A Clinical Trial of Gargling Agents in Reducing Intraoral Viral Load Among COVID-19 Patients (GARGLES)

A Double Blind, Randomized Controlled Pilot Trial of Gargling Agents in Reducing Intraoral Viral Load Among Laboratory Confirmed COVID-19 Patients: GARGLES STUDY

Pakistan is a resource restraint country, it's not possible to carry out coronavirus testing at mass scale. Simple cost effective intervention against the present pandemic is highly desirable.

For patients: Identifying an antiviral gargle that could substantially reduce the colonies of COVID-19 residing in mouth and oro-naso-pharynx is likely to reduce the viral load. Such reduction in the viral load through surface debridement could aid the effective immune response in improving the overall symptoms of the patients.

For dentists: This study is important because the nature of the dental profession involves aerosol production, carrying out dental work on asymptomatic patients carrying coronavirus puts the entire dental team at a great risk of not only acquiring the infection but also transmitting it to the others. Antiviral gargles could be used by dentist and their auxiliaries as prophylaxis.

For physicians and nurses: The risk of morbidity and mortality is high among physicians and nurses involved in the screening and management of Covid-19 patients. Globally, over 215 physicians and surgeons have died while taking care of Covid-19 patients. The cause of death is attributed to high exposure of viral load. The antiviral gargles and nasal lavage can decrease the fatalities among doctors and nurses.

Thus, patients, physicians, nurses and dentists, all could be benefited with this findings of this study.

Study Overview

• Status: Not yet recruiting
• Conditions: Covid-19
• Intervention / Treatment: Drug: Gargle/Mouthwash

Detailed Description

It will be a parallel group, quadruple blind-randomized controlled pilot trial annexed with a laboratory based study. Clinical trial will be carried out at the Aga Khan University Hospital (AKUH), Karachi, Pakistan. Patients will be inducted from the pool of known patients (laboratory confirmed COVID-19 participants) within 7 days of the onset of viral infection symptoms, already admitted at AKUH. Molecular and immunological testing will be done at the Juma laboratory of AKUH. The intervention drugs (Povidone-Iodine, Hydrogen Peroxide and Hypertonic Saline will be obtained from the AKUH distribution department and/ or AKUH pharmacy. The Neem extract will be compounded at the Chemistry department, University of Karachi/ HEJ institute of Organic Chemistry, University of Karachi.

We will need 50 patients. There will be five study groups. Group A (n=10) patients on 10 ml gargle and nasal lavage with of 0.2% Povidone-Iodine for 20-30 seconds, twice daily for 5 days. Group B (n=10) patients will be subjected to 10 ml gargle and nasal lavage with 1% Hydrogen peroxide for 20-30 seconds, twice daily for 5 days. Group C will comprise of (n=10) subjects using 10ml gargle and nasal lavage with Neem extract (Azardirachta indica) for 20-30 seconds, twice daily for 5 days. Group D (n=10) patients will use 2% hypertonic saline gargle and nasal lavage for a similar time period. Group E (n=10) will serve as positive controls. These will be given simple distilled water gargles and nasal lavage for 20-30 seconds, thrice daily for six days. For nasal lavage, a special douche syringe will be provided to each participant. Its use will be thoroughly explained by the data collection officer.

Data collection: The baseline oral swab will be taken from the posterior pharyngeal wall/ tonsillar area on day one before initiating the gargles by trained dentist. The end-point oral swab will be taken on day 7, just after using the prescribed gargle. Patient will be provided with a special hood so that they themselves don't generate aerosol in the immediate vicinity while carrying out the gargling and nasal lavage.

Data will be analyzed using SPSS for Windows (version 23.0 SPSS) and Graph Pad Prism 7.0 software.

Mean and standard deviation of the continuous variables (age, COVID-19 viral counts and cytokine profiles at baseline and endpoint etc.) will be computed. Frequency distribution of the categorical variables will be determined (gender, co-morbids, presence of hypertension, diabetes, periodontal status etc.) Repeated measures ANOVA will be used to compare the reduction in intra-oral viral load and the changes in the inflammatory biomarkers in the study groups. In case of substantially low count of participants in the study groups, non-parametric tests such as Kruskal-Wallis or Friedman test will be employed. Multiple linear regression (MLR) will done to predict changes in the Covid-19 viral load and cytokine profiles. A subset analysis using Zero inflated negative binomial (ZINB) model will be employed, provided a significant reduction in viral load is observed in any of the study groups. A p-value of <0.05 will be taken as statistically significant. {20a}

The biases and confounders can be taken care at following four levels:

At recruitment stage, we will use restriction i.e. only those COVID positive subjects will be recruited who have no other major co-morbidities. At intervention assignment, the random group allocation will ensure even distribution of the confounders in the study groups thus their differential effect on the outcome will be addressed. At analysis, we will employ regression analysis (as described above) to account for biases and confounders and lastly, the subset analysis will stratify the data and nullify the effect of biases.

Interim analysis {20b} is not planned on account of a short duration of the study. Missing data/ uncompliant patients {20c} will be omitted from the final analysis.

• Study Type: Interventional
• Enrollment (Anticipated): 50
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Farhan R Khan, MS, FCPS; Phone Number: 03052225117; Email: farhan.raza@aku.edu

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 14 years to 61 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• The inclusion criteria are laboratory confirmed Covid-19 positive male or female subjects in the age range of 18-65 years, within seven days of the onset of mild to moderate symptoms of viral infection, already admitted in the hospital.

Exclusion Criteria:

• Edentulous patients, patients with low Glasgow coma score, intubated, immune-compromised, history of radiotherapy or chemotherapy will be excluded. Patients with known pre-existing chronic mucosal lesions such as lichen planus will also be excluded.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Supportive Care
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Quadruple

Number of Arms

5

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Povidone-Iodine 0.2% (BETADINE®); 0.2% Povidone-Iodine (BETADINE®) 10 ml gargle and nasal lavage for 20-30 seconds, thrice daily for 6 days.	Drug: Gargle/Mouthwash; There will be 50 patients in six study groups. Group A (n=10) patients on 10 ml gargle and nasal lavage using 0.2% Povidone-Iodine (Betadiene®) for 20-30 seconds, thrice daily for 6 days. Group B (n=10) patients will be subjected to 10 ml gargle and nasal lavage using 1% Hydrogen peroxide (ActiveOxy®) for 20-30 seconds, thrice daily for 6 days. Group C will comprised of (n=10) subjects on 10ml gargle and nasal lavage using Neem extract solution (Azardirachta indica) formulated locally) for 20-30 seconds, thrice daily for 6 days. Group D (n=10) patients will use 2% hypertonic saline (Plabottle®) gargle and nasal lavage for a similar time period. Group E (n=10) will serve as positive controls. These will be given simple distilled water gargles and nasal lavage for 20-30 seconds, thrice daily for six days Whereas Group F (n=5) will comprise of negative controls, who will not use any gargles or nasal lavage during study period.; Other Names: Gargling agent; Mouthrinse
Experimental: Hydrogen peroxide 1% (ActiveOxy); ActiveOxy (1% Hydrogen peroxide) 10 ml gargle and nasal lavage for 20-30 seconds, thrice daily for 6 days.	Drug: Gargle/Mouthwash; There will be 50 patients in six study groups. Group A (n=10) patients on 10 ml gargle and nasal lavage using 0.2% Povidone-Iodine (Betadiene®) for 20-30 seconds, thrice daily for 6 days. Group B (n=10) patients will be subjected to 10 ml gargle and nasal lavage using 1% Hydrogen peroxide (ActiveOxy®) for 20-30 seconds, thrice daily for 6 days. Group C will comprised of (n=10) subjects on 10ml gargle and nasal lavage using Neem extract solution (Azardirachta indica) formulated locally) for 20-30 seconds, thrice daily for 6 days. Group D (n=10) patients will use 2% hypertonic saline (Plabottle®) gargle and nasal lavage for a similar time period. Group E (n=10) will serve as positive controls. These will be given simple distilled water gargles and nasal lavage for 20-30 seconds, thrice daily for six days Whereas Group F (n=5) will comprise of negative controls, who will not use any gargles or nasal lavage during study period.; Other Names: Gargling agent; Mouthrinse
Active Comparator: Neem extract (Azadirachta indicia); Neem extract (Azadirachta indicia) gargle will be prepared by chemistry laboratory. patients will do 10ml gargle and nasal lavage for 20-30 seconds, thrice daily for 6 days.	Drug: Gargle/Mouthwash; There will be 50 patients in six study groups. Group A (n=10) patients on 10 ml gargle and nasal lavage using 0.2% Povidone-Iodine (Betadiene®) for 20-30 seconds, thrice daily for 6 days. Group B (n=10) patients will be subjected to 10 ml gargle and nasal lavage using 1% Hydrogen peroxide (ActiveOxy®) for 20-30 seconds, thrice daily for 6 days. Group C will comprised of (n=10) subjects on 10ml gargle and nasal lavage using Neem extract solution (Azardirachta indica) formulated locally) for 20-30 seconds, thrice daily for 6 days. Group D (n=10) patients will use 2% hypertonic saline (Plabottle®) gargle and nasal lavage for a similar time period. Group E (n=10) will serve as positive controls. These will be given simple distilled water gargles and nasal lavage for 20-30 seconds, thrice daily for six days Whereas Group F (n=5) will comprise of negative controls, who will not use any gargles or nasal lavage during study period.; Other Names: Gargling agent; Mouthrinse
Active Comparator: Hypertonic saline (2%NaCl); 10 ml gargle and nasal lavage using Hypertonic saline for 20-30 seconds, thrice daily for 6 days.	Drug: Gargle/Mouthwash; There will be 50 patients in six study groups. Group A (n=10) patients on 10 ml gargle and nasal lavage using 0.2% Povidone-Iodine (Betadiene®) for 20-30 seconds, thrice daily for 6 days. Group B (n=10) patients will be subjected to 10 ml gargle and nasal lavage using 1% Hydrogen peroxide (ActiveOxy®) for 20-30 seconds, thrice daily for 6 days. Group C will comprised of (n=10) subjects on 10ml gargle and nasal lavage using Neem extract solution (Azardirachta indica) formulated locally) for 20-30 seconds, thrice daily for 6 days. Group D (n=10) patients will use 2% hypertonic saline (Plabottle®) gargle and nasal lavage for a similar time period. Group E (n=10) will serve as positive controls. These will be given simple distilled water gargles and nasal lavage for 20-30 seconds, thrice daily for six days Whereas Group F (n=5) will comprise of negative controls, who will not use any gargles or nasal lavage during study period.; Other Names: Gargling agent; Mouthrinse
Placebo Comparator: Positive controls; 10 ml gargle and nasal lavage using distilled water for 20-30 seconds, thrice daily for 6 days.	Drug: Gargle/Mouthwash; There will be 50 patients in six study groups. Group A (n=10) patients on 10 ml gargle and nasal lavage using 0.2% Povidone-Iodine (Betadiene®) for 20-30 seconds, thrice daily for 6 days. Group B (n=10) patients will be subjected to 10 ml gargle and nasal lavage using 1% Hydrogen peroxide (ActiveOxy®) for 20-30 seconds, thrice daily for 6 days. Group C will comprised of (n=10) subjects on 10ml gargle and nasal lavage using Neem extract solution (Azardirachta indica) formulated locally) for 20-30 seconds, thrice daily for 6 days. Group D (n=10) patients will use 2% hypertonic saline (Plabottle®) gargle and nasal lavage for a similar time period. Group E (n=10) will serve as positive controls. These will be given simple distilled water gargles and nasal lavage for 20-30 seconds, thrice daily for six days Whereas Group F (n=5) will comprise of negative controls, who will not use any gargles or nasal lavage during study period.; Other Names: Gargling agent; Mouthrinse

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Intraoral viral load	Intraoral viral load as deciphered by RT-PCR	Five days of using gargles

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Salivary cytokine profile	Salivary cytokine profiles of IL-2, IL-4, IL-6, IL-10, TNF-α, IFN-γ and IL-17.	Five days of using gargles

Collaborators and Investigators

• Sponsor: Aga Khan University
• Collaborators: University of Karachi
• Investigators: Study Director: Syed MR Kazmi, FCPS, Aga Khan University

Publications and helpful links

General Publications

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• Xu Z, Shi L, Wang Y, Zhang J, Huang L, Zhang C, Liu S, Zhao P, Liu H, Zhu L, Tai Y, Bai C, Gao T, Song J, Xia P, Dong J, Zhao J, Wang FS. Pathological findings of COVID-19 associated with acute respiratory distress syndrome. Lancet Respir Med. 2020 Apr;8(4):420-422. doi: 10.1016/S2213-2600(20)30076-X. Epub 2020 Feb 18. No abstract available. Erratum In: Lancet Respir Med. 2020 Feb 25;:
• Ramalingam S, Graham C, Dove J, Morrice L, Sheikh A. A pilot, open labelled, randomised controlled trial of hypertonic saline nasal irrigation and gargling for the common cold. Sci Rep. 2019 Jan 31;9(1):1015. doi: 10.1038/s41598-018-37703-3.
• Eggers M, Koburger-Janssen T, Eickmann M, Zorn J. In Vitro Bactericidal and Virucidal Efficacy of Povidone-Iodine Gargle/Mouthwash Against Respiratory and Oral Tract Pathogens. Infect Dis Ther. 2018 Jun;7(2):249-259. doi: 10.1007/s40121-018-0200-7. Epub 2018 Apr 9.
• Peng X, Xu X, Li Y, Cheng L, Zhou X, Ren B. Transmission routes of 2019-nCoV and controls in dental practice. Int J Oral Sci. 2020 Mar 3;12(1):9. doi: 10.1038/s41368-020-0075-9.
• Shafiq HB, Amin U, Nawaz S. Comparative analysis of various antimicrobial agents present in locally available mouthwashes against oral pathogens. Pak J Pharm Sci. 2018 Sep;31(5):1881-1887.
• Tanzer JM, Slee AM, Kamay BA. Structural requirements of guanide, biguanide, and bisbiguanide agents for antiplaque activity. Antimicrob Agents Chemother. 1977 Dec;12(6):721-9. doi: 10.1128/AAC.12.6.721.
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• Hirata K, Kurokawa A. Chlorhexidine gluconate ingestion resulting in fatal respiratory distress syndrome. Vet Hum Toxicol. 2002 Apr;44(2):89-91.
• Tiwari V, Darmani NA, Yue BY, Shukla D. In vitro antiviral activity of neem (Azardirachta indica L.) bark extract against herpes simplex virus type-1 infection. Phytother Res. 2010 Aug;24(8):1132-40. doi: 10.1002/ptr.3085.
• Ahmad A, Javed MR, Rao AQ, Husnain T. Designing and screening of universal drug from neem (Azadirachta indica) and standard drug chemicals against influenza virus nucleoprotein. BMC Complement Altern Med. 2016 Dec 16;16(1):519. doi: 10.1186/s12906-016-1469-2.
• Chen L, Liu HG, Liu W, Liu J, Liu K, Shang J, Deng Y, Wei S. [Analysis of clinical features of 29 patients with 2019 novel coronavirus pneumonia]. Zhonghua Jie He He Hu Xi Za Zhi. 2020 Feb 6;43(0):E005. doi: 10.3760/cma.j.issn.1001-0939.2020.0005. Online ahead of print. Chinese.
• Sharma R, Hebbal M, Ankola AV, Murugaboopathy V, Shetty SJ. Effect of two herbal mouthwashes on gingival health of school children. J Tradit Complement Med. 2014 Oct;4(4):272-8. doi: 10.4103/2225-4110.131373.
• Chatterjee A, Saluja M, Singh N, Kandwal A. To evaluate the antigingivitis and antipalque effect of an Azadirachta indica (neem) mouthrinse on plaque induced gingivitis: A double-blind, randomized, controlled trial. J Indian Soc Periodontol. 2011 Oct;15(4):398-401. doi: 10.4103/0972-124X.92578.
• Chava VR, Manjunath SM, Rajanikanth AV, Sridevi N. The efficacy of neem extract on four microorganisms responsible for causing dental caries viz Streptococcus mutans, Streptococcus salivarius, Streptococcus mitis and Streptococcus sanguis: an in vitro study. J Contemp Dent Pract. 2012 Nov 1;13(6):769-72. doi: 10.5005/jp-journals-10024-1227.
• Alzohairy MA. Therapeutics Role of Azadirachta indica (Neem) and Their Active Constituents in Diseases Prevention and Treatment. Evid Based Complement Alternat Med. 2016;2016:7382506. doi: 10.1155/2016/7382506. Epub 2016 Mar 1.
• Badam L, Joshi SP, Bedekar SS. 'In vitro' antiviral activity of neem (Azadirachta indica. A. Juss) leaf extract against group B coxsackieviruses. J Commun Dis. 1999 Jun;31(2):79-90.
• Arora R, Chawla R, Marwah R, Arora P, Sharma RK, Kaushik V, Goel R, Kaur A, Silambarasan M, Tripathi RP, Bhardwaj JR. Potential of Complementary and Alternative Medicine in Preventive Management of Novel H1N1 Flu (Swine Flu) Pandemic: Thwarting Potential Disasters in the Bud. Evid Based Complement Alternat Med. 2011;2011:586506. doi: 10.1155/2011/586506. Epub 2010 Oct 13.
• Siddiqui BS, Ali SK, Ali ST, Naqvi SN, Tariq RM. Variation of major limonoids in Azadirachta indica fruits at different ripening stages and toxicity against Aedes aegypti. Nat Prod Commun. 2009 Apr;4(4):473-6.
• Burton MJ, Clarkson JE, Goulao B, Glenny AM, McBain AJ, Schilder AG, Webster KE, Worthington HV. Antimicrobial mouthwashes (gargling) and nasal sprays administered to patients with suspected or confirmed COVID-19 infection to improve patient outcomes and to protect healthcare workers treating them. Cochrane Database Syst Rev. 2020 Sep 16;9(9):CD013627. doi: 10.1002/14651858.CD013627.pub2.
• Khan FR, Kazmi SMR, Iqbal NT, Iqbal J, Ali ST, Abbas SA. A quadruple blind, randomised controlled trial of gargling agents in reducing intraoral viral load among hospitalised COVID-19 patients: A structured summary of a study protocol for a randomised controlled trial. Trials. 2020 Sep 14;21(1):785. doi: 10.1186/s13063-020-04634-2.

Helpful Links

• Burden of disease in COVID-19 pandemic
• Recommendation on elective and cosmetic dental procedures by ADA
• Report on mortality of doctors and nurses combating corona virus pandemic
• Data of Covid-19 patients in Pakistan

Study record dates

Study Major Dates

• Study Start (Anticipated): December 1, 2021
• Primary Completion (Anticipated): June 30, 2022
• Study Completion (Anticipated): July 31, 2022

Study Registration Dates

• First Submitted: April 6, 2020
• First Submitted That Met QC Criteria: April 9, 2020
• First Posted (Actual): April 10, 2020

Study Record Updates

• Last Update Posted (Actual): July 20, 2021
• Last Update Submitted That Met QC Criteria: July 19, 2021
• Last Verified: July 1, 2021

More Information

Terms related to this study

• Keywords: topical therapy; coronavirus disease; gargle; hydrogen peroxide; povidone; Covid-19;; neem extracts
• Additional Relevant MeSH Terms: Coronavirus Infections; Coronaviridae Infections; Nidovirales Infections; RNA Virus Infections; Virus Diseases; Infections; Respiratory Tract Infections; Respiratory Tract Diseases; Pneumonia, Viral; Pneumonia; Lung Diseases; COVID-19
• Other Study ID Numbers: 2020-Sur-ERC-4926

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: No

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No