Prevention and Early Treatment of COVID-19 Essay
The covid19 pandemic is one of the health problems that have affected millions of people globally since its discovery in 2019. Covid19 is a viral infection that mainly affects the respiratory system. Its mode of transmission is through contact with infected droplets. All populations are increasingly predisposed to the infection. Nurses and other healthcare providers comprise the most vulnerable population since they work with patients suspected of suffering from covid19 (Yuki et al., 2020). Since its discovery, several interventions have been explored to prevent covid19 and facilitate faster recovery of patients affected by the disease. One of the interventions is the use of mouthwashes and nasal sprays to prevent and initiation of early treatment of covid19 (Burton et al., 2020). Despite its widespread use in hospitals and by populations, there is scarce evidence on its efficacy in preventing covid19 and enhancing outcomes in its early treatment. Therefore, the purpose of this paper is to review the literature on the efficacy of mouthwashes and nasal spray interventions in the prevention and early treatment of covi19. The paper also explores the pathophysiology of covid19, which may affect viral susceptibility to nasal sprays and mouthwashes. It also explores the literature on the topic and its effect on clinical practice.
Covid19 is a viral disease that affects the respiratory system that was first discovered in Wuhan, China in 2019. The infection started as a zoonotic transmission and was later discovered to involve human transmission in its global presence. Covid19 primarily targets the respiratory system and can involve other organ systems. Patients develop symptoms that include dyspnea, dry cough, headache, dizziness, diarrhea, vomiting, and general body weakness. The mortality rate due to covid19 is high, with increased risks seen in elderly patients and individuals suffering from comorbid conditions such as diabetes and heart disease among others. Countries implemented interventions that include social distancing, lockdowns, and immunization of the public to minimize the spread of the infection in the public.
Pathophysiology of Covid19
Covid19 virus gains its entry to the host through direct contact with infected media, including saliva when one coughs. The virus enters the host through membrane fusion or endocytosis and attaches to host receptors (Grasselli et al., 2020). The virus then releases viral contents when inside the host cells where entry of viral RNA into the nucleus occurs for replication. The viral mRNA makes new viral proteins via biosynthesis, to increase the viral load in the host. The coronavirus is a spike protein, with cleavage and self-activate (Yuki et al., 2020). The host develops response mechanisms following viral entry, replication, and invasion. They develop symptoms that range from mild to severe respiratory failure that involved multiple organ failures. The responses include increased expression of angiotensin-converting enzyme 2 in the lungs, which enhances the possibility of viral destruction of alveolar macrophages, epithelial cells, and dendritic cells. There is also the activation of T-cell mediated responses that act through macrophages and direct cells (Kumar & Al Khodor, 2020). The consequence of these responses includes patients developing symptoms that include coughing, fever, shortness of breath, pneumonia, severe acute respiratory syndrome, multiple organ failure, and even death (Dhont et al., 2020; Grasselli et al., 2020).
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Susceptibility of Covid19 Virus to Nasal Sprays and Mouthwashes
Prevention and timely treatment of covid19 is crucial to minimizing the risk of complications and mortalities. Nasal sprays and mouthwashes have been considered effective in preventing covid19 and used in the early treatment of the disease. Their use relies mainly on the mechanism of infection by covid19 and the action of the chemicals used for nasal spray and mouthwashes (Cegolon et al., 2020). Covid19 has a high affinity to cells of the respiratory system, cornea, and intestines due to the increased expression of receptors that include angiotensin-converting enzyme 2, which enhances viral entry. The use of mouthwashes and nasal sprays reduces viral entry into these target cells and organs, reducing the overall viral load (Arefin, 2021). Mouthwashes and nasal sprays also provide the desired prophylaxis for increased risk of exposure in treatments such as dental care and endotracheal intubations (Burton et al., 2020).
Several products have been considered for use as nasal sprays and mouthwashes to prevent covid19 and early treatment of the infection. One of them is Povidone iodine (PVP-I), an antimicrobial agent that acts by penetrating and oxidizing the nuclear structures of the covid19 virus (Arefin, 2021). Studies show that exposure of PVP-I to the covid19 virus for 2 minutes reduces its infectivity to undetectable levels. The use of 1% concentration of PVP-I for 30 seconds on the covid19 virus also reduces its viral charge, hence, lowering the infectivity rate (Santos-López et al., 2020).
The other agent used as nasal spray and mouthwash to prevent and treat covid19 is Cyclodextrins. Cyclodextrins are glucose natural derivatives that have high biocompatibility and simplicity in use (Carrouel et al., 2020). It produces its effect when used in preventing covid19 and its early stages of treatment by attracting the virus to inactivate it irreversibly and alter its outer membranes (Santos-López et al., 2020). It also destroys infected particles when it is exposed to them. Hydrogen peroxide mouthwashes also demonstrate effectiveness in the prevention and early treatment of covid19. It works by oxidizing the cell structures of the covid19 virus, which damages its interior composition as well as the cell wall (Ortega et al., 2020). The safe concentration of hydrogen peroxide for use as mouthwash is 3% in 10 volumes, three times a day, and nebulizer for nasal spray twice a day (Santos-López et al., 2020).
Studies have been conducted to determine the efficacy of nasal sprays and mouthwashes in preventing cvid19 and use in early treatment. One of these studies is the research by Guenezan et al., (2021). The study by Guenezan et al., (2021) was a randomized controlled trial that investigated if the application of nasal Povidone iodine could reduce viral load in patients suffering from non-severe covid19 symptoms. The study used adult outpatients diagnosed with covid19. The intervention in the study entailed the participants using four successful mouthwashes and gargles with 25 ml of 1% of aqueous Povidone iodine solution followed by one 2.5 ml of nasal pulverization into each nostril using an automatic intranasal delivery device. The participants in the intervention were group were also required to massage the nostril after the administration of the Povidone iodine solution to facilitate the spread of the ointment. Participants were trained and offered materials and guidance to enable them to perform the intervention four times a day for five days. Follow-up was done over one week to determine efficacy and decolonization safety. Nasopharyngeal swabs were taken for use in quantifying viral RNA using RT-PCR. A linear mixed model for repeated measures was used to compare the changes in viral load over time in the study groups.
The results of the study by Guenezan et al., (2021) demonstrated that the use of Povidone iodine did not have any influence on the changes in the quantity of viral RNA over time. Patients also reported unpleasant nasal tingling but completed the study. There was also an elevation of thyroid-stimulating hormone in all patients after five days of using Povidone iodine, with a return to baseline after 7-12 days. Therefore, the authors concluded that despite Povidone iodine being effective in facilitating nasopharyngeal decolonization, it has the risk of causing thyroid dysfunction. Larger clinical trials should be conducted to confirm the efficacy and benefits of Povidone iodine in covid19.
da Silva Santos et al., (2021) conducted another randomized controlled study that investigated the beneficial effects of using a mouthwash that contained antiviral phthalocyanine derivative on the hospital stay duration for covid19 patients. The study was a two-arm and triple-blind randomized controlled investigation performed on 41 hospitalized patients who were diagnosed with covid19. All the participants received the standard guidelines of the World Health Organization for treatment and prevention of covid19 using mouthwash or non-active mouthwash. The participants in the control group received the usual care plus adjunct mouthwash that encompassed one-minute mouth rinsing or gargling five times a day until the period of discharge. Data analysis revealed that the use of a mouthwash containing an anionic phthalocyanine derivative was highly effective in reducing covid19 viral load, shortening hospital stay, and severity of covid19 symptoms. Therefore, the authors recommended the use of anionic phthalocyanine derivative mouthwash as an adjunct intervention to improve treatment outcomes in covid19 patients.
Moskowitz and Mendenhall (2020) conducted another in vitro study to evaluate and compare the efficacy as well as cytotoxicity of four different mouthwashes. The mouthwashes included 1.5% hydrogen peroxide, 0.12% chlorhexidine, 0.2% povidone, and 100-ppm molecular iodine. The focus was on the ability of the mouthwashes to inactive severe acute respiratory syndrome coronavirus 2 (covid19). The researchers inoculated covid19 virus stocks at room temperature for use in testing the efficacy and cytotoxicity of the mouthwashes. Data analysis showed that 100-ppm molecular iodine had the greatest long-reduction value at every exposure time compared to other oral rinses. The mouthwashes also did not demonstrate any cytotoxicity. The use of 100-ppm molecular iodine showed a long-reduction value of 2.6 at 15 seconds and the entire inactivation of covid19 virus at 30 and 60 seconds. Therefore, the authors recommended 100-ppm molecular iodine for use in preventing the spread of the covid19 virus.
Gandhi et al., (2022) also conducted a systematic review on in vivo studies to determine the effectiveness of mouth rinses as adjuvant treatments in covid19 patients. The authors performed a literature search on databases that included Google Scholar, PubMed-MEDLINE, Scopus, EMBASE, ProQuest, Web of Science, and CINAHL. The analysis of data obtained from 12 articles that met the inclusion criteria showed that mouthwashes containing chlorhexidine and povidone iodine were effective in transiently reducing covid19 viral load.
The selected studies for this literature review have some strengths that increase the reliability and validity of their findings. For instance, the study by Gandhi et al., (2022) is a systematic review of in vivo randomized controlled trials that examined the efficacy of mouth rinses in covid19. The study provides level I evidence, which can be applied in clinical settings to inform practice. The study by Moskowitz and Mendenhall (2020) is associated with the strength of being an in vitro study that compared the effectiveness of four mouthwashes that are largely used in practice. The study provides level II evidence that can be used to guide clinical practice. The study also provided results obtained in a controlled environment that can mimic the actual outcomes when mouthwashes are used in patient care. The studies by da Silva Santos et al., (2021) and Guenezan et al., (2021) have the strengths of randomizing study participants to enhance the validity and reliability of outcomes. Randomization enhances the generalizability of findings. The studies provide level II evidence that can be translated into clinical practice.
The selected studies for the review share some similarities. Accordingly, da Silva Santos et al., (2021) and Guenezan et al., (2021) adopted closely related approaches to randomizing participants to either control or intervention groups. However, they differ based on the fact that the study by da Silva Santos et al., (2021) was a two-arm and triple-blind randomized controlled investigation while that of Guenezan et al., (2021) was a one-arm randomized controlled trial. The studies by Gandhi et al., (2022) and Moskowitz & Mendenhall (2020) share the similarity that they did not focus on human subjects. The study by Moskowitz and Mendenhall (2020) was an in vitro investigation while that by Gandhi et al., (2022) was a systematic review of in vivo studies. The selected studies have weaknesses that threaten the reliability and validity of their reported findings. The studies by da Silva Santos et al., (2021), Gandhi et al., (2022), and Guenezan et al., (2021) have the weakness of using small sample sizes. The findings cannot be generalized to a larger population. The study by Moskowitz and Mendenhall (2020) has the weakness of being a laboratory investigation, which has conditions that may not reflect patients’ experiences. Therefore, replication of the laboratory conditions may be a challenge in practice.
Informing Clinical Practice
The above literature review informs clinical practice in some ways. First, the results of the literature review demonstrate the effectiveness of nasal sprays and mouthwashes in reducing covid19 viral load. The reduction in viral load results in positive treatment outcomes that include a reduction in hospital stay, severity of symptoms, and mortality rates. The findings of the literature review also show that nasal sprays and mouthwashes could prevent the spread of covid19. The antimicrobial effect of the nasal sprays and mouthwashes reduces the infectivity rate of covid19. As a result, they can be incorporated into the clinical practices utilized in the prevention of disease transmission in hospital settings. The last way in which the findings inform clinical practice is the fact that they point to the need for large randomized studies to determine the efficacy of nasal sprays and mouthwashes. The study by Guenezan et al., (2021) demonstrated that povidone iodine has thyroid toxicity for some patients. However, the authors agree with those in the selected studies that the findings should not be relied on in their entirety due to the use of small sample sizes.
Overall, nasal sprays and mouthwashes have a positive effect on preventing covid19 spread and use in the early stages of covid19 treatment. Nasal sprays and mouthwashes have an antimicrobial activity that inactivates, destroys, and reduces the infectivity of the covid19 virus. Povidone iodine, 100-ppm molecular iodine, and mouthwash containing antiviral phthalocyanine derivatives have enhanced effectiveness against covid19. However, povidone iodine may be associated with thyroid toxicity. The current evidence on the efficacy of nasal sprays and mouthwashes has been obtained from studies conducted using small sample sizes. Therefore, large randomized controlled studies should be conducted to inform practice.
Arefin, M. K. (2021). Povidone Iodine (PVP-I) Oro-Nasal Spray: An Effective Shield for COVID-19 Protection for Health Care Worker (HCW), for all. Indian Journal of Otolaryngology and Head & Neck Surgery. https://doi.org/10.1007/s12070-021-02525-9
Burton, M. J., Clarkson, J. E., Goulao, B., Glenny, A.-M., McBain, A. J., Schilder, A. G., Webster, K. E., & Worthington, H. V. (2020). Antimicrobial mouthwashes (gargling) and nasal sprays to protect healthcare workers when undertaking aerosol‐generating procedures (AGPs) on patients without suspected or confirmed COVID‐19 infection. The Cochrane Database of Systematic Reviews, 2020(9), CD013628. https://doi.org/10.1002/14651858.CD013628.pub2
Carrouel, F., Conte, M. P., Fisher, J., Gonçalves, L. S., Dussart, C., Llodra, J. C., & Bourgeois, D. (2020). COVID-19: A Recommendation to Examine the Effect of Mouthrinses with β-Cyclodextrin Combined with Citrox in Preventing Infection and Progression. Journal of Clinical Medicine, 9(4), 1126. https://doi.org/10.3390/jcm9041126
Cegolon, L., Javanbakht, M., & Mastrangelo, G. (2020). Nasal disinfection for the prevention and control of COVID-19: A scoping review on potential chemo-preventive agents. International Journal of Hygiene and Environmental Health, 230, 113605. https://doi.org/10.1016/j.ijheh.2020.113605
da Silva Santos, P. S., da Fonseca Orcina, B., Machado, R. R. G., Vilhena, F. V., da Costa Alves, L. M., Zangrando, M. S. R., de Oliveira, R. C., Soares, M. Q. S., Simão, A. N. C., Pietro, E. C. I. N., Kuroda, J. P. G., de Almeida Benjamim, I. A., Araujo, D. B., Toma, S. H., Flor, L., Araki, K., & Durigon, E. L. (2021). Beneficial effects of a mouthwash containing an antiviral phthalocyanine derivative on the length of hospital stay for COVID-19: Randomised trial. Scientific Reports, 11(1), 19937. https://doi.org/10.1038/s41598-021-99013-5
Dhont, S., Derom, E., Van Braeckel, E., Depuydt, P., & Lambrecht, B. N. (2020). The pathophysiology of ‘happy’hypoxemia in COVID-19. Respiratory Research, 21(1), 1–9.
Gandhi, G., Thimmappa, L., Upadhya, N., & Carnelio, S. (2022). Could mouth rinses be an adjuvant in the treatment of SARS-CoV-2 patients? An appraisal with a systematic review. International Journal of Dental Hygiene, 20(1), 136–144. https://doi.org/10.1111/idh.12555
Grasselli, G., Tonetti, T., Protti, A., Langer, T., Girardis, M., Bellani, G., Laffey, J., Carrafiello, G., Carsana, L., & Rizzuto, C. (2020). Pathophysiology of COVID-19-associated acute respiratory distress syndrome: A multicentre prospective observational study. The Lancet Respiratory Medicine, 8(12), 1201–1208.
Guenezan, J., Garcia, M., Strasters, D., Jousselin, C., Lévêque, N., Frasca, D., & Mimoz, O. (2021). Povidone Iodine Mouthwash, Gargle, and Nasal Spray to Reduce Nasopharyngeal Viral Load in Patients With COVID-19: A Randomized Clinical Trial. JAMA Otolaryngology–Head & Neck Surgery, 147(4), 400–401. https://doi.org/10.1001/jamaoto.2020.5490
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The following assessment is designed to enable you to develop skills in writing a literature
review, which is not unlike an essay. The rubric on Moodle gives a clear indication of how
marks will be allocated. The skills learnt in Tutorials 1 & 2 and relevant lectures will be useful
when writing this paper, including appraising the literature, integrating the literature, and
critiquing research. The information that you provide in this paper should be supported by a
range of quality academic literature and referenced both intext and in the final Reference List
according to APA style (7th ed).
Write a literature review on the following topic:
Discuss the efficacy of mouthwashes and nasal spray interventions in the
prevention and early treatment of COVID-19.
When planning and writing your literature review you should include:
âž¢ An introduction that states the purpose of the review and major concepts to be
presented in your paper.
âž¢ A background that identifies the pathophysiology of COVID-19 which may impact viral
susceptibility to mouthwashes and nasal sprays (e.g., povidone-iodine, Listerine,
chlorhexidine, hydrogen peroxide) in the upper respiratory tract
âž¢ The body should include a critical review and comparison of 3-4 articles central to the
topic. You should highlight the selected studiesâ€™ main findings and comment on the
limitations and benefits of the research design and method according to the evidence
hierarchy. The strengths, weaknesses and bias of each study should be explored, along
with their similarities and differences. Finally, you will need to illustrate how the literature
informs clinical practice.
âž¢ The conclusion of your paper should introduce no new information but provide a
summary of the current knowledge of the topic.
Possible search terms for online databases include: coronavirus, COVID-19, povidone-iodine,
Betadine, Listerine, chlorhexidine, hydrogen peroxide, gargling, nasal, oral, virucidal,
prophylaxis, prevention, treatment.
Your literature review must:
âž¢ Be formatted according to the Avondale assignment template provided in Moodle.
âž¢ Use a minimum of 10 references published in the last 5 to 8 years.
âž¢ Only use references from reputable or clinical sources, i.e. journals. Some government
websites may be included. Textbooks are not permitted as secondary sources when
critiquing research papers.
âž¢ Be presented and referenced in accordance with APA style (7th ed)
âž¢ Be submitted through Turnitin on Moodle.