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

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}