key: cord-0770887-0ktw9ya9 authors: Amoah, Albert G.B.; Sagoe, Kwamena W.; Quakyi, Isabella A.; Ayettey-Anie, Hannah N.G.; Ayettey-Adamafio, Mary N.B.; Ayettey Brew, Ruth N.A.; Newman-Nartey, Merley; Nartey, Nii Otu; Brightson, Kennedy T.C.; Kessie, Gladstone; Ayettey, Andrews S.; Konotey-Ahulu, Felix I.D. title: Further observations on hydrogen peroxide antisepsis and COVID-19 cases among healthcare workers and inpatients date: 2022-05-18 journal: J Hosp Infect DOI: 10.1016/j.jhin.2022.05.007 sha: a2ac35527e6081264309dc26431440ebca9c075e doc_id: 770887 cord_uid: 0ktw9ya9 Background The use of prophylactic antisepsis to protect against COVID-19 has been suggested. We report Hydrogen Peroxide antisepsis (HPA) at two hospitals in Ghana. Methods COVID-19 cases in healthcare workers (HCW) using HP (HP-HCW) or not (NHP-HCW), vaccinated or unvaccinated, were recorded at the Shai-Osudoku Hospital (SODH), Dodowa, and the Mount Olives Hospital (MOH), Techiman, between May 2020 and December 2021. The effect of HPA in all inpatients at MO was also observed. Permutation tests were used to determine p values. Findings At SODH from May to December 2020, there were 62 (13.5%) COVID-19 cases among 458 HCW not on HPA, but none among 8 on HPA (p=0.622). Between January and March 2021, 10 (2.7%) of 372 HCW had COVID-19, but none among 94 on HPA (p=0.206). At MOH, prior to HPA, 17 (20.2%) of 84 HCW and five (1.4%) of 370 inpatients had COVID-19 in July 2020. From August 2020 to March 2021, two of 54 (3.7%) who stopped HPA had COVID-19; none of 32 staff not on HPA contracted it. At SODH from April to December 2021), none of 23 unvaccinated HCW on HPA had COVID-19, compared with 35 (64%) of 55 not on HPA who contracted it (p<0.0001). None of 34 vaccinated HCW on HPA contracted COVID-19, compared with 53(13.6%) of 390 not on HPA who had it (p=0.015). No inpatient on HP prophylactic antisepsis (total 7,736) contracted COVID-19. Conclusion Daily and regular HPA protects HCW from COVID-19 and curtails nosocomial spread of SARS-CoV-2 The use of prophylactic antisepsis to protect against COVID-19 has been suggested. We report Hydrogen Peroxide antisepsis (HPA) at two hospitals in Ghana. Two years after the first reported cases of the SARS-CoV-2 infection in Wuhan, China, the COVID-19 pandemic has affected over 400 million people with about 5.9 million deaths to date. 1 In addition, within this relatively short period, several variants of the parent SARS-CoV-2 have emerged, four of which have been identified by the WHO as variants of concern (VOC), including the more recent Omicron variant. 2 3 All these VOC have been associated with marked increases in infection rates. 2 For that reason, many countries worldwide have experienced a fourth wave of COVID-19 infections. Ghana recently confirmed the presence of the Omicron variant, marked by a significant increase in the number of daily cases from December 2021 as its fourth wave. 4 In the global effort to limit SARS-CoV-2, focus has been on protecting healthcare workers (HCW) who receive and manage infected individuals including the critically ill. Although these workers could contract SARS-CoV-2 in the community, they are more likely to do so from exposure to diagnosed, suspected and unsuspected cases of COVID-19 in the hospitals and during contacttracing. [5] [6] [7] [8] [9] The health of hospital workers is therefore extremely important, especially since there is already an estimated 17.4 million shortage of these workers globally, the greatest challenges being in Africa and South-East Asia. 8 Furthermore, although HCW represent less than 2-3% of the population in a majority of countries, 14-35% of them have already contracted COVID-19, with some fatalities, on account of their increased risk. 10 Moreover, nearly a quarter of them have experienced stress induced depression, anxiety and burnout-phenomenon. 10 More disturbing also is a report of resurgence of infection in a highly vaccinated Health System workforce. 11 Indeed, over the past 12 months, several of COVID-19 vaccines have been developed and deployed on a massive scale globally under emergency use certificates to prevent SARS-CoV-2 infection. It has turned out, however, that a fully vaccinated individual would now need one or two more booster doses to remain protected from severe forms of COVID-19. It is unlikely, therefore, that the global herd immunity projected if 70% to 85% of the population were fully vaccinated, can be achieved, as more and more booster doses will be needed. The search for new strategies to contain the pandemic must, therefore, continue, and include focusing on measures to prevent contracting and spreading SARS-CoV-2. The growing interest in the use of oro-and nasopharyngeal antiseptics to inactivate SARS-CoV-2 to control the pandemic is, therefore, not, surprising. [12] [13] [14] [15] J o u r n a l P r e -p r o o f In a recent preliminary communication 16 , we drew attention to clinical information on hydrogen peroxide antisepsis (HPA) against SARS-CoV-2 in HCW in two hospitals and, in one of them, inpatients as well. As a follow-up to that paper, we report here observations on the use of HP among HCW at the Shai-Osudoku District Hospital, (SODH), Dodowa, covering the period May 2020 to December 2021, and among HCW and inpatients at the Mount Olives Hospital, Techiman, from August 2020 to December 2021. The Shai-Osudoku District Hospital (SODH) is a 135-bed capacity government hospital providing secondary level healthcare. It is located at Dodowa, 34 km East of Accra, the capital city of Ghana. HCW and inpatients wore pre-pandemic facility-issued clothing. For the first three months (July to September 2020), N95 masks were used. Subsequently they used masks sold on the open market. Mask wearing was mandatory at the facility. As already noted in our preliminary report, 16 this observational study began fortuitously in April 2020. We had learnt that eight nurses at the Emergency Department of SODH were, on their own volition, using HP daily which our team had proposed for prevention of COVID-19 in the community. With permission from the SODH management, we closely monitored COVID-19 cases among HCW using HPA (HP-HCW) and those not (NHP-HCW) at the SODH from May 2020 to December 2021. Over time more HCW started HPA at the facility. Similarly, upon permission from the Chief Executive Officer of MOH we noted occurrence of COVID-19 cases among HCW at the facility from July 2020 prior to introduction of HPA. Following voluntary introduction of HPA use through advocacy by management, based on our publication on it 17 , we noted COVID-19 cases among HCW on HPA (HP-HCW) and those not (NHP-HCW) at MOH from August 2020 to Dec 2021. For all inpatients at MOH, management adopted and modified the recommendation of major Dental Associations such as the American Dental Association of predental-treatment oral rinse with HP and other oral hygiene solutions from August 2020. 18 As noted above, the daily use of HP antisepsis among HCW has been entirely voluntary at both institutions. 16 The concentration of HP used for mouthwash/gargle was 1%, and for nasal rinse (two drops per each nostril) was 0.5%. The duration of mouthwash and gargle and nasal rinse was each one minute. At SODH, HPA was practised daily except during peak periods of SARS-CoV-2 transmission when some HCW resorted to twice daily application. At MOH, HPA was applied twice We report COVID-19 cases n (%) among HCW on HPA (HP-Users) and those not (Non-HP Users) and also note effect of vaccination on COVID-19 cases in relation to HPA in HCW at SODH. At MOH we note COVID-19 cases prior to prophylactic HPA and the effect of HPA and vaccination on COVID-19 cases in HCW and in inpatients. Data at both SODH and MOH was collected by staff designated by management and was reviewed by the heads of the two institutions and representatives of our team. Statistical significance of the influence of HPA on COVID-19 cases during the pre-vaccine and the vaccine periods at SODH was J o u r n a l P r e -p r o o f determined with permutation testing (using the Infer package in R; there were 10,000 permutations producing the null distribution in each test), and a level of significance at p < 0.05. Data on COVID-19 cases in HCW (SODH, MOH), HPA and vaccination status and in inpatients (MOH) were checked and rechecked to ensure correctness of the information obtained from the facilities. Moreover, facilities had opportunity to confirm their respective data from this manuscript. The study followed ethical principles, with prior permission obtained from management of SODH and MOH for collection of data on HP prophylaxis, COVID-19 occurrence, and RT-PCR testing. Management was assured that information provided would be kept strictly confidential and that published reports would be devoid of personal identifiers of staff and patients. The aggregated data reported is, therefore, devoid of any personal details. Before submission for publication, Management of both institutions were shown a copy of this manuscript for their approval and to ensure that both staff and patient identity had been protected. The use of HPA was beneficial to both vaccinated and unvaccinated HCW and offered significant protection for both groups at SODH. HPA also curtailed nosocomial spread of COVID-19 at MOH. No COVID-19 deaths occurred in HCW during the period of observation. No adverse events of HP use were reported. Table 1 shows details of COVID-19 status among HCW using and not using HP at SODH, prior to the introduction of vaccines in Ghana. Between May and December 2020, no COVID-19 cases were recorded among eight HCW using HP. In contrast, a number of cases occurred in HCW not using HP, (p = 0.622). From January 2021 to March 2021, the number of HCW at SODH using HP increased markedly from eight to 96, and none of them contracted COVID-19, whilst some of those not using did, (p = 0.206). Incidentally, two of the 62 Non-HP HCW who had COVID-19 in 2020 were reinfected in January 2021 after fully recovering. As at the end of July 2020, HP was not in use among staff or inpatients at MOH. In that month alone, The results of this real-world observational study provide clinical evidence that prophylactic HP antisepsis protects healthcare workers and inpatients from COVID-19. Over a period of 19 months, no healthcare worker, vaccinated or unvaccinated, using 1% HP for mouthwash and throat gargle and 0.5% for nasal rinse at least once daily developed COVID-19 at Shai-Osudoku District Hospital. Among these were the eight frontline-emergency-care nurses who had used HP daily from May 2020. HCW who interrupted HPA, therefore, highlights also the importance of maintaining daily and regular use of HP to be protected, noting that HP inactivation of the virus happens within its short incubation period. As the Omicron variant has a much shorter incubation period 19 During the period of the study, all variants of the virus of global concernthe Alpha, Beta, Delta, and Omicron were encountered 4 20 , suggesting that HP effectively inactivated all these variants. It can be surmised with some degree of confidence, therefore, that HP remains relevant as an oxidizing agent against the viral envelope and the S protein of all SARS-CoV-2 variants, including the Omicron VOC. Attention therefore ought to be paid now to the growing evidence that oral and nasal antiseptics and, especially, HP, protect from SARS-CoV-2 infections. It is important to note that the use of HP in low concentrations on daily basis and over several decades has also been shown to be safe in dentistry. 21 In this study too, no adverse events of HP use were reported. In this real-world observational study, we collected no personal data, such as age, gender and comorbidities and clinical information from HP-HCW, NHP-HCW, vaccinated, unvaccinated or in J o u r n a l P r e -p r o o f inpatients; we have not also considered the influence of co-variates. Moreover, HPA was not randomized, as the decision to use HPA was personal at SODH and influenced by management and not the study team at MOH. The study, nevertheless, provides useful information of evidential value to fill a knowledge gap of clinical evidence that HPA protects against SARS-CoV-2 infections. 13 Our observations clearly indicate that daily and regular use of HP in low concentrations for the duration of one minute as 1% mouthwash and throat gargle, and 0.5% for nasal rinse for the same duration, effectively protects against SARS-CoV-2 infections. This mimics its mode of action when used on inanimate surfaces to inactivate coronaviruses. 22 HP, therefore, has the potential to mitigate the pandemic, a solution simpler than had been imagined and which had been proposed earlier. 17 23 HP could further mitigate the pandemic when used by both symptomatic and asymptomatic COVID-19 patients, by inactivating the viruses these patients shed. 24 In summary, the significant clinical evidence of HP protection against COVID-19, and likewise considering that it is also quite safe, inexpensive and readily available, makes it a valuable prophylaxis to be recommended to protect HCW, inpatients and all vulnerable groups against COVID-19. These vulnerable groups might include the unvaccinated, the elderly, those in long term care facilities or homes, sportsmen and sportswomen, teachers, students, front-line security service personnel, airline crew, pregnant and lactating women. 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Funding Sources: None