Swiss Cheese, Seaweed, the Small Big and COVID-19!
Updated: Jul 7
If this sounds more like a cooking recipe than a scientific finding, allow me to explain. When I heard about a potential new pandemic from a novel virus, my first thought was that we needed to be ready, especially if it was similar to SARS or MERS. As time passed, it became clear we weren’t ready at all. Certainly not ready for the number of healthcare workers infected and the numbers of patients with the virus who were dying. As a pharmacist with over 20 years hospital experience, I’ve always tried to stay up to date and research information so I can provide educated opinion to customers and colleagues. Having worked in healthcare for so long, I knew there is often limited information available early on in a crisis, but think tanks and global experts are easy now to access on-line. When I saw the main strategy for protection was inadequate (using physical distancing and wearing PPE), as healthcare workers were becoming infected, I thought about these two models of prevention. How might they be enhanced? I’m a fan of Steve Martins “The Small Big”. I was a long-time follower of the behavioural insights team in the UK as well as the “Nudge theory” and the “Swiss Cheese” model of risk reduction. I could see there might be something small I could do to prevent healthcare workers contracting SARS-CoV-2 from their patients. What if there was a way to add another layer of PPE? The swiss cheese model has a basic premise - to reduce risk, add more and different layers of risk reduction. Experts were pointing to aerosols as being a primary vector of infection in healthcare workers using PPE who were becoming infected. Once in the air, expelled in breathing by infected patients, it is incredibly easy to inhale viral infection. More worrying was the cited prevalence of asymptomatic spread by patients early in their infection and viral carriers who suffered no symptoms whatever, but nevertheless could easily infect those who came into close proximity of their breath, or surfaces on which their breath might have deposited virus. The answer therefore was to seek to inactivate the virus at source. With a vaccine this would be achieved systemically. However, without a vaccine, the most logical area to treat was the mouth and nose where viral aerosols must pass before being expelled into the air. Air leaving the lungs would naturally pick up viral material in the mouth and nose – limiting this reservoir became a legitimate target. Thinking as a pharmacist, I imagined there might exist an agent which could make the macro environment of the nasal and oral cavity hostile to an in-coming virus. In military terms, don’t let it get a “beach head”. On the 17th of March after extensive investigation, I hit upon Povidone Iodine (PVP-I). Povidone iodine is widely used as a constituent of industrial disinfectants in hospitals provided for topical application to surfaces and to skin before some surgical procedures. The industrial formulation however could not be considered due to the presence of phenols (potential carcinogens) and surfactants, used to generate surface tension in topical applications but not tested for human consumption and likely to be harmful to human health too. However, with my background I imagined if I could formulate an aqueous solution acceptable for use in the nose and mouth, this might hold great potential and could be key to an effective strategy to fight this virus before it got a foot hold in the nasal or oral cavity, or to reduce viral load in expelled aerosols from infected patients. First, I needed to assess if the base hypothesis was reasonable? So, I started digging through the literature – suddenly evidence for the efficacy for Povidone iodine started appearing everywhere - inactivation of SARS, MERS, and Ebola. Not only that but viricidal activity from exposure times measured in seconds, rather than minutes or hours. As if this was not exciting enough, the effects were achieved at concentrations human mucosal tissues could easily tolerate – the target I had in mind. One can’t imagine my excitement – I must tell somebody. I did and Povidien was formed. The company has a single goal – to make a usable pre-procedural treatment for mouth and nose in a remarkably short period of time and get it to where it is needed -into the hands of Healthcare professionals to enhance protection for their patients, staff and themselves. At the time, we made some logical extrapolations of the available data, which subsequent evidence has validated. Does the molecule Povidone Iodine inactivate the SARS-CoV2? The answer is yes! Is it possible that PVP-I could inactivate at concentrations of between 0.23-1% w/v? In my opinion yes? Could PVP-I at a concentration of between 0.23-1% w/v in contact with nasal passage or oral mucosa for as little as 60 seconds inactivate SARsCoV2? In my opinion, yes it could! Could this approach reduce viral load in the nasal and oral cavity if applied? In my opinion and in the opinion of ENT and Dental surgeons across the globe, the answer is yes. So that is the journey we are now engaged with – to bring PVP-I in a solution for use in healthcare settings to reduce the potential for transmission of aerosols containing SARS-CoV2 between patients and healthcare workers. A simple pre-treatment and rinse of the oral mucosa could impact the presence and infectivity of SARS-CoV-2. It might sound like too simple an approach, not something meaningful like a vaccine or a new drug developed at the cost of billions. However, when one thinks about the purpose of Personal Protective Equipment, it is to create a shield between the patient and their healthcare worker. As an extra layer and level of PPE, this simple, cheap and effective measure can be really meaningful, especially in dental practice and in ENT (ear, nose and throat) surgery. Topical PVP-I is considered exceptionally safe. Doctors recommending its use will of course exclude patients who may be allergic to iodine, are pregnant, or who are considered unsuitable for a pre-treatment rinse. But for most people, using a mouthwash and nasal rinse, may soon become an additional logical step we take when visiting the dentist’s office or attending for ENT examination. Just as we fasten our seat belt before we drive and hope never to need it, in the event that we do, we are delighted that such a simple safety measure can help so much to protect our health.