you choose to use another substance, follow the respective instructions, never suppose that more works better! The Chinese lady who purportedly ate 1.5 kg of garlic seriously damaged her body.
- Dr. Davidson advises to “wash your hands and face well with soap and warm water, including — on a finger — a quarter-inch into each nostril. Then gently blow your nose. DON’T use those irrigating devices, like neti pots, that might force virus further inside! Brush your teeth and tongue, swish and spit, and gargle once or twice with an antiseptic mouthwash. Limit sedation before sleep during an epidemic [alcohol, sleeping pills].” (The “don’t use irrigating devices” supposes that you have just caught the virus and it is still in your nostril and you don’t want to do anything to bring the virus from there to the place where it best can replicate, the deep throat; apply this thought to your own situation.)
- Regarding the mouthwash, which Dr. Davidson does not specify (this could mean that in his view an OTC drug store mouthwash labelled “antiseptic” is sufficient if you clean the mouth as he proposes), measure a small mouthful of the diluted solution (ca. 10-20 ml), take it into your mouth and tilt your head back. Gargle and swish the mixture around in your mouth for 60 seconds.
- Spit the solution out after gargling.
- If used appropriately in the proposed concentration, major side effects are rare, even when swallowed, but redness and irritation of the gums can happen yet should go away after a few hours. Do not use it again on irritated mucosa. In the improbable case that this becomes a major problem, limit it mainly to the throat or switch to another substance.
To facilitate a somewhat deeper contextual understanding of what we suggest, in the remaining part of this article we will provide some additional as well as more detailed information on
- why washing and disinfecting the mouth can prevent pneumonia and why to do it especially before going to bed,
- which other mouthwash options exist and what viral reductions you can expect,
- what else you could do to minimize viral load in the throat.
Why washing and disinfecting the mouth can prevent pneumonia and why to do it especially before going to bed
Dr. Davidson points to a finding that probably all normal people will have aspirated throat content by the end of a given week and that this is the way pneumonia usually develops. (There are many studies demonstrating successful prevention of pneumonia by using mouthwash in the ICU setting.)
Chances of aspiration of bigger amounts are even higher if the sleep is deeper, such as after taking a sleeping pill or a couple of beers or shots, or in older people who have swallowing coordination problems, or in the case of lung damage due to smoking.
All of which is why, in addition to thoroughly washing one’s hands, face and nostrils with warm water and soap, brushing one’s teeth and tongue, swishing and spitting, Dr. Davidson recommends to gargle once or twice with an antiseptic mouthwash.
What other mouthwash options are there and what viral reductions can you expect
But what mouthwash? Any mouthwash with the label ‘antiseptic’?
We are obviously looking for an antiseptic mouthwash that is known or at least logically likely to be effective against the novel Coronavirus, and that, importantly, is not known to do any harm.
What mouthwash is effective against the Coronavirus?
Of the substances that Kampf et al. report to be effective against the novel Coronavirus, the following except ethanol are used during dental procedures or to prevent pneumonia during a stay at the intensive care unit, they have been used for many decades also at home, are readily available and seem sufficiently safe:
Hydrogen peroxide, min. 60 % ethanol and povidone iodine are very effective,
Chlorhexidine is reported to be less effective, but for the respective study a much smaller dose was used than the usual one which had already been shown to be effective against coated viruses such as the Coronavirus.
Are the proposed antiseptics able to prevent the Coronavirus from populating the throat in significant quantities?
Hydrogen peroxide 0,5 %, min. 60 % ethanol and povidone iodine can all reduce a Coronavirus strain after 1 minute by more than 4 orders of magnitude (Kampf et al.).
This means that the average virus RNA load per swab measured by Professors Drosten and Wendtner during the first 5 days of 6.76×10^5 (maximum: 7.11X10^8 copies/swab) would be reduced to 70 copies (resp. 70000 maximum). Interestingly, they found that virus isolation success also depended on viral load: samples containing <10^6 copies/ml never yielded a “living” infectious virus.
This means that after a mouthrinse/gargle, viral transmission as well as aspiration of infectious material to one’s own lungs can be expected to be drastically minimized.
- Hydrogen peroxide. The effective concentration of 0,5 % is relatively small, 1 % is common for a medical gargle solution to be used up to 3 times a day. Generally, it does not pose any longterm risk, but of course it can be harmful if not used appropriately, in order to not harm good oral bacteria avoid using it more than once a day for a longer duration.
- Povidone iodine is regarded as a good option but can be harmful if one has thyroid problems or an allergy against it.
- 60 % ethanol is not used in clinical settings/trials as a mouthwash, one would probably have to mix it by combining alcohol in high concentration with pure (96%) ethanol. I tried it myself so see how it feels (burning!), after a friend of mine, a doctor and department head in a German hospital, told me that she had told her parents, living in an eastern European country where antiseptics were soon out of supply, to use their self-burnt vodka having a 60 % concentration for hand disinfection and taking a good swallow of it in the mouth when unsure about potential infectious contacts, especially when having to leave their home. Interestingly, the idea of mouth disinfection was perfectly natural to her just from her clinical understanding of a viral pneumonia and the Coronavirus, just as every single other medical practitioner I have so far spoken to said that this was a good idea. Interestingly, also, my friend, having advised her parents on mouth disinfection, did not apply it to herself, telling me: “I would not know how often to do it during the day as I am exposed to infected patients all the time; I just have to somehow get through it.” It is, of course, better to do it four times a day than not at all, and it should not be necessary at all to to it after every single patient contact.
- Another substance used as a gargle during dental procedures and to prevent pneumonia in a hospital setting is chlorhexidine in a concentration of 0,12 percent. In this concentration it seems to generally have a good killing activity against coated viruses but was only tested against corona viruses in a concentration of 0.02 percent and in this concentration found to be less effective.
- There is also evidence that the Listerine antiseptic, a common mouthwash, probably has antiviral activity against coated RNA viruses (such as the novel Coronavirus which was not tested specifically). So before doing nothing, this may be an alternative (and possibly congruent to Dr. Davidson’s unspecific protocol).
In summary, we suggest to use 1 % hydrogen peroxide. Interestingly, such a rinse is a recent “common sense recommendation” by a dentists’ association to request of patients before each appointment in order to prevent Coronavirus transmission (if you follow the link above, under “Coronavirus Frequently Asked Questions” click on “Questions regarding coronavirus, the virus which causes COVID-19”; the recommendation we cite is the second to last and has since been updated to read “1,5 %” instead of “1 %”).
What we do additionally
We personally do take small nuggets of very dark chocolate (90 % cocoa) in our mouths, place them between our teeth and our cheeks and just let them melt there, without actively swallowing the melted chocolate, to let it cover the mucosa, helping to counter the continuous viral attacks originating from our small children. This was discussed by medical doctors (who had tried it on themselves) in a professional online discussion board as being successful in combating a running nose and coughing. According to our experience, it helps best (and probably only) at the onset of the very first symptoms of a throat infection (sore throat).
Based on new scientific data (the virus replicates massively in the throat before and during the first 5 days after symptoms appear; there is viral leak from the throat into the lung) as well as the long-established understanding of how pneumonia, the severe COVID 19 complication, initiates (via aspiration), in order to both individually as well as systemically minimize the Coronavirus impact, we propose dedicated throat disinfection as described in this article as a preventative as well as a treatment measure. Prevention of pneumonia and prevention of viral disease transmission by disinfection of the mouth with antiseptic solutions are common practice and regarded by medical practitioners as a “common sense recommendation” (again, if you follow the link, under “Coronavirus Frequently Asked Questions” click on “Questions regarding coronavirus, the virus which causes COVID-19”; the recommendation we cite is the second to last and has since been updated to read “1,5 %” instead of “1 %”).
Van Doremalen et al. conclude in a paper published today, March 17, 2020, in the NEJM (Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1), DOI: 10.1056/NEJMc2004973:
“We found that the stability of SARS-CoV-2 was similar to that of SARS-CoV-1 under the experimental circumstances tested. This indicates that differences in the epidemiologic characteristics [higher transmission of SARS-CoV-2] of these viruses probably arise from other factors, including high viral loads in the upper respiratory tract and the potential for persons infected with SARS-CoV-2 to shed and transmit the virus while asymptomatic.”
This confirms that it appears highly advisable that everyone seek to substantially reduce the (potential or actual) high viral load in his throat on a regular basis in the way described above.
Xi He et al. report on an extensive study conducted in Hong Kong, posted to doi.org on March 18, 2020 and since updated (“Temporal dynamics in viral shedding and transmissibility of COVID-19”), doi: https://doi.org/10.1101/2020.03.15.20036707:
“We report temporal patterns of viral shedding in 94 laboratory-confirmed COVID-19 patients and modelled COVID-19 infectiousness profile from a separate sample of 77 infector-infectee transmission pairs. We observed the highest viral load in throat swabs at the time of symptom onset, and inferred that infectiousness peaked on or before symptom onset. We estimated that 44% of transmission could occur before first symptoms of the index.”
This further confirms that the initial and therefore primary battlefield in the case of COVID-19, unlike with SARS 2003, is the throat, with the infection moving further down into the lung – eventually causing pulmonary inflammation – only at a later stage.
So again, preventively disinfecting the throat in the way we describe above should mostly resolve the problem as it (1.) slows the development of a possible infection, if not suppressing it outright, to the point where the immune system is given the necessary time to develop a sustained response; and (2.) drastically reduces infectiousness.
It has come to our attention that one clinical trial presumably testing what we have proposed in our article is reported to have been registered with the World Health Organization. The “Type of medicine” is specified as “Hydrogen peroxide”, and the hypothesized “mechanism of action” is specified as “Non-specific supposed antiviral action in the throat”.
We have now established that the trial referred to in Update 3 is being conducted in Guangdong, People’s Republic of China.
The trial design appears to provide that only patients who have already developed pneumonia are included in the study. Instead of focusing on combating COVID-19 induced pneumonia, however, the study’s stated intent is only “to determine whether the novel coronavirus exists in the oral environment, and discuss the transmission route of the virus and the influence of oral gargle on the virus, to provide reference for the early diagnosis of COVID-19 and the prevention and control of infection during the clinical diagnosis and treatment of oral cavity.”
We insist that decisive emphasis should be put on employing gargling with a solution of hydrogen peroxide as a preventive measure, or at least as early as possible in the course of an infection. Once pneumonia has developed in the absence of such prevention, a regular gargle in the way we have described in detail in this article should still help prevent the soiling of additional lung regions or reinfection, alleviating disease and winning potentially decisive time for the immune system to develop its response.
The conclusion that the authors of the study conducted in Hong Kong (see update 2) have drawn from their findings regarding probable presymptomatic transmission of the virus have been further corroborated by a study done in Singapore.