Educational Articles

COVID-19 Advice for the General Public

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Several clip-on devices have been marketed to have protective effects against viruses and bacteria. They claim to release chlorine dioxide and reach concentrations around 0.017 ppm (parts per million) to create a protective barrier for the user, although the exact mechanism of this release is not specified.

Chlorine dioxide is considered a toxic substance by most agencies including the Centers for Disease Control and Prevention (CDC) and World Health Organisation (WHO). In concentrations of 0.1ppm or higher, it can cause airway irritation leading to coughing, sore throat, severe headaches, and lung damage. Contact with skin and eyes may also lead to skin and eye irritation and burning. While the concentration of chlorine dioxide in these devices should be too low to cause these side effects, improper use or device malfunction may lead to harmful side effects as mentioned .

Chlorine dioxide gas has been used in some countries to disinfect healthcare facilities. This involves exposing a sealed room to toxic levels of 300ppm and above for several hours, much higher than possible with the clip-on devices. Hence without further information as to how the gas is released through these clip on devices, or evidence that such low concentrations sufficient to destroy the COVID-19 virus, it is highly unlikely that these devices will prevent COVID-19
infection.

Authored by
Annie Tran Anh Nhi, Choo Yan Cheng & Kng Li Lin, Grace
Members of Pharmaceutical Society of Singapore
30th March 2020

References:

Take home message:
Supplements work best if a person has a specific deficiency or need. If you are unsure whether you require a supplement, always speak to your doctor or pharmacist.

Currently there are no supplements that have been proven to treat or prevent COVID-19 infections. In this article, we will discuss some commonly used supplements that are marketed to have immune-boosting effects and their presumed effects on common respiratory infections (eg common cold, influenza and pneumonia).

  1. Vitamin C
    Vitamin C is important for supporting the immune response against infections. People with vitamin C deficiency, or scurvy have poor wound healing, weakened immunity and are more susceptible to infections. The Health Promotion Board1 recommends an average daily intake of 100mg of Vitamin C from either food or dietary supplements to maintain good immune response. However, there is currently no evidence that taking vitamin C at above 100mg a day will boost the immune system. Currently researchers at Zhong Wuhan University are studying the effects of megadose of vitamin C infusion (up to 24,000mg daily, 240 times higher than the required amount) on reducing excessive inflammatory symptoms caused by COVID-19 infection. However, the result will only be concluded when the study ends in September 20202.
  2. Vitamin D
    Vitamin D is known to protect the body against inflammation, regulates and activates immune responses. Low levels of vitamin D have been associated with decreased lung function3, and increased risk of infections and immune-related disorders4-6. The Health Promotion Board recommends an average daily dose of 100 IU of vitamin D. To ensure adequate vitamin D, you may consider allowing the sun to shine on your arms and legs for 5 to 30 minutes, at least twice a week from 10am to 3pm7. Alternatively, taking supplementation of 400IU to 2000IU a day is reasonable5 for most adults who do not suffer from long term diseases which affect the kidney. Overconsumption of vitamin D should be avoided as the body cannot eliminate excess vitamin D and accumulation can lead to toxicity.
  3. Zinc
    Zinc is an essential mineral for the immune system as it is involved in the development and communication of many immune cells. Zinc deficiency leads to increased risk of infections and diseases8. Children, who are prone to zinc deficiency due to reduced absorption, may receive the most benefit of zinc supplementation9. However, in children and adults with a balanced diet, zinc supplementation do not prevent respiratory illnesses. At best, taking 75mg of zinc lozenges daily can help soothe your throat and shorten the duration of symptoms by 2 or 3 days.
  4. Black elderberries
    Black elderberries (Sambucus nigra) have long been used as a home remedy for cold and flu. Laboratory experiments have shown that black elderberries have antibacterial and antiviral properties11-12. However, few reliable studies have been done demonstrating its influenza preventing effects in humans. The largest study done on a human only involved 180 participants13. The result from this review showed a significant reduction in influenza symptoms in black elderberry users if taken within 48 hours of symptom onset.

Authored by
Annie Tran Anh Nhi, Choo Yan Cheng & Kng Li Lin, Grace
Members of Pharmaceutical Society of Singapore
30th Mar 2020

References:

  • Health Promotion Board (2019). Recommended dietary allowances (https://www.healthhub.sg/livehealthy/192/recommended_dietary_allowances)
  • Vitamin C Infusion for the Treatment of Severe 2019-nCoV Infected Pneumonia (2020). (https://clinicaltrials.gov/ct2/show/NCT04264533)
  • Aranow C (2013). Vitamin D and the Immune SystemJournal of Investigative Medicine 2011;59:881-886
  • Bergman P (2013) Vitamin D and Respiratory Tract Infections: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. PLoS ONE 8(6): e65835. (https://doi.org/10.1371/journal.pone.0065835)
  • Martineau A R (2017). Vitamin D supplementation to prevent acute respiratory tract infections: systematic review and meta-analysis of individual participant data. BMJ 2017;356:i6583
  • Vitamin D: Recommended Dietary Allowances, Food Sources, and Side Effects. (https://www.healthxchange.sg/foodnutrition/supplements/vitamindrecommended-dietary-allowances-food-sources-side-effects)
  • Prasad AS (2009). Zinc: Role in Immunity, Oxidative Stress and Chronic Inflammation. Curr Opin Clin Nutr Metab Care. 12(6):646–652.
  • Lassi ZS (2016). Zinc supplementation for the prevention of pneumonia in children aged 2 months to 59 months. Cochrane Database of Systematic Reviews, Issue 12. Art. No.: CD005978.
  • Singh M (2013)Zinc for the common cold. Cochrane Database of Systematic Reviews, Issue 6. Art. No.: CD001364. DOI:10.1002/14651858.CD001364.pub4.
  • Hemilä, H. (2017). Zinc lozenges and the common cold: a meta-analysis comparing zinc acetate and zinc gluconate, and the role of zinc dosage. JRSM Open. (https://doi.org/10.1177/2054270417694291)
  • Krawitz, C., et al. (2017) Inhibitory activity of a standardized elderberry liquid extract against clinically-relevant human respiratory bacterial pathogens and influenza A and B viruses. BMC Complement Altern Med 11, 16
  • Torabian G (2019). Anti-influenza Activity of Elderberry (Sambucus nigra). Journal of Functional Foods 54, 353-360
  • Hawkins J (2019). Black Elderberry (Sambucus nigra) Supplementation Effectively Treats Upper Respiratory Symptoms: A Meta-analysis of Randomized, Controlled Clinical Trials. Complementary Therapies in Medicine, 42, 361-365
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Acknowledgements:
PSS Public Education Chapter
Victoria Chor Jia Min

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There is currently no specific study published that addresses this specific question. However, there is a wealth of data from various studies on washing with soap (with or without antibacterial agents) on other microbes to suggest that the act of washing with soap and water is an effective measure to reduce contamination and aid infection prevention strategies to stay well. Of notable mention, one study evaluated the efficacy of soap and water versus alcohol-based hand-rub preparations against live H1N1 influenza virus on the hands of human volunteers. It found that both methods were highly effective in reducing influenza A virus on human hands.

In the study, the soap used was with a non-medicated liquid soap (pH-balanced, with emollient and moisturiser, but not containing sodium lauryl sulfate, instead contains other surfactants), which was found to be effective in reducing viral load from the hands after washing for 40 seconds. Using soap to wash hands is more effective than using water alone, and is postulated because the surfactants in soap lift soil and microbes from skin, and people tend to scrub hands more thoroughly when using soap, which further removes germs. Thus from the above information, it would be expected that use of such cleansers should still work, esp. for selective individuals with eczema or sensitive dry hands, where frequent hand-washing may increase existing irritation and compromise the skin barrier. The WHO 20-second hand washing technique should be used regardless of the type of soap for effective cleaning.

Authored by:
Dr Wang Aiwen
Member of Pharmaceutical Society of Singapore

References:

Take home message:
Antimalarials like chloroquine and hydroxychloroquine are currently being studied for their effectiveness and safety when used to treat COVID-19. While Chloroquine may be purchased from a licenced pharmacist in Singapore for the prevention of malaria, we do not recommend self-medication for treatment of COVID-19 without proper medical assessment and evaluation. If you suspect that you could have COVID-19 infection or experiencing COVID-19 symptoms, seek medical attention immediately.

The Issue
Media reports and social media have been buzzing with news of “effective treatment for COVID-19”. You might also have read claims that one of the medicines, Chloroquine, which is also used to treat malaria, “has [purportedly] been approved by the Food and Drug Administration (FDA) to treat COVID-19”. Since then, self-medication of chloroquine has led to several cases of poisoning in Nigeria. A second agent by the name of hydroxychloroquine has also been mentioned.

The Facts
In Singapore, chloroquine can be bought directly from licenced pharmacists for the prevention of malaria. Hydroxychloroquine is more often used for the treatment of medical conditions like Lupus and Rheumatoid Arthritis. It is only available with a doctor’s prescription.

Back in 2005, chloroquine was found to be active against the “SARS” virus in laboratory experiments. Hence, in the wake of the COVID-19 epidemic, the same group of scientists suggested that it may be useful against COVID-19 too. Since then, a French report described that COVID-19 infection was shortened by 6 days for more than half of the 24 participants with the use of hydroxychloroquine. Similarly, the Chinese describe the shortening of infection and prevention of worsening of pneumonia with chloroquine in 100 patients. However, just based on these reports, neither agencies like U.S. FDA nor Health Sciences Authority of Singapore can approve chloroquine for routine use in COVID-19 infections. A well-designed clinical trial is needed to prove effectiveness and safety of these agents before they can be licenced and labelled for COVID-19 treatment.

Besides, some risks are involved with the use of antimalarials and thus medical oversight is necessary. In people with Glucose-6-Phosphate Dehydrogenase(G6PD) deficiency, use of chloroquine and hydroxychloroquine can cause red blood cells to break down, leading to anemia and jaundice. Both agents may reduce blood sugar levels for people on anti-diabetic medicines. Occasionally, these medicines have been associated with adverse reactions related to the eyes and the heart. When used without the proper oversight of a trained healthcare professional or appropriate monitoring, one could suffer from serious side effects.

As mentioned in our first advisory published on 19 March 2020, there is currently no specific medicine recommended to prevent and/or treat COVID-19. Instead, we could look forward to the results for existing medicines that are repurposed like lopinavir-ritonavir combination pill (which could be used with interferon injection), chloroquine and ribavarin and new medicines like remdesivir, favipiravir and tocilizumab which are undergoing clinical trials.

For reliable and timely information on COVID-19, we point the reader to trusted agencies and their official websites. Some examples include the weekly Saw Swee Hock School of Public Health reports on COVID-19, the Centers for Disease Control and Prevention (CDC), U.S. FDA and the World Health Organisation (WHO) websites. For clarification or further information, do “Just Ask” your friendly pharmacist.

Authored by：
Ms Grace Kng, Dr Ng Tat Ming and Dr Doreen Tan Su-Yin
Members of Pharmaceutical Society of Singapore
Taiwan Young Pharmacists Group
Ms Stephenie Lim
21 March 2020

References:

Take home message:
Until more information is available, paracetamol would still be the preferred fever or pain medication, unless your doctor has told you paracetamol is not suitable for you (e.g. a bad reaction to paracetamol). If you are already taking ibuprofen or another non-steroidal anti-inflammatory (NSAID) on the advice of a healthcare professional, do not stop without first checking with your healthcare professional. If you are intending to self-medicate for fever or pain and have questions, do speak to your pharmacist or doctor for advice and evaluation. Should you experience severe cough, breathing difficulties, fever, or other COVID-19-like symptoms, do seek immediate medication attention rather than self-medication at this time.

The Issue
Recent news and social media reports seem to suggest that the use of non-steroidal anti-inflammatory drugs (NSAIDs), including ibuprofen, could make COVID-19 infections easier and potentially could worsen its complications.

The Facts
Paracetamol is generally first choice treatment in most patients with fever, or mild to moderate pain, as it is safer than NSAIDs. NSAIDs are important in the control of inflammatory conditions like Rheumatoid Arthritis. Aspirin, a type of NSAID, is associated with the risk of Reye’s syndrome in children with viral infections. Ibuprofen is commonly used in children, as second-choice or as an add-on to paracetamol, because uncontrolled fever is more dangerous than the potential risk of Reye’s Syndrome. There is currently no strong scientific evidence to advise people to stop using NSAIDs, especially if you are using it for chronic conditions such as rheumatoid arthritis. However, do note that self-medication with paracetamol and NSAIDs could mask symptoms of fever associated with COVID-19 infections, thus delaying medical attention if one does need it. World Health Organisation (WHO) has just issued an official statement of clarification that they do not recommend against the use of ibuprofen as well, as at 8am Singapore time on 19 Mar 2020.

Examples of common NSAIDs used in Singapore include ibuprofen, mefenamic acid, naproxen, indomethacin, celecoxib and etoricoxib.

Authored by
Dr Wang Aiwen & Dr Doreen Tan Su-Yin
Members of Pharmaceutical Society of Singapore
Taiwan Young Pharmacists Group
Ms Stephenie Lim

References:

Take home message:
Patients on ACE-Is and ARBs should not discontinue them on their own, particularly if they have compelling reasons to be on this class of medicines.  If you have specific questions about your health status, please discuss this with your doctor or pharmacist in-charge.

The Issue
A recent scientific opinion paper published in the Lancet suggested that a particular bodily enzyme (by the name of ACE2) is raised in patients who were taking the above medications for their heart conditions and blood pressure, thus may put these patients at risk of COVID-19 infections. They mention a small case series of COVID-19 patients, many of whom had background use of ACE-Is prior to admission, suggesting that the use of ACE-I was associated with contracting COVID-19. They further speculate that ACE-Is and ARBs increase the levels of ACE2, and extrapolate that these medicines may be a concern with COVID-19 infections. They suggest that alternative medicines, which do not raise ACE2, could be considered for lowering blood pressure.

The Facts
Angiotensin Converting Enzyme inhibitors (ACE-Is) or Angiotensin Receptor Blockers (ARBs) are common anti-hypertensives used to manage high blood pressure through antagonising the renin angiotensin aldosterone system (RAAS) hormones. Some patients with weak heart function (also known as Heart Failure) or kidney problems (e.g. proteinuria) need to be on ACE-Is and ARBs.

Although there is some speculation about how these medicines may increase enzymes that makes COVID-19 infections easier or more severe, there is no strong scientific basis or evidence to support discontinuation of these agents at this time. The European Society of Cardiology and the American College of Cardiology, American Heart Association, and the Heart Failure Society of America have made official statements that there is no data in humans to prove that there is increased risk of COVID-19 infections in people who use RAAS antagonists. They have strongly recommended that doctors and patients continue treatment with ACE-I or ARBs.

Common examples of ACE-Is and ARBs used in Singapore include: enalapril, lisinopril, perindopril, ramipril, candesartan, irbesartan, losartan, telmisartan, and valsartan.

Authored by
Dr Wang Aiwen & Dr Doreen Tan Su-Yin
Members of Pharmaceutical Society of Singapore
Taiwan Young Pharmacists Group
Ms Stephenie Lim

References:

To date, there is no specific medicine recommended to prevent or treat the new coronavirus, also known as COVID-19. However, those infected with the virus should receive appropriate care to relieve and treat symptoms, and those with severe illness should receive optimized supportive care. Some specific treatments are under investigation and would be started under medical supervision and care.