"The use of Povidone Iodine nasal spray
and mouthwash during the current
COVID-19 pandemic may reduce cross
infection and protect healthcare
J Kirk-Bayley MRCP FRCA EDIC FFICM
Consultant Intensivist & Anaesthetist,
Royal Surrey County Hospital
VS Sunkaraneni LLM FRCS (2009)
Consultant Rhinologist, Royal Surrey County Hospital
SJ Challacombe, PhD, FRCPath, FDSRCS, FMedSci, DSc(h.c), FKC
Martin Rushton Professor of Oral Medicine, King’s College London
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In late 2019 a novel coronavirus, SARS-CoV-2 causing
Coronavirus disease 2019 (COVID-19) appeared in
Wuhan China, and on 11th March 2020 the World
Health Organisation declared it to have developed
pandemic status. In early SARS-CoV-2 infection,
viral titres of greater than 107/mL in saliva and nasal
mucous can be found; minimisation of these titres
should help to reduce cross infection. Povidone-
iodine (PVP-I) disinfectant has better anti-viral activity
than other antiseptics and has already been proven
to be an extremely effective virucide in vitro against
severe acute respiratory syndrome and Middle East
respiratory syndrome coronaviruses (SARS-CoV and
MERS-CoV). Its in vivo virucidal activity is unknown,
but it retains its antimicrobial activity against bacteria
in vivo intraorally and one application can reduce
oral microbial flora for greater than 3 hours.
PVP-I disinfectant has been shown to be safe when administered to the nasal cavity and as a mouthwash. We propose a protocolised intra-nasal and oral application of PVP-I for both patients and their attendant healthcare workers (HCWs) during the current COVID-19 pandemic to help limit the spread of SARS-CoV-2 from patients to healthcare workers and vice versa. The aim is to reduce the viral ‘load’ in two of the key areas from where droplets and aerosols containing the virus are expectorated (the lower respiratory tract being the other). The aim of use in HCWs is to destroy virus that has entered the upper aerodigestive tract before it has the opportunity to infect the host.
We suggest the protocol is considered for routine use during the care of COVID-19 patients, particularly before any procedure that involves the upper aerodigestive tract, including intubation, nasal and oral procedures, endoscopy and bronchoscopy. We suggest it should be considered when such procedures are carried out in all patients during the pandemic regardless of COVID-19 status, due to the reported significant rates of asymptomatic infection
The total iodine exposure proposed is well within previously recorded safe limits in those without contraindications to its use. The intervention is inexpensive, low risk and potentially easy to deploy at scale globally.
1 Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. [The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) in China]. Zhonghua liu xing bing xue za zhi = Zhonghua liuxingbingxue zazhi 2020;41:145–51. doi:10.3760/cma.j.issn.0254-6450.2020.02.003
2 Wang D, Hu B, Hu C, et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA : the journal of the American Medical Association 2020;323:1061–9. doi:10.1001/jama.2020.1585 This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3563092
3Respiratory care committee of Chinese Thoracic Society. [Expert consensus on preventing nosocomial transmission during respiratory care for critically ill patients infected by 2019 novel coronavirus pneumonia]. Zhonghua jie he he hu xi za zhi = Zhonghua jiehe he huxi zazhi = Chinese journal of tuberculosis and respiratory diseases 2020;17:E020--E020. doi:10.3760/cma.j.issn.1001-0939.2020.0020
4 To KK-W, Tsang OT-Y, Chik-Yan Yip C, et al. Consistent detection of 2019 novel coronavirus in saliva. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 2020;361:1319. doi:10.1093/cid/ciaa149
5 Zou L, Ruan F, Huang M, et al. SARS-CoV-2 Viral Load in Upper Respiratory Specimens of Infected Patients. The New England journal of medicine Published Online First: 2020. doi:10.1056/NEJMc2001737
6 Kim ES, Chin BS, Kang CK, et al. Clinical Course and Outcomes of Patients with Severe Acute Respiratory Syndrome Coronavirus 2 Infection: a Preliminary Report of the First 28 Patients from the Korean Cohort Study on COVID-19. Journal of Korean medical science 2020;35:e142. doi:10.3346/jkms.2020.35.e142
7 Zou L, Ruan F, Huang M, et al. SARS-CoV-2 Viral Load in Upper Respiratory Specimens of Infected Patients. The New England journal of medicine 2020;382:1177–9. doi:10.1056/NEJMc2001737
8 Berkelman RL, Holland BW, Anderson RL. Increased bactericidal activity of dilute preparations of povidone-iodine solutions. Journal of clinical microbiology 1982;15:635–9./pmc/articles/PMC272159/?report=abstract
9 Kawana R, Kitamura T, Nakagomi O, et al. Inactivation of human viruses by povidone-iodine in comparison with other antiseptics. Dermatology (Basel, Switzerland) 1997;195 Suppl:29–35. doi:10.1159/000246027
10 Kariwa H, Fujii N, Takashima I. Inactivation of SARS coronavirus by means of povidone-iodine, physical conditions and chemical reagents. Dermatology (Basel, Switzerland) 2006;212 Suppl:119–23. doi:10.1159/000089211
11 Eggers M. Infectious Disease Management and Control with Povidone Iodine. Infectious diseases and therapy 2019;8:581–93. doi:10.1007/s40121-019-00260-x
12 Wu C, Liu Y, Yang Y, et al. Analysis of therapeutic targets for SARS-CoV-2 and discovery of potential drugs by computational methods. Acta Pharmaceutica Sinica Bhttps://doi.org/10.1016/j.apsb.2020.02.008
13 Eggers M, Eickmann M, Zorn J. Rapid and Effective Virucidal Activity of Povidone-Iodine Products Against Middle East Respiratory Syndrome Coronavirus (MERS-CoV) and Modified Vaccinia Virus Ankara (MVA). Infectious diseases and therapy 2015;4:491–501. doi:10.1007/s40121-015-0091-9
14 Eggers M, Koburger-Janssen T, Eickmann M, et al. In Vitro Bactericidal and Virucidal Efficacy of Povidone-Iodine Gargle/Mouthwash Against Respiratory and Oral Tract Pathogens. Infectious diseases and therapy 2018;7:249–59. doi:10.1007/s40121-018-0200-7
15 Shiraishi T, Nakagawa Y. Evaluation of the bactericidal activity of povidone-iodine and commercially available gargle preparations. Dermatology (Basel, Switzerland) 2002;204 Suppl:37–41. doi:10.1159/000057723
16 Kawana A, Kudo K. [A trial of povidone-iodine (PVP-I) nasal inhalation and gargling to remove potentially pathogenic bacteria colonized in the pharynx]. Kansenshogaku zasshi The Journal of the Japanese Association for Infectious Diseases 1999;73:429–36. doi:10.11150/kansenshogakuzasshi1970.73.429
17 Nagata K, Takasu N, Akamine H, et al. Urinary iodine and thyroid antibodies in Okinawa, Yamagata, Hyogo, and Nagano, Japan: the differences in iodine intake do not affect thyroid antibody positivity. Endocrine journal 1998;45:797–803. doi:10.1507/endocrj.45.797
18 Ader AW, Paul TL, Reinhardt W, et al. Effect of mouth rinsing with two polyvinylpyrrolidone-iodine mixtures on iodine absorption and thyroid function. Journal of This Clinical Endocrinology and Metabolism Published Online First: 1988. doi:10.1210/jcem-66-3-632
19 NELSON N, PALMES ED. The absorption, excretion, and physiological effect of iodine in normal human subjects. The Journal of clinical investigation 1947;26:301–10.http://eutils.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&id=20257789&retmode=ref&cmd=prlinks
20 Verger P, Aurengo A, Geoffroy B, et al. Iodine kinetics and effectiveness of stable iodine prophylaxis after intake of radioactive iodine: a review. Thyroid : official journal of the American Thyroid Association 2001;11:353–60. doi:10.1089/10507250152039082
21 World Health Organization, ICCIDD U. Recommended iodine levels in salt and guidelines for monitoring their adequacy and effectiveness. https://www.who.int/nutrition/publications/micronutrients/iodine_deficiency/WHO_NUT_96.13/en/
22 Videne® Summary of Product Characteristics. https://www.surgery-express.co.uk/files/ww/V002-Videne-Antiseptic.pdf
23 Gray PEA, Katelaris CH, Lipson D. Recurrent anaphylaxis caused by topical povidone-iodine (Betadine). Journal of Paediatrics and Child Health. 2013. doi:10.1111/jpc.12232
24 Lachapelle JM. Allergic contact dermatitis from povidone-iodine: A re-evaluation study. Contact Dermatitis Published Online First: 2005. doi:10.1111/j.0105-1873.2005.00479.x
25 Lachapelle JM. A comparison of the irritant and allergenic properties of antiseptics. European Journal of Dermatology. 2014. doi:10.1684/ejd.2013.2198
26 Ramaswamykanive H, Nanavati Z, Mackie J, et al. Cardiovascular collapse following povidone-iodine wash. Anaesthesia and Intensive Care. 2011. doi:10.1177/0310057x1103900121
27 dela Cruz F, Brown DH, Leikin JB, et al. Iodine absorption after topical administration. Western Journal of Medicine 1987.
28 BETADINE® Gargle & Mouthwash, Mundipharma Pharmaceuticals Pte Ltd, Singapore.
29 BETADINE® Sore Throat Spray.
30 Panchmatia R, Payandeh J, Al-Salman R, et al. The efficacy of diluted topical povidone-iodine rinses in the management of recalcitrant chronic rhinosinusitis: a prospective cohort study. European Archives of Oto-Rhino-Laryngology Published Online First: 2019. doi:10.1007/s00405-019-05628-w
31 Mullings W, Panchmatia R, Samoy K, et al. Topical Povidone-Iodine as an Adjunctive Treatment for Recalcitrant Chronic Rhinosinusitis. European Journal of Rhinology and Allergy Published Online First: 2019. doi:10.5152/ejra.2019.166
32 Leung NHL, Chu DKW, Shiu EYC, et al. Respiratory virus shedding in exhaled breath and efficacy of face masks. Nature Medicine 2020;:1–5. doi:10.1038/s41591-020-0843-2
33 Gluck U, Martin U, Bosse B, et al. A clinical study on the tolerability of a liposomal povidone-iodine nasal spray: Implications for further development. ORL Published Online First: 2007. doi:10.1159/000097758
34 Dawes C, Watanabe S, Biglow-Lecomte P, et al. Estimation of the Velocity of the Salivary Film at Some Different Locations in the Mouth. Journal of Dental Research Published Online First: 1989. doi:10.1177/00220345890680110201
35 Aasenden R, Brudevold F, Richardson B. Clearance of fluoride from the mouth after topical treatment or the use of a fluoride mouthrinse. Archives of Oral Biology 1968;13:625–36. doi:10.1016/0003-9969(68)90141-6
36 Tsuda S, Soutome S, Hayashida S, et al. Topical povidone iodine inhibits bacterial growth in the oral cavity of patients on mechanical ventilation: A randomized controlled study. BMC Oral Health Published Online First: 2020. doi:10.1186/s12903-020-1043-7
37 Kanagalingam J, Feliciano R, Hah JH, et al. Practical use of povidone-iodine antiseptic in the maintenance of oral health and in the prevention and treatment of common oropharyngeal infections. International Journal of Clinical Practice Published Online First: 2015. doi:10.1111/ijcp.12707
38 Wu C, Zheng M. Single-cell RNA expression profiling shows that ACE2, the putative receptor of Wuhan 2019-nCoV, has significant expression in the nasal, mouth, lung and colon tissues, and tends to be co-expressed with HLA-DRB1 in the four tissues. Preprints 2020. www.preprints.org (accessed 9 Apr 2020).
39 Liu L, Wei Q, Alvarez X, et al. Epithelial Cells Lining Salivary Gland Ducts Are Early Target Cells of Severe Acute Respiratory Syndrome Coronavirus Infection in the Upper Respiratory Tracts of Rhesus Macaques. Journal of Virology Published Online First: 2011. doi:10.1128/jvi.02292-10
40 Sungnak W, Huang N, Bécavin C, et al. SARS-CoV-2 Entry Genes Are Most Highly Expressed in Nasal Goblet and Ciliated Cells within Human Airways. Published Online First: 13 March 2020.http://arxiv.org/abs/2003.06122 (accessed 9 Apr 2020).
41 ADA Interim Guidance for Minimizing Risk of COVID-19 Transmission.
https://www.ada.org/~/media/CPS/Files/COVID/ADA_COVID_Int_Guidance_Treat_Pts.pdf?utm_source=cpsorg&utm_medium=cpsalertbar&utm_content=cv-pm-ebd-interim-response&utm_campaign=covid-19 (accessed 16 Apr 2020).
42 Loh K-C. Amiodarone-induced thyroid disorders: a clinical review. Postgraduate Medical Journal 2000;76:133–40. doi:10.1136/PMJ.76.893.133