Is prevention better than a cure? A letter to the editor on “World Health Organization declares global emergency: A review of the 2019 novel coronavirus (COVID-19)”

Dear Editor,

We read the article by Sohrabi et al. on the COVID-19 pandemic with keen interest and we would like to add our thoughts on the subject. Sohrabi et al. provided a holistic insight on the COVID-19 pandemic with topics ranging from prevention to lessons learned from the disease outbreak, all of which, considerably contribute to the expanding body of evidence on COVID-19 [1].

In this letter, we discuss current measures in place for infection prevention amongst healthcare professionals (HCPs), the limitations of current measures, and explore more obscure preventative procedures that may have utility in reducing the transmission of SARS-CoV-2.

The commonest route of transmission of SARS-CoV-2 is direct or indirect contact with the immediate environment. Another route involves transmission over short distances by air droplets from the respiratory tract of one individual directly onto a mucosal surface of another individual. The dispersion of aerosol droplets during aerosol-generating procedures is also implicated in the airborne spread of SARS-CoV-2. Indeed, healthcare professionals are susceptible to infection by the aforementioned routes when working in a clinical setting which necessitates effective preventative processes [2].

Both Public Health England (PHE) and the World Health Organization (WHO) have encouraged the regular practice of adequate hand hygiene before and after the delivery of patient care to limit direct and indirect contact transmission. Despite its ease of implementation, hand hygiene may be ineffective in situations wherein patients, patients' family members, and other carers may contaminate the clinical environment. It is also probable that many individuals do not adhere to satisfactory hand hygiene practice hence, if the number of non-compliant individuals is significant, the likelihood of infection transmission will remain constant or increase and ultimately extend the duration and magnitude of the pandemic [2].

Health authorities have also advised healthcare professionals to practise social distancing by standing at least 2 m away from other personnel. It is thought that the maximum distance for cross-transmission from droplets is approximately within a 2-m radius. However, this area of safety is dependent on the size of the infective agent within a droplet, relative humidity, and airflow. Therefore, the exact area of safety is indeterminate, and HCPs may unknowingly contract the virus once close to the droplets [2].

The utilisation of personal protective equipment (PPE) is the preventative measure of choice for protection against aerosol viral transmission. More specifically, a class 3 filtering facepiece respirator (FFP3) has been endorsed by PHE to be used by HCPs to filter a significant proportion of airborne droplets. Although, there is a risk of contaminant extravasation into the mask due to the negative pressure created during inhalation as well as the gradual reduction in the assigned protection factor of the mask if the face seal is inadequate [2].

Vitamin D supplementation may attenuate the spread of SARS-CoV-2. Emerging evidence suggests that vitamin D deficiency is prevalent amongst obese, elderly, and the Black, Asian, and minority ethnic population. As the vulnerable population remains under lockdown, they may have diminished sun exposure and therefore a reduction in vitamin D synthesis. A high-quality systematic review by Jolliffe et al. revealed that 25-hydroxyvitamin D induces antimicrobial peptides in response to viral stimuli and supplementation, therefore confers protection against acute respiratory tract infections. As such, we recommend that health authorities actively encourage vulnerable individuals to commence daily vitamin D supplementation of 400 international units following NICE guidelines [3].

Exercise may also be an essential preventative modality for viral infection. At its root and stem, moderate-intensity exercise is known to be safe, cost-effective, and elicits a multitude of physiological benefits. Nicola et al. described the adverse impact of COVID-19 on the economy as many businesses are at risk of closure and their employees have been made redundant. Consequently, many unemployed and perhaps employed individuals working from home may not undertake ample exercise whilst under lockdown. We propose that all medically stable individuals should undertake consistent, moderate-intensity exercise as a prophylactic intervention against SARS-CoV-2 as exercise can down-regulate inflammation within the respiratory tract and augment the immune response to respiratory viral infections [4,5].

Greater exploration and innovation of preventative measures are warranted whilst, to date, vaccine production is ongoing, and delivery is not imminent. It is hoped that health authorities, HCPs, and the general population acknowledge and diligently integrate vitamin D supplementation and exercise into their daily routine to guard against SARS-CoV-2 infection.

Provenance and peer review

Not commissioned, internally reviewed.

Data statement

No primary research or confidential patient data was obtained due to the nature of this article. No data sets were generated or analysed.

Ethical approval

No ethical approval necessary.

Sources of funding

None to declare.

Author contribution

Immanuel Sani – Writing.

Yaser Hamza – Writing.

Jubilent Amalendran – Writing.

Youssef Chedid– Contributor.

Hassan Ubaide - Contributor.

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Guarantor

Immanuel Sani.

Declaration of competing interest

None to declare.